Every finding on record at Fayetteville Health and Rehabilitation Center

Based on record review and interview, the facility failed to ensure family was notified of a change in condition for one (Resident #132) of two sampled residents. The findings include: A review of Resident #132's quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE], revealed the resident had diagnoses which included Alzheimer's and Non-Alzheimer's dementia, heart disease, and type II diabetes mellitus. Resident #132's MDS also revealed a brief interview for mental status score of 06, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #132 was under Hospice care. A review of Resident #132's Care Plan revealed the resident was receiving services from Hospice ([DATE]). Resident #132's Hospice Care Plan records indicated Hospice and facility staff would assist family member in having an active role in care planning and the family member would be kept informed of Resident #132's care and changes in disease progression. A review of Resident #132's Progress Notes, dated [DATE] at 4:55 AM, revealed Licensed Practical Nurse (LPN) #1 documented that a change in condition was noted at 6:00 PM on [DATE]. According to the Progress Note, Resident #132 was described as significantly less responsive and lethargic with increased respirations. Resident #132's Progress Note revealed that Hospice was notified at that time, and again at 3:30 AM, and medication recommendations were made. A review of Resident #132's Hospice Contract on [DATE] at 9:22 AM, revealed the nursing home should inform the provider of any significant change in condition of the Hospice patient, and that both parties should comply with rules and regulations. During a telephone interview on [DATE] at 3:38 PM, a family member of Resident #132 reported that neither the facility or Hospice company called any family member when Resident #132 took a sudden decline and died 12 hours later in the facility on [DATE]. Resident #132's family member refused to answer any additional questions. During an interview with the Administrator and Assistant Director of Nursing (ADON) on [DATE] at 1:31 PM, the ADON stated, Hospice and the facility are responsible for notifying the family when there is a change of condition. The Administrator agreed the facility should have made sure the family was contacted regarding Resident #132's change in condition. The ADON stated that in the resident's Progress Notes on [DATE] at 8:38 AM, LPN #3 charted that at 6:48 AM, Hospice was notified that Resident #132 was without respirations and the Hospice Nurse told them they could not come out due to the weather on the roads, but that they would contact the family. The ADON then stated the Hospice Nurse called and told Director of Nursing she forgot to call the family after the 6:48 AM phone conversation. This surveyor pointed out that on [DATE] at 4:55 AM, LPN #1 documented at 6:00 PM on [DATE], there was a significant change in condition and Resident #132 was significantly less responsive and lethargic. When asked who was responsible for notifying the family that Resident #132 had a significant decline, the ADON reiterated that both Hospice and the facility were responsible for making sure the family was informed. The Administrator agreed with this statement. On [DATE] at 4:12 PM, this surveyor received a copy of a Progress Note from a Hospice Nurse stating LPN #1 called and Resident #132 was getting pain medication every hour and anti-anxiety medication as ordered. The Progress Note also revealed the resident's respiration rate was 30 breaths per minute and labored [the normal respiratory rate for adults at rest is between 12 and 20 breaths per minute], pulse was in the 30s [a normal resting heart rate for adults ranges from 60 to 100 beats per minute], pulse oxygen (SpO2) was in the 70s [SpO2, or peripheral oxygen saturation, measures the percentage of oxygen in your blood, with a normal range for healthy individuals being 95% to 100%]. LPN #1 was instructed to give a one-time dose of pain medication to see if that was more effective and call back with further concerns. During an interview on [DATE] at 9:02 AM, LPN #1 stated she worked the 10:00 PM-6:00 AM shift and could not recall any Hospice in-services being done at the facility. LPN #1 said, I was trained to call Hospice and follow instructions when there is a change in condition. LPN #1 revealed the Hospice company might tell facility staff to give medication or take vitals. LPN #1 said, It is my understanding Hospice should call the family when there is a change in condition, and said a change in condition was any type of change in baseline from mental status, vitals, pulse, increase or decrease in respirations or temperature, and/or reduced output. LPN #1 confirmed nobody called Resident #132's family during her shift when the resident declined. LPN #1 then stated she could not remember having a conversation with the charge nurse about Resident #132, but LPN #1 always communicated with the charge nurse and would have called the resident's family if told to. LPN #1 said she was under the impression Hospice would contact Resident #132's family. During an interview on [DATE] at 12:00 PM, LPN #2 reported previously caring for Hospice residents, and that it was their understanding staff were to call the Hospice company with a change in condition. LPN #2 said, I do not know what the regulation is, so when I call Hospice, I always just ask them if they are calling the family, or do they want me to call the family. LPN #2 said she could not remember if she took care of Resident #132. During an interview on [DATE] at 1:29 PM, LPN #3 stated she was not familiar with Resident #132 and did not remember being involved with Resident #132's care. LPN #3 revealed the facility called Hospice when there was a change in condition, and we will contact the family if Hospice asks us to call the family. LPN #3 revealed she had not received any Hospice in-servicing. During an interview on [DATE] at 1:30 PM, the Administrator said, I expect the family to be notified. Going forward, the expectation is that staff will have a conversation with Hospice about who is notifying the family and will make sure family is notified. I can understand how this happened because Hospice normally does contact the family, so I can see how staff would expect them to contact the family. The Administrator revealed Hospice provided in-services to the facility and he believed they had done an in-service within the year but was unable to find documentation. The Administrator said, I reached out to Hospice, but they have not provided in-service documentation.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure interventions of the comprehensive care plan were implemented to prevent possible skin tears to one (Resident #22) of two residents sampled. The findings include: During an observation on 09/22/2025 at 2:07 PM, this surveyor observed Resident #22 ambulating in the hallway of the [gender specific] secure neighborhood. Resident #22 was observed wearing a short sleeve top and had a partially healed skin tear to the outer aspect of their right elbow that was actively bleeding, as well as a bandage to the area below the thumb of their right hand. The resident was not wearing protective sleeves of any type at this time. During subsequent observations on 09/23/2025 at 8:56 AM and 1:43 PM, and again on 09/24/2025 at 11:50 AM, this surveyor observed Resident #22 wearing clothing that did not have long sleeves, nor was the resident wearing any type of protective sleeve. A review of Resident #22's Face Sheet indicated the facility admitted the resident on 09/18/2023 with diagnoses, which included dementia, chronic obstructive pulmonary disease, and cerebrovascular disease. A review of Resident #22's significant change of condition Minimum Data Set (MDS) with an assessment reference date of 08/13/2025, revealed a staff assessment of mental status score of 03, which indicated Resident #22 was severely cognitively impaired and never/rarely made decisions. Resident #22's MDS indicated the resident ambulated without assistance, required moderate to maximal assistance with hygiene and maximal assistance with dressing, had experienced two or more falls with injury, and took an antiplatelet medication [medication used to prevent or treat blood clots, which prevents platelets from sticking together]. A review of Resident #22's Care Plan, with an edited date of 04/15/2025 indicated, . [Resident #22] is at risk for bruises and skin tears related to fragile skin. Staff educated to ensure resident wears long sleeves or (brand name for protective sleeves) [protective sleeves designed to shield fragile skin, particularly in the elderly, from friction, shearing, and subsequent tears and abrasions]. During an interview on 09/23/2025 at 3:16 PM, Certified Nursing Assistant (CNA) #4 was asked how staff knew what care each resident required and verbalized that staff used the Care Plan to guide each resident's care and provide what they required. CNA #4 went on to relate that following the Care Plan was part of orientation when employees were hired. During an interview on 09/24/2025 at 12:15 PM, the Director of Nursing indicated she expected the staff to follow each resident's plan of care. A review of the facility policy titled, Person Centered Care Plans with an effective date of 08/15/2018 indicated, This will provide the CNA with individualized information needed to meet the resident care needs.

Based on record review, interview, and facility policy review, the facility failed to ensure one (Resident #94) of one sampled resident received an ordered medication, and to ensure a physician's order was followed for one (Resident #4) of one sampled resident. The findings include: Resident #94 A review of Resident #94's Resident Face Sheet indicated the facility admitted the resident on 12/30/2019 with diagnoses which included unspecified intellectual disabilities, depression, and generalized anxiety disorder. A review of Resident #94's quarterly minimum data set with an assessment reference date of 07/14/2025, revealed a staff assessment for mental status score of 03, which indicated the resident was severely cognitively impaired and never/rarely made decisions A review of Resident #94's September Physician Orders documented, [Name Brand Contraceptive] administer 150mg intramuscularly every three months. Once a day on the 29th of every 3rd month, start date 03/31/2025. The medication was used to induce amenorrhea [the absence of monthly periods]. A review of Resident #94's Medication Administration Record (MAR) for the month of June did not indicate the [Name Brand Contraceptive] injection was administered. During an interview on 09/24/2025 at 1:30 PM, Licensed Practical Nurse (LPN) #10 indicated that Resident #94 received a [Name Brand Contraceptive] injection on 03/29/2025, but did not receive the scheduled injection in June. LPN #10 then stated that Resident #94's next [Name Brand Contraceptive] injection was scheduled to be administered in September. LPN #10 revealed she did not know why Resident #94 did not receive the ordered injection in June. During an interview on 09/24/2025 at 3:00 PM, the Director of Nursing (DON) indicated she ordered the [Name Brand Contraceptive] in March and she was not sure why Resident #94 did not get the ordered June injection. The DON revealed any of the nurses could order the [Name Brand Contraceptive] injection, and that Resident #94 did not receive the June dose, because it was not ordered. She stated the [Name Brand Contraceptive] shot should be scheduled with the pharmacy. The DON revealed the injection was reordered for September, and Resident #94's guardian was aware. The DON indicated that an in-service was not completed after the facility determined that Resident #94 did not receive the ordered [Name Brand Contraceptive] injection. During an interview on 09/24/2025 at 4:00 PM, the Medical Director indicated that Resident #94 should receive a [Name Brand Contraceptive] injection every three months, to maintain the medication's effect. During an interview on 09/25/2025 at 10:46 AM, the Administrator indicated staff should follow physician orders and make sure the medications are documented on the MAR. A review of a policy titled, General Dose Preparation and Medication Administration, indicated to document medications when they are given, injection site of the medication, and if medications are refused. Resident #4 A review of Resident #4's Physician Orders revealed an order, dated 10/09/2025 with an open-ended end date, for the resident's HOB to be positioned at 30-45 degrees while in bed. A review of Resident #4's Care Plan revealed an intervention of Head of bed elevated, created on 10/14/2024. A review of Resident #4's annual Minimum Data Set (MDS) with an assessment reference date of 09/26/2025, revealed a staff assessment for mental status score of 03, which indicated Resident #4 was severely cognitively impaired and never/rarely made decisions. The resident's MDS also indicated Resident #4 was dependent on staff for bed mobility, with the helper doing all of the effort. During an observation on 09/22/2025 at 3:00 PM, this surveyor observed Resident #4 lying flat on their back while in bed, with the Head of Bed (HOB) not elevated, as ordered. During an observation on 09/22/2025 at 4:47 PM, this surveyor observed Resident #4 lying flat on their back while in bed, with the HOB not elevated, as ordered. During an observation on 09/23/2025 at 8:30 AM, this surveyor observed Resident #4 lying flat on their back while in bed, with the HOB not elevated, as ordered. During an observation on 09/23/2025 at 3:14 PM, this surveyor observed Resident #4 lying flat on their back while in bed, with the HOB not elevated, as ordered. During an observation on 09/25/2025 at 8:00 AM, this surveyor observed Resident #4 lying flat on their back while in bed, with the HOB not elevated, as ordered. During an interview on 09/23/2025 at 3:28 PM, CNA #6 stated, I mainly work on the shower team, but I am helping out on the floor today [09/23/2025] since showers are done. CNA #6 revealed they had worked at the facility for five years and had received trainings on caring for a resident with a feeding tube, providing perineal care, keeping the tubing for the feedings clean, and making sure the feeding tubing was clamped and if it was not, to were to notify the nurse. Resident #4 was observed lying in their bed with the HOB not elevated, during the interview. During an interview on 09/24/2025 at 10:15 AM, Licensed Practical Nurse (LPN) #3 said Resident #4 should never be allowed to sleep or lay flat on their back, the HOB should be elevated. LPN #3 stated the resident's guardian requested the resident's HOB be elevated while the resident was in bed. LPN #3 looked at Resident #4's Physician Orders, and confirmed the order dated 10/09/2024, instructed for the resident's HOB to be elevated to 30-45 degrees, while in bed. During an interview on 09/24/2025 at 10:25 AM, the MDS Nurse confirmed Resident #4's Physician's Order specified the residents HOB should be raised 30-45 degrees, while in bed. The resident's Care Plan stated, HOB elevated, but did not specify a degree. The MDS Nurse said Resident #4's Care Plan did not include the Physician's Order for the HOB to be elevated while the resident was in bed. During an interview on 09/24/2025 at 12:00 PM, the Director of Nursing (DON) said the Physician's Order and Care Plan should be followed by the facility staff when providing care to any resident. The DON reviewed Resident #4's Physician Order and confirmed the order required the resident's HOB to be elevated at 30-45 degrees, while in bed. The DON then said, if the HOB was not elevated; the resident could aspirate. During an interview on 09/24/2025 at 12:30 PM, the Administrator said they expected the staff to follow the Physician's Orders and Care Plan when providing care to any resident. During an interview on 09/24/2025 at 2:54 PM, the Medical Director (MD)/Physician stated any resident who received bolus feedings, should have their HOB elevated when lying in bed, so they would not aspirate or regurgitate. The MD said they were familiar with Resident #4 and with their order for their HOB to be elevated 30-45 degrees, while in bed. The MD then confirmed Resident #4's HOB should be elevated at 30-45 degrees, and their expectations of the staff at the facility was that the Physician Orders be followed word for word.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure staff followed appropriate Enhanced Barrier Precautions (EBP) when providing care for one (Resident #14) of one sampled resident. The findings include: During an observation on 09/24/2025 at 9:50 AM, this surveyor observed an EBP sign outside Resident #14's door and the Treatment Nurse preparing to provide wound care. She put on gloves and walked into Resident #14's room, without putting on a gown. During an observation on 09/24/2025 at 9:52 AM, this surveyor observed the Treatment Nurse remove a bandage from Resident #14's right outer heel. The bandage was dated 09/22/2025 and had a yellowish drainage on it. She cleaned the resident's wound with wound cleanser and patted it dry. Resident #14 had a low bed and the Treatment Nurse was kneeled on the side of the bed. When she leaned over to provide treatment to Resident #14's wound, her shirt and pants touched the resident's bed. A review of Resident #14's Face Sheet indicated the facility admitted the resident on 03/11/2024, with diagnoses, which included an unspecified open wound to the right foot. A review of Resident #14's quarterly minimum data set with an assessment reference date of 07/02/2025, revealed a brief interview of mental status score of 01, which indicated the resident had severe cognitive impairment. A review of Resident #14's Physician Orders documented, Enhanced Barrier Precautions related to wound, start date 08/02/2024. During an interview on 09/24/2025 at 10:04 AM, the Treatment Nurse indicated that she just started Monday, and today [09/24/2025] was her second time providing wound care treatment for Resident #14. She indicated Resident #14 was on EBP, and a gown and gloves should be worn for direct resident care. The Treatment Nurse confirmed she should have worn a gown when she provided wound care for Resident #14 but forgot to wear a gown because she thought her clothing would not come in contact with the resident. During an interview on 09/24/2025 at 4:05 PM, the Medical Director indicated that Resident #14 had a wound, therefore a gown and gloves should be worn when providing wound care. During an interview on 09/24/2025 at 4:20 PM, the Director of Nursing verified Resident #14 was on EBP and a gown and gloves should be worn during wound care. A review of a form titled, One on one in-service education and training report, dated 09/24/2025, was signed by the Treatment Nurse. It documented, Follow EBP policy when providing direct patient care to residents with any portal of entry for possible infection, i.e., wound, PEG [Percutaneous Endoscopic Gastrostomy], ostomy, catheter, and IV. A review of a policy titled, Enhanced Barrier Precautions, revealed, EBP requires donning of gown and gloves during high contact resident /guest care activities that provide opportunities for transfer of MDRO's [Multidrug-Resistant Organisms] to staff hands and clothing.

42016 Based on observation, interview, and record review the facility failed to ensure food stored in the refrigerator, freezer, and storage room were labeled and dated and expired food items and left over foods were promptly removed from stock; and ensure employees avoided the use of alcohol-based hand rub (ABHR)/hand sanitizer gel in lieu of proper handwashing during food distribution, in 1 of 1 kitchen observed. These failed practices had the potential to affect 99 residents who received meals from the 1 of 1 kitchen. The findings are: 1. On [DATE] at 11:16 AM, the following observations were made: a. Two clear plastic disposable containers of a smooth brown substance, covered with a clear lid, contained no description of contents or date. The Dietary Manager stated it was gravy and should have been labeled. The Dietary Manager removed the items from the refrigerator and placed them in trash can outside door of refrigerator. b. A clear plastic food storage container was not labeled or dated. Dietary Manger identified the contents as chocolate frosting. c. An individual container of yogurt was located on a metal shelf and did not contain a resident's name. The Dietary Manager stated it was for a resident but did not know the resident's name. The container had a handwritten date of ,d+[DATE]. d. A clear plastic food storage container was labeled as Tomato Sauce with a date of ,d+[DATE]. e. A clear plastic food storage container was labeled Chocolate Frosting with a date of ,d+[DATE]. f. A clear plastic food storage container was labeled as Chicken Noodle Soup with a date of ,d+[DATE]. g. An unlabeled and undated clear plastic food storage container held a cloudy white/tan colored fluid with food items identified by the Dietary Manager as hot dogs. h. An unlabeled and undated clear plastic food storage container held a thick red substance identified by the Dietary Manager as spaghetti sauce. i. Two open, undated, one-gallon containers of Italian dressing were located on a top metal shelf. j. An open plastic container of coleslaw, dated ,d+[DATE]. k. An open clear plastic bag of lettuce wrapped with clear plastic film was undated. l. During an interview on [DATE] at 11:19 AM, the Dietary Manager stated the food was past the 3 days and would have to be thrown away. 2. On [DATE] at 11:20 AM, the following observations were made: a. A clear plastic food storage container was labeled as turkey with an open date of ,d+[DATE]. b. A sealed clear plastic storage bag contained an open, used plastic dispensing bag of whipped topping with no open date. 3. During an observation on [DATE] at 7:20 AM, a cell phone was laying on the silver preparation counter with a bottle of spray hand sanitizer, to the left of the Dietary Manager. The cell phone sounded with music, the dietary manger touched the phone to silence the sound, picked up the hand sanitizer and sprayed left hand, placed sanitizer back on preparation counter, and rubbed hands together. The Dietary Manger continued to place cereal, yogurt, condiments, and beverages on resident trays being passed through the service window to be served to residents. At 7:30 AM the cell phone sounded and was silenced by the Dietary Manager. The cell phone sounded an additional 4 times and was silenced each time by the Dietary Manger. The Dietary Manger used spray sanitizer and continued placing items on resident breakfast trays. At 7:38 AM, the Dietary Manger opened and entered the walk-in refrigerator, obtained three containers of yogurt, returned to the service counter, placed 1 yogurt on a resident tray, two yogurts into a holding bin. No hand hygiene was performed. At 7:45 AM, the Dietary Manager returned to walk in refrigerator and obtained two containers of grape juice, placed on tray and used spray hand sanitizer. 4. A facility policy titled, Food Receipt and Storage, dated [DATE], provided by the Dietary Manager on [DATE] at 10:14 AM indicated, . Purpose: Foods should be received and stored properly to prevent food borne illness . II. Storage of Foods . k. Open food items should be covered, labeled, and dated 5. A facility policy titled, Food Preparation Guidelines, dated [DATE], provided by the Dietary Manager on [DATE] at 10:14 AM indicated, . Purpose: To assure that the nutritive value of food is not compromised because of prolonged food storage . Attached is an exhibit . Storage of Refrigerated Foods . cover and label with item name and date . Leftovers discarded after 72 hours (3 days) if not used 6. A review of a facility policy titled, Leftover Food Storage and Use, dated [DATE], provided by the Dietary Manager on [DATE] at 10:14 AM indicated, . Purpose: To assure that food borne illnesses are avoided . b. Leftover foods should be covered, labeled and dated . c. Refrigerated leftover foods should be used within 72 hours (three days). If not used within 72 hours, refrigerated foods should be discarded . 7. A review of a facility policy titled, Hand-washing Guidelines, dated [DATE], provided by the Dietary Manager on [DATE] at 10:14 AM indicated, To prevent the spread of bacteria that may cause food borne illnesses .Frequency of Handwashing; Hands should be washed in the following situations . After hands have touched anything unsanitary . 8. On [DATE] at 4:20 AM, 2 of 2 containers that contained poultry seasoning were on a rack in the kitchen with an expiration date of [DATE]. 9. On [DATE] at 4:21 AM, a bag of sandwich bread was on the food preparation counter with an expiration date of [DATE]. 10. On [DATE] at 4:28 PM, the following observations were made in the walk-in refrigerator: a. The temperature of the walk-in refrigerator was 50 degrees Fahrenheit. The surveyor asked the Dietary Manager to check the internal temperature of the milk in a gallon. She did so, and stated, It was 50 degrees. A different temperature gauge was used to check milk, which remained at 50 degrees Fahrenheit. The surveyor asked the Dietary Manager to check a carton of milk and milk from different gallons with an initial temperature gauge. She did and both milks registered to be 40 degrees Fahrenheit. b. An opened box of sausage was on a shelf. The box was not covered or sealed. c. A container of leftover peanut butter dated [DATE] was on a shelf in the refrigerator. The surveyor asked the Dietary Manager how long could the leftover food item be kept in the refrigerator? She stated, We keep it for a week. I don't think it was on the 12th. I think they were trying to put 22, instead of 12. 11. On [DATE] at 5:25 PM, Dietary [NAME] (DC) #1 wore gloves on his hands while serving supper. DC #1 picked up tray cards, straws and placed them on the trays, contaminating the gloves. Without changing gloves and washing his hands, DC #1 picked up sandwiches with his contaminated gloved hand and placed them on the plates to be served to the residents. 12. On [DATE] at 5:29 PM, the following observations were made in the storage room. a. Nine bags of bread on the bread rack in the storage room with an expiration date of [DATE]. b. Two bags of bread with an expiration date of [DATE]. c. One bag of hot dog buns with 8 buns in it with an expiration date of [DATE]. d. There were 2 bags of corn chips on the rack with an expiration date of [DATE]. e. There were 2 -20 boxes of pinto beans with an expiration date of [DATE] and 8 bottles of sauce on a rack with an expiration date of [DATE] Dietary Manager stated, I don't even know why the sauce and pinto bean were still there we never used them. 13. On [DATE] at 5:54 PM, DC #1 walked out of the freezer carrying a pan that contained chicken salad sandwiches and placed it on the counter. Without washing his hands, DC #1 placed gloves on his hands, contaminating the gloves. DC #1 then used his gloved hands to pick up chicken salad sandwiches and placed them on the plates and served them to the residents for supper. a. At 6:00 PM, the Surveyor asked DC #1 what he should have done after touching the freezer door and walked out with a pan of chicken salad sandwiches and/or before handling food items. He stated, I should have changed gloves and washed my hands. 14. On [DATE] at 5:57 PM, the following observations were made in the freezer. a. There were 3 opened boxes of biscuits on a shelf in the freezer. The boxes were not covered or sealed. b. An opened box of hamburger patties was on a shelf in the freezer. The box was not covered or sealed. c. A partially opened box of vanilla ice cream was on a shelf in the freezer. The ice cream was discolored. The surveyor asked the Dietary Manager to describe the appearance of the ice cream. She stated, It looked like it has been melted and refroze. 15. On [DATE] at 6:28 PM, the ice machine panel, which was in contact with the ice before dropping into the ice collector, had wet orange residue on it. The Surveyor asked the Dietary Manager to wipe the panel. She did so, and the residue easily transferred to the paper towel. The Surveyor asked her to describe the substance. She stated, It was orange dirt. The Surveyor asked the Dietary Manager to wipe the inside back panel. She did so, and accumulation of wet black residue easily transferred to the paper towel. The Surveyor asked her to describe the substance. She stated, It was gunk. The Surveyor asked, How often is the ice machine cleaned? She stated, I don't know how often. The housekeeping supervisor cleans it. The Surveyor asked, Does it look like it has been cleaned once a week? She stated, No. The Surveyor asked, Who uses ice from the machine? She stated, They use it to fill beverages served to the residents at mealtimes. That's the ice the CNAs. [Certified Nursing Assistants] use for the water pitchers in the resident ' s rooms. On [DATE] at 8:41 AM, the Surveyor asked housekeeping and Laundry Supervisor who was responsible for cleaning the ice machine in the Dining Room. She stated, It has been missed a couple of times. We will in-service them on cleaning ice machine. 16. On [DATE] at 6:30 PM, the ice scoop holder on the wall by the ice machine had a wet accumulation of black grayish residue at the bottom of it. The ice scoop was stored in the scoop holder in direct contact with the residue. The surveyor asked the Dietary manager to wipe the black residue at the bottom of the scoop holder. She did so, and the black residue easily transferred to the tissue. The Surveyor asked the Dietary Supervisor to describe the appearance of what was inside the scoop holder. She stated, There is black dirt. That's where the scoop was brushing onto. The Surveyor asked, How often do you clean the scoop holder? She stated, I clean it two times a day. 17. On [DATE] at 7:19 AM, a Certified Nursing Assistant (CNA) #8 who was on the tray line assisting with breakfast meal picked up condiments and carton of beverages and placed them on the trays, contaminating her hands. Without washing her hands, she picked up glasses that contained beverages to be served to the residents for the breakfast meal and placed them on the trays. 18. On [DATE] at 8:57 AM, the surveyor and Dietary Manager observed the ice machine in front of the nurse's station. The surveyor asked the Dietary Manager to wipe the inside of the ice machine spout. She did so, and an orange residue easily transferred to the paper towel. The Surveyor asked her to describe the substance. She stated, It was orange dirt. The Surveyor asked the Dietary Manager to wipe the inside of the waterspout attached to the ice machine. She did so, and yellow residue easily transferred to the paper towel. The Surveyor asked her to describe the substance. She stated, It was yellow dirt. The Surveyor asked, How often is the ice machine cleaned? She stated, I don't know how often. The maintenance supervisor cleans it. The Surveyor asked, Who uses ice from the machine? She stated, Everybody, residents, and the staff, At 9:21 AM, the surveyor asked the Maintenance Supervisor who is responsible for cleaning the ice machine spout and how often. He stated, I am. I clean it once a month. 19. On [DATE] at 11:10 AM, Dietary Aide (DA) #10 picked up a box of dinner rolls from a cart in the storage room and placed it on top of another utility cart, contaminating her hands. DA #10-then pushed the cart into the dish washing room. Without washing her hands, DA #10 picked up dishes from clean racks and placed them on the cart with her fingers inside of them. 20. On [DATE] at 11:15 AM Dietary aide (DA) #10 picked up the water hose with her bare hand, used it to spray leftover food from inside of the dishes, contaminating her hands. She placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side of the dishwasher area and picked up clean dishes and placed them on the clean cart to be used in serving lunch meal to the residents. The Surveyor asked her immediately what you should have done after touching dirty objects or before handling clean Equipment? She stated, I should have washed my hands. 21. On [DATE] at 11:29 AM, DC #11 wore gloves on her hands when she picked up a box of dinner rolls from a cart in the storage room and placed it on the counter, contaminating the gloves. DC #11 opened the box of dinner rolls. She then used her gloved hands to remove dinner rolls from the box and placed them in a pan to be heated up and served to the residents for lunch. The surveyor asked DC #11 what she should have done after touching dirty objects and before handling food items and clean equipment? She stated, I should have removed gloves and washed my hands. 22. On [DATE] at 11:46 AM, DC #11 walked into the kitchen from the storage wearing gloves on her hands carrying a bag of bacon bites and placed it on the counter. She picked up scissors and used cut open bag of bacon bites. Without changing gloves and washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets for lunch meal. The Surveyor immediately stopped DC #11 and asked what she should have done after touching a bag of bacon bites, scissors and before handling clean equipment and/or handling. She stated, I should have changed gloves and washed my hands.

