Every finding on record at Glasgow State Nursing Facility

Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety, which had the potential to affect 68 of the facility's 68 residents who consumed food from the kitchen.The findings include: 1). Review of the facility policy titled, Refrigerated Storage, effective 07/11/2024, revealed all foods were to be properly wrapped and/or stored in sealed containers and dated and labeled. Observation on 08/20/2025 at 11:25 AM, revealed signage posted on the freezer door which stated, Label and date all food that has been opened with 2 dates. The 1st date is the day it was opened. The 2nd is 7 days after. Continued observation at 11:30 AM, of Freezer 1 revealed a bag of chicken nuggets, a bag of fish sticks, a bag of soup, and (2) pound cakes, all stored out of their original containers that were not labeled or dated. Further observation at 11:30 AM, revealed a box of dinner rolls in the original box with the flaps partially closed; however, with the plastic packaging inside the box not covered. In interview with the Dietary Manager (DM), on 08/20/2025 at 11:50 AM, he stated the items in the freezer should have been labeled and dated. He stated staff knew those procedures were required, but worked at such a high volume. The DM said staff might have just forgotten; however, that was not excuse for the failure to follow the policy. He reported if staff did not follow the necessary guidelines for food storage and safety residents could be served food that was freezer burnt and which had the potential for cross-contamination. The DM further stated that was not acceptable. In interview on 08/21/2025 at 1:45 PM, [NAME] 2 stated the process of returning items to the freezer after opening and removing the food item from its original container was to place the remaining items in a Ziploc bag, label and date it using two dates. She said if the food item's original container was still available, then the Ziploc bag could be put in it and placed in freezer; if it was not available then the Ziploc bag could be placed in the freezer. [NAME] 2 reported it was the responsibility of whoever was using the food item to ensure it was appropriately labeled, dated, and stored in the freezer. She further stated if a food item was not labeled correctly, it potentially cause the food to be contaminated or frostbitten and might make someone sick. [NAME] 2 additionally said, sometimes people just don't do what they should. In interview on 08/21/2025 at 1:55 PM, [NAME] 3 stated the process of returning items to freezer was to place the food items in a zip lock container, label it and put 2 dates on it, before placing it in the freezer. She reported if the food item(s) were not dated, that could potentially make someone sick. In interview on 08/21/2025 at 3:47 PM, the Administrator stated her expectations was for dietary staff items to be dated as required. In interview on 08/21/2025 at 3:52 PM, the Director of Nursing (DON) stated it was her expectation for kitchen staff to make sure food was labeled and dated (as per the facility's policy). 2). Review of the facility policy titled, Employee Sanitary Practices, effective 08/25/2010, revealed all employees were to wear hairnets or restraints, clean attire and clean shoes per facility policy. Observation on 08/20/2025 at 11:30 AM, revealed [NAME] 1 to have uncontained hair in the back neckline area above the ears (approximately two inches across back and approximately one inch bilaterally), and uncovered bangs (approximately one- and one-half inches uncovered across her forehead). In interview with [NAME] 1, on 08/20/2025 at 11:33 AM, she stated she forgot to put on the other net and knew better. She additionally stated she had hair halfway down her back and normally wore two hair nets to ensure all her hair was covered. Observation on 08/20/2025 at 11:35 AM, revealed the Food Service Worker (FSW) had uncovered facial hair (an exposed beard) under his chin (approximately two inches onto his neck). Per observation, FSW also had other uncovered facial hair along the bilateral jaw lines (approximately one inch width). In interview with FSW, on 08/20/2025 at 11:36 AM, he stated beard covers were available for use. He further stated he wondered if he should be wearing one, and would use one from then on. In an interview on 08/21/2025 at 1:55 PM, [NAME] 3 stated hairnets were to be worn so staffs' hair did not get in the residents' food and to protect the patient. In continued interview on 08/21/2025 at 3:47 PM, the Administrator stated her expectations for the kitchen staff included that everyone wear hair nets and beard coverings, if they had a beard as required. She stated potential outcomes if staff did not follow the facility's policy included there being outdated food, infection control issues, and sanitation type things occurring to residents. In continued interview on 08/21/2025 at 3:52 PM, the DON stated it was also her expectation for kitchen staff to wear hairnets in the kitchen. She further stated potential outcomes of kitchen staff not following the facility's policy included it's not sanitary, hair could be in food, food might go bad, residents could get sick.

Based on interview, record review and review of facility's policy, the facility failed to implement the care plan for one of nine sampled residents (Resident #1) R1. The facility assessed R1 as a high risk for wandering and developed a care plan with interventions that addressed that behavior. The facility failed to ensure the care plan interventions were implemented. On 06/24/2024 at 6:09 AM, R1 exited Pod 2 (where he resided), a secured unit, behind a kitchen staff member, who did not ensure the door was secured after going through the doors. A Housekeeper passed R1 in the hall; the Housekeeper failed to intervene. R1 proceeded to the front lobby where the Security Guard was stationed and also failed to intervene when R1 went out the front door. A Registered Nurse (RN) on her way to work, observed R1 walking on the sidewalk near the end of the street, and notified the facility at 6:20 AM of that information. R1 was approximately 0.6 miles from the facility when the RN observed him. R1 exited the front door at 6:09 AM and was returned to the facility at 6:31 AM. The facility's failure to have an effective system in place to ensure each resident's care plan interventions were implemented to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 07/08/2024 and was determined to exist on 06/24/2024 in the area of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656. The facility was notified of the Immediate Jeopardy on 07/08/2024. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 07/10/2024, alleging removal of the IJ on 06/25/2024. An Extended Survey was initiated on 07/10/2024, and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on 07/10/2024. The SSA validated the immediacy of the IJ had been removed on 06/25/2024, as alleged. Therefore, the IJ was determined to be Past IJ. Further the SSA determined the facility was in substantial compliance on 07/02/2024. The findings include: Review of the facility's policy titled, MDS 3.0 Assessment: Nursing Care Plans, dated 01/31/2020, revealed each resident was to have an individualized interdisciplinary care plan based upon his or her immediate needs and individual preferences when appropriate. Continued review revealed successful implementation of the care plan involved three closely related activities: communicating the care plan; administering the care; and coordinating all patient (resident) care. Review further revealed all direct care staff were accountable for complying with all interventions outlined in the resident's plan of care. Review of the closed record, Face Sheet and History and Physical, dated 03/25/2024 for R1 revealed the facility admitted the resident on 03/14/2023, with the following diagnoses: polysubstance abuse disorder, chronic schizophrenia, and neurocognitive disorder. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 05/07/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eight out of 15. This score indicated R1 was moderately cognitively impaired. Review of the facility's,Wander Risk Assessment, dated 04/22/2024 for R1, completed by the Director of Nursing (DON), revealed a score of thirteen (13) which indicated the resident was at high risk for wandering and wander risk precautions were indicated. Review of R1's Comprehensive Care Plan, dated 03/20/2023, revealed the facility care planned the resident as at high risk for wandering. Per review of the care plan, the interventions included: redirecting R1 away from the door and back to his room; ensure all doors were closed securely when entering or exiting the pod (unit); and, observe for the behavior of wandering and redirect as needed. Continued review of the care plan revealed the interventions additionally included: if the resident had been identified as high/moderate wander risk notify all staff to pay attention to R1 and implement increased monitoring utilizing the Increased Monitoring Log as needed (PRN). Further review revealed the goal noted R1 was to remain safely engaged in activity-focused care to decrease wandering. Additional review revealed an intervention dated 05/09/2024, for R1 to be on close observation (in staff's line of sight at all times) from 9:00 PM to 7:00 AM. The incident occurred at 6:09 AM. In an interview with the Security Guard on 07/03/2024 at 9:30 AM, he stated he had never had contact with any residents in the facility, but had been trained on the elopement binders. The Security Guard stated he looked up and saw R1 leaving out the front door wearing a gray shirt. He stated R1 did not say anything to him and just left out the front door. The Security Guard stated he thought R1 was a staff member. He stated he was made aware a resident was missing when a nurse came to the lobby and asked him if he had seen anyone. He stated he told the nurse someone had gone out the front door. In interview on 07/03/2024 at 12:38 PM, the Dietary Aide (who R1 followed out the pod door on 06/24/2024) stated when he exited the pod on 06/24/2024, he had not ensured the door was closed in his hurry to get back to the kitchen. The Dietary Aide stated he should not have left the area until the doors had been secured. He stated he had not seen R1 exit through the door after him, and only learned of a missing resident when someone paged it overhead. The Dietary Aide stated the DON came to the kitchen that day and did a quick in-service with dietary staff. In interview on 07/03/2024 at 12:46 PM, Nurse Aide State Registered #1 (NASR1) stated R1 had been care planned as a high wander risk with interventions and that information was in the facility's Resident ID (Identification) Binder. She stated R1 typically stayed in his room during the night, but sometimes sat in a chair by his room door. In interview on 07/08/2024 at 2:51 PM, NASR6 stated on R1's care plan it said he was a high wander risk, but she had not observed the resident wandering on the unit. She stated R1 had been on close observation from 7:00 AM until 9:00 PM prior to him getting out the pod doors. However, he was not on close observation at the time of exiting the pod. [NAME] 6 said close observation meant the resident was to be in their sight at all times. In interview on 07/05/2024 at 8:58 AM, the MDS Coordinator stated residents' care plans were printed with the annual or a significant change MDS Assessments. She stated the care plans were in a binder at each nurses' station and she updated the printed care plans as changes occurred. The MDS Coordinator further stated interventions had been in place for R1 and staff knew to make sure the pod doors were closed before leaving the area. In interview on 07/10/2024 at 1:42 PM, the Director of Nursing (DON) stated her expectations were for residents' care plans to be implemented and followed as required. She stated staff were aware they were not to leave the pod area until the doors closed. The DON stated she expected whoever was working the front desk to be observing the facility's security camera monitor. She stated a policy revision had been completed and all staff had been re-educated on the policy. The DON stated dietary staff were not aware of what was on a resident's care plan, but all staff had been trained on ensuring the pod doors were closed before leaving the area. In interview on 07/10/2024 at 2:14 PM, the Facility Director stated her expectations were for staff to ensure resident safety. She stated R1 was care planned as a wander risk and she expected the resident's care plan interventions to be followed. The DON stated if residents were outside of the pod area without staff, then staff were to always stay with the resident, keep them in sight, and call for assistance.

