Every finding on record at Cal Turner Rehab and Specialty Care

Based on observation, interview, record review and facility policy review, the facility failed to ensure drugs and biologicals used in the facility were current for use and/or labeled in accordance with currently accepted professional principles, including the expiration date when applicable. Insulin was opened but not labeled or dated and expired medication was available for use. This failure involved one of two medication carts reviewed (out of a total of four carts), as well as one medication storage room reviewed (out of a total of two medication storage rooms), and affected two (Resident (R) 35 and R8) residents, The findings include: 1. Review of a facility policy titled, Formulary Management, reviewed 04/2014, revealed medications acquired from a wholesaler, another pharmacy, or manufacturer would be stored in the pharmacy according to manufacturer guidelines. Review of a facility policy titled, Administration of Medication, revised 09/2019, revealed all multi-dose vials/pens should be marked with the date to be discarded (beyond use date). The policy further revealed all multi-dose vials/pens should be discarded 28 days after the initial puncture of the vial, or less if recommended by the manufacturer. Review of R8's Face Sheet revealed that the resident was admitted to the facility on [DATE] with medical diagnoses including type 2 diabetes mellitus with diabetic neuropathy. Review of R8's electronic Medication Administration Record (MAR) revealed that the resident was ordered and administered Basaglar insulin, 40 units subcutaneously nightly at bedtime for type 2 diabetes mellitus. Observation on 03/11/2025 at 1:10 PM of the medication storage room on C-hall revealed one package with two opened 10 milliliter (ml) vials of R8's Basaglar insulin inside the medication refrigerator that were not dated. In an interview with Registered Nurse (RN) 1 on 03/11/2025 at 1:45 PM, she stated that for medications that require refrigeration, such as insulins, it is the nursing staff's responsibility to write the date the bottle was opened on the package or vial. Interview with RN3, on 03/13/2025 at 2:35 PM, revealed that if she opened a new vial of insulin, she needed to write the beyond use date on the vial, which was 28 days from the date that the vial was opened. She stated that if she were to find a vial of insulin in the refrigerator without a beyond-use date, she would dispose of the vial and contact the pharmacy to order more insulin for the resident. She stated that a possible negative outcome of giving a resident undated insulin would be decreased effectiveness of the insulin. Interview with Pharmacy Technician 1, on 03/13/2025 at 3:05 PM, confirmed that when nurses open new vials of insulin, they are expected to write a beyond use date of 28 days after the date it was opened, unless the expiration date of the insulin is before the beyond use date. Pharmacy Technician 1 said that when she comes to restock the medication rooms, she checks for expired medicines or medicines without a date written on them, and if there are any, she takes them out of the refrigerator. She added that there was not a specific policy that states this task is assigned to pharmacy technicians, but she attempts to take care of it when she comes up to the med room. Further interview with Pharmacy Technician 1 revealed that a possible negative outcome of giving undated insulin to a resident could be that the insulin would not be as effective and could cause harm to the resident, but she stated it would depend on how outdated the insulin was. In an interview with the Director of Nursing (DON) on 03/13/25 at 4:33 PM, she stated that her expectation of staff after they opened a new vial of insulin, would be for them to date the medication with a use by date. In addition, she stated that she expected her staff to check expiration dates on medications before giving the medications to the residents. Interview with the Administrator on 03/13/25 at 4:39 PM revealed her expectation of the nursing staff was that they put dates on medications after opening the medication. 2. Review of an Admission Record revealed the facility admitted R35 on 08/01/2022 with diagnoses including anxiety disorder and unspecified dementia with agitation. Review of current physician orders revealed the resident had an order for hydroxyzine pam (medication which can be used to treat anxiety) as needed (PRN). Observation of the B hall medication cart, on 03/12/2025 at 1:10 PM, with RN1 and Licensed Practical Nurse (LPN) 1, revealed R35 had a blister pack containing ten tablets of hydroxyzine pam 50 milligrams (mg) tablets, with a preprinted expiration date of 01/2025. During an interview with RN1 on 03/12/2025 at 1:13 PM, she the stated night shift nurses were responsible to check the medication carts for expired medications. She stated the hydroxyzine should have been caught, disposed of and reordered. During an interview with LPN5 on 03/13/2025 at 10:16 AM, she stated anyone assigned to the medication cart should audit for expired medications. LPN5 stated if she saw an expired medication, she would send it back to the pharmacy and reorder the medication. She stated anyone on the cart was responsible and should observe for expired medications during their shift. During an interview with RN3 on 03/13/2025 at 2:41 PM, she stated she attempts to check the medication cart every shift. RN3 stated expired medications should not be administered and should be placed in the medication room with a note attached to notify the pharmacy to pick it up. RN3 further stated the medication should then be reordered. RN 3 stated if an expired medication was administered, it probably would not be as effective. During an interview with LPN2 on 03/13/2025 at 2:56 PM, she stated she works night shift, and the nurse or medication technician assigned to the cart is responsible for checking the medication carts for expired medications. LPN2 stated night shift usually had more time to do that than day shift. However, LPN2 further stated that anyone assigned to the medication cart could check for expired medications. She stated the expired medication should be placed in the medication room for pharmacy to pick up, the medication should be reordered. She stated if an expired medication was administered it would not be as effective as an in-date medication and it may lose it potency. During an interview with the DON on 03/13/2025 at 4:33 PM, she stated she expected expired medications to be caught prior to being given. The DON stated the night shift nurse or Certified Medication Technician (CMT) puts the bulk of the pills away and would be responsible for checking the cart for expired medications. The DON stated she would expect for the staff to check medication expiration dates prior to administration to prevent a possible negative outcome. During an interview with the Administrator on 03/13/2025 at 4:38 PM, she stated she expected nursing staff to review all of the medications in the cart to ensure they were active and not expired.

Based on observation, interview, and review of the facility's policy, the facility failed to post survey results in a place readily accessible, where individuals wishing to examine survey results did not have to ask to see them. The facility's failure affected 10 residents who attended the resident council meeting (Resident (R)2, R21, R25, R37, R39, R40, R50, R62, R63, R85) and had the potential to affect all residents residing in the facility, as well as family/representatives, and visitors of the facility who had the right to review the facility's survey history. The findings include: Review of a facility policy titled, Rights and Responsibilities of Residents, reviewed 06/2024, revealed each resident and resident representative had the right to have access to all inspection reports at the facility. A meeting was conducted on 03/12/2025 at 1:03 PM, with residents who regularly attend Resident Council meetings. During the meeting, interview with the residents who were present (R2, R21, R25, R37, R39, R40, R50, R62, R63, and R85) revealed they did not know where the survey book (results of the facility's surveys) was located. Observation on 03/11/2025 at 11:00 AM revealed a sign in the main entrance hallway stating that State Law KRS 216.457 required state inspection reports on the facility to be made available to you upon request and to ask a representative of the facility. Further observation in this area, as well as throughout the facility, revealed no evidence that the required survey reports were present and/or accessible for independent review. During an interview with the Director of Nursing (DON) on 03/12/2025 at 4:40 PM, she stated her belief that the survey binder results were located behind each nursing station, but she would have to confirm that was correct. Additional interview with the DON, on 03/12/2025 at 4:54 PM, revealed the survey binder results were located behind the B-hall nursing station. The DON stated the facility added glass dividers to the nursing stations and the binder had been moved behind the nursing station during that time and had never been placed back out into view. She indicated the facility needed to move the binder back to the other side of the glass so residents and visitors would have access to the survey results. During an interview with the Minimum Data Set (MDS) Coordinator on 03/13/2025 at 2:40 PM, she confirmed that the facility survey binder had been behind the B-hall nursing station desk until yesterday. She stated if someone asked to see the binder, she would have informed the nursing supervisor. During an interview with Registered Nurse (RN) 3 on 03/13/2025 at 2:41 PM, she stated the facility survey results binder was kept behind the B-hall nursing station along with other binders. RN 3 stated residents and/or visitors would have had to ask to see the binder. Additional interview with the DON, on 03/13/2025 at 2:56 PM, revealed the facility survey results binder should be visible to allow anyone to look at it at any time. During an interview with the Administrator on 03/13/2025 at 4:38 PM, she stated she expected that, according to regulations, the facility survey results binder should be accessible for family members or residents to view any of the facility's survey findings.

Based on interview, record review, facility investigation and policy review, and hospital record review, it was determined the facility failed to implement the Comprehensive Care Plan for one (1) of twenty-two (22) sampled residents (Resident #14). Resident #14 was care planned for two (2) assist with transfers. On 02/03/2020, a Certified Nurse Aide (CNA) attempted to transfer the resident from the toilet to resident's wheel chair without the assistance of another staff, which resulted in the resident falling. Because of the fall, the resident sustained [REDACTED]. The findings include: Review of the facility policy titled. Person-Centered Care Plans, last revised January 2020, revealed the objective is to provide consistent, continuous care; comprehensive person-centered care, and care that is interdisciplinary. Staff is expected to follow the Plan of Care for each resident. 1. Record review revealed the facility admitted Resident #14 on 12/14/2018 with diagnoses, which included [MEDICAL CONDITION] and [MEDICAL CONDITION] following Cerebral Infarction Affecting Right Dominate Side, Muscle Weakness, Difficulty in Walking, Abnormalities of Gait and Mobility, and Lack of Coordination. Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE] revealed the facility assessed Resident #14's cognition as severely impaired with a Brief Interview for Mental Status (BI[CONDITION]) score of four (4) , which indicated the resident was not interviewable. Review of Resident #14's Comprehensive Care Plan for Activities of Daily Living (ADL's), dated [DATE]; and Visual/Bedside Kardex Report, printed 0[DATE]20, revealed the resident required extensive assistance of two (2) staff for toileting and to move between surfaces, as necessary; initiated on [DATE]18. However, review of Nurses Note dated 02/03/2020 at 7:18 AM, and facility investigation dated 02/03/2020 revealed the resident was assisted to transfer off the toilet by one (1) CNA and the resident started to lean to the right. The CNA tried to assist resident to floor but was unable to and the resident landed on floor on right side by the toilet. The resident complained of hip and shoulder pain; and there was a hematoma to right side on head. The resident was sent to Emergency Department (ED). The CNA failed to ensure there were two staff to assist with transfer. Review of Hospital Operative Note, dated 02/03/2020, revealed the resident was diagnosed to have a right femoral neck fracture and a right anterior total hip replacement was performed. Interview with CNA #12 on 0[DATE]20 at 3:37 PM, revealed she assisted Resident #14 up off the toilet and attempted to transfer the resident back into the wheel chair without anyone assisting her and the resident fell . She stated, in hindsight, she should have waited for help, or went to get help to assist the resident with the transfer. She stated, she was not one-hundred percent (100%) sure what the resident's care plan read, until after the resident had fallen and her supervisor and the DON made her aware the resident was a two (2) assist. She stated she did not look at the care plan before taking care of the resident and was unaware the resident was a (2) assist until after the fall. Interview with Certified Medication Technician (CMT) #1 on 0[DATE] at 3:15 PM, revealed Resident #14 had a previous right sided stroke, had weakness on the right side, and was care planned for an assist of two (2) staff for transfer, toileting and bed mobility. Interview with Licensed Practical Nurse (LPN) #3 on 0[DATE]20 at 3:25 PM, revealed she was fairly new as she had just started on the night shift in December 2019, but she was fairly certain the resident was a two (2) assist with transfer and care. Interview with Nursing Supervisor on 0[DATE]20 at 1:52 PM, revealed was made of Resident #14's fall on 02/03/2020, when LPN #3 came to give her the incident report. She stated LPN #3 made her aware CNA #12 had transferred Resident #14 off the toilet by herself and had not used a gait belt, which is the facility's practice. She revealed Resident #14 was transported to a local hospital and required surgical intervention of the right hip and was still in the hospital (0[DATE]20). She stated CNA #12 was reeducated on following the care plan and was given a written counseling on 02/03/2020. Interview with the Physician on 0[DATE]20 at 3:54 PM revealed Resident #14 required surgical intervention of his/her right hip, and had a right total hip replacement. She stated the resident had a history of [REDACTED]. She further revealed she expected staff to follow the care guide when providing care for the resident and if staff followed the care guide, this fall could have been prevented as well as preventing surgical intervention. Interviews on 0[DATE]20 with CNA #7 at 2:45 PM; CNA #8 at 2:53 PM; CNA #9 at 2:55 PM; CNA #10 at 3:08 PM and CNA #11 at 3:13 PM, revealed Resident #14 was care planned for two (2) assist with transfers, bed mobility and toileting. Interview with the Director of Nursing (DON) on 0[DATE]20 at 4:45 PM, revealed the Nursing Supervisor notified her of Resident #14's fall. The DON stated the facility determined the root cause of the fall was improper use transfer; and failure to follow the care plan. She revealed CNA #12 failed to follow the care plan related to two (2) assist with transfers and did not use the gait belt which is the facility's practice. She revealed Resident #14 was transported out to the ER for evaluation and treatment and required surgical intervention of a total hip replacement. The DON further revealed the Nursing Supervisor reeducated CNA #12 that morning and later that day. The DON stated CNA #12 was educated regarding to use the gait belt because that is a facility practice. Interview (Post Survey) with the Administrator on 0[DATE] at 10:43 AM, revealed it was her understanding from the DON that all staff had been educated on the proper use of the gait belt as well as following the care plan. However, surveyor interviews on 0[DATE]20 with CNA #7 at 2:45 PM; CNA #8 at 2:53 PM; CNA #9 at 2:55 PM; CNA #10 at 3:08 PM and CNA #11 at 3:13 PM, revealed they were educated on using the gait belt and did not recall any education being presented regarding following the resident's care plan. Further interview with the Administrator revealed there was no documentation specific to staff education on care plans, however, there was documentation the staff were educated on the proper use of gait belts. She stated they are currently in the process of re-educating all the staff on following the care plans.

