Every finding on record at Friendship Manor

Based on observation, interview and record review, the facility failed to ensure food was prepared in a sanitary manner, failed to ensure food in the freezer was covered and labeled, and failed to ensure hot foods were maintained at 135 degrees Fahrenheit or greater on the steam table and cold foods were maintained below 41 degrees Fahrenheit when served. This has the potential to affect all 70 residents residing in the facility. The findings include:The CMS 671 form dated 6/2/26 showed 70 residents resided in the facility on 6/2/26.The facility's matrix, provided by the facility on 6/2/26 did not identify any residents that received tube feedings and no residents with tube feedings were observed during the survey.On 6/2/26 at 10:35 am, the walk-in freezer had turkey on a rack cooling right in front of the cooling unit that keeps the freezer at the appropriate temperatures. The turkey was not covered, labeled or dated. V14 (Dietary Manager) said the turkey was cooked that morning. V15 (Executive Chef) showed this surveyor the cooling log for the turkey showing it was placed in the cooler at 8:40 AM that morning. V15 said the turkey should have been covered, labeled and dated.On 6/2/26 at 10:56 AM, V16 (Dietary Cook) picked up the recipe book and opened the book to check the recipe for the lunch meal. V16 had gloves on both of his hands. V16 walked over to the chart that was on the cooler door to check the number of residents being served a mechanical diet for the lunch meal. V16 touched the chart with his right gloved hand. V16 got a pan of cooked coconut shrimp, started pulling the tails off the shrimp and put them in the food processor. V16 had on the same gloves he used to check the recipe book, the chart on the cooler, and the handle to the hotbox (a heating unit to store foods in to keep them warm). After processing the shrimp for the mechanical soft diets, V16 walked over to grab some smaller pans to put the shrimp in. While walking by a large trash can, V16 touched the top of the garbage can with his left gloved hand. V16 carried back 4 smaller pans to the area. 2 of the pans were in his right-gloved hand and the other two he was holding with his left arm up against his apron. V16 emptied the shrimp that was already processed into two of the smaller pans, then pulled the tails off more shrimp and put them in the food processor, while wearing the same gloves. After processing the shrimp, he put it in a smaller pan, put plastic wrap over all three smaller pans, and put them in the hotbox, touching the handle to the hotbox and the door of the hotbox. V16 walked back over to the food processor and pulled the tails off the shrimp for the pureed meals. V16 had the same gloves on. V16 pureed the shrimp and put the pureed shrimp in a small pan, covered the pan with plastic and put it in the hotbox, touching the handle. V16 took the dishes for the food processor to the dish washing area and placed them in the sink. V16 removed the gloves he had on since starting the altered diet food preparation. V16 did not wash his hands. V16 took all the pans for the lunch meal out of the hotbox and placed them on the cart. Then V16 went around the kitchen grabbing the utensils needed to serve the lunch meal. V16 put one glove on his left hand and obtained the food temperatures after the pans were placed on the steam table for the meal service. After obtaining the food temperatures, V16 went back in to finish the pureed foods. V16 did not wash his hands and was only wearing the one glove on his left hand. At 11:34 AM, V16 grabbed the dishes for the food processor and placed it on the food processor. He pureed the baked beans, then placed plastic over the pan and put it in the hotbox. V16 removed the dish for the food processor and took it to the dish washing area. He rinsed the dish out in the sink and placed it on a rack to send through the dish washing machine. V16 removed the glove from his left hand and did not wash his hands. He walked over to the clean dish area and grabbed a food processor dish that had already been sanitized with his bare hands, placed it on the food processor, and prepared the pureed beets. While the beets were being pureed, V16 picked up the pan the unprocessed beets had been in and went over to a sink to rinse the pan out. V16 carried the pan over to the food processor and poured the pureed beets into the pan when he was done processing them.On 6/2/26 at 11:53 AM, V14 (Dietary Manager) said V16 should have removed the gloves and washed his hands after touching the handle and the door to the hotbox, the garbage can, or any other surface, before he touched any food because that is cross-contamination.On 6/2/26 at 12:03 PM, the temperatures of the food for the lunch meal in the assisted dining room were obtained. V15 (Executive Chef) obtained the food temperatures in the assisted dining room. V17 (food server) in the assisted dining room said she has not taken the temperatures before on the steam table so V15 will do it. The following foods were not kept at 135 degrees Fahrenheit or greater on the steam table:Pureed beans 130 degrees Fahrenheit.Mechanical hotdogs 129 degrees Fahrenheit.Shrimp 120 degrees Fahrenheit. While taking the temperature, V15 said That temperature is going down.Pureed shrimp 130 degrees Fahrenheit.Mechanical shrimp 123 degrees Fahrenheit.After obtaining the food temperatures, no food was removed from the steam table to be reheated.On 6/2/26 at 12:13 PM, V17 (food server) was plating the foods for the Certified Nursing Assistants to give to the residents. V17 had gloves on both hands. V17 was touching the residents' meal tickets, the cart that had the cake and gelatin dessert on it, the food trays, plates, and the serving utensils in the food pans, then reaching into the hotdog bag, pulling apart the hotdog buns, and grabbing buns with the same gloves. V17 repeated this process several times while serving the lunch meal to the residents in the assisted dining room. At 12:15 PM, the temperature of the gelatin dessert was obtained. The temperature measured 59 degrees Fahrenheit with the food thermometer.On 6/2/26 at 2:03 PM, V15 (Executive Chef) said V16 should have removed his gloves and washed his hands, then applied clean gloves so he did not cross-contaminate the food. V15 said food should be held at 135 degrees Fahrenheit or higher on the steam table. Anything below that should be reheated to 165 degrees Fahrenheit to prevent foodborne illness. V15 said cold foods should be kept at 41 degrees Fahrenheit or below until served. V15 said V17 (Server in the assisted dining room) should not have reached into the bag of hotdog buns and touched the hotdog buns after touching the meal tickets or anything else. V15 said the staff touch the meal tickets with their bare hands. V15 said V17 should have used tongs to prevent cross-contamination. V15 said he went back to check temperatures with the digital thermometer to make sure the issue wasn't that the thermometers that were used were not calibrated. V15 said the temperatures measured on the digital thermometer were not that different from the other thermometer that was used.The facility's undated policy and procedure titled Bare Hand Contact with Food and Use of Plastic Gloves showed Single-use gloves will be worn when handling food directly with hands to ensure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. The policy showed 3. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning work with food) and after removing single-use gloves.5. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed.

Based on observation, interview, and record review the facility failed to ensure medications were prepared at the time of administration for 5 of 9 residents (R6, R34, R62, R70, R83) reviewed for medication administration in the sample of 48. The findings include:R34's face sheet showed she was admitted to the facility 3/1/24. R34's June 2026 eMAR (electronic Medication Administration Record) showed her medications due at 8:00 AM included amlodipine 10 mg, aspirin 81mg, furosemide 40 mg, metoprolol succinate 25 mg, potassium chloride 10 meq, cranberry extract 500 mg, Tylenol arthritis 650 mg, senna plus 8.6 mg-50 mg, propranolol 10 mg, and Fluoxetine 20 mg. R6's face sheet showed he was admitted to the facility 6/5/25. R6's June 2026 eMAR showed his medications due at 8:00 AM included finasteride 5 mg, acetaminophen 500 mg, metoprolol succinate 25 mg, Eye Health Plus Lutein 1,000 unit-200mg-60 unit-2 mg, Fiber-Lax 625 mg, Baclofen 5 mg, Glipizide ER 2.5 mg, Duloxetine 30 mg, and docusate sodium 250 mg. R70's face sheet showed she was admitted to the facility 3/31/23. R70's June 2026 eMAR showed her medication due at 8:00 AM was Lamictal 100 mg. R62's face sheet showed she was admitted to the facility 3/3/26. R62's June 2026 eMAR showed her medications due at 8:00 AM included aspirin 81 mg, clopidogrel 75 mg, metoprolol tartrate 25 mg, and duloxetine 20 mg. R83's face sheet showed she was admitted to the facility 6/2/26. R83's June 2026 eMAR showed her medications due at 8:00 AM included amlodipine 2.5 mg, CoQ10 100 mg, Magnesium Oxide 400 mg, Meloxicam 7.5 mg, Senna 8.6 mg, Vitamin C 1,000 mg, Vitamin D3 1000 units, Vitamin E 400 units, Simethicone 125 mg, and calcium carbonate 200 mg.On 6/3/26 at 9:30 AM, during the medication administration task, V5 (Licensed Practical Nurse/LPN) opened the top drawer of her medication cart. In the top drawer there were medication cups lined up in the front of the drawer with resident initials on them. On 6/3/26 at 9:35 AM, V5 said the medications in the top drawer were for R34, R6, R70, and R62. V5 said she knows she isn't supposed to prepare the medications in advance, but these residents usually line up in morning to receive their medications, but they did not today. At 9:37 AM, this surveyor observed a medication cup in the trash bin on the medication cart with pills in it. V5 said these pills were duplicates for R83 because this surveyor had just observed medication pass for this resident and she had already prepared R83's medications. On 6/4/26 at 1:43 PM, V2 (Chief Nursing Director) and V3 (Director of Nursing) were interviewed together. V2 and V3 said nursing staff should not be preparing resident medications in advance for safety purposes because medications could be given to the wrong resident, medications could get mixed up, and it is not part of the 5 rights of medication administration. The facility's policy and procedure reviewed 10/2025 showed, [The Facility] Administering Medications policy statement; Medications are administered in a safe and timely manner, and as prescribed. A policy was requested regarding presetting resident medications but was not received.

Based on observation, interview, and record review the facility failed to ensure resident dignity was maintained for 1 of 1 resident (R37) reviewed for dignity in the sample of 48. The findings include:R37's undated face sheet showed diagnoses of weakness, amnesia, repeated falls, and dysphagia. R37' physician orders showed admission to hospice services on 5/20/26 with a diagnosis of corticobasal syndrome (progressive brain disease). R37's facility assessment dated [DATE] showed severe cognitive impairment. The same assessment showed R37 is fully dependent on staff for transfers, bathing, dressing, and hygiene.On 6/2/26 at 11:38 AM, R37 was being wheeled down the hallway by V10 (Hospice Certified Nursing Assistant/CNA). R37 was reclined backwards in a high back wheelchair. R37 had a white towel draped over his shoulders and another one across his torso. R37's hips, thighs, and legs were visible. R37 was shivering, appeared cold, and uncomfortable. It was obvious R37 was naked under the towel. R37 was wheeled into his room and transferred into bed by V10 and V9 (CNAs) using a mechanical lift. V10 stated R37 gets showers by twice a week in the group shower room about four doors down the hallway. On 6/3/26 at 9:52 AM, V11 (Shower Aide) stated residents are typically dressed in the group shower room, unless they are a mechanical lift. Those residents are dressed in their rooms where it is easier to transfer them. They should be wrapped in a bath blanket before leaving the shower room. A big bath blanket is used to keep them warm and comfortable. Aides should be sure residents are fully covered before leaving the shower room. It is a dignity thing. V11 said the shower rooms are typically stocked with large bath blankets, but it has not been done yet today. On 6/4/26 at 11:48 AM, V3 (Director of Nurses) stated residents should be fully covered and all private areas covered during transport. Mechanical lift residents do get dressed in their rooms after a shower. Dignity and privacy should be maintained during all care. R37's care plan showed a focus area start dated 6/2/26 (day of survey) related to hospice services and the hospice aides to provide showers twice a week. The facility's Resident Rights Guidelines policy revision dated 4/2026 states: 1.staff must have appropriate in-service training on resident rights, including.b. resident dignity and respect. The same policy states: .provide for the resident's privacy when providing care.

Based on observation, interview, and record review the facility failed to ensure interventions were in place to reduce leg edema for 1 of 1 resident (R35) reviewed for quality of care in the sample of 48. The findings include: R35's undated face sheet showed diagnoses including but not limited to heart failure, peripheral vascular disease, respiratory failure, and fluid/electrolyte imbalance. R35's facility assessment dated [DATE] showed no severe cognitive impairment.On 6/2/26 at 11:21 AM, two signs were posted directly above the head of R35's bed and recliner next to the bed. Both signs stated float heels, elevate feet between meals, and tubi grips (compression leg wraps) to be applied in the morning and off at bedtime. At 12:34 PM, R35 was seated in a wheelchair in her room. Both feet were directly on the floor and there were no staff present. R35 was dressed for the day in shoes and socks. R35 was asked about the signs and said they were there to remind staff to put her feet up. R35 said she has circulation issues and needs her feet up. R35 said staff don't always do it. R35 said her recliner has been broken for the past two days or so. It will no longer go up since something snapped off underneath it. R35 said she wears compression wraps to help with the circulation. R35 lifted her pant legs and was not wearing any compression leg wraps.On 6/3/26 at 9:38 AM, R35 was seated in her wheelchair and alone in her room. The recliner was tipped on the side, and a repair cart was next to it. R35 said they have been working on it for the last hour. R35 said no one has elevated her legs at all today. At 9:42 AM, a maintenance staff member entered and said the chair is not working. It will no longer elevate up. R35 said she hasn't been able to elevate her feet since it broke and no one has given her anything else to raise her feet. On 6/4/26 at 8:30 AM, R35 was seated in a different recliner in her room. R35 was not wearing compression wraps on her legs. R35's feet were flat on the floor. She was dressed for the day in shoes and socks. R35 said she did not know how to raise the feet of the chair. At 8:35 AM, V9 (Certified Nursing Assistant) entered the room and located the leg wraps in R35's bathroom. V9 located the handheld power control for the recliner on the floor, under R35's chair. V9 had to move the chair several inches away from the wall before it would elevate correctly. On 6/4/26 at 8:39 AM, V6 (Registered Nurse) stated R35 needs both the interventions in place. She has CHF (congestive heart failure) and edema builds up in her legs. The tubi grips should be on daily and staff need to raise her feet to help with the edema problem. It could continue to build up if those things are not done. On 6/4/26 at 11:59 AM, V3 (Director of Nurses) stated R35's signs are posted to remind staff to do those things. V3 said, yes, both interventions should be done and R35 needs them. It is important for reducing leg edema and leg swelling. V3 confirmed R35 is alert and oriented with no memory problems.R35's care plan showed focus areas with interventions to assist and encourage to elevate legs. The care plan did not address the need for the compression leg wraps.

Based on observation, interview, and record review the facility failed to ensure gait belts were used during transfers for 2 of 7 residents (R2, R64) reviewed for safety in the sample of 48. The findings include:1. R2's undated face sheet showed diagnoses including but not limited to vascular dementia, hypertension, anxiety, seizures, and repeated falls. R2's facility assessment dated [DATE] showed moderate cognitive impairment and requiring partial to moderate staff assist for toilet transfers. R2's care plan showed transfers to be done as an extensive assist of one staff using a gait belt. On 6/2/26 at 11:03 AM, V9 (Certified Nursing Assistant/CNA) transferred R2 from her wheelchair onto the toilet. V9 exited the room while V7 (Registered Nurse/RN) remained with the resident until V9 returned. V9 stood R2 up, provided pericare, and put on a fresh incontinent brief. V9 pulled up R2's pants and transferred her back to the wheelchair. V9 held onto the back of her pants while transferring the resident. V9 wore a gait belt around her own waist during the entire care process. On 6/2/26 at 11:20 AM, R2 stated the aides don't always use a gait belt during transfers. They just pull up on the back of my pants. They have ripped the elastic out of my pants in the past holding me back there, especially the aides with longer fingernails. On 6/4/26 at 9:20 AM, V9 (CNA) stated we need to use the gait belts to steady residents. It makes sure we have something to hold on to, instead of their arms. We should be using one all the time if they are care planned for it. 2. R64's undated face sheet showed diagnoses including but not limited to dementia, rhabdomyolysis (muscle breakdown), hypertension, anxiety, and neuropathy. R64's facility assessment dated [DATE] showed severe cognitive impairment and requiring partial to moderate staff assist for toilet transfers. R64's care plan showed transfers to be done as an extensive assist of one staff using a gait belt.On 6/2/26 at 12:21 PM, R64 was seated in a wheelchair in her room. The call light was on and V8 (Licensed Practical Nurse/LPN) entered. R64 asked to use the bathroom and V8 transferred her from the wheelchair to the toilet. R64's feet were approximately one foot off the floor while seated on the toilet. V8 said your short, little legs have a hard time with the high toilet. V8 stood R64 up, provided pericare, and a fresh brief. V8 transferred R64 back to the wheelchair. R64 did not have a gait belt on during the entire process. On 6/4/26 at 11:48 AM, V3 (Director of Nurses) said gait belts need to be used for all one-on-one transfers. They are important to ensure the safety of residents. Holding on to the back of a resident's pants is unsafe, and someone could fall. Staff know to use the gait belts per the education provided and our policy. The facility's Safe Lifting and Movement of Residents (Gait Belt, Mechanical Lifting Device, Slide Boards) policy review dated 10/25 states: 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.

Based on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 25 opportunities with 3 errors resulting in a 12% medication error rate. This applies to 1 of 9 residents (R82) observed in the medication pass. The findings include:R82's medical record showed she was admitted to the facility 5/27/26. R82's physician order sheet showed an order for acetaminophen 500 mg (2 tablets) to be given by mouth three times a day at 7:00 AM, 3:00 PM, and 9:00 PM; Eliquis 2.5 mg to be given by mouth every 12 hours at 8:00 AM and 8:00 PM; and Calcium Citrate 250 mg to be given by mouth daily. On 6/3/26 at 9:37 AM, V4 (Licensed Practical Nurse) administered R82's acetaminophen 500 mg (1 hours and 37 minutes late) and Eliquis 2.5 mg (37 minutes late). V4 administered Calcium Citrate 400 mg and 12.5 of D3 instead of Calcium citrate 250 mg per R82's physician order. On 6/04/2026 at 1:01 PM, V19 (Registered Nurse) said, [R82's] order is for Calcium citrate 250 mg but the bottle in the medication cart is Calcium citrate 400 mg and 12.5 of D3. V19 said they have an hour before and an hour after the scheduled medication administration time to get the medications done. V19 said I think the reason the acetaminophen is scheduled for 7:00 AM is because it is scheduled 3 times a day. On 6/04/2026 at 1:43 PM, V2 (Chief Nursing Director) and V3 (Director of Nursing) were interviewed together. Both V2 and V3 said, medications should be passed within an hour before and an hour after the scheduled time and that medications brought into the facility for the resident should be reconciled when brought in and the expiration date checked. The facility's policy and procedure reviewed 10/2025 showed, [The Facility] Administered Medications; Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions. 7. Medications are administered within one (1) hour of their prescribed time. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication. before giving the medication.

Based on observation, interview, and record review the facility failed to ensure multiuse medications were dated and labeled. The facility also failed to ensure medications were not expired for 3 of 3 residents (R33, R65, and R81) reviewed for medication storage and labeling in the sample of 48. The findings include:R81's face sheet showed she was admitted to the facility 5/28/26. R81's Physician Order Sheet showed an order for Lantus Solostar Insulin 100 unit/ml subcutaneous at bedtime and Fiasp FlexTouch Insulin 100 unit/ml, 12 units subcutaneous three times a day.R65's face sheet showed he was admitted to the facility 5/14/26. R65's Physician Order Sheet showed an order for Humalog KwikPen Insulin 100 unit/ml subcutaneous per sliding scale. R33's face sheet showed she was admitted to the facility 1/22/25. R33's Physician Order Sheet showed an order dated 1/22/25 for Ibuprofen 200 mg - as needed. Take 400 mg every eight hours as needed for pain/fever. On 6/3/26 at 9:37 AM, during the medication storage and labeling task. R81's Fiasp and Lantus were in the medication cart and not labeled with an open date. R65's Humalog KwikPen Insulin 100 unit/ml was in the medication cart and not labeled with the open date. R33's ibuprofen was observed in the medication cart. R33's ibuprofen was observed to have an expiration date of September 2015. V5 (Licensed Practical Nurse) confirmed the expiration date as September 2015. V5 said medications should be reviewed prior to putting them in the medication cart to ensure they are not expired. V5 said all insulins should be labeled with an open date as soon as they are opened.On 6/4/26 at 1:43 PM, V3 (Director of Nursing) said, Insulin should be labeled as soon as they opened with date and initials. Insulin is to be labeled to make sure it hasn't expired when they give it. The nursing staff should be labeling all medications brought from home and checking the expiration date.The facility's policy and procedure reviewed 10/2025 showed, [The Facility] Administering Medications; Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 12. When opening a multi-dose container, the date opened is recorded on the container. 15. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administered insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident.A policy was requested for expired medications but was not received.