Based on observation, interview, record review, facility document and policy review, and Google Maps, the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of nine (9) sampled residents assessed for high elopement risk Resident #1 (R1). The facility assessed R1 as being at risk for wandering and care planned the resident for being a wandering risk. R1's care plan interventions included: ensuring all doors were closed securely when entering or exiting the resident's pod (unit), redirecting the resident away from doors, and observing for wandering behavior with redirection as needed. However, on 06/24/2024, facility staff failed to follow the resident's care plan interventions and allowed R1, who ambulated independently, to exit the facility without staff's knowledge at 6:09 AM. R1 was located by a staff person, walking on the sidewalk down the street, 0.6 miles from the facility. The staff notified the facility at 6:20 AM. The facility's failure to have an effective system to ensure each resident received adequate supervision and monitoring to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 07/08/2024 and was determined to exist on 06/24/2024 in the area of 42 CFR 483.25 Quality of Care, F 689 at a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was also identified at 42 CFR 483.25 Quality of Care, F689. The facility was notified of the Immediate Jeopardy on 07/08/2024. An acceptable Immediate Jeopardy (IJ) Removal Plan was received on 07/10/2024, alleging removal of the IJ on 06/25/2024. An Extended Survey was initiated on 07/10/2024, and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on 07/10/2024, and determined the deficient practice was corrected as alleged on 06/25/2024. Therefore, the IJ was determined to be Past IJ. Further the SSA determined the facility was in substantial compliance on 07/02/2024. The findings include: Review of the facility's policy titled, Safe Environment, dated 06/14/2023, revealed the purpose of the policy was to describe the (facility's) responsibilities related to the protection of its individuals. Continued review revealed elopement, was an event in which an individual had not been accounted for when expected to be present or had left the facility grounds without permission. Review of the facility's policy titled, Wander Risk Precautions, dated 08/29/2016 and revised on 06/24/2024 (the day of R1's elopement), revealed it was the facility's policy to identify residents who walked or wheeled about unrestricted and were at risk to leave the facility unattended without staffs' knowledge. Further review revealed a wander risk assessment was to be completed on all residents at admission, quarterly, and with any significant change. Review of the Face Sheet and History and Physical, dated 03/25/2024, located in the closed medical record, revealed the facility admitted R1 on 03/14/2023. R1's diagnoses included: chronic schizophrenia, neurocognitive disorder, and polysubstance abuse disorder. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 05/07/2024, revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of eight out of 15. This score indicated the resident had moderate cognitive impairment. Review of the facility's Wander Risk Assessment, dated 04/22/2024, completed by the Director of Nursing (DON) for R1 revealed a score of thirteen (13) which indicated the resident was a high risk for wandering and wander risk precautions were indicated. R1 was not observed or interviewed as he/she had been transferred to a State Psychiatric Hospital on 06/25/2024. Observation on 07/05/2024 at 9:50 AM, of Pod 2 (a men's only unit) revealed the resident's room was located directly across from the nurse's station and approximately 21 steps to the exit door. Continued observation revealed the pod had automatic doors and could only be accessed using a facility-designated badge. Further observation revealed both of the pod doors opened once a badge was used and the open-door button was pushed. Review of the facility's investigation dated 06/24/2024, revealed on that date at 6:09 AM, R1 exited Pod 2 a secured unit, behind a kitchen staff member, who had not ensured the pod door was secured. Per review, a housekeeper passed R1 in the hall and asked where he was going, and he gave no response. Continued review revealed the housekeeper failed to intervene, and R1 proceeded to the front lobby where security personnel further failed to intervene when R1 went out the front door. Review of the facility's investigation also revealed a Registered Nurse (RN) on her way to work, observed R1 walking on the sidewalk near the end of the street the facility was located near a car dealership lot. Further review revealed R1 was approximately 0.6 miles from the facility. RN1 notified the facility at 6:20 AM of the resident's location. R1 exited the front door at 6:09 AM and was returned to the facility at 6:31 AM with no injuries noted. The SSA Surveyor drove to the location where RN1 first saw R1, (the route was also verified by Google Maps) was noted to be 0.6 miles from the facility. Google Maps indicated was a 13 minute walk. Review of the Underground weather website revealed the air temperature (temp) on 06/24/2024 at 6:00 AM was 64 degrees Fahrenheit (F). Review of the facility's video camera clip 1 revealed on 06/24/2024 at 6:07 AM, a dietary aide entered the secured unit (R1's pod) to deliver clean water pitchers. Continued review of the video camera clip 1 revealed at 6:09 AM, the dietary aide exited the unit and failed to wait for the door to secure. R1 stopped the door from closing all the way, waited about three seconds and opened the door and exited the unit in a rushed manner. Additional review revealed R1 had been wearing a long-sleeved gray shirt, blue pants, and tennis shoes. Review of the facility's video camera clip two (2) revealed on 06/24/2024 at 6:09 AM, R1 could be observed entering the facility's lobby area and exiting out the front door. Further review of video camera clip 2 revealed a security guard sitting at the front desk, who did not intervene and allowed R1 to exit the facility. Review of the facility's video camera clip three (3) revealed on 06/24/2024 at 6:31 AM, R1 was returned to the facility accompanied by 2 staff members. In interview with the Security Guard on 07/03/2024 at 9:30 AM, he stated he had been employed as the facility's night shift security guard for approximately four months. He stated his primary duties were to stay at the desk and answer the phones and watch the door. The Security Guard stated he received training during orientation, and had been made aware of the elopement binders. During the interview, he stated he had never had contact with any of the residents living in the facility, and had not done rounds on the units. He stated he did not know what side of the building R1 had came from and he looked up and saw the resident leaving out the front door. The Security Guard stated R1 had on a gray shirt when he exited the facility and that was all he could recall. He stated R1 had not said anything and just left out the front door. The Security Guard stated he thought the person (R1) leaving was a staff member, and anyone could get out the doors, but he had to let people in. He stated he was made aware a resident was missing when a nurse, whose name he did not know, came to the lobby and asked him if he had seen anyone. He stated he told the nurse someone had left out the front door. The Security Guard stated he was terminated that same day for letting R1 out the front door. In interview with the dishwasher (dietary staff personnel) on 07/03/2024 at 12:38 PM, he stated he had taken the bus carts to Pod 2, and when he exited the pod he did not ensure the door was latched as he was in a hurry to get back to the kitchen as tray line was starting. He stated he did not see R1 exit through the door; however, he should have ensured the door was closed before leaving the pod area. The dishwasher stated he only learned of a resident missing when someone paged that information overhead. He further stated the DON did a inservice with dietary staff that same day (06/24/2024). During an interview with Nurse Aide State Registered #1 (NASR1) on 07/03/2024 at 12:46 PM, she stated R1 typically stayed in his room during the night and sometimes he would sit in a chair by his room door. She stated R1 was independent with ambulation. NASR1 stated she and NASR2 were doing AM (morning) care, getting people up, and making beds when she saw R1 sitting in a chair by his door. She stated around 6:20 AM, the nurse had them do a head count and it was discovered R1 was gone. The [NAME] stated she left the pod to look for R1, and when in the lobby area she asked the security guard if he had seen a man. She said the security guard told her a man had gone out the front door. She stated she and Administrative (Admin1) Staff 1 went out the front door and checked the grounds; however, they did not see R1. In interview with RN1 on 07/03/2024 at 2:26 PM, she stated she was driving to work on 06/24/2024, and when she turned onto a side street she saw a man walking and realized it was R1. She stated she immediately called the facility and when she checked the time her phone was at 6:20 AM. RN1 stated she turned around and pulled into the parking lot of a closed business and shouted at R1 to get his attention, who was near the bottom of a hill near a car dealership. She stated she got R1's attention and started walking towards him and he started walking towards her. The RN stated she and R1 waited in the parking lot for other staff to arrive. She further stated R1 never said a word and she did not ask where he was going or what he had been doing. In interview with Licensed Practical Nurse #1 (LPN1) on 07/03/2024 at 3:00 PM, he stated he had been the nurse on duty on the day R1 exited the facility (06/24/2024). He stated R1 had been quiet with no concerns throughout the night. The LPN stated at 6:10 AM, he was in the kitchenette getting coffee ready for the residents when housekeeping staff informed him she had seen a resident in the hall. He stated he immediately left the pod and looked on both the halls leaving Pod 2 and he had not seen any residents. LPN1 stated he returned to the pod and had NASR1 and NASR2 do a head count of residents. Per interview with LPN1, NASR1 informed him R1 was not on the unit, so he notified RN2. RN2 paged the missing resident over the intercom. He stated he took the call from RN 1 stating she had seen R1 walking down the street on the sidewalk and was with the resident at a closed business down the street. LPN1 stated he informed RN2 of that information, and he (LPN1) and the Staff Development Coordinator (SDC) got in his car and went to pick R 1 up. He further stated R1 got in the car without incident, and when he asked R1 if he was okay the resident replied he had just wanted to go out for a walk. During an interview with the SDC on 07/03/2024 at 3:40 PM, she stated she had arrived to work and saw a staff member in the parking lot who told her R1 was missing. She stated she entered the facility's side door and went to the front desk where RN1 was on the phone with law enforcement saying R1 had been located. The SDC stated she and LPN1 drove down the street to pick R1 up, and when she asked the resident if he was okay he started to cry a little and said he wanted to go home. She stated R1 got in the car with no problem, walked in the facility and to his pod and sat down. The SDC stated during orientation the elopement binders were shown to new staff and discussed. She further stated all staff, to include contract staff, received the orientation and training on the elopement binders. In interview with the Housekeeper on 07/05/2024 at 10:19 AM, she stated she had been working on 06/24/2024, when R1 left the facility. She stated she had been on Pod 2 around 6:00 AM and saw R1 sitting in a chair outside his room door. The Housekeeper stated residents were not supposed to be in the hall without a staff member. She stated she had been walking down the hall when R1, almost running, passed her. The Housekeeper stated housekeeping staff were not to physically touch residents, and were to report concerns to the nurse. The Housekeeper stated she asked R1 where he was going, but he just kept walking fast. She said she knew R1 was a resident; however, she did not known his name. The Housekeeper stated she went to Pod 2 and told the nurse she had seen a resident in the hall and the nurse stopped what he was doing and went and checked the hall. She further stated she then returned to what she had been doing, but learned the next day, from the DON, she should have kept R1 in her sight. During interview with RN2 on 07/05/2024 at 10:55 AM, he stated he had arrived to work at 5:45 AM, the morning of R1's elopement, and had been in the office working when he heard fast-paced foot steps. He stated NASR6 had been in the hall and told him R1 was missing. The RN stated he went to the front desk, reviewed the Resident Identification (ID) Binder and called 911. He stated RN1 called and said she was with R1 in a parking lot, and he (RN2) had LPN1 and the SDC go pick the resident up. During interview with the Facility Services Supervisor (Risk Manager) on 07/05/2024 at 1:24 PM, she stated she was responsible for the security staff members. She stated the Security Guard present when R1 exited the facility, had been working at the facility about six months. The Facility Services Supervisor stated she was unsure what qualifications the Security Guard had when employed and would have to look at his file to see. She stated all staff were made aware of the Resident Identifier Reports binder when hired, and the SDC provided orientation for the new hires. The Facility Services Supervisor further stated the Security Guard said he thought the man (R1) was an employee. In addition, she stated the Security Guard had been terminated on 06/24/2024, for letting a resident leave out the facility's front door. In interview with NASR6 on 07/08/2024 at 2:51 PM, she stated she had been working the morning R1 left the facility. She stated housekeeping had cleaned the beds on the unit and she and NASR1 were getting residents up and making their beds. NASR6 stated R1 seldom came out of his room, but when he did he sat in a chair by his door. She stated she had been making a bed when [NAME] 1 told her they needed to do a headcount of residents. The [NAME] said she checked rooms and closets and NASR1 reported R1 was not on the unit. In interview with the DON on 07/10/2024 at 1:42 PM, she stated she had been on her way to the facility on [DATE], when she received a phone call informing her R1 had eloped. She stated she called the Facility Director, and facility staff followed protocol in locating a missing resident. The DON stated the facility's investigation showed the dietary aide failed to ensure the Pod 2 door was secure before walking away, which allowed R1 to exit the pod. She stated when R1 entered the lobby the Security Guard, who should have been watching the camera monitors, allowed the resident to exit the facility thinking R1 was a staff member. The DON stated the Security Guard was terminated and she sent paperwork in to initiate disciplinary action for the dietary aide which was pending due to the State's process regarding disciplinary actions. She stated she did not think there were potential adverse outcomes for R1 as he knew to stay on the sidewalk. The DON stated R1 made a calculated decision and knew what he was doing. During interview with the Facility Director on 07/10/2024 at 2:14 PM, she stated the DON had made her aware of R1 exiting the facility. She stated R1 was returned to the facility when she arrived. The Facility Director stated the facility followed its policy and protocol for Missing Resident. She stated the facility initiated an investigation and it was determined the dietary aide's and Security Guard's failure to intervene, which allowed R1 to leave out the front door, were the root cause of the event. The Facility Director stated staff were aware of the elopement binders on each Pod and lobby area. The Facility Director stated if residents were outside of the pod without staff then staff were to stay with the resident at all times, keep them in sight, and call for assistance. She stated the facility had an AdHoc (unplanned meeting for a special purpose) Quality Assurance Performance Improvement (QAPI) meeting with the Medical Director, after R1's elopement, to discuss the incident and put a plan in place to complete education and training and develop tools for monitoring. She stated her expectations were for staff to ensure residents' safety.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for two (2) of six (6) sampled residents, Resident #45 and Resident #39. 1. On 11/23/2023 at 3:50 PM, it was noted Certified Nurse Aide (CNA) #4 abused Resident #45. The facility investigated the incident, and CNA #4 was suspended pending the outcome of the investigation. Resident #45 was noted to have behaviors the day of the incident, and tried to get up into other people's personal space. CNA #4 pushed Resident #45's chair under the table in the common area of the Pod which resulted in the resident sustaining a skin tear. It was also reported the CNA hit Resident #45's arm twice and poked the resident with her index finger over and over just beneath his/her shoulder. 2. Resident #39 was involved in a resident to resident altercation on 04/27/2023 at 6:30 PM. Resident #39 was assessed as a wanderer, who wandered into other residents' rooms. On 04/27/2023, Resident #39 wandered into the room of Resident #47, who repeatedly told Resident #39 to leave and get out of his/her room. Resident #39 did not leave Resident #47's room, so he/she got up and grabbed Resident #39 by the shirt and hit the resident on the ear and slapped his/her face. Resident #39 was observed by staff walking down the hallway, with blood dripping from his/her left ear and blood on his/her face. (Cross Reference F656) The findings include: Review of the facility policy titled, Safe Environment, dated 06/2023 revealed the purpose of the policy was related to the protections of individuals who were served by the Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID). Per review, managing incidents through Risk Management included: the components of effective abuse protection; incident investigation, tracking and trending of incidents; incident data analysis; and implementing effective actions to protect individuals served from harm. Continued review revealed Risk Management was a component of a larger Quality Improvement program through which the emphasis was on improvement of systems and processes through the collection and analysis of data. Review revealed a Systemic Approach to Prevent Abuse/Neglect and was to be integrated into the facility's systems to ensure all individuals served were free from abuse, neglect, exploitation, mistreatment, injuries of unknown origin, peer-to-peer aggression with injury, serious injuries and other harms. Policy review further revealed the facility was responsible for organizing its systems in such a manner as to proactively assure individuals were free from serious and immediate threat to their physical and psychological health and safety. 1. Medical record review revealed the facility admitted Resident #45 on 09/26/2022, with diagnoses which included: major neurocognitive disorder, dementia (Alzheimer's type) and anxiety disorder. Review of the Annual Minimum Data Set (MDS) Assessment, dated 09/19/2023, revealed the facility assessed Resident #45 to have a Brief Interview for Mental Status (BIMS) Score of ninety-nine (99), which indicated the resident had severe cognitive impairment. Review of Resident #45's Behavioral care plan dated 09/28/2022, revealed the facility care planned the resident to have the potential for behaviors related to diagnosis of major neurocognitive disorder, anxiety disorder, depression and insomnia requiring the use of anti-psychotics and anti-depressants. Continued review revealed Resident #45 had a history of wandering away from the facility, answering the facility phone, attempting to help other residents which required redirection from staff. Per care plan review, Resident #45 had a history of working at a nursing home for forty (40) years, and wanting to take care of others as well as hugging staff. Review further revealed the facility's interventions included intervening as necessary to protect the rights and safety of others; divert his/her attention and remove from a situation; observe him/her for behavior episodes and attempt to determine underlying cause. In addition, review revealed other interventions noted in Resident #45's care plan were to cue, reorient and supervise the resident as needed; observe for him/her invading other people's personal space and redirect as needed. Review of the facility's investigation dated 11/23/2023, revealed an allegation of physical abuse occurred on that day at 3:50 PM involving Resident #45. Review revealed CNA #4 was caring for another resident who was on Close Nurse Observation, when Resident #45 was observed to keep trying to hug other residents and staff and get in their personal space. Per review, CNA #1 and CNA #5 were standing on the Pod area (a long corridor where residents interacted, did activities, and ate their meals) at the time. The investigation noted CNA #4 tried to redirect Resident #45 away from the nurses' station. Continued review revealed CNA #4 told Resident #45 to stop touching her and was witnessed slapping the resident with an open hand on his/her right hand, which made a popping sound. Continued review of the facility investigation dated 11/23/2023, revealed Resident #45 was redirected by CNA #1, CNA #4 and CNA #5 to a table in the common area, where the resident sat down in a chair; however, continued to try to touch others. Per review, revealed CNA #4 was noted to have slapped Resident #45's left upper arm then to push the resident's chair under the table. Per review, CNA #4 got in front of Resident #45's face (approximately six [6] inches away), and took her right index finger and poked the resident's left shoulder/collarbone area five (5) to six (6) times while stating to him/her, Stop touching people when they do not want to be touched. Further review of the facility's investigation, dated 11/23/2023, also revealed Resident #45 reportedly commented to CNA #4 keep your hands off me, and CNA #4 walked away from the resident. Review also revealed Resident #45 told CNA #1 she (CNA #4) hurt my hand, after CNA #4 walked away. In addition, review of the investigation revealed Resident #45 showed CNA #1 and CNA #5 his/her right hand where a skin tear was located. Further review revealed it was noted the CNAs reported the skin tear to Licensed Practical Nurse (LPN) #4 who assessed the injury and applied a bandage to it. Further review revealed it was noted LPN #4 was told by CNA #4, it's from where I pushed the resident's chair under the table. Review of CNA #4's personnel file revealed a criminal background check had been completed as well as the Nurse Abuse Aide Registry as required. Per review, CNA #4's State Certification was current. Further review revealed CNA #4 was hired by the facility on 03/01/2021, and had been educated on abuse and taken a quiz afterwards. Review of the handwritten Facility Sign in Sheet (a document staff log into and out of work on), dated 11/23/2023 for CNA #4 which noted her time in and out for work, revealed the CNA had started work on 11/23/2023 (the day of the incident) at 2:55 AM, and left work that day at 4:00 PM. Continued review revealed CNA #4 was not allowed to return to work during the investigation, and was subsequently terminated after the investigation was completed. Observation, on 12/01/2023 at 12:20 PM, revealed Resident #45 sitting at a table in the common area awaiting lunch, and stood up to greet the State Survey Agency (SSA) Surveyor. In a telephone interview with CNA #4, on 12/06/2023 at 10:03 AM, she stated (on the day of the incident) she had been assigned to monitor her own resident, who Resident #45 kept trying to bother. She stated she advised CNA #1 of what Resident #45 was doing and asked CNA #1 for assistance; however, the CNA kept looking at her phone and eating a cookie, and did not help her. In continued interview CNA #4 denied pushing or slapping Resident #45, and stated she did not poke the resident with her finger. She further stated she had received a call from the police department and had to go there for an interview. The CNA additionally stated she was told by the police officer that no charges would be filed against her. In an interview with CNA #1, on 12/04/2023 at 12:54 PM, she stated the incident involving Resident #45 occurred around 3:50 PM on 11/23/2023. She stated staff had been trying to redirect Resident #45 as he/she wanted to hug everyone. CNA #1 stated she observed CNA #4 slap Resident #45 on his/her left hand with her right hand, and the resident became anxious. She stated she and CNA #5 did not report the allegation of abuse until after CNA #4 left work at 4:00 PM, because they were afraid CNA #4 would retaliate against them. CNA #1 further stated she had been working through an agency at the time, and she was terminated after the incident. In an interview with CNA #5, on 12/06/2023 at 2:24 PM, she stated she had been at the nurses' desk (on the day of the incident) when Resident #45 was touching everybody. The CNA stated staff had been trying to redirect Resident #45; however, she could not recall who took the resident to the table in the common area. She stated Resident #45 had been sitting in a chair where he/she had been trying to move his/her chair closer to another resident. CNA #5 said she attempted to redirect Resident #45, and stated she saw CNA #4 at the table with the resident. The CNA stated she saw CNA #4 punching Resident #45 in his/her left upper arm, and poking the resident with her index finger near his/her collarbone. In continued interview she stated CNA #4 kept talking to Resident #45 and heard the resident say, well you keep your hands off of me. She reported she also heard Resident #45 also say, you hurt my hand, and then saw the skin tear on the resident's hand. CNA #5 stated the skin tear was reported to the nurse; however, the abuse incident was not reported until after CNA #4 had left for the day, which was about about ten minutes after the incident. She stated LPN #3 provided wound care and applied a dressing to the skin tear of Resident #45's hand. In an interview with LPN #3, on 12/04/2023 at 3:31 PM, he stated he was charting at the nurses' station when the alleged allegation of abuse occurred. Per the interview, LPN #3 stated Resident #45 required frequent redirection at times. LPN #3 stated he became aware of the alleged allegation of abuse when CNA #1 and CNA #5 reported the allegation to him, after CNA #4 had left the building. LPN #3 stated the CNAs reported they were afraid that if they said something, they would get into trouble. LPN #3 stated that after he had learned of the situation, he notified the house supervisor. In an interview with the House Supervisor on, 12/04/2023 at 3:45 PM, he stated the day of the incident involving Resident #45, he had received a call from LPN #3 reporting the allegation of abuse. He stated he reported the incident to the facility's Risk Manager, and he interviewed both CNA #1 and CNA #2 about the incident. In a interview with the Social Services (SS) Clinician/Investigator, on 12/06/2023 at 8:44 AM, she stated she substantiated the abuse allegation related to the skin tear on Resident #45's hand. The SS Clinician/Investigator was informed about the allegation by the Administrator on Call (AOC) on 11/23/2023 at 5:00 PM. She stated the House Nursing Supervisor had notified the AOC, who in turn called her to initiate the investigation. She stated she started the investigation, which was her first investigation to complete alone since her training. In an interview with the Director of Nursing (DON), on 12/21/2023 at 2:47 PM, she stated Resident #45 received the skin tear to his/her right hand when CNA #4 pushed the chair in which the resident was sitting in, under the table. 2.Medical record review revealed the facility admitted Resident #39 on 02/24/2021, with diagnoses which included dementia secondary to alcoholism, neurocognitive disorder and Bipolar disorder. Review of the Significant Change MDS, dated [DATE], revealed the facility assessed Resident #39 to have a BIMS score of ninety-nine (99), which indicated his/her cognition was severely impaired. Review of Resident #39's care plan, dated 03/01/2021, revealed the facility care planned the resident for wandering with interventions for redirection and to have him/her in close observation at all times. Review of the facility's investigation dated 04/27/2023 at 6:30 PM, revealed Resident #39 was noted to have been wandering on Pod 200, and had wandered into Resident #47's room where he/she was asked to leave. Per review, Resident #39 did not leave Resident #47's room as requested and the other resident got up and grabbed him/her by the shirt. Continued review revealed Resident #47 then punched Resident #39 in the ear and slapped him/her in the face, causing an injury to Resident #39's ear and scratches to his/her face. Review further revealed Resident #39 was transported to the emergency room for evaluation, and upon return to the facility both Residents #39 and #47 were separated and placed on increased supervision. Review of the hospital emergency room (ER) record dated 04/27/2023, revealed Resident #39 was treated for a laceration to the left ear which required three (3) sutures. Continued review of the ER record revealed the ER physician ordered a Computed Tomography (CT) scan of Resident #39's head and cervical spine, with the results being no fractures noted. Per review, Resident #39 was returned to the facility with discharge instructions for follow up with his/her primary care doctor and suture removal in seven (7) to ten (10) days. Further review revealed Resident #39 was prescribed Keflex (an antibiotic) two-hundred fifty milligrams (250 mg) four (4) times a day for seven (7) days. 2(b). Review of the care plans for Resident #47, dated 03/20/2023, revealed the resident was care planned for behaviors as the resident had the potential for being threatening to hurt others and was aggressive toward staff. Continued review revealed interventions included to initiate Close Observation to ensure the resident was closely monitored by staff. CNA #3, in an interview on 12/04/2023 at 4:00 PM, stated it was not unusual for Resident #39 to wander around the facility. The CNA revealed the day of the incident she was making rounds on the residents and Resident #39 came to the nurses desk and she noted the resident was bleeding from his/her left side of his/her face and ear. The resident was provided wound care prior to being transported to the emergency room . In a telephone interview with CNA #8, on 12/08/2023 at 9:43 AM, she stated she saw Resident #39 walking toward her (on the day of the incident) and observed he/she was bleeding from the left ear and left cheek. The CNA stated she asked a resident in the area if they had seen what happened to Resident #39; however, the resident provided no information. She stated she then walked to Resident #47's room and observed the resident had blood on his/her hands. CNA #8 stated when she asked Resident #47 where the blood on his/her hands came from, the resident stated he/she did not know. She stated she then asked Resident #47 again and the resident stated Resident #39 had came into his/her room again. In continued interview the CNA said Resident #47 stated he/she was tired of Resident #39 coming into his/her room, so the resident stated he/she hit Resident #39 in the ear and slapped him/her. CNA #8 further stated she reported her findings to the nurse. In an interview with the Risk Manager, on 12/06/2023 at 9:04 AM, she stated she had completed the investigation for the resident-to-resident altercation between Resident #39 and Resident #47. She further stated after completing the investigation, the facility substantiated her findings. In an interview with RN #3, on 12/09/2023 at 7:04 PM, she stated the facility did room/hall checks every fifteen (15) to thirty (30) minutes and every resident must be seen. RN #3 stated the CNA's documented in the facility's data entry program, and it was the responsibility of the nurse to ensure the checks have been completed as required and documented. She advised there was always staff on the Pod to complete the resident checks, and Resident #39 was always on close observation with a staff person assigned to him/her. She further stated Residents #39 and #47 were now on different Pods. In interview with the Director of Nursing (DON), on 12/06/2023 at 3:02 PM, she stated after the altercation between Residents #39 and #47, both were placed on close observation, which indicated the residents had to be within eyesight of the staff member watching them. She further stated Resident #39 was moved to a different room on another Pod on 06/21/2023, where he/she continued to wander. In interview with the facility's Director, on 12/05/2023 at 4:14 PM, she stated the resident-to-resident allegation was investigated by the Risk Manager who reported her findings to the her. Per the Director, the allegation was substantiated after completion of the investigation.