Based on observation, record review, and interview the facility failed to maintain an effective pest control program to ensure the kitchen service areas the main dining room were free of pests. This failed practice had the potential to affect all residents who resided in the facility. The findings are: 1. The following Pest Elimination Invoice dated 4/19/2024 documented, . Inspected and treated selected areas. Performed Exterior Rodent Service, Performed Interior Rodent Service and re set traps. Target Pests Mice, Cockroaches, flies' location kitchen. 2. An Invoice dated 5/30/2024 documented, .large fly serviced .Performed Interior spot treatment, for large flies. Performed Exterior fly treatment .Target Pests .Flies. large Equip. Location. Kitchen. Application Method. Stop Location applied. Dining interior, Exterior Area, kitchen area interior, near entry. 3. On 06/26/2024 8:25 AM, there were 5 flies in the storage room. The Dietary Manager closes the door between the storage room and the kitchen. 4. On 06/26/2024 at 11:58 AM, a fly was at the edge of a plate on the plate warmer. The surveyor showed it to Dietary [NAME] (DC) #11 who shooed it away. 5. On 06/26/2024 at 12:02 PM, a fly was crawling at the edge of a pan that contained baked apples. 6. On 06/26/2024 12:26 PM, a fly was crawling at the back of a scoop on the counter by the steam table. The surveyor showed it to Dietary [NAME] (DC) #11 and she shooed it away. 7. On 06/26/2024 at 1:11 PM, Resident #93 was sitting in a wheelchair in the dining room and was served a lunch tray. Immediately after the tray was served, a fly flew inside the bowl that contained salad. The surveyor immediately showed it to the Certified Nursing Assistant (CNA) #18 who was assisting residents in the dining room. She immediately removed it and brought another bowl of salad to the resident. 8. On 06/26/2024 at 1:29 PM, the surveyor observed Dietary [NAME] (DC) #6 enter the kitchen through the storage room door and left the door opened. At 1:30 PM, the surveyors informed DC #6 that the door was not closed when he came into the kitchen through the door. DC #6 was asked by the survey to count the flies that were in the storage room. He stated, We have problems with flies. I counted 8 flies or more. That's a lot of flies. They come in when the door is left open. There is a dumpster close to the kitchen. 9. On 06/26/2024 at 1:44 PM, CNA #12 stated, We have a lot of smokers. Fly comes in when they hold the door to let residents out. 10. An Invoice dated 06/26/2024 documented, Inspected and treated selected areas. Performed Exterior and interior fly treatment, placed 2 bags on building exterior, added fly light dining area, added baited fly panels to kitchen.

Based on observation, record review, and interview the facility failed to ensure care plans were revised for 2 of 2 sampled Residents (Resident #78 and #89). The findings are: 1. A review of the Face Sheet reveals that Resident #78 had diagnoses of severe intellectual disabilities and developmental disorders. a. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 06/06/2024 showed Resident #78 had a Staff Assessment of Mental Status (SAMS) completed that reveals memory problem for long-term and short-term memory. b. A review of the Care Plan revealed an intervention of resident door open at all times for easy visualization related to inability to utilize call light. No other interventions are in place for the recent removal of the call light. c. On 06/24/2024 at 11:36 AM, Surveyor observed Resident #78 sitting on bed crossed legged with the call light going off continuously and no call light located on Resident #78 ' s side of the room or plugged into the board on the wall. d. On 06/24/2024 at 12:00 PM, during an interview Certified Nursing Assistant (CNA) #28 stated it has only been like this a few days, We had to take the call light away as the resident kept wrapping it around their neck. CNA #28 stated Resident #78 ' s roommate will usually ring a bell as a way for them to know that they need care. CNA #28 stated this behavior from Resident #78 is normal, and They pull the call light out of the wall consistently. e. On 06/24/2024 at 2:00 PM, Surveyor observed the call light still going off continuously. f. On 06/25/2024 at 10:00 AM, Surveyor observed the call light still going off continuously. g. On 06/26/2024 at 9:00 AM, Surveyor observed a plug has been put into place, Resident #78 does not have a call light at this time. h. On 06/26/2024 at 9:05 AM, during an interview with CNA #28 stated the call light was fixed yesterday afternoon, and that Resident #78 does not have a call light. CNA #28 stated Resident #78 is non-verbal but that they do frequent rounds and watch for cues with Resident #78 to provide care. i. On 06/27/2024 at 8:26 AM, during an interview with the MDS Coordinator confirmed that there were no interventions for the removal of the call light in the care plan. MDS Coordinator stated that a comprehensive care plan was important as the resident could go without needs being met. 2. A review of the Face Sheet revealed that Resident #89 had a diagnosis of Amyotrophic Lateral Sclerosis (ALS). a. A review of the Quarterly MDS with an ARD of 05/321/2024 reveals that Resident #89 had a SAMS completed that revealed the resident had a memory problem for long-term and short-term memory. b. A review of the Care Plan revealed no interventions for limited range of motion. c. On 06/24/2024 at 11:58 AM, Surveyor observed both of Resident #78 ' s hands were contracted with the fingers touching the forearms, no interventions are in place. d. On 06/25/2024 at 9:40 AM, Surveyor observed no interventions in place for the contractures. e. On 06/25/2024 at 2:37 PM, during an interview with CNA #24 stated when Resident #89 was first admitted to facility rolled washcloths and stretches were used. CNA then stated that they have moved to D hall for the last few months and that they remembered no charting for contractures. f. On 06/25/2024 at 2:45 PM, during an interview with CNA #20 stated that they are familiar with the resident and work this hall often and can think of no charting for the contractures. CNA #20 stated during care they do range of motion stretches and attempt washcloths, but it is difficult with the level of contracture the resident has. g. On 06/27/2024 at 8:26 AM, during an interview the MDS Coordinator confirmed that no interventions were in place for contractures on the care plan and stated that it is important to have an accurate care plan so staff know how to care for the resident, such as skin integrity in this case, or even know not to try and stretch the contractures too far. Interventions can help prevent worsening of limited range of motion. h. On 06/27/2024 at 08:50 AM, during an interview the Director of Nursing (DON) stated it is important to have an accurate care plan. It is an expected part of their maintenance and that way staff know how to bridge the gap for care. 3. A review of the facility policy Person Centered Care Plans revealed When a new approach or goal is identified, the entry should be dated using the date the goal/approach is entered on the care plan.

Based on observation, record review, and interview the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. The failed practices had the potential to affect 7 residents who received pureed diets, 1 resident who received pureed meat only, 60 residents who received regular diets and 30 residents who received mechanical soft diets from 1 of 1 kitchen. The findings are: 1. The 06/25/2024 supper menu documented the residents who received pureed diets were to receive 3-ounce of chicken salad and 4-ounce (1/2 cup) of pureed country macaroni salad and for the residents on regular diets were to receive 3/4 cup of toss salad with dressing. 2. On 06/25/2024 at 5:26 PM, the following observations were made during the supper meal service. a. Dietary Aide #7 used a tong to serve a small portion of toss salad to the residents on regular diets. b. Dietary [NAME] (DC) #6 served mashed potatoes to the residents on pureed diets, instead of pureed country macaroni salad. At 06:05 PM, the surveyor asked DC #6 the reason residents on pureed diets did not receive pureed macaroni salad. DC #6 stated, Bunch of people like mashed potatoes. We should have followed the menu. c. 06/25/24 6:03 PM, the surveyor asked Dietary aide (DA) #7 to measure the same amount of toss salad that she had served to the residents for supper. DC #7 placed the same amount of toss salad on a plate and transferred it into a 4-ounce spoon and stated, They supposed to have 4 ounces. The surveyor asked Dietary aide (DA) #7 if she reviewed the menu before serving supper meal. DA #7 stated, No, I thought they were supposed to have 1/2 cup. 3. The 06/26/2024 noon menu documented the residents who received pureed diets were to receive 2 ounce (1/4 cup) of pureed dinner roll. a. On 06/26/24 at 1:08 PM, the residents on pureed diets were not served pureed dinner rolls. b. On 06/26/24 at 1:10 PM, the surveyor asked DC #11 the reason residents on pureed diets did not receive pureed dinner rolls. DC #11 stated, I forgot.

Based on record review, observation, and interview the facility failed to provide residents with a safe, functional, sanitary, and comfortable environment to promote dignity and safety. The findings are: On 06/24/2024 at 3:02 PM, the top of bedside table in room [ROOM NUMBER] observed with hard, thick, vinyl ripped and torn, and edges pointed and sharp. On 06/26/2024 at 11:21 AM, a bedside table in room [ROOM NUMBER] was observed placed over the resident ' s bed. The vinyl is torn and ripped, exposing pointed and sharp edges. The Maintenance Director revealed during an interview the bedside table had not been reported. The table could not be fixed, and they are usually thrown away. Maintenance verbally described the table as peeling vinyl and pointed, guaranteed to cause injury, and should have been reported. On 06/27/24 8:30 AM, Certified Nursing Assistant (CNA) #12 revealed during an interview that if something needed to be fixed in the facility, they have a book they write in that goes to maintenance, but that she usually tells the maintenance man and keeps after him until it is fixed. On 06/24/2024 at 11:24 AM, Surveyor observations during initial rounds of room [ROOM NUMBER], the gold doorknob was loose, with a gap at the top of the doorknob revealing it had separated from the door. On side B a green armchair is observed with part of the fabric missing on the front of the left arm, wood and brackets are exposed. In the bathroom the outside bowl is covered in a yellow grime substance, the drain hole under the toilet bowl has no cover. On 06/24/2024 at 12:13 PM, Surveyor observed the C Unit Dining Room, on the left-hand wall is a small patch of missing dry wall, the wall itself is observed to be covered in a brown gummy like substance. Above the end table in the corner drywall is missing matching the length of it, a brown substance covers the surface of the end table. The door to the courtyard has a tile missing at the entrance. The refrigerator in the right-hand corner, a dustpan is observed overflowing with trash including cups, juice cartons, and milk cartons. On the back wall two dents are observed, the top dent a patch has been started, paint is peeling in the area, the lower dent has drywall exposed, the electrical outlet has a piece of drywall missing right behind the top part of the plastic, and the wall itself is covered in brown substance throughout it. On the right wall above the air conditioner unit, a corner has drywall missing exposing metal. On 06/24/2024 at 1:30 PM, Surveyor observed in room [ROOM NUMBER], side B, the wall behind the headboard is missing paints, and pieces of drywall, a live spider is observed to be hanging near the bed. The bed is against the wall, large gouges of drywall and paint are missing, and under the bed debris can be seen from the damage observed. The outlet is missing the lower plastic part, the air conditioner is plugged in, and the right side is hanging out of the outlet slightly. 06/25/2024 at 2:52 PM, during an interview with Maintenance he stated I have a paper log but I do not keep the papers. Then stated Everybody has my number, usually they text me night and day what is needed throughout the building, I am on call 24/7. Maintenance then stated the project they are working on right now is the vents throughout the building with nothing back logged. Maintenance stated they could forward the messages or write them down. On 06/26/2024 at 12:22 PM, during environmental rounds and interview Maintenance stated that in room [ROOM NUMBER], the doorknob was reported Monday, but they Haven't had time to pick it up. Maintenance stated the exposed wood on the armchair was rough, feels course, sharp could be hazardous. Then stated this was not reported to him. Maintenance stated the drain and other issues in the bathroom has not been reported to him and could be fixed easily. When Surveyor asked about the concerns in the dining room, Maintenance stated this was reported to him three weeks ago, but it has not been taken care of as the residents are in here all day. This makes it difficult to repair in here, as they interrupt while I am working. While walking to the next room Maintenance stated he could not come in early or stay late as I work a second job at this time, and it really can burn you out quick with how many repairs are needed in this facility, I am constantly getting pulled from one project to another. Maintenance stated for room [ROOM NUMBER], that the walls or the electrical outlet has not been reported to him, and he stated that this could be hazardous to the resident especially the outlet. He stated that the wall where the bed was up against has deep scratches. A review of the facility policy Federal Rights of Resident/Guest(s) states (i) Safe environment. The facility must provide, (i)1A safe, clean, comfortable, and homelike environment. 49689

42016 Based on record review, observation and interview the facility failed to ensure staff implemented hand hygiene to prevent the spread of disease and infection for 3 (Residents #39, #20, and #12) of 3 sampled residents, and failed to ensure a resident was not exposed to pests while in their room for 1 resident (Resident #73). The findings are: 1. A review of a Face Sheet indicated the facility admitted Resident #39 with diagnoses that included hemiplegia, hemiparesis, and dementia. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/2024 revealed Resident #39 had a Staff Assessment for Mental Status (SAMS) score of 2, which indicated the resident moderately impaired for their daily decision making. Skin and ulcer treatments included, pressure relieving device for chair and bed. On 06/25/2024 at 12:57 PM, Certified Nursing Assistant (CNA) #17 touched the top of Resident #20 ' s head with her right bare hand and patted her head. CNA #17 did not perform hand hygiene. On 06/25/2024 at 12:57 PM, CNA #17 served a meal tray from the kitchen window to Resident #39 with bare hands. CNA #17 placed the meal tray onto the table and removed silverware and started cutting up resident ' s meat with a knife and fork. CNA #17 opened the salt and pepper and sprinkled on Resident #39 ' s food. On 06/25/2024 at 12:59 PM, CNA #17 assisted CNA #8 and placed a gait belt around Resident #39 ' s waist. CNA #8 and CNA #17 assisted Resident #39 up with gait belt and placed into a regular chair and pushed resident to the table. CNA #17 went to the kitchen window and continued to touch shirt with bare hands. CNA #17 did not perform hand hygiene. On 06/25/2024 at 1:01 PM, CNA #17 removed a meal tray from the kitchen window and placed it on the table in front of Resident #12. CNA #17 removed food from the meal tray and placed it on the table in front of Resident #12. CNA #17 opened the salt and pepper packets and put salt and pepper on Resident #12 ' s food. CNA #17 removed silverware and put butter on Resident #12 ' s bread. CNA #17 placed a clothes protector on Resident #12. CNA #17 did not perform hand hygiene. On 06/25/2024 at 1:45 PM, during an interview with CNA #17, CNA #17 revealed hand hygiene should be performed during meal service, and between each tray, and hand hygiene was important, so germs are not passed around during meal service. germs, I know better. On 06/27/2024 at 8:30 AM, CNA #12 revealed during an interview hands should be sanitized between each resident meal tray to prevent cross contamination. On 06/27/24 at 12:37 PM, during an interview with the Director of Nursing (DON), the DON revealed hand hygiene should be performed during meal service before, during, and after to ensure germs are not taken from one resident to another. 2. A review of the Face Sheet, indicated the facility admitted Resident #73 with diagnoses that included atherosclerotic heart disease and current diagnoses that included atrial fibrillation, vascular dementia, and obstructive and reflux uropathy. The annual MDS with an ARD of 05/29/2024 revealed Resident #73 had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. Resident #71 required supervision/touching assistance with dressing, partial/moderate assistance with personal hygiene, bathing, putting on footwear and had an indwelling catheter. Review of Resident #73's Care Plan(s) revealed the resident a catheter. Interventions included, observe for signs and symptoms of infections . Fragile skin .observe for environmental concerns . During a concurrent observation and interview on 06/25/2024 at 8:59 AM, CNA #18 stated there are 6 flies on Resident #73's blanket, 3 down here (pointed at the bottom area of the bed near footboard) and 4 up there, (pointed to the top of blanket near Resident #73's shoulders). The trash can is full and looks like hot chocolate with a fly on it. (pointed at a brown substance in a drip pattern down the side of bag extending over rim of trash can) Those are flies on the recliner. CNA #18 stated Maintenance is notified by phone or by placing information in the logbook but could not recall if notification was made regarding the files. During a concurrent observation and interview on 06/26/2024 at 9:44 AM, in room [ROOM NUMBER], Maintenance stated, flies on the floor, bed, and chair were being treated. No additional information was provided. A review of a facility policy titled, Infection Prevention and Control Program Overview, dated 09/14/2020, indicated, .Goals .Identify and correct problems relating to infection prevention & control practices .Provide a safe, sanitary and comfortable environment . A review of a Named Pest Company Customer Service Report with a service date of 04/19/2024 documented, Service-Related Comment .Named Company Large Fly Program serviced . Glue boards checked. Performed interior spot treatment for large flies .glue boards were 75% full. A review of a Named Pest Company Customer Service Report with a service date of 05/30/2024 documented, Service-Related Comment .Inspected and treated selected areas .Named Company Large Fly Program serviced. Glue boards checked. Glue boards were 75% full .Performed interior spot treatment for large flies .

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 7 residents who received pureed diet, and one resident who received pureed meat only. The findings are: 1. On 06/25/2024 at 4:53 AM, the following observations were made on the steam table: a. A pan of pureed cut green beans, the consistency was runny. b. A pan of pureed chicken, the consistency was gritty, not smooth, and had water in the mixture. c. A pan of pureed beef sauce, the consistency was running. 2. On 06/25/2024 at 6:28 PM, the surveyor asked the Dietary Manager to describe the consistency of the pureed food items served to the residents on pureed diets at supper meal. She stated, Pureed cut green beans look like nectar. Pureed chicken was gritty and pureed beef sauce was watery. 3. On 06/26/2024 at 7:14 AM, the following observations were made on the steam table: a. A pan of pureed oatmeal. The consistency was thick. b. A pan of biscuit. The consistency was lumpy. c. A pan of pureed sausage. The consistency was gritty and not smooth. Pieces of bread were visible in the mixture. d. A pan of cream of wheat. The consistency was watery. 4. On 06/26/2024 at 7:26 AM, the surveyor asked Dietary Manager to describe the pureed food items served to the residents on pureed diet for breakfast. She stated, Pureed sausage was gritty and had pieces of bread in it. Pureed biscuit was lumpy, and pureed oatmeal was thick. 5. On 06/26/2024 at 11:11 AM, Dietary [NAME] (DC) #11 used a #12 scoop to place 8 servings of diced ham into a blender, added broth and pureed. She poured the pureed ham into a pan and placed it on the steam table. The consistency of the pureed ham was runny. 6. On 06/26/2024 at 12:00 PM, DC #11 used a #6 scoop to place 6 servings candy yam into a blender, added a little water, garlic powder and pureed. She poured the pureed yam into a pan and placed it on the steam table. The consistency of the pureed yam was runny. 7. On 06/26/2024 at 12:23 PM, DC #11 placed 8 servings of spinach with eggs into a blender, added broth and pureed. She poured it into a pan and placed it on the steam table. The consistency was runny.

Based on observation, record review, and interview the facility failed to ensure food was prepared by methods that maintained appearance; hot foods were served hot and cold foods were served cold to maintain palatability and encourage adequate nutritional intake for 1 of 1 meal observed on the B Hall and C Hall. The failed practice had the potential to affect 14 residents who received meal trays in their room on B Hall and 18 residents who received meal trays in their rooms on A-Hall. The findings are: 1. On 06/24/2024 at 2:53 PM, Resident #29 stated the food is always cold when asked if the hot food is hot when received to the room on a tray. 2. On 06/25/2024 at 1:42 PM, an unheated cart that contained trays for lunch was delivered to the B Hall by Certified Nursing Assistant (CNA) #14. 06/26/24 2:02 PM, immediately after the last resident received their tray in their room on B-Hall (Unit), the temperatures of the food items on a test tray from the food cart were checked by the Dietary Manager and read by Certified Nursing Assistant #13. The results were as follows: a. Ground ham with gravy - 92 degrees Fahrenheit. b. [NAME] yam - 80 degrees Fahrenheit. c. Cut green beans - 100 degrees Fahrenheit. d. Ham - 99 degrees Fahrenheit. 2. On 06/26/2024 at 5:24 PM, an unheated food cart that contained 23 trays for supper was delivered to A Hall by the Certified Nursing Assistant #15. At 5:41 PM, immediately after the last resident received their tray in their room on A-Hall, the temperatures of the food items on a test tray from the food cart were checked by the Dietary Manager and read by Licensed Practical Nurse (LPN) #16. The results were as follows: a. Potato salad - 60 degrees Fahrenheit. b. Ground riblets 90 degrees Fahrenheit. c. Riblets 99 degrees Fahrenheit.