Based on observation, interview, and record review, the facility failed to ensure signage indicating Enhanced Barrier Precautions was posted on a resident's door, and the facility failed to ensure contracted staff wore the appropriate personal protective equipment (PPE) while providing direct care for a resident on enhanced barrier precautions due to having a urinary drainage catheter, and a history of urinary tract infections for 2 of 2 residents (R8, R63) reviewed for catheters in the sample of 48. The findings include:1. R63's admission Record, provided by the facility on 6/4/26, showed he had diagnoses including, but not limited to glaucoma, urinary incontinence, dementia, anxiety disorder, stage 3 chronic kidney disease, a personal history of prostate cancer, and the need for assistance with personal care. R63's Physician's Orders, provided by the facility on 6/4/26, showed he was admitted to hospice on 1/20/26 due to cerebral vascular disease. The Physician's Orders show an order was started on 6/4/26 for Enhanced Barrier precautions every shift. Wear gown and gloves with any high-contact cares for stage 2 heel wound. R63's care plan dated 4/30/26 showed he had an unstageable pressure ulcer to his left heel. The care plan did not address the need for enhanced barrier precautions. R63's facility assessment dated [DATE] showed he had severe cognitive impairment, required substantial/maximal assistance from staff for eating, bed mobility, and transfers. The assessment showed R63 was dependent on staff for bathing, dressing, toileting, personal and oral hygiene, and was always incontinent of bowel and bladder. On 6/4/26, the facility provided a list of residents with pressure injuries. R63 was listed as one of the residents with a pressure injury. The facility's matrix that had been provided on 6/2/26 had not listed R63 as having a pressure wound.On 6/3/26 at 9:42 AM, no signage was seen on or near R63's door indicating he was on enhanced barrier precautions. R63 was not in his room at the time. On 6/4/26 at 10:23 AM, no EBP signage was on or near R63's door. At 11:10 AM, no signage was on or near the door to R63's room indicating he was on enhanced barrier precautions. At 11:14 AM. V23 (Licensed Practical Nurse/LPN) said if a resident has open wounds, they should be on EBP precautions and staff should be wearing a gown and gloves during care. V23 went with this surveyor to R63's room and verified there was no sign indicating EBP precautions for R63 on the door to his room. V23 said she thought there used to be a sign on the door. On 6/4/26 at 11:52 AM, V2 (Chief Nursing Director) said R63 has a pressure wound and EBP signage should be posted on the door to his room. V2 said she told staff today (6/4/26) to put the EBP sign up on R63's door. R63's 6/4/26 notes from the facility's contracted wound nurse practitioner showed he has an unstageable pressure wound to his left heel measuring 3.2 centimeters (cm) x 3.4 cm x +0.1 cm duration of left heal wound since 4/30/26. The notes also showed R63 had an open wound to his left upper buttock measuring 2.9 cm x 1.8 cm x 0-0.1 cm since 4/13/26. 2. R8's admission Record, provided by the facility on 6/4/26, showed he had diagnoses including, but not limited to stage 3 chronic kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, and bladder-neck obstruction.On 6/4/26 at 10:39 AM, V21 (Hospice Certified Nursing Assistant/CNA) was in R8's room providing care for R8. V21 was only wearing gloves. V21 was not wearing a gown. A sign on R8's door showed he was on enhanced barrier precautions (EBP). The sign showed a gown and gloves should be worn when direct-care activities such as catheter care and bathing/dressing were being provided. R8 was lying in bed. V21 emptied the contents of R8's urinary drainage bag into a container and emptied the container in the toilet. V21 then provided a bed bath and catheter care (washing the tubing to the catheter where it is inserted into the body) for R8. While providing the bed bath and catheter care for R8, V21's clothing touched R8's bed linens and R8's skin several times. After providing the bed bath and catheter care, V21 left the gloves on that she used to provide care with, put lotion on R8's stomach and legs, and touched R8's arms, legs, feet, clothing and his pillow.On 6/4/26 at 11:14 AM, V23 (Licensed Practical Nurse/LPN) said if a resident is on EBP precautions, staff should be wearing a gown and gloves during care.On 6/4/26 at 11:52 AM, this surveyor was talking to V2 (Chief Nursing Director) about V21 not wearing a gown while bathing and providing catheter care for R8. V2 said she heard about that, and she talked to V21 about PPE use for residents on enhanced barrier precautions. V2 said V21 should have been wearing a gown and gloves during care.R8's Physician's Orders, provided by the facility on 6/4/26, showed an order dated 10/1/25 for a urinary drainage catheter due to urine retention. The Physician's orders also show an order dated 10/2/25 for Enhanced Barrier Precautions. The order showed a gown and gloves should be worn during catheter care.R8's care plan dated 3/22/26 showed he had a urinary drainage catheter due to bladder outlet obstruction. The care plan showed he was on enhanced barrier precautions.R8's facility assessment, with an observation end date of 4/29/26, showed he had moderate cognitive impairment, was dependent on staff for toileting, bathing, dressing, personal hygiene, and transfers. The assessment showed R8 had an indwelling urinary catheter and was occasionally incontinent of bowel.The facility's policy and procedure titled Urinary Catheter Care, with a reviewed date of 4/2026, showed Routine Perineal Hygiene.4. Personal protective equipment (e.g., gowns, gloves, mask, etc.,) as needed. The procedure showed after providing catheter care/perineal hygiene, staff should make sure the catheter is secure with the securement device, check to make sure it is draining properly, and 14. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly.R8's Infection Reports, provided by the facility on 6/4/26, showed he had three urinary tract infections (UTIs) in the last six months requiring treatment with antibiotics. The UTIs were on 1/27/26, 3/6/26, and 5/3/26.The facility's policy and procedure titled Enhanced Barrier Precautions, with a reviewed date of 10/2025, showed Enhanced Barrier Precautions are utilized to prevent the spread of multi-drug-resistant organisms (MDROs). MDRO transmission is common in long term care facilities contributing to resident morbidity and mortality, and increased healthcare costs. CDC recommendations include the use of enhanced barrier precautions (EBP) during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status. The policy showed 2. EBPs employ targeted gown and glove use during high-contact resident care activities.3. Examples of high-contact resident care activities requiring the use of gown and gloves for enhanced barrier precautions (relative to the reason for EBP) may include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube).and wound care (any skin opening requiring a dressing). This does not apply to a shorter-lasting wound such as skin break or skin tear covered with an adhesive bandage or similar dressing. Examples of chronic wounds include, but are not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcer. The policy also showed 5. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.

Based on interview and record review the facility failed to ensure Resident Assessments were submitted within the 14 day timeframe for 4 or 5 residents (R18, R19, R30, R51) reviewed for Resident Assessments in the sample of 48. The findings include:1.) R19's admission dates provided by the facility showed he was admitted to the facility [DATE]. R19 had an Assessment Reference Date/ARD date of [DATE] at the end of a Medicare stay. R19's Assessment Lookup report showed his discharge MDS (Minimum Data Set) had not been transmitted as of [DATE] (142 days after discharge from a Medicare stay). R19's Final Validation Report provided by the facility [DATE] showed the assessment was transmitted [DATE] and showed, . Warning. Record Submitted Late: The submission date is more than 14 days after. 2.) R51's admission dates provided by the facility showed she was admitted to the facility [DATE]. This same report showed R51 expired on [DATE]. R51's Assessment Lookup report showed her discharge MDS had not been submitted as of [DATE] (73 days after her expiration).3.) R18's admission dates provided by the facility showed she was admitted to the facility [DATE] and discharged [DATE]. R18's Assessment Lookup report showed she had an ARD of [DATE] and her MDS was not submitted until [DATE] (23 days later).4.) R30's admission dates provided by the facility showed she was admitted to the facility on [DATE]. R30's Assessment Look Up report showed she had an ARD date of [DATE] and her MDS was not submitted until [DATE] (58 days later).On [DATE] at 2:40 PM, V24 (MDS Coordinator Nurse) said, R19 was discharged from skilled care [DATE]. His discharge MDS has not been submitted yet. R18's was also discharged [DATE]. She had end of Medicare stay on [DATE]. That MDS was transmitted [DATE]. R51 was discharged [DATE]. I was on medical leave at that time. We hired a consulting company to cover while I was gone. It has not been submitted yet. These should be submitted within 14 days. The facility's policy reviewed 7/2025 showed, MDS Completion and Submission Timeframes. Policy Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation: 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' Internet Quality Improvement Evaluation System (iQIES) in accordance with current federal and state guidelines.

Based on interview and record review the facility failed to follow their policy and use two staff members to perform a mechanical lift transfer for one of three Residents (R1) reviewed for Falls in a sample of six.Findings include:The Facility Lifting Machine, Using a Mechanical Lift Policy, revised 7/2017, documents: to establish general principles of safe lifting using a mechanical lifting device; at least two people are needed to safely move a Resident with a mechanical lift; and before the Resident is lifted, double check the security of the sling attachment; check the stability of the straps.The Facility Safe Lifting and Movement of Residents Policy, revised 9/17/25, documents: to protect the safety and well-being of staff and Residents to promote quality care, this Facility uses appropriate techniques and devices to lift and move Residents; Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of Residents; staff responsible for direct Resident care will be trained in the use of mechanical lifting devices; mechanical lifting devices (total lifts) shall be used for heavy lifting, including lifting and moving Residents when necessary; and mechanical lifting devices require two-to-one staff assistance.The Certified Nurse's Aide Job Description, undated, documents: to assist with lifting, moving and transporting Residents into and out of beds, chairs and lifts; and to follow established safety precautions in the performance of all duties.The Facility Fall Incident Report, dated 11/2025, documents R1 sustained a witnessed fall on 11/27/25 at 5:00 pm and sustained an abrasion to the ear.R1's Minimum Data Set/MDS, Section C (Cognitive Patterns), dated 9/11/25, documents severe cognitive impairment (rarely/never understood) and dependent on staff for Activity of Daily Living/ADL assistance with transfers.R1's current Care Plan documents: that R1 is receiving Hospice End of Life services for a diagnosis including Alzheimer's; alert with confusion and mumbled speech; and extensive two-person assistance with mechanical lift transfer.R1's Fall Risk Assessment, dated 9/11/25, documents R1 is at a high risk for falls and requires a two-person assist with ambulation.The Facility's Final Incident Report, dated 12/1/25, documents R1 sustained a fall from a mechanical lift on 11/27/25. The Incident Report documents that on 11/27/25 at 5:00 pm, V7 (R1's Private Caregiver) and V5 (Certified Nursing Assistant/CNA) placed R1 into a mechanical lift for transfer from R1's bed to R1's recliner. During the transfer, R1 slipped out of the bottom of sling and fell onto R1's buttocks onto the floor. Due to R1's Alzheimer's and inability to verbalize pain, R1 was sent to the local hospital for evaluation. The hospital Comminuted Tomograph/CT (spine and head/brain) and Pelvic X-ray were negative for fractures/injury. R1 sustained a Left Ear superficial abrasion. R1's local Hospital Emergency Notes, dated 11/27/25, document negative results Comminuted Tomography/CT (spine and head/brain) and Pelvic X-ray for fractures/injury.V5 (Certified Nursing Assistant/CNA) Employee Human Resource Records/File, documents: hire date of 4/8/25; completion of mechanical lift training on 4/14/25 and 11/20/25; and a Performance Correction Notice (dated 12/1/25) for improperly placing a mechanical lift sling.On 1/29/26 at 11:00 am, V7 (R1's Private Caregiver) was providing care to R1 in R1's room and stated, On 11/27/25 around dinner time, I was assisting (V5 CNA) with a (mechanical lift) transfer from (R1's) bed to (R1's) recliner. (V5) was the only CNA available to help with (R1's) transfer, so I helped (V5). I attached the two top loops onto the mechanical lift and (V5) attached the bottom loops. When we were transferring (R1) from the bed, we were almost done and ready to place (R1) into the recliner, and (R1) slipped out of the sling and fell on buttocks onto the floor. We realized that the sling was not properly placed between (R1's) legs and that caused (R1) to slip onto the floor. I am not a CNA, and I did not have any training with the mechanical lift, I provide private duty general care for (R1). I was told that I should not help with transferring (R1) because I am not trained. They always used to use just one CNA, so I would help them. Now they have to use two Facility CNAs. I have been (R1's) private caregiver for over two years, so I rode with (R1) to the hospital, and we were back to the Facility by about 8:00 pm. (R1) did not have any injuries except a small little minor scratch on (R1's) left ear from it hitting the side of the lift.On 1/29/26 at 12:04 pm, V5 (CNA) stated, My other co-worker had gone to lunch, so (V7 R1's Private Caregiver) assisted me with the mechanical lift transfer. I am a fairly new CNA and (R1) had a different kind of sling that I was not familiar with. I did not have the loops placed correctly between (R1's) legs and the sling slipped and caused (R1) to slip onto the floor. I did get counseled about the fall and they did educate me on how to use the mechanical lifts correctly.On 1/29/26, V2 (Director of Nursing) stated, On 11/27/25, (V5 CNA) was using a mechanical lift to transfer (R1) from the bed to the recliner. (V7 R1's Private Caregiver) should not have been helping with the mechanical lift transfer because (V7) is not a Facility employee and had not been trained on our mechanical lifts. I counseled (V5) on proper use of the mechanical lift and the placement of the sling. We now make sure to use two of our own CNAs for mechanical lift transfers.

Based on interview and record review, the facility failed to ensure 1 of 3 residents (R1) was transferred safely. This failure resulted in R1 falling and fracturing her right femur.The findings include: On 9/12/25 at 12:45 PM, V9 (Certified Nursing Assistant/CNA) said she was R1's CNA when R1 fell on the morning of 9/2/25. V9 said a couple days prior when she was caring for R1, R1 complained of arm pain and wanted to get up in her chair because of her arm pain. The morning of 9/2/25, R1 complained of right arm pain again and asked V9 to put her in her chair (recliner). V9 said she changed and dressed R1 with pants, shoes, socks, and a clean brief, then she helped position R1 on the side of her bed. V9 said she put the transfer aid device/lift machine, up against the bed and assisted R1 to put her feet on the platform, then R1 grabbed the bar and V9 used the back of R1's pants to help her stand up. V9 said the lift machine was so close to the bed, she couldn't get the paddles down, so she took the brakes off and pulled the lift machine out away from the bed. V9 said before she could get the paddles down, R1 said I'm falling and let go of the bar. V9 said she tried to grab the back of R1's pants/brief to somewhat catch her, so she didn't have a direct hit on the floor, but R1 ended up falling on the floor into a sitting position with her legs straight out. V9 said the machine got pushed out in front of R1. V9 said she went and told V8 (Licensed Practical Nurse/LPN). V9 said R1 was screaming at them and yelling that her leg hurt, that they broke her leg, and they dropped her on the ground. V9 said she felt that something was wrong, because R1 doesn't really yell at her like that. V9 said she should have used a gait belt when transferring R1. V9 said she was told R1 fractured her leg. V9 said she probably should have automatically had a gait belt on R1 when using the machine so she could have held it and prevented R1 from falling. V9 said she wasn't thinking there was going to be issues with the transfer, so she didn't use one.On 9/12/25 at 12:23 PM, V10 (Certified Nursing Assistant/CNA) said V9 came and got him because she needed his help because R1 was on the floor outside of her bathroom. V10 said V9 told him when she was putting the paddles (of the machine) in position, R1 sat back, and the paddles were not in place and R1 fell onto the floor. V10 said R1 did not have a gait belt on when he arrived to assist V9 with R1. V10 said you should always use a gait belt when transferring a resident, especially when using a device where the resident needs to pull themselves up. V10 said if a resident was having arm pain while preparing to use the lift machine to transfer them, he would stop the process. V10 said they are empowered to use their own judgement and could get a total lift device instead. V10 said R1 is a little feisty and unpredictable and he feels like there should be two persons to transfer R1 specifically. V10 said she can be rambunctious at times, and she doesn't want to help much at times. V10 said when using the machine, you scooch the machine right up to the resident, put their feet on the platform, lock the brakes, and the resident reaches for the bar. The staff member uses the gait belt to assist the resident to standing. Once they are standing securely, staff gets the paddles into position as quickly and as smartly as possible, then instructs the resident to lean back on their bottom. On 9/12/25 at 2:10 PM, V8 (LPN) said he was R1's nurse when she fell. V8 said V9 came to him and needed help with R1. V8 said when he got to R1's room, R1 was tangled in the lift machine in front of her bathroom door. V8 said she was dangling half in and half out of the lift. R1's feet were off the platform, her arms were draped over the grab bar, and one paddle was in the up position and the other was in the down position. V8 said R1 was hollering and screaming; she was hanging from the lift. V8 said R1 couldn't move because she was basically wedged in by the paddle. V8 said they moved the paddle and lowered R1 down to the floor. V8 said when using the machine, they are supposed to lock the brakes, use a gait belt to help the resident so they can grab the bar, and then engage the paddles so they can lean back/sit on them. V8 said R1 complained of right lower extremity pain, so he requested an Xray. V8 said R1 eventually went to the hospital and was diagnosed with a displaced fracture.On 9/12/25 at 11:35 AM, V3 (Director of Rehab/Physical Therapist) said when using a lift machine for a resident transfer, the machine is positioned directly in front of the resident, their feet go onto the platform, the machine is locked so it doesn't roll forward, then the resident reaches out and pulls themself to a standing position and the paddles are rotated down to form a seat and the resident's knee/shins saddle into the knee/shin pads and they sit onto the seat formed by the paddles. V3 said the machine can be used with one staff person with the resident wearing a gait belt. V3 said the resident has to have the core strength to pull themself up into a standing position.On 9/12/25 at 1:42 PM, V2 (Director of Nursing/DON) said R1 had been a transfer via the lift machine. V2 said R1 was getting weaker and either fell, or almost fell, so they changed her to a (name of a different kind of lift machine). V2 said R1 hated that lift because it was uncomfortable, so they went back to a (name of previous lift machine). V2 said R1 has not been ambulatory for at least two years. V2 said when using the lift machine, it is required to use a gait belt on the resident.R1's Detailed Summary (undated) provided by the facility shows R1's diagnoses include, but are not limited to, osteoarthritis, arthritis, tremor, unsteadiness on feet, need for assistance with personal care, muscle weakness (generalized), difficulty in walking, history of falling, and weakness. R1's Interdisciplinary Notes dated 9/2/25 at 6:33 AM show R1 was on the floor this morning from a transfer with the (name of lift machine). R1 did not have seat pads in place and was not standing up well, and she let go of the bar and went down to the floor. R1's legs caught and were tangled on the (name of lift machine). R1 was screaming about her right leg being broken. R1's current care plan provided by the facility shows R1 has a potential to fall due to impaired balance. R1 is unable to ambulate and has a history of falls. R1 has severely impaired cognition. R1 can become agitated with staff, combative, and verbally aggressive and resistive to cares. R1 requires extensive staff assistance for transfers. R1's Minimum Data Set, dated [DATE] shows R1 has severely impaired cognition and requires substantial/maximal assistance (helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with sit to stand, chair/bed-to chair transfer, roll left and right, sit to lying, and lying to sitting on side of bed.R1's results of her right femur Xray obtained on 9/2/25 show the Xray was taken due to right leg pain after a fall. The Impression shows a displaced periprosthetic fracture of the distal right femur.The facility's (name of lift) Transfer Aid Policy/Procedure (undated) shows the steps for use are to raise the two split seat units so they are parallel to the side of the device, have the patient positioned at the edge of the surface to be transferred from, move the (name of lift) in front of the patient and position the patient so their feet are firmly on the platform and their knees and shins are in contact with the two cupped kneepads. LOCK the casters, have the patient grasp the cross bar closest to them and, using their own strength, pull themselves up into a standing position securely on the base platform. Lower both of the split seat units into position to form a complete seat, then have the patient lower themselves down onto the seat while keeping their knees and shins in the kneepads while continuing to hold the cross bar with both hands. Then UNLOCK the casters and move the device to the new surface.

Based on observation, interview and record review, the facility failed monitor and record cool down temperatures for prepared meats and leftover items that were prepared ahead and stored in the facility's fridge for future use. These failures have the potential to affect all 72 residents residing in the facility. Findings include: The facility's General HACCP (Hazard Analysis and Critical Control Point) Guidelines for Food Safety policy, dated 2021, documents Food and nutrition services staff will be educated and supervised on all HACCP information and procedures. A good training program and the proper systems and tools will help to assure a successful HACCP/Food Safety Program. Cool from 135 degrees Fahrenheit to 70 degrees Fahrenheit in two hours and from 70 degrees Fahrenheit to 41 degrees Fahrenheit in four hours (not to exceed six hours). If food is not cooled to 41 degrees Fahrenheit within six hours, reheat to 165 degrees Fahrenheit for at least 15 seconds within two hours and discard if not served immediately. This includes mechanically altered foods. Take temperatures frequently to determine if altered methods are needed. The facility's (undated) HACCP Cooling log documents Food labels Cool Down Procedure. Item, Date, Temp, and Initial. Cool to 70 degrees within two hours and 70 degrees then 41 degrees or below in an additional four hours On 5/12/24 at 10:45 AM, the facility's refrigerator located next to the stove in the kitchen contained several leftover metal food containers including but not limited to turkey, ham, green beans, carrots, and roast beef. At this time V15 (Executive Chef) stated We have not had to keep cool down temperatures since Thanksgiving of 2024. V15 stated he was not aware that staff placed turkey, ham, green beans, and carrots in the refrigerator over the weekend. The facility's Resident Room roster dated 5/12/25 and provided by V1 (Administrator), documents there are 72 residents residing in the facility.

Based on observation, interview, and record review the facility failed to perform indwelling urinary catheter care per the facility's policy for one of one residents (R323) reviewed for urinary catheters in the sample of in the sample of 35. Findings include: The facility's Urinary Catheter Care, dated/reviewed August 2024, states The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Perineal Care, use soap and water or bathing wipes for routine daily. Routine Perineal Hygiene, wash basin, soap and water and washcloths or bathing wipes, towels, bed protector and personal protective equipment (gowns, gloves, mask, as needed). Steps in the procedure, place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached. Wash and dry your hands thoroughly. Fill the ash basin one half full of warm water (or if using bathing wipes, open the package). Place the wash basin or wipes on the bedside stand within easy reach. Put on gloves. Provide privacy. Cover the resident with a sheet or towel, exposing only the perineal area. Remove catheter from securement device. For a male resident use a washcloth with warm water and soap (or a clean bathing wipe) to cleanse around the meatus. Cleans the glans using circular strokes form the meatus outward and down. Change the position of the washcloth (or wipe) with each cleansing stroke. With a clean washcloth (or wipe), rinse the using the above technique. Use clean washcloth with warm water and soap (or bathing wipe) to cleans and rinse the catheter from insertion site to approximately four inches outward. Secure catheter with catheter securement device. Check drainage tubing and bag to ensure that the catheter is draining properly. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Reposition covers. Make resident comfortable. Place call light within easy reach of the resident. Clean wash basin and return to designated storage area. Clean the beside stand and/or overbed table to its proper position. Wash and dry hands thoroughly. On 05/12/2025 at 12:35 PM, V16 (Certified Nursing Assistant) was preparing catheter care for R323. V16 wash her hands, donned gloves, and a gown then began R323's indwelling catheter care. V16 used alcohol swabs to clean R323's meatus and around the urinary catheter tube. R323's meatus and urinary catheter tube had dried blood covering the area. V16 used a new alcohol swab each time the previous swab was covered in dried blood. V16 then used another alcohol swab to clean down the urinary catheter tube. V16 then removed catheter leg bag. V16 did not wash R323's perineum area. On 05/12/2025 at 12:45 PM, V16 stated, I should have had multiple wash clothes that were soapy, non-soapy, and dry while performing (R323's) catheter care. V16 verified she should have cleansed the perineum during R323's catheter care.

Based on observation, interview, and record review the facility failed to follow a physician order for oxygen use and ensure an oxygen care plan was developed for one resident (R29) reviewed for oxygen in the sample of 35. Findings Include: The facility's Oxygen Administration Policy, reviewed August 2024, documents The purpose of this procedure is to provide guidance for safe oxygen administration. Verify that there is a physician's order for this procedure, assemble the equipment and supplies needed. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 or 3 liters per minute. R29's Physician Order Sheet, dated 5/12/25, documents oxygen therapy at 2 liters per minute per nasal cannula. On 5/13/2025 at 1:15 PM, R29 was sitting in her wheelchair with oxygen flowing at 3.5 liters per nasal cannula. On 5/13/2025 at 1:30 PM, V13 (Registered Nurse/RN) confirmed R29's oxygen per nasal cannula was set at 3.5 liters. On 5/14/2025 at 10:00 AM, R29 was sitting in her wheelchair with oxygen flowing at 4 liters per nasal cannula. R29's current Care Plan, dated 5/9/2025, does not address R29's oxygen use. On 5/14/2025 at 10:35 AM, V2 (Director of Nursing) verified R29's order for oxygen should have been set at 2 liters per nasal cannula. V2 also verified that R29's current care plan did not address R29's oxygen use. On 5/14/2025 at 11:00 AM, V13 (RN) confirmed R29's oxygen per nasal cannula was set at 4 liters. V13 verified that R29's oxygen should not have been set that high.