Based on interview, record review and review of facility's policy it was determined, the facility failed to follow the care plan for one (1) of fifteen (15) residents, Resident #45. On 11/23/2023 at 3:50 PM, Certified Nurse Aide (CNA) #4 abused Resident #45. The incident was investigated by the facility and CNA #4 was suspended pending the outcome of the investigation. On the day of the incident Resident #45 had behaviors and was trying to get up into other people's space. CNA #4 pushed Resident #45's chair under the table with the resident sustaining a skin tear on his/her hand. It was also reported CNA #4 hit Resident #45's arm twice and poked her index finger over and over just beneath the resident's shoulder. Resident #45 was care planned with interventions which included redirecting him/her, and providing diversional activities; however, facility staff failed to implement the resident's interventions. (Cross Reference F600) The findings include: Review of the facility policy titled, MDS 3.0 Assessment: Nursing Care Plans, dated 04/30/2019, revealed each resident was to have an individualized interdisciplinary Care Plan based upon his or her immediate needs and individualized preferences when appropriate. Continued review revealed the care plans were to be implemented with appropriate documentation from each staff member involved in the resident's care. Per review, it was the responsibility of all resident care and service(s) providers to comply with the outlined care plan interventions and monitor the resident's response. Further review revealed the successful implementation of residents' care plans involved communicating the care plan, administering the care and coordinating all patient (resident) care (multidisciplinary). In addition, review revealed each team member was to be aware of all problems identified, with the goals and approaches. Review further revealed in implementation of the care plan, all direct care staff were accountable for complying with all the interventions outlined in the plan of care. Review of the facility policy titled, 1:1 Observation of Residents/Nursing Close Observation/Hall Monitoring, undated, revealed residents were to be monitored by staff to ensure the provision of optimal safety. Continued review revealed residents were to be monitored through nursing observation when exhibiting behaviors, such as wandering behavior, agitated behavior, unsteadiness, self-abusive behavior not assessed to be an immediate danger to self or other behaviors that involved safety issues. Per review, when close observation was needed it required close monitoring of the resident and for him/her to remain within full view of staff at all times. Review of Resident #45's medical record revealed the facility admitted the resident on 09/26/2022, with diagnoses which included major neurocognitive disorder, dementia (Alzheimer's type) and anxiety disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #45 to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident had severe cognitive impairment. Review of Resident #45's behavioral care plan dated 09/28/2022, revealed the facility care planned the resident for potential for behaviors related to diagnoses of major neurocognitive disorder, anxiety disorder, depression and requiring the use of anti-psychotics and anti-depressants. Continued review revealed Resident #45 had a history of wandering away from the facility, answering the facility phone, attempting to help other residents which required redirection from staff. Per review, interventions included: intervening as necessary to protect the rights and safety of others; diverting his/her attention and removing him/her from a situation; observing for behavior episodes and attempting to determine the underlying cause. In addition, review revealed interventions also included: staff to cue, reorient and supervise Resident #45 as needed and observe for him/her invading other people's personal space and redirect the resident as necessary. Review further revealed an intervention added on 10/05/2022, to observe Resident #45 for invading other peoples' personal space and redirect him/her as needed. In addition, on 10/06/2022, an intervention was added to offer Resident #45 a baby doll to meet his/her need to take care of others; and on 11/02/2022, an intervention added to offer diversional activities when he/she was attempting to hug staff. Review of the Certified Nurse Aide (CNA) Care Plan, undated, revealed the interventions noted were to redirect Resident #45 as needed to keep him/her out of others' personal space, and to offer diversional activities. Review of the facility investigation dated 11/23/2023, revealed an allegation of physical abuse occurred that day at 3:50 PM. Review revealed CNA #4 had been caring for a resident on Close Nurse Observation, when she observed Resident #45 keep trying to hug other residents and staff and get in their personal space. Per review, CNA #1 and CNA #5 were standing on the Pod area (a long corridor where residents interacted, did activities, and ate their meals) and observed CNA #4 trying to redirect Resident #45 away from the nurses' station. Continued review revealed staff overheard CNA #4 tell Resident #45 to stop touching her and witnessed the CNA slapping the resident with an open hand on his/her right hand, which made a popping sound. Review revealed Resident #45 was redirected by CNA #1, CNA #4 and CNA #5 to sit in a chair at a table in the common area. Ongoing review revealed however, Resident #45 kept on trying to touch others while sitting in the chair. Review of the investigation also revealed CNA #4 was noted to slap Resident #45's left upper arm then to push the resident's chair in under the table. Further review of the facility's investigation dated 11/23/2023, revealed CNA #4 got close in front of Resident #45's face, and stated to the resident Stop touching people when they do not want to be touched. Continued review revealed CNA #4 then took her right index finger and poked the resident's left shoulder/collarbone area five (5) to six (6) times. Review also revealed Resident #45 reportedly told CNA #4 to keep your hands off me, and CNA #4 then walked away from the resident. Per review, after CNA #4 walked away from Resident #45, the resident told CNA #1 she (CNA #4) hurt my hand, and then showed CNA #1 and CNA#5 his/her right hand where a skin tear was. Additional review revealed the CNAs reported the skin tear on Resident #45's hand to Licensed Practical Nurse (LPN) #3 who assessed and applied a bandage to the injury. Review further revealed LPN #3 was told by CNA #4, it's from where I pushed Resident #45's chair under the table. Review of the police report dated 11/23/2023, revealed the officer's report of his investigation, which noted the investigation was completed by the officer with a closure of the case and no assault charges pressed against CNA #4. In an interview with CNA #1, on 12/04/2023 at 12:54 PM, she stated she witnessed the entire event between Resident #45 and CNA #4, but did not intervene to prevent the abuse of the resident. The CNA reported she was afraid of retaliation by CNA #4 if she intervened. She further stated CNA #4 told her the facility's upper management and she were very close knit. The CNA further stated she was familiar with the care needs of Resident; however, failed to implement the resident's care plan. In interview with LPN #3, on 12/04/2023 at 3:31 PM, he stated he was at the nurses' station and from where he was seated he was unable to see the incident that occurred between CNA #4 and Resident #45. He stated two (2) other CNA's reported the allegation to him after CNA #4 left work for the day. LPN #3 stated he could not hear the activity going on (incident involving CNA #4 allegedly abusing Resident #45) from where he had been sitting behind the nurses desk. He further stated LPNs were responsible for monitoring staff and the care they provided and ensure residents' care plans were implemented. In an interview with the House Nursing Supervisor, on 12/04/2023 at 3:45 PM, he stated he was made aware of the allegation by LPN #3 and he then notified the Administrator on Call (AOC). He stated he made sure CNA #4 had left the building. The Nursing House Supervisor stated during his conversation with LPN #3, he was told CNA #1 and CNA #5 did not report the incident immediately because CNA #4 was tight with the DON and the Assistant Director of Nursing (ADON) and they thought CNA #4 would get them fired. He stated Resident #45's care plan interventions should have been implemented as written. In an interview with CNA #4, on 12/06/2023 at 10:03 AM, she stated the day of the incident with Resident #45, she was assigned to close observation of Resident #43. She stated Resident #45 kept getting into other peoples' personal space, and she attempted to redirect the resident. CNA #4 stated she had asked for help from CNA #1 and CNA #5; however, did not receive assistance from them. The CNA denied pushing, slapping or poking Resident #45 with her finger. CNA #4 stated she had tried to redirect Resident #45; however, had been unable to as she had to keep watch of her assigned resident. In interview with CNA #5, on 12/06/2023 at 2:24 PM, she stated she was at the nurses' station and Resident #45 was touching everybody. She stated staff were trying to redirect Resident #45; however, the resident continued to try to get closer to staff and other residents. CNA #5 stated she was aware of the interventions for Resident #45; however, failed to protect the resident as per the care plan when the incident occurred. In interview with the DON, on 12/21/2023 at 2:47 PM, she stated she expected staff to follow residents' care plans as written. She stated however, the CNA's had not followed Resident #45's care plan interventions. The DON further stated abuse was to be reported immediately and staff should always intervene when seeing a resident being abused. In an interview with the facility's Director, on 12/21/2023 at 3:24 PM, she stated if staff witnessed abuse, she expected them to immediately protect the resident and remove the accused person. She further stated it was also her expectation for staff to follow residents' care plans to prevent potential negative outcomes. The Director stated she did not feel staff had implemented Resident #45's care plan interventions when the incident occurred.

