Every finding on record at Hammond Nursing Home

Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan which met the needs of 1 (#37) of 32 residents reviewed in the final sample. The facility failed to ensure Resident #37 was care planned for PTSD and Dementia. Findings: Review of Resident #37's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Non-Alzheimer's Dementia and PTSD. Review of Resident #37's quarterly MDS, with an ARD of 10/29/2025, revealed a BIMS of 15, which indicated she was cognitively intact. Review of Resident #37's current Care Plan revealed no interventions developed which met the needs related to PTSD or Dementia. Review of Resident #37's current physician orders revealed the following:Start date:12/18/2025- Sertraline HCL 50 mg, take 3 tablets by mouth every day Start date:12/18/2025- Buspirone HCL 15 mg take 1 tablet by mouth two times a day Start date:09/25/2025- Clonazepam 0.5 mg take 1 tablet by mouth two times a day Start date:10/18/2025- Aricept HCL 5 mg 1 tablet by mouth at bedtime On 01/05/2026 at 11:00 a.m., an interview was conducted with Resident #37. She stated she had a history of PTSD. She stated she had poor memory. On 01/06/2025 at 10:00 a.m., an interview was conducted with S3ADON. She stated she was responsible for completing Care Plans. She reviewed Resident #37's diagnoses on the clinical chart and confirmed Resident #37 had a diagnosis of PTSD and Dementia. She reviewed the Care Plan dated 10/18/2025 and confirmed Dementia and PTSD had not been included and should have been.

Based on observations, interviews and record review, the facility failed to ensure 1 (#78) of 1 resident reviewed for range of motion received services and assistance to maintain or improve mobility. Resident #78 was admitted to the facility on [DATE] with diagnosis which included, CVA, Hemiplegia and Hemiparesis Affecting Left Non-Dominant Side. Review of the Comprehensive MDS with an ARD of 11/06/2025 revealed Resident #78 had a BIMS of 7, which indicated the resident was severely cognitively impaired. Further review revealed, in part, the resident had limited range of motion in the lower extremity on left side. Review of Resident #78's active physician's orders revealed no orders related to range of motion. Review of Resident #78's current Care Plan revealed the resident was unable to perform ADL's related to a CVA and left arm and left leg hemiplegia with contracture.There was no notation of an intervention related to range of motion for the left hand and left leg to prevent further decline in ROM. On 01/07/2026 at 10:09 a.m., an observation and interview was conducted with Resident #78. Resident #78's left arm was bent at the elbow and her hand was closed in a fist position. Resident #78's left leg was slightly bent at the hip and bent at the knee with her lower leg pointed toward her upper thigh/buttocks. She stated she was unable to move her left arm and leg. She stated she had not received any therapy since she was admitted to the facility until recently after returning from the hospital. She stated staff had not performed PROM. On 01/07/2025 at 10:25 a.m., an interview as conducted with S8CNA. She stated Resident #78 could not move her left arm and left leg. She stated she did not perform PROM during ADL care.On 01/07/2025 at 10:35 a.m., an interview was conducted with S9CNA. She stated Resident #78 was admitted with a contracture to her left hand and left leg. She stated she had not seen Resident #78 receive any type of therapy or PROM. She stated she did not perform PROM during ADL care. On 01/07/2025 at 10:47 a.m., an interview was conducted with S10TD. She stated therapy screened residents on admission and every three months. She stated Resident #78 was admitted on Hospice with a contracture to her left upper extremity and left lower extremity. She stated when Resident #78 was discharged from Hospice in March 2025, she was re-screened. She stated she had no documentation Resident #78 had been re-screened since 03/2025. She stated Resident #78 had recently returned from the hospital and was re-screened on 01/06/2025. She confirmed therapy had not provided any services for Resident #78.On 01/07/2025 at 11:05 a.m., an interview was conducted with the S3ADON. She stated Resident #78 had a history of a CVA with Hemiparesis to her left side. She confirmed Resident #78 had contractures to her left arm and left leg. She stated she expected CNA's to perform PROM with Resident #78 while providing ADL care to prevent further decline in ROM. She reviewed the care plan and physician orders and confirmed Resident #78 had no interventions to prevent further decline of ROM and should have.

Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#78) resident out of a total of 32 sampled residents. The facility failed to ensure Resident #78 was coded accurately for functional abilities. Findings: Review of Resident #78's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included a CVA and Hemiplegia/Hemiparesis Left Side. A review of Resident #78 Comprehensive MDS with an ARD of 11/06/2025 revealed Resident #78 had a BIMS of 07, which indicated she was moderately cognitively intact. Further review revealed she was coded for no impairment to left upper extremities. A review of the Resident #78's current care plan revealed the resident was care planned for having a contracture to her left arm. On 01/05/2026 at 10:10 a.m., an observation was made of Resident #78 lying in bed. An observation was made of her left arm and left leg visibly contracted. On 01/07/2026 at 10:09 a.m., an interview was conducted with Resident #78's. She stated her left arm and left leg were contracted, and she was unable to move them. On 01/07/2026 at 10:25 a.m., an interview was conducted with S8CNA. She stated Resident #78's left arm and left leg were contracted, and she was unable to move them.On 01/07/2026 at 11: 00 a.m., an interview was conducted with S2DON. She stated she was responsible for completing Resident #78's MDS assessment. She confirmed Resident #78's left arm and left leg were both contracted. She reviewed Resident #78's Comprehension MDS with an ARD of 11/06/2025 and confirmed Resident #78 was not coded accurately for limited range of motion to upper extremity and should have been.

Based on record reviews and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a PASRR Level II evaluation as required for 2 (#9 and #20) of 4 sampled residents records reviewed for PASRR. Findings: Resident #9 Review of Resident #9's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed diagnoses of Atypical Psychosis and Depression dated 03/11/2025, with no evidence of a Level II PASRR evaluation. Review of Resident #9's Level 1 PASRR dated 01/07/2024 revealed the following, in part: Section III: Mental Illness. 1. Do you suspect the applicant has, or has the applicant ever been diagnosed as having a mental illness? No On 01/06/2026 at 9:15 a.m., an interview was conducted with S2DON. She stated Resident #9 was originally admitted from home and did not have any mental health diagnoses. She stated Resident #9 had been admitted to an outpatient behavioral health facility March 2025 and returned with the new diagnoses of Depression and Psychosis. She confirmed a resident review had not been submitted with the new diagnoses of Depression and Psychosis and should have been. Resident #20 Review of Resident #20's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis, which included Bipolar Disorder. Further review revealed additional medical diagnoses of Mood Disorder with Psychotic Features dated 09/03/2025, with no evidence of a Level II PASRR evaluation. Review of Resident #20's Level 1 PASRR dated 08/15/2022 revealed the following, in part: Section III: Mental Illness. 1. Do you suspect the applicant has, or has the applicant ever been diagnosed as having a mental illness? No On 01/07/2026 at 2:00 p.m., an interview was conducted with S2DON and S3ADON. S2DON reviewed Resident #20's admission diagnosis of Bipolar Disorder and Level 1 PASRR. She verified Resident #20's Level 1 PASRR dated 08/15/2022 indicated Resident #20 did not have a mental health diagnosis and was not resubmitted to include Bipolar Disorder. S2DON and S3ADON reviewed Resident #20's diagnosis of Mood Disorder with Psychotic Features dated 09/03/2025 and confirmed a Resident Review form was not resubmitted to OBH after Resident #20's new mental health diagnosis and should have been.