49689 Based on record review, observation, and interview, the facility failed to ensure residents rights were acknowledged and treated in a manner to promote dignity for 6 (Resident #3, #39, #46, #55, #68, and #95) of 6 sample mix residents. The findings are: 1. A review of a Face Sheet indicated the facility admitted Resident #39 with diagnoses that included hemiplegia, hemiparesis, and dementia. a. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/2024 revealed Resident #39 had a Staff Assessment for Mental Status (SAMS) score of 2, which indicated the resident was moderately impaired for their daily decision making. Skin and ulcer treatments included a pressure relieving device for chair and bed. b. Review of Resident 39's Care Plan, dated 10/23/2017, revealed the resident was at risk for skin breakdown, with interventions that included utilizing pressure reducing cushion while up in chair. c. On 06/24/2024 at 1:13 PM, (Certified Nursing Assistant) CNA #35 assisted Resident #39 into a regular chair from a specialized chair in the dining room. The dining room was full of residents and staff. Resident #39 ' s pants dropped down exposing Resident #39 ' s brief and upper buttocks. d. On 06/27/2024 at 8:30 AM, CNA #12 revealed she was in the dining room the day Resident #39 was transferred from the specialized chair to the dining room chair and saw Resident #39 ' s pants fall down exposing the resident ' s brief and buttocks. CNA #12 revealed Resident #39 had lost a lot of weight and the clothes the resident had on that day were very loose and when they stood Resident #39 up, the pants fell and exposed the brief and buttocks. CNA #12 revealed they should ensure Resident #39 ' s clothes fit better, that is something that should have been addressed before the resident went to breakfast, and it could have been avoided. e. On 06/27/2024 at 12:37 PM, the Director of Nursing (DON) revealed that it is the responsibility of the staff member to ensure a resident's dignity is maintained during meal service while transferring from one chair to another. 2. A review of the Face Sheet indicated the facility admitted Resident #95 with diagnoses that included neurocognitive disorder with Lewy bodies. a. The Admission MDS with an ARD of 04/09/2024 revealed Resident #95 had a BIMS score of 11, which indicated the resident was had moderate cognitive impairment. Resident #95 required supervision or touching assistance with eating, partial/moderate assistance for oral hygiene, substantial/maximal assistance with upper body dressing and personal hygiene and was dependent with lower body dressing and toileting. b. A review of Resident #95's Care Plan revealed the resident was at risk for aspiration. Interventions included thickened liquids and allowing sufficient time to feed/eat. c. During an observation and interview on 06/24/2024 at 1:11 PM, Resident #95 was sitting in a specialized wheelchair in the dining room. CNA #29 was standing to the left of Resident #95, using a spoon to provide fluid and a fork to place food into Resident #95's mouth. CNA #29 stated Resident #29 has good and bad days and today is unable to eat without assistance. d. During an interview on 06/24/2024 at 1:55 PM, CNA #29 stated they would sit or stand while assisting Resident #95 depending on the height the resident was at. CNA #29 further stated that when Resident #95 eats in their room, and the bed is raised, the CNA would stand to assist. CNA #29 stated they had to stand because there were no additional chairs in the dining room and did not think about getting a chair from the resident's room. e. During an observation on 06/26/2024 at 2:14 PM, Resident #95 was sitting in a specialized wheelchair in the dining room. CNA #13 was standing to the left of Resident #95 placing food and beverage into Resident #95's mouth. f. During an interview on 06/26/2024 at 2:31 PM, CNA #34 stated Resident #95 required assistance with meals and if Resident #95 wanted to eat in their room, CNA #34 sits in the chair to help them eat. If Resident #95 chose to eat in the dining room and it is full, CNAs stand to provide assistance. CNA #34 indicated training was received on dignity and it doesn't matter if CNAs sit or stand to provide assistance. CNA #34 indicated that if Resident #95 required assistance with a meal, Resident #95 would prefer to have someone sit to provide the assistance. g. During an interview on 06/26/2024 at 2:42 PM, CNA #13 stated Resident #95's disease had worsened and they required assistance with eating and it is better to sit and be eye to eye with the resident to see if the Resident is swallowing and not pocketing (holding food in your cheeks). CNA #13 indicated dignity training was received and it was better to sit and feed the resident. h. During an interview on 06/27/2024 at 11:10 AM, Licensed Practical Nurse (LPN) #32 stated residents should be positioned at a 90-degree angle if possible, and staff should sit with the resident if assistance is being provided and should never stand over them and assist due to dignity. i. During an interview on 06/27/2024 at 12:26 PM, the Director of Nursing stated Resident #95 is dependent and requires assistance with meals. When staff provides assistance with meals they should sit and not stand to feed a resident. 3. A review of the Face Sheet revealed that Resident #3 had diagnosis of dementia with agitation, bipolar disorder, and schizoaffective disorder. a. A review of the Quarterly MDS with an ARD of 05/30/2024 revealed that Resident #3 scored an 11 (moderately impaired) on the BIMS. b. A review of the Face Sheet revealed that Resident #46 had diagnosis of dementia, delusional disorders, and depressive disorders. c. A review of the Quarterly MDS with an ARD of 04/23/2024 revealed that Resident #46 scored an 8 (moderately impaired) on the BIMS. d. A review of the Face Sheet revealed that Resident #55 had diagnosis of dementia, paranoid disorder, and anxiety disorder. e. A review of the Quarterly MDS' with an ARD of 05/08/2024 revealed that Resident #55 scored a 9 (moderately impaired) on the BIMS. f. A review of the Face Sheet revealed that Resident #68 had diagnoses of dementia, and attention and concentration deficit. g. A review of the Quarterly MDS with an ARD of 05/30/2024 revealed that Resident #68 scored a 7 (severely impaired) on the BIMS. h. On 06/24/2024 at 12:38 PM, Surveyor observed Resident #55 was set up by staff with a lunch tray. i. On 06/24/2024 at 12:42 PM, Resident #46 and Resident #3 were set up by staff with a lunch tray. Resident #68 was observed to be looking at the other residents eating in the dining room. j. On 06/24/2024 at 12:45 PM, Resident #68 stated that they were not thrilled with lunch today. Then stated to the other residents that they were tired of waiting. Resident #68 keeps looking at the doorway for staff to come in with lunch trays and was wringing their hands together while waiting for lunch. k. On 06/24/2024 at 12:51 PM, CNA #28 came into the dining room and set up Resident #68's tray. l. On 06/24/2024 at 12:53 PM, during an interview CNA #28 confirmed the last tray passed was Resident #68 ' s. CNA stated they were to pass trays table by table, so there is no one sitting there watching others eat. CNA stated the issue for the residents is they are having to wait for food, and it could be dignity as well. m. On 06/25/2024 at 11:52 AM, during an interview Licensed Practical Nurse (LPN) #20 stated generally the procedure for passing trays is table by table so residents will not be watching other residents eat. LPN #20 stated the resident could feel envious of others and that it is a dignity issue. 4. A review of the policy Federal Rights of Resident/Guest(s) states Resident/Guest rights. A facility must treat each resident/guest with respect and dignity and care for each resident/guest in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident/guest(s) individuality.

Based on observation, interview, and record review the facility failed to ensure expired bubble pack medications were removed from the medication cart once the expiration date has been reached for 3 of 5 medications carts checked for review, the facility failed to ensure controlled substances were properly removed once the seal to the medication had been broke to prevent the possible misappropriation of medication for 1 of 3 medication carts checked for review, the facility failed to ensure that medications were stored and labeled out of resident reach for 1 (Resident #32) of 1 residents. The findings are: 1. On 06/27/2024 at 09:51 AM Surveyor checked E Hall Cart for compliance with Licensed Practical Nurse (LPN) #33. The findings are: (1) bubble pack card of Ibuprofen 600 mg (milligram)tablets with an expiration date of 10/17/2023 with 13 pills remaining (1) bubble pack card of Ibuprofen 600 mg tablets with an expiration date of 10/17/2023 with 12 pills remaining (1) bubble pack card of Hyoscyamine 0.125 mg sublingual tablets with an expiration date of 05/10/2024 with 30 pills remaining (1) bubble pack card of Ondansetron 4 mg tablets with an expiration date of 05/10/2024 with 24 pills remaining (1) bubble pack card of hydrochlorothiazide 25 mg tablets with an expiration date of 05/30/2024 with 29 pills remaining During an interview on 06/27/2024 at 9:51 AM, the LPN #33 stated medication carts are checked every few weeks and corporate came in on 06/20/2024 and checked the medication carts for any expired medications. LPN #33 also stated medication carts are checked to ensure that residents do not receive expired medications. 2. On 06/27/2024 at 10:04 AM Surveyor checked D Hall Cart for compliance with LPN #33. The findings are: (1) bubble pack card of hydroxyzine hcl (Hydrochloric Acid) 25 mg tablets with an expiration date of 05/29/2024 with 3 pills remaining (1) bubble pack card of hydroxyzine hcl 25 mg tablets with an expiration date of 05/07/2024 with 7 pills remaining (1) bubble pack card of ondansetron hcl 4 mg tablets with an expiration date of 05/22/2024 with 3 pills remaining (1) bubble pack card of Hyoscyamine 0.125 mg sublingual tablets with an expiration date of 05/29/2024 with 27 pills remaining 3. On 06/27/2024 at 10:18 AM Surveyor checked A Hall Cart for compliance with LPN #19. The findings are: (1) bubble pack card of Oxybutynin chloride 5mg tablets with an expiration date of 05/03/2024 with 7 pills remaining (1) bubble pack card of Urogesic- blue tablets with an expiration date of 04/30/2024 with 28 pills remaining (1) bubble pack card of oxybutynin chloride 5 mg tablets with an expiration date of 04/11/2024 with 3 pills remaining (1) bubble pack card of oxybutynin chloride 5 mg tablets with an expiration date of 04/11/2024 with 7 pills remaining (1) bubble pack card of oxybutynin chloride 5 mg tablets with an expiration date of 05/03/2024 with 7 pills remaining During an interview on 06/27/2024 at 10:18 AM, LPN #19 stated the medication carts are checked at least monthly, but the as needed medications are not checked unless the Pharmacists is here. LPN #19 also stated that medication carts are checked to ensure that residents do not receive expired medications, remove the cards if no longer taking, and to ensure they have the prescribed medication available. 4. On 06/27/2024 at 10:18 AM Surveyor reconciled controlled substances on Medication cart A and B with LPN #19. The findings are: (1) bubble pack card of clonazepam 0.5 mg tablets with 15 tablets remaining with a broken seal on pill #4 (1) bubble pack card of Morphine sulfate 15 mg ER tablets with 14 tablets with a taped in pill on pill #14 (1) bubble pack card of diazepam 5 mg tablets with 47 tablets remaining with a broken seal on pill #9, 10, 20 (1) bubble pack card of Tramadol 50 mg tablets with 6 tablets with a taped in pill on pill #6 During an interview on 06/27/2024 at 10:18 AM, the LPN #19 stated controlled substance pills should be wasted once the seal is broken by two nurses and signed out in the controlled substance book because you don't know for sure what pill is in there. It's the point of the seal. 5. During an interview on 06/27/2024 at 11:05 AM, the Director of Nursing (DON) stated during count of controlled substance medications the nurses should be checking for breaks in the seal. Once the seal is broken the nurse needs to secure the break, the nurse can remove the pill and waste it, or it can be taped by the nurse. The DON stated this is to ensure there are no missing medications. The DON stated medication carts are checked monthly by the Pharmacists which were in the facility and checked carts on 06/26/2024 and the corporate quality assurance consultant checks the carts quarterly. The medication carts are checked to ensure the residents do not receive an expired medication. 6. A review of a facility policy titled, Storage of Medications and Biologicals, dated 04/20 indicated, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. 7. A review of a Face Sheet indicated the facility admitted Resident #32 with a diagnosis that included dementia. a. A review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2024 revealed Resident #32 had scored a 12 on a Brief Interview for Mental Status, indicating moderate cognitive impairment. b. On 06/24/2024 at 11:45 AM, Resident #32 lying in bed. A bottle of 5% eye solution was on the bedside table. Resident # 32 states they do not self-administer eye drops and does not take eye drops. c. On 06/25/2024 at 5:27 PM, Resident #32 was observed lying in bed. An unlabeled medicine cup containing a white cream substance was observed on resident nightstand. Resident #32 was asked what the cream was used for. Resident #32 stated, They use it on my legs I guess. d. On 06/25/2024 at 5:30 PM, LPN #19 was asked if Resident #32 had an order for eye drops. LPN #19 revealed Resident #32 did not have an order for the eye drops. LPN #19 revealed she did not know what the cream was in the medicine cup, and that it was a hazard and dangerous to leave those items in the resident's room. e. On 06/25/2024 at 5:37 PM, LPN #36 revealed during an interview that the cream in the unlabeled medicine cup looked like barrier cream, but could not say for sure, and that it should not be left in a resident room because they could ingest it. f. On 06/27/2024 at 12:37 PM, during an interview the DON revealed medications should be stored in the medication room, medication carts, or treatment carts so they are not in reach of people who should not have them.

Based on record review, observation, and interview, the facility failed to ensure a transfer lift was properly working to prevent the potential for harm for 2 (Resident #76 and Resident #79) of 2 sampled residents; and the facility failed to ensure chemicals were contained / stored when not in use to prevent the possible ingestion and injury for 1 (Resident #32) sampled resident. The findings are: 1. A review of a Face Sheet indicated the facility admitted Resident #32 with a diagnosis of dementia. a. A review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2024 revealed Resident #32 had scored a 12 on a Brief Interview for Mental Status, indicating moderate cognitive impairment. b. On 06/25/2024 at 5:27 PM Resident # 32 observed lying in bed. A canister of disinfecting wipes was observed on resident nightstand. c. On 06/25/2024 at 5:30 PM, Licensed Practical Nurse (LPN) #19 was asked about the disinfecting wipes and revealed it was possible the resident's family brought them in, and it was a hazard and dangerous to leave those items in the resident's room. d. On 06/27/2024 12:37 PM, the Director of Nursing (DON) revealed during an interview that disinfecting wipes should be stored in the supply room or the bottom drawer of the medication cart because it is a chemical and should be out of reach of people who should not have them. 2. On 06/25/2024 at 9:00 AM, Surveyor observed a transfer lift on D hall missing the upper right and lower right metal moveable attachments. a. On 06/25/2024 at 2:19 PM, Surveyor observed a lift transfer with Resident #76, Certified Nursing Assistant #21 (CNA) and CNA #18. Surveyor observed the transfer, with both moveable attachments missing. b. On 06/25/2024 at 2:52 PM. during an interview CNA #18 stated that their last training was in school nine years ago, and that they have been at the facility for over a year. CNA #18 then stated that the lift was the only one throughout the building and if it breaks, they page for Maintenance at the nurse's station. CNA #18 stated that the residents have to wait their turn for the lift, when it gets really busy. c. On 06/25/2024 at 2:52 PM, during an interview with Maintenance he stated that I have a paper log, but I do not keep the papers. Then stated that Everybody has my number, usually they text me night and day what is needed throughout the building, I am on call 24/7. d. On 06/25/2024 at 6:22 PM, during an interview CNA #22 stated, I was last trained during school in 2011, and some new jobs require us to do a demonstration. CNA#22 then stated if any issues arise, I go directly to my nurse after that I go to the maintenance book and mark it down. e. On 06/25/2024 at 6:43 PM, CNA #27 was interviewed and revealed the last time she had training on the lifts was about 6-7 months ago during CNA classes, and she reports issues with the lift to the maintenance man, and he takes care of it. f. On 06/25/2024 at 6:45 PM, the surveyor observed the transfer of Resident #79 from wheelchair into bed with missing clips, during the transfer the right top hanger a missing moveable metal attachment is missing, the strap moved up and came close to slipping out. During an interview CNA #22 and CNA #23 agreed they have never noticed the missing metal attachments on the transfer lift. CNA #22 then stated that now they realized it has been like that for a month and half. g. On 06/25/2024 at 6:45 PM, during an interview CNA #25 stated the last training for the mechanical lift was about 2 months ago and was on how to properly use the lift. h. On 06/25/2024 at 7:20 PM, during an interview Licensed Practical Nurse (LPN) #26 reported working nights at the facility for 5 months, and stated the lift is checked by maintenance regularly and if there were any issue maintenance would take care of it. i. On 06/25/2024 at 7:22 PM, during an interview Maintenance stated they inspected the lifts once a month and offered the inspection logs. Maintenance confirmed they were trained to inspect the lifts and stated the issues they saw were no rubber skids on top of the legs at the base, and the two missing clips, on one the top right and one on the bottom left. The issue is that if somebody pulls on it or if it is not properly positioned it could slip and a resident could get hurt. j. On 06/25/2024 at 7:30 PM, during an interview Registered Nurse #3 (RN) stated if the lift is in use and works, it is safe to use. If it wasn't safe, it would have been taken out of service. k. On 06/25/2024 at 8:10 PM, during an interview the Director of Nursing (DON) stated they train staff annually on lift usage. Any issues are to be reported to a member of management or maintenance and if the lift is used when it is broken, it could lead to injury. l. A review of the facility policy Lifting Device Policy states to 2. Follow manufacturer's directions for specific lift or repositioning device usage. m. A review of the Named Lift 50/600 RPL450-2, RPL600-2 Battery- Powered Patient Lift User Manual indicated, DO NOT move the patient if the sling is not properly connected to the hooks of the hanger bar. When the sling is elevated a few inches off of the stationary surface and before moving the patient, check again to make sure the sling is properly connected to the hooks of the hanger bar. If any attachments are NOT properly in place, lower the patient back onto the stationary surface and correct this problem; otherwise, injury or damage may occur.

Based on observation, record review, and interview the facility failed to ensure that physicians orders were followed for oxygen therapy for 1of 1 Resident #89 sampled resident. These are our findings: A review of the Face Sheet revealed that Resident #89 had diagnosis of amyotrophic lateral sclerosis (ALS). A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/321/2024 reveals that Resident #89 had a Staff Assessment of Mental Status (SAMS) completed that revealed had a memory problem for long term and short-term memory. A review of the Care Plan states that the care plan goal is Resident #89 Will exhibit no shortness of breath, and interventions include administer oxygen therapy as ordered. A review of the Physicians Order List revealed Resident #89 had a physician's order for oxygen 2 liters per minute via nasal cannula for shortness of breath. On 06/24/2024 at 11:58 AM, Surveyor observed Resident #89 had uneven labored respirations, the oral cavity is red and cracked from mouth breathing. Surveyor observed Resident #89's oxygen concentrator set to 1 liter per minute (LPM). On 06/25/2024 at 9:40 AM, Surveyor observed Resident #89 had uneven labored respirations and the oral cavity is cracked from mouth breathing. Surveyor observed Resident #89's oxygen concentrator set to 1 LPM. On 06/25/2024 at 9:50 AM, during an interview Licensed Practical Nurse #19 (LPN) confirmed that Resident #79 ' s oxygen was reading in-between 1 liter per minute (LPM) and 1.5 LPM. LPN #19 confirmed that the order was for 2 LPM for the resident. LPN #19 stated not following a physician's order can lead to death, discomfort, or struggling, especially this resident as they are on Hospice and comfort is the goal. On 06/26/2024 at 08:50 AM, during an interview the Director of Nursing (DON) stated it's important to follow physician orders to meet their care needs. The DON stated that not following a physician order for a resident could lead to incorrect care. A review of the facility policy Oxygen Administration states that Oxygen should be administered under orders of the attending physician. Process: 1. Obtain physician's orders for the rate of flow and route of administration of oxygen.

Based on record review, observation, and interview, the facility failed to ensure interventions to prevent pressure ulcers to prevent skin breakdown or worsening of skin issues, were utilized for 1 (Resident #39) of 1 sampled resident. The findings are: 1. A review of a Face Sheet indicated the facility admitted Resident #39 with diagnoses that included hemiplegia, hemiparesis, and dementia. a. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/2024 revealed Resident #39 had a Staff Assessment for Mental Status (SAMS) score of 2, which indicated the resident moderately impaired for their daily decision making. Skin and ulcer treatments included a pressure relieving device for chair and bed. b. Review of Resident 39's Care Plan, dated 10/23/2017, revealed the resident was at risk for skin breakdown, with interventions that included utilizing a pressure reducing cushion while up in chair. c. On 06/24/2024 at 1:10 PM, Resident #39 observed sitting in a specialized chair in the dining room. There was no cushion in Resident #39 ' s specialized chair. d. On 06/25/2024 at 12:15 PM, Resident #39 observed sitting in a specialized chair in the dining room. There was not a cushion in Resident #39 ' s specialized chair. Resident #39 was sitting on the plastic straps. e. On 06/25/2024 at 12:31 PM, Resident #39 observed sitting in a specialized chair in the dining room. There was no cushion in Resident ' s specialized chair. Resident was sitting directly on the plastic straps. f. On 06/25/2024 at 12:53 PM, Resident #39 observed sitting in a specialized chair in the dining room. There was no cushion in Resident #39 ' s specialized chair. The Resident was sitting on plastic straps. g. On 06/25/2024 at 6:03 PM, Certified Nursing Assistant (CNA) #31 and CNA #1 was observed to transfer Resident # 39 from the dining chair to a specialized chair using a gait belt. CNA #31 and CNA #1 lifted Resident #39 and transferred into the specialized chair. There was no cushion in the specialized chair. Resident #39 was sitting on thick plastic/rubber straps. CNA #31 revealed during an interview that she did not know if Resident #39 was supposed to have a cushion in their wheelchair as she did not work that hall. h. On 06/25/2024 at 01:45 PM, during an interview CNA #17 revealed that most of the specialized chairs have a cushion, but Resident #39 did not have one and I don't know why, and that cushions were put in specialized chairs to prevent skin breakdown. i. On 06/27/2024 at 8:30 AM, CNA #12 revealed during an interview that Resident #39 had not had a cushion in the Resident #39 ' s specialized chair and a corporate lady gave her a cushion this morning and asked if she would put it in Resident # 39 chair. j. On 06/27/2024 at 12:37 PM, the Director of Nursing (DON) revealed during an interview that she did not know why Resident #39 did not have a cushion in the specialized chair and all care staff is responsible for ensuring pressure relieving devices are in residents' chairs.

Based on observations, record review, and interview the facility failed to ensure a Minimum Data Set (MDS) was accurately coded for 1 (Resident #89) sampled resident. The findings are: A review of the Face Sheet revealed that Resident #89 had a diagnosis of amyotrophic lateral sclerosis (ALS) A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/321/2024 revealed that Resident #89 had a Staff Assessment of Mental Status (SAMS) completed that revealed had a memory problem for long-term and short-term memory. A review of Section GG revealed that it was coded for one upper extremity with limited range of motion. A review of the Care Plan for Resident #89 revealed no interventions for limited range of motion. On 06/24/2024 at 11:58 AM, the Surveyor observed both of Resident #89 ' s hands contracted with the fingers touching the forearms, no interventions are in place. On 06/25/2024 at 9:40 AM, Surveyor observed no interventions in place for the contractures. On 06/25/2024 at 2:37 PM, during an interview with Certified Nursing Assistant (CNA) #24, CNA #24 stated when Resident #89 was first admitted to the facility, rolled washcloths and stretches were used to treat the contractures. CNA #24 stated that they have moved to D hall for the last few months and that they remembered no charting for contractures. On 06/25/2024 at 2:45 PM, during an interview CNA #20 stated that they are familiar with Resident #89 and worked this hall often and cannot think of any charting for the contractures. CNA #20 stated during care they do range of motion stretches and attempt washcloths, but it is difficult with the level of contracture the resident has. On 06/27/2024 at 8:26 AM, during an interview the MDS Coordinator stated the most recent MDS is coded for one upper extremity in section GG, limited range of motion. MDS Coordinator stated can we go look at the resident, I am not sure if that is correct. The MDS Coordinator confirmed on observation that the MDS was not correctly coded, the resident has two contractures, then stated the MDS is important to ensure care plans are accurate, and the resident summary is as well. The MDS Coordinator stated that they just recently switched to this position but stated that the criteria is if the resident cannot do full range of motion, it is limited in some capacity. On 06/27/2024 at 8:50 AM, during an interview the Director of Nursing stated that the MDS is the most thorough assessment for the residents. It is important to have an accurate MDS to care for the resident properly. A review of the facility policy Resident Assessment Instrument (RAI) revealed Purpose: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop a plan of care; Standard: According to federal regulations the facility conducts initially and periodically a comprehensive, accurate, and standardized assessment of each resident's functional capacity.