Based on interview, record review, facility policy and investigation review, and hospital record review, it was determined the facility failed to ensure adequate supervision and assistive devices to prevent accidents were provided for one (1) of three (3) residents with falls in the selected sample of twenty-two (22) residents (Resident #14). The facility assessed and care planned Resident #14 required two (2) staff assist with transfer. In addition, the facility's protocol was for staff to use gait belt during transfers. However, on 02/03/2020, one (1) Certified Nurse Aide (CNA) attempted to transfer the resident off the toilet into the resident's wheel chair without assistance, which resulted in a fall. Resident #14's fall resulted in a Right Femoral Neck Fracture, which required a right anterior total hip replacement. The findings include: Review of facility policy titled, Fall Risk Assessment and Intervention last revised August 2018, revealed the purpose of the policy was to ensure that each resident receives adequate supervision and assistance devices to prevent falls, to ensure that a resident's individualized plan of care adequately address's fall prevention measures, and at the same time, focuses on maintaining the residents highest possible level of independence. The facility will support and promote a culture of safety that focuses on each and every employee playing his/her part in fall prevention. Record review revealed the facility admitted Resident #14 on 12/14/18 with diagnoses, which included [MEDICAL CONDITION] and [MEDICAL CONDITION] following Cerebral Infarction Affecting Right Dominate Side, Muscle Weakness, Difficulty in Walking, Abnormalities of Gait and Mobility, and Lack of Coordination. Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #14's cognition as severely impaired with a Brief Interview for Mental Status (BI[CONDITION]) score of four (4) which indicated the resident was not interviewable. Further review of the MDS revealed the facility assessed Resident #14 required extensive assistance of two (2) persons for bed mobility, transfers and toileting. Review of Resident #14's quarterly Fall assessment dated [DATE] revealed a score of sixty ([AGE]), which indicated the resident was at high risk for falls. Review of Resident #14's Comprehensive Care Plan for Activities of Daily Living (ADL's) Self-care Performance Deficit related to [MEDICAL CONDITION] and [MEDICAL CONDITION] following Cerebral Infarction affecting right dominate side, dated [DATE]; and the Visual/Bedside Kardex report, printed 0[DATE]20; revealed interventions that the resident required extensive assistance of two (2) staff for toileting and to move between surfaces as necessary. Review of Nurses Notes dated 02/03/2020 at 7:18 AM, revealed Resident #14 was being transferred off the toilet to wheel chair and was holding on to bathroom bar with left hand; however, when the resident stood up the resident started to lean to the right side. The CNA tried to assist resident to floor but was unable to maintain resident in sitting position and resident landed on floor on right side by the toilet. Further review of the note revealed the resident was assessed, complained of hip and shoulder pain, and there was a hematoma to right side on head. The resident was sent to the Emergency Department (ED). Review of Hospital Operative Note, dated 02/03/2020, revealed Resident #14's preoperative [DIAGNOSES REDACTED]. Further review revealed the procedure performed was a right anterior total hip replacement. Review of the facility Investigative Preliminary Report, dated 02/03/2020, revealed Resident #14 was on the toilet and finished voiding, the resident stood up with CNA in bathroom, and grabbed grab bar with left hand. The CNA reached to get wheel chair behind resident and the resident started leaning towards the right side. The CNA attempted to lower the resident to the ground; however, the resident fell on his/her right side by the toilet. Further review of the Summary of Investigator's Findings, dated 02/03/2020 revealed, Resident was assisted on to the toilet by CNA and the resident was assessed to be transferred with two (2) staff members. CNA assisted resident to stand and utilize the grab bar with his/her unaffected left hand. While CNA was placing the wheel chair behind the resident, the resident started to lean to his/her right affected side. The CNA did not have a gait belt on and attempted to assist the resident to the ground. The resident landed on his/her left side in the bathroom floor. The findings were discussed with the CNA and the CNA was re-educated on following the care plan and utilizing the gait belt for safe transfers. The CNA was scheduled to meet with Director of Nursing (DON). Interview with CNA #12 on 0[DATE]20 at 3:37 PM, revealed she assisted Resident #14 up off the toilet by herself and had attempted to transfer the resident back into the wheel chair. CNA #12 stated she instructed the resident to grab hold of the grab bar with his/her good hand, then the resident started to lean and became very heavy for her to hold on to. She revealed as she was reaching for the wheel chair, she lost control of the resident, and the resident started too leaned over and became to heavy for her to hold. The resident fell to the floor hitting his/her head on the floor, and landed on his/her right side. She stated the resident yelled out in pain, and was holding his/her right leg and yelling out. She revealed she yelled out the door for assistance and Certified Medication Technician (CMT) #1 came to the room, and went and told the nurse. She further stated, in hindsight, she should have waited for help, or went to get help to assist the resident with the transfer. She stated she was not one-hundred percent (100%) sure of what the resident's care plan read, until after the resident had fallen and her supervisor and the DON made her aware the resident was a two (2) assist. She revealed she did not look at the care plan before taking care of the resident and was unaware the resident was a (2) assist until after the fall. She further revealed she thought she was just in trouble for not using the gait belt when she transferred the resident, because staff are required to use a gait belt with all transfers, no matter if they are a one (1) assist or a two (2) assist. She stated she was not told in report the resident was a (2) assist with transfers, and she does not review the resident's care plans before providing care to the residents. She further stated, she had been re-educated on 02/03/2020 regarding the safe transfer with a gait belt and to always follow the resident's care plan. Interview with CMT #1 on 0[DATE] at 3:15 PM, revealed she was working on the medication cart, not too far from Resident #14's room, when she heard CNA #12 yell out for help. CMT #1 stated she immediately went and saw Resident #14 on the bathroom floor, yelling in pain and pointing to his/her leg. She immediately went and got the nurse. Interview with Licensed Practical Nurse (LPN) #3 on 0[DATE]20 at 3:25 PM, revealed CNA #12 was providing care for Resident #14 on 02/03/2020. LPN #3 stated it was early in morning about 5:00 AM on 02/03/2020 when CMT #1 came and told her the resident had fallen in the bathroom. She stated she grabbed the vital sign machine and went to the resident's room, and when she arrived to the room, Resident #14 was lying in the bed. She revealed Resident #14 complained of pain to the right hip and was pointing to his/her right hip, and there was a Hematoma to the right side of his/her head. She stated after she completed her assessment of the resident, she called the physician and the family to make them aware of the fall. The physician ordered the resident to be sent out to the emergency room (ER) for evaluation and treatment. She further stated she was fairly new as she had just started on the night shift in December 2019, and was fairly certain the resident was a two (2) assist with transfer and . She stated she was aware the resident had a stroke in the past and had a lot weakness. She revealed she filled out a incident report, and told her nursing supervisor about the fall. Interview with Nursing Supervisor on 0[DATE]20 at 1:52 PM, revealed she became aware of Resident #14's fall the morning of 02/03/2020, when LPN #3 came to give her the incident report. She stated LPN #3 made her aware of all the details of the fall, which included that CNA #12 had transferred Resident #14 off the toilet by herself and had not used a gait belt, which is the facility's practice. She revealed Resident #14 was transported to a local hospital and required surgical intervention of the right hip and was still in the hospital (0[DATE]20). She stated CNA #12 was reeducated on following the care plan and was given a written counseling on 02/03/2020. Interview with the Physician on 0[DATE]20 at 3:54 PM revealed the facility called and made her aware of Resident #14's fall, and she ordered the resident to be sent out to the ER for evaluation and treatment. She stated Resident #14 required surgical intervention of his/her right hip, and had a right total hip replacement. She further revealed, the resident had a history of [REDACTED]. She stated she expected staff to follow the care guide when providing care for the resident and if staff followed the care guide, this fall could have been prevented as well as prevented surgical intervention. Interview with the Director of Nursing (DON) on 0[DATE]20 at 4:45 PM, revealed the Nursing Supervisor notified her of Resident #14's fall. The DON stated the facility determined the root cause of the fall was improper use transfer; and failure to follow the care plan. She revealed CNA #12 failed to follow the care plan related to two (2) assist with transfers and did not use the gait belt which is the facility's practice. She revealed Resident #14 was transported out to the ER for evaluation and treatment and required surgical intervention of a total hip replacement. The DON further revealed the Nursing Supervisor reeducated CNA #12 that morning, and later that day she called CNA #12 back, and asked her why the incident occurred and why she did not follow the care plan or use the gait belt. She stated CNA #12 replied to her she just did not do it. She also asked CNA #12 what she learned from this incident and CNA #12 indicated she learned a valuable lesson, and realized she had made a grave mistake. The DON stated CNA #12 was educated regarding to use the gait belt because that is a facility practice, she said she did not use the gait belt, nor did she follow the resident's care plan. Interview (Post Survey) with the Administrator on 0[DATE] at 10:43 AM, revealed members of the Interdisciplinary Team (IDT) met the morning of the fall (02/03/2020) during their morning meeting to discuss Resident #14's fall. The Administrator stated the morning after the fall ([DATE]20), all members of their Quality Assurance (QA) team met except the Medical Director who was unable to attend; however, he was already aware of the fall with injury. She stated they discussed the fall with injury, and the failures of the CNA not using the gait belt and following the care plan. She revealed the facility had not had an official QA meeting since 01/30/2020. She further stated it was her understanding from the DON that all staff had been educated on the proper use of the gait belt as well as following the care plan. However, surveyor interviews on 0[DATE]20 with CNA #7 at 2:45 PM; CNA #8 at 2:53 PM; CNA #9 at 2:55 PM; CNA #10 at 3:08 PM and CNA #11 at 3:13 PM, revealed they were educated on using the gait belt; however they did not recall any education being presented regarding following the resident's care plan. Further interview with the Administrator revealed there was no documentation specific to staff education on care plans, however, there was documentation the staff were educated on the proper use of gait belts. She stated they are currently reviewing, auditing, and monitoring care plans, and are in the process of re-educating all the staff on following the care plans.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure medical records, were complete and accurately documented for one (1) unsampled resident not in the selected sampled of twenty-two (22) residents (Resident #1). The facility failed to ensure medical record were complete for Resident #1 related to the placement, assessments, and removal of [MEDICATION NAME] (hep) lock. The findings include: Review of facility policy titled, Documentation, last revised August 2018, revealed the purpose was to provide a complete and accurate record that reflects observations regarding resident status, nursing care provided to the resident, the effectiveness of nursing interventions, medical treatment ordered, and discharge preparation activities and to specify the individuals authorized to document in the medical record to include routine procedures and observations. Record review revealed the facility admitted Resident #1 on 10/24/19 with diagnoses, which included [MEDICAL CONDITION] and [MEDICAL CONDITION] following Cerebral Infarction Affecting Right Dominant Side. Observation of Resident #1 on 02/11/2020 at 2:39 PM revealed an Intravenous (IV) hep lock to the left forearm that was not dated. Interview with Resident #1 and Registered Nurse (RN) #2 at this time revealed the hep lock was placed yesterday at the acute center for some testing of blood work for resident. Observation of Resident #1's Left Forearm on 02/12/20 at 1:45 PM, revealed the IV hep lock was no longer in place on the resident's left forearm. However, review of Resident #1's Nursing notes, dated 02/11/2020 and 02/12/2020 revealed there was no documentation showing an IV hep lock was placed in the left forearm, shift assessments of hep lock were completed, and the removal of the IV hep lock to the left forearm. Interview with RN #2 on 0[DATE] at 11:28 AM, revealed she removed the IV hep lock from Resident #1's left forearm but did not remember if she documented the removal in the nursing notes. She stated it was facility policy to document on IV's every shift and when It is removed from resident. Interview with Nursing Supervisor and Registered Nurse (RN) #1 on 0[DATE] at 11:04 AM, revealed they were aware it was the facility's policy to document the removal of IV's in a resident's nursing progress note. They stated RN #2 had removed the IV hep lock yesterday and had failed to document in nursing note. Interview with LPN #2 on 0[DATE] 01:43 PM, revealed she acknowledges facility policy of assessing and documenting of IV hep locks during every shift and that it is policy to document IV assessments in each resident's nursing notes. Interview with Director of Nursing (DON) on 0[DATE] at 4:34 PM, revealed she expected nursing to document every shift assessments of IV hep lock and the discontinuation of IV hep lock for any resident that has one in order to have complete and accurate medical records for each resident.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to treat each resident with respect, dignity and care in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality for two (2) of twenty-two (22) sampled residents, (Resident #25 and #55). Staff failed to respond to Resident #55's call light timely when the resident needed to use the bedpan and failed to ensure Resident #25's face and shirt were clean after eating meals and receiving medications. The findings include: Review of the facility's policy titled, Rights and Responsibilities of Residents, last revised April 2017, revealed to treat each resident with consideration, respect and full recognition of his dignity, and individuality, including privacy in treatment and in care for his/her personal needs. 1. Record review revealed the facility admitted Resident #55 on 0[DATE] with diagnoses, which included [MEDICAL CONDITION], Acquired Absence of Left and Right Leg below the Knee, Diabetes Type 2, and Anxiety Disorder. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #55's cognition as intact with a Brief Interview of Mental Status (BI[CONDITION]) score of fifteen (15) which indicated the resident was interviewable. Observation on 02/11/2020 at 11:58 AM revealed Resident #55 turned on call light at 11:46 AM at his/her bedside. Staff members were in the hallway and passed by resident's room; however, staff did not enter the room to offer assistance. A staff member answered the call light from the desk over the call light system stating can I help you, can I help you; however, Resident #55 was not able hear the staff's reply due to the high volume of the television in the room and the resident was hard of hearing. Further observation revealed the call light was no longer activated and no one came to assist either resident in the room. Interview with Resident #55, on 02/11/2020 at 12:10 PM, revealed there is an ongoing problem with staff responding to his/her call light in a timely manner. Resident #55 stated he/she has had episodes of bowel incontinence waiting for staff to answer his/her call light. Resident #55 stated, I can feel the urge to go but it takes a while for someone to get me on the bed pan then I soil myself; and I don't like if I soil myself and someone has to clean me up. The resident further revealed he/she uses the urinal independently but he/she was unable to put him/herself on the bedpan. Interview with Certified Nursing Assistant (CNA) #4, on 02/12/2020 at 9:37 AM, revealed Resident #55 tells staff when he/she needs to have a bowel movement. CNA #4 stated, Sometimes may have an accident if staff not available to get him/her on the bedpan in time. CNA #4 also revealed Resident #55 was continent of urine and able to use urinal independently. Interview with CNA #5, on 02/12/2020 at 4:19 PM, revealed Resident #55 is always continent of bladder and bowel with occasional bowel incontinence during evening and/or night shift. CNA #5 stated Resident #55 always uses the call light to let staff know of need to have a bowel movement and the resident gets upset if not assisted timely on the bedpan and is incontinent of bowels. Interview with Nursing Supervisor, on 0[DATE]20 at 10:29 AM, revealed Resident #55 uses call light frequently. She stated the resident uses the urinal independently however, occasionally requires help positioning it. She stated a Care Conference with the resident's son revealed the resident does not have patience and perception of time is not always accurate. Interview with the Director of Nursing (DON), on 0[DATE]20 at 11:16 AM, revealed she expected staff to go to the resident's room if call light is on and when the resident does not respond when staff offers assistance from desk call system. The DON stated she expected staff to maintain the resident's dignity, including privacy while meeting their care needs. 2. Record review revealed the facility admitted Resident #25 on 03/17/16 with diagnoses, which included [MEDICAL CONDITION] with Late Onset, and Dementia in other diseases classified elsewhere with behavioral disturbance. Review of the Quarterly MDS assessment, dated 11/21/2019, revealed the facility assessed Resident #25's cognition as intact with a BI[CONDITION] score of twelve (12), however, multiple attempts to interview Resident #25 revealed the resident was not interviewable. Observations on 02/11/2020 at 10:22 AM, revealed Resident #25 was lying in bed on his/her back with dark brown food matter on abdomen area of shirt and perimeter of mouth. Observations on 02/11/2020 at 10:51 AM revealed Resident #25 lying in bed on his/her back with same soiled shirt on with dark brown food matter on abdomen area of shirt. However, further observation revealed the resident's perimeter of mouth had been cleaned Observations on 02/11/2020 at 12:04 PM revealed Resident #25 had a white food substance on same shirt as earlier in AM with white food matter on perimeter of mouth after lunch. Observations on 02/12/2020 at 8:21 AM revealed Resident #25 had brown colored food substance on perimeter of mouth and had on a clean shirt. Interview with CNA #1, 0[DATE]20 at 11:35 AM, revealed facility policy states it is a dignity issue for residents to have a dirty mouth or food droppings on clothes. She stated Resident #25 often leaves the dining room before the aides finish feeding other residents and she may not have been able to address wiping his/her mouth before Resident #25 left the dining area. Interview with CNA #6 on [DATE]20 at 1:39 PM, revealed it is a dignity issue for Resident #25 to not have clean mouth after meals and the soiled shirt changed. She stated she tries to make sure to clean his/her face and shirt after meals. Interview with Licensed Practical Nurse (LPN) #2 on 0[DATE]20 at 1:43 PM, revealed it is a dignity issue if Resident #25 needed mouth cleaned after administering medications or eating and residents should have their shirt replaced if soiled. Interview with DON, on 0[DATE]20 at 4:34 PM, revealed she expected staff to follow facility policy for Resident Rights and that included wiping residents' mouths after meals and medication pass; and changing residents' shirts when they become soiled with food. She stated Resident #25's behavior does not always allow for prompt hygiene to face or changing clothing because he/she sometimes becomes combative when CNA's try to provide care.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of twenty-two (22) sampled residents (Residents #[AGE] and #48) A Licensed Nurse failed to ensure standard precautions were followed while performing wound care for Resident #[AGE]. In addition, staff failed to ensure Resident #48's catheter bag was kept off the floor. The findings include: Review of the facility policy, Infection Prevention last revised February 2020 revealed, the facility will ensure that Standard Precautions shall be practiced to reduce the risk of transmission of communicable and infectious diseases in the long term care setting. 1. Record review revealed the facility admitted Resident #[AGE] on 06/04/2019 with [DIAGNOSES REDACTED]. Observation of wound care for Resident #[AGE] on 0[DATE]20 at 8:56 AM revealed RN #3 failed to provide a barrier or to clean the bedside table prior to laying down supplies for wound care and RN #3 failed to put a barrier down before placing foot on the heel boot after taking old bandage off of right heel. In addition, RN #3 picked up the 4x4 gauze she placed on top of trash liner bag on bed and used it on the resident's wound on the right heel. RN #3 then removed the dressing to coccyx, which had stool on it, and contaminated the coccyx wound with feces. Interview with RN #3 on 0[DATE]20 at approximately 9:00 AM revealed she did not use a barrier or clean the worktable. RN #3 stated she put Resident #[AGE]'s heel down on the boot after taking soiled bandage off and she removed the 4x4 bandage out of the trash bag and used it on heel wound. RN #3 further revealed she did not provide wound care according to professional standards of practice to prevent infection. Interview with Director of Nursing (DON) on 0[DATE]20 at 4:34 PM revealed she expected staff to use standard precautions for infection control when changing wound dressing. She stated she expected staff to use barriers or to clean work space prior to laying supplies down on an unclean surface and to use a barrier after taking the dressing off a resident's wound and before placing wound down on bedding or other unclean surface. She further revealed picking up an item from the trash bag to use on a wound is not acceptable infection control standards of care. 2. Record review revealed the facility admitted Resident #48 on 01/31/19 with diagnoses, which included [MEDICAL CONDITION], and Neuromuscular Dysfunction of the Bladder. Observation on 02/11/2020 at 10:16 AM, on 02/12/2020 at 8:32 AM, and on 0[DATE]20 at 9:08 AM revealed Resident #48's catheter bag was laying on the floor. Interview with Certified Nurse Aide (CNA) #2 on 0[DATE]20 at 9:08 AM revealed the catheter bag was not supposed to be on the floor. Interview with the Charge Nurse on 0[DATE]20 at 10:11 AM revealed the indwelling catheter bag should not be laying on the floor. Interview with the DON, on 0[DATE]20 at 11:05 AM revealed catheter bags should be off the floor. She stated she expected staff to follow facility policies as written.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) residents with tube feedings, in the selected sample of twenty-two (22) residents, received care in accordance with professional standards of practice (Resident #61). Licensed staff failed to ensure Resident #61's tube feeding container of Vital 1.2 was labeled with the date and time the feeding was hung. The findings include: Review of the facility's policy titled, Tube Feeding - Continuous and intermittent, dated January 2019, revealed .the feeding container and tubing should be changed every eight (8) hours unless ordered otherwise. Ready to hang bags can hang up to forty-eight hours however; spike sets should be changed every twenty-four (24) hours. Label the pump set with the date and time of hanging. Record review revealed the facility readmitted Resident #61 on 12/24/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #61's cognition as severely impaired with Brief Interview for Mental Status (BI[CONDITION]) score of zero (0), which indicates the resident was not interviewable. Review of Resident #61's Physician Orders, dated 02/07/2020, revealed an order for [REDACTED]. Bolus remaining amount two (2) times a day for supplemental nutrition. Observation on 02/12/2020 at 11:04 AM revealed Resident #61's tube feeding container of Vital 1.2 was infusing; however, further observation revealed the container of feeding was not labeled with the date and time it was hung per professional standards. Interview with Registered Nurse (RN) #1, on 0[DATE] at 3:24 PM, revealed the licensed staff is expected to label, date, and time all tube feeding nutrients that were hung. RN #1 stated the policy does not necessarily indicate that, however, it is the facility's expectation that any tube feeding contents be labeled with content, date, and time feeding was hung. Interview with the Director of Nursing (DON), on 0[DATE] at 4:35 PM, revealed she expected each tube-feeding container to be labeled with the date and time the feeding was hung. The DON stated the date and time hung should be recorded on the tube-feeding container.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident receives pressure ulcer care, consistent with professional standards of practice, to promote healing, and prevent infection for one (1) of four (4) resident with pressure ulcers, in the selected sample of twenty-two (22) residents (Resident #[AGE]). Licensed staff failed to provide pressure ulcer care for Resident #[AGE] according to professional standards of practice, which resulted in the nurse contaminating the wound. The findings include: Review of facility policy titled, Routine Skin Care and Pressure Ulcer Management, last revised on September 2019 revealed the purpose of the policy was to provide guidelines for the prevention and treatment of [REDACTED]. Review of the facility policy, Infection Prevention last revised February 2020 revealed, the facility will ensure that Standard Precautions shall be practiced to reduce the risk of transmission of communicable and infectious diseases in the long term care setting. Record review revealed the facility admitted Resident #[AGE] on 06/04/2019 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE]20 revealed the facility assessed Resident #[AGE]'s cognition as severely impaired with a Brief Interview of Mental Status (BI[CONDITION]) score of three (3), which indicated the resident was not interviewable. However, interview of Resident #[AGE] revealed the resident was able to display awareness and to have appropriate cognitive communication, and able to call surveyor's name each time presented. Review of a Comprehensive Care Plan for actual skin impairment, dated 01/06/2020 revealed Resident #[AGE] has actual impairment to skin integrity related to, fragile skin with the potential for further skin breakdown due to use of right heel to push and reposition self; and, immobility, and incontinence. A Suspected Deep Tissue Injury (SDTI) to right lateral heel was changed to an unstageable as of 08/14/19 and on 12/05/19; a Stage II was identified to the resident's sacrum. Further review of the care plan revealed the resident was readmitted on [DATE] from the hospital with an unstageable pressure wound to sacrum and interventions for staff to follow facility protocols for treatment of [REDACTED]. Review of Physician Order, dated 12/24/2019 revealed to cleanse pressure injury to right heel with Normal Saline (NS), apply NS moistened gauze, cover with dry gauze, and secure with [MED] daily every day shift for unstageable pressure injury. Further review of Physicians Orders revealed an order received on 01/06/2020, to use Dakin's (1/2) strength) solution 0.25%, applied to sacral wound topically every day shift for pressure injury. Cleanse with normal saline, then apply Dakin's moistened gauze, cover with Abdominal Pad, and Secure with Hypefix and [MEDICATION NAME]. Observation of wound care on 0[DATE]20 at 8:56 AM revealed the Wound Care Nurse/Registered Nurse (RN) #3 and Licensed Practical Nurse (LPN) #1 failed to provide wound care according to professional standards of practice. RN #3 failed to provide a barrier or to clean the bedside table prior to laying down supplies for wound care and failed to put a barrier down before placing foot on the heel boot after taking old bandage off of right heel. In addition, RN #3 picked up the 4x4 gauze she placed on top of a trash liner bag on bed and proceeded to squeeze the extra saline solution out before using on the resident's wound on the right heel. RN #3 then removed the dressing to sacral area. The removed dressing was contaminated with dark colored rings resembling stool stains, which contaminated the sacral wound with feces. Interview with RN #3 on 0[DATE]20 at approximately 9:30 AM revealed she did not use a barrier or clean the worktable, prior to putting down supplies for wound care. RN #3 stated she placed Resident #[AGE]'s heel down on the boot after taking soiled bandage off. She further stated she removed the 4x4 bandage off the trash bag she had placed on the bed prior to beginning the dressing changes to the right heel and used it on the heel wound. RN #3 revealed she failed to provide wound care according to professional standards of practice. Interview with Director of Nursing (DON) on 0[DATE] at 4:34 PM revealed she expected staff to use professional standards of practice when changing wound dressings to prevent infection. She stated this would include using barriers or cleaning workspace prior to laying supplies down on an unclean surface and using a barrier after taking the dressing off a resident's wound and before placing wound down on bedding or other unclean surface. She further revealed staff not using clean to dirty technique with the trash bag does not help to effectively treat and prevent or heal Pressure Ulcers.