Based on observations, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure a resident's oxygen was administered at the physician ordered rate for 1 of 1 (#83) resident reviewed for respiratory care.Review of Resident #83's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease.Review of Resident #83's current Physician Orders revealed the following, in part:Start date 05/30/2023 - Oxygen at 2L per nasal cannula as needed.An observation was made on 01/05/2026 at 9:00 a.m. of Resident #83 in his room wearing oxygen per nasal cannula at 3L.An observation was made on 01/06/2026 at 8:35 a.m. of Resident #83 in his room wearing oxygen per nasal cannula at 3L.An interview was conducted on 01/06/2026 at 8:40 a.m. with S7RN. S7RN confirmed Resident #83 had an order for oxygen per nasal cannula as needed at 2L. S7RN confirmed Resident #83's oxygen was set at 3L.An interview was conducted on 01/06/2026 at 8:55 a.m. with S2DON. She confirmed all residents' oxygen should be administered at the ordered rate.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 2 of 2 (#10 and #76) residents observed for incontinence care. The facility failed to ensure staff performed hand hygiene and proper glove use for Residents #10 and #76 during incontinence care.Resident #76 Review of Resident #76's Clinical Record revealed he was admitted to the facility on [DATE]. On 01/06/2026 at 9:32 a.m., an observation was made of S5CNA performing incontinence care for Resident #76. Resident #76 was observed to have had a bowel movement. S5CNA wiped the bowel movement from Resident #76's buttocks, then without changing gloves or performing hand hygiene, she applied a clean incontinence pad and brief to Resident #76. Then, with the same gloves, S5CNA grabbed a bottle of barrier cream, opened it, and applied it to Resident #76's buttocks. After applying the barrier cream, S5CNA changed gloves. On 01/06/2026 at 9:48 a.m., an interview was conducted with S5CNA. She confirmed she did not change gloves or perform hand hygiene after she wiped the bowel movement from Resident #76's buttocks. She stated she was unaware she was supposed to change gloves after removing the bowel movement from Resident #76's buttocks and before touching the clean incontinence pad, brief, and barrier cream. On 01/06/2026 at 3:50 p.m., an interview was conducted with S1ADM and S2DON. S1ADM and S2DON confirmed CNAs should change gloves and perform hand hygiene after cleaning bowel movements and before touching clean items. Review of the facility's undated policy titled Infection Control-Hand Hygiene, revealed the following, in part: Intent: It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health Organization. Procedure: 2. According to the World Health Organization, hand hygiene is to be performed: c. When moving from a contaminated body site to a clean body site such as when changing a brief. Resident #10Review of Resident #10's Clinical Record revealed he was admitted to the facility on [DATE].On 01/06/2026 at 10:40 a.m., an observation was made of S6CNA performing incontinence care for Resident #10. Resident #10 was observed to have had a bowel movement. S6CNA wiped the bowel movement from Resident #10's buttocks, then without changing gloves or performing hand hygiene, she applied a new brief to Resident #10. Then, with the same gloves, S6CNA dressed Resident #10. After dressing Resident #10, S6CNA changed gloves and performed hand hygiene. On 01/06/2026 at 10:45 a.m., an interview was conducted with S6CNA. She confirmed she did not change gloves after she wiped the bowel movement from Resident #10's buttocks. She stated she should have changed her gloves after cleaning the bowel movement and prior to touching the clean items.

Based on observations and interview, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure: 1. Food was properly sealed and dated after opening; and 2. Presence of expired food intended for use. There were a total of 78 out of 85 facility residents who were provided meals and beverages from the facility's kitchen. Findings: Review of the facility's undated policy titled, Food Service to Prevent Risk of Cross Contamination revealed the following, in part; Purpose: To ensure that all residents meals are cooked, stored, transported, and served using methods that reduce risk of cross contamination and food borne illnesses. Process: 4. All food shall have a date of delivery and used by the manufacturer's recommendation. Opened product shall be dated as to the date opened and not kept on shelf beyond the manufacturer's recommendation. During the initial tour of the facility's kitchen on [DATE] at 8:37 a.m., with S3DM the following observations were made: Cooking area: ,d+[DATE]oz. bottle of seasoned salt was opened and undated. ,d+[DATE]oz. bottle of garlic and herb seasoning was opened and undated. Walk in Freezer: 1-,d+[DATE] bag of chicken nuggets-opened, unsealed, and undated. Walk in Refrigerator: 2-packages of 6 tortillas expired [DATE]. ,d+[DATE] count of hot dog buns were undated with delivery date. ,d+[DATE] count of hamburger buns were undated with delivery date 1-loaf of white bread was undated with a delivery date. Pantry: 24-individually wrapped cereal expired [DATE]. 3-boxes of corn starch expired [DATE]. On [DATE] at 9:00 a.m., an interview was conducted with S3DM. S3DM confirmed the aforementioned items during initial tour, and she confirmed the dates of expired items. S3DM confirmed expired items should have been discard prior to today. S3DM confirmed all items which were opened should have been sealed and dated with open dates. S3DM further confirmed the bread products should have been dated with delivery date and was not. On [DATE] at 1:28 p.m., an interview was conducted with S1ADM. S1ADM confirmed all expired foods should be discarded appropriately. S1ADM confirmed all opened items should be dated and labeled with an open date.