Based on interview, record review and facility policy review it was determined, the facility failed to ensure violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury for two (2) of six (6) sampled residents, Resident #39 and Resident #45. 1. An incident involving Resident #45 occurred on 11/23/2023 at 3:50 PM, when CNA #4 was observed by CNA #1 and CNA #5 to push Resident #45's chair up to the table during which the resident sustained a skin tear. CNA #4 was also observed to hit Resident #45's arm twice and to poke the resident with her index finger in just beneath the shoulder over and over, without the CNAs intervening or reporting the abuse to Administration immediately. Resident #45 told CNA #1 that CNA #4 hurt my hand, and showed his/her hand to the CNA where a skin tear was located. The CNAs reported the skin tear to Licensed Practical Nurse (LPN) #3 who assessed the injury and applied a bandage; however, did not report the observed abuse of Resident #45. CNA #4 told LPN #4 the skin tear was from where I pushed the resident's chair under the table. CNA #1 and CNA #5 failed to report the the incident as alleged abuse until after CNA #4 left work at 4:00 PM, as they were afraid CNA #4 would retaliate against them. Therefore, the allegations of abuse of Resident #45 were not reported to the CNA's supervisor or State Agency as required. 2. An allegation of abuse of Resident #39 was not reported as required within two (2) hours after the allegation was determined to have happened. The incident occurred on 04/27/2023 at 6:30 PM; however, was not reported to the State Agency by the facility investigator until 04/27/2023 at 10:19 PM, thus not meeting the regulatory guidelines. Resident #39 was assessed to be a wanderer and on the day of the incident had been wandering into other residents' rooms, including Resident #47's. Resident #39 went into Resident #47's room, who repeatedly told Resident #39 to leave and get out. Resident #39 did not leave Resident #47's room, so the resident got up and grabbed Resident #39 by the shirt and struck him/her on the ear and also slapped his/her face. Staff noticed Resident #39 had blood dripping from his/her left ear and blood was also on his/her face when the resident came down the hall. The findings include: Review of the facility policy titled, Safe Environment, dated 06/2023, revealed the purpose of the policy was regarding the protection of individuals who were served by the Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID). Per review, the management of incidents included the components of effective abuse protection, incident investigation, tracking and trending of incidents, incident data analysis, and implementing effective actions to protect those served from harm. Further review revealed applicable staff were to report incidents of alleged abuse immediately but no later than two (2) hours after forming the suspicion of possible abuse having occurred. 1. Medical record review revealed the facility admitted Resident #45 on 09/26/2022, with diagnoses which included dementia (Alzheimer's type), anxiety disorder, and major neurocognitive disorder. Review of the Annual Minimum Data Set (MDS) Assessment, dated 09/19/2023, revealed the facility assessed Resident #45 as having a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), indicating he/she was severely cognitively impaired. Review of the facility's investigation dated 11/23/2023 revealed at 3:50 PM that day revealed an allegation of abuse occurred at that time. Continued review revealed however, the abuse allegation was not reported to the State Agency until 9:01 PM on 11/23/2023. In an interview with Certified Nurse Aide (CNA) #1, on 12/04/2023 at 12:54 PM, she stated she witnessed CNA #4 abuse Resident #45. She stated she saw CNA #4 push Resident #45's chair which he/she was sitting in, under the table causing a skin tear on the resident's hand. The CNA stated she also observed CNA #4 being up in the face of Resident #45 and telling the resident no one wanted him/her to hug on them. She further stated CNA #4 was also observed poking her index finger into Resident #45's left upper chest, near the collarbone, which made the resident anxious. 2. Medical record review revealed the facility admitted Resident #39 on 02/24/2021, with diagnoses which included bipolar disorder, dementia secondary to alcoholism, and neurocognitive disorder. Review of the most recent Significant Change MDS Assessment, dated 10/10/2023, revealed the facility assessed Resident #39 to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), indicating the resident was severely cognitively impaired. Review of the facility's investigation revealed an allegation of resident-to-resident abuse was discovered on 04/27/2023 at 6:30 PM. Continued review revealed the abuse allegation was not made to the State Agency until 04/27/2023 at 10:19 PM, thus not meeting the regulation. In an interview with CNA #8, on 12/08/2023 at 9:43 AM, she stated she was the first person to find Resident #39 bleeding from his/her ear and face. She stated she told the nurse about how she had found Resident #39. CNA #8 further stated when Resident #47 was asked about what happened a second time, the resident admitted to hitting Resident #39 on the head because he/she would not leave Resident #47's room when asked. The CNA reported she was educated on abuse when hired but was not sure of what the reporting requirements were. In interview with the Director of Nursing (DON), on 12/06/2023 at 3:02 PM, she stated she expected all allegations of abuse would be reported as stated in the facility's policy and according to regulations. The DON stated she was aware of the two (2) hour time frame for reporting abuse. She further stated she also would have expected staff to intervene and increase observations. In interview with the facility's Director, on 12/05/2023 at 4:14 PM and on 12/21/2023 at 3:24 PM, she stated it was her expectation all abuse allegations would be reported per the facility policy as well as the regulation. She stated it was her expectation for staff to intervene to prevent further abuse and to keep the residents safe. The Director stated allegations of abuse were to be reported immediately, within two (2) hours. She further stated staff had received additional abuse education regarding the reporting of abuse within the required time frame. In a interview with the Medical Director, on 12/17/2023 at 9:33 AM, he stated it was his expectation abuse would be reported immediately and for residents to remain safe.

Based on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to ensure one (1) of twenty (20) sampled residents was assessed after being found on the floor (Resident #10). On 12/05/18, Resident #10 was found on the floor and staff failed to assess the resident to determine if any injury. The Certified Nurse Aides found the resident on the floor and transferred the resident back to bed without notifying the nurse. The findings include: Review of the facility policy Fall Scene Investigation/Emergency Situations revealed the policy defines the procedure for resident assessment, physician, and guardian notification, and incident reporting of a resident fall. Any time an act of falling occurs where the resident has direct contact with the floor or other potentially injurious objects or surfaces. The resident will be thoroughly assessed and closely monitored for any indication of possible injury. The Physician will be notified immediately of any fall which results in injury and has the potential for requiring physician intervention. The procedure revealed any time an act of falling occurs where the resident has direct contact with the floor or other potentially injurious objects or surfaces, the following steps will be implemented: 1. Assess the resident for injury and notify the Registered Nurse (RN) Supervisor. Document responses from resident and complete Fall Scene Investigation Report form. 2. If fall is a life-threatening situation, call 911. 3. Initiate required treatment if injury is present. 4. Notify the on-call physician of injury that has the potential for requiring physician intervention. Record review revealed the facility admitted Resident #10 on 09/28/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/11/18 revealed the facility assessed Resident #10's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of ten (10) which indicated the resident was interviewable. Surveyor heard a knocking sound coming from Resident #10's room on 12/05/18 at 3:26 PM and observation revealed Certified Nurse Aides (CNA) #3 and #4 looked at each other and got up and went to Resident #10's room. The CNA's knocked and opened the door; and surveyor observed a pair of feet and legs on the floor. The CNA's went into the room and shut the door. Approximately five (5) minutes later, the CNA's were observed to come out of the room and shut the door, returning to what they were doing prior to going to the room. Further observation revealed CNA#3 and #4 did not tell the Charge Nurse the resident was found on the floor. Observation of Resident #10's skin assessment on 12/06/18 at 11:24 AM revealed the resident had multiple abrasions/wounds/bruises on body in various stages of healing. Interview with CNA #2 on 12/05/18 at 02:49 PM revealed she found Resident #10 sitting on the floor, hitting her feet against the door. She stated the resident was care planned for falling on the floor. She stated she had never been told if a resident was found on the floor it was considered a fall and the resident does that all the time. She also revealed she was unable to assess the resident for injuries but that the resident did not have any obvious injuries. On 12/05/18 at 2:52 PM, an interview with CNA #4 revealed he found Resident #10 sitting on the floor. He stated the resident falls all the time and we go into the room and put him/her back in the bed. He also revealed the resident is care planned to be on the floor. He revealed he does not know if she had fallen, all he knows is the resident was on the floor and he helped to put the resident in the bed. Interviews on 12/06/18 with CNA #2 at 2:06 PM and CNA #1 at 2:00 PM revealed if they found a resident on the floor, they would call for the nurse, and start vital signs while the nurse assessed the resident. Interview with Licensed Practical Nurse #1 (LPN) on 12/06/18 at 2:28 PM revealed if staff find a resident on the floor, staff should come get her and she would assess the resident, obtain vital signs, and start neuro checks if it looks like they have hit their head. LPN #1 stated next staff would move the resident back to bed if no injuries were found. Interview with Resident #10's Physician by phone on 12/06/18 at 9:09 AM revealed Resident #10 did slide on to the fall mats at times but if the resident was found on the floor at the end of the bed, he expected the resident to be assessed. Interview on 12/06/18 at 3:20 PM with the Director of Nursing revealed if a resident has a fall, she expected staff to let the charge nurse know so that the nurse can assess the resident if found on the floor. She revealed Resident #10 was care planned for falls and slides him/herself on to the fall mat at bedside. She revealed there was no way to know if the resident fell since no one witnessed if the resident slid on to the mat or fell since she was found at foot of bed kicking the door.

Based on observation, interview, and record review, it was determined the facility failed to implement the written care plan in regard to resident rights for three (3) of fifteen (15) sampled residents (Residents #4, #11, and #13). The findings include: 1. Record review revealed the facility admitted Resident #11 on 03/11/13 with [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set (MDS), dated [DATE], revealed under the preferences for customary routine and activities, the resident stated it was very important to him/her that they go outside and get fresh air when weather was good. Review of the most recent MDS assessment, dated 07/14/15, revealed the facility conducted a Brief Interview for Mental Status (BIMS), with a score of nine (9) out of possible fifteen (15), indicating the resident was interviewable. The facility assessed the resident to be independent with transfers and ambulation. Review of the comprehensive care plan, initiated on 05/03/13 and reviewed on 07/21/15, revealed the facility had determined the resident was independent for meeting emotional, intellectual, physical, and social needs. The care plan stated the resident's preferred activities included being outdoors. Observation of Resident #11, on 09/16/15 at 2:02 PM, revealed the resident was outside in the courtyard with another resident and one (1) staff member. The resident was observed to be outside approximately fifteen (15) minutes. Interview with the resident, on 09/16/15 at 2:23 PM, revealed the resident was a farmer and loved the outdoors. The resident stated he/she would go outside whenever staff would take him/her. The resident stated he/she could not go outside in the courtyard or off the Pod without staff because it was against the rules. The resident stated the staff had told him/her it was a rule that staff had to be with any resident off the Pod or in the courtyard. The resident stated when he/she was at another nursing facility, they could sit outside on a porch and watch traffic go by whenever he/she wanted. The resident said he/she liked that and had never attempted to leave that facility. Review of the Activity Participation Sheet the facility utilized revealed three (3) codes for outside events. Review of the July 2015 Participation Sheet revealed Resident #11 participated in one (1) outside activity. In August 2015, the resident participated in two (2) outside activities, and in September 2015, the resident participated in three (3) outside activities, two (2) outside activities during the Recertification Survey. A Post-Survey telephone interview was conducted, on 09/22/15 at 10:14 AM, with Activity Aide #1. She revealed she was the person who developed the care plan for Resident #11. She stated the resident was assessed to be independent in making choices of activities he/she wanted to attend. She stated the resident loved going outside to talk and reminiscence about the past. The resident was a framer and worked on cars and loved to talk about those subjects. She continued to say the resident did not always participate in activities, but liked to watch others. The resident would go on activity outings and loved the Van rides, especially looking at the local farms. She stated the resident did not need any physical assistance, but only needed to be escorted off the Pod or outside. She stated as far as care plan implementation, she knew the residents and tailored the plan to them. She stated she knew the resident liked outdoor activities and tried to offer those activities. She stated it was everyone's responsibility to invite and encourage residents to attend activities of their choice. She said she would document on the participation sheet what activities residents attended. 2. Record review revealed the facility admitted Resident #4 on 06/04/15 with [DIAGNOSES REDACTED]. Review of the admission MDS, dated [DATE], revealed the resident stated it was very important to him/her to go outside to get fresh air when the weather was good. Review of the care plan, dated 06/10/15, and reviewed on 09/08/15, revealed interventions to invite the resident to scheduled activities and assist/escort to the activity function. Review of the August 2015 Activity Participation Sheet revealed the resident participated in outdoor activities four (4) times that month with a total of one (1) hour outdoors. A Post-Survey telephone interview with Activity Aide #1, on 09/22/15 at 10:14 AM, revealed the resident ambulated independently, enjoyed movies, church, books, magazines, going on outings to the lake. She stated the resident could choose what activity he/she wanted to attend and enjoyed being outside. She stated the resident would usually go outside whenever there was an activity conducted outside. She stated if the weather was pretty, the activity department would try to conduct as many activities outside as possible because everyone loved the outside activities. 3. Record review revealed the facility admitted Resident #13 on 11/06/14 with [DIAGNOSES REDACTED]. Review of the most recent annual MDS assessment, dated 09/01/15, revealed the facility assessed the resident to have no cognition loss with a BIMS score of fifteen (15) out of possible fifteen (15). The facility assessed the resident to be independent with transfers and ambulation with a steady gait and no balance deficit. The resident was assessed at risk for falls related to left ankle contracture. The assessment revealed no mood or [MEDICAL CONDITION] noted and no wandering behaviors were documented. The record revealed the facility placed the resident on an ambulation maintenance program in August 2015 to maintain lower extremity strength. The resident was to ambulate to the main dining room twice a day for meals. The resident was escorted by staff. Review of the comprehensive care plan, initiated on 11/11/14 and revised on 09/03/15, revealed the resident was independent for meeting emotional, intellectual, physical, and social needs. The goal was for the resident to attend activities of choice twice (2) per week. The interventions were to provide a activity program of activities of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility. The care plan revealed the resident needed assistance/escort to activity functions. In addition, under the at risk for falls care plan, initiated on 11/20/14 and revised on 09/10/15, revealed the resident was to be encouraged to participate in activities that promote exercise, physical activity for strengthening and improve mobility such as walking. Observation during a tour of Pod-2, on 09/15/15 at approximately 9:05 AM, revealed Resident #13 laying in bed with his/her eyes closed. Observation, on 09/17/15 at 9:40 AM, revealed the resident standing beside the bed exercising. Observation of the Pod revealed an outside activity was being held with ten (10) residents in attendance. Interview with Resident #13, on 09/17/15 at 9:41 AM, revealed he/she loved to exercise and walk. Further interview revealed the resident loved to walk and spend time outdoors. The resident was unaware of the outside activity in progress and had not been asked to attend. The resident then stated he/she did not like to be outside with other residents, that he/she liked to be alone. However, he/she stated they could not go outside in the secure courtyard without staff, it was against the rules. Review of the activity participation sheet for July and August 2015 revealed the resident participated in two (2) outings (one each month), and in September the resident was documented to be outside two (2) days, one (1) being on September 17, 2015, during the survey. Interview with Activity Staff #1, on 09/17/15 at 9:50 AM, revealed Resident #13 liked to exercise and walk. She stated the resident would request to go outside infrequently but she did not know if the resident had been invited to the outdoor activity (oldies music) in progress. She stated there was no reason the resident could not go outside but had to be supervised when outside for safety reasons. She validated residents could not go outside into the secure courtyard alone. She stated if the weather was good, the Activity Department tried to conduct activities outside. A Post-Survey telephone interview with Activity Aide #1, on 09/22/15 at 10:14 AM, revealed Resident #13 ambulated independently to the main dining room for meals. Staff had to escort the resident because the main dining room was located off the Pod. She revealed the Activity Department had worked on getting the resident out of his/her room. She revealed the resident liked watching the television-loved westerns, and attended Happy Hour (coffee and honey buns) when offered. She stated the exercising and walking was very important to the resident. She stated staff would escort the resident on walks around the building (inside) where the resident liked to visit other Pods to socialize. When the weather was good, the staff would walk with the resident outside. She stated the resident chose not to go outside during the group activities. She stated the resident liked to go outside in the courtyard alone but staff had to escorted and supervise the resident while outside in the courtyard. She stated the care plan developed was to allow the resident the choice on what the resident liked to do or not. She stated the resident was independent in meeting his/her needs. She stated care plan implementation was individualized. She stated the Activity Department had assessed what the resident liked and tailored the plan to meet them. She stated Resident #13 liked to exercise and they tried to offer activities that include exercises. She stated the she would invite and encourage the resident to attend those activities. She revealed she documented what activities the resident attended on the participation sheet. A telephone interview with the MDS Coordinator, on 09/21/15 at 1:31 PM, revealed she had completed the nursing sections of the MDS assessment and completed the care plan according to those sections. She stated all residents must be supervised/escorted off the Pod, no exceptions. She stated neither resident required physical assistance with ambulation-only supervision. She stated she did not ensure the care plan was implemented, the direct care staff does. A post survey telephone interview with the Interim Director of Nursing (DON), on 09/21/15 at 1:43 PM, revealed she was familiar with Residents #4, #11, and #13's care needs. She stated all three (3) residents were independent with ambulation. She stated Resident #13 was encouraged to ambulate and was placed on a walk and dine program where the resident to walk to dining room for meals. However, all residents must be escorted when off the Pod or in the courtyard.