Based on observation, interview and record review, the facility failed to update a plan of care and failed to offer medically related social services for one of one resident (R53), whose son recently passed away unexpectedly, in a sample of 35. Findings Include: The facility job description for Social Service Designee documents, Purpose: The primary purpose of your position as Social Services Designee, is to perform duties and implement programs that meet physical, mental and psychosocial needs of the residents. R53's facility Face Sheet documents that R53 was admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarct with Hemiplegia, Hypertension and Arthritis. R53's recent Minimum Data Set Assessment, dated [DATE] documents R53's cognition as 13 out of a maximum score of 15 (cognitively intact). R53's Nursing Progress Notes, dated [DATE] document, (R53's) daughter made this nurse aware that (R53's) son had a massive stroke and is in a (regional Trauma Center). (R53) will need to be ready by 8:30 (A.M.) tomorrow ([DATE]) morning (for pick up) and sent with lunch and dinner medications. R53's Nursing Progress Notes, dated [DATE] document, (R53) tearful this morning. Family came and told (R53) that her son had passed away late last night. On [DATE] at 1:59 P.M., R53 was seated in a wheelchair in her room. R53 was tearful concerning the recent, unexpected death of her son. A review of R53's current Care Plan on [DATE] makes no mention of R53's recent loss nor does it include a plan to monitor and assist R53 in dealing with her loss. On [DATE] at 1:00 P.M., V10 (Social Services Director) stated she was made aware of the recent, unexpected loss of R53's son last week, had not met R53 about the recent loss of her son nor developed a plan of care to address R53's recent loss. On [DATE] at 1:29 P.M., R53 was seated in a wheelchair in her room, crying. At that time, R53 stated her son died very unexpectedly after suffering a stroke. R53 further stated he was only 63 and actively employed as a local fireman. R53 stated she constantly thinks of him, cries daily and no staff have talked to her about her loss.

Based on interview and record review the facility failed to administer a physician ordered antibiotic to a resident with a diagnosis of UTI (Urinary Tract Infection), for one of one resident (R323) reviewed for medication errors in a sample of 35. Findings include: The facility's Administering Medications policy, dated/reviewed 10/2024, documents Medications are administered in a safe and timely manner, and as prescribed. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. Medications administered in accordance with prescriber orders, including any required time frame. The facility's Adverse Drug Reaction/Medication Errors policy, dated/reviewed 9/2024, documents The interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions and side effects. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principals of the professionals' providing services. Examples of medication errors include omission-a drug is ordered but not administered. R323's Physician Order sheet, dated 05/2025, documents R323 has Physician ordered Tetracycline 500 mg (milligram) capsule (generic), one capsule by mouth twice daily for UTI (urinary tract infection). This order has a start date of 5/12/2025. R323's Medication Administration record, dated 5/2025, documents from 5/12/2025-5/13/2025, R323 did not receive a dose of Tetracycline at scheduled times. (N) was documented as (not administered), with no documented explanation. On 5/14/2025 at 1:00 PM, V2 (Director of Nursing) confirmed R323's Tetracycline was not administered at 8:00 AM or 4 PM on 5/12/2025-5/13/2025. V2 stated This medication should not have taken three days to fill and receive for R323.

Based on observation, interview and record review facility staff failed to cleanse a shared blood glucose monitoring machine after use and between residents for two residents (R30 and R43) of two residents reviewed for blood glucose monitoring, in a sample of 35. Findings Include: The facility policy, Shared Glucometer Cleaning Protocol, dated (revised) 2/11/2020 directs staff, The disinfectant recommended for the (glucometer) at this facility is a low-level disinfectant. Glucometers shared by multiple (residents) will be thoroughly wiped with an approved low-level disinfectant and allowed to dry after every use and between every (resident). Use a fresh, approved low level disinfectant wipe each time the glucometer is used. Wipe all surfaces, top, bottom and sides. Avoid wetting the meter test strip port. Allow to air dry before use on the next (resident). Throughout the procedure, perform appropriate hand hygiene. R30's current Physician Order Sheet, dated May 2025 includes the following diagnosis: Diabetes Mellitus. Also included is the following physician order: (Blood glucose monitoring) four times a day for Diabetes Mellitus. R43's current Physician Order Sheet, dated May 2025 includes the following diagnosis: Diabetes Mellitus. Also included is the following physician order: (Blood glucose monitoring) four times a day for Diabetes Mellitus. On 5/12/25 at 11:03 A.M., V11 (Licensed Practical Nurse/LPN) prepared to perform blood glucometer testing for R30. V11 applied gloves, removed the shared blood glucose monitor from the top drawer of the medication cart and without disinfecting the monitor, entered R30's room and obtained a blood sample from R30's finger. Upon completion of the test, V11 exited R30's room, removed her gloves, applied an alcohol-based hand gel to her hands, and placed the uncleansed blood glucose monitor in the top drawer of the medication cart. At that time, V11 prepared to administer medications for the next resident. On 5/12/2025 at 11:23 A.M., V11 (LPN) prepared to perform blood glucometer testing for R43. V11 applied gloves, removed the shared blood glucose monitor from the top drawer of the medication cart and without disinfecting the monitor, entered R43's room and obtained a blood sample from R43's finger. Upon completion of the test, V11 exited R43's room, removed her gloves, applied an alcohol-based hand gel to her hands, and placed the uncleansed blood glucose monitor in the top drawer of the medication cart. At that time, V11 confirmed she had not disinfected the shared blood glucose monitor after use for R30 and again after use for R43.

Based on observation, interview, and record review the facility failed to ensure a resident that required assistance was provided care in a dignified manner for one resident (R225) of 18 reviewed for dignity in a sample of 35. Findings include: The facility's Dignity policy, revised 02/2021, documents that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. This form also documents that demeaning practices and standard of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered; b. promptly responding to a resident's request for toileting assistance. R225's current care plan documents that (R225) is receiving hospice care for end of life. (R225) will be kept comfortable and allowed to die with dignity through the next review. This form documents to assist (R225) with care needs that (R225) is unable to perform. Respect (R225) privacy and rights. This form also documents to assist (R225) with toileting needs at least every two hours. On 5/12/25 11:15am, V9 (Certified Nursing Assistant/CNA) entered the resident's room to answer R225's call light. R225 asked V9 to use the toilet. V9 told R225 that he had a brief on and to urinate in the brief. At 11:25am, R225 had the call light on again. R225 told V9 that he needed to use the bathroom. V9 again told R225 that he had a brief on, to urinate in the brief. V9 covered R225 up with a blanket and walked out of the room. On 5/12/25 at 11:30am, V9 stated that R225 is a mechanical lift, and it will not fit into the bathroom. V9 also stated that the mechanical lift sling does not allow residents to sit on the toilet. V9 stated that R225 had a brief on and could be changed when he was put to bed after lunch. On 5/12/25 at 11:50am, V12 (Registered Nurse) stated that V9 should never have told R225 to urinate in his brief. V12 stated that R225 can use the bathroom while in a mechanical lift sling. On 5/13/25 at 10:00am, V2 (Director of Nursing) verified that mechanical lifts can be assisted to the toilet if needed. V2 verified that R225 should have been assisted to the toileted, and not told to urinate in his brief.

Based on interview and record review, the facility failed to include an active mental illness diagnosis during a PASARR (Pre-Admission Screening and Resident Review) screen for one of one resident (R43) reviewed for PASARR screening, in the sample of 35. Findings Include: The facility policy, Guidelines for PASARR Process, dated 5/17/2023 documents, PASARR is a federally mandated process that requires all states to pre-screen all residents regardless of their payer source or age who are seeking admission to a Medicaid funded nursing facility. PASARR has three goals (including) To ensure residents receive the required services for mental illness. Residents who are confirmed to have Mental Illness are evaluated to determine the need for specialized services, and appropriate placement options are reviewed. R43's facility Face Sheet documents that R43 was admitted to the facility on [DATE] with the following diagnoses: Major Depressive Disorder, Bipolar Disorder and Generalized Anxiety Disorder. R43's Notice of PASARR Level 1 Screen Outcome, dated 12/14/2023 and signed as accurate and complete by V10 (Social Services Director) documents, Mental Health Diagnoses: Check any or all of the following mental health conditions that are diagnosed or suspected for this individual now or in the past: Depression/Depressive disorder. On 5/15/2025 at 9:50 A.M., V10 verified she signed R43's Notice of PASARR on 12/14/2023. At that time V10 stated she did not include R43's diagnosis of bipolar disorder on R43's Level 1 Screen as she didn't think it was an active diagnosis. V10 confirmed that bipolar disorder is an active diagnosis for R43 and should have been included at the time of R43's Level 1 screen was performed.

Based on interview, and record review, the facility failed to ensure restorative services were being provided for one of three residents (R27) reviewed for range of motion in a sample of 35. Findings include: The facility's Resident Mobility and Range of Motion policy (not dated) documents, Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM (range of motion). Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and will be consistent with state laws and practice arts. R27's Restorative: Passive Range of Motion to LUE (left upper extremity) and LLE (left lower extremity) 6 to 7 days a week for minimum of at least 15 minutes dated 5/1/25-5/12/25. The following dates were not documented as being done on 5/3/25, 5/7/25, 5/9/25, and 5/11/25. R27's Restorative: Active Range of Motion to RLE (right lower extremity), Active Range of Motion to RUE (right upper extremity) 6 to 7 days a week for minimum of at least 15 minutes dated 5/1/25-5/12/25. The following dates were not documented as being done on 5/3/25, 5/7/25, 5/9/25, and 5/11/25. On 5/12/2025 at 11:30 A.M., R27 was in her room, dressed, and in her wheelchair. R27 stated she does not receive physical therapy anymore and the CNAs (Certified Nursing Assistants) do not help her with any range of motion. R27 stated the only time she gets any range of motion activity in her left arm is when she does it by herself because the CNAs do not have time. On 5/15/25 at 10:30 A.M., V2 (Director of Nursing) confirmed the dates R27 did not receive range of motion.

Based on observation, interview, and record review the facility failed to ensure a resident was safely positioned in bed for 1 of 3 residents (R2) reviewed for safety in the sample of 5. This failure resulted in R2 falling from her bed and sustaining a laceration requiring staples. The findings include: R2's physician visit form documents she was admitted to the facility on [DATE] with multiple diagnoses including vascular dementia, and history of falling. R2's quarterly resident assessment and care screening of 2/17/25 documents her to have severe cognitive impairment. Her mobility assessment shows she requires substantial/maximal assistance with rolling right to left. Meaning the helper provides more than half of the effort to perform the task. The 2/17/25 care plan for hospice services notes R2 requires extensive to dependent assistance with 1 staff for all cares and uses a mechanical lift for transfers. The facility incident report of 3/26/25 documents R2 had a fall at 4:50 AM in her bedroom by the bedside. The description of the incident was staff preparing resident to get up and resident rolled out of the bed and fell on the floor with head injury and bleeding. Sent to the ER (emergency room ) for further evaluation. On 4/9/25 at 10:22 AM, V13 (Certified Nursing Assistant/CNA) said on the morning of 3/26/25, she was getting R2 ready to get out of bed. When she does care for any resident, she has the bed in the high position, so it is easier on her back, and she had R2's bed in the high position, probably to her waist or higher. V13 said during cares, R2 can either be stiff and difficult to move, or she is wiggly. V13 said on that morning, after she had R2 dressed, she rolled her towards the wall, and placed the mechanical lift sling under her and needed to pull it through. V13 said she moved R2's bed out from the wall, and standing between the wall and the bed, she rolled R2 towards the other side, and R2 began moving her legs and fell off the side of the bed. She said the bed had no side rails, so R2 just fell to the floor, landing on the concrete floor on her back. V13 said there was nothing she could do to stop it because she was on the opposite side of the bed. V13 said there was immediately blood present, and she notified the nurse. The ED (emergency department) report for 3/26/25 documents the reason for the visit was a laceration to the scalp. The physical exam shows a 1 cm (centimeter) laceration to the occipital (back of the head) area. The laceration repair included the placement of 4 staples. On 4/9/25 at 11:00 AM, R2 said she had no pain and forgot she had staples to her head. She was sitting up in her reclining wheelchair visiting with her sister. She had no bruising or signs of any further injury. On 4/9/25 at 2:30 PM, V2 (Director of Nursing) said the incident was reported to her, and she spoke with V13 about the details. She said V13 was by herself when providing care for R2, when she went to the opposite side of the bed, leaving R2 facing the open side of the bed. V13 reported to her, she was placing the mechanical lift sling when R2 put her foot out over the edge of the bed and fell because there was no one there to catch her. V2 said none of the beds have side rails, so there was nothing to catch R2. V2 said she did not know how high the bed was raised at the time of the fall; a lot of staff raise the beds for better body mechanics. She said maybe it was not safe to have 1 person providing care. And R2's fall mat should have been in place. On 4/10/25 at 8:20 AM, V12 (Licensed Practical Nurse/LPN) said on the morning of 3/26/25, V13 had poked her head out of R2's room and notified him of the fall. Upon arrival to R2's room he found her lying on the floor, face up with blood coming from her head. V12 said he immediately called 911 to have her sent out to the emergency room . He said R2 was on the concrete floor and the fall mat was off to the side. He observed R2's bed to be in a higher position, probably about 3 feet up in the air. The facility's 2018 falls and fall risk management defines a fall as unintentionally coming to rest on the ground, floor, or other lower level. Fall risk factors 1. Environmental factors that contribute to the risk of falls include c. incorrect bed height. 2. Resident conditions that may contribute to the risk of falls include: c. delirium and other cognitive impairment.

Based on observation, interview, and record review the facility failed to follow the facility's fall program and provide supervision for three (R15, R18, and R60) of six residents reviewed for falls in the sample of 28. These failures resulted in: R15's hospitalization resulting from nasal fractures; R18's hospitalization resulting from a tibial fracture; and R60's hospitalization s resulting from a right hip fracture and then left hip fracture. Findings include: The facility's undated Managing Falls and Fall Risk policy and procedure, documents: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling . 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. The Falling Star Program sign documents A falling star is placed on the doorway and w/c (wheelchair) if resident meets the following criteria: 1) Has had more than 2 or more falls in the past 3 months. Follow these Falling Star Guidelines: 1) Do Not leave unattended in the bathroom or room (if up in w/c), 2) Refer to restorative, 3) Attempt to keep in highly visible area when up in w/c. The facility's Falling Star Program, dated 6/1/2023, documents Upon admission, the nursing staff will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The fall risk assessment will be used to implement the Falling Star program to alert staff that a resident has a higher risk for falling. The Falling Star symbol will be placed on the resident's name tag and wheelchair if applicable. The Falling Star program would be implemented if the resident triggers high risk for falls per the fall assessment. The interventions for the Falling Star program should be resident specific and follow the care plan. On 7/23/24 at 3:39 pm, V3 (Chief Nursing Director) and V2 (Director of Nursing/DON) stated they do all the reportable fall incidents together to determine route cause and make sure there are interventions in place. On 7/24/24 at 10:55 am, V3 (Chief Nursing Director) confirmed the Falling Star Program posted signage was for residents who are at a high risk for falls, depends on the resident, and resident specific. V3 confirmed these residents should not be left unsupervised. 1. R15's Face Sheet includes the following diagnoses for R15 as: Alzheimer's Disease, Unspecified Dementia, Generalized Anxiety Disorder, Major Depressive Disorder, Cognitive Communication Deficit, Lack of Coordination, and Need for Assistance with Personal Care. The Annual MDS (Minimum Data Set) Assessment for R15, dated 6/20/24, documents R15 with severe cognitive impairment and requires substantial to maximal assistance with toileting hygiene, bathing, lower body dressing, personal hygiene. R15 requires partial to moderate assistance with oral hygiene, upper body dressing and is dependent for putting on/removing footwear. R15 requires substantial to maximal assistance with all mobility. The Fall Risk Assessment for R15, dated 3/25/24 and 6/20/24, document a fall risk score of 13 and 12 respectively and documents A score of 10 or more indicates High Risk for Falls. The current Care Plan for R15, documents R15 has potential to fall due to impaired balance, requires one-to-one assist to transfer with a non-mechanical lift, and does not call for assist consistently. R15 requires extensive assistance from staff with bed mobility, dressing, bathing, hygiene, transfers, and toileting. This same Care plan documents R15 had prior falls on 9/25/23, 12/20/23, and 2/28/24. Interventions include to assist with reposition every two hours and as needed. An intervention was added after R15's 9/25/23 fall to not be left unattended in her room while sitting in her wheelchair. The Progress Note for R15, dated 7/18/24 at 5:54 pm, documents (R15) unwitnessed fall from w/c to floor in hallway. Nurse sitting at nurse's station and heard. (R15) observed lying on right side, right arm under body, (R15) facing the floor. (R15) bleeding from nose and above left eye. Cool compress applied to side of nose and left eye. R15 sent to the local hospital for evaluation and treatment. The Progress Note for R15, dated 7/18/24 at 9:28 pm, documents R15 returned from local hospital with fractured nose and to apply ice and elevate head of bed for comfort. Hospice service was notified, and new order received for safety mats at bedside. Discoloration right eye and nose and bruise to right elbow. The Incident Report for R15, dated 7/18/24 at 5:30 pm, R15 had unwitnessed fall in the hallway from her wheelchair to the floor resulting in bruising with bleeding from contusion. R15 has a history of multiple falls, R15 was leaning forward in her wheelchair and fell out. R15 complained of pain and was sent to the local hospital for evaluation. The Hospital Discharge paperwork, dated 7/18/24, includes a Maxillofacial (face and jawbones) CT (Computed Tomography), dated 7/18/24 that documents findings as: Mildly displaced left greater than right nasal bone fracture, slightly deviated to the left. Overlying nasal bridge swelling. Right preseptal periorbital superior orbital rim contusion. There is minimal fluid stranding left ethmoid air cells. Impression: Right superior periorbital soft tissue preseptal contusion changes. Suspect nondisplaced bilateral nasal bone fractures. On 7/21/24 at 9:57 am, R15 was sitting in recliner lounge chair with her eyes closed. Yellow and green fading discoloration was noted surrounding R15's bilateral eyes and to bridge of R15's nose. R15's wheelchair was across the room out of R15's reach with a Falling Star sticker attached to the back of her wheelchair and name plate on doorway, a non-mechanical lift was in R15's bathroom and floor fall mats were in an upright position leaning against the wall. On 07/23/24 at 10:55 AM, R15 was sitting on the toilet in her bathroom with a non-mechanical lift placed in front of her and there were no staff present. At 10:57 AM, V8 (Certified Nursing Assistant/CNA) entered R15's bedroom, walked into R15's bathroom, assisted R15 off the toilet with the non-mechanical lift, assisted R15 to sit in the wheelchair, and pushed R15 out of the bedroom into the hallway. On 7/23/24 at 11:04 AM, V8 (CNA) stated R15 does not generally get up by herself. On 7/24/24 at 10:45 AM, R15's bathroom call light illuminated outside of R15's bedroom. Entered R15's bedroom with V3 (Chief Nursing Director) and observed R15 sitting on the toilet in the bathroom, a non-mechanical lift in front of her, and no staff present. V3 assisted R15 off the toilet with the non-mechanical lift and assisted R15 to sit in the wheelchair. A Falling Star sticker was attached to the back of R15's wheelchair and posted to R15's name plate at entrance of bedroom. A Falling Star Program instruction sheet was posted on the Nurses Station peg board documenting Do Not leave unattended in the Bathroom or room (if up in w/c) and Attempt to keep in highly visible area when up in w/c. On 7/24/24 at 10:55 AM, V3 (Chief Nursing Director) stated she does not feel that R15 is unsafe on the toilet. R15's 7/18/24 fall was in the hallway, due to R15 leaning in the wheelchair and R15 had not done that before and hasn't done that since her fall. On 7/24/24 at 11:15 am, the video surveillance, dated 7/18/24, was reviewed with V3. This video shows R15 sitting in her wheelchair, leaning forward, head positioned over her knees, bilateral arms over wheelchair armrests, hands holding onto the chair wheels, propelling her wheelchair out of her bedroom with no staff supervising. R15 continued to attempt to propel the wheelchair forward, head moving forward until she fell out of the wheelchair, hitting her head on the floor. On 7/24/24 at 10:56 AM, V11 (Licensed Practical Nurse/LPN) stated the Falling Star program is for residents at risk for falls and they should not be left in their room. We usually keep them near the nurse's station. On 7/24/24 at 10:59 AM, V12 (CNA) stated the stars on the doors are for residents who are at risk for falling. They should not be left in the bathroom by themselves. V12 stated R15 will try to get up by herself at times, and I would not leave her in the bathroom by herself. We try to keep her near the nurse's station so we can keep an eye on her. 2. R60's Face Sheet includes the following diagnoses: Dementia, Cognitive Communication Deficit, Fracture of Left Femur, Fracture of Right Femur, Fracture around Internal Prosthetic Hip Joint, Unsteadiness on Feet, and Need for Assistance with Personal Care. The Admission MDS (Minimum Data Set) Assessment for R60, dated 2/4/24, documents R60 with severe cognitive impairment with no functional limitations in range of motion. R60 requires partial to moderate assistance of staff for all activities of daily living, dependent for lower body dressing and putting on footwear, and requires partial to moderate assistance for all mobility. R60 has a history of falls within the last 2 to 6 months prior to admission and one fall without injury since admission and was not receiving skilled therapy services. The Quarterly MDS Assessment for R60, dated 5/26/24, documents R60 with moderately impaired cognition, functional limitation in range of motion to one lower extremity, now requiring substantial to maximal assistance for toileting hygiene, bathing, lower body dressing, footwear, personal hygiene. R60 now requires substantial to maximal assistance with all mobility. R60 with falls in last month, falls in last 2 to 6 months, fracture related to falls, and receiving skilled therapy services. The Fall Risk Assessments for R60, dated 2/4/24, 3/6/24, 4/24/24, and 5/24/24 document R60 with fall risk scores greater than 10. These forms also document A score of 10 or more indicates High Risk for Falls. The current Care Plan for R60, documents R60 with dementia, confusion, and severe impaired cognition requiring cues and supervision for safe decision making, monitor positioning while in wheelchair and assist as needed. Needs reminders of using the call light. Fall risk-staff to monitor. Will try to self-transfer at times, has a hx (history) of falls and has poor safety awareness. R60 requires one-to-one assist to stand and walk short distances, and history of self-transfers. R60 has had five unwitnessed falls and two witnessed falls between 2/21/24 through 5/16/24 with unwitnessed fall on 4/20/24 resulting in a right hip fracture and 5/16/24 unwitnessed fall resulting in a left hip fracture. Interventions include Offer bed or recliner after meals; Toilet prior to putting in recliner or offered to stay up; Monitor positioning when in wheelchair and assist as needed. The Incident Report and Fall Investigation for R60, dated 2/21/24 at 6:30 pm, documents R60 had an unwitnessed fall in her room trying transfer from her wheelchair to her bed, and doesn't remember to use her call light for assistance. The interventions were to ask R60 if she wanted to sit in her recliner or go to bed after meals and R60 was educated to use her call light and for staff to check on R60. The Incident Report and Fall Investigation for R60, dated 3/2/24 at 9:00 am, documents R60 had unwitnessed fall in her room from her recliner and was found scooting on her buttocks from her room into the hallway looking for help. The reports document R60 had taken off her slippers, does not use the call light, is unaware of her limitations, requires one-to-one assist to stand. The intervention listed was for staff to ensure R60 is toiled prior to placing in recliner or wheelchair. The Incident Report and Fall Investigation for R60, dated 3/19/24 at 6:35 pm, documents R60 had a witnessed fall in the Activity Center during Bingo, was moving back and forth in her wheelchair, and slid out onto the floor on her buttocks. The investigation documents R60 has a history of falls, does not use her call light, requires one-to-one assist for transfers and ambulation. Dementia is main factor related to this fall, as well as her previous level of independence. The intervention listed is for staff to monitor R60's positioning when up and to assist as needed. The Incident Report and Fall Investigation for R60, dated 4/20/24 at 10:10 pm, documents R60 had an unwitnessed fall in her room from bed and found on the floor next to her bathroom during the CNA care rounds, was sent to the local hospital and diagnosed with a right hip fracture requiring surgical repair. This investigation documents R60 is non-verbal, and grimacing in pain when attempts to move right hip and leg, sent to the local hospital, diagnosed with a right hip fracture requiring surgical repair. The immediate intervention listed was for bed to be in the lowest position. The Incident Report and Fall Investigation for R60, dated 5/12/24 at 1:00 pm, documents R60 had an unwitnessed fall from her wheelchair in front of the Nurse's Station and was found sitting on the floor in front of her wheelchair. R60 was trying to get out of the wheelchair. This investigation documents R60 does not ask for assist and requires one-to-one assist with transfers and ambulation. V12 and V14 CNAs were in other resident rooms assisting and V15 RN (Registered Nurse) was downstairs in another part of the facility, indicating R60 was left unsupervised. Intervention listed was to lay R60 down after lunch and staff were educated Do Not leave (R60) alone. The Incident Report and Fall Investigation for R60, dated 5/14/24 at 8:00 am, documents R60 had witnessed fall during therapy services, became weak and shaky, and was lowered to the floor. The intervention listed was to work slowly and monitor R60 and for blood work review. The Incident Report and Fall Investigation for R60, dated 5/16/24 at 6:15 pm, documents R60 had an unwitnessed fall in the hallway, self-transferred from her wheelchair, walked to the nurse's medication cart, picked up the pill crusher mechanism, which is heavy and fell to her left side. R60 was sent to the local hospital and diagnosed with a left hip fracture requiring surgical repair. This investigation documents R60 is currently receiving therapy for her right hip fracture, is unsafe to be up without one-to-one assist, and will self-transfer without asking for assist. R60's room was moved this day closer to nurse's station. This investigation also documents V14 (CNA) had taken meal trays downstairs, V16 (CNA) was in another resident room assisting, and V17 (Licensed Practical Nurse/LPN) was downstairs in another part of the facility, indicating that R60 was left unsupervised. On 7/21/24 at 9:00 AM R60's doorway held a name plate with a Falling Star sticker and fall mats were upright resting against the wall. R60 was not in her room at this time. On 7/21/24 at 10:00 AM, and 7/22/24 at 3:00 pm, R60 was sitting in a wheelchair across from the nurse's station with a Falling Star attached to the back of R60's wheelchair. On 7/24/24 at 10:44 AM, R60 was sitting in a wheelchair across from the nurse's station with no staff supervising. On 7/24/24 at 10:59 AM, V12 (CNA) stated the stars on the doors are for residents who are at risk for falling. They should not be left in the bathroom by themselves. V12 stated R60 will try to get up by herself at times, and I would not leave her in the bathroom by herself. We try to keep her near the nurse's station so we can keep an eye on her. On 7/23/24 at 3:39 pm, V3 (Chief Nursing Director) and V2 (DON) confirmed R60 had an unwitnessed fall in her bedroom, by her bathroom, went out to the local hospital and received surgical repair of her right hip on 4/20/24. V3 stated the Intervention for R60's fall was not to leave her in her room when she is up in a wheelchair. V3 stated R60 was previously on the memory care unit prior to coming to the rehab floor where she was with her husband and was able to be up and about independently. R60 was not used to asking for help and is confused. We watched R60's fall on 5/16/24 on the camera and R60 just got up, walked to the medication cart, picked up the pill crusher and fell over and not sure what you mean by root cause of the fall. R60 has Dementia, is confused, and a high risk for falls. V3 and V2 stated they are unsure of fall interventions or route cause for R60's fall on 5/16/24. V3 stated R60 doesn't know what is going on and doesn't know why she fell . V3 stated the facility doesn't do one-on-one monitoring, the CNAs have to answer call lights, and the nurse was passing medications when R60 fell on [DATE]. V3 stated We always have enough staff on that floor. The current Care Plan for R60 does not reflect R60's individualized specific needs related to her previous falls. There is no documented evaluation for the various interventions based on R60's assessment, nature and category of her falls, and no monitoring or response to implemented failed or successful interventions, resulting in continued falls for R60. 50962 3. The Admission MDS (Minimum Data Set) dated 6/27/24 documents R18 is cognitively intact, upper body dressing at partial/moderate assistance, lower body dressing at substantial/maximal assistance, and putting on/taking off footwear at dependent. The current Fall Care Plan for R18 documents R18 has the potential for falls due to impaired balance, requires one to one assist with standing and walking short distances and is a high risk for falls. This Care Plan also documents R18 fell on [DATE] with new intervention put in place to encourage R18 to stay where she is seated until staff can help her. The facility's final report and investigation dated 7/19/24 documents R18 had a fall on 7/17/24 while sitting on the side of the bed receiving staff assistance getting dressed and documents that a CT showed: subarticular sclerosis of the medial tibial plateau compatible with nondisplaced impaction fracture injury. The Progress note dated 7/17/24 at 9:06am documents at 7:45am resident (R18) was being assisted from bed. She was seated on the side of the bed. Resident (R18) scooted to the edge of the bed and slid off of the bed landing first on her knees and then forward on her forehead. No loss of consciousness. Large hematoma to forehead. Ice applied. This note also documents R18 received a Skin tear on left upper arm and a bruise to the left knee and complained of pain in her right knee. R18 sent to local hospital for evaluation. On 07/21/24 at 08:26 AM R18 noted to be lying in bed with a large, raised, pinkish-red bump to left forehead, bilateral eyes with dark, purple discoloration around orbits and chin area. R18 stated that Wednesday (7/17/24) she was getting out of bed when she slid off the side onto the floor hitting her face on the metal base of the over bed table. R18 stated she went to the hospital and was found to have a crack in her leg below her right knee. R18 stated she is to wear a brace to her right leg and a brace to her right wrist. Neither brace noted in room. On 07/22/24 at 12:45 PM R18 noted sitting in wheelchair in room with Lower Extremity brace to right leg and feet on wheelchair pedals. Bruising to face is turning green in color today. On 07/24/24 at 11:20 AM R18 noted to be sitting alone in her wheelchair in her room. A Falling star sticker noted on R18's door and on her wheelchair. On 7/24/24 at 09:30 AM V9 (CNA) stated on 7/17/24 that she was assisting R18 with dressing with bed at mid-level when V13 (CNA) came into R18's room to ask a question. V9 stated she turned her head toward V13 and answered question. V13 gasped causing V9 to turn back to R18 and noted R18 laying on the floor. V9 stated she should not have turned away from R18 because fall would not have happened. On 07/24/24 at 09:40 AM V10 (Registered Nurse/RN) stated she was called to R18's room by V13 stating R18 had fallen. V10 entered R18's room and V9 was kneeling next to R18 laying on the floor. V10 stated she assessed R18's vital signs, did a neurological check, cleaned and bandaged skin tear to left arm and assessed R18's range of motion (ROM). During ROM V10 noted a small bruise to R18's left knee and R18 complained of soreness to her right knee. V9 and V13 put R18 in bed and R18 was sent to local hospital for evaluation.