Based on interview, record review and facility policy review it was determined the facility failed to make prompt efforts to resolve grievances the resident may have, for one (1) of three (3) sampled residents (Resident #1). Resident #1 and Resident #1's daughter revealed the daughter had expressed concerns to the Administrator and Director of Nursing (DON) that Certified Nurse Aides (CNA) #1 and #2 on night shift had a hateful attitude and did not like to take care of Resident #1. They stated the CNA's would rush the resident, and question why he/she frequently needed to go to the bathroom. In addition, the CNA's reported to the DON that they could not make the resident happy and thought they needed to provide care to Resident #1 in pairs, However, the DON failed to conduct an investigation to try to resolve the grievance per facility policy. The findings include: Review of facility policy titled, Handling of Grievances of Residents and Family Members, last revised (MONTH) (YEAR) revealed the policy is a process for handling grievances, complaints, and recommendations by a resident, family member, guardian, and/or a resident's committee. Procedure .The following steps shall be used as a guideline to ensure proper handling of verbal and/or written grievances, complaints, and/or recommendations on the for prompt resolution [NAME] Reporting: When a resident, resident representative, guardian, and or committee has a specific grievance, this shall immediately be directed to the attention of the Director of Nursing (DON) (designee) and or Social Services (SS) 1. Any employee aware of a resident grievance must notify the DON or SS immediately. 2. Residents, family members, guardians, and/or resident committees are encouraged to report any grievances directly to the DON and/or SS. Complaints may be submitted to the 5000 Quality Line to the Patient Satisfaction Coordinator (Universal Grievance Resolution Policy) B. Level one facility process: The DON or designee will actively investigate the grievance to seek a resolution including but not limited interviews with any witness or individual related to the grievance. In addition, the resident representative will be notified to participate in the active process to seek resolution of the grievance. If the DON and/or SS are not able to facilitate prompt resolution with the resident and family representative group, the Administrator will be notified. The facility will actively seek a scheduled meeting with resident, family and the facility Administrator C. Level two facility process: It shall be the Administrator's responsibility to schedule a conference with the resident and/or representative, obtain all facts and completely assess the situation D. Division of Licensure and Regulation Level: None of the above sections preludes the resident, family member, guardian, and/or resident's committee from reporting the grievance to the Division of Licensing and Regulations or the Social Security Administration E. Level of Filing: Residents family members, guardians, and/or committee may report grievances at any level. However, it is desirable that the outlined steps of this policy are followed. The state ombudsman can be notified at level one or two with any identified resident advocacy need or resident right concerns. Record review revealed the facility admitted Resident #1 on 12/06/17 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable. Interview with Resident #1 on 03/05/19 at 1:30 PM revealed about a month ago it took staff over an hour to answer the call light, and when the staff does not get here soon enough, she has accidents. He/she stated he/she had an accident last night because they did not get to him/her in time. Resident #1 further revealed there were two CNA's (CNA #1 and #2) that work night shift that do not want to help him/her. He/she stated he/she was not afraid of them but just do not think they treat him/her right. The resident revealed his/her daughter spoke to the facility about the concerns one (1) month ago so they were aware. He/she further stated, they never refuse to care for me but need to change their ways or not work here, or take care of me. Interview with Resident #1's daughter, on 03/05/19 at 10:15 AM, revealed she felt some of the CNA's are too rough with the elderly. She stated she had voiced her concerns with the Administrator and the Director of Nursing related to two (2) CNA's (CNA #1 and #2) on night shift that had a hateful attitude. She further revealed the only answers she got was they are short on help, and they never offered to change units so the two (2) CNA's did not have to care for her family member. Interview with CNA #1 on 03/05/19 at 4:30 AM revealed Resident #1 may ask them to slow down and she felt the resident wanted her to spend more time with him/her. She stated she has told the resident you just went to the bathroom when the resident asked to go to the bathroom. She revealed when she said this she was afraid maybe the resident was getting his/her [MEDICATION NAME] (diuretic) to late and the medication was making him/her need to go to the bathroom to often. Interview with CNA #2 on 03/05/19 at 4:45 PM revealed she denied ever being asked to slow down by Resident #1 or reminded the resident they had just gone to the bathroom. She revealed she just asked what was needed, then assisted with the need. Interview with the Unit Manager (UM) 03/06/19 at 9:10 AM revealed she was not aware of the concerns related to Resident #1 and CNA #1 and CNA #2. She stated she would have obtained more details, interviewed the resident, and intervened as needed if she was aware of the concern. Interview with the Director of Nursing (DON) on 03/05/19 at 5:00 PM revealed at one time, CNA #1 and CNA #2 had come to her stating nothing they did pleased Resident #1, and they felt it would be a good idea if they went in the room together. She stated she told them then that is what you need to do. Further interview with the DON on 03/06/19 at 8:15 PM, revealed she denied the daughter made her aware of any concerns and stated she did not talk to the resident or investigate any of the concerns. Interview with the Administrator on 03/06/19 at 9:20 AM revealed she was not aware there was a problem or would have investigated the situation, pulled the CNA's off that unit if needed and then put any found interventions on the care plan. She further revealed she expected any concerns related to resident's and staff be brought to her attention and to fix the concerns.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observation of the kitchen, on 12/05/18 and on 12/06/18, revealed there were no sanitation buckets with sanitation solution present, meat being thawed inappropriately, and dishes not stored properly. Review of the facility Census and Condition, dated 12/05/18, revealed ninety (90) of ninety-eight (98) residents received their meals from the kitchen. The findings include: 1. Review of facility policy Sanitizing Food Contact Surfaces, last revised (MONTH) (YEAR), revealed each work area shall be equipped with sanitizing solution. Observation of the kitchen on 12/04/18 at 3:33 PM, revealed no sanitation buckets in use or present with sanitizing solution. Interview with Dietary Aide #1 on 12/04/18 at 3:33 PM, revealed there were no sanitation buckets in use and they were all dumped out and she did not know they needed to be refilled for use. 2. Review of facility policy Storage of Pots, Dishes, Flatware, Utensils, last revised (MONTH) (YEAR), revealed pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pests or other means. It further stated to invert the top plate, bowel or any dish of any stacks of dishes. Observation of the kitchen on 12/04/18 at 3:36 PM, revealed stacks of bowls being stored on a multi-level rack cart, not inverted with white flaky material noted in the top bowls. 3. Review of facility policy Food Handling Guidelines, last revised (MONTH) (YEAR), revealed frozen meat, poultry or seafood is to be thawed under refrigeration, as part of the cooking process in a microwave, or under running water at a water temperature of 70 degrees Fahrenheit or below. Observation of the kitchen on 12/05/18 at 4:00 PM, revealed chicken breasts were being thawed under running steaming hot water in the sink. The Food Services Director checked the water at that time and confirmed the water was too hot to be used for thawing the chicken breasts. Interview with Director of Food and Nutrition Services on 12/06/18 at 12:33 PM, revealed sanitizing solution needed to be present in the buckets and in place in the kitchen for use. She stated bowls/dishes needed to be stored in an inverted manner and frozen meats should not be thawed under hot water but under cold or cool water. She also stated she expected the kitchen staff to follow facility policy and procedures.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure an ongoing program to support one (1) of twenty (20) sampled residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of the resident (Resident #4). The facility failed to provide resident centered one to one (1:1) activites to meet the interests and support the physical, mental, and psychological well-being of Resident #4. The findings include: Review of the facility policy titled, Activity Program last revised (MONTH) (YEAR), revealed the facility must provide services that will enhance the quality of life for each resident and the activity program provided must be appropriate to the needs and interests of the residents. Further review of the policy revealed one on one daily activities will be provided for all residents in the facility as needed. A daily participation record is maintained on each resident to reflect participation in the activity program. Record review revealed the facility admitted Resident #4 on 11/10/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data (MDS) assessment dated [DATE], revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) interview. Review of Resident #4's Comprehensive Plan of Care, dated 11/17/16 , revealed a focus area of the residents dependence on staff for meeting emotional, intellectual, physical, and social needs related to the residents requiring assistance with mobility, his/her decreased endurance to sit up in a wheelchair and to participate in events and his/her preferring to stay in his/her room and engaging in 1;1 discussions. The Goals included: maintain involvement in cognitive stimulation, participation in activities of choice 2-3 times weekly. Interventions to accomplish the goals included providing the resident with an activity calendar, 1:1 bedside/in-room visits and activities. Review of Resident #4's Activity Participation Roster, dated 11/01/18 through 12/11/18, revealed the resident received five (5) activity/socialization interactions during the forty-one (41) day report period. The activities included (5) 1:1 activities/visits. Observation on 12/05/18 at 9:04 AM, 10:31 AM, and 2:20 PM, revealed Resident #4 lying in bed, on left side, eyes closed. Observation on 12/06/18 at 9:54 AM, revealed Resident #4 lying in bed, eyes open, and no staff present. Interview with the Activity Coordinator on 12/06/18 at 9:28 AM, revealed there has been a new activity aide hired and Resident #4 does receive one to one visits in his/her room. She stated she failed to document the visits and is unable to recall how frequent the visits were. She further stated she would expect the documentation to reflect one to one visits per the residents care plan and as needed. Interview with Program Assistant #1 on 12/06/18 at 1:13 PM, revealed she is new to the position and responsible for conducting visits for Resident #4. She stated she failed to document the visits and was unable to recall how often she conducted the visits. Interview with the Manager of Specialty Services on 12/06/18 at 12:14 PM, revealed she had reviewed the Activity logs for Resident #4 and there were no regular documented one to one visits for Resident #4 for the last forty-one days. She stated all staff interact with the resident, however, could not recall how often. Interview with the Director of Nursing (DON) on 12/06/18 at 3:33 PM, revealed she expected all residents to be offered activities per the residents care plan. She stated she would expect the documetaion of activities to be complete.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure a resident does not develop pressure ulcers unless clinically unavoidable for one (1) of twenty (20) sampled residents {Resident #11}. Resident #11 was assessed at risk for skin breakdown with no care plan with intervention to prevent skin breakdown in place. On 06/22/18, Resident #11 was identified to have developed a Stage II pressure sore to his/her right outer ankle The findings include: Review of the facility's policy titled,Routine Skin Care and Pressure Ulcer Management, last revised (MONTH) (YEAR), revealed it is the facility's purpose to identify predisposing factors for pressure ulcer, evaluate clinical conditions and pressure ulcer risks factors, to provide guidelines for the prevention and treatment for [REDACTED]. Record review revealed the facility admitted Resident #11 on 03/29/18 with diagnoses which include Acute Kidney Failure, Legionnaires' Disease, Type two (2) Diabetes Mellitus without Complications, Unspecified Dementia without Behaviors, Hypertension, [MEDICAL CONDITION] with lower Urinary Symptoms, Cognitive Communication Deficit, Weakness, other Malaise and Anorexia. Review of admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #11 to be at risk for pressure ulcers according to Section M 0150. Review of the Comprehensive Care Plans for Resident #11 revealed there was no care plan developed for at risk for skin breakdown, Review of Wound-Weekly observation tool, dated 07/05/18, revealed the facility identified the resident had an acquired pressure sore on 06/22/2018 located on right outer ankle. The facility assessed the pressure sore to be a Stage II pressure ulcer measuring 2.5 centimeters (cm) by 2.1 cm. by 0.1 cm. Observations on 12/05/18 at 4:31 PM, of wound care provided for Resident #11, revealed the pressure area on the right outer ankle measured 1.1 cm by 0.7 cm x 0.0 cm. The area was cleansed with normal saline, and Mepliex border 4x4 dressing applied. Interview on 12/06/18 at 3:20 PM with Registered Nurse (RN) #1, revealed she had reviewed the medical record for Resident #11 in its entirety and was unable to locate any documentation of the initial skin assessment that was completed on 06/22/18, and was not sure of Resident #11's actual measurements. According to the clinical record the first documentation of the facility acquired was recorded on 07/05/18. RN #1 stated the facility went to Point Click Care charting system, and she was unable to locate the skin assessment for 06/22/18, to locate the measurements of the facility acquired pressure ulcer. RN #1 further revealed the resident was admitted with no pressure ulcers or skin conditions and she saw no diagnoses that would put him/her at risk for developing a pressure ulcer after admission, and she was unsure how the pressure area actually occurred. Interview with the Director of Nursing (DON) on 12/06/18 at 3:28 PM, revealed as the clinical director she saw no where in Resident #11's medical record where a stage two (2) pressure ulcer was avoidable. The DON stated Resident #11 has diabetes and the pressure ulcer is taking longer to heal than normal. The DON stated there was nothing in the medical record that would have indicated the resident was high risk for obtaining a pressure ulcer. She was unable to locate the initial wound assessment for the date on 06/22/18, and the wound nurse who completed the wound assessment was no longer an employee.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to ensure one (1) of (20) sampled residents received an accurate assessment, reflective of the resident's status at the time of the assessment (Resident #96). Resident #96 was admitted from another nursing home/swing bed, on 11/14/18, however, review of the Minimum Data Set (MDS) assessment. revealed staff inaccurately coded Section E of the Admission MDS Assessment as a 0, indicating Resident #'96's behavior was the same as compared to the previous assessment when there was no previous assessment. The findings include: Interview with Social Services on 12/06/18 at 3:26 PM, revealed she used the RAI manual for instructions on completing the MDS assessments for residents. Review of the RAI Version 3.0 User Manual on Coding instructions for E1100, Changes in Behavior or Other Symptoms, revealed prior to coding in this section all of the symptoms assessed in items E0100 through E 1000 should be considered. Further review of the instructions for Section E1100 revealed a 3 should be coded if there is no prior MDS assessment for comparison. Record review revealed the facility admitted Resident #96 on 11/14/18, with [DIAGNOSES REDACTED]. Review of Resident #96's Admission MDS Assessment, dated 11/21/18, revealed Section E1100 was coded 0, indicating the residents behaviors were the same. However, there was no prior MDS assessment for comparison. Further interview with Social Services on 12/06/18 at 3:26 PM, revealed she had made an error when coding Resident #96''s behaviors as being the same, as it should have been coded a three (3) because there was no prior assessment for comparison. Interview with the Director of Nursing (DON), on 12/06/18 at 3:33 PM, revealed she expected the resident assessments to be coded per the RAI manual.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty (20) residents received adequate supervision to prevent accidents (Resident #35). Resident #35 was assessed and care planned to require supervision/assistance of two (2) staff for transfers using a Viking Lift; however, observation on 12/05/18 revealed Certified Nurse Aide (CNA) #1 transferred the resident with a Viking Lift without the assistance of another staff. The findings include: Review of the facility policy titled, Lift, Mechanical, last revised (MONTH) 2011, revealed a mechanical lift is used to transfer residents who are unable to safely transfer by any other method. Further review of the policy revealed a minimum of two (2) staff members will be utilized to transfer residents while using a mechanical lift. Record review revealed the facility readmitted Resident #35 on 05/28/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Sets (MDS) assessment, dated 09/27/18, revealed the facility assessed Resident #35's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was interviewable. Further review of the MDS assessment revealed the facility assessed the resident required extensive assistance of two (2) staff for transfers. Review of Resident #35's Comprehensive Care Plan dated 05/22/18, revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit related to [MEDICAL CONDITION]. Further review of the care plan revealed a goal to improve current level of function in personal care through next review date with an intervention to transfer with a Hoyer lift with assist of two (2) staff with transfers. Observation on 12/05/18 at 9:08 AM, revealed Certified Nurse Aide (CNA) #1 transferred Resident #35 from the bed to his/her wheelchair with the use of a Hoyer lift without the assistance of a second staff member. Interview with CNA #1 on 12/15/18 at 1:47 PM, revealed she should have followed the care plan for the resident because the resident could have fallen. She stated it was easier to do it alone rather than wait for help. Interview with the Director of Nursing (DON) on 12/06/18 at 3:33 PM, revealed she would have expected the care plan to be followed as it is written. She stated CNA #1 was no longer employed by the facility.