Based on observation, interview, record review, and review of the facility's policy, and Resident Handbook, it was determined the facility failed to ensure six (6) of fifteen (15) sampled residents (Residents #4, #5, #6, #10, #11, and #13), exercised their rights in regard to what time they arose each morning, choice to eat in their rooms or dining room, keep snacks in their rooms, and access to the secure courtyard without staff's presence. The findings include: Review of the Resident Handbook, dated 2015, revealed a section on Resident Rights was included. Review of the Resident Rights revealed forty (40) rights. Review of Right #20 revealed the resident had the right, if responsible, not to be detained against his/her will. Further review revealed The resident shall be permitted and encouraged to go outdoors and leave the premises as they wish unless a legitimate reason can be shown and documented. Additionally, The above stated rights shall apply in all cases unless medically contraindicated and documented by a physician in writing in the resident's medical record. Review of the Community Living Rules revealed the facility would provide daily meals in the dining room or designated areas on the Resident Care Pods. A physician's orders [REDACTED]. A request should be made by the legal representative forty-eight (48) to seventy-two (72) hours ahead of time to the unit nurse or Social Service for any such approval. Review of the facility's policy for the Resident Courtyard, dated 09/27/13, revealed the courtyard was built to give residents access to the outdoors and to be around nature with its healing effects. Staff must be in the courtyard to ensure resident safety. At no time shall a resident be allowed to enter or be in the courtyard unattended. Observation during the initial tour of the facility, on 09/15/15 at 8:24 AM, revealed the resident's living quarters were divided into four (4) Pods that were locked and required a badge to enter. Tour of Pod-2, on 09/15/15 at 8:26 AM, revealed there were thirteen (13) resident rooms inside the Pod with a census of twenty-four (24) residents. Observation revealed a enclosed courtyard leading off the Pod. A badge was required to access the courtyard. A Group Resident Council Meeting was held, on 09/15/15 at 2:30 PM, with eight (8) residents in attendance including the Vice-President. During the interview regarding facility rules, Resident #10 voiced he/she had to get up at a certain time for breakfast. He/she stated residents were not allowed to eat in their rooms, that it was against the rules. The resident also voiced a concern about Resident Rights regarding not being able to go outside in the courtyard without staff. The resident stated it was a facility rule that residents could not go off the Pod or go outside in to the enclosed courtyard without staff. All eight (8) residents agreed with Resident #10's statements. Observation of the lunch meal, on 09/17/15 at 12:24 PM, revealed five (5)residents eating at the dining table inside Pod-2 and four (4) residents eating on bedside tables in the same area. Five (5) residents were escorted to the main dining room (off the Pod) by staff. There were no residents eating in their rooms. 1. Record review revealed the facility admitted Resident #11 on 03/11/13 with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment, dated 07/14/15, revealed the facility conducted a Brief Interview for Mental Status (BIMS), with a score of nine (9) out of possible fifteen (15), indicating the resident was interviewable. The facility assessed the resident to be independent with transfers and ambulation. Review of the comprehensive MDS, dated [DATE], revealed under the preferences for customary routine and activities, the resident stated it was very important to him/her that they go outside and get fresh air when the weather was good. Review of the comprehensive care plan, initiated on 05/03/13 and reviewed on 07/21/15, revealed the facility had determined the resident was independent for meeting emotional, intellectual, physical, and social needs. The care plan revealed the resident's preferred activities included being outdoors. Observation of Resident #11, on 09/16/15 at 2:02 PM, revealed the resident was outside in the courtyard with another resident and one (1) staff member. The resident was observed to be outside approximately fifteen (15) minutes. Interview with Resident #11, on 09/16/15 at 2:23 PM, revealed he/she was a farmer and loved the outdoors. The resident stated he/she would go outside whenever staff would take him/her. The resident stated he/she could not go outside in the courtyard or off the Pod without staff because it was against the rules. The resident stated the staff had told him/her it was a rule that staff had to be with any resident off the Pod or in the courtyard. The resident stated when he/she was at another nursing facility, they could sit outside on a porch and watch traffic go by whenever he/she wanted. The resident said he/she liked that and had never attempted to leave that facility. Further observation of Resident #11, on 09/17/15 at 9:02 AM, revealed the resident sitting on the bed in the resident's room. Interview with the resident revealed residents could not eat in their rooms because it was against the rules. The resident stated the residents had to go to the main dining room or eat on the Pod. He/she stated the residents had been told they cannot keep snacks, candy, cookies, or gum, in their room. If family brings snacks to them, the snacks must be kept locked at the nurses' station and the residents must ask the staff when they want a snack. He/she stated the residents must eat the snacks at the table inside the Pod and was not allowed to eat in their rooms. The resident stated he/she loved coffee but must drink the coffee at the table inside the Pod, and cannot take the coffee to his/her room. The resident stated he/she could not go outside alone and cannot go outside in the evenings, which was something the resident loved to do. The resident indicated, since the courtyard and Pod was locked, the resident was dependent on staff to allow him/her access to the courtyard or off the Pod. Review of the Activity Participation Sheet revealed the facility utilized revealed three (3) codes for outside events. Review of the July 2015 Participation Sheet revealed Resident #11 participated in one (1) outside activity. In August 2015, the resident participated in two (2) outside activities, and in September 2015, the resident participated in three (3) outside activities, two (2) of which were during the Recertification Survey. 2. Record review revealed the facility admitted Resident #4 on 06/04/15 with [DIAGNOSES REDACTED]. Review of the admission MDS, dated [DATE], revealed the resident stated it was very important to him/her to go outside to get fresh air when the weather was good. Review of the care plan, dated 06/10/15 and reviewed on 09/08/15, revealed interventions to invite the resident to scheduled activities and assist/escort to the activity function. Observation of Resident #4, during tour of Pod-2, on 09/15/15 at 8:26 AM, revealed the resident was in bed with his/her eyes closed. Observation at 11:45 AM, revealed the resident was dressed and ambulating independently on the Pod. At 2:30 PM, the resident was in attendance of the Group Resident Council Meeting with the surveyor. The resident was in agreement when Resident #10 stated the courtyard was locked and residents could not access this area without staff's assistance. Review of the August 2015 Activity Participation Sheet revealed the resident participated in outdoor activities four (4) times that month with a total of one (1) hour outdoors. 3. Record review revealed the facility admitted Resident #13 on 11/06/14 with [DIAGNOSES REDACTED]. Review of the most recent annual MDS assessment, dated 09/01/15, revealed the facility assessed the resident to have no cognition loss with a BIMS score of fifteen (15) out of possible fifteen (15). The facility assessed the resident to be independent with transfers and ambulation with a steady gait and no balance deficit. The resident was assessed at risk for falls related to left ankle contracture. The assessment revealed no mood or [MEDICAL CONDITION] noted and no wandering behaviors were documented. The record revealed the facility placed the resident on an ambulation maintenance program in August 2015 to maintain lower extremity strength. The resident was to ambulate to the main dining room twice a day for meals. The resident was escorted by staff. Review of the comprehensive care plan, initiated on 11/11/14 and revised on 09/03/15, revealed the resident was independent for meeting emotional, intellectual, physical, and social needs. The goal was for the resident to attend activities of choice twice (2) per week. The interventions were to provide a activity program of activities of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility. The resident needs assistance/escort to activity functions. In addition, under the at risk for falls care plan, initiated on 11/20/14 and revised on 09/10/15, revealed the resident was to be encouraged to participate in activities that promote exercise, physical activity for strengthening and improve mobility such as walking. Observation during a tour of Pod-2, on 09/15/15 at approximately 9:05 AM, revealed Resident #13 laying in bed with his/her eyes closed. Observation, on 09/17/15 at 9:40 AM, revealed the resident was standing beside the bed exercising. Observation of the Pod revealed an outside activity was being held with ten (10) residents in attendance. Interview with Resident #13, on 09/17/15 at 9:41 AM, revealed he/she loved to exercise and walk. Further interview revealed the resident loved to walk and spend time outdoors. The resident was unaware of the outside activity in progress and had not been asked to attend. The resident then stated he/she did not like to be outside with other residents, he/she liked to be alone. The resident stated he/she could not go outside in the secure courtyard without staff, it was against the rules. The resident revealed he/she liked to drink coffee but had to sit at the table beside the nurses' station and was not allowed to drink the coffee inside his/her room. The resident stated no food or drink was allowed in his/her room, it was against the rules. Interview with Activity Staff #1, on 09/17/15 at 9:50 AM, revealed Resident #13 liked to exercise and walk. She stated the resident would request to go outside infrequently, but she did not know if the resident had been invited to the outdoor activity (oldies music) in progress. She stated there was no reason the resident could not go outside, but all residents must be supervised while outside for safety reasons. She validated residents could not go outside into the secure courtyard alone. She stated if the weather was good, the Activity Department tried to conduct activities outside. Observation, on 09/17/15 at 9:55 AM, revealed Activity Staff #1 assisted Resident #13 outside and walked with the resident in the secure courtyard. The resident was observed to be independent with ambulation without balance deficit. Review of the activity participation sheet for July and August revealed the resident participated in two outings (one each month), and in September the resident was documented to be outside two (2) days, one (1) time being on September 17, 2015, during the survey. Interview with the LPN #2, on 09/17/15 at 10:30 AM, revealed the resident likes to walk and the staff walked with the resident outside the Pod but within the building. She stated residents are not allowed to walk outside the Pod or in the courtyard without staff. She stated the resident is escorted off the Pod to the main dining room for meals. Interview with the Social Worker/Activity Director, on 09/17/15 at 2:32 PM, revealed she completed the Cognition, Mood, and Psychosocial sections of the MDS assessments. She completed the interview for Activity Preferences for the residents and noted Residents #4, #11, and #13 stated it was very important for them to go outside when the weather was good. She stated Resident Rights are reviewed with the residents upon admission and given a copy. In addition, Resident Rights are reviewed during the Resident Council meetings. She validated residents are escorts from the Pods and must be supervised by staff outside in the courtyard. She said residents are not allowed to eat in their room without supervision, including snacks. She stated another resident could wander into the resident's room and choke on the food. She stated all snacks must be locked in the kitchenette (locked room) and the nursing staff must supervise the snacks and liquids given to the residents. This would include coffee, soda, and any liquid. Residents cannot drink in their rooms. 4. Record review revealed the facility admitted Resident #5 on 07/21/14 with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility had assessed Resident #5's cognition as intact with a Brief Interview Mental Status (BIMS) score of fifteen (15), indicating the resident was interviewable. Interview with Resident #5, on 09/17/15 at 10:47 AM, revealed he/she liked to go outside to the courtyard at the facility. Resident #5 stated due to the facility rules, he/she was only allowed to go outside when the facility staff could go with him/her. Additional interview with Resident #5 revealed he/she was only able to eat at the dining table in the Pod area or in the main dining area. Resident #5 stated sometimes he/she would like to eat in his/her room. 5. Record review revealed the facility admitted Resident #10 on 04/21/15 with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment, dated 07/07/15, revealed the facility had assessed Resident #10 as moderately impaired with a BIMS score of eleven (11), indicating the Resident was interviewable. During the Group Resident Council Meeting, held on 09/15/15 at 2:30 PM, Resident #10 voiced he/she had to get up at a certain time for breakfast. The resident stated residents were not allowed to eat in their rooms, that it was against the rules. The resident also voiced a concern about Resident Rights regarding not being able to go outside in the courtyard without staff. The resident stated he/she had been told it was a facility rule that residents could not go off the Pod or go outside in the enclosed courtyard without staff. Interview with the Social Worker/Activity Director, on 09/17/15 at 2:32 PM, revealed all residents have to be supervised when off the Pod or outside in the secure courtyard. She stated this was for the residents' safety. She said that was how the facility had always done it and did not know about a particular policy. She stated that had always been the rule. She revealed there was no specific outside activities placed on the activity calendar but if the weather was pretty, the activity department tried to conduct activities outside. She stated the resident could request to go outside and if staff was available, they would escort them outside. She stated not all locations within the enclosed courtyard could not be visualized by staff. She continued to say, a resident could fall and sustain an injury without staff's knowledge if left in the courtyard alone. Interview with the Interim Director of Nursing (DON), on 09/17/15 at 3:08 PM, revealed the facility had a policy for all residents to be supervised in the courtyard. Staff must be present during activities and visits in the courtyard. Residents cannot go outside without staff present, this was for the residents' safety. She stated it was all about safety. She validated the courtyard was secure but still required staff supervision. No exceptions. Interview with the Associate Director, on 09/17/15 at 3:50 PM, revealed the facility policy was for the safety of the residents. She stated the supervision of all resident when in the courtyard was for safety. She had not considered the residents' rights. Interview with the Administrator, on 09/17/15 at 4:10 PM, revealed the courtyard policy was developed upon the move to the new building. She stated it was for the safety of all residents to be supervised by staff because a portion of the courtyard could not be visualized from inside the building. She stated a resident could fall where the staff could not see them. It could be a safety hazard. She stated she wanted residents to be able to go outside and be safe. She revealed the camera outside was pointed toward the exit door and did not include all of the courtyard. She stated again that the facility had to look at safety. 6. Record review revealed the facility admitted Resident #6 on 06/27/15 with [DIAGNOSES REDACTED]. Review of the most recent Significant Change Minimum Data Set (MDS) assessment, dated 08/11/15, revealed the facility assessed the resident to have no cognitive loss with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of a possible fifteen (15). The facility assessed the resident to be independent with eating and required help with set up only for eating. Interview with Resident #6, on 09/15/15 at 12:30 PM, revealed he/she preferred to eat his/her breakfast in his/her room. He/she stated the residents were not allowed to eat in their rooms and that it was against the rules to eat in one's room. The resident commented he/she did not mind eating lunch or supper in the Dining Room or on the Pod, but really preferred to eat breakfast in his/her room, but was not allowed. Interview with RN #1, on 09/16/15 at 3:20 PM, revealed residents were not allowed to eat or drink in their rooms without the supervision of one (1) nurse or two (2) nursing assistants. Interview with LPN #1, on 09/17/15 at 1:00 PM, revealed none of the residents are allowed to eat in their rooms. She stated that is just the way it is around here. Interview with CNA #1, on 09/17/15 at 12:20 PM, revealed if a resident were to eat in their room, there must be two (2) nursing assistants or one (1) nurse present because of the facility's choking protocol. Therefore, residents eat in the Pods or in the Main Dining Room unless they are ill. Interview with the Social Service Director (SSD), on 09/17/15 at 2:35 PM, revealed it is the facility's policy that a resident must have a nurse or two (2) nursing assistants in their room to supervise while eating or drinking in their rooms. Interview with the Interim Director of Nursing (DON), on 09/17/15 at 3:08 PM, revealed the residents could eat in their rooms but staff would have to be present. She stated it was policy that all oral intake must be supervised including those residents who do not have any swallowing or chewing problems. She stated residents cannot keep snacks in their rooms. The snacks must be kept in a locked kitchenette and residents have to ask whenever they want their snacks. The residents were not allowed to have a refrigerator in their rooms. She stated another resident could wander into the resident's room and obtain the food and choke. Interview with the Associate Director, on 09/17/15 at 3:50 PM, revealed the facility policy was for the safety of the residents. She stated it was a rule that residents cannot have snacks/food in their rooms. She stated the policy had not been reviewed since the move into the new building. Interview with the Administrator, on 09/21/15 at 3:00 PM, revealed the residents should have the right to chose where they want to eat their meals, if they are assessed to be safe to eat independently. The Administrator stated there needs to be some education and communication concerning the residents' rights to make choices.