Based on observation, interview and record review, the facility failed to protect a resident from mental and emotional abuse for one of three residents (R1) reviewed for abuse in the sample of three. This failure resulted in (R1) verbalizing feeling demeaned, degraded, and angry. Findings include: The facility's Abuse, Neglect and Exploitation Prevention policy, dated 2/24/23, documents Our residents have the right to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment and involuntary seclusion. Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etcetera, to assist in preventing resident abuse. The facility's Identifying Types of Abuse policy (undated), documents As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This same policy documents Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. R1's (State agency) Incident Report, dated 4/21/23, documents On 4/21/23 at 9:39 PM, (R1) reported that aide (V4 Certified Nursing Assistant/CNA) had placed a gait belt around her neck. R1's Current Minimum Data Set assessment, dated 4/25/23, documents R1's cognition is intact and that R1 requires the extensive assistance of one staff member for toileting. R1's Current Care plan, dated 4/27/23, documents I (R1) have risk factors that may impact my activity participation they are Anxiety, Depression and Shortness of Breath. This same care plan documents R1 receives scheduled medication for Anxiety, Depression and Panic attacks. On 5/15/23 at 11:30 AM, R1 was sitting in a recliner in her room. R1 stated I do remember the incident that occurred with a CNA (V4) a couple weeks ago. I had to use the restroom and the CNA (V4) came in and started to help me up, but then said she can't do that cause her back will get hurt. I asked her if there was anyone to help and she said she was the only one here. (V4) then took the gait belt from my closet door and put it over my head, around my neck. It was caught on my glasses, and I was trying to adjust my glasses and I said, What are you doing?. She was just laughing and wrapped it around my neck a couple times then pulled slightly like you would a dog, but as she was doing that, I stuck my finger in to loosen the belt and said, What are you doing?. She just laughed about it and didn't say anything. I felt demeaned, less than human, like an old person. I thought it was very degrading of her to do that. I wouldn't do that to anyone. I didn't think she was going to murder me, but it was demeaning and like she was putting me in my place. I was so angry when I got out of the bathroom, I called (V8 R1's family member) and said, You need to get me out of here!. I was just shocked that she did that to me. I do feel vulnerable here. I need help for most things. I was so upset about the whole thing. On 5/15/23 at 2:15 PM, V5 (Licensed Practical Nurse) stated I was the nurse the night of the incident with (R1 and V4). (R1) is the one who notified me and then I believe (V8) called me after that. (R1) wasn't concerned as much for herself after it happened, but that it might happen to someone else who can't verbalize what happened. (R1) was concerned and uncomfortable and just shocked that it happened. I was also shocked. I made sure she was okay and in an okay place mentally. It took me several seconds to even grasp what had happened. On 5/15/23 at 10:30 AM, V1 (Administrator) stated We fired the CNA (V4). I couldn't believe what I was hearing and didn't know what I was coming into that night. The police came and interviewed (R1) and (V4) and (V4) said it occurred but was in a joking manor, the resident agreed but we couldn't take any chances and (V4) was terminated that day.

Based on observation, interview, and record review, the facility failed to ensure interventions were implemented for a resident (R1) assessed as high risk for wandering, failed to provide supervision when a wandering, cognitively impaired resident (R1) exited the hallway via a wheelchair into an unattended, unalarmed stairwell and failed to ensure that the Short Stay Rehab 1 Main door was alarmed to notify staff of an unsupervised resident in a stairwell. These failures resulted in R1 not being adequately supervised and exiting the unattended, unalarmed door, into the facility stairwell on 11/20/22 around 5:30 P.M. R1 suffered a contusion/abrasion to the right temporal region and mid forehead, a 5.5 centimeter (cm) laceration to the right posterior occipital region, bruising to the right dorsal side of the middle and index fingers, and bruising to the right forearm. R1 is one of seven residents (R4, R5, R6, R7, R8, R9), reviewed for falls and wandering behavior, in a sample of 9. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified to have begun on 11/20/22 when R1 entered an unalarmed, unattended stairwell via a wheelchair and was found injured at the bottom of the stairs. V1 (Administrator) and V2 (Director of Nurses) were notified of the Immediate Jeopardy on 12/6/22 at 11:08 A.M. While the immediacy was removed on 12/7/2022, the facility remains out of compliance at a Severity Level 11, as the facility implements the following: Instillation of an alarming, 15- second delay (alarm system) on the facility Main, facility Short Stay Rehab Unit 1 door; the development of a Performance Improvement Plan related to residents at risk for elopement; on-going Quality Assurance monitoring to audit the keypad and bracelet functioning checks; Education and on-going monitoring of staff knowledge of the temporary alarm system and elopement risk identification program. FINDINGS INCLUDE: The facility policy, Wandering and Elopements, dated (revised March 2019) documents, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. R1's Facility Incident Report, dated 11/20/22 and signed by V5 (Licensed Practical Nurse/LPN) documents, (R1) was found pounding on basement door, yelling for help. V3 (Housekeeper) got V6 (Certified Nursing Assistant/CNA). V6 stayed with (R1) while V3 got V5. (R1's) wheelchair found after first flight of stairs. Laceration noted to back of head. Bruising on temple and right hand. Sent to ER (emergency room ). R1's hospital emergency room Report, dated 11/20/22 at 6:18 P.M., (R1) is a [AGE] year old female presenting to the ED (Emergency Department) by ambulance for a laceration on the back of her head after falling today. (R1) is coming from (facility). (R1) does not remember falling and does not know how long she was on the ground. (R1) also has bruising to her right wrist and fingers, left knee pain and neck pain. Examination: Tenderness to posterior skull. Contusion/abrasion to right temporal region and mid forehead. Laceration to right posterior occipital region, Bruising to right dorsal side of middle and index fingers. Bruising to right forearm. Procedure: Laceration repair to 5.5 CM (Centimeter), right posterior occipital region. Clinical Impression: Facial contusion; Traumatic injury of head; Complex laceration of scalp. R1's facility Face Sheet (Detailed Summary) documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Dementia, Macular Degeneration, Osteoarthritis, Unsteadiness on Feet and Generalized Muscle Weakness. R1's current Minimum Data Set Assessment, dated 9/12/22 documents R1's vision (Section B: Hearing, Speech and Vision) as Moderately impaired - limited vision. This same form documents R1's cognition (Section C: Cognitive Status) as Three : Fifteen - cognitively impaired. This document also includes R1's Functional Status (Section G: Walking) as Requires assistance from staff. R1's Fall Risk Assessment, dated 11/20/22 documents that R1 is at high risk for falls (Score: 22, greater than 10 equals high risk). R1's Elopement Risk Assessment, dated 9/12/22 documents that R1 is at high risk for elopement (Score 34, greater than 12 equals high risk). R1's current Care Plan, dated 9/12/22 includes the following problem Area: (R1) has a tenancy to wander up and down the halls and will forget where her room is or what she is doing. (R1) will often tell staff that she lives right down the street and will walk home. (R1) wears a (name of alarm system) for her safety. (R1) has been exit seeking during this assessment period. Also included are the following Approaches: Please intervene as needed to ensure my safety and the safety of others; Reorient resident as needed; Redirect (R1) away from any exits; Modify (R1)'s environment, situations or treatments to minimize (R1)'s episodes; Redirect (R1) to more appropriate activities; Ask (R1) if she would like a cup of coffee. On 12/5/22 at 8:30 A.M., A tour of the facility Short Stay Rehab Unit 1 door with V4 (Assistant Director of Nurses) shows R1 entered the unlocked stair-well from the first floor, Main facility Short Stay/Rehab Unit 1 door, unattended. This stairwell then leads to another unlocked door with an approximate 2-foot platform then a flight of 5 steps down, a landing platform with a turn to the left and then 11 steps down, another left turn with 3 steps down, another left turn and ends at the facility basement door. At this time, the doors remain unlocked and unattended. A second exit door, on the facility first floor is locked and alarmed with a (alarm system) to notify staff if a facility-identified, cognitively impaired, wandering resident attempts to open the door, unattended. A tour of the facility second floor shows both exit doors locked and alarmed with a (alarm system). On 12/5/22 at 8:27 A.M., R1 was seated in a wheelchair at a table by herself in the facility Bistro finishing the morning meal. At that time, R1 wheeled herself away from the table, out the door and into the hallway. R1 propelled her wheelchair past her room and down the hall. At that time, a staff member stopped R1 and the staff member wheeled R1 into R1's room and placed her in bed. On 12/5/22 at 12:23 P.M., R1 was seated in a wheelchair, propelling herself from the dining room. R1 turned her wheelchair, away from her room, towards the Short Stay Rehab 1 door. At that time, a facility staff member stopped R1 and wheeled R1 into R1's room and placed her in bed. On 12/5/22 at 8:47 A.M., V3 (Housekeeper) stated, I have been employed here for almost [AGE] years, as a housekeeper. I was working the evening that (R1) fell down the stairs. It was around 5:30 P.M. I was in the basement, and I heard knocking on the door. I looked through the glass and could see (R1) leaning against the door, with blood coming from the top of her head. I couldn't get her to step back from the door, so I could open it. I ran to the basement elevator and went to the first floor. I yelled at V6 (CNA) to get V5 (LPN). I had to enter the stairwell to get to (R1). The Short Stay Rehab 1 door was unlocked like it usually is. I found (R1's) wheelchair turned over at the bottom of the next flight of stairs. There was also one shoe and a large pool of blood. When I got to the bottom of the stairwell, outside of the basement door, I found (R1). (R1) was bleeding heavily from her head. A couple of nurses and other staff came to help her. I left then, so they could help her. Those doors have never been locked or even alarmed. I don't know why. The second floor (Rehab 2 Unit) has two doors that are locked and have alarms on them. On 12/5/22 at 10:05 A.M., V5 (LPN) stated, I was (R1's) nurse the night she fell down the stairs. It was (11/20/22) around 5:30 , when V7 (LPN) came running by me and said that (R1) was found at the bottom of the stairs. We went through the door on Rehab 1, then through the next door, where there are just a few steps. That's where we found her wheelchair and a big puddle of blood. None of the doors are locked or alarmed there. When we got to the bottom, at the basement door, that's where we found (R1). (R1) was bleeding from her head pretty badly. We got (R1) in (R1's) wheelchair and took her up the elevator to the nurse's station and called the ambulance. (R1) was pretty restless all afternoon, before she fell . (R1) was up in her wheelchair, just wandering around. (R1) had eaten her supper around 4:00 (PM) or so. (R1) has fallen a number of times. I'm not sure if any other resident has fallen down the stairs or not. They could have, those doors are unlocked and there isn't an alarm on them. On 12/5/22 at 1:11 P.M., V1 (Administrator) stated, After (R1) fell down the stairs through that door, I was shocked to find out there isn't an alarm on that door. That door (Short Stay Rehab 1) has never been alarmed. I was told that back in 2010, a State Architect said we couldn't alarm it with a 15-second delayed egress alarm. Basically, an alarm for elopement. I have the city Fire Marshall coming sometime later this week to look at it. No, there isn't currently a door alarm without a 15 second delay, on that door, to alert staff when the door is opened. That door is not an exit door, it only goes to the basement or to the second floor. On 12/5/22 at 2:132 P.M., V6 (CNA) stated, I was working the evening that (R1) fell down the stairs. She was in my group (assignment). I came on (shift) at 2:00 PM and (R1) was very agitated and irritable, (R1's) normal self. I'm not sure what (R1's) care plan says to do when (R1) acts like that. I just left (R1) alone. The last I saw (R1), before the accident, was in the dining room. I was in the Cafe (independent eating dining room) and I saw (R1) in there, that would have been after 4:00 o'clock. That's when they start serving supper. A little while later, when I finished in the Cafe, I went over to the Sunshine Room (dependent eating dining room) and helped feed (residents that require assistance). The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1.Documentation provided on 12/8/22 indicates that on 12/6/22 an Elopement Risk Assessment was completed on all residents. 2.Documentation provided on 12/8/22 indicates that on 12/6/22 all residents identified as high elopement risk were issued a (alarm system) bracelet, if not already in place, with their Care Plans updated. 3.Documentation provided on 12/8/22 indicates that on 12/9/22 a new door alarm system will be installed if parts arrive as expected. 4.Documentation provided on 12/8/22 indicates that on 12/6/22 and 12/7/22 the high elopement risk program was implemented, and all staff were in-serviced on. 5.Documentation provided on 12/8/22 indicates that on 12/6/22 an elopement risk identification program was initiated for those at high risk for elopement involving a symbolic identifier on the wheelchair and room name plate. 6.Documentation provided on 12/8/22 indicates that on 12/6/22 a temporary auditory alarm system has been installed on the door involved in the incident. 7.Documentation provided on 12/8/22 indicates that on 12/6/22 an In-service of direct care staff regarding temporary alarm system and elopement risk identification program was began. In servicing was completed 12/7/22. 8.Documentation provided on 12/8/22 indicates that on 12/6/22 an audit of all current residents with a (alarm system) placement and working function of the systems was completed. 9.Documentation on 12/8/22 indicates that on 12/6/22 the individual resident (alarm system) bracelets are checked every shift for function and placement by the nurse and documented on the Treatment Administration Record. 10.Documentation on 12/8/22 indicates that on 12/6/22 Keypad operation of the alarm system currently in place on the Short Stay Rehab 1 North door and The Short Stay Rehab 2 North and South door is checked daily by our second shift maintenance staff to ensure keypads are responding to bracelets as designed. 11. Documentation on 12/8/22 indicates that beginning 12/6/22 Quality Assurance to audit the keypad and bracelet functioning checks quarterly by the Administrator or designee to ensure these checks are being completed. These audits will be performed for a minimum of one year. 12.Documentation on 12/8/22 indicates that beginning 12/6/22 a Performance Improvement Plan related residents at risk for elopement will be developed to review and refine related processes.