Based on observations, record reviews, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 3 (#71, #82, and #84) of 5 (#39, #63, #71, #82, and #84) residents reviewed for Infection Control. The facility failed to: 1.) Identify Residents who required Enhanced Barrier Precautions (EBP) 2.) Ensure staff adhered to Enhanced Barrier Precautions while providing direct care to indwelling devices Findings: Resident #71 A review of Resident #71's Clinical Record revealed the resident was admitted to the facility on [DATE]. A review of Resident #71's Admission MDS with an ARD of 10/13/2024 revealed he had a BIMS of 13, which indicated he was cognitively intact. Further review revealed Resident #71 had a venous stasis ulcer. A review of the facility's Pressure Ulcer Weekly Log revealed Resident #71 had a stasis ulcer to the left leg, acquired on 09/30/2024. A review of Resident #71's Physician Orders revealed no orders for EBP. On 11/06/2024 at 9:05 a.m., an interview and observation was conducted with Resident #71. Resident #71 had a dressing to his left foot. Resident #71 stated he had wounds on his left ankle and left toe. On 11/06/2024 at 10:41 a.m., an observation was made of S4RN providing wound care for Resident #71. S4RN did not wear a gown while performing wound care to Resident #71's wounds. There was no EBP signage on the resident's door and no PPE noted outside the door or in the residents room. On 11/06/2024 at 2:05 p.m., an interview was conducted with S4RN. She stated she was unaware of what Enhanced Barrier Precautions were. She confirmed she did not wear a gown while performing wound care to Resident #71. Resident #82 A review of Resident #82's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Percutaneous Endoscopic Gastrostomy (PEG) tube. A review of Resident #82's Quarterly MDS with an ARD of 10/09/2024 revealed the following: Section K- Swallowing/Nutritional Status K0520- Nutritional Approaches- B. Feeding Tube On 11/06/2024 at 8:29 a.m., an observation was made of Resident #82's room. There was no PPE observed outside of the resident's room and no EBP signage observed on the resident's door. On 11/06/2024 at 11:10 a.m., an observation was made of S7LPN administering a bolus tube feeding to Resident #82. S7LPN did not wear a gown while administering the tube feeding to Resident #82. On 11/06/2024 at 1:11 p.m., an interview was conducted with S7LPN. She confirmed she did not wear a gown when she administered Resident #82's tube feeding. She stated she was unaware she needed to utilize EBP prior to providing direct care to Resident #82. Resident #84 A review of Resident #84's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Percutaneous Endoscopic Gastrostomy (PEG) tube. A review of Resident #84's Quarterly MDS with an ARD of 09/24/2024 revealed the following: Section K- Swallowing/Nutritional Status K0520- Nutritional Approaches- B. Feeding Tube On 11/06/2024 at 11:50 a.m., an observation was made of S6LPN administering a bolus feeding and medications through the PEG for Resident #84. S6LPN did not wear a gown while administering the tube feeding and medications for Resident #84. On 11/06/2024 at 1:20 p.m., an interview was conducted with S6LPN. She confirmed she did not wear a gown while administering the bolus feeding and medications through Resident #84's PEG. She stated she was unaware she needed to utilize EBP prior to providing direct care to Resident #84. On 11/06/2024 at 3:55 p.m., an interview was conducted with S2DON. She stated there were no residents who currently resided in the facility who were on EBP at this time. She confirmed she was unaware it was required for staff to wear a gown when providing direct care for Residents #71, #82, and #84. 47191 47546