Based on interview, record review and review of facility policy, it was determined the facility failed to develop or implement a comprehensive person-centered care plan for four (4) of twenty (20) sampled residents (Residents #11 #35, #4, and #96). The facility failed to provide one to one (1:1) activities consistently to Resident #4, and failed to ensure two (2) staff transferred Resident #35 using a Viking Lift on 12/05/18. In addition, the facility failed to create a care plan for pain for Resident #96. The findings include: Review of the facility policy titled, Person-Centered Care Plan, last revised (MONTH) (YEAR), revealed staff are expected to follow the plan of care for each resident. Further review of the policy revealed all residents will be assessed by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) and a baseline care plan will be devised from the resident assessment and interview, and history and physical. 1. Record review revealed the facility admitted Resident #4 on 11/10/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data (MDS) assessment dated [DATE], revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) interview. Review of Resident #4's Comprehensive Plan of Care, dated 11/17/16 , revealed Interventions to provide the resident with an activity calendar, and 1:1 bedside/in-room visits and activities. Review of Resident #4's Activity Participation Roster, dated 11/01/18 through 12/11/18, revealed the resident received five (5) activity/socialization interactions during the forty-one (41) day report period. The activities included (5) 1:1 activities/visits. Observation on 12/05/18 at 9:04 AM, 10:31 AM, and 2:20 PM, and on 12/06/18 at 9:54 AM revealed Resident #4 lying in bed, with no staff present. Interview with the Activity Coordinator on 12/06/18 at 9:28 AM, revealed there has been a new activity aide hired and Resident #4 does receive one to one visits in his/her room. She stated she failed to document the visits and is unable to recall how frequent the visits were. She further stated she would expect the documentation to reflect one to one visits per the resident's care plan and as needed. Interview with Program Assistant #1 on 12/06/18 at 1:13 PM, revealed she is new to the position and responsible for conducting visits for Resident #4. She stated she failed to document the visits and was unable to recall how often she conducted the visits. Interview with the Manager of Specialty Services on 12/06/18 at 12:14 PM, revealed she had reviewed the Activity logs for Resident #4 and there were no regular documented one to one visits for Resident #4 for the last forty-one days. She stated all staff interact with the resident, however, could not recall how often. Interview with the Director of Nursing (DON) on 12/06/18 at 3:33 PM, revealed she expected all residents to be offered activities per the residents care plan. She stated she would expect the documentation of activities to be complete. 2. Record review revealed the facility readmitted Resident #35 on 05/28/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Sets (MDS) assessment, dated 09/27/18, revealed the facility assessed Resident #35's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was interviewable. Further review of the MDS assessment revealed the facility assessed the resident required extensive assistance of two (2) staff for transfers. Review of Resident #35's Comprehensive Care Plan dated 05/22/18, revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit care plan with interventions to transfer with a Hoyer lift with assist of two (2) staff with transfers. However, observation on 12/05/18 at 9:08 AM, revealed Certified Nurse Aide (CNA) #1 transferred Resident #35 from the bed to his/her wheelchair with the use of a Hoyer lift without the assistance of a second staff member. Interview with CNA #1 on 12/15/18 at 1:47 PM, revealed she should have followed the care plan for the resident because the resident could have fallen. She stated it was easier to do it alone rather than wait for help. Interview with the DON, on 12/06/18 at 3:33 PM, revealed she would have expected the care plan to be followed as it is written. She stated CNA #1 was no longer employed by the facility. 3. Record review revealed the facility admitted Resident #96 on 11/14/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed Resident #96's cognition as intact with a Brief Interview for Mental Status (BIMS) score of eleven (11), indicating the resident was interviewable. Review of Resident #96's Pain Interview, dated 11/21/18. revealed Resident #96 experienced frequent pain within the last five days. Further review of the assessment revealed Resident #96 rated his/her pain intensity as a nine (9) on a scale of zero (0) to ten (10). However, review of Resident #96's care plan revealed no specific care plan for pain. Interview with the Minimum Data Set (MDS) coordinator #1 on 12/06/18 at 2:59 PM, revealed she had completed the pain interview for Resident #96, but failed to create a care plan for pain. She further stated Resident #96's pain was related to headaches and Tylenol was ordered on an as needed basis for any complaints of pain. Interview with the DON on 12/06/18 at 3:33 PM, revealed she would have expected a care plan to be created for Resident #96 related to pain based on the residents interview. 4. Record review revealed the facility admitted Resident #11 on 03/29/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated , 04/05/18, Section M0150, revealed Resident #11 was at risk of developing Pressure ulcer's; however, review of the Comprehensive Care Plan revealed the facility failed to develop a care plan to address the resident's risk for pressure sores. Review of Wound-Weekly observation tool, dated 07/05/18, revealed staff identified Resident #11 had a facility acquired pressure ulcer on 06/22/2018 and it was located on the right outer ankle. Further review of the observation tool revealed the pressure ulcer was Stage II and measured 2.5 centimeters (cm) by 2.1 (cm) by 0.1 (cm). Interview with Registered Nurse (RN) #1, on 12/06/18 at 3:20 PM after reviewing Resident #11's care plans revealed there was no care plan developed for risk for skin breakdown on admission. RN #1 stated a care plan was not developed until 06/22/18, when the resident acquired the area to his/her right (R) outer ankle. She further stated she was not the who developed care plans on admission; however, there should have been a skin integrity care plan developed. Interview on with MDS Coordinator#1, on 12/06/18 at 4:03 PM, revealed there was no initial care plan developed for resident for skin integrity. She stated there should have been one developed on admission and it was an over site when creating the admission care plans. Interview with the Director of Nursing (DON) on 12/06/18 at 3:28 PM, revealed as the clinical director she would have expected to see a skin integrity care plan created on admission for Resident #11.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure health information was maintained in a private and confidential manner for one (1) of twenty (20) sampled residents (Resident #37). On 12/05/18, Resident #37's Medication Administration Record [REDACTED]. The findings include: Review of the facility policy, Confidentiality, last revised 08/07/18, revealed the facility will use reasonable care to assure confidentiality and privacy of all Commonwealth Health Corporation information including data in Commonwealth Health Corporation information systems and data in paper records. Record review revealed the facility admitted Resident #37 on 08/06/18, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MD'S), dated 10/01/18, revealed the facility assessed Resident #37's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was interviewable. Observation, on 12/05/18 at 9:16 AM, revealed an unattended medication cart on C-Hall, in front of a resident's room. Further observation revealed Resident #37's MAR indicated [REDACTED]. Four (4) Certified Nurse Aides (CNA's) were observed to pass by the medication cart. Interview with Certified Med Tech (CMT) #1, on 12/05/118 at 9:20 AM, revealed she should not have left the resident's MAR pulled up on the computer screen, because health information should be kept confidential. Interview with the Director of Nursing (DON), on 12/06/18 at 3:33 PM, revealed she would have expected the computer screen containing confidential health information to be locked when staff are not present.

Based on interview, record review, and review of facility policy and procedure, it was determined the facility failed to ensure one (1) of three (3) sampled residents' was free from abuse (Resident #1). On 08/28/18 at 4:00 AM, Certified Nurse Aide (CNA) #7 witnessed CNA #8 physically and verbally abuse Resident #1. CNA #7 and CNA #6 reported the allegation to Registered Nurse (RN) #3 at approximately 4:20 AM; however, the RN failed to protect residents from further potential abuse by not immediately removing CNA #8 from resident care. CNA #8 continued to work until the end of her shift (7:30 AM-approximately three {3} hours later). The findings include: Review of facility policy titled, Suspected Abuse, Neglect, Exploitation and Misappropriation of Resident Property, last revised (MONTH) (YEAR), revealed each resident has the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes but not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. All incidents of suspected crimes are to be reported immediately to the Administrator, Director of Nursing or designee, the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located. All staff must report incidents or allegations of abuse, neglect, exploitation and misappropriation of property once discovered to the Administrator and Director of Nursing. The resident or residents will be protected by the immediate removal of the individual suspected of abuse, neglect, exploitation or misappropriation of property until the investigation is complete. Record review revealed the facility admitted Resident #1 on 11/28/17 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/20/18, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable Review of facility self report abuse allegation, dated 08/28/18, revealed it was alleged that when CNA #7 walked into the room to help care for Resident #1, and CNA #7 witnessed CNA #8 shouting at Resident #1 to stop hitting her and pushed the resident's hands away. CNA #8 proceeded to tell Resident #1 to stop urinating or she would cut his penis off. CNA #8 then jerked Resident #1's legs off the bed and took his/her hands and transferred Resident #1 into the wheelchair. CNA #7 asked another coworker {CNA #6} for assistance and Resident #1 was taken to the nurse's station, where RN #3 was made aware of the allegation. CNA #8 was not removed from resident care and the allegation was not reported or acted on until approximately 7:30 AM, when the DON reported to work. Interview with CNA #7 on 08/30/18 at 2:43 PM, revealed around 4:00 AM, CNA #8 yelled out to the nurse's station she needed help with Resident #1, and CNA #8 appeared pretty irritated with Resident #1. CNA #7 stated CNA #8 threw Resident #1's hand back toward his/her head, and started yelling I am going to cut your pecker off, if you do not stop peeing. She further stated CNA #8 then decided to go ahead and get Resident #1 up out of the bed to change the linen, and CNA #8 took Resident #1's feet and swung them back over the bed to the side, then jerked and yanked Resident #1's hands. CNA #7 revealed she told CNA #6 what she observed and CNA #6 went and placed Resident #1 in front of the nurse's station, then her and CNA #6 went and reported to what had taken place to RN #3. Interview with CNA #8 (alleged perpetrator) on 08/30/18 at 12:38 PM, revealed Resident #1 began hitting CNA #7 and herself at approximately 4:00 AM, and she asked Resident #1 to stop hitting them and told Resident #1 she wished she could turn his pee-er off. She stated it was just a general statement, because Resident #1 had peed everywhere and the bed was soaked with urine. She revealed she put Resident #1's hands into her hands, and Resident #1 jerked his/her hands away from her and became combative with care. She stated in hindsight she should have walked away and let the resident calm down but she was just trying to get the resident cleaned up. She revealed RN #3 was on duty and never spoke to her about Resident #1 and she continued to provide care on the unit until she clocked out at 7:30 AM on 08/30/18. Interview with CNA #6 on 08/30/18 at 5:54 PM, revealed she became aware about the concern around 4:00 AM, when CNA #7 came and told her what was going on with CNA #8 and Resident #1. She stated she immediately went to check on Resident #1, and Resident #1 was angry and yelled that [***] grabbed my hands. CNA #6 revealed she and CNA #7 immediately went and reported the incident to RN #3. Interview with Registered Nurse (RN) #3, on 08/30/18 at 1:29 PM revealed CNA #7 and CNA #6 came and reported the allegation of abuse to her around 4:20 AM. RN #3 stated, Frankly I did not believe CNA #7 or CNA #6, because I could not believe CNA #8 would do such a thing. RN #3 revealed she was in charge that night and did not remove CNA #8 from resident care, or report the allegation immediately to the Director of Nursing (DON). She stated, I was not aware an allegation of verbal or physical abuse was to be reported immediately, and where she worked previously verbal abuse was not required to be reported immediately, and only a definite confirmed abuse was reportable. Interview with RN #1, on 08/30/18 at 3:15 PM revealed at approximately 7:30 AM, RN #3 stated she needed to talk with her and told her she was not sure what had went on during the night, but CNA #7 and CNA #6, had told her that CNA #8 told Resident #1 if he/she did not stop peeing, she was going to cut his/her pecker off. RN #1 stated the CNA's said CNA #8 was really rough when transferring the resident into his/her wheelchair. RN #1 revealed she asked RN #3, have you told anyone about what was reported to you, and RN #3 stated she had already spoken to the Director of Nursing (DON). RN #3 stated after speaking with the DON, it was revealed RN #3 had not reported the allegation to the DON. Interview with the DON, on 08/30/18 at 4:57 PM revealed the facility determined CNA #8 abused Resident #1 and terminated the CNA. The DON stated RN #3 failed to immediately remove CNA #3 from resident care, and CNA #3 continued to provide resident care from approximately 4:00 AM until CNA #3 clocked out at 7:30 AM. The DON stated RN #3 failed to immediately notify her of the allegation of verbal and physical abuse, according to their policy. Interview with the Administrator on 08/30/18 at 3:41 PM, revealed the facility's investigation and interviews with all staff present the morning of 08/28/18 determined CNA #8 abused Resident #1; and, RN #3 failed to immediately remove CNA #3 from resident care, and failed to immediately notify the DON of the allegation of physical and verbal abuse. She stated she would have expected RN #3 to have followed their abuse and neglect policy.

Based on interview, record review, and review of facility policy and procedure, it was determined the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately for one (1) of three (3) sampled residents (Resident #1). On 08/28/18, Certified Nurse Aide (CNA) #7 observed CNA #8 physically and verbally abuse Resident #1. CNA #7 reported the allegation of abuse to CNA #6 at approximately 4:10 AM, who then reported the allegation to Registered Nurse (RN) #3 at 4:15 AM. However, RN #3 failed to report the allegation to the Director of Nursing (DON) until approximately 7:35 AM {approximately three {3} hours later}. The findings include: Review of facility policy titled, Suspected Abuse, Neglect, Exploitation and Misappropriation of Resident Property, last revised (MONTH) (YEAR) revealed all incidents of suspected crimes are to be reported immediately to the Administrator, Director of Nursing or designee, the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located. All staff must report incidents or allegations of abuse, neglect, exploitation and misappropriation of property once discovered to the Administrator and Director of Nursing. Record review revealed the facility admitted Resident #1 on 11/28/17 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/20/18, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Review of the facility investigation dated 08/28/18 and interviews on 08/30/18 with CNA #7 at 2:43 PM, and CNA #6 at 5:54 PM, revealed CNA #7 walked into the room to help care for Resident #1, and witnessed CNA #8 shouting at Resident #1 to stop hitting her and she pushed the reisdnet's hands away. CNA #8 proceeded to tell Resident #1 to stop urinating or she would cut his penis off. CNA #8 then jerked Resident #1's legs off the bed and jerked his/her hands and transferred Resident #1 into the wheel chair. CNA #7 asked another coworker {CNA #6} for assistance and Resident #1 was taken to the nurse's station, where RN #3 was made aware of the allegation. RN #3 did not report the allegation of abuse until approximately 7:30 AM, when the DON reported to work. Interview with Registered Nurse (RN) #3, on 08/30/18 at 1:29 PM revealed CNA #7 and CNA #6 came and reported to her about the allegation between CNA #8 and Resident #1 around 4:20 AM. She stated Frankly I did not believe CNA #7 or CNA #6, because she could not believe CNA #8 would do such a thing. RN #3 revealed she was in charge that night and did not report the allegation immediately to the Director of Nursing (DON). She stated, she was not aware an allegation of verbal or physical abuse was to be reported immediately and where she had worked at previously, verbal abuse was not required to be reported immediately, and only a definite confirmed abuse was reportable. Interview with RN #1, on 08/30/18 at 3:15 PM revealed at approximately 7:30 AM, RN #3 told her CNA #7 and CNA #6 reported CNA #8 told Resident #1 if he/she did not stop peeing, CNA #8 was going to cut his/her pecker off. RN #1 stated RN #3 said CNA #7 stated CNA #8 was really rough when transferring Resident #1 to the wheelchair. RN #1 revealed she asked RN #3 have you told anyone about the allegation, and RN #3 stated she told the DON; however, RN #3 had not reported the allegation to the DON. Interview with the DON, on 08/30/18 at 4:57 PM revealed according to the facility policy, RN #3 should have immediately called her to report the allegation of verbal and physical abuse. Interview with the Administrator on 08/30/18 at 3:41 PM, revealed according to the facility policy she would have expected RN #3 to have immediately removed called the DON regarding the allegation of verbal and physical abuse.