Based on observation, record review and interview, the facility failed to protect one resident from emotional abuse. E4 and E5 wore R2's wig in front of R2 laughing and making fun of R2 which caused emotional upset and embarrassment for R2 which continues. The facility also failed to protect one resident from sexual abuse. E9 inappropriately touched R24 on one occasion (1/5/16) and continued to have access to R24 when E9 made a sexually inappropriate comment to R24 approximately one week later (1/13/16). R2 and R24 were two of three residents reviewed for allegations of abuse in the supplemental sample. E4, E5 and E9 had continued access to all residents in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4/14/16, the facility remains out of compliance at a Severity Level II. Additional time is needed to monitor the effectiveness of the facility's abuse policy and procedure revision and staff in-service training. Findings include: 1. R2's Minimum Data Set (dated 1/31/16) documents a Brief Interview for Mental Status score of 11, indicating R2 is a reliable candidate for an interview. R2's initial Incident Report dated 12/15/15 and completed by E8 (Assistant Director of Nursing/Acting Abuse Coordinator) documents that the facility initiated an investigation on 12/15/15 for an allegation of emotional abuse involving R2. The facility's faxed initial report dated 12/15/15 and completed by E8 (Assistant Director of Nursing/Acting Abuse Coordinator) to (State Agency) documents the following: This is to report an allegation of abuse of a resident's belongings. A CNA was reportedly wearing (R2)'s wig. (R2) has some confusion and a [DIAGNOSES REDACTED]. The facility's faxed final investigation report dated 12/18/15 and completed by E8 to (State Agency) documents the following: This follow-up is in regards to the previously reported allegation of abuse. A full investigation was conducted in which two employees, (E4 and E5, Certified Nursing Assistants) were interviewed; (R2) was interviewed twice and (R25, R2's roommate) was also interviewed. During the interviews, both E4 and E5 admitted (R2) was upset because the (E4 and E5) were washing (R2's) wig which had ice cream on it. The date of the incident, per (E4 and E5) was 12/10/15. After interviewing (E4 and E5) and (R2), it is difficult to determine whether there was abuse of (R2's) belongings. (R2) continues to report that (E4 and E5) were wearing (R2)'s wig and it was upsetting to (R2). (E4 and E5) maintain (R2) spilled ice cream and they (E4 and E5) were simply cleaning it. Although (R2) does have a [DIAGNOSES REDACTED]. We (the facility) cannot conclude abuse was substantiated; however, we (the facility) will terminate employment of (E4 and E5) to protect our residents in case this situation did occur. On 4/7/16 at 1:15 PM, E8 (Assistant Director of Nursing/Acting Abuse Coordinator) stated, It was brought to my attention that two CNA ' s (Certified Nursing Assistants) were in (R2)'s room, put (R2)'s wig on and was dancing around. This upset (R2). I think E6 (Licensed Practical Nurse) told me (E8). E6 usually works second shift. I think E6 told me face-to-face. I (E8) became aware of the incident on 12/15/15. The CNA's were (E4 and E5). On 12/15/15, I (E8) met with (E5) and (E5) was taken off of the schedule. I (E8) met with (E4) on 12/16/15. (E4) couldn't come in on 12/15/15. I (E8) reported to (E1, Administrator) on 12/15/15 .We terminated both CNA's (E4 and E5). On 4/7/16 at 2:20 p.m., E6 (Licensed Practical Nurse) stated that on 12/10/15 (E6) saw a picture of (E4 and E5) wearing wigs on a (Social Media Picture Website). E6 stated, The picture only lasts a few seconds. I (E6) saw (E4 and E5) with wigs on (E4 and E5)'s heads in a picture. I (E6) tried to take a screen shot of it, but it only lasts a short time and it (the picture) was already gone. I (E6) couldn't tell where they were just that they (E4 and E5) were wearing wigs. The next day, (R2) complained to (E21, former Certified Nursing Assistant). E21 went and got E7 (Licensed Practical Nurse) and (E7) came and told me (E6). It was approximately 8:00 p.m. (E7) said (R2) told (E7) about it. I (E6) told (E7) I (E6) would report it. I (E6) reported it immediately to (E8, Assistant Director of Nursing/Acting Abuse Coordinator) by phone. The night (12/11/15) that I (E6) called (E8), (E4 and E5) were both working. I (E6) called (E8) and left a message. (E8) didn't call back. (E8) called me (E6) the Monday (12/14/15) after the weekend. I (E6) want to say that I saw the picture on a (Social Medial Picture Website) on 12/10/15, heard about and reported (R2's) complaint to (E8) on 12/11/15, and spoke to (E8) about it on 12/14/15. (E4 and E5, Certified Nursing Assistants) were smiling in the picture thinking they (E4 and E5) were funny . On 4/11/16 at 12:09 PM, E7 (Licensed Practical Nurse) stated that E7 usually works third shift, but worked a second shift on 12/11/15. E7 then stated that on 12/11/15 at approximately 7:00 PM, (R2) become upset after a (E21, former Certified Nursing Assistant) attempted to give (R2) a shower. E7 stated, (R2) was hysterical. (R2) was trying to kick (E21) out of the room. (R2) thought that (E21) was one of the CNA's (Certified Nursing Assistants) that was wearing (R2's) wigs (on 12/10/15). I (E7) talked to (R2) and calmed (R2) down and then (R2) allowed (E21) to care for (R2). I (E7) went and told (E6) what (R2) had told me and (E6) said 'Wow it really happened.' (E6) said to me (E7) that (E6) had seen a picture of (E4 and E5) last night (12/10/15) posted on a (Social Media Picture Website) and (E4 and E5) were wearing wigs. (E4 and E5) were both working on 12/11/15. (E6) called (E8, Assistant Director of Nursing/Acting Abuse Coordinator) and left a message. (E4 and E5) worked the rest of their (E4 and E5)'s shifts on 12/11/15. (R2) continued talking about this for a couple weeks. (R2) would become upset about something, but it seemed that the root of the problem always went back to (E4 and E5) wearing (R2)'s wigs. (R2) was extremely upset. (R2) felt degraded and (R2) felt that (E4 and E5) were making fun of and laughing at (R2). R2's written interview dated 12/16/15 and signed by (E8) and (E15, Social Service Director) documents the following: Two girls got real fresh with me the other night. They had my wig in the bathroom and they were posing in the mirror with it on. One was overweight, wearing all black and the other was small. She had black hair and was working the next night. Everything they said was hurtful. I don't think I went to supper. I had ice cream as a snack. The small one was really brazen and paraded around my bed, she grabbed the wig and I asked her to put it on the stand but she went into the bathroom and was posing in the mirror. R2 then denied spilling anything on R2's wig and stated, They were laughing a lot. They were dancing around with my wig on. Making fun of me. Why are you asking me so many questions. You don't care. You don't care! I didn't spill anything on my wig, they were making fun of me! On 4/11/16 at 12:05 PM, R2 was lying in R2's bed. R2's hair was extremely thin and disheveled exposing several areas of R2 ' s scalp. R2's wigs were located and neatly kept on a shelf next to R2's bed. R2 stated, I (R2) do not want to repeat it. I prefer them (E4 and E5) not take care of me ever again. They were very . (R2 unable to finish statement) when asked about the 12/10/15 incident involving E4 and E5. R2 appeared very withdrawn and avoided eye contact continually staring at the floor. R2 immediately changed the subject of the conversation and stated that R2 was waiting for a meal tray. Upon further discussion and subsequent mention of the 12/10/15 incident, R2 stated, I (R2) hate this place. When R2 was asked how E4 and E5 (Certified Nursing Assistants) made R2 feel when E4 and E5 were wearing R2's wigs on 12/10/15, R2 again stared at the floor and avoided eye contact, sat in silence for approximately one minute and with a flat affect did not answer the question and stated, You can go anytime now. R2's full final Abuse Investigation (dated 12/18/15) does not include witness interviews or written statements from E21, E6 or E7. On 4/11/16 at 10:49 AM, E8 (Assistant Director of Nursing/ Acting Abuse Coordinator) verified that E8 could not produce written witness statements or interviews from E21, E6 or E7 regarding R2's verbalized concerns on 12/11/15 and stated that E8 only documented one of the two interviews conducted with R2 because E8 did not have a staff member to witness the second interview. On 4/12/16 at 10:07 AM, E8 stated that emotional abuse is any kind of statement made that is taken offensively by the resident or makes them upset. Misappropriation of resident ' s property is stealing from the residents or taking the resident ' s funds. E8 then stated that E8 considered E4 and E5 ' s behavior inappropriate on both parts of E4 and E5. E8 then stated that R2 gave R2 ' s statement and there was no witness to the 12/10/15 incident. E8 also stated when asked if E8 considered the 12/10/15 incident regarding R2 abuse, No. I don ' t consider it abuse. I consider it stupidity. Unfortunately, there was no witness. If (E4 and E5) were indeed wearing (R2) ' s wigs, I (E8) would consider it misappropriation of property, but there is no proof of it. On 4/7/16 at 12:48 PM, E2 (Director of Nursing) stated that E2 was off at the time of R2 ' s complaint regarding (E4 and E5) ' s wearing R2 ' s wigs, and the investigation was conducted by E8 (Assistant Director of Nursing/Acting Abuse Coordinator). E2 stated that any resident complaint about an employee is looked into and that all staff are expected to immediately report any potential allegations of abuse. E2 stated, I (E2) interviewed both (E4 and E5) over the phone and we (the facility) fired them because their (E4 and E5) ' s stories did not match what was on camera. E4 and E5 ' s Employee Detail Report Time Cards (dated 12/1/15- 12/31/15) document that both E4 and E5 worked full eight hour shifts on 12/10/15, 12/11/15 and 12/14/15. 2. R24's Initial Incident Report dated 1/15/16 documents that an abuse investigation was initiated on 1/15/16 regarding an allegation of an inappropriate comment made on 1/13/16 to R24 by E9 (Former Certified Nursing Assistant). E10 ' s (former Certified Nursing Assistant) written statement dated 1/13/16 at 8:30 PM documents the following: While myself (E10) and (E9) were in (R24) ' s room cleaning (R24) up for bed, (E9) leaned (E9) ' s head around to look at (R24) and said, 'Am I (E9) getting you riled up?' After (E9) left the room, (R24) stated (to E10) that (R24) is very uncomfortable with (E9) working with (R24) because of what (E9) says and (E9) touches (R24). On 4/6/16 at 1:10 p.m., E10 verified the above written statement and stated, Sometimes when you ' re wiping a male in that area, blood begins to flow and they can't help it (getting an erection). E10 indicated that R24 began to get an erection when E9 was cleaning R24 ' s peri-anal area. E10 then stated, The incident occurred sometime before dinner on 1/13/16. 8:30 PM is the time I (E10) sat down on 1/13/16 and wrote out the statement. After it occurred, I (E10) called the (E11, Licensed Practical Nurse) into (R24) ' s room. That's not the first time something like this has happened. (R24) and others reported previous concerns to (E12, Licensed Practical Nurse). (E12) went to (E8, Assistant Director of Nursing/Acting Abuse Coordinator) multiple times over this. (E12) refused to have (E9) work (R24) ' s floor. When (E11) was in the room on 1/13/16, I told (E11) what I (E10) had witnessed. (E11) asked (R24) how (R24) felt and (R24) said that (R24) didn ' t want (E9) back in the room at all. E10 then stated that E10 felt E9 ' s comment was indeed, Abusive in nature because the way (E9) said it and the look on (E9) ' s face. It was degrading to (R24). E10 then stated that E10 did not report the incident to E2 (Director of Nursing/Abuse Coordinator) or E1 (Administrator) because E10 had reported it to E11 on 1/13/16 and E12 on the afternoon of 1/14/16. E10 also stated that E10 called the facility on the morning of 1/14/16 and reported the incident to E8 (Assistant Director of Nursing/Acting Abuse Coordinator) because E2 was off and E8 was acting as the Abuse Coordinator. E12 ' s (Licensed Practical Nurse) written statement dated 1/15/16 documents the following: On 1/14/16, (R24) was sitting by the nurse's station and stated that (E9) was inappropriate with (R24) again last night. (E12) asked (R24) what happened and (R24) said (R24) was being cleaned up by (E9, Former Certified Nursing Assistant) and (E10, Former Certified Nursing Assistant) was assisting (E9) and (E10) was standing by (R24) as (R24) was telling (E12) that when (E9) was wiping (R24), (E9) asked (R24) if that felt good or excited (R24) (I (E12) couldn't remember which term) but (R24) stated it made (R24) feel uncomfortable. Writer (E12) reported this to (E8) today 1/15/16. On 4/6/16 at 12:20 PM, E12 verified the above written statement and stated that E12 was not working when the incident involving E9 and R24 occurred on 1/13/16. E12 stated that E12 did not report the above incident to anyone on 1/14/16 because R24 did not want E12 to say anything and stated, I (E12) should have called that day (1/14/16). What (R24) told me (E12) that (E9) said was abusive in nature. I reported it to (E8, Assistant Director of Nursing/Acting Abuse Coordinator) on 1/15/16 in the morning. (E12) then stated, Sexual abuse is any inappropriate touching from anyone or verbally inappropriate sexual comments and verbal abuse is any comment made that is inappropriate or makes someone feel sad or upset or uncomfortable. On 4/7/16 at 9:52 AM, E12 stated, There was one other occasion when (R24) mentioned that (E9) had made (R24) feel uncomfortable. It was about a week before (R24) told (E12) about the comment that (E9) made on 1/13/16. (R24) said that (E9) rubbed (R24) ' s back and it made (R24) feel uncomfortable. (E12) asked (R24) why and (R24) said (R24) had (R24)'s shirt off at the time (E9) started rubbing (R24) and (R24) didn ' t want (E9) back in (R24) ' s room. (E12) reported this to (E8) in morning report right after (R24) reported the incident to (E12). The care plan team meets together every morning. (E12) told (E8) when (E8) came to get daily updates. After the morning meeting, (E12) went into the office with (E8) and discussed it further. (E9) was just different. I (E12) can see why people felt uncomfortable. I (E12) even felt uncomfortable with (E9) . At this same date and time, E12 then stated that E12 was first aware of the 1/13/16 incident on 1/14/16 around 2:00 PM when R24 told E12 with E10 (Former Certified Nursing Assistant) standing next to R24. E12 then stated, (R24) is pretty easy going. It was out of character for (R24) to complain about someone. (E10) told me (E12) that (E10) told the nurse that was working the night before. E12 stated that the first incident regarding the touching occurred on 1/5/16 and E9 didn't work a set area but floated and worked all areas of the building. E12 then stated that R24 looked shocked when R24 told E12 about the 1/13/16 incident and, (R24) was upset. (R24) may have been trying to mask it because (R24) was in the Army and is not an overly emotional person. If it happened to me (E12) or my parents, I (E12) would be really upset. (R24) possibly could be humiliated or embarrassed from a comment like that. E11 ' s (Licensed Practical Nurse), undated written statement documents the following: On 1/14/16, (R24) stated that (E9) made an inappropriate comment about getting (R24) riled up while (E9) was cleaning (R24) ' s backside. (R24) stated that (R24) was uncomfortable with (E9) giving (R24) cares. I reported this to (E8, Assistant Director of Nursing/Acting Abuse Coordinator) on 1/15/16. On 4/6/16 at 12:15 p.m., E11 stated that R24 told E11 that R24 was uncomfortable with E9 providing care to R24. E11 stated that E11 reported this to E2 (Director of Nursing/Abuse Coordinator) or E8 and E9 was told to go home the day E11 reported R24 ' s concerns. On 4/6/16 at 11:45 a.m., R24 stated that E9 (Former Certified Nursing Assistant) made a remark to R24 on 1/13/16 that, Made me (R24) very uncomfortable. R24 then stated that E9 would, Rub (E9) ' s hands on my shoulders and it made me (R24) feel uncomfortable. It takes a lot to make me (R24) feel very uncomfortable. If a man did that to a woman, then he would be in big trouble . I (R24) did not want (E9) touching me like (E9) was. It was more inappropriate than friendly. I (R24) let it go by for a while, a few weeks, before I (R24) said anything. On 4/7/16 at 11:45 a.m., R24 stated that when E9 touched and rubbed R24 ' s shoulders, it, Creeped me (R24) out. I (R24) do not like (E9). R24 then stated that the comment E9 made to R24 on 1/13/16, Surprised me (R24). I (R24) was uncomfortable and upset and wanted it addressed. R24 then stated that R24 prefers to no longer discuss the 1/13/16 incident. On 4/6/16 at 1:39 PM, E1 (Administrator) stated that E1 was first notified of any concerns from R24 by a text message from E8 on 1/15/16. E1 provided a copy of the text message dated 1/15/16 and timed 3:17 p.m. which documents the following by E8: Nursing staff member (E9) is being taken off the schedule per (E8). (E9) was helping clean (R24) and made sexually inappropriate comments about him getting aroused. (E8) is making report. On 4/6/16 at 2:50 PM, E8 (Assistant Director of Nursing/Acting Abuse Coordinator) stated that E8 was Acting Abuse Coordinator at the time of R24 ' s verbalized concern on 1/13/16. E8 stated that E8 was notified of R24 ' s concerns from 1/13/16 by E12 (Licensed Practical Nurse) on 1/15/16. E8 then stated, (E12) stated that (R24) had expressed feelings that (E9) made comments that made (R24) feel uncomfortable. (E10) was in the room at the time and witnessed the comment. The incident occurred on 1/13/16. I think staff was unsure if it was an actual abuse thing. They (the staff) thought it was inappropriate. I (E8) feel that it was something that would be reportable. It's not right. I (E8) would expect to be immediately notified of an allegation of abuse. When (the 1/13/16) incident was reported, I (E8) recognized it as a potential allegation of abuse .I (E8) know (R24) said (E9) touched (R24) ' s shoulder. (E9) was a little slower . E8 also stated that sexual abuse is, A suggestive statement made to a resident by a CNA (Certified Nursing Assistant) or Nurse or inappropriate touching. On 4/7/16 at 11:04 AM, E8 stated that something was brought to E8 ' s attention approximately a week to a week and a half before the 1/13/16 incident involving R24 and E9 by E12. E8 stated that R24 said R24 was uncomfortable after E9 gave R24 a back rub. E8 stated no report or investigation was conducted at that time and E8 did not speak to R24 about R24 ' s complaint. E8 then stated, I think it (E9 ' s comment to R24 on 1/13/16) was inappropriate .The only thing (R24) has ever complained about is (E9). I (E8) investigated it (1/13/16 incident) because it is protocol. (R24) made the complaint and when it was brought to my (E8) attention, I (E8) investigated. I (E8) investigate all complaints. E8 then stated that there was no investigation or follow up to the first incident regarding (R24) and (E9) because, A back rub is part of HS (bedtime) cares. It's standard of care. CNA's (Certified Nursing Assistant) do that. E9 ' s signed Performance Correction Notice dated 1/20/16 documents the following: You made an inappropriate comment to a resident while caring for him. The resident was in a compromising position, as you were providing personal care to his private area. You stated to the resident while cleansing him 'does this get you riled up?' This is inappropriate and made the resident feel uncomfortable. While this may not constitute direct abuse, this is considered borderline both physically and verbally. The resident is not confused and is a reliable source. This is a violation of the harassment policy as well. Your employment at (the facility) is terminated. On 4/7/16 at 12:48 PM, E2 (Director of Nursing) stated if a resident complains about an employee, it's looked in to. E2 stated E2 was off at the time of the 1/15/16 investigation involving R24 and E9 but was kept informed by E8, who conducted the investigation. E2 then stated, If (R24) complains to a staff member about back rubs making (R24) uncomfortable, then it should be reported to (E2) or (E8) and we would follow up. If staff receives a complaint about the same employee a second time, I (E2) expect them to immediately report to (E2) or (E8) . E2 then stated regarding the 1/13/16 incident involving R24 and E9, If they (staff) didn't report it immediately, they (staff) didn't consider it abuse. It was a stupid comment. It was no way sexual abuse. It was a dumb statement. I don't consider the comment (E9) made sexual abuse or sexual harassment. On 4/11/16 at 3:30 PM, E2 stated that Certified Nursing Assistants typically get assigned to the same hallway for continuity but can get floated to another hall at any time to fill staffing needs or assist. The Resident Census and Conditions of Residents form (Centers for Medicare and Medicaid Services- Form 672) dated 4/4/16 and completed by E2 (Director of Nursing) indicates 78 residents currently reside in the facility. The Immediate Jeopardy was identified at 1:00 PM on 04/13/2016 to have begun on 12/10/15 when E4 and E5 emotionally abused and misappropriated R2 ' s property. E1 and E2 were notified of the Immediate Jeopardy on 04/13/2016 at 1:15 PM. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. The facility previously reported both incidents of suspected abuse to the State Agency. The facility reported the first incident on December 15, 2015 and December 18, 2015. The facility reported the second incident on January 15, 2016 and January 20, 2016. Completed December 18, 2015 & January 20, 2016 2. The facility reported the suspected sexual abuse (second incident) to the resident ' s physician and representatives on January 15, 1016. A comprehensive physical examination was performed for the residents, and no injuries were noted. The facility followed up with the resident to ensure he felt reassured and felt safe in the community. The facility ' s investigation was initiated on January 15, 2016 and completed January 20, 2016. The staff member involved was immediately suspended on January 15, 2016, upon receipt of the allegation. Following investigation, the staff member was terminated January 20, 2016. Completed January 20, 2016 3. The facility reported the alleged misappropriation of property and emotional abuse (first incident) to the resident ' s physician and representatives on December 15, 2015. The facility followed up with the resident to ensure she felt reassured and felt safe in the community. The facility ' s investigation was initiated on December 15, 2015 and completed December 18, 2015. The staff members involved were immediately suspended on December 15, 2015, upon receipt of the allegation. Following investigation, staff members were terminated December 18, 2015. Completed December 18, 2015 4. The facility ' s Assistant Director of Nursing conducted a thorough investigation of the incidents, including interviewing facility staff and affected residents. The Director of Nursing, although on leave, participated in interviews and was notified of ongoing investigation daily. A final Incident Report was provided to the State Agency. Completed December 18, 2015 & January 20, 2016 5. The Attorneys provided one-on-one training to the Director of Nursing on regulatory requirements for abuse and neglect identification, investigation, response and reporting beginning April 5 and completing April 13, 1016. Completed April 13, 2015 6. The facility ' s Director of Nursing provided immediate in-service training all staff at the facility on the facility ' s policies and procedures relating to abuse and neglect identification and reporting as well as reporting and investigating protocols for allegations and suspicions of abuse and neglect. The in-service re-trained staff on the obligation to immediately report any allegation, accusation, or suspicion of abuse or neglect to the facility Director of Nursing. For any nursing home staff who have not yet participated in this in-service training, the Director of Nursing or designee will provide the in-service training before nursing staff work their next shift at the facility. Initiated on April 13, 2016 7. The facility has reviewed its Policy and Procedure on Abuse/Neglect Prevention and Response to ensure it complies with all applicable law and provides adequate direction to all staff, including clear communication of expectations of staff. Completed April 13, 2016. 8. The facility has interviewed all interviewable residents to determine if there are any outstanding unreported incidents involving potential abuse or misappropriation. No further issues identified. Completed April 13, 2016 9. To monitor continued compliance, the facility ' s Administrator and/or Director of Nursing are performing a re-training of all nursing facility staff on the Facility ' s Policy and Procedure on Abuse/Neglect Prevention and Response. Thereafter, the Administrator and/or Director of Nursing or her designee will conduct random audits of RN, LPN, C.N.A., housekeeping, laundry, social service and kitchen staff to determine staff proficiency and compliance with the policy and procedure; the audits will be done daily on each shift for the next two weeks, and then once per week per shift for the following two weeks 10. The facility's DON, or designee, will perform an audit of every allegation, accusation, or suspicion of abuse or neglect at the facility, weekly for the next six weeks, to verify that the policy and procedure for identifying, reporting and investigating is properly followed by staff and administration. Initiated on April 13, 2016.