Based on observation, interview, and facility policy review, it was determined the facility failed to store, prepare, distribute and serve food under sanitary conditions. Observations of the kitchen, revealed undated food items stored in the refrigerator and freezer; the range hood vents were noted to have a coating of dust and debris and a sanitizer bucket had no evidence of measurable sanitizer in the bucket. Review of the facility's Census and Condition, dated 06/24/14, revealed there were seventy-five (75) residents in the facility and ten (10) of those residents were tube feeders and did not eat food from the kitchen area. The findings include: Review of the facility's, "Frozen Storage Policy", dated 08/15/13, revealed all frozen food would be properly wrapped, dated and labeled. 1. Observation of the freezer and refrigerators on 06/25/14 at 8:45 AM, revealed the following items undated: one (1) quart of "Specialty Salad"; four (4) pints of chicken base; one (1) pint of beef base; fifteen (15) popsicles; four (4) ice cream "Drumsticks"; one (1) bag of french fries; five (5) coconut pies; two (2) boxes of sugar cookie dough; and, one (1) apple pie. Interview with the Dietary Manager, on 06/25/14 at 9:00 AM, revealed the facility went by the food vendor's date on the box of food or the stamped "use by" date, to tell the expiration dates of food items. However, some of the food items had been taken out of the boxes and some had no "use by" dates marked on the product. The Dietary Manager stated "they should have been marked." Interview with the Dietician, on 06/26/14 at 9:45 AM, revealed the pies were good for four-hundred and twenty-five (425) days when kept in the freezer. However, there was no box or markings to indicate what date the products had been placed in the refrigerator and freezer. 2. Review of the "Employee Sanitary Practices" policy, dated 08/25/10, revealed cloths used for wiping food spills on food contact surfaces would be stored in a sanitizing solution between uses during the day. Observation of the chemical test strip measure of sanitizer in the sanitizer bucket, on 06/25/14 at 11:50 AM, revealed the sanitizer bucket had no evidence of sanitizer noted on the chemical test strip. Interview with Dietary Aide #1, on 06/25/14 at 11:50 AM, revealed she had filled the bucket with the sanitizing agent, and mixed it with water, at approximately 6:30 AM. She further stated she had wiped the counters with this solution "10 minutes ago." Interview with the Dietary Manager, on 06/25/14 at 11:53 AM, revealed the sanitizer buckets were to be changed at 6:00 AM, after each use or when the staff noticed the water was dirty. Interview with the Dietician, on 06/26/14 at 9:50 AM, revealed she had interviewed the staff and found the sanitizer bucket had been changed at 8:30 AM that morning. She further stated the buckets should be changed "about every two hours". In addition, she stated "every food particle decreases the sanitizer agent." Further interview revealed the sanitizer agent should have measured 200 parts per million (PPM.) 3. Observation of the kitchen equipment, on 06/25/14 at 9:10 AM; and, on 06/26/14 at 9:00 AM, revealed a build up of dust and debris on the vents of the range hood, over the stove. Interview with the Dietary Manager, on 06/25/14 at 9:15 AM; and, on 06/26/14 at 9:05 AM, revealed the hood was last cleaned on 04/26/14 when the hood was inspected by an outside contractor. Further interview revealed the Dietary Manager had been hesitant to clean the hood due to a gas pipeline and separation wall that ran behind the stove. Interview with the Dietician, on 06/25/14 at 9:20 AM, revealed the range hood was scheduled to have been cleaned every two (2) weeks. Interview with the Administrator, on 06/26/14 at 2:55 PM, revealed she was not aware of any problems with undated food items, the sanitizer buckets or the range hood until "today" and stated this would be remedied .

Based on observation, interview, record review, and a review of the facility's policies, tit was determined he facility failed to ensure four (4) of seventeen (17) sampled residents (Resident #2, #7, #13, #14) were free from physical restraints. Residents #2 and #14 were observed to utilize a lap buddy, Resident #7 utilized a pelvic device and Resident #13 utilized a merry walker while out of bed; however, there was no evidence the devices were utilized to treat a medical symptom. Resident #14's lap buddy was implemented on May 4, 2010; however, there was no evidence the facility had obtained a physician's orders [REDACTED]. In addition, there was no evidence the facility had informed the responsible party of the risks/benefits related to the use of the lap buddy for Resident #2. The findings include: A review of the facility's Restraint policy/procedure (dated August 25, 2010) revealed a trial of least restrictive measures would be documented prior to utilizing a restraint device, unless the physical restraint was necessary to provide life-saving treatment. The policy noted a pre-restraint assessment was required to be completed by the licensed nurse at the time a restraint was ordered by the physician and evaluated/updated every three (3) months. In addition, the policy noted a physician's orders [REDACTED]. The policy further noted a consent for the restraint was required to be obtained from the Resident and/or legal guardian and the risks, benefits, and alternatives for the restraint would be discussed and documented in the Resident's medical record. The policy also noted the restraint assessment would be reviewed for restraint reduction quarterly by the multidisciplinary team. 1. Resident #2 was observed on April 26, 2011, at 4:40 p.m. and at 5:50 p.m., to be sitting in a wheelchair in the facility hallway with a lap buddy in place on the wheelchair. On April 27, 2011, Resident #2 was observed at 1:30 p.m. to be in the wheelchair with the lap buddy in use. The resident was unable to remove the lap buddy upon request on April 27, 2011, at 1:30 p.m. Interview with the resident on April 27, 2011, at 1:30 p.m., revealed the lap buddy kept the resident from getting up out of the wheelchair and described the lap buddy as "a nuisance". Again on April 28, 2011, at 9:15 a.m., the resident was observed in a wheelchair with a lap buddy in place. A review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a significant change Minimum Data Set (MDS) assessment completed on March 22, 2011, revealed the facility assessed Resident #2 to require extensive assistance of two staff for bed mobility, transfers, ambulation, and toileting. In addition, the resident was assessed to have no impairments with range of motion and did not require the use of a restraint. The facility's fall risk assessment form indicated a score of eight (8) or greater revealed the resident was at high risk for falls. A review of the fall risk assessment completed on March 28, 2011, revealed Resident #2 was assessed to have a score of twelve (12) and was at risk for falls. A review of the fall history for Resident #2 revealed the resident fell [DATE], when the resident attempted to self transfer from the wheelchair to the resident's walker. A Review of the POS [REDACTED]. Further record review revealed a physician's orders [REDACTED]. However, there was no evidence the facility had identified a specific medical symptom to support the use of the lap buddy. Review of the Pre-Restraint/Bed rail assessment revealed on April 15, 2011, the Pre-Restraint/Bed rail assessment was updated and the lap buddy/restraint was added due to the resident sustaining a fall during an attempt to self transfer on April 15, 2011. However, the assessment failed to identify a medical symptom to justify the use of the lap buddy for Resident #2. Furthermore, the facility failed to evaluate how the use of the lap buddy would assist the resident to attain/maintain the resident's highest practicable level of physical and psychosocial well-being. The last page of the Pre-Restraint assessment contained information regarding the risk/benefits of the restraint device and a consent form to be signed by the resident or responsible party (R/P). However, this page of the assessment had not been completed and had not been signed by the resident's R/P. Interviews conducted with Certified Nurse Aides (CNA #3 and #4) on April 27, 2011, at 2:00 p.m. and at 3:15 p.m. revealed staff utilized a lap buddy for Resident #2 to prevent the resident from getting up out of the wheelchair. The CNAs stated the lap buddy was considered to be a restraint for Resident #2. CNA #3 and #4 stated the resident was not able to remove the lap buddy independently. An interview conducted with RN #2 on April 27, 2011, at 1:40 p.m., revealed the RN was responsible for completing the Pre-Restraint assessment when a restraint device was ordered by the physician. However, RN #2 stated he did not believe he was working on April 15, 2011 when the lap buddy was implemented for Resident #2. An interview conducted with Resident #2's R/P on April 27, 2011, at 3:00 p.m., revealed the R/P lap buddy had been initiated to prevent Resident #2 from falling out of the wheelchair and the lap buddy benefited the resident. The R/P stated she had been notified when the lap buddy had been implemented. However, according to the R/P, she had not been informed of the risks/benefits related to the use of the lap buddy. An interview conducted with Licensed Practical Nurse (LPN) #5 on April 28, 2010, at 2:20 p.m., revealed the LPN wrote the telephone physician's orders [REDACTED]. LPN #5 stated the registered nurse (RN) was responsible to complete the restraint assessment. LPN #5 further stated the lap buddy prevented Resident #2 from getting out of the wheelchair and no other restraint devices had been attempted for the resident. 2. Resident #14 was observed on April 27, 2011, at 11:35 a.m., to be in a wheelchair in the hallway. The resident was observed to be sitting toward the edge of the wheelchair and was using his/her feet to propel the wheelchair. A lap buddy was observed to be in place on the resident's wheelchair. Resident #14 was not interviewable due to cognitive status. A review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a significant change MDS assessment completed on February 1, 2011 revealed the facility assessed Resident #14 to have short/long term memory deficits with moderately impaired decision making skills, required total assistance of two (2) staff persons for transfers, bed mobility, and was non-ambulatory. In addition, Resident #14 was assessed to utilize a trunk restraint (lap buddy) daily. Further review of the medical record revealed a lap buddy had been implemented for Resident #14 in 2008 due to the resident's fall history. A review of the progress notes revealed attempts to reduce/remove the lap buddy had been attempted and on April 20, 2010, the lap buddy was discontinued . Documentation in the progress notes revealed Resident #14 sustained a fall on May 4, 2010 and the lap buddy was reapplied to the resident's wheelchair. However, there was no evidence the facility had obtained a physician's orders [REDACTED]. A review of the annual restraint evaluation completed on February 5, 2011, revealed the lap buddy was used for Resident #14 due to the resident scooting to the edge of the wheelchair seat and had the potential of sliding out of the chair. The assessment indicated the resident did not follow cues/commands and did not attempt to self transfer. The assessment further noted recommendations to continue the use of the lap buddy. A review of the April 2011 physician's orders [REDACTED].#14. However, there was no evidence the physician had ordered the lap buddy to be used for Resident #14. An interview conducted with RNs #1 and #3 on April 28, 2011, at 6:10 p.m., revealed a physician's orders [REDACTED]. The RNs stated a pre-restraint and quarterly restraint evaluation was required to be completed by the RNs. RN #1 and #3 stated the lap buddy was used to prevent Resident #14 from getting out of the wheelchair unassisted and stated the resident could not remove the lap buddy independently. The RNs stated there was no evidence a physician's orders [REDACTED].#14. 3. Resident #13 was observed on April 28, 2011, at 3:00 p.m., in a merry walker in the hallway and to move down the hallway using his/her feet. Resident #13 was not interviewable due to his/her cognitive status. A review of the April 2011 physician's orders [REDACTED].#13. A review of the medical record revealed Resident #13 was admitted to the facility on March 31, 2009 with [DIAGNOSES REDACTED]. A review of the annual MDS assessment completed on February 1, 2011 revealed the facility assessed Resident #13 to have short/long term memory deficits with severely impaired decision making skills, and required assistance of one (1) staff person for transfers. In addition, staff noted Resident #13 utilized a chair that prevented rising on a daily basis. Further review of the medical record revealed staff documented on the pre-restraint assessment for Resident #13 dated February 5, 2011, the specific reason for the restraint was "Resident had prior use of merry walker with crossbar at transferring facility, and he/she had been admitted to the facility in March 2009, with orders for use of the merry walker." In addition, there was no documentation that staff had assessed a medical symptom for the use of a merry walker for Resident #13. An interview conducted with the DON on April 28, 2011, at 6:20 p.m., revealed a physician's orders [REDACTED]. The DON stated that Resident #13 had always had the merry walker and a physician's orders [REDACTED]. However, the DON reviewed the medical record for Resident #13 and acknowledged that she was unable to find documentation of an order for [REDACTED]. An interview with LPN # 3 conducted on April 28, 2011, at 7:00 p.m., revealed Resident #13 was unable to release his/her self from the merry walker. 4. Resident #7 was observed at 5:15 p.m., on April 26, 2011, to be sitting in a broda (reclined geri) chair with a pelvic restraint in place. Resident #7 was unable to remove the pelvic restraint upon command. Resident #7 was not interviewable. A review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the annual comprehensive Minimum Data Set (MDS) completed on March 21, 2011, revealed the facility assessed Resident #7 to require the assistance of two (2) staff persons for bed mobility, transfers, and toileting. Resident #7 was assessed to have no limitations in range of motion, severely impaired decision making skills, and required the use of a chair to prevent rising. Review of the medical record revealed an order had been obtained for the broda chair on March 10, 2010. However, there was no evidence the facility had determined the medical symptom to require the use of the broda chair and the pelvic restraint. A Pre- Restraint/ Bed rail Assessment updated on March 14, 2011 revealed the broda chair enabled Resident #7 to have a secured upright posture in a sitting position, and to provide support to the upper and lower extremities. In addition, Resident #7 utilized the use of a pelvic restraint to prevent injury to the resident related to involuntary movements. A review of the comprehensive care plan updated on March 21, 2011, revealed Resident #7 was at high risk for falls, and required the use of a broda chair with a pelvic restraint. Resident #7 was assessed to have a score of fifteen (15) on the fall risk assessment (score of eight (8) or greater at high risk for falls). An interview was conducted with LPN #6 at 3:30 p.m., on April 28, 2011. The LPN stated the broda chair enabled resident #7 to be out of bed. The LPN further stated resident #7 had constant involuntary movement, and the pelvic restraint prevented resident #7 from flinging self from the broda chair. An interview on April 28, 2011, at 8:50 p.m., with the Minimum Data Set (MDS) nurse revealed she reviewed the flow records related to restraints to ensure the restraints were released every two (2) hours. The MDS nurse revealed she only reviewed documents required to complete the MDS assessment such as the type of restraint required or if the restraint was still effective. The MDS nurse stated she did not review the physician's orders [REDACTED].