Based on interview, record review, and review of the facility policy titled Suspected Abuse, Neglect, Exploitation and Misappropriation of Resident Property, it was determined the facility failed to implement written policies and procedures to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately and the immediate removal of the individual suspected of abuse for one (1) of three (3) sampled residents (Resident #1). On 08/28/18 at approximately 4:00 AM, Certified nurse Aide (CNA) #7 observed and heard CNA #8 physically and verbally abuse Resident #1. CNA #7 reported the allegation of abuse to CNA #6 at approximately 4:10 AM, who then reported the allegation to Registered Nurse (RN) #3 at 4:15 AM. However, RN #1 failed to remove CNA #8 immediately from resident care, and failed to report the allegation immediately to the Director of Nursing (DON) per facility policy. RN #3 told RN #1 of the allegation at approximately 7:30 AM (approximately three {3} hours later) and RN #1 reported the allegation to the DON. The findings include: Review of facility policy titled, Suspected Abuse, Neglect, Exploitation and Misappropriation of Resident Property, last revised (MONTH) (YEAR) revealed all incidents of suspected crimes are to be reported immediately to the Administrator, Director of Nursing or designee, the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located. All staff must report incidents or allegations of abuse, neglect, exploitation and misappropriation of property once discovered to the Administrator and Director of Nursing. The resident or residents will be protected by the immediate removal of the individual suspected of abuse, neglect, exploitation or misappropriation of property until the investigation is complete. Record review revealed the facility admitted Resident #1 on 11/28/17 with [DIAGNOSES REDACTED]. Review of the facility investigation dated 08/28/18 and interviews on 08/30/18 with CNA #7 at 2:43 PM, and CNA #6 at 5:54 PM, revealed CNA #7 walked into the room to help care for Resident #1, and witnessed CNA #8 shouting at Resident #1 to stop hitting her and she pushed his hands away. CNA #8 proceeded to tell Resident #1 to stop urinating or she would cut his penis off. CNA #8 then jerked Resident #1's legs off the bed and jerked his/her hands and transferred Resident #1 into the wheel chair. CNA #7 asked another coworker {CNA #6} for assistance and Resident #1 was taken to the nurse's station, where RN #3 was made aware of the allegation. RN #3 did not remove CNA #8 from resident care and the allegation was not reported or acted on until approximately 7:30 AM, when the DON reported to work. Interview with Registered Nurse (RN) #3, on 08/30/18 at 1:29 PM revealed CNA #7 and CNA #6 came and reported to her about the allegation between CNA #8 and Resident #1 around 4:20 AM. RN #3 stated, Frankly I did not believe CNA #7 or CNA #6, because she could not believe CNA #8 would do such a thing. RN #3 revealed she was in charge that night and she did not remove CNA #8 from resident care, nor did she report the allegation immediately to the Director of Nursing (DON). She stated, I was not aware an allegation of verbal or physical abuse was to be reported immediately, and where she had worked previously verbal abuse was not required to be reported immediately, and only a definite confirmed abuse was reportable. Interview on 08/30/18 at 3:15 PM with RN #1, revealed approximately 7:30 AM, RN #3 revealed she needed to talk with her, RN#3 said, she was not sure what had went on during the night, but CNA #7 and CNA #6, told RN #3, that CNA #8 told Resident #1 if he/she did not stop peeing, CNA#8 was going to cut his/her pecker off, and was really rough when transferring the resident. RN #1 asked RN #3 have you told anyone about the allegation, and she thought RN #3 had already spoken to RN #3. However, RN #3 had not reported the allegation to the DON. Interview with the DON, on 08/30/18 at 4:57 PM revealed RN #3 RN #3 should have immediately removed CNA #8 from resident care, and immediately called her to report the allegation per the facility policy. Interview with the Administrator on 08/30/18 at 3:41 PM, revealed according to the facility's policy and procedures she would have expected RN #3 to have immediately removed CNA #3 from resident care, and immediately called the DON regarding the allegation of verbal and physical abuse.

Based on observation, interview, review of the facility's policy and procedure/inservices, and review of the Administrator's job description revealed the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being. The Administrator failed to ensure the facility had detailed written plans and procedures that addressed the mechanisms used to unlock doors so that facility's staff could evacuate residents in the event of an emergency or disaster. The Administrator failed to ensure staff was trained and procedures were periodically reviewed with staff related to the use of these mechanisms to unlock the emergency exit doors in the event of an emergency or disaster. In addition, the Administrator failed to follow Life Safety Code procedures to ensure staff was able to readily unlock emergency exit doors at all times for means of egress. The failure of the Administrator to ensure staff was able to unlock the emergency exit doors to evacuate residents timely, in the event of an emergency or disaster is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/31/12 and determined to exist on 07/31/12. An acceptable AoC was received on 08/03/12. The AoC was verified on 08/03/12 and it was determined the Immediate Jeopardy was removed on 08/02/12, as alleged in the AoC. The S/S was lowered to a "F", based on the facility's need to continue to evaluate the implementation of changes and quality assurance activities. Refer to F517 and F518. Findings include: A review of the Vice President/Administrator's job description, last revised 01/2011, revealed the Administrator should work collaboratively with department heads and clinical managers to identify and optimize opportunities for improvements at the long term care facility and conduct disaster preparation demonstrating knowledge and understanding of assigned roles and responsibilities. Observations of all four exit doors with Facility Manager revealed they were in lock down mode which prevented emergency egress through the door in the event of an emergency requiring evacuation. Observations on 07/31/12 at 4:30 PM, 4:43 PM, 4:50 PM and 4:53 PM, revealed one staff's (Facility Manager) badge failed and several staff did not have their badge on their person. Four staff was unsuccessful in immediately unlocking the exit doors upon request to demonstrate their ability to assist in egress and evacuation. Interviews with nine staff including the Clinical Educator who trains staff revealed the staff was not knowledgeable of the pass code. A review of the Emergency Operation Plan and Emergency Management Plan revealed they were last reviewed on 01/2012; however, there was no evidence the plans detailed the locking mechanism on the doors, that the doors were maintained in lock down, or the mechanisms used to unlock the doors. Furthermore, interview with the Administrator, on 08/01/12 at 2:45 PM, revealed he was not aware the facility's emergency plans and procedures did not address the use of a pass code to ensure staff were able to evacuate residents in the event of an emergency or disaster. Additionally, interview with the Clinical Educator, revealed he trained new employees on the emergency system but was unaware of the pass code. Interview with the Administrator revealed he was not aware the staff were not trained on the bypass code for the emergency exit doors. He was aware there were no competency checks completed with staff to ensure they were able to bypass the locked emergency exit doors. He revealed the staff would not be able to open the emergency exit doors timely if the staff did not have functioning name badges or if the alarm system was not functioning appropriately. The facility submitted an acceptable Allegation of Compliance on 08/02/12 which alleged the removal of Immediate Jeopardy on 08/01/12. The State Agency verified Immediate Jeopardy was removed on 08/02/12, through the following review: Interviews with the Vice President of Facilities and the Administrator, on 08/02/12 at 4:25 PM and 4:33 PM, revealed they investigated and determined the exit doors could be placed in an unlocked status and if the Roam Alert Status was activated to lock the doors that staff could use their badge swipe, pass code, or fire alarm to bypass the locking mechanism on 07/31/12. Observations of the emergency exit doors and interview with the Facility Manager, on 08/02/12 at 5:12 PM, revealed: 1) the locking function of the exit doors was changed to being unlocked at all times on 07/31/12. 2) A standardized bypass code was programmed in the exit doors for all staff to use in cases where the Roam Alert system becomes active and there is a need to unlock the door. 3)The Engineering Staff initiated checking to ensure the standardized code would unlock the doors when the Roam Alert system was activated on 07/31/12. This function will continue daily through 08/05/12, then weekly thereafter. 4) the Engineering staff initiated testing of the fire alarm system to ensure the doors were unlocked in cases of fire alarms or power failures. This will continue daily through 08/05/12 and three times a month thereafter. A review of the Fire Alarm Function Monitoring, Pass code Function Monitoring and Badge Swipe Function Monitoring forms revealed the checks were completed daily from 08/01/12 to 08/03/12 (last day of survey). Interview with the Clinical Educator, on 08/02/12 at 5:27 PM, revealed he initiated training of all staff in the building, on 07/31/12, on how to use the badge swipe, new standardized pass code and fire alarm pull station to bypass the Roam Alert locking mechanism. This included the revisions to the Roam Alert and Wander Risk precautions policies and procedural guidelines regarding the standardized pass code. All staff not present would be educated before working their next scheduled shift. He also revealed he updated the new employee orientation on 07/31/12, to include the new standardized pass code. He stated he developed a computer based learning module for ongoing staff competency training. This material was distributed to all staff on 07/31/12 and will be completed by all staff prior to their next scheduled shift. A review of the inservice documentation, dated 07/31/12 and 08/01/12, revealed all staff were trained on how to use the badge swipe, new standardized pass code and fire alarm pull station to bypass the Roam Alert locking mechanism. A review of the Roam Alert System policy and procedure, last revised 07/2012, revealed it was revised to include to exit the facility by an outside door, swipe you badge and push the door open at the handle, the doors can be deactivated by a badge swipe, entering the pass code, or pulling the fire alarm station to exit and push the door open at the handle, and if you obtain a new badge, notify engineering before working your scheduled shift. Observations and interviews with RN #2, LPN #2, LPN #3, Housekeeper #4 and #6, CNA #3, CNA #8 and a Unit Clerk, on 08/02/12 at 7:00 PM, 7:10 PM, 7:15 PM, and 7:20 PM, and on 08/03/12 at 9:42 AM, 9:47 AM, 9:50 AM and 9:55 AM, respectively, revealed they were able to open the emergency exit doors with their name badges and with the pass code. The staff revealed they received inservicing and computer module training related to exiting the emergency exit doors with their badges, pass code and fire alarm. The staff stated Administration also had them demonstrate that they were able to open the doors with the pass code and name badge. Interview with the Director of Nursing, Assistant Director of Nursing, and Clinical Educator, on 08/02/12 at 12:30 PM, 5:27 PM and 6:27 PM, respectively, revealed all scheduled staff completed a return demonstration competency on how to bypass locked doors prior to working. All remaining employees will do a return demonstration prior to working the next scheduled shift. A review of 2012 Competency Program Attendance Records, dated 08/01/12, revealed all staff demonstrated the use of the name badge and pass code to bypass the roam alert locking mechanism. The Clinical Educator stated he revised the initial competency tool and the Facilities Manager revised the Hazardous Surveillance tool to assess staff's ongoing competency using the new standardized pass code. A review of the Initial Placement Competency Assessment and and Hazard Surveillance Tool revealed the tools included a competency to use employee badge and pass code to bypass the Roam Alert locking mechanism. The staff revealed if an employee failed to demonstrate competency in using the badge swipe, pass code, and fire alarm, the employee will be removed from long term care. Based on the above observations, interviews and documentation reviews, it was determined the Immediate Jeopardy was removed, effective 08/02/12, with the scope and severity lowered to a "F."

Based on observation, interview, and review of facility's policy and procedures, it was determined the facility failed to have a detailed written plan and procedure to meet all potential emergencies and disasters. The facility's policy and procedure failed to detail the exit door lock down system and did not address the mechanisms utilized to unlock the door (badge/pass code) in the event of an emergency requiring evacuation. The facility's review of the policy dated 01/2012 failed to identify this as a concern. One staff was observed having six minutes of failed attempts to exit the facility; as his badge was not functional. Two staff was observed without their badge having no knowledge of the pass code and were unable to immediately open the door. Interviews with nine staff revealed they were not aware of a pass code to bypass to bypass the locks on the emergency exit doors if their name badges were not available or did not function. A review of the Census and Condition, dated 07/31/12, revealed there were 107 residents in the building. The facility's failure to have a detailed written plan and procedure to address the mechanisms used to unlock emergency exit doors so that facility staff could evacuate residents in the event of an emergency or disaster is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/31/12 and determined to exist on 07/31/12. An acceptable AoC was received on 08/03/12. The AoC was verified on 08/03/12 and it was determined the Immediate Jeopardy was removed on 08/02/12, as alleged in the AoC. The S/S was lowered to a "F", based on the facility's need to continue to evaluate the implementation of changes and quality assurance activities. Findings include: A review of the facility's Emergency Operation Plan and Emergency Management Plan, last reviewed on 01/2012, and review of the Roam Alert System policy and procedure, last revised 06/2007, revealed the plans and policy and procedure did not detail the mechanisms in place to bypass the locked emergency exit doors in the event of an emergency or disaster and the need to evacuate residents. Observation on 07/31/12 between 4:30 PM and 5:00 PM revealed the four emergency exit doors doors located in the long term care facility were locked and could not be opened. Interview with the Facility Manager, on 07/31/12 at 4:40 PM, revealed the four emergency exit doors on the Long Term Care Unit (buildings 4 and 5) were kept locked and staff was required to utilize their badge or the pass code to unlock the doors for emergency evacuation. An observation of the Facility Manager, on 07/31/12 at 4:30 PM, revealed he attempted to exit the emergency exit door on the north side of building 4 and his badge failed to open the exit door. He tried to enter a pass code but was unable to get the door to open. He tried to use another employee's badge and was able to open the door with the badge. It took approximately six minutes for the Facility Manager to finally exit the building. Interview, on 07/31/12 at 4:40 PM, with the Facility Manager, revealed he was aware the security badge would open the door but he thought the MRI machine must have deleted his badge and caused it not to work. He revealed he did not know the pass code to open the door. Further observation with the Facility Manager, on 07/31/12 at 4:43 PM, revealed Registered Nurse (RN) #1 attempted to exit the north emergency exit door of building 4 without using her employee badge. She attempted to push the door open but was unable to open the door. She did not attempt to enter a pass code to exit the building. The Facility Manager instructed RN #1 to use her employee badge to open the door. RN #1 did not have her employee badge with her as she had left it on her medication cart. She retrieved the badge and was able to unlock the door and exit the building using the badge. Interview, on 08/01/12 at 1:38 PM with RN #1, revealed she was knew her employee badge would open the emergency exit doors. She stated she was trained, when the system was installed several years ago, on how to use the badge to exit the door. She revealed she was not aware of a pass code to open the door in case the badge failed to open the door. Continued observation with the Facility Manager, on 07/31/12 at 4:50 PM, revealed Certified Nurse Aide (CNA) #1 did not have her badge and was not aware of a pass code to open and exit the south emergency exit door in building 5. Interview, on 08/01/12 at 2:06 PM with CNA #1, revealed she had not been educated that her employee badge would open the emergency exit doors and had not been educated on a pass code that would open the doors. Continued observation with the Facility Manager, on 07/31/12 at 4:55 PM, revealed Licensed Practical Nurse (LPN) #1, attempted to exit the south emergency exit door of building 5 by swiping her name badge then repeatedly tried to push the door open, unsuccessfully. The Facility Manager had to slam the door hard to get it to open. Interview, on 08/01/12 at 1:30 PM with LPN #1, revealed the only time she was trained on how to use her name badge to open the door was when she was hired back in April 2006. She stated she was not aware the door was stuck and that she had to press harder on the door. Interviews with the Facility Manager, RN #1, RN #2, LPN #1, LPN #7, CNA #1, CNA #12, CNA #15 and CNA #17, on 07/31/12 at 4:30 PM and 4:40 PM, on 08/01/12 at 10:25 AM, 10:30 AM, 10:45 AM, 11:30 AM, 1:30 PM, 1:38 PM and 3:50 PM, respectively, revealed they were not aware of a pass code to bypass the locked emergency exit doors if they did not have their badges or their badges did not function appropriately. Interview with the Clinical Educator, on 08/01/12 at 12:09 PM, revealed he was trained upon his hire on how to operate the emergency exit doors with his employee badge and the pass code system. He stated he thought his employee id number was the pass code, but he was not sure of that. He stated he does the training of the new employees in their orientation. Interview with the Administrator, on 08/01/12 at 2:45 PM, revealed he was not aware the facility's emergency plans and procedures did not address the use of a pass code to ensure staff were able to evacuate residents in the event of an emergency or disaster. He was not aware the staff were not trained on the bypass code for the emergency exit doors. He was aware there were no competency checks completed with staff to ensure they were able to bypass the locked emergency exit doors. He revealed the staff would not be able to open the emergency exit doors timely if the staff did not have functioning name badges or if the alarm system was not functioning appropriately. The facility submitted an acceptable Allegation of Compliance on 08/02/12 which alleged the removal of Immediate Jeopardy on 08/01/12. The State Agency verified Immediate Jeopardy was removed on 08/02/12, through the following review: Interviews with the Vice President of Facilities and the Administrator, on 08/02/12 at 4:25 PM and 4:33 PM, revealed they investigated and determined that the exit doors could be placed in an unlocked status and if the Roam Alert Status was activated to lock the doors that staff could use their badge swipe, pass code, or fire alarm to bypass the locking mechanism on 07/31/12. Observations of the emergency exit doors and interview with the Facility Manager, on 08/02/12 at 5:12 PM, revealed: 1) the locking function of the exit doors was changed to being unlocked at all times on 07/31/12. 2) A standardized bypass code was programmed in the exit doors for all staff to use in cases where the Roam Alert system becomes active and there is a need to unlock the door. 3)The Engineering Staff initiated checking to ensure the standardized code would unlock the doors when the Roam Alert system was activated on 07/31/12. This function will continue daily through 08/05/12, then weekly thereafter. 4) the Engineering staff initiated testing of the fire alarm system to ensure the doors were unlocked in cases of fire alarms or power failures. This will continue daily though 08/05/12 and three times a month thereafter. A review of the Fire Alarm Function Monitoring, Pass code Function Monitoring and Badge Swipe Function Monitoring forms revealed the daily checks had been initiated and completed on 08/01/12 and continued. Interview with the Clinical Educator, on 08/02/12 at 5:27 PM, revealed he initiated training of all staff in the building, on 07/31/12, on how to use the badge swipe, new standardized pass code and fire alarm pull station to bypass the Roam Alert locking mechanism. This included the revisions to the Roam Alert and Wander Risk precautions policy and procedural guidelines regarding the standardized pass code. All staff not present would be educated before working their next scheduled shift. He also revealed he updated the new employee orientation on 07/31/12, to include the new standardized pass code. He stated he developed a computer based learning module for ongoing staff competency training. This material was distributed to all staff on 07/31/12 and will be completed by all staff prior to their next scheduled shift. A review of the inservice documentation, dated 07/31/12 and 08/01/12, revealed all staff was trained on how to use the badge swipe, new standardized pass code and fire alarm pull station to bypass the Roam Alert locking mechanism. A review of the Roam Alert System policy and procedure, last revised 07/2012, revealed it was revised to include: to exit the facility by an outside door, swipe your badge and push the door open at the handle, the doors can be deactivated by a badge swipe, entering the pass code, or pulling the fire alarm station to exit and push the door open at the handle, and if you obtain a new badge, notify engineering before working your scheduled shift. Observations and interviews with RN #2, LPN #2, LPN #3, Housekeeper #4 and #6, CNA #3, CNA #8 and a Unit Clerk, on 08/02/12 at 7:00 PM, 7:10 PM, 7:15 PM, and 7:20 PM, and on 08/03/12 at 9:42 AM, 9:47 AM, 9:50 AM and 9:55 AM, respectively, revealed they were able to open the emergency exit doors with their name badges and with the pass code. The staff revealed they received inservicing and computer module training related to exiting the emergency exit doors with their badges, pass code and fire alarm. The staff stated Administration also had them demonstrate that they were able to open the doors with the pass code and name badge. Interview with the Director of Nursing, Assistant Director of Nursing, and Clinical Educator, on 08/02/12 at 12:30 PM, 5:27 PM and 6:27 PM, respectively, revealed all scheduled staff completed a return demonstration competency on how to bypass locked doors prior to working. All remaining employees will do a return demonstration prior to working the next scheduled shift. A review of 2012 Competency Program Attendance Records, dated 08/01/12, revealed all staff demonstrated the use of the name badge and pass code to bypass the roam alert locking mechanism. The Clinical Educator stated he revised the initial competency tool and the Facilities Manager revised the Hazardous Surveillance tool to assess staff's ongoing competency using the new standardized pass code. A review of the Initial Placement Competency Assessment and and Hazard Surveillance Tool revealed the tools included a competency to use employee badge and pass code to bypass the Roam Alert locking mechanism. The staff revealed if an employee failed to demonstrate competency in using the badge swipe, pass code, and fire alarm, the employee will be removed from long term care. Based on the above observations, interviews and documentation reviews, it was determined the Immediate Jeopardy was removed, effective 08/02/12, with the scope and severity lowered to a "F."