Based on observations and interviews, the facility failed to ensure walls in residents' rooms were maintained in good repair to provide a clean and homelike environment for residents who resided on 2 (B Hall and D Hall) of 2 halls observed. Findings include: During an observation of room [ROOM NUMBER] on 06/24/2024 at 12:28 PM, the golden colored wall next to the bed was damaged exposing the gypsum compound which is used to patch and fix drywall and was exposed from under the paint in white irregular shaped areas visible above the edge of the side of the bed. The edge of the door to the resident ' s bathroom had chipped paint and rough cracked areas with brown debris in the cracks on the edge of the door, above and below the handle and on the door jam. There was a gouged area in the middle of the door exposing raw wood. The toilet seat on the toilet in the resident ' s bathroom was peeling and had yellow, brown and black staining covering the top where resident would sit on the toilet. During an observation on 06/24/2024 at 1:52 PM, the doorknob to room [ROOM NUMBER] was loose and the escutcheon plate was not seated and was falling forward against the door handle interfering with operation of the door handle. During an observation of room [ROOM NUMBER] on 06/25/2024 at 8:56 AM, inside the room on the left side of the door opening just over the threshold, the brown tile had an oval shaped area missing tile and exposing the concrete floor below. There were lines around the missing tile in a cracked type of pattern extending across to another tile. The bathroom sink in room [ROOM NUMBER] was missing the drain cover and had damage in a cracked pattern spreading outward around the drain and across the bottom of the sink. The area around the exposed drain and bottom of the sink in cracks contained a brownish black gritty substance. The wall to the right side of bed B was damaged, from the level of the top of the headboard extending toward the floor, both vertically and horizontally in an irregular, scrape/scratch like pattern with white patches and peeling paint, exposing the gypsum compound which is used to patch and fix drywall and was exposed from under the paint. The resident did not understand why the wall could not be fixed and stated, It makes me feel like they don't care about me. During an interview on 06/25/2024 at 8:59 AM, Certified Nursing Assistant (CNA) #18 stated the floor of room [ROOM NUMBER] was a fall risk because of the damaged tile and the damage needed repair. CNA #18 stated the bathroom sink has grit in the bottom that could be felt, and the sink was stained. During an interview on 06/25/2024 at 3:20 PM, Maintenance stated there are two maintenance log books, one white and one black at the nurses ' station, but Maintenance was unable to locate the log books. During an interview on 06/26/2024 at 9:41 AM, Maintenance was asked if the facility had a maintenance program or schedule. Maintenance stated rounds are done monthly, two halls per month and a monthly calendar is used to track what rooms needed repairs. Damaged walls, leaking bathrooms, and other things are fixed in an order from worst to least. If a room is bad and the resident refuses to allow maintenance to work on it, the repairs are not done until there is a room change or a discharge. Maintenance stated notification of needed repairs is done by the person requesting the repair. During a concurrent observation and interview on 06/26/2024 at 9:44 AM, in room [ROOM NUMBER], Maintenance stated the wall behind bed B needed to be textured, sanded, and painted. The floor has a missing chunk of tile about 1.5 inches by 2.0 inches and 1/8th inch deep. Maintenance reported the tile will have to be cut out and replaced. Maintenance was asked if the floor was safe for residents in the room and stated if the floor is not repaired it would be bumpy and there is a concern it would destabilize their walker. During a concurrent observation and interview with Maintenance in room [ROOM NUMBER], Maintenance stated the toilet seat was replaced at 4:30 PM on 06/24/2024 after the surveyor had been in the room. Maintenance stated the toilet seat was worn out and he would not have sat on the seat to use the bathroom. Maintenance stated the bathroom door in room [ROOM NUMBER] was scuffed up and needed to be painted to cover the chipped and gouged area. Maintenance stated the wall, next to the side of the bed, in room [ROOM NUMBER] needed to be textured and painted. During a concurrent observation and interview in room [ROOM NUMBER], Maintenance stated the handle to the room door was loose and the screw that goes under the cap is loose ad needs to be tightened. When asked what should be done, Maintenance stated the handle needed to be replaced because if the door was closed and the handle fell off, they would have to pick up the handle, put it back on and turn it to open it. During a concurrent observation and interview, on 06/26/2024 at 10:23 AM, the Administrator was asked if the facility had a maintenance program or maintenance schedule. The Administrator stated if a room is vacant, they go in and do repairs. If repairs require a resident to be relocated, they do that if the resident agrees. In room [ROOM NUMBER], the Administrator was asked if the wall in the room was acceptable. The Administrator stated the damage would be addressed and resident may have to be relocated if the resident agrees. The Administrator was aware of the floor damage and stated Maintenance was previously asked to address the floor damage, and the damage could be a hazard with use of the walker. The Administrator opened the bathroom door and stated the sink would be looked at as well.

Based on observation, record review, and interview, the facility failed to ensure the kitchen was clean, sanitary and maintained; floor tiles and baseboard were replaced; a loose baseboard was secured; storage areas and kitchen vents were cleaned to provide a sanitary environment for food preparation, failed to ensure food items stored in the refrigerator and freezer were sealed or covered and were stored in accordance with the manufacturer's instructions; failed to ensure dietary staff washed their hands between dirty and clean tasks and before handling clean dishes or food items; failed to ensure the ice machine and ice scoop holder were maintained in clean and sanitary condition; failed to ensure hot foods were maintained at or above 135 degrees Fahrenheit (F.) while awaiting to be served to prevent potential food borne illness, and failed to ensure leftover food items were not used for residents who received meals from 1 of 1 kitchen to maintain food quality and prevent the growth of bacteria. These failed practices had the potential to affect 92 residents who received meals from the 1 of 1 kitchen (total census: 92), as documented on a list provided by the Dietary Supervisor on 05/25/23 The findings are: 1. On 05/22/23 at 11:09 AM, the following observations were made in the Kitchen: a. The ceiling vents between the food preparation counter and the door leading to the Storage Room were black encrusted. b. The wall baseboard by the food preparation counter was loose. c. The wallpaper mixed with paint above the 3-compartment sink was peeling, exposing the cement. d. The bottom shelf below the food preparation where clean pans were stored was chipped exposing the metals. e. The floor tiles leading to the walk-in refrigerator were missing. The areas where tiles were missing were covered with black residue. f. The baseboard wall above the racks where canned goods were stored was peeling, exposing the wood. 2. On 05/22/23 11:10 AM, Dietary Employee (DE) #1 turned on the hand washing sink and washed her hands. She then turned off the faucet with her bare hands, contaminating her hands. She then removed tissue papers from the dispenser and dried her hands. Without washing hands, she picked up clean bowls with her fingers inside the bowls and placed them on the counter to be used in portioning desserts to be served to the residents for lunch. 3. On 05/22/23 at 11:20 AM, the following observations were made in the Kitchen: a. The base board around the wall leading to the Janitor's Closet was missing, exposing the concrete. There were 3 missing tiles in front of the door in the Storage Room leading to the outside. b. The floor tiles in front of the entrance door to the Kitchen were missing exposing the concrete. 4. On 05/22/23 at 11:31 AM, DE #2 removed a bag of bread from the bread rack and untied it with gloves on her hands, contaminating the gloves. Without changing gloves and washing her hands, she removed hot dog buns from the bag and placed them in a to go box. She then, placed polish sausage on each bun to be served to the residents for the lunch meal. At 1:17 PM, the Surveyor asked DE #2 what should you do after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 5. On 05/22/23 at 11:36 AM, DE #1 turned on the hand washing sink and washed her hands. She then turned off the faucet with her bare hands, contaminating her hands. She then removed tissue papers from the dispenser and dried her hands. She picked up a box of gloves from under the food preparation counter and placed it on the counter. She removed the gloves from the box and placed them on her hands, contaminating the gloves. Without changing gloves and washing her hands, she scooped ice into individual glasses, using her contaminated gloved hand to push ice cubes into individual glasses that contained beverages to be served to the residents for the lunch meal. 6. On 05/22/23 at 11:38 AM, an opened box of hot dogs was on a shelf in the refrigerator. The box was not covered or sealed. 7. On 05/22/23 at 11:44 AM, the following observations were made on shelves in the walk-in freezer: a. An opened box of broccoli. The box was not covered or sealed. b. An opened box of omelets. The box was not covered or sealed properly. c. An opened box of mixed vegetables. The box was not covered or sealed. 8. On 05/22/23 at 11:56 AM, the ice scoop holder on the wall by the ice machine had a wet accumulation of black grayish residue at the bottom of it. The ice scoop was stored in the scoop holder in direct contact with the residue. The Dietary Supervisor was asked to wipe the black residue at the bottom of the scoop holder. She did so, and the black residue easily transferred to the tissue. The Surveyor asked the Dietary Supervisor to describe the appearance of what was inside the scoop holder. She stated, There is gray silver color residue. The Surveyor asked, How often do you clean the scoop holder? She stated, We clean it daily. 9. On 05/22/23 at 11:58 AM, the ice machine panel, which was in contact with the ice before dropping into the ice collector had an accumulation of brown substance on it. The Surveyor asked the Dietary Supervisor to wipe the panel. She did so, and the residue easily transferred to the paper towel. The Surveyor asked her to describe the substance. She stated, It was a black film. The Surveyor asked, How often is the ice machine cleaned? She stated, I don't know who cleans it. The Surveyor asked, Does it look like it has been cleaned once a week? She stated, No. The Surveyor asked, Who uses ice from the machine? She stated, They use it to fill beverages served to the residents at mealtimes. That's the ice the CNAs [Certified Nursing Assistants] use for the water pitchers in the residents' rooms. a. On 05/25/23 at 8:23 AM, the Surveyor asked the Housekeeping and Laundry Supervisor who was responsible for cleaning the ice machine in the Dining Room. She stated, We do. They check it every other day and deep clean it. 10. On 05/22/23 at 12:09 PM, DE #2 checked the temperatures of the hot food items that had been placed on the serving line on the steam table in preparation for the lunch meal service. The temperatures were: a. Hamburger buns - 120 degrees Fahrenheit. b. Ground hot dogs - 125 degrees Fahrenheit. c. Pureed hamburger patties - 120 degrees Fahrenheit. d. Pureed potatoes - 125 degrees Fahrenheit. e. The above food items were not reheated before being served to the residents. The Surveyor asked DE #2, What should you do when food items are not hot enough on the steam table? She stated, Reheat them. 11. On 05/22/23 at 4:31 PM, DE #1 walked into the kitchen wearing gloves on her hands carrying a container of ice cubes and placed it on the counter. Without changing gloves and washing her hands, she picked up a glass contaminating the glass. She then used the glass to scoop ice into each glass that contained beverages to be served to the residents for the supper meal. The Surveyor immediately stopped DE #1 and asked what she should have done after touching the container of ice and before handling clean equipment and/or handling food items. She stated, I should have changed gloves and washed my hands. 12. On 05/22/23 at 4:40 PM, DE #4 used tissue paper to wipe her face. Without washing her hands, she placed gloves on her hands, contaminating the gloves. She then used her gloved hands to pick up glasses that contained beverages and placed them in a pan to be served to the residents for supper. The Surveyor immediately asked DE #4 what she should have done after touching dirty objects and before handling food items and clean equipment. She stated, I should have washed my hands. 13. On 05/23/23 at 8:14 AM, DE #5 turned on the hand washing sink and washed his hands. He then turned off the faucet with his bare hands, contaminating his hands. He then picked up clean dishes to be used in portioning food items to be served to the residents for lunch from the plate warmer with his fingers inside the plates. The Surveyor asked what he should you have done after touching dirty objects and before handling clean equipment and food items. He stated, I should have washed my hands. 14. On 05/25/23 at 8:02 AM, DE #2 pureed leftover sausage from breakfast and poured it into a pan. She covered the pan with foil. At 8:12 AM, DE #2 pureed leftover scrambled eggs from breakfast. The Surveyor asked what the pureed eggs and pureed sausage were for. She stated they use leftover eggs and leftover sausage the next day for the residents on pureed diets. 15. The facility policy titled, Hand Washing Guidelines, provided by the Dietary Supervisor on 05/25/23 at 9:09 AM documented, .Hands should be washed in the following situations: .After hands have touched anything unsanitary . 16. The facility policy titled, Leftover Food Storage and Use, provided by the Dietary Supervisor on 05/25/23 at 12:07 PM documented, .h. Pureed foods should not be re-used. Leftover food will not be provided to residents receiving a pureed diet unless they select the leftover food item .

Based on record review and interview the facility failed to ensure insulin was administered as ordered to prevent diabetic complications for 1 (Resident #1) of 3 (Resident's #1, #2 and #3) case mix residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility removed the Immediate Jeopardy and corrected the failed practice on 6/1/2021 prior to the survey. The Registered Nurse (RN) Consultant was notified of the Past Immediate Jeopardy on 6/11/2021. The findings are: 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day Discharge Minimum Data Set with an Assessment Reference Date of 6/1/2021 documented the resident scored 11 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status and received insulin injections 5 days during the last 7 days or since admission / reentry if less than 7 days. a. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Pts [patients] blood sugars have been uncontrolled and greater than 400 several times per week. + [add] [MEDICATION(S)] 0.75 Pen once weekly for one month than re access . b. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 03/28/2021 . Discontinue Date: 06/01/2021 . [MEDICATION(S)] 1.5 MG [Milligrams]/0.5 ML [Milliliters] PEN give 0.75 SQ [subcutaneous] every week on Thursday . Discontinue Date: 6/03/2021 . c. A (Hospital) Clinical Discharge Summary dated 05/28/2021 documented, .Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications .insulin [MEDICATION(S)] ([MEDICATION(S)] [MEDICATION(S)] Pen 100 units/ml subcutaneous solution) 35 Unit(s) Subcutaneous once a day (in the morning) . d. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 0.75 MG/0.5 ML PEN inject 0.75 (0.5 ml) subcutaneous once a week . The [MEDICATION(S)] was not initialed or checked off as given on 05/29/2021, 05/30/2021, 05/31/2021, and 06/01/2021. The [MEDICATION(S)] was not initialed or checked off as given on 05/20/2021. e. The (Hospital) Records dated 06/01/2021 documented, .History of Present Illness [Resident #1] is a [AGE] year-old white female with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She has been hospitalized on a multitude occasions for diabetic ketoacidosis. She has been hospitalized here 3 times in the last 30 days for the same problem. Interestingly, she was recently admitted to a nursing home after she was restrained on a court order because it was not felt that she can take care of herself. Therefore, she has gone into DKA twice since being admitted to [Facility]. The patient assures me that she has been getting her insulin although I am not confident about that. According to the outside Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . She was discharged according to the discharge summary on 28 units subcu [subcutaneous] [MEDICATION(S)], however I do not see this on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . I have discussed this case with the hospitalist team, and they are planning to contact the director of nursing at [Facility] for further clarity . f. On 6/11/2021 at 10:50 a.m., the Assistant Director of Nursing (ADON) was asked, Why did [Resident #1] not get her [MEDICATION(S)] [insulin] orders restarted when she was discharged from the hospital on 5/28/2021? The ADON stated, I did do the orders for [Resident #1]. I just missed it. The morning of the first [6/1/2021] we started looking at her chart. That morning around 7:30 a.m. the [nurse] came to me and said her blood sugar read High and she was vomiting. This was before she went to the hospital. It had been the third time she had been discharged to the hospital related to high blood sugars. The DON usually does the orders. We pull the orders from their last hospital stay and put into [Electronic Health Record] under Physician Orders. I had spent days putting in orders. It just happened. g. On 6/11/2021 at 11:30 a.m., the DON was asked, Why are the May 2021 Medication Administration Records for [Resident #1] so difficult to make sense of? The DON stated, We had computer issues somewhere in the middle of May and had to go to paper charting. The DON was asked, Did [Resident #1] get her [MEDICATION(S)] insulin on 5/20/2021? The DON stated, I couldn't tell you. I know the hospital discontinued the [MEDICATION(S)] the last time she was admitted . h. On 6/11/2021 at 11:50 a.m., the Registered Nurse (RN) Consultant was asked, Were there any other medication errors related to residents not getting their prescribed insulin? The RN Consultant stated, No, we didn't discover any. We looked at new residents and resident's that had been readmitted to the facility. The RN Consultant stated, Was [Resident #1] getting her [MEDICATION(S)] weekly prior to her discharge on 6/1/2021? The RN Consultant stated, As far as I know, she was getting it. The RN Consultant was asked, Do you know if [Resident #1] got her [MEDICATION(S)] on 5/20/2021? The RN Consultant stated, I imagine one of the nurse's just forgot to chart it. We can ask them. 2. The Plan of Correction for Transfer Orders From Hospital dated 6/1/2021 documented: a. Quality Issue Problem [Resident #1] - Transfer orders from hospital were not properly transferred into [Electronic Health Record] on re-admission to facility . b. Action . 1. 6/1/2021 it was found that resident's new transfer orders from hospital were not correctly written on readmission to the facility. Corrective Action ADON/DON provided retraining to charge nurses on writing transfer orders on admission and readmission. 2. Admission chart audit done on all admission and readmission transfer orders from hospital from 5/24/2021-6/9/2021. If any errors noted during audit MD [Medical Director] to be notified and medication error report begin. 3. To ensure deficient practice does not reoccur. On 6/1/2021 shift to shift in-servicing has been initiated on writing transfer orders on admission and readmission per policy & [and] procedure. 4. Monitoring: Charge nurse to have another charge nurse or DON/ADON to review each admission transfer orders and compare with written orders in [Electronic Health Record]. Once reviewed by two nurses each nurse to sign printed orders from [Electronic Health Record] and place in chart. Each admission or readmission chart is to be brought to each am [morning] clinical meeting and reviewed by clinical subcommittee until compliance achieved. 5. QA [Quality Assurance]: DON/Designee will present all findings to the QA Committee monthly for further review.

Complaint # (AR 308) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure a resident was free of physical and mental abuse, as evidenced by Certified Nursing Assistant (CNA) #1 who placed her mask and hand over a resident's mouth and held it on the face of 1 of 1 (Resident #1) case mix resident who was alleged victim of physical and mental abuse. This failed practice resulted in Past Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #1 who was physically and mentally abused by CNA #1. The Administrator was notified of Past Immediate Jeopardy on 08/20/2020 at 4:20 PM. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/20/2020 documented resident scored 0 (0-7 indicates severely impaired) on the Brief Interview of Mental Status (BIMS) and required extensive assistance of two staff members for all personal hygiene. a. The Plan of Care with a revision date of 6/4/2020, documented, make bathing process pleasant . Quality of Life . explain procedures before and during care and attempt later if resistance . Explain procedures prior to preforming to decrease anxiety or fear . b. The Office of Long-Term Care (OLTC) Incident and Accident Report Division of Medical Services (DMS) form documented RN (Registered Nurse) #1 Title . RN .Date Submitted to OLTC 08/15/2020 . Time .12:56 (p.m.) Date and time of incident 08/14/2020 at 2300 (11:00 p.m.) .Type of incident . Physical .Name of Involved Resident (Resident #1). At approximately 2300 (11:00 p.m.) on 8/14 (CNA #2 and #3) were in (Resident #1) room providing him with a bath. Resident was being combative and spitting at them during this care, (CNA #3) was rubbing resident's hand to help calm him during the care that was effective. At that time another (CNA #1) entered room and stated, we don't have to take this kind of abuse, he needs to be transferred out of this facility. At that time the witnesses state that (CNA#1) removed her surgical mask from her face and placed over the resident's face as he had gotten upset again and started spitting. Resident removed the mask himself per staff, then (CNA#1) placed mask over residents face held it there with her hand. (CNA #2) left room at time to go notify nurse of what was going on. (Nurses #1 and #2) entered room and at that time (CNA#1) had removed the mask from resident's face and placed back on her face. Nurses had all staff leave room. Resident was in safe place for staff to leave. (Nurse #2) notified (Director of Nursing (DON)) and at that time (CNA#1) was suspended pending investigation. (CNA#1) was asked to provide witness statement for investigation. c. The OLTC Witness Statement Form dated 08/14/2020 at 11:30 PM CNA #2 documented, (CNA #3) and I went to give resident a bed bath and were in the process of doing it when (CNA#1) walked into the room she was the CNA on the hall. When (CNA#1) comes in she put gloves on and stood and watched she noticed resident was trying to spit on (CNA #3) and she took her mask off of her face and put it over his mouth so he couldn't spit. I took it off and (CNA#1) put it back on. Resident then rips it off to spit on her and she put her hand over his mouth and left it there. I immediately left the room and let the nurse know. When I return to room resident tries to spit and hit us again right after that she began laugh saying he needs to be transferred facilities. She kept making rude remarks towards him, the nurses, (Nurse #1 and #2) came into the room and pulled us all out. When she put the mask on her face it was forceful. Resident is always this way, especially with bathing. It's his normal personality it does not take much to calm him down though. She did not take her hand off his face until me and the nurses were heard walking in.' d. The OLTC Witness Statement Form dated 08/14/20 at 11:30 PM CNA #3 documented, (CNA #2) and I enter resident #1 room to give him a bed bath. (CNA#1) enters room and proceed to see (Resident #1) spitting and states no one should have to put up with this behavior. Resident proceeds hit and spit at (CNA #2) and myself and pinch myself. I try to calm (Resident#1) down by rubbing his hand he goes to spit and (CNA#1) proceeds to take personal mask off and places it on (Resident #1) face (around his ears and placed correctly at first). This causes a reaction out of (Resident#1) even more than before. He pulls it up over his head she yanks it back down to wear it was first placed before he pulls it up (CNA#1) covers his whole face with it, and begins to laugh that it made him upset I said please take it off him he is starting to get more upset. She states she was trying to get him to not spit at us he basically is blowing air out with his tongue. He get turn to proceed the bed bath towards me and he spits and scratches me. (CNA#1) proceeds to place hand over (Resident's #1) mouth. (CNA #2 and #3) get to brief on and (CNA #2) gives me the hey I gotta go get something, I'll be back. I knew she was going to get our nurse, I stayed to continue working with resident. e. The OLTC Witness Statement form dated 08/14/20 at 12:00 a.m. completed by CNA #1 documented, I was helping girl 1&2 control (Resident #1) during bed bath and changing sheets on bed. I went in the room to get vitals first then noticed (Resident #1) was hitting, spitting, scratching them so I stepped in to help them and I put a mask on (Resident#1) because he was spitting and running a temp which I had notified the nurse about the temp she said take it again took it three times every time over 100, so for the safety of us in the room I put a mask on resident since COVID is transfer through body fluid. We rolled him to make bed and put brief on him swinging arms and spitting because he took the mask off shortly after I put it on. f. The OLTC witness statement completed by LPN (Licensed practical Nurse) #1 dated 08/14/2020 at 11:40 PM. Documented, .made aware of the allegation by (LPN #2.) (LPN#2) and I went to evaluate the situation and assess resident made sure resident was safe and unharmed. Ask all aides to leave room. Followed protocol with reporting incident. g. On 08/19/2020 at 9:44 a.m., the Director of Nursing (DON) was asked, How did you ensure that the other residents were safe? She stated, Body audits and assessing the residents. (CNA#1) was pulled out of the room and not left alone until suspended. The DON was asked, Who notified you of the alleged abuse? She stated, (LPN #2) called. I instructed her to get statements and let (CNA#1) know that she is to leave, and she was suspended. The DON was asked, Did you report the alleged abuse the administrator? She stated, Yes, that night and the police was called.