Based on record review, observations, and interviews, the facility failed to ensure drugs were stored and labeled properly in accordance with current accepted professional principles. The facility failed to ensure: 1. Insulin pen and vial containing multiple doses of insulin were labeled with an open date in 1 (Med Room A) of 1 medication room reviewed; 2. Liquid medications were labeled with an open date in 1(Med Cart A) of 3 (Med Cart A, B, and C) medication carts reviewed; and 3. Medication Cart A and Cart C was locked when unattended. Findings: 1. On 11/04/2024 at 12:30 p.m., an observation was made of Med Room A with S5RN, which revealed the following: 1-Lantus insulin pen was opened and undated. 1-Lantus insulin vial was opened and undated. On 11/04/2024 at 12:33 p.m., an interview was conducted with S5RN. S5RN confirmed all insulin should be dated when opened, and was not. On 11/04/2024 at 12:38 p.m., an interview was conducted with S2DON. S2DON confirmed staff was expected to date insulin after opening. 2. On 11/04/2024 at 12:19 p.m., an observation was made of Med Cart A with S5RN, which revealed the following: 1-16 oz. bottle of Docusate Sodium Liquid 50 mg/ 5 mL was opened and undated. 1-16 oz. bottle of Lactulose Solution 10g/15 mL was opened and undated. On 11/04/2024 at 12:25 p.m., an interview was conducted with S5RN. She confirmed the above findings, and stated the medication bottles should have been dated when opened and were not. On 11/04/2024 at 12:38 p.m., an interview was conducted with S2DON. S2DON confirmed she expected staff to date liquid medications after opening. 3. On 11/06/2024 at 8:08 a.m., an observation was made of medication Cart A unlocked and unattended. On 11/06/2024 at 8:10 a.m., an observation was made Cart A unattended, unlocked, while a resident, staff, and visitor passed by. On 11/06/2024 at 8:14 a.m., an interview was conducted with S6LPN. S6LPN confirmed medication Cart A should have been locked when unattended. On 11/06/2024 at 11:20-11:24 a.m., an observation was made of medication Cart C unattended and unlocked. On 11/06/2024 at 12:09 p.m., an interview was conducted with S4RN. S4RN confirmed medication Cart C should have been locked when unattended. On 11/06/2024 at 2:00 p.m., an interview was conducted with S2DON. S2DON confirmed she expected staff to keep medication carts locked when unattended.

Based on record review, observation, and interviews, the facility failed to provide pharmaceutical services, including procedures which assure administering of all drugs and biologicals, to meet the needs of each resident. The facility failed to ensure an insulin pen needle was primed prior to administration of insulin per manufactures guidelines for 1 of 1 (#46) resident observed for insulin administration. Findings: Review of the Insulin Lispro's manufacturer insert revealed the following, in part: Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. Review of Resident #46's current Physician Orders revealed, in part: Accucheck four times a day Insulin Lispro 100 unit/mL, inject sliding scale four times a day. On 11/06/2024 at 11:35 a.m., an observation was made of S4RN performing an accucheck on Resident #46, which revealed a blood sugar of 378 requiring 10 units of insulin per sliding scale. On 11/06/2024 at 11:40 a.m., an observation was made of S4RN preparing and administering Resident #46's Insulin Lispro pen. S4RN prepared 10 units of insulin without priming the insulin pen needle prior to administering the insulin to Resident #46. On 11/06/2024 at 2:15 p.m., an interview was conducted with S4RN. S4RN stated she was not aware how to prime the insulin pens. S4RN confirmed she did not prime the insulin pen needle prior to administering Resident #46's insulin dose, and should have. On 11/06/2024 at 1:03 p.m., an interview was conducted with S2DON. S2DON stated an insulin pen should be primed prior to administration. S2DON confirmed she expected staff to follow manufacturer's recommendation of priming the insulin pens as directed.