Based on observation, interview, record review and a review of the facility's policy/incident reports/incident tracking logs, it was determined the facility failed to thoroughly investigate and report injuries of unknown origin (bruises, skin tears and abrasions) to the required state agencies for six (6) of seventeen (17) sampled Residents (Residents #2, #4, #6, #9, #10 and #14). The findings include: Review of the facility's abuse policy subtitled Safe Environment dated July 13, 2009, revealed the facility would conduct an objective investigation of all allegations of abuse, neglect, exploitation and Class 3 incidents, in a timely and thorough manner. Further review of the policy revealed the facility would classify incidents according to the potential for harm to individuals into three (3) categories. Each category revealed if there was reasonable cause present to suspect abuse, neglect or exploitation, the incident should be reported immediately to the appropriate authorities. Review of the three (3) categories revealed incidents were classified according to the potential for harm to individuals and had established protocols for recording and follow-up. The policy directed staff that immediate follow-up for all incidents should include the cause of the incident with interventions for future prevention. Review of Class 3 Incidents listed on the policy included: injury of unknown cause if the injury required more than first aid, was suspicious of abuse, neglect or exploitation or if the facilities' tracking and trending of similar injuries indicated suspected abuse, neglect or exploitation. 1. Review of the medical record revealed Resident # 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Significant Change in MDS assessment dated as completed on April 11, 2011, revealed the facility assessed Resident #9 as being severely impaired in daily decision making, and required extensive to total assistance from two (2) staff members for any activity of daily living. Review of the incident reports and incident log for Resident #9 revealed on December 29, 2010, the resident sustained [REDACTED]. On March 6, 2011, during the provision of morning care, staff noted Resident #9 had an abrasion (1 centimeter by 1 centimeter) to the right knee. In addition, on March 17, 2011, Resident #9 was assessed to have two (2) abrasions (1 centimeter by 1 centimeter and 1 centimeter by 0.3 centimeter) on the right lower leg. The incident report dated March 17, 2011, also indicated the resident had redness of the right lower extremity. The facility failed to investigate the injuries to Resident #9 to determine a possible cause of the injuries and failed to report the injuries of unknown origin to the appropriate state agencies. Observations on April 26, 2011, at 1:40 p.m., 4:00 p.m., and on April 27, 2011 at 1:35 p.m., revealed Resident #9 was in a wheelchair in the hallway of the facility and was slowly moving about in the hallway by using the handrails and pushing with his/her feet. Continued observation revealed Resident #9 had tremors of the left upper extremity, had geri-sleeves in place on both upper extremities and was wearing a protective helmet. An attempt was made on April 27, 2011, at 2:50 p.m., to conduct a skin assessment of Resident #9, however, the Resident became very agitated, cursed and instructed staff to "get away". Interview on April 27, 2011, at 3:00 p.m., with Registered Nurse (RN) #1/floor supervisor revealed staff were to assess resident's for injuries after a report of any incident, complete a report of the incident, begin "alert" charting for seventy-two (72) hours, notify the resident's guardian of the incident and if the resident's injury was "serious" staff were to notify the resident's physician. RN #1 also stated if a resident sustained [REDACTED]. RN #1 stated incident reports were forwarded to Risk Management for review and the Risk Management would determine if an investigation was needed. 2. A review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the significant change MDS assessment conducted on March 22, 2011, revealed Resident #2 was assessed to require extensive assistance of two (2) staff persons for bed mobility, transfers, ambulation, and toileting. Resident #2 was observed to be sitting in a wheelchair with geri-sleeves on both upper extremities, and knee Hi [MEDICAL CONDITION] Embolic Deterrent, (TED ) hose (used to decrease the occurrence of blood clots of the legs) on both lower extremities on April 26, 2011, at 4:40 p.m., on April 27, 2011, at 8:50 a.m., and on April 28, 2011, at 9:15 a.m. A skin assessment conducted with facility staff on April 28, 2011, at 3:45 p.m. revealed no alterations in the resident's skin condition. A review of the incident report dated October 20, 2010 revealed facility staff identified a skin tear to Resident #2's right forearm. The report noted treatment was provided to the skin tear and an intervention was implemented for staff to assist the resident to navigate difficult areas, such as doorways. On December 23, 2010, an "old" skin tear was noted to be "reopened" and steri-strips were applied. Further review of the incident reports revealed a skin tear was discovered on January 24, 2011 on the resident's left shin area when the CNA went into Resident #2's room. However, there was no evidence these three (3) incidents had been thoroughly investigated to identify a possible cause for the injury or to evaluate for possible abuse. In addition, there was no evidence the facility had reported these injuries of unknown source to the appropriate state agencies. An interview conducted with RN #2 on April 27, 2011, at 1:40 p.m., revealed staff were required to complete an incident report when a skin tear was identified. RN #2 stated the Risk Manager would determine if an investigation would be conducted of an incident after a review of the incident report. RN #2 also stated he was not sure if a skin tear sustained by a resident would be investigated. The RN stated he was one of the facility's three (3) investigators, and he had not conducted any investigations in the past one (1) to two (2) years. 3. Resident #10 was admitted to the facility on [DATE]. The Resident's [DIAGNOSES REDACTED]. A review of the significant change MDS assessment conducted on February 8, 2011 revealed the facility assessed Resident #10 had moderate impairment with cognition, required total assistance of staff for bed mobility, transfers, toileting, personal hygiene, and was non-ambulatory. Resident #10 was observed on April 26, 2011, at 5:00 p.m., to be sitting in a wheelchair in the facility dining room. The Resident was dressed in personal clothing with geri-sleeves to both upper extremities and a dressing on the right foot/ankle. On April 27, 2011, at 8:55 a.m. and at 1:30 p.m., Resident #10 was observed again to be up in a wheelchair with geri-sleeves to both upper extremities. Resident #10 was not interviewable due to cognitive impairment. A skin assessment conducted on April 27, 2011, at 2:55 p.m., revealed a closed ulcer on the Resident's right outer foot. No other areas of redness or skin breakdown was noted. A review of a incident report revealed a skin tear was noted to Resident #10's left elbow when direct care staff were transferring the Resident to the bed on December 22, 2010. The report noted the area was cleaned and a band-aid was applied. On January 15, 2011, a skin tear was found on the Resident's left hand that measured .5 cm X. 5 cm. There was no other information noted on the incident report. Further review of the incident reports revealed skin tears were again noted to Resident #10 on January 21, 2011. The incident report noted a skin tear (measuring 1.5 cm X 5 cm) was discovered on the resident's right upper forearm and a skin tear (measuring 2 cm X 2 cm) was noted on the resident's left upper forearm. However, there was no evidence the three (3) incidents had been thoroughly investigated to determine a possible cause or to evaluate the injuries for possible abuse of the resident. In addition, there was no evidence the facility had reported the three (3) incidents of unknown injury to the state agencies. An interview conducted with RN #2 on April 27, 2011, at 1:40 p.m., revealed the Risk Manager was responsible to determine if incidents met criteria for investigation. RN #2 also stated he was not sure if an investigation would be conducted for a skin tear. The RN stated he was one (1) of the facility's three (3) investigators, and he had not conducted any investigations in the past one (1) to two (2) years. An interview with the Risk Manager (RM) on April 28, 2011, at 1:35 p.m., revealed there was no evidence the facility had conducted an investigation into the three (3) incidents of skin tears for Resident #10. In addition, the RM stated these incidents had not been reported to the state agencies. 4. Resident #14 was admitted to the facility on [DATE]. The Resident's [DIAGNOSES REDACTED]. A review of the significant change MDS assessment completed on February 1, 2011 revealed the facility assessed Resident #14 had short/long term memory deficits with moderately impaired decision making skills, required total assistance of two (2) staff persons for transfers, bed mobility, and was non-ambulatory. Resident #14 was observed on April 27, 2011, at 11:35 a.m., to be in a wheelchair in the hallway. The Resident was observed to be sitting toward the edge of the wheelchair and was using his/her feet to propel the wheelchair. Resident #14 was not interviewable due to cognitive status. A review of the incident report dated January 4, 2011 revealed Resident #14 was assessed to have bruising to the top of both hands, redness to the perineal area, a bruise to the right upper leg, and a skin tear to the right lower leg. However, there was no evidence the facility had conducted an investigation to determine a possible cause of these injuries. On February 5, 2011, nursing staff assessed Resident #14 to have a red area (measuring 2 cm X 2 cm) on the Resident's right knee with a 1 cm X 1 cm "yellow scabbed" area to the center when the direct care staff went into the Resident's room. There was no evidence the facility had conducted an investigation into this incident. In addition, there was no evidence these incidents of injury of unknown origin had been reported to the state agencies. An interview conducted with RN #2 on April 27, 2011, at 1:40 p.m., revealed the Risk Manager determined if an investigation would be conducted into an incident. RN #2 also stated he was not sure if an investigation would be conducted for a skin tear. The RN stated he was one of the facility's three (3) investigators, and he had not conducted any investigations in the past one (1) to two (2) years. An interview with the Risk Manager (RM) on April 28, 2011, at 1:35 p.m., confirmed there was no evidence the facililty had conducted an investigation or reported these incidents involving Resident #14 to the state agencies. 5. A review of the medical record for Resident # 6 revealed the Resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly Minimal Data Set (MDS) for Resident #6 dated April 12, 2011, revealed the facility had assessed the Resident to be moderately cognitively impaired, and to require the total dependence of two (2) persons to transfer the Resident. The MDS further revealed the Resident used a wheelchair for mobility. A review of the incident reports for Resident # 6 revealed the Resident had sustained bruising to the right index finger which was observed by the family on August 22, 2010, at 3:25 p.m.. The incident reports further revealed on October 16, 2010, at 5:10 a.m., Resident # 6 had been observed by nursing staff to have discoloration to the Resident's right knee, measuring 0.2 centimeters by 2.0 centimeters. There was no documentation that the facility had investigated the injuries in an attempt to determine a cause of the injuries,or had reported the injuries of unknown origin to the appropriate state agencies. Observation of Resident # 6 on April 26, 2011, at 6:30 p.m., April 27, 2011, at 8:55 a.m., 9:30 a.m., 1:30 p.m., 2:30 p.m., and April 28, 2011, at 9:00 a.m., revealed the Resident to be up in the wheelchair and able to propel his/herself. An attempt to perform a skin assessment on April 28, 2011, at 9:30 a.m., was unsuccessful. The Resident refused and stated, "no, go away." An interview conducted with Licensed Practical Nurse (LPN) #6 on April 27, 2011, at 3:30 p.m., revealed the nurse was to complete an incident report of any injury to Residents. The LPN further revealed the nurse was to place the completed report on a clipboard for the physician to review. The LPN further stated the physician was in the facility on a daily basis. The LPN also revealed Administration obtain the incident reports every day, to discuss them in the morning meeting. An interview conducted with the facility's Director of Nursing (DON) on April 28, 2011, at 7:20 p.m., revealed he/she was unaware of how Resident #6 sustained the bruises on August 22, 2010, and October 16, 2011. The DON further revealed she had only felt major incidents such as broken bones, bruises with fingerprints, needed to be investigated, or reported to the state agencies. 6. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a significant change MDS assessment completed on February 7, 2011, revealed the facility assessed Resident #4 was severely impaired in daily decision making, and required extensive assistance with all activities of daily living. A skin assessment observation conducted on April 28, 2011 at 10:50 a.m. with LPN #3, and CNA #1, revealed Resident #4 had a bruise to lower right inner leg, that was brown in color, and was approximately two (2) centimeters round. Further observation revealed a bruise to top of the resident's left thumb, that was purple in color and approximately one (1) centimeter round. There was no documentation provided that the bruises had been thoroughly investigated or reported to the appropriate state agency. An interview with the Risk Manager (RM) on April 28, 2011, at 10:15 a.m., revealed the Administrator, Social Workers, Director of Nursing (DON), MDS Nurse, and the RM reviewed incident reports daily. Further interview with the Risk Manager (RM) on April 28, 2011, at 1:35 p.m., related to the investigation of skin tears/abrasions/injuries of unknown origin for Residents' #2, #4, #6, #9, #10 and #14, revealed all incident reports were reviewed daily during the Incident Management Meeting to determine if the incident report met the criteria to be investigated. The RM stated the Administrator, Assistant Administrator, Social Services Director (SSD), Director of Nurses (DON), MDS Nurse, and the RM attended the daily Incident Management Meetings. The RM stated incidents were reviewed for possible causes and, if a cause could not be determined, the incident would be marked "unknown". The RM also stated she was responsible to report incidents to the appropriate state agencies. The RM further stated the skin tears sustained by Residents' #2, #4, #6, #9, #10 and #14, had not been investigated and not had not been reported to the state agencies. An interview with LPN #3 on April 28, 2011, at 10:55 a.m., during skin assessment of Resident #4, revealed that she was unaware Resident #4 had bruises present. LPN #3 stated staff were to notify the charge nurses if a Resident was observed to have bruises, and the bruises would be documented. An interview conducted with RN #2 on April 28, 2011, at 11:15 a.m., revealed that if staff were to complete an incident report if bruising was identified on a resident. RN #2 stated an attempt would be made to determine how th bruise occurred. However, the RN was unaware of who was to be notified of bruises of unknown origin. The facility Administrator (ADM) stated in an interview conducted on April 28, 2011, at 6:35 p.m. incident reports were reviewed daily during the Incident Management Meeting. The ADM stated an investigation was only conducted if the incident met the facility's criteria (Class I, Class II, and Class III) for investigation. The ADM stated injuries of unknown source were not reported to the stated agencies unless a "major" injury had occurred. An interview conducted with the facility's Director of Nursing (DON) on April 28, 2011, at 7:20 p.m., revealed she was unaware bruises of unknown origin would need to be investigated, or reported to the state agencies.

Based on interview, record review, and review of facility policies, it was determined the facility failed to ensure the quality assessment and assurance committee was effective in identifying and correcting quality deficiencies related to restraint use for residents. Residents #2, #7, #13, and #14 were observed to utilize a lap buddy, pelvic restraint, or a merry walker; however, there was no evidence the facility followed established policy/procedures to ensure residents remained free from physical restraints. In addition, there was no evidence the facility identified the residents' R/P were not being informed regarding the possible risks/benefits associated with restraint use. (Refer to F221). The findings include: A review of the Continuous Quality Improvement (QI) policy (reviewed on October 15, 2008) revealed the facility would maintain a quality improvement program to identify and address quality of life issues to provide the highest possible level of care for the facility residents. The policy further noted the QI committee was responsible to identify quality deficiencies, to develop plans of action to correct the quality deficiencies, and to monitor the effect of these corrections. The policy also noted the committee would obtain and utilize input from the residents, families, guardians, and the interdisciplinary team to design or revise programs within the facility. A review of the facility Restraint policy/procedure (dated August 25, 2010) revealed a physician's orders [REDACTED]. The policy noted a pre-restraint assessment was required to be completed by the licensed nurse at the time a restraint was ordered and evaluated/updated every three (3) months. In addition, the policy noted a consent for the restraint was required to be obtained from the resident and/or legal guardian and the risks, benefits, and alternatives for the restraint would be discussed and documented in the resident's medical record. Residents #2, #7, #10, and #14 were observed to utilize a lap buddy, pelvic restraint, or a merry walker during the survey conducted on April 26-28, 2011. However, there was no evidence the devices were utilized to treat a medical symptom. Resident #14's lap buddy was implemented on May 4, 2010; however, there was no evidence the facility had obtained a physician's orders [REDACTED]. In addition, there was no evidence the facility had informed the responsible party of the risks/benefits related to the use of the lap buddy for Resident #2. An interview conducted with the Director of Nursing (DON) on April 28, 2011, at 7:30 p.m., revealed the facility did not have an audit and/or tool to review/evaluate the use of restraints for Residents. The DON stated the Minimum Data Set (MDS) nurse monitored the amount of time the resident utilized the restraint daily and reported this information to the QI committee. The DON further stated no staff was specifically responsible to monitor/evaluate the use of restraints to ensure restraints were necessary for residents and to ensure the established restraint policy/procedures were being followed. An interview conducted with the Superintendent Associate (SA) and the Risk Manager (RM) on April 28, 2011, at 7:45 p.m., revealed the SA and the RM shared the responsibility as the QI coordinator. Both the SA and the RM stated they did not have anything to do with the restraint program and no one was specifically assigned to monitor/evaluate restraint use in the facility. The SA and RM also stated the MDS nurse was responsible for tracking the amount of time each Resident spent in the restraint in an attempt to reduce the use of the restraint; however, the facility did not have an audit and/or monitor in place to evaluate the restraint program and to ensure Residents remained free from restraints. An interview on April 28, 2011, at 8:50 p.m., with the Minimum Data Set (MDS) nurse revealed she reviewed the flow records related to restraints to ensure the restraints were released every two (2) hours. The MDS nurse revealed she only reviewed documents required to complete the MDS assessment such as the type of restraint required or if the restraint was still effective. The MDS nurse stated she did not review the physician's orders [REDACTED].

Based on observation, interview, and record review, it was determined the facility failed to provide a sanitary, orderly, and comfortable interior. One door with chipped paint, one loose hallway baseboard, cracked tile in two (2) hallways,one (1) Resident wheelchair with worn and torn arms, and one (1) Resident geri-chair with worn and torn armrests were observed on the environmental tour on April 28,2011. The findings include: The facility was asked for a policy related to maintenance repairs and none was provided. During the environmental tour of the facility on April 28, 2011, at 4:15 p.m., the following items were observed to be in need of repair: -The Solarium door on the Second Floor of the facility was observed to have chipped paint. -The baseboard was observed to be loose in the hallway between Resident rooms 301 and 302. -The tile in the hallway between Resident room 402 and the linen room was observed to be cracked. -The tile in the hallway in front of the Fourth Floor nurses station was observed to be cracked. -A wheelchair being used by Resident #9 was observed to have worn and torn armrests. -A geri-chair being used by Resident #18 was observed to have worn and torn armrests. An interview conducted with the Maintenance Supervisor (MS) for the facility on April 28, 2011, at 4:55 p.m., revealed the facility utilized a work order system. The MS stated any staff member could obtain a work order at the nurses station to inform the Maintenance Department of anything that needed to be repaired. The MS stated he checked each nurses station three times a day for work requests, and also conducted a daily walk through on each nursing unit. The MS further revealed he made an environmental round on one floor every week.