Based on observation, record review, and interview, the facility failed to ensure an effective system was in place to ensure a physician-ordered narcotic pain medication was promptly acquired and available for administration when needed, to prevent unrelieved severe pain for 1 (Resident #20) of 8 (Residents #20, #98, #6, #45, #56, #91, #93, and #96) sampled residents who had physician orders for pain medication. This failed practice resulted in a pattern of harm to Resident #20, who experienced severe pain at levels of 7, 8 and 9 on a scale of 1 to 10 and did not receive her physician-ordered pain medication, and had the potential to cause more than minimal harm to 9 residents who had physician's orders for [MEDICATION NAME] and [MEDICATION NAME], according to a list provided by the Administrator on 7/10/19. The facility also failed to ensure documentation of the administration of pain medications on an as-needed (PRN) basis was free of discrepancies to ensure nursing staff were able to ascertain when the resident was last medicated and accurately determine the medication's effectiveness over time for 1 (Resident #20) of 27 (Residents #20, #3, #90, #93, #96, #98, #56, #61, #85, #45, #53, #77, #48, #97, #84, #7, #1, #46, #15, #82, #65, #95, #10, #6, #26, #11, #44) sampled residents who had physician orders for pain medications, according to a list provided by the Administrator on 7/10/19. The facility also failed to ensure an effective system was in place to ensure medications were acquired and administered in accordance with physician orders to ensure the accurate administration of medications and minimize the potential for complications for 6 (Residents #67, #72, #45, #402, #34 and 85) and failed to ensure a respiratory medication was discontinued as ordered to assure accuracy of medication administration for 1 (Resident #44) of 13 residents observed during the medication passes on 7/24/19 and 7/25/19. The findings are: 1. Resident #20 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/19 documented the resident scored 12 (8-12 moderate cognitive impairment) on a Brief Interview for Mental Status; was independent with set-up help only for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene; required pain assessments; did not receive scheduled or as needed pain medication; did not receive non-medication interventions for pain; and received an Opioid medication 1 out of the last 7 days. a. A physician's order dated 1/15/19 documented, .Tylenol ([MEDICATION NAME]) 325 mg (milligrams) tablet give 2 tablets to equal 650 mg every 6 hours as needed for mild to moderate pain. Do Not Exceed 4000 mg [MEDICATION NAME] (Tylenol) in 24 hours . Dx. (Diagnosis) . Pain . b. A physician's order dated 4/4/19 documented, . [MEDICATION NAME] 10-325 mg tablet give 1 tablet PO (by mouth) Q (every) 4 hours PRN (as needed) (for) severe pain . c. A Care Plan with a revised date of 8/15/18 documented, .Potential for Pain . observe for effectiveness of medication . measure resident pain level using pain scale 0 - 10 . d. The Medication Administration Record (MAR) dated (MONTH) 2019 documented Resident #20 received no as needed (PRN) [MEDICATION NAME] 10-325 mg on 6/2/19, 6/3/19, 6/6/19, 6/7/19, 6/9/19, 6/10/19, 6/12/19, 6/16/19, 6/17/19, 6/18/19, 6/21/19, 6/22/19, and 6/23/19. The MAR dated (MONTH) 2019 and the Narcotic Medication Disposition / Log Book contained discrepancies regarding the administration of the resident's narcotics. e. On 6/15/19 at 5:30 a.m., the Narcotic Medication Disposition / Log Book documented a balance of 4 tablets of [MEDICATION NAME] 10-325 mg. The Narcotic Log Book documented the following between 6/15/19 and 6/18/19: 6/15/19 at 5:30 a.m. [MEDICATION NAME] 10-325 mg 1 tablet administered, 6/15/19 at 8:00 a.m. [MEDICATION NAME] 10-325 mg 1 tablet administered; 6/15/19 at 1700 (5:00 p.m. [MEDICATION NAME] 10-325 mg 1 tablet administered; 6/15/19 at 1600 (4:00 p.m. [MEDICATION NAME] 10-325 mg 1 tablet administered; 6/16/19 at 1200 (12:00 p.m.) [MEDICATION NAME] 10-325 mg 1 tablet administered, leaving a balance of 0 tablets for the remainder of 6/16/19; 6/17/19 0 tablets available for administration; 6/18/19 0 tablets available for administration until 2300 (11:00 p.m.) at which time the facility received 59 [MEDICATION NAME] tablets from the pharmacy. f. There were no Nurse's Notes documented between 6/14/19 at 3:33 a.m. and 7/25/19 at 1:22 a.m. g. The Emergency Drug Box contained a Controlled Substance Withdrawal Log entry dated 6/18/19 at 12:23 p.m. which documented [MEDICATION NAME] / HCL ([MEDICATION NAME]) 5/325 mg (times) 2 were removed from the Emergency Drug Box / Kit for Resident # 20. h. The Pharmacy Prescription Resident Profile dated 6/18/19 documented [MEDICATION NAME] / [MEDICATION NAME] 10/325 mg was dispensed / received for Resident #20. i. On 6/24/19 at 2:59 p.m., Resident #20 was asked, do you have pain, and is it controlled? Resident #20 stated, When I get my pain pill. Resident #20 was asked, does the pain pill help with the pain? Resident #20 stated, Oh yeah. But they ran out of them last weekend. I was out of pain pills from last Friday (6/14/19) to Tuesday (6/18/19) . I take maybe 3 or 4 (doses of pain medication) a day. I can have it every 4 hours if needed, and I hurt worse than I ever have. I got them on Tuesday (6/18/19) night. Resident #20 was asked, how did it make you feel not having your medication and being in pain? Resident #20 stated, I just hurt all over, from my head to my toes. I couldn't lay down. I couldn't stand up. I never hurt so bad . Resident #20 was asked, did you talk to anyone about not having your medication? Resident #20 stated, Yes. Resident #20 was asked, what did they tell you? Resident #20 stated, They just said they were out of them. There were other residents that were out of medications at that time. We talked to the last Administrator. j. On 6/27/19 at 8:19 a.m., Licensed Practical Nurse (LPN) #2 was asked, do you have paper Medication Administration Records (MARs)? LPN #2 stated, Only when the computer goes down. LPN #2 was asked, where are the paper MARs located? LPN #2 stated, The record is in the resident's chart. LPN #2 was asked to provide a copy of the paper Medication Administration Record (MARs). The last paper MAR LPN #2 was able to provide was dated (MONTH) 2019. k. On 6/27/19 at 10:16 a.m., Registered Nurse (RN) #2 was asked, where do you chart medication administration when the computer goes down? RN #2 stated, I don't have an answer. I guess they have paper Medication Administration Records (MARS), I'm not sure. RN #2 was asked, have you ever been trained on what to do if the computer goes down? RN#2 stated, No. l. On 6/27/19 at 10:22 a.m., LPN #2 was asked, where do you chart medication administration when the computer goes down? LPN #2 stated, A paper MAR. LPN #2 was asked, have you ever been trained on what to do if the computer goes down? LPN #2 stated, Yes. m. On 6/27/19 at 10:24 a.m., LPN #1 was asked, where do you chart medication administration when the computer goes down? LPN #1 stated, Usually we have a paper chart. LPN #1 was asked, Have you ever been trained on what to do if the computer goes down? LPN #1 stated, Yes. n. On 6/27/19 at 12:59 p.m., RN #3 was asked, what is the policy for administering narcotics? RN #3 stated, Check the MAR (Medication Administration Record) and the Narc (Narcotic Log Book) Book to make sure it's due. RN #3 was asked, then what do you do? RN #3 stated, If the drug is available for administration, you pop the drug (out of the package), sign off, and administer to the resident. Make sure they take it, assess for pain. Pain should be documented, click off the MAR and sign it. They should sign the Narcotic Book when they pop it. If the resident doesn't take it, they need another nurse to sign off with them to waste it. RN #3 was asked, are your nurses trained to do this? RN #3 stated, Yes. o. On 6/27/19 at 12:59 p.m., RN #3 and RN #4 (Nurse Consultant) were asked, was (Resident #20) out of [MEDICATION NAME] 10-325 mg tablets from 6/16/19 through 6/18/19 at 2300 (11:00 p.m.)? RN #3 stated, Yes. RN #3 stated, I took two [MEDICATION NAME] 5/325 mg from the E-kit (Emergency Drug Box / Kit) on 6/18/19, and LPN #5 took two 5/325 mg for (Resident #20). RN #3 stated, I had called and got another authorization code to pull another dose from the E-Kit for LPN #5. She was supposed to take the dose out. RN #3 was asked, can you tell me why (Resident #20) was out of her medication? RN #3 stated, When I called the pharmacist back to ask about another resident, they asked about the hard script (prescription) for (Resident #20). I had to call the doctor to get a hard script. I asked about a one-time order for the E-Kit, and the doctor said 'No'. I'll fax the hard script to the pharmacy. So, the pharmacist said I can give you the first dose out of the E-kit. LPN #5 called at 6:15 p.m. and said (Resident #20's) medication wasn't on the run, I called the pharmacy. That's when they gave me another authorization code to give to LPN #5 to take a dose from the E-Kit because it was going to take 3 hours to get the meds (medications) here. RN #3 was asked, can you tell me about the two 5/325 mg [MEDICATION NAME] you took from the E-Kit on 6/18/19? RN #3 stated, I took the medication from the E-Kit on 6/18/19 for (Resident #20). RN #3 was asked, did you document that anywhere? RN #3 stated, No. I did not. p. On 6/27/19 at 12:59 p.m., RN #3 was asked, can you show me where the administration of [MEDICATION NAME] 10/325 mg for (Resident #20) is documented according to the Narcotic Book? RN #3 stated, There is no documentation. RN #3 was asked, can you provide (Resident #20's) pain scale and pain intensity when the [MEDICATION NAME] 10/325 mg was administered to (Resident #20). RN #3 stated, There is a pain scale, but not when the medication is administered. The Medication Administration Record (MAR) dated (MONTH) 2019 documented a pain scale for Resident #20 should be documented every shift. q. On 6/27/19 at 3:00 p.m., LPN #5, who worked on 6/18/19, was asked, does (Resident #20) ever complain of pain? LPN #5 stated, Yes. LPN #5 was asked about the severity of Resident #20's pain and stated, Usually 7 to 9. She fell recently, so she has a lot of pain. LPN #5 was asked, what do you do for (Resident #20) to relieve her pain? LPN #5 stated, She has [MEDICATION NAME] that she gets every 4 hours. LPN #5 was asked, do you document the pain assessment anywhere? LPN #5 stated, Usually with her check-offs. LPN #5 was asked, what do you mean by check-offs? LPN #5 stated, When I'm checking her chart at night, it will ask about her pain level. LPN #5 was asked, do you assess her pain and document her pain level when you administer (Resident #20's) pain medications? LPN #5 stated, I don't think it does. Just every shift. LPN #5 was asked, should it be documented? LPN #5 stated, Yes. LPN #5 was asked, do you remember the incident on 6/18/19 regarding (Resident #20's) pain medication? LPN #5 stated, Yes. She ran out because we needed a script (prescription) from the doctor because the Advanced Practice Registered Nurse (APRN) can't do the narcotics, and it was on the weekend. LPN #5 was asked, has (Resident #20) ever run out of pain medication, the [MEDICATION NAME]? LPN #5 stated, Yes. She had 5 pills that Friday, and she ran out. But we got them from the E-kit (Emergency Kit). There was one day she did not receive any pain meds, and they didn't think to get it out of the E-Kit. LPN #5 was asked, should it be marked on the Medication Administration Record when (Resident #20) was given [MEDICATION NAME]? LPN #5 stated, Yes. I don't know what happened. LPN #5 was asked, on 6/18/19, do you remember what (Resident #20's) pain level was? LPN #5 stated, 7, 8, 9. It is always a high level. It's never anything below. 2. Resident #67 had a [DIAGNOSES REDACTED]. a. A Physician's Order dated 9/19/18 documented, [MEDICATION NAME] Powder Give one scoop by mouth twice a day. A physician's order clarified / dated on 6/25/19 documented, .[MEDICATION NAME] Powder . mix 2 teaspoonfuls in 8 oz (ounces) of water and give by mouth twice a day . b. On 6/24/19 at 2:58 p.m., RN #1 placed 7.5 milliliters (ml) of [MEDICATION NAME] Powder in the medication cup. RN #1 was asked, how much is in that medication cup? RN #1 did not look, and stated, There is 10 milliliters. RN #1 poured the [MEDICATION NAME] in 4.5 milliliters of water. RN #1 was asked, how much is this? RN #1 stated, Around 10 milliliters. He just gets a little bit. 3. Resident #72 had a [DIAGNOSES REDACTED]. a. A physician's order dated 6/24/19 documented, . Eliquis 5 mg (milligrams) . Give one tablet by mouth twice a day . b. On 6/24/19 at 3:20 p.m., Licensed Practical Nurse (LPN) #1 stated, It (the Eliquis) is not here to administer. c. On 6/25/19 at 9:08 a.m., the resident's Eliquis medication had been delivered to the facility from the pharmacy; however, none of the tablets had been removed from the package for administration. 4. Resident #45 had a [DIAGNOSES REDACTED]. a. A physician's order dated 4/16/19 documented, . CBG (Capillary Blood Glucose) . Notify MD immediately if (less than) 40 mg/DL (milligrams per deciliter) or 500 mg/dl . Humalog Sliding Scale AC (Before Meals) . If 0 to 200 = 0 units . 201 to 250 = 4 units . 251 to 300 = 6 units . 301 to 350 - 8 units . 351 to 400 = 10 units . 401 to 450 = 12 units . 451 to 500 = 15 units . 501 or greater = 20 units and call doctor . b. On 6/24/19 at 3:49 p.m., Registered Nurse (RN) #2 obtained a capillary blood glucose reading of 295. The resident was to receive 6 units of Humalog sliding scale insulin. RN #2 looked for the resident's insulin, and stated, I can't find the Humalog (Insulin). c. On 6/25/19 at 9:10 a.m., the resident's Humalog was on the A / B Hall medication cart and was unopened. d. On 6/25/19 at 9:10 a.m., RN #2 was asked, did you give the resident's Humalog yesterday? RN #2 stated, It came in as I was leaving the building. 5. Resident #34 had a [DIAGNOSES REDACTED]. a. A physician's order dated 9/12/18 documented, .[MEDICATION NAME] 15 mg . 1 tablet po daily . b. On 9/25/19 at 8:05 a.m., the [MEDICATION NAME] 15 mg was not available to administer to the resident. c. On 9/25/19 at 11:00 a.m., LPN #2 stated, We found the bubble package in the drug destruction bin. The bubble package had one tablet that had been popped out since 6/17/19. LPN #2 was asked, So, the medication has not been used? LPN #2 stated, No, it has not been. 6. Resident #44 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 5/3/19 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; and had no shortness of breath. a. The Care Plan dated 1/28/19 documented, .Altered respiratory function r/t (related to) [MEDICAL CONDITIONS] . I will not have complications R/T (related to) altered respiratory function AEB (as evidenced by) no unrelieved SOB (shortness of breath), congestion (times) 90 days . b. On 6/23/19 at 5:20 p.m., Resident #44 was in room her sitting on the bed. A respiratory updraft / Nebulizer treatment machine was on a chair beside the resident's bed. c. On 6/25/19 at 8:33 a.m., Resident #44 stated, . I'm supposed to have 3 breathing treatments a day. I'm lucky if I get one, and I have to ask for it . d. On 6/25/19 at 8:36 a.m., a respiratory updraft / nebulizer treatment machine was on a chair beside the resident's bed. e. As of 6/27/19 at 8:30 a.m., the resident's clinical record contained no physician's order for a nebulizer treatment. f. On 6/27/19 at 8:45 a.m., LPN #2 was asked if Resident #44 received any kind of nebulizer or breathing treatment. He stated, She gets [MEDICATION NAME] 2 times a day, I think. I gave her one this morning. He began looking at the resident's Medication Administration Record, and stated, .I do not see it on the MAR (Medication Administration Record). He checked the resident's physician's orders, and stated, It was discontinued on the 21st (5/21/19), and yes, I did give it this morning. g. On 6/27/19 at 3:09 p.m., the Director of Nursing was asked if a resident should continue to receive a nebulizer treatment after receiving a physician order to discontinue the treatment. She stated, No, if there is no order.

Based on observation, record review, and interview, the facility failed to ensure a physician-ordered narcotic pain medication was available for administration when needed, to prevent unrelieved severe pain, and failed to ensure the resident's pain level was consistently assessed before and after administration of pain medications, in order to determine if the medication was effective for 1 (Resident #20) of 8 (Residents #20, #98, #6, #45, #56, #91, #93, and #96) sampled residents who had physician's orders [REDACTED]. This failed practice resulted in a pattern of actual harm to Resident #20, who experienced severe pain levels of 7, 8 and 9 on a scale of 1 to 10 and did not receive her physician-ordered pain medication, and had the potential to affect 9 residents who had physician's orders [REDACTED].#4) on 6/27/19 at 10:06 a.m. The findings are: Resident #20 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/19 documented the resident scored 12 (8-12 moderate cognitive impairment) on a Brief Interview for Mental Status; was independent with set-up help only for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene; required pain assessments; did not receive scheduled or as needed pain medication; did not receive non-medication interventions for pain; and received an Opioid medication 1 out of the last 7 days. a. A physician's orders [REDACTED].Tylenol ([MEDICATION NAME]) 325 mg (milligrams) tablet give 2 tablets to equal 650 mg every 6 hours as needed for mild to moderate pain. Do Not Exceed 4000 mg [MEDICATION NAME] (Tylenol) in 24 hours . Dx. (Diagnosis) . Pain . b. A physician's orders [REDACTED]. [MEDICATION NAME] 10-325 mg tablet give 1 tablet PO (by mouth) Q (every) 4 hours PRN (as needed) (for) severe pain . c. A Care Plan dated 7/10/18 documented, .Potential for Pain . observe for effectiveness of medication . measure resident pain level using pain scale 0 - 10 . d. The Medication Administration Record (MAR) dated (MONTH) 2019 documented Resident #20 received no as needed (PRN) [MEDICATION NAME] 10-325 mg on 6/2/19, 6/3/19, 6/6/19, 6/7/19, 6/9/19, 6/10/19, 6/12/19, 6/16/19, 6/17/19, 6/18/19, 6/21/19, 6/22/19, and 6/23/19. The MAR dated (MONTH) 2019 and the Narcotic Medication Disposition / Log Book contained discrepancies regarding the administration of the resident's narcotics. e. On 6/15/19 at 5:30 a.m., the Narcotic Medication Disposition / Log Book documented a balance of 4 tablets of [MEDICATION NAME] 10-325 mg. The Narcotic Log Book documented the following between 6/15/19 and 6/18/19: 6/15/19 at 5:30 a.m. [MEDICATION NAME] 10-325 mg 1 tablet administered, 6/15/19 at 8:00 a.m. [MEDICATION NAME] 10-325 mg 1 tablet administered; 6/15/19 at 1700 (5:00 p.m. [MEDICATION NAME] 10-325 mg 1 tablet administered; 6/15/19 at 1600 (4:00 p.m. [MEDICATION NAME] 10-325 mg 1 tablet administered; 6/16/19 at 1200 (12:00 p.m.) [MEDICATION NAME] 10-325 mg 1 tablet administered, leaving a balance of 0 tablets for the remainder of 6/16/19; 6/17/19 0 tablets available for administration; 6/18/19 0 tablets available for administration until 2300 (11:00 p.m.) at which time the facility received 59 [MEDICATION NAME] tablets from the pharmacy. f. There were no Nurse's Notes documented between 6/14/19 at 3:33 a.m. and 6/25/19 at 1:22 a.m. g. The Emergency Drug Box contained a Controlled Substance Withdrawal Log entry dated 6/18/19 at 12:23 p.m. which documented [MEDICATION NAME] / HCL ([MEDICATION NAME]) 5/325 mg (times) 2 were removed from the Emergency Drug Box / Kit for Resident # 20. h. The Pharmacy Prescription Resident Profile dated 6/18/19 documented [MEDICATION NAME] / [MEDICATION NAME] 10/325 mg was dispensed / received for Resident #20. i. On 6/24/19 at 2:59 p.m., Resident #20 was asked, do you have pain, and is it controlled? Resident #20 stated, When I get my pain pill. Resident #20 was asked, does the pain pill help with the pain? Resident #20 stated, Oh yeah. But they ran out of them last weekend. I was out of pain pills from last Friday (6/14/19) to Tuesday (6/18/19) . I take maybe 3 or 4 doses of pain medication) a day. I can have it every 4 hours if needed, and I hurt worse than I ever have. I got them on Tuesday (6/18/19) night. Resident #20 was asked, how did it make you feel not having your medication and being in pain? Resident #20 stated, I just hurt all over, from my head to my toes. I couldn't lay down. I couldn't stand up. I never hurt so bad . Resident #20 was asked, did you talk to anyone about not having your medication? Resident #20 stated, Yes. Resident #20 was asked, what did they tell you? Resident #20 stated, They just said they were out of them. There were other residents that were out of medications at that time. We talked to the last Administrator. j. On 6/27/19 at 8:19 a.m., Licensed Practical Nurse (LPN) #2 was asked, do you have paper Medication Administration Records (MARs)? LPN #2 stated, Only when the computer goes down. LPN #2 was asked, where are the paper MARs located? LPN #2 stated, The record is in the resident's chart. LPN #2 was asked to provide a copy of the paper Medication Administration Record (MARs). The last paper MAR LPN #2 was able to provide was dated (MONTH) 2019. k. On 6/27/19 at 10:16 a.m., Registered Nurse (RN) #2 was asked, where do you chart medication administration when the computer goes down? RN #2 stated, I don't have an answer. I guess they have paper Medication Administration Records (MARS), I'm not sure. RN #2 was asked, have you ever been trained on what to do if the computer goes down? RN#2 stated, No. l. On 6/27/19 at 10:22 a.m., LPN #2 was asked, where do you chart medication administration when the computer goes down? LPN #2 stated, A paper MAR. LPN #2 was asked, have you ever been trained on what to do if the computer goes down? LPN #2 stated, Yes. m. On 6/27/19 at 10:24 a.m., LPN #1 was asked, where do you chart medication administration when the computer goes down? LPN #1 stated, Usually we have a paper chart. LPN #1 was asked, Have you ever been trained on what to do if the computer goes down? LPN #1 stated, Yes. n. On 6/27/19 at 12:59 p.m., RN #3 was asked, what is the policy for administering narcotics? RN #3 stated, Check the MAR (Medication Administration Record) and the Narc (Narcotic Log Book) Book to make sure it's due. RN #3 was asked, then what do you do? RN #3 stated, If the drug is available for administration, you pop the drug (out of the package), sign off, and administer to the resident. Make sure they take it, assess for pain. Pain should be documented, click off the MAR and sign it. They should sign the Narcotic Book when they pop it. If the resident doesn't take it, they need another nurse to sign off with them to waste it. RN #3 was asked, are your nurses trained to do this? RN #3 stated, Yes. o. On 6/27/19 at 12:59 p.m., RN #3 and RN #4 (Nurse Consultant) were asked, was (Resident #20) out of [MEDICATION NAME] 10-325 mg tablets from 6/16/19 through 6/18/19 at 2300 (11:00 p.m.)? RN #3 stated, Yes. RN #3 stated, I took two [MEDICATION NAME] 5/325 mg from the E-kit (Emergency Drug Box / Kit) on 6/18/19, and LPN #5 took two 5/325 mg for (Resident #20). RN #3 stated, I had called and got another authorization code to pull another dose from the E-Kit for LPN #5. She was supposed to take the dose out. RN #3 was asked, can you tell me why (Resident #20) was out of her medication? RN #3 stated, When I called the pharmacist back to ask about another resident, they asked about the hard script (prescription) for (Resident #20). I had to call the doctor to get a hard script. I asked about a one-time order for the E-Kit, and the doctor said 'No'. I'll fax the hard script to the pharmacy. So, the pharmacist said I can give you the first dose out of the E-kit. LPN #5 called at 6:15 p.m. and said (Resident #20's) medication wasn't on the run, I called the pharmacy. That's when they gave me another authorization code to give to LPN #5 to take a dose from the E-Kit because it was going to take 3 hours to get the meds (medications) here. RN #3 was asked, can you tell me about the two 5/325 mg [MEDICATION NAME] you took from the E-Kit on 6/18/19? RN #3 stated, I took the medication from the E-Kit on 6/18/19 for (Resident #20). RN #3 was asked, did you document that anywhere? RN #3 stated, No. I did not. p. On 6/27/19 at 12:59 p.m., RN #3 was asked, can you show me where the administration of [MEDICATION NAME] 10/325 mg for (Resident #20) is documented according to the Narcotic Book? RN #3 stated, There is no documentation. RN #3 was asked, can you provide (Resident #20's) pain scale and pain intensity when the [MEDICATION NAME] 10/325 mg was administered to (Resident #20). RN #3 stated, There is a pain scale, but not when the medication is administered. The Medication Administration Record (MAR) dated (MONTH) 2019 documented a pain scale for Resident #20 should be documented every shift. q. On 6/27/19 at 3:00 p.m., LPN #5, who worked on 6/18/19, was asked, does (Resident #20) ever complain of pain? LPN #5 stated, Yes. LPN #5 was asked about the severity of Resident #20's pain and stated, Usually 7 to 9. She fell recently, so she has a lot of pain. LPN #5 was asked, what do you do for (Resident #20) to relieve her pain? LPN #5 stated, She has [MEDICATION NAME] that she gets every 4 hours. LPN #5 was asked, do you document the pain assessment anywhere? LPN #5 stated, Usually with her check-offs. LPN #5 was asked, what do you mean by check-offs? LPN #5 stated, When I'm checking her chart at night, it will ask about her pain level. LPN #5 was asked, do you assess her pain and document her pain level when you administer (Resident #20's) pain medications? LPN #5 stated, I don't think it does. Just every shift. LPN #5 was asked, should it be documented? LPN #5 stated, Yes. LPN #5 was asked, do you remember the incident on 6/18/19 regarding (Resident #20's) pain medication? LPN #5 stated, Yes. She ran out because we needed a script (prescription) from the doctor because the Advanced Practice Registered Nurse (APRN) can't do the narcotics, and it was on the weekend. LPN #5 was asked, has (Resident #20) ever run out of pain medication, the [MEDICATION NAME]? LPN #5 stated, Yes. She had 5 pills that Friday, and she ran out. But we got them from the E-kit (Emergency Kit). There was one day she did not receive any pain meds, and they didn't think to get it out of the E-Kit. LPN #5 was asked, should it be marked on the Medication Administration Record when (Resident #20) was given [MEDICATION NAME]? LPN #5 stated, Yes. I don't know what happened. LPN #5 was asked, on 6/18/19, do you remember what (Resident #20's) pain level was? LPN #5 stated, 7, 8, 9. It is always a high level. It's never anything below.