Based on observation, interview and record review the facility failed to immediately report an allegation of abuse to the Administrator; failed to recognize sexual abuse, emotional abuse and misappropriation of resident property; failed to thoroughly investigate an abuse allegation; and failed to immediately remove alleged perpetrators from resident contact. E4 and E5 wore R2 ' s wig in front of R2 laughing and making fun of R2 which caused emotional upset and embarrassment for R2 which continues. E9 inappropriately touched R24 on one occasion (1/5/16) and continued to have access to R24 when E9 made a sexually inappropriate comment to R24 approximately one week later (1/13/16). R2, R24 and R100 were three of three residents reviewed for allegations of abuse on the supplemental sample. E4, E5 and E9 had continued access to all residents in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4/14/16, the facility remains out of compliance at a Severity Level II. Additional time is needed to monitor the effectiveness of the facility's abuse policy and procedure revision and staff in-service training. Findings include: 1. R2 ' s Minimum Data Set (dated 1/31/16) documents a Brief Interview for Mental Status score of 11, indicating R2 is a reliable candidate for an interview. R2's initial Incident Report dated 12/15/15 and completed by E8 (Assistant Director of Nursing/Acting Abuse Coordinator) documents that the facility initiated an investigation on 12/15/15 for an allegation of emotional abuse involving R2. On 4/7/16 at 1:15 PM, E8 (Assistant Director of Nursing/Acting Abuse Coordinator) stated, It was brought to my attention that two CNA ' s (Certified Nursing Assistants) were in (R2) ' s room, put (R2) ' s wig on and were dancing around. This upset (R2). I think E6 (Licensed Practical Nurse) told me (E8). E6 usually works second shift. I think E6 told me face-to-face. I (E8) became aware of the incident on 12/15/15. The CNA's were (E4 and E5). On 12/15/15, I (E8) met with (E5) and (E5) was taken off of the schedule. I (E8) met with (E4) on 12/16/15. (E4) couldn't come in on 12/15/15. I (E8) reported to (E1, Administrator) on 12/15/15 .We terminated both CNA's (E4 and E5). On 4/7/16 at 2:20 p.m., E6 (Licensed Practical Nurse) stated that on 12/10/15 (E6) saw a picture of (E4 and E5) wearing wigs on a (Social Media Picture Website). E6 stated, The picture only lasts a few seconds. I (E6) saw (E4 and E5) with wigs on (E4 and E5) ' s heads in a picture. I (E6) tried to take a screen shot of it, but it only lasts a short time and it (the picture) was already gone. I (E6) couldn't tell where they were just that they (E4 and E5) were wearing wigs. The next day, (R2) complained to (E21, former Certified Nursing Assistant). E21 went and got E7 (Licensed Practical Nurse) and (E7) came and told me (E6). It was approximately 8:00 p.m. (E7) said (R2) told (E7) about it. I (E6) told (E7) I (E6) would report it. I (E6) reported it immediately to (E8, Assistant Director of Nursing/Acting Abuse Coordinator) by phone. The night (12/11/15) that I (E6) called (E8), (E4 and E5) were both working. I (E6) called (E8) and left a message. (E8) didn't call back. (E8) called me (E6) the Monday (12/14/15) after the weekend. I (E6) want to say that I saw the picture on a (Social Medial Picture Website) on 12/10/15, heard about and reported (R2's) complaint to (E8) on 12/11/15, and spoke to (E8) about it on 12/14/15. (E4 and E5, Certified Nursing Assistants) were smiling in the picture thinking they (E4 and E5) were funny . E6 then stated that E6 did not immediately report R2's concern to E1 (Administrator). On 4/11/16 at 12:09 PM, E7 (Licensed Practical Nurse) stated that E7 usually works third shift, but worked a second shift on 12/11/15. E7 then stated that on 12/11/15 at approximately 7:00 PM, (R2) become upset after a (E21, former Certified Nursing Assistant) attempted to give (R2) a shower. E7 stated, (R2) was hysterical. (R2) was trying to kick (E21) out of the room. (R2) thought that (E21) was one of the CNA ' s (Certified Nursing Assistants) that was wearing (R2's) wigs (on 12/10/15). I (E7) talked to (R2) and calmed (R2) down and then (R2) allowed (E21) to care for (R2). I (E7) went and told (E6) what (R2) had told me and (E6) said 'Wow it really happened.' (E6) said to me (E7) that (E6) had seen a picture of (E4 and E5) last night (12/10/15) posted on a (Social Media Picture Website) and (E4 and E5) were wearing wigs. (E4 and E5) were both working on 12/11/15. (E6) called (E8, Assistant Director of Nursing/Acting Abuse Coordinator) and left a message. (E4 and E5) worked the rest of their (E4 and E5) ' s shifts on 12/11/15 and had access to all residents in the facility. (R2) continued talking about this for a couple weeks. (R2) would become upset about something, but it seemed that the root of the problem always went back to (E4 and E5) wearing (R2) ' s wigs. (R2) was extremely upset. (R2) felt degraded and (R2) felt that (E4 and E5) were making fun of and laughing at (R2). R2's written interview dated 12/16/15 and signed by (E8) and (E15, Social Service Director) documents the following: Two girls got real fresh with me the other night. They had my wig in the bathroom and they were posing in the mirror with it on. One was overweight, wearing all black and the other was small. She had black hair and was working the next night. Everything they said was hurtful. I don't think I went to supper. I had ice cream as a snack. The small one was really brazen and paraded around my bed, she grabbed the wig and I asked her to put it on the stand but she went into the bathroom and was posing in the mirror. R2 then denied spilling anything on R2's wig and stated, They were laughing a lot. They were dancing around with my wig on. Making fun of me. Why are you asking me so many questions! You don't care. You don't care! I didn't spill anything on my wig, they were making fun of me!!! On 4/11/16 at 12:05 PM, R2 was lying in R2 ' s bed. R2 ' s hair was extremely thin and disheveled exposing several areas of R2 ' s scalp. R2 ' s wigs were located and neatly kept on a shelf next to R2 ' s bed. R2 stated, I (R2) do not want to repeat it. I prefer them (E4 and E5) not take care of me ever again. They were very . (R2 unable to finish statement) when asked about the 12/10/15 incident involving E4 and E5. R2 appeared very withdrawn and avoided eye contact continually staring at the floor. R2 immediately changed the subject of the conversation and stated that R2 was waiting for a meal tray. Upon further discussion and subsequent mention of the 12/10/15 incident, R2 stated, I (R2) hate this place. When R2 was asked how E4 and E5 (Certified Nursing Assistants) made R2 feel when E4 and E5 were wearing R2 ' s wigs on 12/10/15, R2 again stared at the floor and avoided eye contact, sat in silence for approximately one minute and with a flat affect did not answer the question and stated, You can go anytime now. R2's full final Abuse Investigation (dated 12/18/15) does not include witness interviews or written statements from E21, E6 or E7. On 4/11/16 at 10:49 AM, E8 (Assistant Director of Nursing/ Acting Abuse Coordinator) verified that E8 could not produce written witness statements or interviews from E21, E6 or E7 regarding R2's verbalized concerns on 12/11/15 and stated that E8 only documented one of the two interviews conducted with R2 because E8 did not have a staff member to witness the second interview. On 4/12/16 at 10:07 AM, E8 stated that emotional abuse is any kind of statement made that is taken offensively by the resident or makes them upset. Misappropriation of resident ' s property is stealing from the residents or taking the resident ' s funds. E8 then stated that E8 considered E4 and E5 ' s behavior inappropriate on both parts of E4 and E5. E8 then stated that R2 gave R2 ' s statement and there was no witness to the 12/10/15 incident. E8 also stated when asked if E8 considered the 12/10/15 incident regarding R2 abuse, No. I don ' t consider it abuse. I consider it stupidity. Unfortunately, there was no witness. If (E4 and E5) were indeed wearing (R2) ' s wigs, I (E8) would consider it misappropriation of property, but there is no proof of it. On 4/7/16 at 12:48 PM, E2 (Director of Nursing) stated that E2 was off at the time of R2 ' s complaint regarding (E4 and E5) ' s wearing R2 ' s wigs, and the investigation was conducted by E8 (Assistant Director of Nursing/Acting Abuse Coordinator). E2 stated that any resident complaint about an employee is looked into and that all staff are expected to immediately report any potential allegations of abuse. E2 stated, I (E2) interviewed both (E4 and E5) over the phone and we (the facility) fired them because their (E4 and E5) ' s stories did not match what was on camera. On 4/11/16 at 10:36 AM, E2 stated that E2 could not provide documentation that E1 (Administrator) was immediately notified of the above abuse allegation verbalized by R2 on 12/11/15. E4 and E5 ' s Employee Detail Report Time Cards (dated 12/1/15- 12/31/15) document that both E4 and E5 worked full eight hour shifts on 12/10/15, 12/11/15 and 12/14/15 thus allowing E4 and E5 continued access to R2 after E6 (Licensed Practical Nurse) recognized and reported an allegation of emotional abuse and misappropriation of R2 ' s property on 12/11/15. 2. R24's Initial Incident Report dated 1/15/16 documents that an abuse investigation was initiated on 1/15/16 regarding an allegation of an inappropriate comment made on 1/13/16 to R24 by E9 (Former Certified Nursing Assistant). E10 ' s (former Certified Nursing Assistant) written statement dated 1/13/16 at 8:30 PM documents the following: While myself (E10) and (E9) were in (R24) ' s room cleaning (R24) up for bed, (E9) leaned (E9) ' s head around to look at (R24) and said, 'Am I (E9) getting you riled up?' After (E9) left the room, (R24) stated (to E10) that (R24) is very uncomfortable with (E9) working with (R24) because of what (E9) says and (E9) touches (R24). On 4/6/16 at 1:10 p.m., E10 verified the above written statement and stated, Sometimes when you ' re wiping a male in that area, blood begins to flow and they can't help it (getting an erection). E10 indicated that R24 began to get an erection when E9 was cleaning R24 ' s peri-anal area. E10 then stated, The incident occurred sometime before dinner on 1/13/16. 8:30 PM is the time I (E10) sat down on 1/13/16 and wrote out the statement. After it occurred, I (E10) called the (E11, Licensed Practical Nurse) into (R24) ' s room. That's not the first time something like this has happened. (R24) and others reported previous concerns to (E12, Licensed Practical Nurse). (E12) went to (E8, Assistant Director of Nursing/Acting Abuse Coordinator) multiple times over this. (E12) refused to have (E9) work (R24) ' s floor. When (E11) was in the room on 1/13/16, I told (E11) what I (E10) had witnessed. (E11) asked (R24) how (R24) felt and (R24) said that (R24) didn ' t want (E9) back in the room at all. E10 then stated that E10 felt E9 ' s comment was indeed, Abusive in nature because the way (E9) said it and the look on (E9) ' s face. It was degrading to (R24). E10 then stated that E10 did not report the incident to E2 (Director of Nursing/Abuse Coordinator) or E1 (Administrator) because E10 had reported it to E11 on 1/13/16 and E12 on the afternoon of 1/14/16. E10 also stated that E10 called the facility on the morning of 1/14/16 and reported the incident to E8 (Assistant Director of Nursing/Acting Abuse Coordinator) because E2 was off and E8 was acting as the Abuse Coordinator. E10 also stated that E9 continued to work until the end of E9 ' s shift on 1/13/16. E12 ' s (Licensed Practical Nurse) written statement dated 1/15/16 documents the following: On 1/14/16, (R24) was sitting by the nurse's station and stated that (E9) was inappropriate with (R24) again last night. (E12) asked (R24) what happened and (R24) said (R24) was being cleaned up by (E9, Former Certified Nursing Assistant) and (E10, Former Certified Nursing Assistant) was assisting (E9) and (E10) was standing by (R24) as (R24) was telling (E12) that when (E9) was wiping (R24), (E9) asked (R24) if that felt good or excited (R24) (I (E12) couldn't remember which term) but (R24) stated it made (R24) feel uncomfortable. Writer (E12) reported this to (E8) today 1/15/16. On 4/6/16 at 12:20 PM, E12 verified the above written statement and stated that E12 was not working when the incident involving E9 and R24 occurred on 1/13/16. E12 stated that E12 did not report the above incident to anyone on 1/14/16 because R24 did not want E12 to say anything and stated, I (E12) should have called that day (1/14/16). What (R24) told me (E12) that (E9) said was abusive in nature. I (E12) reported it to (E8, Assistant Director of Nursing/Acting Abuse Coordinator) on 1/15/15 in the morning. E12 then stated, Sexual abuse is any inappropriate touching from anyone or verbally inappropriate sexual comments and verbal abuse is any comment made that is inappropriate or makes someone feel sad or upset or uncomfortable. E12 also stated that all allegations of abuse are to immediately be reported to E2 (Director of Nursing/Abuse Coordinator). E12 made no mention of the need to immediately notify E1 (Administrator) of any allegation of abuse. On 4/7/16 at 9:52 AM, E12 stated, There was one other occasion when (R24) mentioned that (E9) had made (R24) feel uncomfortable. It was about a week before (R24) told (E12) about the comment that (E9) made on 1/13/16. (R24) said that (E9) rubbed (R24) ' s back and it made (R24) feel uncomfortable. (E12) asked (R24) why and (R24) said (R24) had (R24)'s shirt off at the time (E9) started rubbing (R24) and (R24) didn ' t want (E9) back in (R24) ' s room. (E12) reported this to (E8) in morning report right after (R24) reported the incident to (E12). The care plan team meets together every morning. (E12) told (E8) when (E8) came to get daily updates. After the morning meeting, (E12) went into the office with (E8) and discussed it further. (E9) was just different. I (E12) can see why people felt uncomfortable. I (E12) even felt uncomfortable with (E9) . At this same date and time, E12 then stated that E12 was first aware of the 1/13/16 incident on 1/14/16 around 2:00 PM when R24 told E12 with E10 (Former Certified Nursing Assistant) standing next to R24. E12 then stated, (R24) is pretty easy going. It was out of character for (R24) to complain about someone. (E10) told me (E12) that (E10) told the nurse that was working the night before. E12 stated that the first incident regarding the touching occurred on 1/5/16 and E9 didn't work a set area but floated and worked all areas of the building. E12 then stated that R24 looked shocked when R24 told E12 about the 1/13/16 incident and, (R24) was upset. (R24) may have been trying to mask it because (R24) was in the Army and is not an overly emotional person. If it happened to me (E12) or my parents, I (E12) would be really upset. (R24) possibly could be humiliated or embarrassed from a comment like that. E11 ' s (Licensed Practical Nurse), undated written statement documents the following: On 1/14/16, (R24) stated that (E9) made an inappropriate comment about getting (R24) riled up while (E9) was cleaning (R24) ' s backside. (R24) stated that (R24) was uncomfortable with (E9) giving (R24) cares. I reported this to (E8, Assistant Director of Nursing/Acting Abuse Coordinator) on 1/15/16. On 4/6/16 at 12:15 p.m., E11 stated that R24 told E11 that R24 was uncomfortable with E9 providing care to R24. E11 stated that E11 reported this to E2 (Director of Nursing/Abuse Coordinator) or E8 and E9 was told to go home the day E11 reported R24 ' s concerns. E11 also stated that any allegation of abuse is reported to E2 or E8. E11 was unaware that E1 should be immediately notified of any allegation of abuse. On 4/6/16 at 11:45 a.m., R24 stated that E9 (Former Certified Nursing Assistant) made a remark to R24 on 1/13/16 that, Made me (R24) very uncomfortable. R24 then stated that E9 would, Rub (E9) ' s hands on my shoulders and it made me (R24) feel uncomfortable. It takes a lot to make me (R24) feel very uncomfortable. If a man did that to a woman, then he would be in big trouble . I (R24) did not want (E9) touching me like (E9) was. It was more inappropriate than friendly. I (R24) let it go by for a while, a few weeks, before I (R24) said anything. On 4/7/16 at 11:45 a.m., R24 stated that when E9 touched and rubbed R24 ' s shoulders, it, Creeped me (R24) out. I (R24) do not like (E9). R24 then stated that the comment E9 made to R24 on 1/13/16, Surprised me (R24). I (R24) was uncomfortable and upset and wanted it addressed. R24 then stated that R24 prefers to no longer discuss the 1/13/16 incident. On 4/6/16 at 1:39 PM, E1 (Administrator) stated that E1 was first notified of any concerns from R24 by a text message from E8 on 1/15/16. E1 provided a copy of the text message dated 1/15/16 and timed 3:17 p.m. which documents the following by E8: Nursing staff member (E9) is being taken off the schedule per (E8). (E9) was helping clean (R24) and made sexually inappropriate comments about him getting aroused. (E8) is making report. On 4/6/16 at 2:50 PM, E8 (Assistant Director of Nursing/Acting Abuse Coordinator) stated that E8 was Acting Abuse Coordinator at the time of R24 ' s verbalized concern on 1/13/16. E8 stated that E8 was notified of R24 ' s concerns from 1/13/16 by E12 (Licensed Practical Nurse) on 1/15/16. E8 then stated, (E12) stated that (R24) had expressed feelings that (E9) made comments that made (R24) feel uncomfortable. (E10) was in the room at the time and witnessed the comment. The incident occurred on 1/13/16. I think staff was unsure if it was an actual abuse thing. They (the staff) thought it was inappropriate. I (E8) feel that it was something that would be reportable. It's not right. I (E8) would expect to be immediately notified of an allegation of abuse. When (the 1/13/16) incident was reported, I (E8) recognized it as a potential allegation of abuse .I (E8) know (R24) said (E9) touched (R24) ' s shoulder. (E9) was a little slower . E8 also stated that sexual abuse is, A suggestive statement made to a resident by a CNA (Certified Nursing Assistant) or Nurse or inappropriate touching. On 4/7/16 at 11:04 AM, E8 stated that something was brought to E8 ' s attention approximately a week to a week and a half before the 1/13/16 incident involving R24 and E9 by E12. E8 stated that R24 said R24 was uncomfortable after E9 gave R24 a back rub. E8 stated that no report or investigation was conducted at that time and E8 did not speak to R24 about R24 ' s complaint. E8 then stated, I think it (E9 ' s comment to R24 on 1/13/16) was inappropriate .The only thing (R24) has ever complained about is (E9). I (E8) investigated it (1/13/16 incident) because it is protocol. (R24) made the complaint and when it was brought to my (E8) attention, I (E8) investigated. (E9) was taken out of the building on 1/15/16. I (E8) investigate all complaints. E8 verified that E9 worked E9 ' s entire shift on 1/13/16 and had access to all residents in the facility. E8 then stated that there was no investigation or follow up to the first incident regarding (R24) and (E9) because, A back rub is part of HS (bedtime) cares. It's standard of care. CNA's (Certified Nursing Assistant) do that. E9 ' s Final Employee Detail Report Time Card (dated 1/1/16- 1/31/16) indicates that E9 worked an entire eight hour shift on 1/13/16. E9 ' s signed Performance Correction Notice dated 1/20/16 documents the following: You made an inappropriate comment to a resident while caring for him. The resident was in a compromising position, as you were providing personal care to his private area. You stated to the resident while cleansing him 'does this get you riled up?' This is inappropriate and made the resident feel uncomfortable. While this may not constitute direct abuse, this is considered borderline both physically and verbally. The resident is not confused and is a reliable source. This is a violation of the harassment policy as well. Your employment at (the facility) is terminated. On 4/7/16 at 12:48 PM, E2 (Director of Nursing) stated if a resident complains about an employee, it's looked in to. E2 stated E2 was off at the time of the 1/15/16 investigation involving R24 and E9 but was kept informed by E8, who conducted the investigation. E2 then stated, If (R24) complains to a staff member about back rubs making (R24) uncomfortable, then it should be reported to (E2) or (E8) and we would follow up. If staff receives a complaint about the same employee a second time, I (E2) expect them to immediately report to (E2) or (E8) . E2 then stated regarding the 1/13/16 incident involving R24 and E9, If they (staff) didn't report it immediately, they (staff) didn't consider it abuse. It was a stupid comment. It was no way sexual abuse. It was a dumb statement. I don't consider the comment (E9) made sexual abuse or sexual harassment. 3. R100 ' s Initial Incident Report (dated 10/1/15) documents an allegation of verbal abuse involving R100 was initiated on 10/1/15. R100 ' s timeline of R100 ' s 10/1/15 abuse investigation documents the following: Notified (E1, Administrator). This same report does not document the date or time that E1 was notified of R100 ' s allegation of abuse. On 4/11/16 at 10:36 AM, E2 (Director of Nursing) stated that E2 could not provide any documentation of the time that E1 was notified of R100 ' s allegation of abuse. On 4/11/16 at 3:30 PM, E2 stated that Certified Nursing Assistants typically get assigned to the same hallway for continuity but can get floated to another hall at any time to fill staffing needs or assist. The Resident Census and Conditions of Residents form (Centers for Medicare and Medicaid Services- Form 672) dated 4/4/16 and completed by E2 (Director of Nursing) indicates 78 residents currently reside in the facility. The Immediate Jeopardy was identified at 1:00 PM on 04/13/2016 to have begun on 12/10/15 when E4 and E5 emotionally abused and misappropriated R2 ' s property, and E4 and E5 were not immediately removed from resident contact. E1 and E2 were notified of the Immediate Jeopardy on 04/13/2016 at 1:15 PM. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. The facility previously reported both incidents of suspected abuse to the State Agency. The facility reported the first incident on December 15, 2015 and December 18, 2015. The facility reported the second incident on January 15, 2016 and January 20, 2016. Completed December 18, 2015 & January 20, 2016 2. The facility reported the suspected sexual abuse (second incident) to the resident ' s physician and representatives on January 15, 1016. A comprehensive physical examination was performed for the residents, and no injuries were noted. The facility followed up with the resident to ensure he felt reassured and felt safe in the community. The facility ' s investigation was initiated on January 15, 2016 and completed January 20, 2016. The staff member involved was immediately suspended on January 15, 2016, upon receipt of the allegation. Following investigation, the staff member was terminated January 20, 2016. Completed January 20, 2016 3. The facility reported the alleged misappropriation of property and emotional abuse (first incident) to the resident ' s physician and representatives on December 15, 2015. The facility followed up with the resident to ensure she felt reassured and felt safe in the community. The facility ' s investigation was initiated on December 15, 2015 and completed December 18, 2015. The staff members involved were immediately suspended on December 15, 2015, upon receipt of the allegation. Following investigation, staff members were terminated December 18, 2015. Completed December 18, 2015 4. The facility ' s Assistant Director of Nursing conducted a thorough investigation of the incidents, including interviewing facility staff and affected residents. The Director of Nursing, although on leave, participated in interviews and was notified of ongoing investigation daily. A final Incident Report was provided to the State Agency. Completed December 18, 2015 & January 20, 2016 5. The Attorneys provided one-on-one training to the Director of Nursing on regulatory requirements for abuse and neglect identification, investigation, response and reporting beginning April 5 and completing April 13, 1016. Completed April 13, 2015 6. The facility ' s Director of Nursing provided immediate in-service training all staff at the facility on the facility ' s policies and procedures relating to abuse and neglect identification and reporting as well as reporting and investigating protocols for allegations and suspicions of abuse and neglect. The in-service re-trained staff on the obligation to immediately report any allegation, accusation, or suspicion of abuse or neglect to the facility Director of Nursing. For any nursing home staff who have not yet participated in this in-service training, the Director of Nursing or designee will provide the in-service training before nursing staff work their next shift at the facility. Initiated on April 13, 2016 7. The facility has reviewed its Policy and Procedure on Abuse/Neglect Prevention and Response to ensure it complies with all applicable law and provides adequate direction to all staff, including clear communication of expectations of staff. Completed April 13, 2016. 8. The facility has interviewed all interviewable residents to determine if there are any outstanding unreported incidents involving potential abuse or misappropriation. No further issues identified. Completed April 13, 2016 9. To monitor continued compliance, the facility ' s Administrator and/or Director of Nursing are performing a re-training of all nursing facility staff on the Facility ' s Policy and Procedure on Abuse/Neglect Prevention and Response. Thereafter, the Administrator and/or Director of Nursing or her designee will conduct random audits of RN, LPN, C.N.A., housekeeping, laundry, social service and kitchen staff to determine staff proficiency and compliance with the policy and procedure; the audits will be done daily on each shift for the next two weeks, and then once per week per shift for the following two weeks 10. The facility's DON, or designee, will perform an audit of every allegation, accusation, or suspicion of abuse or neglect at the facility, weekly for the next six weeks, to verify that the policy and procedure for identifying, reporting and investigating is properly followed by staff and administration. Initiated on April 13, 2016.