Based on observation, interview, and review of the facility's policy and procedure and inservices, it was determined the facility failed to train staff when hired on the pass code to bypass the locked emergency exit doors. In addition, the facility failed to periodically review the procedures with staff related to the mechanisms to unlock the emergency exit doors in the event of an emergency or disaster. Observations of four staff revealed they were unable to immediately exit the emergency exit doors using their name badges and were not aware of the pass code to bypass the locked emergency doors. Staff was observed with failing badges on their person and/or no knowledge of the pass code to unlock the exit door. Nine staff had no knowledge of the pass code to open the emergency exit doors in the event they did not have their name badge of the name badge was not functional. Furthermore, the Clinical Educator, who was responsible for training staff, was not knowledgeable of the pass code to unlock the door in the event of an emergency. The facility's failure to train staff related to the mechanisms to bypass the locked emergency exit doors in the event of an emergency or disaster is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/31/12 and determined to exist on 07/31/12. An acceptable AoC was received on 08/03/12. The AoC was verified on 08/03/12 and it was determined the Immediate Jeopardy was removed on 08/02/12, as alleged in the AoC. The S/S was lowered to a "F", based on the facility's need to continue to evaluate the implementation of changes and quality assurance activities. Findings include: Observation, on 07/31/12 at 4:30 PM, with the Facilities Manager and the Administrator, revealed the emergency exit doors at the north and south exits of buildings 4 and 5 were locked and there were Velcro stop signs placed in front of the doors. Interview with the Facility Manager, on 07/31/12 at 4:40 PM, revealed the four emergency exit doors on the Long Term Care Unit (buildings 4 and 5) were kept locked and staff was required to utilize their badge or the pass code to unlock the doors for emergency evacuation. The Facility Manager demonstrated how the doors worked at the northwest exit door. He swiped his badge; however, the badge failed to open the exit door. He then tried to enter a pass code but still could not get the door to open. He got another employee's badge, and was able to open the door with the badge. Approximately six minutes passed during the Facility Manager's attempts to try to unlock the door for exit before he was successful. An interview with the Facility Manager, on 07/31/12 at 4:40 PM, revealed he was aware the security badge would open the door but was not aware of the pass code to open the door. Observation of Registered Nurse (RN) #1, on 07/31/12 at 4:43 PM, revealed she came to the exit door without her employee badge. She tried several times to push the door open; however, she did not try to enter a pass code or use her badge to exit the building. The Facilities Manager told RN #1 to use her employee badge. She retrieved the badge from her medication cart and was then able to exit the building. Interview with RN #1, on 08/01/12 at 1:38 PM, revealed she was aware that she needed to have her badge to exit the building. She stated it had been a while since she had any kind of training on the exit doors. She was trained briefly when the system was installed on how to use the badge to exit the door but was unaware of a pass code to open the door in case the badge failed to open the door. Observation of Certified Nurse Aide (CNA) #1, on 07/31/12 at 4:50 PM, revealed she was unable to open the exit doors and did not try to operate the exit door at the South West exit. Interview with CNA #1, on 08/01/12 at 2:06 PM, revealed she was unaware of how to open the door using her badge or the pass code. She stated she was unaware the badge was required to open the exit doors. Observation of Licensed Practical Nurse #1, on 07/31/12 at 4:53 PM, revealed she walked up to the exit door, swiped her badge at the reader and then tried several times to push the door open. Once she stopped trying, the Facility Manager had to slam hard on the door to get it to open. Interview with LPN #1, on 08/01/12 at 10:25 AM and 1:30 PM, revealed she was aware to use her badge to exit the building. She stated she was trained on this during her new hire orientation back in April of 2006. She did not know that the door was stuck and that she just needed to press harder on the door. She stated there had been no training since her hire date on exiting the building through the egress doors. She further revealed she was unaware of the pass code to unlock the exit door. Interview with RN #2, LPN #7, CNA #15, CNA #17 and CNA #12, on 08/01/12 at 10:25 AM, 10:30 AM, 10:45 AM, 11:30 AM and 3:50 PM, respectively, revealed the staff was not aware of a code to open the emergency exit doors in case their badges did not work. CNA #12 had no recollection of an inservice on how to exit the door prior to the inservice on 07/31/12. RN #2 stated she was only aware that swiping the badge should allow you access to exit the doors and stated the facility had yearly inservices. Interview with the Director of Nursing, on 08/02/12 at 11:30 AM, revealed she was the Clinical Educator when the locked down system was placed on the emergency exit doors of the facility. She stated staff was trained on the use of their badges to bypass the locked doors when the system was initiated. She stated she thought another mechanism to bypass the doors was staff could punch in their employee identification numbers, but she was not sure if the employees were ever made aware of their identification numbers. The only inservicing she was aware of was conducted when the system was installed and when new staff were hired. She was not aware of any periodic training with staff related to using their name badges and pass codes to exit the building through the emergency exit doors. Interview with the Clinical Educator, on 08/01/12 at 12:09 PM, revealed he was trained upon his hire in 2009 on how to operate the exit doors with his employee badge and the pass code system. He stated he thought his employee identification number was the pass code, but he was not sure of that and he did not recall if he was given his employee identification number. He stated he does the training of the new employees in their orientation but has never given them their employee identification number. He also stated the only training completed with staff related to exiting the emergency exit door was during orientation when staff were hired. Further interview revealed when he trained employees during the training yesterday he identified there were some employee badges that did not open the emergency exit doors. Interview with the Administrator, on 08/01/12 at 3:44 PM, revealed the education staff trained new hires on the use of their identification badges to bypass the locked emergency exits at employee orientation. He was not aware of any ongoing education related to the use of the identification badges or pass code to exit the building. The facility submitted an acceptable Allegation of Compliance on 08/02/12 which alleged the removal of Immediate Jeopardy on 08/01/12. The State Agency verified Immediate Jeopardy was removed on 08/02/12, through the following review: Interview with the Vice President of Facilities and the Administrator, on 08/02/12 at 4:25 PM and 4:33 PM, revealed they investigated and determined that the exit doors could be placed in an unlocked status and if the Roam Alert Status was activated to lock the doors that staff could use their badge swipe, pass code, or fire alarm to bypass the locking mechanism on 07/31/12. Observations of the emergency exit doors and interview with the Facility Manager, on 08/02/12 at 5:12 PM, revealed: 1) the locking function of the exit doors was changed to being unlocked at all times on 07/31/12. 2) A standardized bypass code was programmed in the exit doors for all staff to use in cases where the Roam Alert system becomes active and there is a need to unlock the door. 3)The Engineering Staff initiated checking to ensure the standardized code would unlock the doors when the Roam Alert system was activated on 07/31/12. This function will continue daily through 08/05/12, then weekly thereafter. 4) the Engineering staff initiated testing of the fire alarm system to ensure the doors were unlocked in cases of fire alarms or power failures. This will continue daily though 08/05/12 and three times a month thereafter. A review of the Fire Alarm Function Monitoring, Pass code Function Monitoring and Badge Swipe Function Monitoring forms revealed the checks were completed daily from 08/01/12 to 08/03/12 (last day of survey). Interview with the Clinical Educator, on 08/02/12 at 5:27 PM, revealed he initiated training of all staff in the building, on 07/31/12, on how to use the badge swipe, new standardized pass code and fire alarm pull station to bypass the Roam Alert locking mechanism. This included the revisions to the Roam Alert and Wander Risk precautions policies and procedural guidelines regarding the standardized pass code. All staff not present would be educated before working their next scheduled shift. He also revealed he updated the new employee orientation, on 07/31/12, to include the new standardized pass code. He stated he developed a computer based learning module for ongoing staff competency training. This material was distributed to all staff on 07/31/12 and will be completed by all staff prior to their next scheduled shift. A review of the inservice documentation, dated 07/31/12 and 08/01/12, revealed all staff were trained on how to use the badge swipe, new standardized pass code and fire alarm pull station to bypass the Roam Alert locking mechanism. A review of the Roam Alert System policy and procedure, last revised 07/2012, revealed it was revised to include to exit the facility by an outside door, swipe you badge and push the door open at the handle, the doors can be deactivated by a badge swipe, entering the pass code, or pulling the fire alarm station to exit and push the door open at the handle, and if you obtain a new badge, notify engineering before working your scheduled shift. Observations and interviews with RN #2, LPN #2, LPN #3, Housekeeper #4 and #6, CNA #3, CNA #8 and a Unit Clerk, on 08/02/12 at 7:00 PM, 7:10 PM, 7:15 PM, and 7:20 PM, and on 08/03/12 at 9:42 AM, 9:47 AM, 9:50 AM and 9:55 AM, respectively, revealed they were able to open the emergency exit doors with their name badges and with the pass code. The staff revealed they received inservicing and computer module training related to exiting the emergency exit doors with their badges, pass code and fire alarm. The staff stated Administration also had them demonstrate that they were able to open the doors with the pass code and name badge. Interview with the Director of Nursing, Assistant Director of Nursing, and Clinical Educator, on 08/02/12 at 12:30 PM, 5:27 PM and 6:27 PM, respectively, revealed all scheduled staff completed a return demonstration competency on how to bypass locked doors prior to working. All remaining employees will do a return demonstration prior to working the next scheduled shift. A review of 2012 Competency Program Attendance Records, dated 08/01/12, revealed all staff demonstrated the use of the name badge and pass code to bypass the roam alert locking mechanism. The Clinical Educator stated he revised the initial competency tool and the Facilities Manager revised the Hazardous Surveillance tool to assess staff's ongoing competency using the new standardized pass code. A review of the Initial Placement Competency Assessment and and Hazard Surveillance Tool revealed the tools included a competency to use employee badge and pass code to bypass the Roam Alert locking mechanism. The staff revealed if an employee failed to demonstrate competency in using the badge swipe, pass code, and fire alarm, the employee will be removed from long term care. Based on the above observations, interviews and documentation reviews, it was determined the Immediate Jeopardy was removed, effective 08/02/12, with the scope and severity lowered to a "F."

Based on interview, record review, review of the facility's investigation report, and review of the facility's policy/procedure, it was determined the facility failed to maintain a complete clinical record related to nurse's notes and intake and output for one resident (#11), in the selected sample of twenty-two (22) residents. The facility failed to follow their "Documentation" and "Intake and Output" policies and procedures. On 06/02/12, family requested care for Resident #11's catheter due to his/her discomfort, flushed appearance and watery eyes. The staff delayed in providing timely care and services for more than one hour. The facility failed to ensure accurate documentation related to care and services and the condition of Resident #11. The facility, at approximately 6:45 PM, irrigated the bladder and emptied the catheter bag twice; however there was no documentation in the medical record. Findings include: A review of the facility's policy/procedure, Documentation, effective date 06/06 and last revised 09/11, revealed "The licensed nurse is responsible for maintaining accurate nursing documentation in the medical record." A review of the facility's policy/procedure, Intake and Output, effective date 04/96 and last revised 07/12, revealed "If the resident has a catheter drainage bag or other drainage collection device in place, empty at the end of the shift and record the amount." A record review revealed the facility admitted Resident #11 on 05/29/10 with [DIAGNOSES REDACTED]. During initial tour of the facility, on 07/31/12 at 4:10 PM, a family member voiced concerns with the care Resident #11 received related to his/her catheter. A review of the facility's Investigation Report, dated 06/08/12, revealed Resident #11's family reported to the Assistant Director of Nursing (ADON), on 06/05/12, that they had reported to Registered Nurse (RN) #3 about Resident #11's complaint of pressure and his/her face being flushed. It was documented in the report that RN #3 responded to the resident and adjusted the catheter to ensure flow of urine to the bag. She reviewed the chart and the catheter had been recently changed. The report further revealed the family member approached RN #3 again, and RN #3 agreed to lay Resident #11 down and assess the resident. The report further revealed RN #3 delegated staff to lay Resident #11 down, and Licensed Practical Nurse (LPN) #2 flushed the resident's catheter. An interview with Family Member (FM) #1, on 08/02/12 at 7:35 PM, revealed, on the evening of 06/02/12, the nurse and another staff member took the resident to the bathroom and emptied the catheter bag and irrigated the catheter. FM #1 further stated, after the nurse irrigated the catheter, the resident filled the catheter bag up again, and then the resident was fine. A review of the "Output Record," for 06/12, revealed there was no urine output recorded for 06/02/12 on the evening and night shifts. Furthermore, a review of the nurse's notes revealed there was no documentation in Resident #11's chart between 05/29/12 and 06/06/12, thus detail of the family's concern voiced related to Resident #11's discomfort with the catheter, LPN #2's corrective action taken to assess and identify the need to irrigate the bladder and the relief obtained by the care provided, was not maintained in the record. An interview with the ADON, on 08/03/12 at 4:35 PM, revealed she was unable to determine if Resident #11's catheter had been irrigated, because she found no documentation in the nurse's notes. She further stated she did not review Resident #11's output record. An interview with the Director of Nursing (DON), on 08/02/12 at 1:55 PM, revealed she did not know if RN #3 notified the physician related to the change in Resident #11's condition or the need to irrigate his/her catheter, because there was no documentation in the nurse's notes.