Complaint # (AR 650) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility's Corporate Administration failed to ensure the facility roof was promptly repaired or replaced to prevent structural damage and growth of mold in resident rooms and common areas on 3 (Halls A, C and D) of 6 halls and in the clean side of 1 of 1 laundry area. The roof had been leaking for at least the past 6 months, with no successful repairs completed. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious injury, harm or death to all 109 residents who resided in the facility, as documented on the Roster Sample Matrix dated 12/13/16. The Administrator was informed of the immediate jeopardy situation on 12/14/16 at 1:30 p.m. The findings are: 1. The Corporate Job Descriptions for the Corporate Employees responsible for approving large capital expenditures, such as roof repairs/replacement, were requested from and provided by the Nurse Consultant on 12/14/16 at 4:15 p.m. The Consultant provided the following: a. .Job Title: Divisional Vice President of Operations . Department: Corporate Office .Essential Job Function: Management Function . Duties: 1.) Understanding of financial analysis of the facilities and coordinating adjustments / recommendations when appropriate. 2.) Promote the planning, developing, implementing and monitoring of capital operating budgets for all facilities in the group which will insure the provision of quality of care . 7.) Provide direction to Regional Administrator . 11.) Promote quality assurance programs and ensure that Company resources are deployed in an optimal manner in order to provide compliance with all federal, state, local and Company requirements . b. Job Title: Regional Administrator. Department: Corporate Office . Standard Requirements . 3.) Knowledgeable of resident rights and ensures an atmosphere which allows for . well-being of all residents in a safe, secure environment . 4.) Report to Management immediately . other concerns such as inadequate staffing, etc (et cetera) . 5.) Support, cooperate with, and implement specific procedures and programs for: a. Safety, including standard precautions and safe work practices, established fire/safety/disaster plans, risk management, and security, report and/or correct unsafe working conditions, equipment repair and maintenance needs . 2. A printed copy of an e-mail dated 7/29/16 at 12:06 p.m. from the facility Administrator to the Corporate Office, provided to the survey team by the Administrator on 12/14/16 at 4:38 p.m., documented, .A local company evaluated our roof leaks on 7/12/16 and submitted 3 separate bids for remedy of the leak problem. They stated that the bid . should help stop the current leaks, but it cannot be guaranteed. At this point, we need to get some type of better solution than the patchwork that (Corporate Maintenance and Maintenance Supervisor) have been able to do, because those efforts have not stopped the leaks. The roof problem was reviewed during the current Quality of Life complaint survey (Office of Long Term Care (OLTC) Complaint Investigation Survey conducted 7/25/16 through 7/29/16). The complaint of leaking was substantiated, because it is happening. However, we avoided a deficiency citation, because I had a quote and plan for repair. We need to get this accomplished as soon as possible. Please review the above quotes and let me know the next steps to take toward remedy of this issue . The response from the Corporate Office was dated 7/29/16 at 1:12 p.m. and documented, .I appreciate your attention to this matter . 3. On 12/13/16, during the initial tour of the facility with the Maintenance Supervisor, the following observations were made: a. At 11:07 a.m., on the A hall, the resident who resided in room [ROOM NUMBER] was asked about water leaks and stated, Yes, we have had water leaks, and they have been going on quite a long time. The resident's closet was observed at this time. The closet contained no clothes, and there was a trash can sitting on top of a stack of white blankets on the floor. The blankets had brown stains along the edges. The right, lower side of the closet wall was discolored, and stains ran in a drip pattern down the entire right side of the wall as well. There was a strong musty odor to the room. The right inside area of the closet was discolored and what appeared as a water stain was on the wall that ran from the ceiling to the floor. This area was measured by the Maintenance Supervisor and was 93.5 inches long by 5 inches wide. The wall behind the opened closet door had bubbling, peeling paint and brown drip stains from the ceiling down the entire length of the wall, measuring 93.5 inches. The resident residing in this room stated, It leaks every time it rains. On 12/13/16 at 11:15 a.m., the Assistant Director of Nursing (ADON) was asked where the resident's clothes were stored. The ADON pulled the entrance door back and stated that the three outfit hanging on the back of the door belonged to the resident. The ADON opened the resident's closet door, then shut the door and stated, There's damage in here; I know (Administrator) and the Maintenance Man have been working on it. The ADON was asked what was wrong with it and stated, It leaks. The ADON was asked if any outside company had attempted to repair the leaking roof and stated, No, not to my knowledge. b. At 11:17 a.m., the back, Northeast corner of the Housekeeping Supervisor's office had a very large area of ceiling tile bulging outward and there were brown stains on the ceiling tile and the adjacent wall. The Housekeeping Supervisor was present and was asked if she had ever used a fan to dry out the carpet in the office. She stated, Yes, I have had to use a fan to dry out the carpet. I have been in this office for 2 to 3 years, and it has been leaking ever since I have been here. c. At 12:40 p.m., on the D hall, in room [ROOM NUMBER], there were two wet ceiling tiles to the far right of the entrance of the room. The corner of the wall was wet halfway down to the floor, with 3 areas of brown stains in a drip pattern. The wet ceiling tiles had a black mold like substance present. The private aide who was present in the room stated, The leaks have gotten worse since August (2016). They changed the ceiling tiles 10 times last month. It has had a black mold-looking substance that has been cleaned by Housekeeping with bleach. These ceiling tiles were just changed on Saturday (12/10/16), due to it being wet and bulging. At 3:54 p.m., the wet and stained areas in room [ROOM NUMBER] were measured by the Maintenance Supervisor. The saturated areas on the two ceiling tiles measured 9 by 13 inches; 16 by 10.5 inches; and 12 by 12 inches. The three areas of wet, brown stains in a drip pattern measured 93.5 by 10 inches; 3 by 24 inches; and 34 by 5 inches. d. At 11:30 a.m., on the D hall, in room [ROOM NUMBER], approximately 90% of the ceiling tile above the head of Bed A was stained brown. Approximately 50% of the adjacent ceiling tile was stained brown, and there were brown stains in a drip formation down the wall. The resident stated, It leaks every time it rains. They change the ceiling tiles when it rains. The resident in Bed B stated, What they usually do is change the ceiling tiles to cover it up, but they are out now, or just got some. They have been telling us for a long time now that they were going to fix it and they never have. At 3:49 p.m., each of the stained areas on the tiles and wall were measured by the Maintenance Supervisor as follows: 1.) 7 inches by 8 inches; 2.) 26 inches by 18 inches; 3.) 20 inches by 24 inches; and 4.) the stain down the wall measured 63 inches by 10 inches. e. At 11:23 a.m., on the C hall, in room [ROOM NUMBER], the wall from the ceiling down to approximately 2 to 3 feet from the floor had bubbled and peeling paint and was stained with brown water rings. The ceiling tiles just above the recliner were brown ringed. At 3:45 p.m., the Administrator stated, This is the room that was cleaned with bleach. It had a dark substance on the corner of the wall. This corner area was measured by the Maintenance Supervisor and was 93.5 by 7 inches. The paint was discolored and peeling. The stains on the ceiling tiles above the bed measured 10 inches by 8 inches; 6 inches by 4 inches; and 4 inches by 3 inches. f. At 11:25 a.m., on the C hall, room [ROOM NUMBER] had a sign on the door that documented, Under Construction. Upon entering the room, the wall behind the door had an area that measured approximately 43 inches in width and 1.5 feet in length that had been replaced. The Housekeeping Supervisor stated, There was a long sunk-in spot in that area. At 11:49 a.m., the Maintenance Supervisor stated, I asked for a housekeeper one time when I cut into the wall to clean it up with bleach. It was mold. The area that has been replaced behind the door had mold in it and the mold was visible when I cut into it. I didn't want to breathe it after I cut into it and saw moldy areas. That's when I had them to spray the bleach. g. At 12:47 p.m., the Physical Therapy Department was observed. The Physical Therapist (PT) stated, When it rains, hard water will run down that wall (pointing to an area to the right and back of the room where a picture was hanging on the wall). The picture measured approximately16 by 20 inches and had a dark stain and a green fuzzy substance that covered 50 % of the picture. At 12:52 p.m., the Maintenance Supervisor was shown the picture in the Therapy room and stated, That's mold - what it looks like when it's dry - I was told about it about a month ago. There was an electrical outlet on the wall below the picture, which the PT stated had been leaking. On 12/14/16 at 9:15 a.m., the picture that hung in the Physical Therapy room had been removed. There was a black substance on the wall where the picture had hung, and the backing on the picture had a green fuzzy substance present over the entire length of the picture in an area approximately 4 to 5 inches wide. h. At 1:00 p.m., an area on the ceiling, above and to the right of the dryers, in the clean side of the laundry room had brown water stains. Laundry Employee #1 was asked if the area leaked and stated, When it rains, it leaks. They have tried to fix it. It has leaked more than once. i. At 3:30 p.m., the B Hall dining room had water stained areas measuring 12 by 18 inches on 2 ceiling tiles that were positioned above resident dining tables. The Maintenance Supervisor stated, This is due to the leaking when it rains. 3. On 12/13/16 at 11:17 a.m., during the interview with the Housekeeping Supervisor, she was asked if she had ever been told by anyone to spray areas that appeared to be mold with bleach. She stated, Maintenance has told the Housekeepers to spray bleach on the areas that have leaked and look moldy. He didn't tell me. The Housekeepers told me he had told them to do this. On 12/14/16 from 2:56 p.m. through 3:12 p.m., 3 housekeeping staff members (#1, #2 and #3) were asked about the leaking and mold in the building. They all stated they were aware of the leaking throughout the facility and that they had been instructed by the Maintenance Supervisor to clean any mold area with bleach. 4. On 12/13/16 at 12:00 p.m., the Administrator was asked about the leaks and was reminded of the survey in July 2016, during which the surveyors were provided copies of 2 bids dated 7/13/16, one for a total roof replacement and another for repairing the roof, and had been informed that the Corporate Office was in the process of approving funding for the repair or replacement. The Administrator stated, I have pushed and (Administrator Consultant) has pushed, but we are waiting on Corporate to make the decision if they are going to replace the whole roof or do repairs. The Administrator was asked if any outside company had been consulted to complete any work on the roof since July 2016. The Administrator stated, Nothing has been done to the roof after the surveyors left in July, except for spot patches by (Maintenance Supervisor) and (Corporate Maintenance). The Administrator was asked if she was aware of any possible mold in the facility and stated, (Secure Unit Manager) reported to me that there was mold on C Hall, and they had attempted to clean it up with bleach. Corporate was aware of the mold concern in September (2016), when they came and walked around. We have had Housekeeping to spray bleach on the areas of mold in the rooms where it has leaked. 5. On 12/13/16 at 3:00 p.m., the Administrator provided the surveyors with documentation dated 8/18/16 from a local roofing company, which documented, date 8/18/16 . This repair comes with no implied or written warranty the roof is in poor shape and is in need of a complete reroof . This document had a signature dated 12/8/16 in the approved area, to indicate the repair or replacement plans were approved on that date. The Administrator was asked when she had received this approval and stated, Today. 6. On 12/14/16 at 3:31 p.m., a Certified Mold Inspector was present in the facility. After his assessment of the closet in room [ROOM NUMBER], he stated, This closet has to be remediated; mold is present, and also the entire north wall has to be remediated. I can't tell what species of mold it is until the samples are sent to the lab. The Inspector then began going through every room where leaks had been identified and took air and physical samples. 7. The immediate jeopardy was removed and the scope and severity reduced to F on 12/14/16 at 4:14 p.m. when the facility implemented the following plan of removal: 1.) Relocate residents out of Rooms #5, 21, 23, 31, 33, 37 38 until rooms are inspected by (Environmental Inspection Company) and recommendations are implemented. Laundry room, Dining room on B Hall and PT gym will be placed out of service until cleared by environmental company. 2.) Environmental company to evaluate today, 12/14/16 areas with evidence of leaks for identification and treatment of [REDACTED]. 3.) Maintenance to round facility 12/14/16 to identify any other potential areas of mold due to leakage. 4.) All staff in serviced as to report any leaks or black substance starting 12/14/16 and as they return to work. 5.) Daily walk through by Administrator or designee to identify any new leaks or areas of potential mold, corrective action will be initiated immediately with identification. 6.) (Roofing Company) to make repairs to roof on 12/19/16. 7.) Daily rounds during periods of precipitation to monitor for any new leaks for 6 months.

Complaint # (AR 650) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure the facility roof was promptly repaired or replaced to prevent structural damage and growth of mold in resident rooms and common areas on 3 (Halls A, D and C) of 6 halls and in the clean side of 1 of 1 laundry area. The roof had been leaking for at least the past 6 months, with no successful repairs completed. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious injury, harm or death to all 109 residents who resided in the facility, as documented on the Roster Sample Matrix dated 12/13/16. The Administrator was informed of the immediate jeopardy situation on 12/14/16 at 1:30 p.m. The findings are: 1. A printed copy of an e-mail dated 7/29/16 at 12:06 p.m. from the facility Administrator to the Corporate Office, provided to the survey team by the Administrator on 12/14/16 at 4:38 p.m., documented, .A local company evaluated our roof leaks on 7/12/16 and submitted 3 separate bids for remedy of the leak problem. They stated that the bid . should help stop the current leaks, but it cannot be guaranteed. At this point, we need to get some type of better solution than the patchwork that (Corporate Maintenance and Maintenance Supervisor) have been able to do, because those efforts have not stopped the leaks. The roof problem was reviewed during the current Quality of Life complaint survey (Office of Long Term Care (OLTC) Complaint Investigation Survey conducted 7/25/16 through 7/29/16). The complaint of leaking was substantiated, because it is happening. However, we avoided a deficiency citation, because I had a quote and plan for repair. We need to get this accomplished as soon as possible. Please review the above quotes and let me know the next steps to take toward remedy of this issue . The response from the Corporate Office was dated 7/29/16 at 1:12 p.m. and documented, .I appreciate your attention to this matter . 2. On 12/13/16, during the initial tour of the facility with the Maintenance Supervisor, the following observations were made: a. At 11:07 a.m., on the A hall, the resident who resided in Room #5 was asked about water leaks and stated, Yes, we have had water leaks, and they have been going on quite a long time. The resident's closet was observed at this time. The closet contained no clothes, and there was a trash can sitting on top of a stack of white blankets on the floor. The blankets had brown stains along the edges. The right, lower side of the closet wall was discolored, and stains ran in a drip pattern down the entire right side of the wall as well. There was a strong musty odor to the room. The right inside area of the closet was discolored and what appeared as a water stain was on the wall that ran from the ceiling to the floor. This area was measured by the Maintenance Supervisor and was 93.5 inches long by 5 inches wide. The wall behind the opened closet door had bubbling, peeling paint and brown drip stains from the ceiling down the entire length of the wall, measuring 93.5 inches. The resident residing in this room stated, It leaks every time it rains. On 12/13/16 at 11:15 a.m., the Assistant Director of Nursing (ADON) was asked where the resident's clothes were stored. The ADON pulled the entrance door back and stated that the three outfit hanging on the back of the door belonged to the resident. The ADON opened the resident's closet door, then shut the door and stated, There's damage in here; I know (Administrator) and the Maintenance Man have been working on it. The ADON was asked what was wrong with it and stated, It leaks. The ADON was asked if any outside company had attempted to repair the leaking roof and stated, No, not to my knowledge. b. At 11:17 a.m., the back, Northeast corner of the Housekeeping Supervisor's office had a very large area of ceiling tile bulging outward and there were brown stains on the ceiling tile and the adjacent wall. The Housekeeping Supervisor was present and was asked if she had ever used a fan to dry out the carpet in the office. She stated, Yes, I have had to use a fan to dry out the carpet. I have been in this office for 2 to 3 years, and it has been leaking ever since I have been here. c. At 12:40 p.m., on the D hall, in Room 37, there were two wet ceiling tiles to the far right of the entrance of the room. The corner of the wall was wet halfway down to the floor, with 3 areas of brown stains in a drip pattern. The wet ceiling tiles had a black mold like substance present. The private aide who was present in the room stated, The leaks have gotten worse since August (2016). They changed the ceiling tiles 10 times last month. It has had a black mold-looking substance that has been cleaned by Housekeeping with bleach. These ceiling tiles were just changed on Saturday (12/10/16), due to it being wet and bulging. At 3:54 p.m., the wet and stained areas in Room 37 were measured by the Maintenance Supervisor. The saturated areas on the two ceiling tiles measured 9 by 13 inches; 16 by 10.5 inches; and 12 by 12 inches. The three areas of wet, brown stains in a drip pattern measured 93.5 by 10 inches; 3 by 24 inches; and 34 by 5 inches. d. At 11:30 a.m., on the D hall, in Room 38, approximately 90% of the ceiling tile above the head of Bed A was stained brown. Approximately 50% of the adjacent ceiling tile was stained brown, and there were brown stains in a drip formation down the wall. The resident stated, It leaks every time it rains. They change the ceiling tiles when it rains. The resident in Bed B stated, What they usually do is change the ceiling tiles to cover it up, but they are out now, or just got some. They have been telling us for a long time now that they were going to fix it and they never have. At 3:49 p.m., each of the stained areas on the tiles and wall were measured by the Maintenance Supervisor as follows: 1.) 7 inches by 8 inches; 2.) 26 inches by 18 inches; 3.) 20 inches by 24 inches; and 4.) the stain down the wall measured 63 inches by 10 inches. e. At 11:23 a.m., on the C hall, in Room 31, the wall from the ceiling down to approximately 2 to 3 feet from the floor had bubbled and peeling paint and was stained with brown water rings. The ceiling tiles just above the recliner were brown ringed. At 3:45 p.m., the Administrator stated, This is the room that was cleaned with bleach. It had a dark substance on the corner of the wall. This corner area was measured by the Maintenance Supervisor and was 93.5 by 7 inches. The paint was discolored and peeling. The stains on the ceiling tiles above the bed measured 10 inches by 8 inches; 6 inches by 4 inches; and 4 inches by 3 inches. f. At 11:25 a.m., on the C hall, Room 33 had a sign on the door that documented, Under Construction. Upon entering the room, the wall behind the door had an area that measured approximately 43 inches in width and 1.5 feet in length that had been replaced. The Housekeeping Supervisor stated, There was a long sunk-in spot in that area. At 11:49 a.m., the Maintenance Supervisor stated, I asked for a housekeeper one time when I cut into the wall to clean it up with bleach. It was mold. The area that has been replaced behind the door had mold in it and the mold was visible when I cut into it. I didn't want to breathe it after I cut into it and saw moldy areas. That's when I had them to spray the bleach. g. At 12:47 p.m., the Physical Therapy Department was observed. The Physical Therapist (PT) stated, When it rains, hard water will run down that wall (pointing to an area to the right and back of the room where a picture was hanging on the wall). The picture measured approximately16 by 20 inches and had a dark stain and a green fuzzy substance that covered 50 % of the picture. At 12:52 p.m., the Maintenance Supervisor was shown the picture in the Therapy room and stated, That's mold - what it looks like when it's dry - I was told about it about a month ago. There was an electrical outlet on the wall below the picture, which the PT stated had been leaking. On 12/14/16 at 9:15 a.m., the picture that hung in the Physical Therapy room had been removed. There was a black substance on the wall where the picture had hung, and the backing on the picture had a green fuzzy substance present over the entire length of the picture in an area approximately 4 to 5 inches wide. h. At 1:00 p.m., an area on the ceiling, above and to the right of the dryers, in the clean side of the laundry room had brown water stains. Laundry Employee #1 was asked if the area leaked and stated, When it rains, it leaks. They have tried to fix it. It has leaked more than once. i. At 3:30 p.m., the B Hall dining room had water stained areas measuring 12 by 18 inches on 2 ceiling tiles that were positioned above resident dining tables. The Maintenance Supervisor stated, This is due to the leaking when it rains. 3. On 12/13/16 at 11:17 a.m., during the interview with the Housekeeping Supervisor, she was asked if she had ever been told by anyone to spray areas that appeared to be mold with bleach. She stated, Maintenance has told the Housekeepers to spray bleach on the areas that have leaked and look moldy. He didn't tell me. The Housekeepers told me he had told them to do this. On 12/14/16 from 2:56 p.m. through 3:12 p.m., 3 housekeeping staff members (#1, #2 and #3) were asked about the leaking and mold in the building. They all stated they were aware of the leaking throughout the facility and that they had been instructed by the Maintenance Supervisor to clean any mold area with bleach. 4. On 12/13/16 at 12:00 p.m., the Administrator was asked about the leaks and was reminded of the survey in July 2016, during which the surveyors were provided copies of 2 bids dated 7/13/16, one for a total roof replacement and another for repairing the roof, and had been informed that the Corporate Office was in the process of approving funding for the repair or replacement. The Administrator stated, I have pushed and (Administrator Consultant) has pushed, but we are waiting on Corporate to make the decision if they are going to replace the whole roof or do repairs. The Administrator was asked if any outside company had been consulted to complete any work on the roof since July 2016. The Administrator stated, Nothing has been done to the roof after the surveyors left in July, except for spot patches by (Maintenance Supervisor) and (Corporate Maintenance). The Administrator was asked if she was aware of any possible mold in the facility and stated, (Secure Unit Manager) reported to me that there was mold on C Hall, and they had attempted to clean it up with bleach. Corporate was aware of the mold concern in September (2016), when they came and walked around. We have had Housekeeping to spray bleach on the areas of mold in the rooms where it has leaked. 5. On 12/13/16 at 3:00 p.m., the Administrator provided the surveyors with documentation dated 8/18/16 from a local roofing company, which documented, date 8/18/16 . This repair comes with no implied or written warranty the roof is in poor shape and is in need of a complete reroof . This document had a signature dated 12/8/16 in the approved area, to indicate the repair or replacement plans were approved on that date. The Administrator was asked when she had received this approval and stated, Today. 6. On 12/14/16 at 3:31 p.m., a Certified Mold Inspector was present in the facility. After his assessment of the closet in Room 5, he stated, This closet has to be remediated; mold is present, and also the entire north wall has to be remediated. I can't tell what species of mold it is until the samples are sent to the lab. The Inspector then began going through every room where leaks had been identified and took air and physical samples. 7. The immediate jeopardy was removed and the scope and severity reduced to F on 12/14/16 at 4:14 p.m. when the facility implemented the following plan of removal: 1.) Relocate residents out of Rooms #5, 21, 23, 31, 33, 37 38 until rooms are inspected by (Environmental Inspection Company) and recommendations are implemented. Laundry room, Dining room on B Hall and PT gym will be placed out of service until cleared by environmental company. 2.) Environmental company to evaluate today, 12/14/16 areas with evidence of leaks for identification and treatment of [REDACTED]. 3.) Maintenance to round facility 12/14/16 to identify any other potential areas of mold due to leakage. 4.) All staff in serviced as to report any leaks or black substance starting 12/14/16 and as they return to work. 5.) Daily walk through by Administrator or designee to identify any new leaks or areas of potential mold, corrective action will be initiated immediately with identification. 6.) (Roofing Company) to make repairs to roof on 12/19/16. 7.) Daily rounds during periods of precipitation to monitor for any new leaks for 6 months.