Based on record review and interview, the facility failed to follow operational policies and procedures regarding the following: Immediate notification to the Abuse Coordinator and Administrator; identification of misappropriation of resident property, sexual abuse and mental abuse; and protection of the resident by the removal of the suspected perpetrator of abuse. E4 and E5 wore R2 ' s wig in front of R2 laughing and making fun of R2 which caused emotional upset and embarrassment for R2 which continues. E9 inappropriately touched R24 on one occasion (1/5/16) and continued to have access to R24 when E9 made a sexually inappropriate comment to R24 approximately one week later (1/13/16). R2, R24 and R100 were three of three residents reviewed for allegations of abuse on the supplemental sample. E4, E5 and E9 had continued access to all residents in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4/14/16, the facility remains out of compliance at a Severity Level II as the facility revises operational policies and procedures on Abuse. Findings include: The facility ' s Abuse Investigation policy (revised 1/2015) documents the following: All reports of resident abuse, neglect and injuries of unknown source, crime or mistreatment shall be promptly and thoroughly investigated by facility management . An incident or suspected incident of resident abuse, mistreatment, neglect, crime or injury of unknown source will be immediately reported to the Abuse Coordinator and/or designee and Administrator . The individual conducting the investigation will . Interview the person(s) reporting the incident, Interview any witnesses to the incident, interview the resident (as medically appropriate), interview staff members (on all shifts) who may have had contact with the resident during the period of alleged incident and interview other residents to whom the accused employee provides care or services . Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports . Employees of this facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator . The facility ' s undated Abuse and Neglect Prevention policy documents the following: (The facility) will not tolerate abuse and neglect by any individual including staff, family, volunteer or consultant .Abuse means any act that willfully injures a resident at (the facility) including unreasonable isolation, intimidation, or punishment of a resident. Physical abuse may include hitting, kicking, pinching . or inappropriate sexual language or conduct. Verbal abuse includes the use of words, signs or gestures to intimidate, demean, curse, harass, or threaten harm to the resident . Abuse may also include the misuse of the resident ' s funds or the misappropriation of resident ' s property. Misappropriation of resident property means using a resident ' s cash, clothing or other possessions without authorization by the resident or the resident ' s legal agent . The facility ' s Employee Handbook (dated 2/1/16) documents the following: Harassing conduct includes but is not limited to: epithets, slurs or negative stereotyping; threatening, intimidating or hostile acts; denigrating jokes . Sexual Harassment, according to the Illinois Human Rights Act, Sexual Harassment is defined as: ' Any unwelcome sexual advances, requests for sexual favors or any conduct of a sexual nature . 1. R2's initial Incident Report dated 12/15/15 and completed by E8 (Assistant Director of Nursing/Acting Abuse Coordinator) documents that the facility initiated an investigation on 12/15/15 for an allegation of emotional abuse involving R2. The facility's faxed initial report dated 12/15/15 and completed by E8 (Assistant Director of Nursing/Acting Abuse Coordinator) to (State Agency) documents the following: This is to report an allegation of abuse of a resident's belongings. A CNA (Certified Nursing Assistant) was reportedly wearing (R2) ' s wig . On 4/7/16 at 1:15 PM, E8 (Assistant Director of Nursing/Acting Abuse Coordinator) stated, It was brought to my attention that two CNA ' s (Certified Nursing Assistants) were in (R2) ' s room, put (R2) ' s wig on and were dancing around. This upset (R2). I think E6 (Licensed Practical Nurse) told me (E8). (E6) usually works second shift. I think (E6) told me face-to-face. I (E8) became aware of the incident on 12/15/15. I (E8) reported to (E1, Administrator) on 12/15/15 . E8 then stated that E4 and E5 were not removed from resident care until 12/15/15 following the 12/13/15 incident with R2. On 4/7/16 at 2:20 p.m., E6 (Licensed Practical Nurse) stated that on 12/10/15, E6 saw a picture of E4 and E5 (Former Certified Nursing Assistants) wearing wigs on a (Social Media Picture Website). The next day, R2 complained to E21 (Former Certified Nursing Assistant). E21 went and got E7 (Licensed Practical Nurse) and E7 came and told me (E6). It was approximately 8:00 p.m. I (E6) told E7 that I (E6) would report it. I (E6) reported it immediately to E8 (Assistant Director of Nursing/Acting Abuse Coordinator) by phone. I (E6) called E8 and left a message. E8 didn't call back. E8 called me (E6) the Monday (12/14/15) after the weekend. I (E6) want to say that I saw the picture on a (Social Medial Picture Website) on 12/10/15, heard about and reported R2's complaint to E8 on 12/11/15, and spoke to E8 about it on 12/14/15. E6 then stated that E6 did not immediately report R2's concern to E1 (Administrator) on 12/11/15. On 4/11/16 at 12:09 PM, E7 (Licensed Practical Nurse) verified that E7 worked a second shift on 12/11/15 and was notified of an allegation of abuse involving R2 and E4 and E5. E7 then stated that E7 reported the allegation to E6 (Licensed Practical Nurse) and did not report to anyone else because E6 was addressing it. E7 also stated that E4 and E5 worked the rest of their (E4 and E5) ' s shifts on 12/11/15 and had access to all residents in the facility. On 4/7/16 at 12:48 PM, E2 (Director of Nursing) stated that any resident complaint about an employee is looked into and that all staff are expected to immediately report any potential allegations of abuse (to the Abuse Coordinator). On 4/11/16 at 10:36 AM, E2 stated that E2 could not provide documentation that E1 (Administrator) was immediately notified of the abuse allegation verbalized by R2 on 12/11/15. The facility's faxed final investigation report dated 12/18/15 and completed by E8 (Assistant Director of Nursing/Acting Abuse Coordinator) to (State Agency) documents the following: This follow-up is in regards to the previously reported allegation of abuse . (R2) was interviewed twice . After interviewing (E4 and E5) and (R2), it is difficult to determine whether there was abuse of (R2) ' s belongings. (R2) continues to report that (E4 and E5) were wearing (R2) ' s wig and it was upsetting to (R2) . (R2) was able to identify (E4 and E5) that (R2) felt were wearing (R2) ' s wig. We (the facility) cannot conclude abuse was substantiated . R2's full final Abuse Investigation (dated 12/18/15) does not include witness interviews or written statements from E21, E6 or E7. On 4/11/16 at 10:49 AM, E8 (Assistant Director of Nursing/ Acting Abuse Coordinator) verified that E8 could not produce written witness statements or interviews from E21, E6 or E7 regarding R2's verbalized concerns on 12/11/15 and stated that E8 only documented one of the two interviews conducted with R2. On 4/12/16 at 10:07 AM, E8 stated that emotional abuse is any kind of statement made that is taken offensively by the resident or makes them upset. Misappropriation of resident ' s property is stealing from the residents or taking the resident ' s funds. E8 then stated that E8 considered E4 and E5 ' s behavior inappropriate on both parts of E4 and E5. E8 then stated that R2 gave R2 ' s statement and there was no witness to the 12/10/15 incident. When asked if E8 considered R2 ' s 12/10/15 incident abuse, E8 stated, No. I (E8) don ' t consider it abuse. I consider it stupidity. Unfortunately, there was no witness. If (E4 and E5) were indeed wearing (R2) ' s wigs, I (E8) would consider it misappropriation of property, but there is no proof of it. 2. R24's Initial Incident Report dated 1/15/16 documents that an abuse investigation was initiated on 1/15/16 regarding an allegation of an inappropriate comment made on 1/13/16 to R24 by E9 (Former Certified Nursing Assistant). On 4/6/16 at 1:10 PM., E10 (former Certified Nursing Assistant) stated, that the incident involving R24 and E9 occurred sometime before dinner on 1/13/16. E10 then stated that E10 did not report the incident to E2 (Director of Nursing/Abuse Coordinator) or E1 (Administrator) because E10 had reported it to E11 (Licensed Practical Nurse) on 1/13/16 and E12 (Licensed Practical Nurse) on the afternoon of 1/14/16. E10 stated that E10 called the facility on the morning of 1/14/16 and reported the incident to E8 (Assistant Director of Nursing/Acting Abuse Coordinator). E10 also stated that E9 continued to work the floor caring for residents until the end of E9 ' s shift on 1/13/16. On 4/6/16 at 12:20 PM, E12 stated that E12 did not report the 1/13/16 incident to anyone on 1/14/16 when E12 was made aware of the incident. E12 stated, I (E12) should have called that day (1/14/16). What (R24) told me (E12) that (E9) said was abusive in nature. I (E12) reported it to (E8, Assistant Director of Nursing/Acting Abuse Coordinator) on 1/15/15 in the morning. E12 also stated that all allegations of abuse are to immediately be reported to the Abuse Coordinator. E12 made no mention of the need to immediately notify E1 (Administrator) of any allegation of abuse. On 4/7/16 at 9:52 AM, E12 stated, There was one other occasion when (R24) mentioned that (E9) had made (R24) feel uncomfortable. It was about a week before (R24) told (E12) about the comment that (E9) made on 1/13/16. (R24) said that (E9) rubbed (R24) ' s back and it made (R24) feel uncomfortable. (E12) asked (R24) why and (R24) said (R24) had (R24)'s shirt off at the time (E9) started rubbing (R24) and (R24) didn ' t want (E9) back in (R24) ' s room. (E12) reported this to (E8) in morning report right after (R24) reported the incident to (E12). E12 then stated that the first incident regarding the touching occurred on 1/5/16, and E9 didn't work a set area but floated and worked all areas of the building. E11 ' s (Licensed Practical Nurse), undated written statement documents the following: On 1/14/16, (R24) stated that (E9) made an inappropriate comment about getting (R24) riled up while (E9) was cleaning (R24) ' s backside. (R24) stated that (R24) was uncomfortable with (E9) giving (R24) cares. I reported this to (E8, Assistant Director of Nursing/Acting Abuse Coordinator) on 1/15/16. On 4/6/16 at 12:15 p.m., E11 stated that R24 told E11 that R24 was uncomfortable with E9 providing care to R24. E11 stated that E11 reported this to the Abuse Coordinator and then E9 was told to go home the day E11 reported R24 ' s concerns. E11 also stated that any allegation of abuse is reported to E2 or E8. E11 was unaware that E1 should be immediately notified of any allegation of abuse. On 4/6/16 at 11:45 a.m., R24 stated that E9 (Former Certified Nursing Assistant) made a remark to R24 on 1/13/16 that, Made me (R24) very uncomfortable. R24 then stated that E9 would, Rub (E9) ' s hands on my shoulders and it made me (R24) feel uncomfortable. It takes a lot to make me (R24) feel very uncomfortable. If a man did that to a woman, then he would be in big trouble . I (R24) did not want (E9) touching me like (E9) was. It was more inappropriate than friendly. I (R24) let it go by for a while, a few weeks, before I (R24) said anything. On 4/7/16 at 11:45 a.m., R24 stated that when E9 touched and rubbed R24 ' s shoulders, it, Creeped me (R24) out. I (R24) do not like (E9). R24 then stated that the comment E9 made to R24 on 1/13/16, Surprised me (R24). I (R24) was uncomfortable and upset and wanted it addressed. On 4/6/16 at 1:39 PM, E1 (Administrator) stated that E1 was first notified of any concerns from R24 by a text message from E8 (Assistant Director of Nursing/Acting Abuse Coordinator) on 1/15/16. On 4/6/16 at 2:50 PM, E8 (Assistant Director of Nursing/Acting Abuse Coordinator) stated that E8 was notified of R24 ' s concerns from 1/13/16 by E12 (Licensed Practical Nurse) on 1/15/16. E8 then stated, (E12) stated that (R24) had expressed feelings that (E9) made comments that made (R24) feel uncomfortable. (E10) was in the room at the time and witnessed the comment. The incident occurred on 1/13/16. I think staff was unsure if it was an actual abuse thing. They (the staff) thought it was inappropriate. I (E8) feel that it was something that would be reportable. It's not right. I (E8) would expect to be immediately notified of an allegation of abuse. When (the 1/13/16) incident was reported, I (E8) recognized it as a potential allegation of abuse. On 4/7/16 at 11:04 AM, E8 stated that something was brought to E8 ' s attention approximately a week to a week and a half before the 1/13/16 incident involving R24 and E9 by E12. E8 stated that R24 said R24 was uncomfortable after E9 gave R24 a back rub. E8 stated that no report or investigation was conducted at that time and E8 did not speak to R24 about R24 ' s complaint. E8 then stated, I think it (E9 ' s comment to R24 on 1/13/16) was inappropriate .The only thing (R24) has ever complained about is (E9). I (E8) investigated it (1/13/16 incident) because it is protocol. (R24) made the complaint and when it was brought to my (E8) attention, I (E8) investigated. (E9) was taken out of the building on 1/15/16. I (E8) investigate all complaints. E8 verified that E9 worked E9 ' s entire shift on 1/13/16 and had access to all residents in the facility. E8 then stated that there was no investigation or follow up to the first incident regarding (R24) and (E9) because, A back rub is part of HS (bedtime) cares. It's standard of care. CNA's (Certified Nursing Assistant) do that. E8 also stated that no other residents were interviewed as part of R24 ' s 1/13/16 full abuse investigation. E9 ' s Final Employee Detail Report Time Card (dated 1/1/16- 1/31/16) indicates that E9 worked an entire eight hour shift on 1/13/16. E9 ' s signed Performance Correction Notice dated 1/20/16 documents the following: You made an inappropriate comment to a resident while caring for him. The resident was in a compromising position, as you were providing personal care to his private area. You stated to the resident while cleansing him 'does this get you riled up?' This is inappropriate and made the resident feel uncomfortable. While this may not constitute direct abuse, this is considered borderline both physically and verbally. The resident is not confused and is a reliable source. This is a violation of the harassment policy as well. Your employment at (the facility) is terminated. On 4/7/16 at 12:48 PM, E2 (Director of Nursing) stated if a resident complains about an employee, it's looked in to. E2 then stated, If (R24) complains to a staff member about back rubs making (R24) uncomfortable, then it should be reported to (E2) or (E8) and we would follow up. If staff receives a complaint about the same employee a second time, I (E2) expect them to immediately report to (E2) or (E8) . E2 then stated regarding the 1/13/16 incident involving R24 and E9, If they (staff) didn't report it immediately, they (staff) didn't consider it abuse. It was a stupid comment. It was no way sexual abuse. It was a dumb statement. I don't consider the comment (E9) made sexual abuse or sexual harassment. 3. R100 ' s Initial Incident Report (dated 10/1/15) documents an allegation of verbal abuse involving R100 was initiated on 10/1/15. R100 ' s timeline of R100 ' s 10/1/15 abuse investigation documents the following: Notified (E1, Administrator). This same report does not document the date or time that E1 was notified of R100 ' s allegation of abuse. On 4/11/16 at 10:36 AM, E2 (Director of Nursing) stated that E2 could not provide any documentation of the time that E1 was notified of R100 ' s allegation of abuse. On 4/11/16 at 3:30 PM, E2 stated that Certified Nursing Assistants typically get assigned to the same hallway for continuity but can get floated to another hall at any time to fill staffing needs or assist. The Resident Census and Conditions of Residents form (Centers for Medicare and Medicaid Services- Form 672) dated 4/4/16 and completed by E2 (Director of Nursing) indicates 78 residents currently reside in the facility. The Immediate Jeopardy was identified at 1:00 PM on 04/13/2016 to have begun on 12/10/15 when E4 and E5 emotionally abused and misappropriated R2 ' s property and E4 and E5 were not immediately removed from resident contact. E1 and E2 were notified of the Immediate Jeopardy on 04/13/2016 at 1:15 PM. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. The facility previously reported both incidents of suspected abuse to the State Agency. The facility reported the first incident on December 15, 2015 and December 18, 2015. The facility reported the second incident on January 15, 2016 and January 20, 2016. Completed December 18, 2015 & January 20, 2016 2. The facility reported the suspected sexual abuse (second incident) to the resident ' s physician and representatives on January 15, 1016. A comprehensive physical examination was performed for the residents, and no injuries were noted. The facility followed up with the resident to ensure he felt reassured and felt safe in the community. The facility ' s investigation was initiated on January 15, 2016 and completed January 20, 2016. The staff member involved was immediately suspended on January 15, 2016, upon receipt of the allegation. Following investigation, the staff member was terminated January 20, 2016. Completed January 20, 2016 3. The facility reported the alleged misappropriation of property and emotional abuse (first incident) to the resident ' s physician and representatives on December 15, 2015. The facility followed up with the resident to ensure she felt reassured and felt safe in the community. The facility ' s investigation was initiated on December 15, 2015 and completed December 18, 2015. The staff members involved were immediately suspended on December 15, 2015, upon receipt of the allegation. Following investigation, staff members were terminated December 18, 2015. Completed December 18, 2015 4. The facility ' s Assistant Director of Nursing conducted a thorough investigation of the incidents, including interviewing facility staff and affected residents. The Director of Nursing, although on leave, participated in interviews and was notified of ongoing investigation daily. A final Incident Report was provided to the State Agency. Completed December 18, 2015 & January 20, 2016 5. The Attorneys provided one-on-one training to the Director of Nursing on regulatory requirements for abuse and neglect identification, investigation, response and reporting beginning April 5 and completing April 13, 1016. Completed April 13, 2015 6. The facility ' s Director of Nursing provided immediate in-service training all staff at the facility on the facility ' s policies and procedures relating to abuse and neglect identification and reporting as well as reporting and investigating protocols for allegations and suspicions of abuse and neglect. The in-service re-trained staff on the obligation to immediately report any allegation, accusation, or suspicion of abuse or neglect to the facility Director of Nursing. For any nursing home staff who have not yet participated in this in-service training, the Director of Nursing or designee will provide the in-service training before nursing staff work their next shift at the facility. Initiated on April 13, 2016 7. The facility has reviewed its Policy and Procedure on Abuse/Neglect Prevention and Response to ensure it complies with all applicable law and provides adequate direction to all staff, including clear communication of expectations of staff. Completed April 13, 2016. 8. The facility has interviewed all interviewable residents to determine if there are any outstanding unreported incidents involving potential abuse or misappropriation. No further issues identified. Completed April 13, 2016 9. To monitor continued compliance, the facility ' s Administrator and/or Director of Nursing are performing a re-training of all nursing facility staff on the Facility ' s Policy and Procedure on Abuse/Neglect Prevention and Response. Thereafter, the Administrator and/or Director of Nursing or her designee will conduct random audits of RN, LPN, C.N.A., housekeeping, laundry, social service and kitchen staff to determine staff proficiency and compliance with the policy and procedure; the audits will be done daily on each shift for the next two weeks, and then once per week per shift for the following two weeks 10. The facility's DON, or designee, will perform an audit of every allegation, accusation, or suspicion of abuse or neglect at the facility, weekly for the next six weeks, to verify that the policy and procedure for identifying, reporting and investigating is properly followed by staff and administration. Initiated on April 13, 2016.