Based on observation, interview, review of the facility's policy/procedure and the Final Investigation Report, it was determined the facility failed to ensure written policies and procedures were implemented that prohibit neglect of residents for one resident (#11), in the selected sample of twenty-two (22) residents. The facility failed to implement the Suspected Abuse or Neglect policy/procedure as evidenced by failure to identify an allegation made by Resident #11's family as neglect per their policy's neglect definition. This failure prevented the facility from notifying the State agencies of the allegation. Furthermore, the facility failed to conduct a thorough investigation, having only interviewed two (2) staff regarding the incident. Also, due to the failure of identifying the allegation as neglect, this prevented the facility from reporting the investigation results within five (5) days. On 06/05/12, Resident #11's family reported an allegation of neglect to the Assistant Director of Nursing (ADON), alleging that the facility failed to provide timely care and services to Resident #11 related to catheter care. On 06/02/12, Family Member (FM) #1 and FM #2 alleged staff delayed, for approximately one (1) hour, providing necessary catheter care to Resident #11 who was observably uncomfortable, squirming in the wheelchair, expressing "I'm trying to pee," eyes watering with tears rolling down his/her face. Once staff provided care it was identified the resident's catheter required flushing, the catheter bag had to be emptied twice. Upon receipt of care, the resident's discomfort was relieved. The facility failed to identify the allegation as neglect and their investigation failed to determine neglect occurred. Refer to F224 Findings include: A review of the facility's policy/procedure, "Suspected Abuse or Neglect," last revised 03/10, revealed "It is the policy of this facility to report and thoroughly investigate known or suspected resident abuse, neglect, or exploitation in accordance with applicable law. Investigation of suspected abuse/neglect is aimed at determining if abuse or neglect have occurred, the extent of abuse and/or neglect, the causative factors, and the interventions to prevent further injury. The results of all investigations will be reported to the Department of Community Based Services and the regional office of the Division of Licensing and Regulation within five (5) working days of the incident. Neglect-the deprivation by a caretaker of services, which are necessary to maintain the health and welfare of an adult." A record review revealed the facility admitted Resident #11 on 05/29/10 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility identified the resident with a Brief Interview for Mental Status (BIMS) score of five (5). The resident had an indwelling catheter and was frequently incontinent of bowel. During initial tour of the facility, on 07/31/12 at 4:10 PM, a family member voiced concerns with the care Resident #11 received related to his/her catheter. She further stated the family had requested Registered Nurse (RN) #3 no longer be allowed to provide care to Resident #11. An observation revealed Resident #11 had a urinary catheter with a dignity bag. Interview with FM #1 and FM #2, on 08/02/12 at 7:35 PM and 6:15 PM, respectively, revealed they filed a complaint to the ADON alleging neglect, because the facility did not respond timely to the needs of Resident #11's discomfort related to his/her catheter care. The family members revealed they observed Resident #11, on 06/02/12, stating "I'm trying to pee," having watery eyes with tears rolling down his/her face. They stated FM #1 requested care for Resident #11 to Licensed Practical Nurse (LPN) #2 and RN #3. While RN #3 checked for a kink in the catheter, the action did not correct the problem, and Resident #11 continued to be in discomfort for over an hour before LPN #2 finally flushed and emptied the catheter bag twice. An interview with the ADON, on 08/03/12 at 4:35 PM, revealed she had received a complaint from a family member of Resident #11, on 06/05/12. The ADON stated the family member advised her she had reported to RN #3 concerns with the resident's indwelling catheter related to the resident feeling uncomfortable and his/her face being flushed. The ADON stated the family reported that this continued for approximately an hour with RN #3 just sitting at the desk. The ADON stated the family member told her that LPN #2 came to assist the resident, irrigated the indwelling catheter, with the resident getting instant relief. She stated the family member wanted to know why RN #3 had not done that. The ADON stated she did not consider this to be an allegation of neglect. She stated she considered it to be a customer service issue. She stated it would have been neglect, if RN #3 did not respond. She further stated she had not reported the allegation to the State Agencies. An interview with the Director of Nursing (DON), on 08/02/12 at 1:55 PM, and on 08/03/12 at 6:03 PM, revealed that she did not report it to the State Agencies, because she had not considered it an allegation of neglect. A review of the facility's Investigation Report, dated 06/08/12, revealed Resident #11's family reported to the ADON, on 06/05/12, they had reported to RN #3 about Resident #11's complaint of pressure and his/her face being flushed. Review of the report revealed the facility detailed the allegation did not meet the definition of neglect. Furthermore, the document detailed notification to State Agencies was "N/A" (not applicable). Review of the facility's policy defines neglect as "the deprivation by a caretaker of services, which are necessary to maintain the health and welfare of an adult." Review of the investigation revealed the facility interviewed only LPN #2 and RN #3. There was no evidence they attempted to interview both family members, other staff working at the time of the incident, or other residents of the facility. Interview with the ADON revealed she had not interviewed any Certified Nurse Aides (CNAs) on duty at the time of the incident to determine what they had heard or observed. Interview with the DON revealed she did not interview any CNAs during her investigation of the incident. It was documented in the report that RN #3 responded to the resident and adjusted the catheter to ensure flow of urine to the bag. She reviewed the chart and the catheter had been recently changed. The report further revealed the family member approached RN #3 again, and stated something else about the resident feeling uncomfortable. RN #3 agreed to lay Resident #11 down and assess the resident. The report further revealed RN #3 instructed the staff to lay Resident #11 down, and LPN #2 flushed the resident's catheter and he/she reported feeling better. The report revealed Resident #11 was unable to recall the event. The report revealed RN #3 and LPN #2 were interviewed. There was no evidence the facility interviewed any other staff, the family members or other residents. The facility investigation concluded that staff responded appropriately and follow up was appropriate and timely; however, there was no evidence of time included in the document and no interviews with the family which prevented them from accurately determining if neglect had occurred. Furthermore, while the facility's investigation determined no concerns with staff's response to the family members concern for Resident #11's discomfort, interview with the DON, on 08/02/12 at 1:55 PM, revealed the facility counseled RN #3 on 07/06/12 detailing the family's reported 06/02/12 incident involving Resident #11's catheter care. The counseling report detailed, the family felt Resident #11's "discomfort could have been alleviated immediately by flushing the catheter. The family stated you had allowed the resident to be uncomfortable for an extended period of time." The DON removed RN #3 from caring for Resident #11. Additionally, while the facility determined neglect did not occur, interview with LPN #2, on 08/03/12 at 8:55 AM, revealed neglect was not giving a resident the care they needed. She stated she did not think a resident should be left in that condition for over an hour. An interview with the DON, on 08/02/12 at 1:55 PM, revealed after she completed the investigation, she reported to the Administrator that she did not feel like RN #3 had neglected the resident and had responded appropriately to the resident's needs. She stated she felt like the family thought that RN #3 had not responded quick enough to their concerns. An interview with the Administrator, on 08/02/12 at 10:45 AM, revealed the facility did not consider the complaint an allegation of neglect, and stated it was not reported to the State Agencies.

Based on observation, interview, record review, review of the facility's policy/procedure and review of the facility's investigative report, it was determined the facility failed to consult/notify the physician related to a change of condition for one resident (#11), in the the selected sample of twenty-two (22) residents. The facility failed to follow their "Notification of Physicians" and "Indwelling Urinary Catheters" policy/procedure. On 06/02/12, the facility failed to notify Resident #11's physician when he/she presented with the need to "pee" while having an indwelling catheter, had appearance of being flush and being uncomfortable. Furthermore, the staff completed a catheter irrigation without the physician's order. Family interview revealed the resident was so uncomfortable he/she was crying. Findings include: A review of the facility's policy/procedure, "Notification of Physicians," effective date 04/96, last revised 12/11, revealed "any change in the resident's status warrants a notification call to all attending and consulting physicians on the case." A review of the facility's policy/procedure, "Indwelling Urinary Catheters," revised 12/11, revealed a physician's order is required for bladder irrigation. A record review revealed the facility admitted Resident #11 on 05/29/10 with [DIAGNOSES REDACTED]. Review of Resident #11's care plan revealed the onset date for the indwelling catheter was 06/11/10. A quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility identified the resident with a Brief Interview for Mental Status (BIMS) score of five. The resident had an indwelling catheter and was frequently incontinent of bowel. An interview with Family Member (FM) #1, on 08/02/12 at 7:35 PM, revealed she arrived at the facility on 06/02/12 at approximately 5:15 PM. She stated the resident was in the dining room, and his/her face was red and his/her eyes were watering. She stated the resident kept repeating, "I am trying to pee." She requested a Certified Nurse Aide (CNA) to ask the resident's nurse to come to the dining room. She stated she waited for approximately fifteen (15) minutes, and all the time the resident was straining and appearing to be in discomfort. She stated Registered Nurse (RN) #3 came to the dining room and stated the catheter might be twisted. The family member stated the nurse looked up the resident's pant leg to about his/her knee, and the nurse did not appear to untwist the catheter. She stated that the nurse said his/her bag was full and just put it back in the dignity bag. The family member stated she then texted FM #2, and made her aware of Resident #11's condition. FM #2 stated she was on the way to the facility. FM #1 stated she pushed Resident #11 from the dining room back to the lobby at the nurse's station at around 6:00 PM. She stated the resident had tears rolling down his/her face and was still making grunting sounds. She stated she approached the nurse's desk and advised RN #3 the resident was still hurting. She said the nurse just sat there, but stated she would check the resident when they put him/her to bed. The family member stated the nurse did not tell the CNAs to put the resident to bed. FM #1 stated there was another nurse at the nurse's station. She motioned for us to take the resident to his/her room. The nurse and another staff member took the resident to the bathroom and emptied the catheter bag and irrigated the catheter. FM #1 stated she heard the resident say, "Oh" like he was relieved. FM #1 stated after the nurse irrigated the catheter, the resident filled the bag up again, and then the resident was fine. An interview with FM #2, on 08/02/12 at 6:15 PM, revealed after reviewing her text messages, she had received a text message from FM #1, on 06/02/12 at 5:47 PM and 6:16 PM, stating Resident #1 was "having a hard time peeing and that his/her face was real red." She stated FM #1 said RN #3 said she would check the resident when staff put him/her to bed. FM #2 stated she arrived at the facility at approximately 6:45 PM. She stated she saw Resident #11 had tears rolling down his/her face. She stated RN #3 was sitting at the nurse's station. FM #2 stated FM #1 told her she had made the nurse aware of resident's condition in the dining room, and the nurse told her the catheter was not in a kink, the bag was full, and she would check it later. FM #2 stated FM #1 told her after returning to the nurse's station, she had reported to the nurse another two (2) to three (3) times that Resident #11 was "trying to pee." FM #2 stated RN #3 advised her the catheter had been changed recently. FM #2 stated she told the nurse she did not care. "There is a problem now." FM #2 stated the nurse did not say anything and did not move from her seat. FM #2 stated Licensed Practical Nurse (LPN) #2 stated "Just take the resident to his/her room." She stated the LPN #2 stated "I do not know why RN #3 did not flush the catheter. FM #2 stated LPN #2 took Resident #11 to the bathroom. She stated when the resident came out of the bathroom, he/she was totally different and stated he/she felt fine. FM #2 stated the resident was not red any more. She stated she reported the incident to the Assistant Director of Nursing (ADON) on 06/05/12. She stated she told the ADON what happened over the weekend with RN #3 was unacceptable. She stated she advised the ADON the family did not want RN #3 to provide care for Resident #11 again. An interview with RN #3, on 08/02/12 at 4:50 PM, revealed she was the charge nurse for Resident #11 on 06/02/12. She stated Resident #11 was in the dining room and a family member told her Resident #11 needed to "pee." She stated she assessed the catheter tubing and it was kinked. She stated the catheter started to flow. RN #3 stated the resident did not appear to be in any distress or pain. She stated it appeared there was some relief, because the resident was not saying he/she needed to "pee." She stated twenty (20) to thirty (30) minutes later, FM #2 approached her and asked when had the catheter been changed and had the resident had a urinalysis. She further stated because the resident was still having discomfort she thought she would have to change the catheter related to sediment in the resident's urine. She stated while she attempted to get staff to help lay the resident down twice, she saw LPN #2 walking to the resident's room with the family members. She stated LPN #2 had the resident sit on the toilet and she irrigated his/her catheter. There was no documented evidence that the physician was notified by RN #3. An interview with LPN #2, on 08/03/12 at 8:55 AM and 2:45 PM, revealed she recalled the incident related to Resident #11's catheter occurring. Around 6:00 PM, a family member of Resident #11 asked her who the resident's nurse was, because the family member thought the resident was uncomfortable and needed to go to the bathroom. LPN #2 stated she told the family member the resident's nurse was RN #3. LPN #2 stated she was in and out of the dining room during the dinner meal and recalled the family member saying something about Resident #11 being uncomfortable. She stated she observed Resident #11's face being flush while up in the wheelchair. LPN #2 stated at approximately 7:00 PM, the family member and Resident #11 were in the hallway near the resident's room. She stated the resident looked about the same. His/her face was flush. She stated she flushed the catheter. It started flowing and the resident got relief right away. LPN #2 reviewed the physician's orders. She stated there was not a previous physician order for [REDACTED]. During initial tour of the facility, on 07/31/12 at 4:10 PM, an observation revealed Resident #11 had a urinary catheter with a dignity bag, and a family member voiced concerns regarding Resident #11's care related to his/her catheter. A review of the physician's orders for Resident #11, dated 06/02/12, revealed no evidence the facility received an order to irrigate his/her catheter. An interview with RN #2, on 08/03/12 at 2:45 PM, confirmed there was no order to irrigate Resident #11's urinary catheter on 06/02/12. A review of the nurse's notes, dated 06/02/12, revealed no documented evidence the facility notified the physician regarding a change in Resident #11's status related to the catheter, resident discomfort, or for need to alter treatment with an order to irrigate the bladder. A review of the facility's Investigation Report, dated 06/08/12, revealed Resident #11's family reported to the Assistant Director of Nursing (ADON), on 06/05/12, that they reported to RN #3 about Resident #11's complaint of pressure and his/her face being flush. There was no evidence in the facility's Investigation Report that the physician had been notified related to the catheter, resident discomfort, for need to alter treatment with an order to irrigate the bladder. The was no evidence the facility had obtained a physician's order for the bladder irrigation. An interview with the ADON, on 08/03/12 at 4:35 PM, revealed she reviewed Resident #11's chart and found no documentation in the nurse's notes, on 06/02/12, related to concerns with the resident's catheter or interventions implemented. She further stated there was no physician's order to irrigate the resident's catheter. She stated the facility's policy required a physician's order to irrigate a urinary catheter. She stated she expected the staff to call the physician prior to irrigating a urinary catheter. An interview with the Director of Nursing (DON), on 08/02/12 at 1:55 PM and 6:03 PM, revealed she was unable to recall if RN #3 notified the physician of a change in Resident #11's status related to his/her catheter, because the nurse did not document anything in the nurse's notes. She stated there should have been an order to irrigate the urinary catheter. She further stated she expected the staff to notify the physician of a change in the resident's status.