Based on observation, interview, record review, and policy review, it was determined the facility failed to provide services according to professional standards for one (1) unsampled resident (Resident #19). Resident #19 received liquid/crushed medications per gastrostomy tube (G/T); however, the nurse failed to ensure the resident received the correct dosage as prescribed by the physician. The findings include: A review of the Medication Administration policy/procedure (review date March 2, 2011) revealed the responsibilities of the nurse administering medications included administering the correct dose of medication to residents. The policy/procedure did not include guidance/direction for ensuring how all the medication would be removed from either the plastic sleeve or plastic cup to ensure the resident received the correct dosage of medication. A review of the medical record revealed Resident #19 had physician orders [REDACTED]. The medications were ordered to be administered per gastrostomy tube (G/T). A medication administration observation conducted on April 27, 2011, at 9:15 a.m., revealed Licensed Practical Nurse (LPN) #3 obtained the tablet/capsule medications for Resident #19 and crushed these medications together in a plastic sleeve with a pill crusher. LPN #3 was then observed to pour the crushed medications from the plastic sleeve into a paper cup. The nurse was observed to tap the sides of the plastic sleeve to remove the medications; however several particles/pieces of a white substance was still present in the plastic sleeve. The nurse then poured the two (2) liquid medications into separate plastic cups and took all the medications, into Resident #19's room. The nurse was then observed to check/verify placement of the G/T, mixed the crushed medications with water, and poured the medications into an asepto syringe to administer the medications per G/T to Resident #19 . The nurse was then observed to pour the liquid medications into the asepto syringe. However, a small amount of the liquid medications still remained in each of the plastic medication cups. Observation revealed, the nurse failed to ensure Resident #19 received the prescribed dosage of medication. An interview conducted with LPN # 3 on April 27, 2011, at 10:00 a.m., revealed the facility had implemented the use of the plastic sleeves and "Silent Crusher" for crushing medications approximately two (2) months ago. LPN #3 stated she had been directed to tap the sides of the plastic sleeve to remove all the medications. LPN #3 also stated she had not been directed to rinse the plastic medication cups to ensure all the medications had been removed from the medication cups. An interview conducted with the Director of Nurses (DON) on April 28, 2011, at 10:20 a.m., revealed the nurses were responsible to ensure the residents received the correct dosage of medication as prescribed by the resident's physician. The DON stated the nurse should tap the sides of the plastic sleeve to remove all the medications and to rinse the plastic medication cups to ensure all the medications was administered. The DON stated no inservice/education had been provided to the nurses for the use of the "Silent Crusher" for crushing medications. The DON observed the powder substance that remained in the plastic sleeves after the medications for Resident #19 had been crushed. The DON revealed that some of the medications had been left in the plastic sleeve.

Based on observation, interview and record review, it was determined the facility failed to provide services to one (1) of seventeen (17) sampled residents in accordance with the resident's written plan of care. Review of the written plan of care for Resident #4 revealed staff were to ensure Resident #4 had an abdominal binder on at all times, had skin sleeves on the upper extremities at all times, and had [MEDICAL CONDITION] Embolic Deterrent (TED) hose (elastic stocking to prevent blood clots) applied every morning. In addition, the footboard of the residents bed was to be covered with sheepskin, and Resident #4 was to be up in geri-chair at the nurses station when awake for comfort and supervision. However, observations on April 26, 2011, and April 27, 2011, revealed facility staff had not implemented the interventions as planned for the resident. The findings include: A review of Resident #4's record on April 26, 2011, revealed the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #4's significant change Minimal Data Set (MDS) assessment dated [DATE], revealed the resident required extensive assistance for bed mobility and transfers. A review of Resident #4's plan of care revealed the plan was updated on February 7, 2011, and revealed the resident was at risk for falls/injury, alteration in skin integrity, and alteration in nutrition. interventions included an abdominal binder, skin sleeves, and TED hose on at all times. In addition, the resident's footboard was to be covered with sheepskin at all times. Also, based on a review of the plan of care, the resident was to be assisted up in a geri-chair at the nurses station when awake for comfort and supervision. A review on April 27, 2011, at 4:10 p.m., of the CNA's daily assignment sheet revealed Resident #4 was to have TED hose on in the morning and off in the evening, and an abdominal binder and skin sleeves on at all times. The assignment sheet revealed a sheepskin pad was to be on the footboard of the bed to protect the resident's skin due to the resident's restless movement of legs. In addition, the assignment sheet revealed the resident was to be assisted up to a geri chair every shift for two hours. Observations conducted on April 26, 2011, at 4:00 p.m. revealed Resident #4 was lying in the bed. Based on observation, the TED hose, abdominal binder, or skin sleeves were noted not to be applied. Further observation revealed the footboard of Resident #4's bed did not have a sheepskin covering. Continued observations conducted on April 27, 2011 at 12:00 p.m., 1:30 p.m., 3:05 p.m., 5:00 p.m., revealed no evidence of an abdominal binder or skin sleeves in use for Resident #4. In addition, observation revealed the footboard of Resident #4's bed did not have a sheep skin covering. Resident #4 was not observed to be up in geri chair on this date. Interview conducted on April 27, 2011, with CNA #2 at 4:15 p.m., revealed residents' care needs were indicated on the daily assignment sheets. CNA #2 stated night shift CNA's were responsible to lay skin sleeves out for residents, and stated "it's been awhile since sheepskin has been on Resident #4's bed." CNA #2 was unaware as to why the abdominal binder or skin sleeves were not in place for the resident, as noted on the daily assignment sheet. CNA #2 further revealed, she was aware Resident # 4 required both the abdominal binder and the skin sleeves. Interview conducted on April 28, 2011, at 9:00 a.m., with CNA #1 revealed the daily assignment sheet was used to inform staff of the residents care needs. The CNA stated if the items were not in use as planned, staff were to implement the measures and notify the Charge Nurse. The CNA further revealed she was unaware the items had not been applied to Resident #4, and had not notified the Charge Nurse. Interview with Unit Manager, RN # 2, conducted on April 27, 2011 at 4:20 p.m., revealed he assessed residents every two (2) hours to ensure resident care needs were met. RN #2 stated "honestly I don't know the resident doesn't have an abdominal binder, skin sleeves or why the footboard is not covered with sheepskin." Interview with the DON, conducted on April 28, 2011, at 10:15 a.m., revealed that she relied on the LPN's and RN's to ensure resident care needs were met, and to update the care plans as needed.

Based on observation, interview, record review and policy review, it was determined the facility failed to ensure the residents' environment remained as free from accident hazards as possible. Observation during the environmental tour revealed the facility failed to ensure chemical substances were secured/locked and not accessible to residents. A review of the labels on the containers revealed the chemicals were to be kept out of reach. The findings include: A review of the facility's policy titled Personal Care Supplies, dated April 27, 2010, revealed personal care items were to be kept in the disposable wash basin in the resident's individual closet. The policy further revealed the personal care items were to be taken to the bathroom when care was provided to a resident and returned to the closet when care was completed. Observation during the environmental tour on April 28, 2011, at 09:05 a.m., revealed two (2) bottles of Germ X (hand sanitizer), one (1) bottle of Sween Baza Cleanse and Protect (skin care product), one box of Polident Denture Tablets, and one (1) bottle of Cepacol Antibiotic Mouthwash were sitting on the nightstand in resident room # 205 A. The labels on the containers had a cautionary statement to keep the products out of the reach. A review of the Material Data Safety Sheets (MSDS) from the manufacturers of the products revealed: - Germ X could cause irritation of the respiratory tract if inhaled, could cause nausea, vomiting, or diarrhea if ingested, or could cause irritation to the eyes . -Sween Baza Cleanse and Protect revealed contact of the product with the eyes, and ingestion of the product should be avoided. The MSDS also revealed if the product was ingested, a physician should be consulted. The label on the box of Polident Denture Tablets and the bottle of Cepacol Antibiotic Mouthwash revealed the Poison Control Center was to be contacted if the product was ingested. An interview conducted with Licensed Practical Nurse (LPN) #6 on April 28, 2011, at 3:25 p.m., revealed the facility had eight (8) residents on the Second Floor of the facility who could potentially wander into other resident's rooms and come into contact with the products. An interview conducted with the facility's Administrator on April 28, 2011, at 5:00 p.m., revealed the personal care items should not have been placed on the resident's nightstand. The Administrator further stated the items should have been placed in the wash basin in the resident's closet. The Administrator stated the nurses were responsible for ensuring chemicals were stored in the resident's closet. The Administrator stated the nurse was expected to monitor to ensure chemicals are not left out and in reach of any residents, when the nurse made rounds every two (2) hours.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide foods that were palatable and at a preferable temperature during the lunch and evening meal on April 26, 2011. The findings include: A review of the Point of Service Temperature policy/procedure (dated August 27, 2010) revealed the point of tray delivery temperatures would be at the minimum temperatures when served to the residents. The policy noted the minimum temperatures for the following food items should be delivered to the residents at: meat items (greater than 115-125 degrees), vegetables (greater than 115-125 degrees), creamed soups (greater than 130 degrees), and milk less than 45 degrees. A review of the Tray Line and Meal Service Temperature policy (dated August 25, 2010) revealed a test tray for food temperatures and palatability would be conducted/recorded weekly. The policy noted the test trays would be rotated between breakfast, lunch, and dinner meals and between the regular, ground, and puree consistency of foods. Observation of the noon meal service on April 26, 2011, revealed the first food cart was delivered to the third floor main dining room from the kitchen in a closed, unheated cart at 1:05 p.m. The last tray was removed from the food cart at 1:55 p.m. (50 minutes after the cart was delivered). A palatability test was conducted with facility staff revealed the pureed meat was 114 degrees Fahrenheit and tasted warm, the pureed carrots was 104 degrees Fahrenheit and tasted slightly warm, with no seasoning, and the baked beans was 90 degrees Fahrenheit and tasted slightly warm. Further observation of the noon meal service on April 26, 2011, revealed the second food cart arrived on the third floor for the second dining room at 1:11 p.m. The last tray was removed from the food cart at 1:45 p.m. (34 minutes after the cart was delivered) and a another palatability test was conducted . The food palatability test conducted with facility staff revealed the carrots were 102 degrees Fahrenheit and tasted slightly warm and bland, the baked beans were 96 degrees Fahrenheit and tasted slightly warm, and the hamburger patty was 100 degrees Fahrenheit and tasted cool with no seasoning. Observations of the evening meal service on April 26, 2011, revealed the first closed tray cart was delivered to the third floor from the kitchen at 5:00 p.m. The last tray was removed at 5:38 p.m. (38 minutes after the cart was delivered) and a palatability test was conducted of the food items. The pureed turkey was 110 degrees Fahrenheit and tasted slightly warm, the cream of broccoli soup was 90 degrees Fahrenheit and tasted cool, and the nectar thickened milk was 60 degrees Fahrenheit and tasted cool. An interview was conducted with CNA # 4 on April 26, 2011, at 1:00 p.m. CNA #4 stated if a tray sat for forty (40) minutes before being delivered to a resident, she would re-order the resident a tray. An interview with the Dietary Manager (DM) on April 28, 2011, at 8:50 a.m., revealed weekly test trays had not been conducted per facility policy. The DM stated the Registered Dietitian (RD) was supposed to conduct a monthly test tray; however, the DM stated the RD had missed several months due to the required furlough days. The DM stated the test tray conducted in December 2010, revealed foods were not served at the appropriate food temperatures. However, the DM stated the next test tray conducted in February 2011 revealed the foods temperatures were appropriate and no corrective plan of action had been implemented. An interview conducted with the DON on April 28, 2011, at 7:30 p.m., revealed meal service should be completed within 15-20 minutes.

Based on record review, observation, and interview, it was determined the facility failed to provide a therapeutic dietary supplement for one (1) of seventeen (17) sampled residents. Resident #10 had a physician's orders [REDACTED]. However, staff failed to provide Glucerna for Resident #10 during the evening meal on April 26, 2011. The findings include: A review of the April 2011 physician's orders [REDACTED]. Resident #10 was observed on April 26, 2011, at 6:20 p.m., to be eating in the main dining room on the third floor. A review of the resident's tray card revealed the resident was to have a mechanical soft, no concentrated sweet diet with Glucerna at each meal. Observation of the resident's meal tray revealed no evidence the Glucerna had been provided for Resident #10 as ordered by the resident's physician. An interview conducted with CNA #1 on April 28, 2011, at 9:15 a.m., revealed she was not sure if Resident #10 was required to receive a supplement on each tray. CNA #1 stated the supplements were added to the resident's tray by the dietary department. However, the CNA stated she was required to check the resident's tray card to ensure the resident received the appropriate supplements. An interview conducted at 11:05 a.m., on April 28, 2011 with the Dietary Manager (DM) revealed each dietary staff person who served foods on the tray line was required to check the resident's tray card to ensure the diet was served as ordered. The DM stated Resident #10 did not receive the Glucerna as ordered due to an "oversight" by the dietary staff.

Based on observation, interview, record review, and policy review, it was determined the facility failed to provide a safe, sanitary environment to help prevent the development and transmission of disease and infections for two (2) sampled residents out of seventeen (17), (Residents #11 and #12). During observation of a blood glucose check being performed by the shift Nursing Supervisor (NSV), the NSV failed to perform handwashing after performing the check, and failed to clean the glucometer between residents as instructed by the manufacturer's guidelines. The findings include; A review of the facility's policy titled Optimum Blood Glucose Monitor, dated February 3, 2010, revealed the meter should be cleansed after each use with Gluco Chlor wipes. A review of the facility's policy titled Handwashing, dated February 3, 2010, revealed all personnel were required to wash their hands before and after each resident contact. The policy further revealed a waterless hand sanitizer may be used when soap and water was not available. Observation revealed the NSV conducted a blood glucose check on Resident #11 on April 26, 2011, at 5:55 p.m.. Further observation revealed the NSV failed to wash/sanitize her hands after performing the check. The NSV then cleansed the glucometer with a Tena Wipe. The NSV then proceeded to attempt to perform a blood glucose check on Resident # 12 without cleansing the glucometer with the wipe recommended by the manufacturer. However, the NSV was asked to step out into the hallway by the surveyor. An interview conducted with the NSV on April 26, 2011, at 6:00 p.m., revealed she always cleansed the glucometer with Tena Wipes. The NSV thought she knew what to use to clean the glucometer, but she had picked up the wrong wipes. The NSV then looked through the drawers and pulled out a Gluco Chlor wipe. The NSV then stated "I think this was what I was supposed to use." The NSV further stated she normally cleansed her hands with the Tena wipes, and only used [MEDICATION NAME] Sanitizer after every two (2) residents. Interviews were conducted with LPN #1, LPN #2, LPN #5, LPN #8, RN #5, RN #6 on April 26, 2011, between 6:15 p.m. to 6:30 p.m., and revealed all were knowledgeable of the appropriate method for cleaning the glucometer with the Gluco Chlor wipes. Further interview with staff revealed staff were knowledgeable about the facility's policy and procedure for cleaning the glucometer. All medication carts were observed on April 26, 2011, at 6:30 p.m., and the medication carts contained Gluco Chlor wipes readily available for use. An interview conducted with the Infection Control Nurse for the facility on April 26, 2011, at 6:45 p.m., revealed staff were expected to cleanse the glucometer with Gluco Chlor wipes which were what the manufacturer had recommended for the glucometer the facility was using. The Infection Control Nurse further stated the NSV had attended an inservice on October 28, 2010, on how to properly clean the glucometer. The Infection Control Nurse further revealed Tena wipes were not considered an acceptable form of hand sanitizing and stated the NSV had attended an inservice on handwashing on December 8, 2010. The Infection Control Nurse further revealed all employees must attend the handwashing inservice annually.