Based on interview, observation and record review, the facility failed to ensure that follow up was provided to a resident after episodes of abuse occurred for two of three residents (R2 and R24) reviewed for abuse allegations on the supplemental sample. E4 and E5 wore R2's wig in front of R2 laughing and making fun of R2,which caused emotional upset and embarrassment for R2 which continues. Findings include: 1. R2's Minimum Data Set (dated 1/31/16) documents a Brief Interview for Mental Status score of 11, indicating R2 is a reliable candidate for an interview. R2's initial Incident Report dated 12/15/15 and completed by E8 (Assistant Director of Nursing/Acting Abuse Coordinator) documents that the facility initiated an investigation on 12/15/15 for an allegation of emotional abuse involving R2. The facility's faxed initial report dated 12/15/15 and completed by E8 (Assistant Director of Nursing/Acting Abuse Coordinator) to (State Agency) documents the following: This is to report an allegation of abuse of a resident's belongings. A CNA was reportedly wearing (R2)'s wig . On 4/7/16 at 1:15 PM, E8 (Assistant Director of Nursing/Acting Abuse Coordinator) stated, It was brought to my attention that two CNA ' s (Certified Nursing Assistants) were in (R2)'s room, put (R2)'s wig on and was dancing around. This upset (R2).The CNA's were (E4 and E5) . On 4/7/16 at 2:20 p.m., E6 (Licensed Practical Nurse) stated that on 12/10/15 (E6) saw a picture of (E4 and E5) wearing wigs on a (Social Media Picture Website). E6 stated, The picture only lasts a few seconds. I (E6) saw (E4 and E5) with wigs on (E4 and E5)'s heads in a picture. I (E6) tried to take a screen shot of it, but it only lasts a short time and it (the picture) was already gone. I (E6) couldn't tell where they were just that they (E4 and E5) were wearing wigs. The next day, (R2) complained to (E21, former Certified Nursing Assistant). E21 went and got E7 (Licensed Practical Nurse) and (E7) came and told me (E6). It was approximately 8:00 p.m .(E4 and E5, Certified Nursing Assistants) were smiling in the picture thinking they (E4 and E5) were funny . On 4/11/16 at 12:09 PM, E7 (Licensed Practical Nurse) that on 12/11/15 at approximately 7:00 PM, (R2) become upset after a (E21, former Certified Nursing Assistant) attempted to give (R2) a shower. E7 stated, (R2) was hysterical. (R2) was trying to kick (E21) out of the room. (R2) thought that (E21) was one of the CNA's (Certified Nursing Assistants) that was wearing (R2's) wigs (on 12/10/15). I (E7) talked to (R2) and calmed (R2) down and then (R2) allowed (E21) to care for (R2). I (E7) went and told (E6) what (R2) had told me and (E6) said 'Wow it really happened.' (E6) said to me (E7) that (E6) had seen a picture of (E4 and E5) last night (12/10/15) posted on a (Social Media Picture Website) and (E4 and E5) were wearing wigs .(R2) continued talking about this for a couple weeks. (R2) would become upset about something, but it seemed that the root of the problem always went back to (E4 and E5) wearing (R2)'s wigs. (R2) was extremely upset. (R2) felt degraded and (R2) felt that (E4 and E5) were making fun of and laughing at (R2). R2's written interview dated 12/16/15 and signed by (E8) and (E15, Social Service Director) documents the following: Two girls got real fresh with me the other night. They had my wig in the bathroom and they were posing in the mirror with it on. One was overweight, wearing all black and the other was small. She had black hair and was working the next night. Everything they said was hurtful. I don't think I went to supper. I had ice cream as a snack. The small one was really brazen and paraded around my bed, she grabbed the wig and I asked her to put it on the stand but she went into the bathroom and was posing in the mirror. R2 then denied spilling anything on R2's wig and stated, They were laughing a lot. They were dancing around with my wig on. Making fun of me. Why are you asking me so many questions. You don't care. You don't care! I didn't spill anything on my wig, they were making fun of me! On 4/11/16 at 12:05 PM, R2 was lying in R2's bed. R2's hair was extremely thin and disheveled exposing several areas of R2 ' s scalp. R2's wigs were located and neatly kept on a shelf next to R2's bed. R2 stated, I (R2) do not want to repeat it. I prefer them (E4 and E5) not take care of me ever again. They were very . (R2 unable to finish statement) when asked about the 12/10/15 incident involving E4 and E5. R2 appeared very withdrawn and avoided eye contact continually staring at the floor. R2 immediately changed the subject of the conversation and stated that R2 was waiting for a meal tray. Upon further discussion and subsequent mention of the 12/10/15 incident, R2 stated, I (R2) hate this place. When R2 was asked how E4 and E5 (Certified Nursing Assistants) made R2 feel when E4 and E5 were wearing R2's wigs on 12/10/15, R2 again stared at the floor and avoided eye contact, sat in silence for approximately one minute and with a flat affect did not answer the question and stated, You can go anytime now. R2's current care plan has no mention of the above abuse investigation conducted and does not instruct staff to monitor for any adverse behaviors associated with the event. On 4/11/16 at 9:35 a.m., E24, Care Plan Coordinator, verified that R2's care plan was not updated after the 12/10/15 incident of abuse involving R2, E4 and E5 and stated it should have been. R2's Social Service notes dated 11/3/15 - 2/1/16 have no documentation of any follow up to the incident with R2 and E9. On 4/14/16 at 12:30 p.m., E15, Social Service Director, stated, If any type of abuse was proven, I would do follow up. E15 then stated that R2 had not received any referral or follow up to a psychologist, psychiatrist or counseling. 2. R24's Initial Incident Report dated 1/15/16 documents that an abuse investigation was initiated on 1/15/16 regarding an allegation of an inappropriate comment made on 1/13/16 to R24 by E9 (Former Certified Nursing Assistant). E10 ' s (former Certified Nursing Assistant) written statement dated 1/13/16 at 8:30 PM documents the following: While myself (E10) and (E9) were in (R24) ' s room cleaning (R24) up for bed, (E9) leaned (E9)'s head around to look at (R24) and said, 'Am I (E9) getting you riled up?' After (E9) left the room, (R24) stated (to E10) that (R24) is very uncomfortable with (E9) working with (R24) because of what (E9) says and (E9) touches (R24). On 4/6/16 at 1:10 p.m., E10 verified the above written statement and stated, Sometimes when you ' re wiping a male in that area, blood begins to flow and they can't help it (getting an erection). E10 indicated that R24 began to get an erection when E9 was cleaning R24 ' s peri-anal area. E10 then stated, After it (incident) occurred, I (E10) called the (E11, Licensed Practical Nurse) into (R24)'s room .When (E11) was in the room on 1/13/16, I told (E11) what I (E10) had witnessed. (E11) asked (R24) how (R24) felt and (R24) said that (R24) didn't want (E9) back in the room at all. E10 then stated that E10 felt E9's comment was indeed, Abusive in nature because the way (E9) said it and the look on (E9)'s face. It was degrading to (R24). E12 ' s (Licensed Practical Nurse) written statement dated 1/15/16 documents the following: On 1/14/16, (R24) was sitting by the nurse's station and stated that (E9) was inappropriate with (R24) again last night. (E12) asked (R24) what happened and (R24) said (R24) was being cleaned up by (E9, Former Certified Nursing Assistant) and (E10, Former Certified Nursing Assistant) was assisting (E9) and (E10) was standing by (R24) as (R24) was telling (E12) that when (E9) was wiping (R24), (E9) asked (R24) if that felt good or excited (R24) (I (E12) couldn't remember which term) but (R24) stated it made (R24) feel uncomfortable . On 4/6/16 at 12:20 PM, E12 verified the above written statement. On 4/7/16 at 9:52 AM, E12 stated, There was one other occasion when (R24) mentioned that (E9) had made (R24) feel uncomfortable. It was about a week before (R24) told (E12) about the comment that (E9) made on 1/13/16. (R24) said that (E9) rubbed (R24) ' s back and it made (R24) feel uncomfortable. (E12) asked (R24) why and (R24) said (R24) had (R24)'s shirt off at the time (E9) started rubbing (R24) and (R24) didn't want (E9) back in (R24)'s room .I (E12) can see why people felt uncomfortable. I (E12) even felt uncomfortable with (E9) . At this same date and time, E12 stated, (R24) is pretty easy going. It was out of character for (R24) to complain about someone. E12 then stated that R24 looked shocked when R24 told E12 about the 1/13/16 incident and, (R24) was upset. (R24) may have been trying to mask it because (R24) was in the Army and is not an overly emotional person. If it happened to me (E12) or my parents, I (E12) would be really upset. (R24) possibly could be humiliated or embarrassed from a comment like that. E11's (Licensed Practical Nurse), undated written statement documents the following: On 1/14/16, (R24) stated that (E9) made an inappropriate comment about getting (R24) riled up while (E9) was cleaning (R24)'s backside. (R24) stated that (R24) was uncomfortable with (E9) giving (R24) cares. On 4/6/16 at 12:15 p.m., E11 stated that R24 told E11 that R24 was uncomfortable with E9 providing care to R24. On 4/6/16 at 11:45 a.m., R24 stated that E9 (Former Certified Nursing Assistant) made a remark to R24 on 1/13/16 that, Made me (R24) very uncomfortable. R24 then stated that E9 would, Rub (E9) ' s hands on my shoulders and it made me (R24) feel uncomfortable. It takes a lot to make me (R24) feel very uncomfortable. If a man did that to a woman, then he would be in big trouble . I (R24) did not want (E9) touching me like (E9) was. It was more inappropriate than friendly. I (R24) let it go by for a while, a few weeks, before I (R24) said anything. On 4/7/16 at 11:45 a.m., R24 stated that when E9 touched and rubbed R24's shoulders, it, Creeped me (R24) out. I (R24) do not like (E9). R24 then stated that the comment E9 made to R24 on 1/13/16, Surprised me (R24). I (R24) was uncomfortable and upset and wanted it addressed. R24 then stated that R24 prefers to no longer discuss the 1/13/16 incident. On 4/6/16 at 2:50 PM, E8 (Assistant Director of Nursing/Acting Abuse Coordinator) stated, (E12) stated that (R24) had expressed feelings that (E9) made comments that made (R24) feel uncomfortable. (E10) was in the room at the time and witnessed the comment .They (the staff) thought it was inappropriate .It's not right . On 4/7/16 at 11:04 AM, E8 stated that something was brought to E8's attention approximately a week to a week and a half before the 1/13/16 incident involving R24 and E9 by E12. E8 stated that R24 said R24 was uncomfortable after E9 gave R24 a back rub. E8 then stated, I think it (E9's comment to R24 on 1/13/16) was inappropriate . E9's signed Performance Correction Notice dated 1/20/16 documents the following: You made an inappropriate comment to a resident while caring for him. The resident was in a compromising position, as you were providing personal care to his private area. You stated to the resident while cleansing him 'does this get you riled up?' This is inappropriate and made the resident feel uncomfortable. While this may not constitute direct abuse, this is considered borderline both physically and verbally. The resident is not confused and is a reliable source. This is a violation of the harassment policy as well. Your employment at (the facility) is terminated. R24's Social Service notes dated 12/28/15 - 3/24/16 have no documentation of any follow up to the incident with R24 and E9. On 4/14/16 at 12:30 p.m., E15, Social Service Director, stated E15 did not follow up with R24 after the 1/5/16 and 1/13/16 incidents involving R24 and E9 because, I (E15)didn't see any reason to. E15 then stated that R24 had not received any referral or follow up to a psychologist, psychiatrist or counseling. R24's current care plan has no mention of the abuse investigation conducted on 1/15/16 and does not instruct staff to monitor for any adverse behaviors associated with the event. On 4/7/16 at 1:55 p.m., E24, Care Plan Coordinator, verified that R24's care plan was not revised after the 1/13/16 incident of abuse involving R24 and E9.

Based on interview, observation and record review, the facility failed to ensure that a resident's dignity was maintained for two of three residents (R2 and R24) reviewed for abuse allegations on the supplemental sample. E4 and E5 wore R2's wig in front of R2 laughing and making fun of R2 that caused emotional upset and embarrassment for R2 which continues. Findings include: The undated facility's Quality of Life - Dignity policy documents the following: Residents shall be treated with dignity .Residents' private space and property shall be respected at all times .Staff will not handle or move a resident's personal belongings without the resident's permission . 1. R2's Minimum Data Set (dated 1/31/16) documents a Brief Interview for Mental Status score of 11, indicating R2 is a reliable candidate for an interview. R2's initial Incident Report dated 12/15/15 and completed by E8 (Assistant Director of Nursing/Acting Abuse Coordinator) documents that the facility initiated an investigation on 12/15/15 for an allegation of emotional abuse involving R2. The facility's faxed initial report dated 12/15/15 and completed by E8 (Assistant Director of Nursing/Acting Abuse Coordinator) to (State Agency) documents the following: This is to report an allegation of abuse of a resident's belongings. A CNA was reportedly wearing (R2)'s wig . On 4/7/16 at 1:15 PM, E8 (Assistant Director of Nursing/Acting Abuse Coordinator) stated, It was brought to my attention that two CNA ' s (Certified Nursing Assistants) were in (R2)'s room, put (R2)'s wig on and was dancing around. This upset (R2).The CNA's were (E4 and E5 former Certified Nursing Assistants) . On 4/7/16 at 2:20 p.m., E6 (Licensed Practical Nurse) stated that on 12/10/15 (E6) saw a picture of (E4 and E5) wearing wigs on a (Social Media Picture Website). E6 stated, The picture only lasts a few seconds. I (E6) saw (E4 and E5) with wigs on (E4 and E5)'s heads in a picture. I (E6) tried to take a screen shot of it, but it only lasts a short time and it (the picture) was already gone. I (E6) couldn't tell where they were just that they (E4 and E5) were wearing wigs. The next day, (R2) complained to (E21, former Certified Nursing Assistant). E21 went and got E7 (Licensed Practical Nurse) and (E7) came and told me (E6). It was approximately 8:00 p.m .(E4 and E5, Certified Nursing Assistants) were smiling in the picture thinking they (E4 and E5) were funny . On 4/11/16 at 12:09 PM, E7 (Licensed Practical Nurse) that on 12/11/15 at approximately 7:00 PM, (R2) become upset after a (E21, former Certified Nursing Assistant) attempted to give (R2) a shower. E7 stated, (R2) was hysterical. (R2) was trying to kick (E21) out of the room. (R2) thought that (E21) was one of the CNA's (Certified Nursing Assistants) that was wearing (R2's) wigs (on 12/10/15). I (E7) talked to (R2) and calmed (R2) down and then (R2) allowed (E21) to care for (R2). I (E7) went and told (E6) what (R2) had told me and (E6) said 'Wow it really happened.' (E6) said to me (E7) that (E6) had seen a picture of (E4 and E5) last night (12/10/15) posted on a (Social Media Picture Website) and (E4 and E5) were wearing wigs .(R2) continued talking about this for a couple weeks. (R2) would become upset about something, but it seemed that the root of the problem always went back to (E4 and E5) wearing (R2)'s wigs. (R2) was extremely upset. (R2) felt degraded and (R2) felt that (E4 and E5) were making fun of and laughing at (R2). R2's written interview dated 12/16/15 and signed by (E8) and (E15, Social Service Director) documents the following: Two girls got real fresh with me the other night. They had my wig in the bathroom and they were posing in the mirror with it on. One was overweight, wearing all black and the other was small. She had black hair and was working the next night. Everything they said was hurtful. I don't think I went to supper. I had ice cream as a snack. The small one was really brazen and paraded around my bed, she grabbed the wig and I asked her to put it on the stand but she went into the bathroom and was posing in the mirror. R2 then denied spilling anything on R2's wig and stated, They were laughing a lot. They were dancing around with my wig on. Making fun of me. Why are you asking me so many questions. You don't care. You don't care! I didn't spill anything on my wig, they were making fun of me! On 4/11/16 at 12:05 PM, R2 was lying in R2's bed. R2's hair was extremely thin and disheveled exposing several areas of R2 ' s scalp. R2's wigs were located and neatly kept on a shelf next to R2's bed. R2 stated, I (R2) do not want to repeat it. I prefer them (E4 and E5) not take care of me ever again. They were very . (R2 unable to finish statement) when asked about the 12/10/15 incident involving E4 and E5. R2 appeared very withdrawn and avoided eye contact continually staring at the floor. R2 immediately changed the subject of the conversation and stated that R2 was waiting for a meal tray. Upon further discussion and subsequent mention of the 12/10/15 incident, R2 stated, I (R2) hate this place. When R2 was asked how E4 and E5 (Certified Nursing Assistants) made R2 feel when E4 and E5 were wearing R2's wigs on 12/10/15, R2 again stared at the floor and avoided eye contact, sat in silence for approximately one minute and with a flat affect did not answer the question and stated, You can go anytime now. R2's Social Service notes dated 11/3/15 - 2/1/16 have no documentation of any follow up to the incident with R2 and E9. On 4/14/16 at 12:30 p.m., E15, Social Service Director, stated, I do not feel that the 12/10/15 incident involving (R2) is a dignity issue because nothing was proven, but if any type of abuse was proven, I would do follow up. 2. R24's Initial Incident Report dated 1/15/16 documents that an abuse investigation was initiated on 1/15/16 regarding an allegation of an inappropriate comment made on 1/13/16 to R24 by E9 (Former Certified Nursing Assistant). E10 ' s (former Certified Nursing Assistant) written statement dated 1/13/16 at 8:30 PM documents the following: While myself (E10) and (E9) were in (R24)'s room cleaning (R24) up for bed, (E9) leaned (E9)'s head around to look at (R24) and said, 'Am I (E9) getting you riled up?' After (E9) left the room, (R24) stated (to E10) that (R24) is very uncomfortable with (E9) working with (R24) because of what (E9) says and (E9) touches (R24). On 4/6/16 at 1:10 p.m., E10 verified the above written statement and stated, Sometimes when you're wiping a male in that area, blood begins to flow and they can't help it (getting an erection). E10 indicated that R24 began to get an erection when E9 was cleaning R24's peri-anal area. E10 then stated, After it (incident) occurred, I (E10) called the (E11, Licensed Practical Nurse) into (R24)'s room .When (E11) was in the room on 1/13/16, I told (E11) what I (E10) had witnessed. (E11) asked (R24) how (R24) felt and (R24) said that (R24) didn't want (E9) back in the room at all. E10 then stated that E10 felt E9's comment was indeed, Abusive in nature because the way (E9) said it and the look on (E9)'s face. It was degrading to (R24). E12 ' s (Licensed Practical Nurse) written statement dated 1/15/16 documents the following: On 1/14/16, (R24) was sitting by the nurse's station and stated that (E9) was inappropriate with (R24) again last night. (E12) asked (R24) what happened and (R24) said (R24) was being cleaned up by (E9, Former Certified Nursing Assistant) and (E10, Former Certified Nursing Assistant) was assisting (E9) and (E10) was standing by (R24) as (R24) was telling (E12) that when (E9) was wiping (R24), (E9) asked (R24) if that felt good or excited (R24) (I (E12) couldn't remember which term) but (R24) stated it made (R24) feel uncomfortable . On 4/6/16 at 12:20 PM, E12 verified the above written statement. On 4/7/16 at 9:52 AM, E12 stated, There was one other occasion when (R24) mentioned that (E9) had made (R24) feel uncomfortable. It was about a week before (R24) told (E12) about the comment that (E9) made on 1/13/16. (R24) said that (E9) rubbed (R24) ' s back and it made (R24) feel uncomfortable. (E12) asked (R24) why and (R24) said (R24) had (R24)'s shirt off at the time (E9) started rubbing (R24) and (R24) didn't want (E9) back in (R24)'s room .I (E12) can see why people felt uncomfortable. I (E12) even felt uncomfortable with (E9) . At this same date and time, E12 stated, (R24) is pretty easy going. It was out of character for (R24) to complain about someone. E12 then stated that R24 looked shocked when R24 told E12 about the 1/13/16 incident and, (R24) was upset. (R24) may have been trying to mask it because (R24) was in the Army and is not an overly emotional person. If it happened to me (E12) or my parents, I (E12) would be really upset. (R24) possibly could be humiliated or embarrassed from a comment like that. E11's (Licensed Practical Nurse), undated written statement documents the following: On 1/14/16, (R24) stated that (E9) made an inappropriate comment about getting (R24) riled up while (E9) was cleaning (R24)'s backside. (R24) stated that (R24) was uncomfortable with (E9) giving (R24) cares. On 4/6/16 at 12:15 p.m., E11 stated that R24 told E11 that R24 was uncomfortable with E9 providing care to R24. On 4/6/16 at 11:45 a.m., R24 stated that E9 (Former Certified Nursing Assistant) made a remark to R24 on 1/13/16 that, Made me (R24) very uncomfortable. R24 then stated that E9 would, Rub (E9) ' s hands on my shoulders and it made me (R24) feel uncomfortable. It takes a lot to make me (R24) feel very uncomfortable. If a man did that to a woman, then he would be in big trouble . I (R24) did not want (E9) touching me like (E9) was. It was more inappropriate than friendly. I (R24) let it go by for a while, a few weeks, before I (R24) said anything. On 4/7/16 at 11:45 a.m., R24 stated that when E9 touched and rubbed R24's shoulders, it, Creeped me (R24) out. I (R24) do not like (E9). R24 then stated that the comment E9 made to R24 on 1/13/16, Surprised me (R24). I (R24) was uncomfortable and upset and wanted it addressed. R24 then stated that R24 prefers to no longer discuss the 1/13/16 incident. On 4/6/16 at 2:50 PM, E8 (Assistant Director of Nursing/Acting Abuse Coordinator) stated, (E12) stated that (R24) had expressed feelings that (E9) made comments that made (R24) feel uncomfortable. (E10) was in the room at the time and witnessed the comment .They (the staff) thought it was inappropriate .It's not right . On 4/7/16 at 11:04 AM, E8 stated that something was brought to E8's attention approximately a week to a week and a half before the 1/13/16 incident involving R24 and E9 by E12. E8 stated that R24 said R24 was uncomfortable after E9 gave R24 a back rub. E8 then stated, I think it (E9's comment to R24 on 1/13/16) was inappropriate . E9's signed Performance Correction Notice dated 1/20/16 documents the following: You made an inappropriate comment to a resident while caring for him. The resident was in a compromising position, as you were providing personal care to his private area. You stated to the resident while cleansing him 'does this get you riled up?' This is inappropriate and made the resident feel uncomfortable. While this may not constitute direct abuse, this is considered borderline both physically and verbally. The resident is not confused and is a reliable source. This is a violation of the harassment policy as well. Your employment at (the facility) is terminated. R24's Social Service notes dated 12/28/15 - 3/24/16 have no documentation of any follow up to the incident with R24 and E9. On 4/14/16 at 12:30 p.m., E15, Social Service Director, stated E15 did not follow up with R24 after the 1/5/16 and 1/13/16 incidents involving R24 and E9 because, I (E15)didn't see any reason to. E15 then stated, I (E15) think it is inappropriate. If (R24) were bothered by it, then it may be a dignity issue.

Based on observation, record review and interview staff failed to adequately supervise a resident with a hot beverage. This failure resulted in R1 sustaining thermal burns to both thighs. R1 is one of three residents reviewed for injuries in a sample of three. Findings include: R1's Physician order [REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] is coded " moderately impaired vision- not able to see newspaper headlines but can identify objects". R1's eating skills are coded "extensive (staff) assistance required". R1's cognitive patterns are scored "03-impaired". R1's Incident Report dated 12/3/13 at 11:35 AM states" ...(R1) spilled coffee into lap at lunch...sent to the E.R. (emergency room )...". On 12/13/13 at 10:10 AM, E6 (CNA) stated, " (CNA) yelled at me '(R1)'s been burnt with hot coffee' so I helped put (R1) in bed...(We) took (R1)'s pants off and I saw both of (R1)'s inner thighs were bright red. I knew it was bad, so I left the room and went and got the ADON right away". On 12/13/13 at 10:00 AM, E5 (LPN) stated, "I was (R1)'s nurse the day (R1) got burned by the hot coffee...The ADON called me and told me to get to (R1)'s room, that (R1) had been burned...When I got there (CNAs) had taken (R1)'s pants off . (R1)'s entire inner thighs were bright red... (R1) was crying and saying 'It burns,it burns'...I stayed with (R1) until the ambulance came and took (R1) to the hospital... On 12/12/13 at 2:25 PM, E2 (Director of Nurses) stated," from my investigation into the incident with (R1) on December third, we have concluded that the CNA wheeled (R1) into the Sunshine Dining Room for lunch and placed a cup of hot coffee on the table in front of (R1) and left the room. (CNA) was terminated for leaving a cup of hot coffee with a confused resident... if (CNA) hadn't left that hot coffee with (R1), (R1) wouldn't have gotten those burns". On 12/12/13 at 11:10 AM, E3 (Dietary Service Manager) stated, " I checked the temperature of the coffee that was served that day, it was 174 degrees...". On 12/13/13 at 9:45 AM, E4 (Registered Nurse) was observed performing a treatment to R1's thighs. Both inner thighs from just below the peri area to the knees are bright red with multiple large open areas with necrotic tissue scattered through out, hanging. Wound bed is beefy red. Yellow drainage noted on removed bandages. Despite being medicated with a narcotic analgesic, one hour prior to the treatment, R1 yelled out during the entire treatment. R1's emergency room report dated 12/3/13 states "Clinical Impression: Second degree burns of thighs".