Based on observation, interview, record review, review of the facility's investigation, and review of the facility's policy/procedure, it was determined the facility failed to prohibit neglect of residents for one resident (#11), in the selected sample of twenty-two (22) residents. On 06/02/12 at approximately 5:15 PM, Resident #11 was observed with a red face, eyes watering and stating "I am trying to pee." Family Member (FM) #1 reported to Registered Nurse (RN) #3, on 06/02/12, that Resident #11 was complaining of pressure related to the urinary catheter and his/her face was flushed. RN #3 then adjusted the catheter tubing. For approximately one (1) hour the resident continued to be uncomfortable, and the family requested RN #3 to relieve the resident's discomfort. FM #2, at approximately 6:45 PM, observed Resident #1 with tears rolling down his/her face. FM #2 requested RN #3 to care for Resident #11's discomfort. RN #3 delegated the staff to assist Resident #11 to lay down which still had not been initiated. Licensed Practical Nurse (LPN) #2 flushed the resident's urinary catheter and reported the resident felt better. FM #1 stated the catheter bag had to be emptied twice. The facility's investigation failed to identify the deprivation by a care taker of services which resulted in Resident #11 experiencing discomfort, face flushed and crying for over an hour. Findings include: A review of the facility's policy/procedure, "Suspected Abuse or Neglect," last revision 03/10, revealed documentation to define neglect as "the deprivation by a caretaker of services, which are necessary to maintain the health and welfare of an adult." A record review revealed the facility admitted Resident #11 on 05/29/10 with [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]." Review of the record revealed no additional orders related to the resident's catheter. A record review revealed no evidence of an assessment for Resident #11 on 06/02/12 related to the catheter, resident discomfort, or for need to alter treatment with an order to irrigate the bladder. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility identified the resident to have a Brief Interview for Mental Status (BIMS) score of five (5), which meant the resident was severely cognitively impaired. The resident required extensive assistance of two staff members for bed mobility, transfer, personal hygiene, and toileting needs. The resident had an indwelling catheter and was frequently incontinent of bowel. During initial tour of the facility, on 07/31/12 at 4:10 PM, a family member voiced concerns with the care Resident #11 received related to his/her catheter. She further stated the family had requested that RN #3 no longer be allowed to provide care to Resident #11. An observation revealed Resident #11 had an indwelling catheter with a dignity bag. An interview with FM #1, on 08/02/12 at 7:35 PM, revealed she arrived at the facility on 06/02/12 at approximately 5:15 PM. She stated Resident #11 was in the dining room, his/her face was red and eyes were watering. She stated the resident kept repeating, "I am trying to pee." She requested a Certified Nurse Aide (CNA) to ask the resident's nurse to come to the dining room. She waited for approximately fifteen (15) minutes, and all the time the resident was straining and appearing to be in discomfort. She stated RN #3 came to the dining room and stated the catheter might be twisted. The family member stated the nurse looked up the resident's pant leg to about his/her knee, and the nurse did not appear to untwist the catheter. She stated that the nurse said his/her bag was full and just put it back in the dignity bag. The family member stated she then texted FM #2, and made her aware of Resident #11's condition. FM #2 stated she was on the way to the facility. FM #1 stated she pushed Resident #11 from the dining room back to the lobby at the nurse's station at around 6:00 PM. She stated the resident had tears rolling down his/her face and was still making grunting sounds. She stated she approached the nurses's desk and advised RN #3 the resident was still hurting. She said the nurse just sat there, but stated she would check the resident when they put him/her to bed. The family member stated the nurse did not tell the CNAs to put the resident to bed. FM #1 stated FM #2 arrived at the facility and advised RN #3 we were going to take Resident #11 to the emergency room (ER). FM #1 stated there was another nurse at the nurse's station. She motioned for us to take the resident to his/her room. The nurse and another staff member took the resident to the bathroom and emptied the catheter bag and irrigated the catheter. FM #1 stated she heard the resident say, "Oh" like he/she was relieved. FM #1 stated after the nurse irrigated the catheter, the resident filled the bag up again, and then the resident was fine. An interview with FM #2, on 08/02/12 at 6:15 PM, revealed after reviewing her text messages, she had received a text message from FM #1, on 06/02/12 at 5:47 PM and 6:16 PM, stating Resident #1 was "having a hard time peeing and that his/her face was real red." FM #2 stated she texted FM #1 to have the nurse check his/her catheter. She stated FM #1 texted back that the nurse said she would check the resident when they put him/her to bed. FM #2 stated she arrived at the facility at approximately 6:45 PM. She stated she saw FM #1 sitting on the couch and Resident #11 had "tears" rolling down his/her face. She stated RN #3 was sitting at the nurse's station. FM #2 stated FM #1 told her she had made the nurse aware of the resident's condition in the dining room, and the nurse told her the catheter was not in a kink, the bag was full, and she would check it later. FM #2 stated FM #1 told her after returning to the nurse's station, she had reported to the nurse another two (2) to three (3) times that Resident #11 was "trying to pee." FM #2 stated RN #3 advised her the catheter had been changed recently. FM #2 stated she told the nurse she did not care. "There is a problem now." FM #2 stated the nurse did not say anything and did not move from her seat. FM #2 stated a CNA approached her and asked if she could help. FM #2 stated she told the CNA, "I have already told the nurse. She is aware of the problem. We are going to the ER." FM #2 stated LPN #2 stated "Just take the resident to his/her room." She stated the LPN got the supplies and stated "I do not know why RN #3 did not flush the catheter. LPN #2 stated she had the resident last week, and he/she had the same problem, and all the catheter needed was to be flushed. FM #2 stated LPN #2 took Resident #11 to the bathroom. She stated when the resident came out of the bathroom, he/she was totally different. FM #2 stated she asked the resident if he/she felt better, and the resident stated "Oh, yes." FM #2 stated the resident was not red any more. She stated she reported the incident to the Assistant Director of Nursing (ADON) on 06/05/12. She stated she told the ADON what happened over the weekend with RN #3 was unacceptable. She stated she advised the ADON the family did not want RN #3 to provide care for Resident #11 again. An interview with CNA #7, on 08/03/12 at 10:30 AM and 2:15 PM, revealed he was working the weekend of 06/02/12 to 06/03/12. He stated at approximately 6:30 PM, a family member of Resident #11 stopped him in the hallway and asked if he would put the resident in bed. He stated he recalled Resident #11's complaint about his/her catheter, because his/her catheter had to be adjusted more often than others. He stated he thought LPN #2 flushed his/her catheter. He stated the resident did not appear to be in distress when he laid him/her in bed. He further stated the administrative staff had not interviewed him about the incident. An interview with LPN #2, on 08/03/12 at 8:55 AM, revealed she recalled the incident related to Resident #11's catheter. She stated around 6:00 PM, a family member of Resident #11 asked her who the resident's nurse was, because she thought the resident was uncomfortable and needed to go to the bathroom. LPN #2 stated she told the family member the resident's nurse was RN #3. She stated she told RN #3 the family wanted to speak to her. She stated she did not hear the conversation between RN #3 and the family member. LPN #2 stated the family member took the resident to the dining room. LPN #2 stated she was in and out of the dining room during the dinner meal. She further stated she recalled the family member saying something about the resident still being uncomfortable. LPN #2 stated the resident's face was flushed, and he/she was restless in his/her wheel chair. She stated RN #3 told her that she had checked the resident's catheter to see if it was kinked and would lay the resident down after dinner and check the catheter to see if there was a problem. LPN #2 stated Resident #11 sat through dinner looking uncomfortable. At approximately 7:00 PM, the family member and Resident #11 were in the hallway near the resident's room. She stated the resident looked about the same. His/her face was flushed. She stated RN #3 was sitting at the nurse's station with the night shift nurse. She stated she asked two (2) CNAs, but did not recall who the CNAs were, to take Resident #11 to the bathroom. She stated she flushed the catheter. It started flowing and the resident appeared to be relieved right away. LPN #2 stated her definition of neglect was not giving a resident the care they needed. She further stated she did not think a resident should be left in that condition for over an hour. A review of the "Intake and Output Record," for 06/12, revealed there was no urine output recorded for 06/02/12 evening shift, after Resident #11's catheter was irrigated. An interview with RN #3, on 08/02/12 at 4:50 PM, revealed she was the charge nurse for Resident #11 on 06/02/12. She stated Resident #11 was in the dining room and a family member was present. RN #3 stated she was in the dining room feeding another resident. She stated the family member told her Resident #11 needed to "pee." She stated the tubing was kinked. She unkinked the tubing, and the catheter started to flow. RN #3 stated the resident did not appear to be in any distress or pain. However, she stated it appeared there was some relief, because the resident was not saying he/she needed to "pee." She stated twenty (20) to thirty (30) minutes later, the family member brought the resident back to the lobby area at the nurse's station. RN #3 stated another family member arrived at the facility. She stated this family member asked her when was the last time the catheter was changed and when had the resident had a urinalysis. She stated she reviewed the chart. She further stated because the resident was still having discomfort she thought she would have to change the catheter related to sediment in the resident's urine. She stated she told FM #2 she would have the CNAs lay the resident down. RN #3 stated she had been unsuccessful in the past with irrigating the catheter, and was just going to change the catheter. She stated she went to get the CNAs and asked them to lay the resident down. She further stated she realized the family was getting upset with her, and went a second time to get the CNAs. She stated she saw LPN #2 walking to the resident's room with the family members. She stated LPN #2 had the resident sit on the toilet and she irrigated his catheter. She stated she thought that was the end of it until the DON, approximately ten (10) days later, met with her about the care she had provided to Resident #11 and the family was upset. She stated she was told the family did not want her to provide care to Resident #11 in the future. A review of the facility's Investigation Report, dated 06/08/12, and the Counseling Record Performance Improvement for RN #3, dated 07/06/12, revealed Resident #11's family reported to ADON, on 06/05/12, they had reported to RN #3 about Resident #11's complaint of pressure and his/her face being flushed. It was documented in the report that RN #3 responded to the resident and adjusted the catheter to ensure flow of urine to the bag. She reviewed the chart and the catheter had been recently changed. The family member approached RN #3 again, and stated something else about the resident feeling uncomfortable. RN #3 agreed to lay Resident #11 down and assess the resident and delegated staff to lay Resident #11 down. LPN #2 flushed the resident's catheter and the resident reported feeling better. The report revealed Resident #11 was unable to recall the event. The report revealed the facility interviewed only RN #3 and LPN #2 as there was no evidence the facility interviewed any other staff. The facility investigation concluded there was no indication that neglect occurred; however, a review of the Counseling Record Performance Improvement for RN #3 revealed "the Director of Nursing (DON) met with RN #3 on 06/08/12, to discuss the 06/02/12 incident as a family member reported RN #3 did not properly care for Resident #11. The family member was extremely upset and reported she told RN #3 the resident was uncomfortable because his/her catheter was not working properly. The document revealed family stated RN #3 told them 'when we put him/her to bed we will flush his/her catheter'." Approximately one (1) hour later the family addressed RN #3 as the resident continues to be uncomfortable and asked RN #3 again to take care of the resident to relieve his/her discomfort. LPN #2 reported the resident did appear to be uncomfortable, the resident's face was flushed and he/she was squirming in his/her wheelchair due to discomfort and took the resident to the bathroom and flushed the catheter. A large amount of urine was released, and the resident had immediate relief from his/her discomfort. "This made the family member extremely angry because she realized the resident did not need to be placed in bed as you recommended, but his/her discomfort could have been alleviated immediately by flushing the catheter. The family member stated you had allowed the resident to be uncomfortable for an extended period of time." An interview with the ADON, on 08/03/12 at 4:35 PM, revealed FM #2 reported to her sometime in June, after a weekend shift, that she was upset with the care Resident #11 received from RN #3. FM #2 told her that another family member had called her and said she thought Resident #11 was uncomfortable and wanted the nurse to do something about the resident's catheter, but the nurse would not pay any attention to her. The ADON stated FM #2 told her the nurse was just sitting at the desk and that LPN #2 assisted by irrigating the catheter, and the resident got instant relief. FM #2 asked "Why couldn't RN #3 have done that?" The ADON stated she did not consider this to be an allegation of neglect. She stated she considered it to be a customer service issue. She stated it would have been neglect, if RN #3 had not responded. She further stated she had not reported the allegation to the State Agencies, and she had not interviewed any CNAs on duty at the time of the incident to determine what they had heard or seen. An interview with the DON, on 08/02/12 at 1:55 PM and on 08/03/12 at 6:03 PM, respectively, revealed the family reported the incident related to RN #3 and Resident #11's catheter to the ADON, on 06/05/12, on the evening shift. The family member stated she had thought about it and was aggravated. She stated the ADON then reported the incident to her. The DON stated the family member told the ADON she had reported to RN #3 that Resident #11 was uncomfortable in the dining room. The family member stated she went back to RN #3 approximately one (1) hour later and reported the resident was still uncomfortable. The family member told the DON that RN #3 told her she would get the CNAs to lay the resident down, because his/her catheter may need to be flushed. The DON stated the family member was upset because RN #3 was giving report. The family member reported that LPN #2 came and flushed the resident's catheter. The DON revealed once the catheter was flushed the resident was okay. The DON stated that RN #3 had reported to her this is an ongoing problem with Resident #11's catheter needing to be repositioned or changed. The DON further stated she did not know if RN #3 notified the physician related to the change in Resident #11's condition or the need to irrigate the catheter, because there was no documentation in the nurse's notes. The DON stated she, the ADON and Human Resources (HR) staff interviewed RN #3 after being made aware of the incident. The DON stated that RN #3 stated she did go to the dining room and adjusted the resident's catheter. She stated RN #3 reported that the resident then felt fine. The DON stated she and HR staff had a counseling session with RN #3 on 07/06/12 and advised her she was being removed from caring for Resident #11 per the family's request. The DON stated RN #3 had prior counseling sessions on 11/01/10, 11/25/11 and 11/26/11 and a below standard performance evaluation, making this her "final warning period counseling." The DON stated after she completed the investigation, she reported to the Administrator that she did not feel like RN #3 had neglected the resident and had responded appropriately to the resident's needs. She stated she felt like the family thought that RN #3 had not responded quick enough to their concerns. The DON further stated she did not interview any CNAs during her investigation of the incident, and she had not reported it to the State Agencies, because she had not considered it neglect. An interview with the Administrator, on 08/02/12 at 10:45 AM, revealed he did not think this incident was an allegation of neglect, therefore, they did not investigate or report it. He stated he just heard the family was upset not that they reported it as an allegation of neglect. He stated he would consider it neglect if care was not provided, but care was provided.

Based on record review, staff and family interviews, and review of the facility's policy/procedure, it was determined the facility failed to ensure one resident (#11), in the selected sample of twenty-two (22) residents, was provided appropriate care and treatment related to an indwelling catheter. The facility failed to follow their Indwelling Urinary Catheter's policy and procedure. The facility failed to ensure timely care and services were provided to Resident #11 related to his/her catheter. The facility failed to ensure the care plan was followed as it relates to the resident's catheter and failed to get a physician's orders [REDACTED]. On 06/02/12, at approximately 5:15 PM, family members reported to facility staff that Resident #11 was verbalizing, "I'm trying to pee," had a flushed face, and appeared to be in discomfort. While facility staff looked to see if the catheter was kinked, no further action was taken to assess or identify a problem with the catheter. Resident #11 continued to be in discomfort through the meal service. The family continued to request assistance for Resident #11. At approximately 6:45 PM, Licensed Practical Nurse (LPN) #2 irrigated Resident #11's bladder and emptied the catheter bag twice which resulted in Resident #11's relief from discomfort. Family members reported to Registered Nurse (RN) #3, on 06/02/12, that Resident #11 was complaining of pressure related to the indwelling catheter and his/her face was flushed. RN #3 adjusted the catheter tubing. For approximately one (1) hour the resident continued to be uncomfortable, and the family requested RN #3 to relieve the resident's discomfort. RN #3 delegated to staff to lay Resident #11 down. LPN #2 flushed the resident's catheter and reported the resident felt better. The family reported the incident to the Assistant Director of Nursing (ADON), on 06/05/12. Findings include: A review of the facility's policy/procedure, "Indwelling Urinary Catheters," revised 12/11, revealed a physician's orders [REDACTED]. A review of the facility's policy/procedure, "Admission Assessment/Reassessment, " last revision date 12/11, revealed residents will be reassessed for pain if they exhibit signs of discomfort, restlessness, or receive PRN medications for pain, etc. The nurse will assess for severity using a pain scale, location, duration, intensity, etc. The resident will be assessed for the response to whatever measures are implemented. This will be documented on the Medication Administration Record (MAR) for as needed (PRN) medications or in the nurse's notes. A record review revealed the facility admitted Resident #11 on 05/29/10 with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility identified the resident with a Brief Interview for Mental Status (BIMS) score of five (5), which meant the resident was severely cognitively impaired, and requiring extensive assistance of two staff members for bed mobility, transfer, personal hygiene and toileting needs. The resident had an indwelling catheter and was frequently incontinent of bowel. A review of the physician's orders [REDACTED]." Review of the record revealed no additional orders related to the resident's catheter. A review of the resident's care plan, onset date 06/11/10, "At risk for Urinary Tract Infections (UTIs), related to indwelling catheter and [MEDICAL CONDITION] revealed the goal was to remain free of UTIs. Interventions included encouraging fluid intake, monitoring for signs and symptoms of infection, measuring and recording output, change catheter, tubing and bedside drainage bag monthly per physician's orders [REDACTED]. However, there was no evidence of interventions for bladder irrigation. An interview with Family Member (FM) #1, on 08/02/12 at 7:35 PM, revealed she arrived at the facility on 06/02/12 at approximately 5:15 PM. She stated the resident was in the dining room and had a red face and his/her eyes were watering. She stated the resident kept repeating, "I am trying to pee." She requested a Certified Nurse Aide (CNA) in the dining room to ask the resident's nurse to come to the dining room. She stated she waited for approximately fifteen (15) minutes, and all the time the resident was straining and appearing to be in discomfort. She stated RN #3 came to the dining room and stated the catheter might be twisted. The family member stated the nurse looked up the resident's pant leg to about his/her knee, and the nurse did not appear to untwist the catheter. She stated that the nurse said his/her bag was full and just put it back in the dignity bag. The family member stated she then texted FM #2, and made her aware of Resident #11's condition. FM #2 stated she was on the way to the facility. FM #1 stated she pushed Resident #11 from the dining room back to the lobby at the nurse's station around 6:00 PM, approximately forty-five (45) minutes later. She stated the resident had tears rolling down his/her face and was still making grunting sounds. She stated she approached the nurse's desk and informed RN #3 that Resident #11 was still hurting. She said the nurse just sat there, but stated she would check the resident when they put him/her to bed. The family member stated the nurse did not tell CNAs to put the resident to bed. FM #1 stated FM #2 arrived at the facility and advised RN #3 that they were going to take Resident #11 to the emergency room (ER). FM #1 stated there was another nurse at the nurse's station, and she motioned for us to take the resident to his/her room. The nurse and another staff member took the resident to the bathroom and emptied the catheter bag and irrigated the catheter. FM #1 stated she heard the resident say, "Oh," like he/she was relieved. FM #1 stated after the nurse irrigated the catheter, the resident filled the bag up again, and then the resident was fine. An interview with FM #2, on 08/02/12 at 6:15 PM, revealed after reviewing her text messages, she had received a text message from FM #1, on 06/02/12 at 5:47 PM and 6:16 PM, stating Resident #1 was "having a hard time peeing and that his/her face was real red." FM #2 stated she texted FM #1 to have the nurse check his/her catheter. She stated FM #1 texted back that the nurse said she would check the resident when they put him/her to bed. FM #2 stated she arrived at the facility at approximately 6:45 PM. She stated she saw FM #1 sitting on the couch and Resident #11 had tears rolling down his/her face. She stated RN #3 was sitting at the nurse's station. FM #2 stated FM #1 told her she made the nurse aware of the resident's condition while in the dining room, and the nurse told her the catheter was not in a kink, the bag was full, and she would check it later. FM #2 stated FM #1 told her after returning to the nurse's station, she had reported to the nurse another two (2) to three (3) times that Resident #11 was "trying to pee." FM #2 stated RN #3 advised her the catheter had been changed recently. FM#2 stated she told the nurse she did not care. "There is a problem now." FM #2 stated the nurse did not say anything and did not move from her seat. FM #2 stated a CNA approached her and asked if she could help. FM #2 stated she told the CNA, "I have already told the nurse. She is aware of the problem. We are going to the ER." FM #2 stated LPN #2 stated "Just take the resident to his/her room." She stated the LPN got the supplies and stated "I do not know why RN #3 did not flush the catheter." LPN #2 stated she had the resident last week, and he/she had the same problem, and all the catheter needed was to be flushed. FM #2 stated LPN #2 took Resident #11 to the bathroom. She stated when the resident came out of the bathroom, he/she was totally different. FM #2 stated she asked the resident if he/she felt better, and the resident stated "Oh, yes." FM #2 stated the resident was not red anymore. An interview with RN #3, on 08/02/12 at 4:50 PM, revealed she was the charge nurse for Resident #11 on 06/02/12. RN #3 validated the events on 06/02/12 specifying in the past she had been able to unkink the catheter tubing to get it to flow. She stated the tubing was kinked. The catheter started to flow, and the family member continued to feed the resident. RN #3 stated the resident didn't appear to be in any distress or pain. However, she stated it appeared there was some relief, because the resident was not saying he/she needed to "pee." She stated twenty (20) to thirty (30) minutes later, the family member brought the resident back to the lobby area at the nurse's station. RN #3 stated another family member arrived at the facility. She stated this family member asked her when the catheter had been changed, and when had the resident had a urinalysis, so she reviewed the chart. She further stated because the resident was still having discomfort she thought she would have to change the catheter related to sediment in the resident's urine. She stated she told FM #2 she would have the CNAs lay the resident down. RN #3 stated she had been unsuccessful in the past with irrigating the catheter, and was just going to change the catheter. She stated she went to get the CNAs out of another resident's room and asked them to lay the resident down. She further stated she realized the family was getting upset with her, and went a second time to get the CNAs. She stated she saw LPN #2 walking to the resident's room with the family members. She stated LPN #2 had the resident sit on the toilet and she irrigated his/her catheter. An interview with LPN #2, on 08/03/12 at 8:55 AM, revealed a family member of Resident #11 was visiting the resident. Around 6:00 PM, the family member asked her who the resident's nurse was because she thought the resident was uncomfortable and needed to go to the bathroom. LPN #2 informed RN #3 the family wanted to speak to her. She recalled the family member saying something about the resident still being uncomfortable. LPN #2 stated the resident's face was flushed, and he/she was restless in the wheel chair. She stated RN #3 said, she had checked the resident's catheter to see if it was kinked. She stated RN #3 stated she would lay the resident down after dinner and check the catheter to see if there was a problem. LPN #2 stated Resident #11 sat through dinner looking uncomfortable. At approximately 7:00 PM, the family member and Resident #11 were in the hallway. She stated the resident's face was flushed. She stated she asked two (2) CNAs to take Resident #11 to the bathroom. She stated she flushed the catheter. It started flowing and the resident got relief right away. She stated she did not think a resident should be left in that condition for over an hour. LPN #2 reviewed the physician's orders [REDACTED]. A review of the "Intake and Output Record," for 06/12, revealed there was no urine output recorded for 06/02/12 evening shift, after Resident #11's catheter was irrigated. Review of the nurse's notes, dated 06/02/12 at 5:15 PM to 7:00 PM, revealed there was no documented evidence the facility had been notified by the family of the resident's discomfort related to the catheter and no evidence the staff assessed the resident's catheter, notified the physician or received an order to irrigate the bladder. An interview with the Director of Nursing (DON), on 08/02/12 at 1:55 PM, revealed she was not sure if an order was required to irrigate the resident's catheter. She stated she would check the facility's policy. The DON further stated she did not know if RN #3 notified the physician related to the change in Resident #11's condition or the need to irrigate the catheter, because there was no documentation in the nurse's notes. The DON stated she, the ADON and Human Resources (HR) staff interviewed RN #3 after being made aware of the incident. However, she identified no concerns with the timeliness of catheter care. The DON stated they counseled RN #3 regarding the family's concern with timeliness of catheter care, and the discomfort and pain. The investigation completed by the facility did not identify that there was no documentation of the incident, no documented assessment of the resident and his/her catheter and no notification of the physician to get an order to irrigate the bladder.