Complaint # (AR 370) was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure witnessed staff to resident verbal/mental abuse involving Certified Nursing Assistant (CNA) #1 was immediately reported to the Administrator/designee and that planned interventions involving CNA #1 to reduce the risk of staff to resident abuse was communicated and implemented to ensure 2 of 2 (Residents #1 and #6) cognitive impaired case mix residents were protected from the potential of further abuse and to ensure prompt investigation. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who was cognitively impaired and who alleged staff to resident abuse. According to a list provided by the Director of Nursing (DON) on 8/1/14 at 2:28 p.m., this failed practice had the potential to affect 34 residents in the facility who were cognitively impaired. The facility was informed of the Immediate Jeopardy on 8/1/14 at 12:25 p.m. The findings are. 1. Resident #1 had [DIAGNOSES REDACTED]. The Medicare 30-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/16/14 documented the resident scored 5 (0-7 indicates severe impairment) on a Brief Interview for Mental Status, required extensive assistance from 2 person for transfers, dressing, toilet use, bathing and hygiene. a. The Resident Care Plan dated 6/20/14 documented, "Problem Onset: 10/9/2013 - Behavior Management required ...combative with care/resistive to care..." b. The Behavioral Health Center psychiatric evaluation dated 6/10/14 documented, "...Pt also has refused assistance with ADLs (activities of daily living)... Pt (patient) is a 73 y/o (year old) wm (white male) who presents from (nursing home) after punching staff causing injury ..." c. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) -7734 form dated 7/28/14 documented, " ...At 9:00 a.m. on 7/28/14, (Resident #1) reported to SSD (Social Services Director) that during a shower his ' nipples were twisted ' and something was put in his ' butthole. ' Head to toe assessment of resident revealed a red discolored area to his left forearm measuring 7 x 7 cm (centimeters), no other injuries were noted at that time. Records reviewed showed that (CNA #1) had given (Resident #1) his shower on Saturday evening 7/26/14. CNA #1 was immediately suspended pending investigation. Police, MD (medical doctor) and family were notified and an officer came to the facility to interview the resident with family and staff present. Collection of statements from alert and oriented resident as well as other staff members has begun, investigation continues ..." 1) On 8/1/14 at 8:41 p.m., the Weekend RN Supervisor was asked what she knew about the abuse allegation reported by (Resident #1) concerning (CNA #1). She stated she noticed (Resident #1) in the dining room drinking coffee around 4:00 p.m. Sunday (7/27/14). She stated, " (Resident #1) was quiet and distant that day. There was something odd about his behavior, not himself." The Weekend RN Supervisor stated when she was asked if she knew (CNA #1) was not supposed to provide care to (Resident #1)? She stated, "I had no knowledge (CNA #1) was not supposed to work with (Resident #1), because I would not have scheduled him there. I would just switch halls. If I had an idea at all, any suspicion, I would just change the assignment." The Weekend RN Supervisor's report dated 7/26/14 and 7/27/14 documented, "(Resident #1) change in behavior." 2) The DMS witness statement (no date provided) ( not timed) signed by the DON, documented, " ...I received a call from the facility regarding (Resident #1's son) being concerned because his Dad had acted differently on Sunday 7/27/14 when he took him for coffee. When he had returned to the facility there question about bruising on both his Dad's hands. (Resident #1's son) said he thought they were old, but was worried about his Dad's change in behavior. Weekend RN (Registered Nurse) Supervisor called and informed me at about 3:00 p.m. I could not come to the facility to interview the resident at that time. I called (Administrator) and asked if she could and she said she could. Then on Monday morning in morning meeting we talked about it and asked SSD to talk to (Resident #1). She said she would and afterwards she reported he had his "nipples twisted" and a "finger shoved up his butt." The investigation then began. I did a head to toe assessment on resident at 11:30, he was cooperative, there was a red area to left forearm 7 x 7 cm, 4 bruises to back of both hands. No other areas noted on resident, denied pain to areas..." 3) The DMS witness statement dated 7/30/14 (not timed) signed by the Administrator, documented, " ...On 7/27/14, I got a call from DON that (Resident #1's son) was upset re: his Dad. He had spoken to weekend supervisor and said that his Dad was quiet on their ride to get coffee and appeared upset when he brought him back to the facility. spoke to Weekend supervisor about his Dad's change in behavior - there was discussion about his arms and the bruises - not sure what related to DON was unable to come to facility, but called me and said (around 3ish pm) that (Resident #1) appeared upset and sad and that there were bruises on his arm. I came around 4:30 p.m. and spoke to resident and asked what was wrong. He wouldn't say anything, but sad and distant. I did look at Resident #1's arms and left upper arm was bruised. I did talk to Weekend RN Supervisor and asked her to get witness statements from staff re: bruises and if they know origin ..." 4) The DMS witness statement dated 7/28/14 documented by the SSD, " ...On Monday, 7/28 SSD ask to go see resident, he had been tearful earlier in the morning and didn't want to go to breakfast. Resident told SSD that he had a shower and the staff person that showered him was ' ruff, ' Said he twisted his nipples and rubbed too hard and staff person stuck his finger up residents butt, resident became tearful again. SSD reported to Administrator and residents son contacted." On 7/31/14 at 6:15 p.m., the Social Service Director (SSD) was asked if she knew about the allegation of sexual abuse reported by (Resident #1). She stated, "In the morning meeting on 7/28/14 the Administrator and the DON (Director of Nursing) asked me to talk to (Resident #1) based on the weekend supervisor's report. I was told that (Resident #1) had issues over the weekend and they told me what he had told nursing. I talked to him and asked him what happened during his shower over the weekend. During the interview he did not voluntarily say any one's name. But he did say "that boy." The SSD stated (Resident #1) made the allegation (of abuse) to her and she reported it to the Administrator. 5) The physician's progress notes dated 7/29/14 at 1:21 p.m. documented, "I was asked to see (Resident #1) today by the DON because there was a reportable incident yesterday. (Resident #1) reported that there was a CNA on his floor, whom he does not like, who was responsible for his care in the shower 2 days ago. He reports that the CNA used his finger to penetrate his anus repeatedly. He also used a shower nozzle to slap against his penis. He was also grabbed strongly on his left arm. The patient seems quite upset about this and was able to recall the event in pretty significant detail. He really doesn't have any pain with defecation at this point, and his bowel movements have been normal. He does have some bruising around this left wrist. His penis is normal, and he has no dysuria, and is not suffering bruising in his groin anteriorly. He is alert and cooperative with exam today. ...Left wrist: shows dorsal ecchymosis, about the size of the palm of a hand that appears within 1 to 3 day of age. Genitalia Exam: Reveals normal uncircumcised male. His testes are distended. There is no scrotal ecchymosis or penile ecchymosis. I could see no hernia. There are no skin abrasions in the groin region. Anus Exam: Reveals normal tone. There is one (1) small superficial, less than one (1) centimeter, abrasion on the right buttock, about 4 cm from his anus. It appears pretty fresh as there is no scabbing, but there is no active bleeding either. I could see no anal trauma and no other ecchymosis noted. ...I cannot say for sure whether this lesion is directly attributable to the trauma of 2 days ago, but it is certainly consistent with that age of injury." d. On 7/31/14 at 7:00 p.m., CNA #2 was asked if she had ever heard or seen (CNA #1) be abusive toward (Resident #1). She stated that about a month ago while giving care to (Resident #1), (Resident #1) calls (CNA #1) ' Rambo ' and raised his voice directed toward (CNA #1). He (Resident #1) would ball up his fist, and (CNA #1) would say to him, ' If you think you're going to do anything, I'll pop you." (CNA #1) would be nice to him but (Resident #1) acted like he was going to hit him. (CNA #1) said to (Resident #1), ' If you think you're going to hit me, it will be the last time." Then he would back up. I told (CNA #1) maybe you shouldn't have said that. But that's all he said." e. On 7/31/14 at 8:29 p.m., LPN #1 was asked if she was aware of any abusive behavior by (CNA #1) toward (Resident #1). She stated, " He (Resident #1) is very aggressive, mean, angered easily, been that way ever since I've been here. (CNA #1) kinda antagonizes him. I told him several times to stop it. Before (Resident #1) left out to the behavioral health center, he punched (CNA #1) in the face and stomach. He's really combative with showers. Before the behavioral health center, (CNA #1) gave him his showers. LPN #1 then stated that (CNA #1) was taken off the hall before he (Resident #1) went to the behavioral health center (6/20/14) about a month or so ago." LPN #1 was asked, "So why did (CNA #1) go back on the hall? LPN #1 stated, "That's a really good question. I don't know and he (Resident #1) doesn't like (CNA #3) either. He's called him all kinds of names. E Hall is a really heavy hall and we need muscle down there." LPN #1 was asked if the conflict between (CNA #1) and (Resident #1) had been reported to the DON? LPN #1 stated, "Yes, (DON) knows, because of (CNA #1) being punched and they did take (CNA #1) off that hall when (Resident #1) came back from (behavioral health center)." LPN #1 was asked then why did (CNA #1) go back on the hall the 26th (7/26/14)? LPN #1 stated, "I don't know. If he worked Sunday on that hall, they probably should've known better." f. On 7/31/14 at 6:35 p.m., CNA #3 was asked if he knew of any abusive behavior toward (Resident #1) by (CNA#1). He stated, "(Resident #1) would get really upset because (CNA #1) would keep egging him on and a couple of months ago, (Resident #1) punched him in the face twice and made his lip bleed. I didn't see it; I just saw his (CNA #1's) face after. (CNA #1) disrespects (Resident #1). I never knew (CNA #1) was not supposed to work E Hall. (CNA #1) never made that statement. I heard that the bruise on (Resident #1) was caused by (CNA #1). (Resident #1) said (CNA #1) did it." CNA #3 was asked if he believed (CNA #1) caused the bruising. CNA #3 stated, "It's a big possibility because of the way (CNA #1) talked in front of (Resident #1)." CNA #3 was asked did he ever report anything about (CNA #1). He stated, "Yes. They made me fill out a witness statement when (CNA #1) called me a faggot the first time in front of (Resident #1). Ever since then (Resident #1) calls me a faggot when I provide care. Yesterday, I had to step outside the building in order for me to cool my head, clear my thoughts because it upsets me. Yesterday was the very first time I was told to take someone with me to provide care to (Resident #1)." g. On 7/31/14 at 6:55 p.m., the Staffing Coordinator/LPN #2 was asked about (CNA #1) working on E Hall with (Resident #1). The Staffing Coordinator stated that CNA #1 was not supposed to work with (Resident #1) since June 2014 because I think (Resident #1) assaulted (CNA #1). (Resident #1) punched (CNA #1) in the face. I flipped him to E Hall Saturday (7/26/14) at noon because we had call ins. He was told not to have direct care with (Resident #1). (DON) told me that he was not to work with the resident because of what happened back in June. I don't know why he singled the resident out to give him a shower." On 7/31/14 at 7:15 p.m., (CNA #1's) time sheet was reviewed. According to the time sheet, (CNA #1) worked the 2:00 p.m. to 10:00 p.m. (2/10) shift on 7/26/14 and according to the CNA assignment sheet; CNA #1 worked E Hall where Resident #1 resided. h. On 8/1/14 at 11:00 a.m., the Administrator was asked why (CNA#1) was allowed to work after she was aware of reported abuse by (CNA #1) toward (Resident #1). She stated, "I don't think of it as failure (by the facility) because he (CNA #1) was not assigned to (Resident #1). He was assigned to E Hall. He (CNA #1) knew he was not supposed to work with that resident. He made a conscious choice to do that." She was asked did the weekend staff know he wasn't supposed to be with (Resident #1)? She stated, "I don't know if I even considered that an issue. The responsibility lies with (CNA #1). He could've told the nurses that he couldn't work with him. I can't just side and blame nursing. He's an adult." She was asked if the facility identified an issue with the Staff Coordinator assigning (CNA #1) and instructing him to work E Hall where (Resident #1) resided even though she knew (CNA #1) was not supposed to? The Administrator stated, "But what part goes back to the CNA; to use discernment? It doesn't always fall back on nursing." She was asked so are you saying it is all the CNA's fault? The Administrator stated, "No. I'm not saying it's all the CNA's fault. But CNAs have responsibility too. I'm not taking away that we couldn't have done somewhat better." i. On 8/1/14 at 12:42 p.m., the DON was asked how information is reported to the weekend staff about resident care? She stated, "Well a lot of the carry over is because (Weekend RN supervisor) is here on Friday to inform weekend. Generally, I will post in the med.(medication) room and the break room information. A lot of it is based on (Weekend RN Supervisor)." The DON was asked if the facility identified an issue with the Staff Coordinator assigning (CNA #1) down E Hall where (Resident #1) resided even though she knew CNA #1 was not supposed to work E Hall? The DON stated, "(CNA #1) was a grown adult. I would expect that he would know better. I would expect not to tell him every single time not to provide care to (Resident #1). I don't hold (Staffing Coordinator) accountable. There was another CNA on that hall that could've given him a shower. Even though he was on the hall there were 23 other residents he could've cared for." j. On 8/1/14 at 1:00 p.m., during a body audit of Resident #1, surveyor was able see from thighs up. Chest and abdomen was clear. The buttocks were clear with feces present. There was a large dark purple bruise to his dorsal left hand, and a large bluish discoloration just above his left wrist toward his forearm. 2. Resident #6 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date of 7/17/14 documented the resident scored 2 (0-7 indicates severe impairment) on a Brief Interview for Mental Status, required total assistance of 2 persons for bed mobility, transfers, toileting and bathing and extensive assistance of 1+ persons for eating and personal hygiene. a. On 7/31/14 at 7:00 p.m., CNA #2 was asked if she was aware of anyone being verbally abusive to Resident #6. CNA #2 stated, "(Resident #6) was having episodes of diarrhea one evening about a month and half ago. I was helping him (CNA #1) change (Resident #2). He said to (Resident #6), 'your only reason for living is[***]ing.' Then (Licensed Practical Nurse (LPN)) #1 gave him a verbal warning. I heard her tell him this was his verbal warning." b. On 7/31/14 at 8:29 p.m., LPN #1 was asked, "Has there been any problems with other residents and (CNA #1)? LPN #1 stated, "Yes, (Resident 6), I was doing my PEG (Percutaneous Endoscopic Gastric) tube, this was probably a month and a half ago and I don't remember which CNA was with him, but he told (Resident #6), '...all you have to do in life is[***]' He was irritated because she needed to be cleaned up. I actually had to stop my PEG tube, I went to that room and I said you need to come find me when you are done. So I went back to finish my PEG and he never did come find me. I went and found him. I asked (CNA #1), Do you want to tell me why you said that to (Resident #1), and she's had a bad stroke. You shouldn't say that to anybody. She understands what you say. You do understand that's verbal abuse right? He said ' No. ' I said, I'm sure you didn't. I was extremely upset. I told him he was not to go back in that room for the rest of the night. I told him this was the one and only verbal warning he will ever get from me. I did tell (Director of Nursing (DON)) about it. I've not been doing this for very long." LPN #1 was asked, "When did you inform the (DON)?" LPN #1 stated, "It was the next day. I went into her office and told her. I may have even told her that night too. I can't remember." c. On 8/1/14 at 12:42 p.m., the DON was asked if any verbal abuse involving (Resident #6) by (CNA #1) had been reported to her. The DON stated she was unaware of anything occurring between (CNA #1) and (Resident #6). She stated nothing was ever reported to her. 3. The Immediate Jeopardy was removed on 8/1/14 at 2:15 p.m. and the scope and severity reduced to an H when the facility implemented the following plan of removal: 1) (CNA #1) was suspended on 7/28/14 by Administrator and has not returned to work. 2) Police were notified on 7/28/14 by DON at 12:45 p.m. Administration began interviews with staff and residents starting on 7/28/14 at 11:00 a.m. Any negative findings were corrected immediately. MD assessed Resident #1 on 7/29/14 at 1:21 p.m. On 7/30/14, body audits were started by Nursing Management at 10:30 a.m. on Hall that (CNA #1) last worked and completed by 7/31/14 at 12 p.m. 3) Abuse/Neglect in-service originally started on 7/29/14 at 6 a.m. by Nursing Management. Nursing Management staff began in-services on Abuse/Neglect Reporting and Behavior Modification starting at 11:00 p.m. on 7/31/14 to all staff present and will in-service all shifts prior to start of shifts until all employees have been in-serviced. Any employee who is out will not return to work until instructed. Administrator in-serviced Staff Development LPN on 8/1/14 at 1:30 p.m. on following specific interventions involving known resident and staff conflict and to ensure employee is not to perform direct care on resident in question. On 7/31/14 at 10:00 p.m., DON and Administrator were in-serviced by Regional Nurse Consultant on communicating with weekend management and evening and night shift on interventions specific to residents and staffing needs. 4) DON/designee to perform random interviews of staff and residents daily x2 weeks starting on 8/1/14. Then DON/Designee to perform random interviews of staff and residents 3 x a week until substantial compliance is achieved.

Complaint # (AR 370) was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure staff implemented the facility's abuse policy and procedure as evidenced by the facility ' s failures to ensure witnessed staff to resident verbal/mental abuse involving Certified Nursing Assistant (CNA) #1 was immediately reported to the Administrator/designee and that planned interventions involving CNA #1 to reduce the risk of staff to resident abuse was communicated and implemented to ensure 2 of 2 (Residents #1 and #6) cognitive impaired case mix residents were protected from the potential of further abuse and to ensure prompt investigation. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who was cognitively impaired and who alleged staff to resident abuse. According to a list provided by the Director of Nursing (DON) on 8/1/14 at 2:28 p.m., this failed practice had the potential to affect 34 residents in the facility who were cognitively impaired. The facility was informed of the Immediate Jeopardy on 8/1/14 at 12:25 p.m. The findings are. 1. The facility's Nursing Management Manual Policy Title: Abuse, Neglect, Misappropriation of Resident Property, Injuries of Unknown Source effective date 3/26/14 documented, "...Each employee has an obligation to report any incident immediately that could constitute an instance of abuse or neglect... to the Administrator or the Director of Nursing or the Department Supervisor. ...The facility will report all instances of alleged or suspected abuse, including verbal or mental abuse ... in the following manner: Investigation and Reporting Steps Notify the DON of any unusual situation in the facility, whether reportable or not." 2. Resident #1 had [DIAGNOSES REDACTED]. The Medicare 30-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/16/14 documented the resident scored 5 (0-7 indicates severe impairment) on a Brief Interview for Mental Status, required extensive assistance from 2 person for transfers, dressing, toilet use, bathing and hygiene. a. The Resident Care Plan dated 6/10/14 documented, " ...Problem Onset: 10/9/2013 - Behavior Management required ...combative with care/resistive to care..." b. The Behavioral Health Center psychiatric evaluation dated 6/10/14 documented, "...Pt also has refused assistance with ADLs (activities of daily living)... Pt (patient) is a 73 y/o (year old) wm (white male) who presents from (nursing home) after punching staff causing injury ..." c. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) -7734 form dated 7/28/14 documented, " ...At 9:00 a.m. on 7/28/14, (Resident #1) reported to SSD (Social Services Director) that during a shower his ' nipples were twisted ' and something was put in his ' butthole. ' Head to toe assessment of resident revealed a red discolored area to his left forearm measuring 7 x 7 cm (centimeters), no other injuries were noted at that time. Records reviewed showed that (CNA #1) had given (Resident #1) his shower on Saturday evening 7/26/14. CNA #1 was immediately suspended pending investigation. Police, MD (medical doctor) and family were notified and an officer came to the facility to interview the resident with family and staff present. Collection of statements from alert and oriented resident as well as other staff members has begun, investigation continues ..." 1) On 8/1/14 at 8:41 p.m., the Weekend RN Supervisor was asked what she knew about the abuse allegation reported by (Resident #1) concerning (CNA #1). She stated she noticed (Resident #1) in the dining room drinking coffee around 4:00 p.m. Sunday (7/27/14). She stated, " (Resident #1) was quiet and distant that day. There was something odd about his behavior, not himself." The Weekend RN Supervisor stated when she was asked if she knew (CNA #1) was not supposed to provide care to (Resident #1)? She stated, "I had no knowledge (CNA #1) was not supposed to work with (Resident #1), because I would not have scheduled him there. I would just switch halls. If I had an idea at all, any suspicion, I would just change the assignment." The Weekend RN Supervisor's report dated 7/26/14 and 7/27/14 documented, "(Resident #1) change in behavior." 2) The DMS witness statement (no date provided) (not timed)signed by the DON, documented, " ...I received a call from the facility regarding (Resident #1's son) being concerned because his Dad had acted differently on Sunday 7/27/14 when he took him for coffee. When he had returned to the facility there question about bruising on both his Dad's hands. (Resident #1's son) said he thought they were old, but was worried about his Dad's change in behavior. Weekend RN (Registered Nurse) Supervisor called and informed me at about 3:00 p.m. I could not come to the facility to interview the resident at that time. I called (Administrator) and asked if she could and she said she could. Then on Monday morning in morning meeting we talked about it and asked SSD to talk to (Resident #1). She said she would and afterwards she reported he had his "nipples twisted" and a "finger shoved up his butt." The investigation then began. I did a head to toe assessment on resident at 11:30, he was cooperative, there was a red area to left forearm 7 x 7 cm, 4 bruises to back of both hands. No other areas noted on resident, denied pain to areas..." 3) The DMS witness statement dated 7/30/14 signed 7/31/14 (not timed) by the Administrator, documented, " ...On 7/27/14, I got a call from DON that (Resident #1's son) was upset re: his Dad. He had spoken to weekend supervisor and said that his Dad was quiet on their ride to get coffee and appeared upset when he brought him back to the facility. spoke to Weekend supervisor about his Dad's change in behavior - there was discussion about his arms and the bruises - not sure what related to DON was unable to come to facility, but called me and said (around 3ish pm) that (Resident #1) appeared upset and sad and that there were bruises on his arm. I came around 4:30 p.m. and spoke to resident and asked what was wrong. He wouldn't say anything, but sad and distant. I did look at Resident #1's arms and left upper arm was bruised. I did talk to Weekend RN Supervisor and asked her to get witness statements from staff re: bruises and if they know origin ..." 4) The DMS witness statement dated 7/28/14 documented by the SSD, " ...On Monday, 7/28 SSD ask to go see resident, he had been tearful earlier in the morning and didn't want to go to breakfast. Resident told SSD that he had a shower and the staff person that showered him was ' ruff, ' Said he twisted his nipples and rubbed too hard and staff person stuck his finger up residents butt, resident became tearful again. SSD reported to Administrator and residents son contacted." On 7/31/14 at 6:15 p.m., the Social Service Director (SSD) was asked if she knew about the allegation of sexual abuse reported by (Resident #1). She stated, "In the morning meeting on 7/28/14 the Administrator and the DON (Director of Nursing) asked me to talk to (Resident #1) based on the weekend supervisor's report. I was told that (Resident #1) had issues over the weekend and they told me what he had told nursing. I talked to him and asked him what happened during his shower over the weekend. During the interview he did not voluntarily say any one's name. But he did say "that boy." The SSD stated (Resident #1) made the allegation (of abuse) to her and she reported it to the Administrator. 5) The physician's progress notes dated 7/29/14 at 1:21 p.m. documented, "I was asked to see (Resident #1) today by the DON because there was a reportable incident yesterday. (Resident #1) reported that there was a CNA on his floor, whom he does not like, who was responsible for his care in the shower 2 days ago. He reports that the CNA used his finger to penetrate his anus repeatedly. He also used a shower nozzle to slap against his penis. He was also grabbed strongly on his left arm. The patient seems quite upset about this and was able to recall the event in pretty significant detail. He really doesn't have any pain with defecation at this point, and his bowel movements have been normal. He does have some bruising around this left wrist. His penis is normal, and he has no dysuria, and is not suffering bruising in his groin anteriorly. He is alert and cooperative with exam today. ...Left wrist: shows dorsal ecchymosis, about the size of the palm of a hand that appears within 1 to 3 day of age. Genitalia Exam: Reveals normal uncircumcised male. His testes are distended. There is no scrotal ecchymosis or penile ecchymosis. I could see no hernia. There are no skin abrasions in the groin region. Anus Exam: Reveals normal tone. There is one (1) small superficial, less than one (1) centimeter, abrasion on the right buttock, about 4 cm from his anus. It appears pretty fresh as there is no scabbing, but there is no active bleeding either. I could see no anal trauma and no other ecchymosis noted. ...I cannot say for sure whether this lesion is directly attributable to the trauma of 2 days ago, but it is certainly consistent with that age of injury." d. On 7/31/14 at 7:00 p.m., CNA #2 was asked if she had ever heard or seen (CNA #1) be abusive toward (Resident #1). She stated that about a month ago while giving care to (Resident #1), (Resident #1) calls (CNA #1) ' Rambo ' and raised his voice directed toward (CNA #1). He (Resident #1) would ball up his fist, and (CNA #1) would say to him, ' If you think you're going to do anything, I'll pop you." (CNA #1) would be nice to him but (Resident #1) acted like he was going to hit him. (CNA #1) said to (Resident #1), ' If you think you're going to hit me, it will be the last time." Then he would back up. I told (CNA #1) maybe you shouldn't have said that. But that's all he said." e. On 7/31/14 at 8:29 p.m., LPN #1 was asked if she was aware of any abusive behavior by (CNA #1) toward (Resident #1). She stated, " He (Resident #1) is very aggressive, mean, angered easily, been that way ever since I've been here. (CNA #1) kinda antagonizes him. I told him several times to stop it. Before (Resident #1) left out to the behavioral health center, he punched (CNA #1) in the face and stomach. He's really combative with showers. Before the behavioral health center, (CNA #1) gave him his showers. LPN #1 then stated that (CNA #1) was taken off the hall before he (Resident #1) went to the behavioral health center (6/20/14) about a month or so ago." LPN #1 was asked, "So why did (CNA #1) go back on the hall? LPN #1 stated, "That's a really good question. I don't know and he (Resident #1) doesn't like (CNA #3) either. He's called him all kinds of names. E Hall is a really heavy hall and we need muscle down there." LPN #1 was asked if the conflict between (CNA #1) and (Resident #1) had been reported to the DON? LPN #1 stated, "Yes, (DON) knows, because of (CNA #1) being punched and they did take (CNA #1) off that hall when (Resident #1) came back from (behavioral health center)." LPN #1 was asked then why did (CNA #1) go back on the hall the 26th (7/26/14)? LPN #1 stated, "I don't know. If he worked Sunday on that hall, they probably should've known better." f. On 7/31/14 at 6:35 p.m., CNA #3 was asked if he knew of any abusive behavior toward (Resident #1) by (CNA#1). He stated, "(Resident #1) would get really upset because (CNA #1) would keep egging him on and a couple of months ago, (Resident #1) punched him in the face twice and made his lip bleed. I didn't see it; I just saw his (CNA #1's) face after. (CNA #1) disrespects (Resident #1). I never knew (CNA #1) was not supposed to work E Hall. (CNA #1) never made that statement. I heard that the bruise on (Resident #1) was caused by (CNA #1). (Resident #1) said (CNA #1) did it." CNA #3 was asked if he believed (CNA #1) caused the bruising. CNA #3 stated, "It's a big possibility because of the way (CNA #1) talked in front of (Resident #1)." CNA #3 was asked did he ever report anything about (CNA #1). He stated, "Yes. They made me fill out a witness statement when (CNA #1) called me a faggot the first time in front of (Resident #1). Ever since then (Resident #1) calls me a faggot when I provide care. Yesterday, I had to step outside the building in order for me to cool my head, clear my thoughts because it upsets me. Yesterday was the very first time I was told to take someone with me to provide care to (Resident #1)." g. On 7/31/14 at 6:55 p.m., the Staffing Coordinator/LPN #2 was asked about (CNA #1) working on E Hall with (Resident #1). The Staffing Coordinator stated that CNA #1 was not supposed to work with (Resident #1) since June 2014 because I think (Resident #1) assaulted (CNA #1). (Resident #1) punched (CNA #1) in the face. I flipped him to E Hall Saturday (7/26/14) at noon because we had call ins. He was told not to have direct care with (Resident #1). (DON) told me that he was not to work with the resident because of what happened back in June. I don't know why he singled the resident out to give him a shower." On 7/31/14 at 7:15 p.m., (CNA #1's) time sheet was reviewed. According to the time sheet, (CNA #1) worked the 2:00 p.m. to 10:00 p.m. (2/10) shift on 7/26/14 and according to the CNA assignment sheet, CNA #1 worked E Hall where Resident #1 resided. h. On 8/1/14 at 11:00 a.m., the Administrator was asked why (CNA#1) was allowed to work after she was aware of reported abuse by (CNA #1) toward (Resident #1). She stated, "I don't think of it as failure (by the facility) because he (CNA #1) was not assigned to (Resident #1). He was assigned to E Hall. He (CNA #1) knew he was not supposed to work with that resident. He made a conscious choice to do that." She was asked did the weekend staff know he wasn't supposed to be with (Resident #1)? She stated, "I don't know if I even considered that an issue. The responsibility lies with (CNA #1). He could've told the nurses that he couldn't work with him. I can't just side and blame nursing. He's an adult." She was asked if the facility identified an issue with the Staff Coordinator assigning (CNA #1) and instructing him to work E Hall where (Resident #1) resided even though she knew (CNA #1) was not supposed to? The Administrator stated, "But what part goes back to the CNA; to use discernment? It doesn't always fall back on nursing." She was asked so are you saying it is all the CNA's fault? The Administrator stated, "No. I'm not saying it's all the CNA's fault. But CNAs have responsibility too. I'm not taking away that we couldn't have done somewhat better." i. On 8/1/14 at 12:42 p.m., the DON was asked how information is reported to the weekend staff about resident care? She stated, "Well a lot of the carry over is because (Weekend RN supervisor) is here on Friday to inform weekend. Generally, I will post in the med.(medication) room and the break room information. A lot of it is based on (Weekend RN Supervisor)." The DON was asked if the facility identified an issue with the Staff Coordinator assigning (CNA #1) down E Hall where (Resident #1) resided even though she knew CNA #1 was not supposed to work E Hall? The DON stated, "(CNA #1) was a grown adult. I would expect that he would know better. I would expect not to tell him every single time not to provide care to (Resident #1). I don't hold (Staffing Coordinator) accountable. There was another CNA on that hall that could've given him a shower. Even though he was on the hall there were 23 other residents he could've cared for." j. On 8/1/14 at 1:00 p.m., during a body audit of Resident #1, surveyor was able see from thighs up. Chest and abdomen was clear. The buttocks were clear with feces present. There was a large dark purple bruise to his dorsal left hand, and a large bluish discoloration just above his left wrist toward his forearm. 3. Resident #6 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date of 7/17/14 documented the resident scored 2 (0-7 indicates severe impairment) on a Brief Interview for Mental Status, required total assistance of 2 persons for bed mobility, transfers, toileting and bathing, and required extensive assistance of 1+ persons for eating and personal hygiene. a. On 7/31/14 at 7:00 p.m., CNA #2 was asked if she was aware of anyone being verbally abusive to Resident #6. CNA #2 stated, "(Resident #6) was having episodes of diarrhea one evening about a month and half ago. I was helping him (CNA #1) change (Resident #2). He said to (Resident #6), 'your only reason for living is[***]ing.' Then (Licensed Practical Nurse (LPN)) #1 gave him a verbal warning. I heard her tell him this was his verbal warning." b. On 7/31/14 at 8:29 p.m., LPN #1 was asked, "Has there been any problems with other residents and (CNA #1)? LPN #1 stated, "Yes, (Resident 6), I was doing my PEG (Percutaneous Endoscopic Gastric) tube, this was probably a month and a half ago and I don't remember which CNA was with him, but he told (Resident #6), '...all you have to do in life is[***]' He was irritated because she needed to be cleaned up. I actually had to stop my PEG tube, I went to that room and I said you need to come find me when you are done. So I went back to finish my PEG and he never did come find me. I went and found him. I asked (CNA #1), Do you want to tell me why you said that to (Resident #1), and she's had a bad stroke. You shouldn't say that to anybody. She understands what you say. You do understand that's verbal abuse right? He said ' No. ' I said, I'm sure you didn't. I was extremely upset. I told him he was not to go back in that room for the rest of the night. I told him this was the one and only verbal warning he will ever get from me. I did tell (Director of Nursing (DON)) about it. I've not been doing this for very long." LPN #1 was asked, "When did you inform the (DON)?" LPN #1 stated, "It was the next day. I went into her office and told her. I may have even told her that night too. I can't remember." c. On 8/1/14 at 12:42 p.m., the DON was asked if any verbal abuse involving (Resident #6) by (CNA #1) had been reported to her. The DON stated she was unaware of anything occurring between (CNA #1) and (Resident #6). She stated nothing was ever reported to her. 4. The Immediate Jeopardy was removed on 8/1/14 at 2:15 p.m. and the scope and severity reduced to an H when the facility implemented the following plan of removal: 1) (CNA #1) was suspended on 7/28/14 by Administrator and has not returned to work. 2) Police were notified on 7/28/14 by DON at 12:45 p.m. Administration began interviews with staff and residents starting on 7/28/14 at 11:00 a.m. Any negative findings were corrected immediately. MD assessed Resident #1 on 7/29/14 at 1:21 p.m. On 7/30/14, body audits were started by Nursing Management at 10:30 a.m. on Hall that (CNA #1) last worked and completed by 7/31/14 at 12 p.m. 3) Abuse/Neglect in-service originally started on 7/29/14 at 6 a.m. by Nursing Management. Nursing Management staff began in-services on Abuse/Neglect Reporting and Behavior Modification starting at 11:00 p.m. on 7/31/14 to all staff present and will in-service all shifts prior to start of shifts until all employees have been in-serviced. Any employee who is out will not return to work until instructed. Administrator in-serviced Staff Development LPN on 8/1/14 at 1:30 p.m. on following specific interventions involving known resident and staff conflict and to ensure employee is not to perform direct care on resident in question. On 7/31/14 at 10:00 p.m., DON and Administrator were in-serviced by Regional Nurse Consultant on communicating with weekend management and evening and night shift on interventions specific to residents and staffing needs. 4) DON/designee to perform random interviews of staff and residents daily x2 weeks starting on 8/1/14. Then DON/Designee to perform random interviews of staff and residents 3 x a week until substantial compliance is achieved.

Complaint # (AR 370) was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure Residents #1 and #6, who were cognitively impaired, were free from abuse. The facility identified an incident where Resident #1 physically injured CNA #1 to increase the risk of staff to resident abuse but failed to ensure the planned intervention was implemented. The facility failed to ensure witnessed staff to resident verbal/mental abuse involving Certified Nursing Assistant (CNA) #1 was immediately reported to the Administrator/Designee to ensure residents were protected from the potential of further abuse for 2 of 2 (Residents #1 and #6) case mix residents who were cognitive impaired. The failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 who was cognitively impaired and who alleged staff to resident abuse. According to a list provided by the Director of Nursing (DON) on 8/1/14 at 2:28 p.m., this failed practice had the potential to affect 34 residents in the facility who were cognitively impaired. The facility was informed of the Immediate Jeopardy on 8/1/14 at 12:25 p.m. The findings are. 1. Resident #1 had [DIAGNOSES REDACTED]. The Medicare 30-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/16/14 documented the resident scored 5 (0-7 indicates severe impairment) on a Brief Interview for Mental Status, required extensive assistance from 2 person for transfers, dressing, toilet use, bathing and hygiene. a. The Resident Care Plan dated 6/20/14 documented, " ...Problem Onset: 10/9/2013 - Behavior Management required ...combative with care/resistive to care..." b. The Behavioral Health Center psychiatric evaluation dated 6/10/14 documented, "...Pt also has refused assistance with ADLs (activities of daily living)... Pt (patient) is a 73 y/o (year old) wm (white male) who presents from (nursing home) after punching staff causing injury ..." c. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) -7734 form dated 7/28/14 documented, " ...At 9:00 a.m. on 7/28/14, (Resident #1) reported to SSD (Social Services Director) that during a shower his ' nipples were twisted ' and something was put in his ' butthole. ' Head to toe assessment of resident revealed a red discolored area to his left forearm measuring 7 x 7 cm (centimeters), no other injuries were noted at that time. Records reviewed showed that (CNA #1) had given (Resident #1) his shower on Saturday evening 7/26/14. CNA #1 was immediately suspended pending investigation. Police, MD (medical doctor) and family were notified and an officer came to the facility to interview the resident with family and staff present. Collection of statements from alert and oriented resident as well as other staff members has begun, investigation continues ..." 1) On 8/1/14 at 8:41 p.m., the Weekend RN Supervisor was asked what she knew about the abuse allegation reported by (Resident #1) concerning (CNA #1). She stated she noticed (Resident #1) in the dining room drinking coffee around 4:00 p.m. Sunday (7/27/14). She stated, " (Resident #1) was quiet and distant that day. There was something odd about his behavior, not himself." The Weekend RN Supervisor stated when she was asked if she knew (CNA #1) was not supposed to provide care to (Resident #1)? She stated, "I had no knowledge (CNA #1) was not supposed to work with (Resident #1), because I would not have scheduled him there. I would just switch halls. If I had an idea at all, any suspicion, I would just change the assignment." The Weekend RN Supervisor's report dated 7/26/14 and 7/27/14 documented, "(Resident #1) change in behavior." 2) The DMS witness statement (no date provided) (not timed) signed by the DON, documented, " ...I received a call from the facility regarding (Resident #1's son) being concerned because his Dad had acted differently on Sunday 7/27/14 when he took him for coffee. When he had returned to the facility there question about bruising on both his Dad's hands. (Resident #1's son) said he thought they were old, but was worried about his Dad's change in behavior. Weekend RN (Registered Nurse) Supervisor called and informed me at about 3:00 p.m. I could not come to the facility to interview the resident at that time. I called (Administrator) and asked if she could and she said she could. Then on Monday morning in morning meeting we talked about it and asked SSD to talk to (Resident #1). She said she would and afterwards she reported he had his "nipples twisted" and a "finger shoved up his butt." The investigation then began. I did a head to toe assessment on resident at 11:30, he was cooperative, there was a red area to left forearm 7 x 7 cm, 4 bruises to back of both hands. No other areas noted on resident, denied pain to areas..." 3) The DMS witness statement dated 7/30/14 signed 7/31/14 (not timed) by the Administrator, documented, " ...On 7/27/14, I got a call from DON that (Resident #1's son) was upset re: his Dad. He had spoken to weekend supervisor and said that his Dad was quiet on their ride to get coffee and appeared upset when he brought him back to the facility. spoke to Weekend supervisor about his Dad's change in behavior - there was discussion about his arms and the bruises - not sure what related to DON was unable to come to facility, but called me and said (around 3ish pm) that (Resident #1) appeared upset and sad and that there were bruises on his arm. I came around 4:30 p.m. and spoke to resident and asked what was wrong. He wouldn't say anything, but sad and distant. I did look at Resident #1's arms and left upper arm was bruised. I did talk to Weekend RN Supervisor and asked her to get witness statements from staff re: bruises and if they know origin ..." 4) The DMS witness statement dated 7/28/14 documented by the SSD, " ...On Monday, 7/28 SSD ask to go see resident, he had been tearful earlier in the morning and didn't want to go to breakfast. Resident told SSD that he had a shower and the staff person that showered him was ' ruff, ' Said he twisted his nipples and rubbed too hard and staff person stuck his finger up residents butt, resident became tearful again. SSD reported to Administrator and residents son contacted." On 7/31/14 at 6:15 p.m., the Social Service Director (SSD) was asked if she knew about the allegation of sexual abuse reported by (Resident #1). She stated, "In the morning meeting on 7/28/14 the Administrator and the DON (Director of Nursing) asked me to talk to (Resident #1) based on the weekend supervisor's report. I was told that (Resident #1) had issues over the weekend and they told me what he had told nursing. I talked to him and asked him what happened during his shower over the weekend. During the interview he did not voluntarily say any one's name. But he did say "that boy." The SSD stated (Resident #1) made the allegation (of abuse) to her and she reported it to the Administrator. 5) The physician's progress notes dated 7/29/14 at 1:21 p.m. documented, "I was asked to see (Resident #1) today by the DON because there was a reportable incident yesterday. (Resident #1) reported that there was a CNA on his floor, whom he does not like, who was responsible for his care in the shower 2 days ago. He reports that the CNA used his finger to penetrate his anus repeatedly. He also used a shower nozzle to slap against his penis. He was also grabbed strongly on his left arm. The patient seems quite upset about this and was able to recall the event in pretty significant detail. He really doesn't have any pain with defecation at this point, and his bowel movements have been normal. He does have some bruising around this left wrist. His penis is normal, and he has no dysuria, and is not suffering bruising in his groin anteriorly. He is alert and cooperative with exam today. ...Left wrist: shows dorsal ecchymosis, about the size of the palm of a hand that appears within 1 to 3 day of age. Genitalia Exam: Reveals normal uncircumcised male. His testes are distended. There is no scrotal ecchymosis or penile ecchymosis. I could see no hernia. There are no skin abrasions in the groin region. Anus Exam: Reveals normal tone. There is one (1) small superficial, less than one (1) centimeter, abrasion on the right buttock, about 4 cm from his anus. It appears pretty fresh as there is no scabbing, but there is no active bleeding either. I could see no anal trauma and no other ecchymosis noted. ...I cannot say for sure whether this lesion is directly attributable to the trauma of 2 days ago, but it is certainly consistent with that age of injury." d. On 7/31/14 at 7:00 p.m., CNA #2 was asked if she had ever heard or seen (CNA #1) be abusive toward (Resident #1). She stated that about a month ago while giving care to (Resident #1), (Resident #1) calls (CNA #1) ' Rambo ' and raised his voice directed toward (CNA #1). He (Resident #1) would ball up his fist, and (CNA #1) would say to him, ' If you think you're going to do anything, I'll pop you." (CNA #1) would be nice to him but (Resident #1) acted like he was going to hit him. (CNA #1) said to (Resident #1), ' If you think you're going to hit me, it will be the last time." Then he would back up. I told (CNA #1) maybe you shouldn't have said that. But that's all he said." e. On 7/31/14 at 8:29 p.m., LPN #1 was asked if she was aware of any abusive behavior by (CNA #1) toward (Resident #1). She stated, " He (Resident #1) is very aggressive, mean, angered easily, been that way ever since I've been here. (CNA #1) kinda antagonizes him. I told him several times to stop it. Before (Resident #1) left out to the behavioral health center, he punched (CNA #1) in the face and stomach. He's really combative with showers. Before the behavioral health center, (CNA #1) gave him his showers. LPN #1 then stated that (CNA #1) was taken off the hall before he (Resident #1) went to the behavioral health center (6/20/14) about a month or so ago." LPN #1 was asked, "So why did (CNA #1) go back on the hall? LPN #1 stated, "That's a really good question. I don't know and he (Resident #1) doesn't like (CNA #3) either. He's called him all kinds of names. E Hall is a really heavy hall and we need muscle down there." LPN #1 was asked if the conflict between (CNA #1) and (Resident #1) had been reported to the DON? LPN #1 stated, "Yes, (DON) knows, because of (CNA #1) being punched and they did take (CNA #1) off that hall when (Resident #1) came back from (behavioral health center)." LPN #1 was asked then why did (CNA #1) go back on the hall the 26th (7/26/14)? LPN #1 stated, "I don't know. If he worked Sunday on that hall, they probably should've known better." f. On 7/31/14 at 6:35 p.m., CNA #3 was asked if he knew of any abusive behavior toward (Resident #1) by (CNA#1). He stated, "(Resident #1) would get really upset because (CNA #1) would keep egging him on and a couple of months ago, (Resident #1) punched him in the face twice and made his lip bleed. I didn't see it; I just saw his (CNA #1's) face after. (CNA #1) disrespects (Resident #1). I never knew (CNA #1) was not supposed to work E Hall. (CNA #1) never made that statement. I heard that the bruise on (Resident #1) was caused by (CNA #1). (Resident #1) said (CNA #1) did it." CNA #3 was asked if he believed (CNA #1) caused the bruising. CNA #3 stated, "It's a big possibility because of the way (CNA #1) talked in front of (Resident #1)." CNA #3 was asked did he ever report anything about (CNA #1). He stated, "Yes. They made me fill out a witness statement when (CNA #1) called me a faggot the first time in front of (Resident #1). Ever since then (Resident #1) calls me a faggot when I provide care. Yesterday, I had to step outside the building in order for me to cool my head, clear my thoughts because it upsets me. Yesterday was the very first time I was told to take someone with me to provide care to (Resident #1)." g. On 7/31/14 at 6:55 p.m., the Staffing Coordinator/LPN #2 was asked about (CNA #1) working on E Hall with (Resident #1). The Staffing Coordinator stated that CNA #1 was not supposed to work with (Resident #1) since June 2014 because I think (Resident #1) assaulted (CNA #1). (Resident #1) punched (CNA #1) in the face. I flipped him to E Hall Saturday (7/26/14) at noon because we had call ins. He was told not to have direct care with (Resident #1). (DON) told me that he was not to work with the resident because of what happened back in June. I don't know why he singled the resident out to give him a shower." On 7/31/14 at 7:15 p.m., (CNA #1's) time sheet was reviewed. According to the time sheet, (CNA #1) worked the 2:00 p.m. to 10:00 p.m. (2/10) shift on 7/26/14 and according to the CNA assignment sheet; CNA #1 worked E Hall where Resident #1 resided. h. On 8/1/14 at 11:00 a.m., the Administrator was asked why (CNA#1) was allowed to work after she was aware of reported abuse by (CNA #1) toward (Resident #1). She stated, "I don't think of it as failure (by the facility) because he (CNA #1) was not assigned to (Resident #1). He was assigned to E Hall. He (CNA #1) knew he was not supposed to work with that resident. He made a conscious choice to do that." She was asked did the weekend staff know he wasn't supposed to be with (Resident #1)? She stated, "I don't know if I even considered that an issue. The responsibility lies with (CNA #1). He could've told the nurses that he couldn't work with him. I can't just side and blame nursing. He's an adult." She was asked if the facility identified an issue with the Staff Coordinator assigning (CNA #1) and instructing him to work E Hall where (Resident #1) resided even though she knew (CNA #1) was not supposed to? The Administrator stated, "But what part goes back to the CNA; to use discernment? It doesn't always fall back on nursing." She was asked so are you saying it is all the CNA's fault? The Administrator stated, "No. I'm not saying it's all the CNA's fault. But CNAs have responsibility too. I'm not taking away that we couldn't have done somewhat better." i. On 8/1/14 at 12:42 p.m., the DON was asked how information is reported to the weekend staff about resident care? She stated, "Well a lot of the carry over is because (Weekend RN supervisor) is here on Friday to inform weekend. Generally, I will post in the med.(medication) room and the break room information. A lot of it is based on (Weekend RN Supervisor)." The DON was asked if the facility identified an issue with the Staff Coordinator assigning (CNA #1) down E Hall where (Resident #1) resided even though she knew CNA #1 was not supposed to work E Hall? The DON stated, "(CNA #1) was a grown adult. I would expect that he would know better. I would expect not to tell him every single time not to provide care to (Resident #1). I don't hold (Staffing Coordinator) accountable. There was another CNA on that hall that could've given him a shower. Even though he was on the hall there were 23 other residents he could've cared for." j. On 8/1/14 at 1:00 p.m., during a body audit of Resident #1, surveyor was able see from thighs up. Chest and abdomen was clear. The buttocks were clear with feces present. There was a large dark purple bruise to his dorsal left hand, and a large bluish discoloration just above his left wrist toward his forearm. 2. Resident #6 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date of 7/17/14 documented the resident scored 2 (0-7 indicates severe impairment) on a Brief Interview for Mental Status, required total assistance of 2 persons for bed mobility, transfers, toileting and bathing and required extensive assistance of 1+ persons for eating and personal hygiene. a. On 7/31/14 at 7:00 p.m., CNA #2 was asked if she was aware of anyone being verbally abusive to Resident #6. CNA #2 stated, "(Resident #6) was having episodes of diarrhea one evening about a month and half ago. I was helping him (CNA #1) change (Resident #2). He said to (Resident #6), 'your only reason for living is[***]ing.' Then (Licensed Practical Nurse (LPN)) #1 gave him a verbal warning. I heard her tell him this was his verbal warning." b. On 7/31/14 at 8:29 p.m., LPN #1 was asked, "Has there been any problems with other residents and (CNA #1)? LPN #1 stated, "Yes, (Resident 6), I was doing my PEG (Percutaneous Endoscopic Gastric) tube, this was probably a month and a half ago and I don't remember which CNA was with him, but he told (Resident #6), '...all you have to do in life is[***]' He was irritated because she needed to be cleaned up. I actually had to stop my PEG tube, I went to that room and I said you need to come find me when you are done. So I went back to finish my PEG and he never did come find me. I went and found him. I asked (CNA #1), Do you want to tell me why you said that to (Resident #1), and she's had a bad stroke. You shouldn't say that to anybody. She understands what you say. You do understand that's verbal abuse right? He said ' No. ' I said, I'm sure you didn't. I was extremely upset. I told him he was not to go back in that room for the rest of the night. I told him this was the one and only verbal warning he will ever get from me. I did tell (Director of Nursing (DON)) about it. I've not been doing this for very long." LPN #1 was asked, "When did you inform the (DON)?" LPN #1 stated, "It was the next day. I went into her office and told her. I may have even told her that night too. I can't remember." c. On 8/1/14 at 12:42 p.m., the DON was asked if any verbal abuse involving (Resident #6) by (CNA #1) had been reported to her. The DON stated she was unaware of anything occurring between (CNA #1) and (Resident #6). She stated nothing was ever reported to her. 3. The Immediate Jeopardy was removed on 8/1/14 at 2:15 p.m. and the scope and severity reduced to an H when the facility implemented the following plan of removal: 1) (CNA #1) was suspended on 7/28/14 by Administrator and has not returned to work. 2) Police were notified on 7/28/14 by DON at 12:45 p.m. Administration began interviews with staff and residents starting on 7/28/14 at 11:00 a.m. Any negative findings were corrected immediately. MD assessed Resident #1 on 7/29/14 at 1:21 p.m. On 7/30/14, body audits were started by Nursing Management at 10:30 a.m. on Hall that (CNA #1) last worked and completed by 7/31/14 at 12 p.m. 3) Abuse/Neglect in-service originally started on 7/29/14 at 6 a.m. by Nursing Management. Nursing Management staff began in-services on Abuse/Neglect Reporting and Behavior Modification starting at 11:00 p.m. on 7/31/14 to all staff present and will in-service all shifts prior to start of shifts until all employees have been in-serviced. Any employee who is out will not return to work until instructed. Administrator in-serviced Staff Development LPN on 8/1/14 at 1:30 p.m. on following specific interventions involving known resident and staff conflict and to ensure employee is not to perform direct care on resident in question. On 7/31/14 at 10:00 p.m., DON and Administrator were in-serviced by Regional Nurse Consultant on communicating with weekend management and evening and night shift on interventions specific to residents and staffing needs. 4) DON/designee to perform random interviews of staff and residents daily x2 weeks starting on 8/1/14. Then DON/Designee to perform random interviews of staff and residents 3 x a week until substantial compliance is achieved.