Based on record reviews and interviews, the facility failed to ensure adequate monitoring for side effects with the use of psychotropic medication was completed for 1 (#15) of 5 (#15, #51, #63, #66, and #67) residents reviewed for unnecessary medications. Findings: Review of Resident #15's clinical record revealed a readmitted [DATE] with diagnoses which included: Bipolar, Major Depressive Disorder, Impulse Disorder, and Dementia with Behavioral Disturbances. Review of Resident #15's active physician orders revealed, in part: 08/02/2024- Fluoxetine 40 mg 1 tablet by mouth every day; Namenda 10mg 1 tablet by mouth twice a day; and Zyprexa 2.5 mg 1 tablet by mouth at bedtime. 10/01/2024- Seroquel 50 mg 1 tablet by mouth twice a day. Review of Resident #15's current medication administration record revealed Resident #15 had received the above medications within the last week. Further review revealed there was no documentation of monitoring for psychotropic medication side effects for Resident #15, and the facility was unable to provide documentation. On 11/07/2024 at 10:26 a.m., an interview was conducted with S4RN. S4RN confirmed she had not been monitoring or documenting Resident #15's psychotropic medication side effects, and should have. On 11/07/2024 at 9:40 a.m., an interview was conducted with S2DON. S2DON reviewed Resident #15's clinical record and confirmed there was no documentation of monitoring for side effects of Resident #15's psychotropic medications, and should have been.

Based on interviews and record review, the facility failed to protect the residents' right to be free from verbal abuse by a staff member for 1 (#1) of 3 (#1, #2 and #3) residents reviewed for abuse. The facility failed to protect Resident #1 from verbal abuse by S5CNA. This deficient practice resulted in an actual harm situation on the evening of 02/20/2024 when staff witnessed S5CNA yelling and cursing profanities at Resident #1, a cognitively impaired resident. S6CNA and S7CNA heard S5CNA yell at Resident #1 If you don't stop coming in and out of that room, I am going to bash your mother f****** head, Get up off the f****** floor. Shut the f***up. Get the f*** up. You are gonna get up by yourself. You're gonna lay in that mother f****** s*** and I'm not going to change s***. I'm gonna punch you in the f****** forehead. Following the incident, Resident #1 approached S6CNA crying and stated I hope that CNA isn't going to be taking care of me anymore. I am scared for my life. She has really shaken me. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Resident #1, it could be determined the reasonable person would have experienced severe psychosocial harm as a result of the verbal abuse, since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy titled Reporting of Abuse, Neglect, and/or Misappropriation of Resident Property revealed the following: B. Policy 3. Examples of Violations: -Yelling, swearing, scolding or other forms of verbal abuse; -Threatening a patient for any reason. Review of the facility's policy titled Prohibition of Abuse, Neglect, and/or the Misappropriation of Resident Property revealed the following: 6. Protection c. Suspend the employee until the formal investigation is complete, if needed. Review of the clinical record for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses, which included Bipolar Disorder with Psychosis, Major Depression, Cerebrovascular Accident, Anxiety, and Dementia. Review of Resident #1's quarterly MDS with an ARD of 02/12/2024 revealed the provider assessed the resident as having a BIMS of 5, which indicated the resident had severe cognitive impairment. Review of S5CNA's timecard for 02/20/2021 revealed S5CNA clocked in for the shift at 2:55 p.m. and clocked out at the end of the shift at 11:01 p.m. On 03/06/2024 at 11:53 a.m., an interview was conducted with S6CNA. S6CNA stated she saw S5CNA enter Resident #1's room on 02/20/2024 between 7:30 p.m. and 9:00 p.m. and heard her yell at Resident #1. S6CNA stated she heard S5CNA yelling If you don't stop coming in and out of that room, I am going to bash your mother f****** head. S6CNA stated she saw Resident #1 enter her room and push her walker into the bedside table which had an open soda can on it. She stated the soda can fell , spilling its contents on the bed, floor, and on Resident #1. S6CNA stated because of the spill on the floor, Resident #1 slipped and fell . S6CNA stated she then heard S5CNA say Get up off the f****** floor. You are gonna get up by yourself. You're gonna lay in that mother f****** s*** and I'm not going to change s***. S6CNA stated Resident #1 approached her crying and stated I hope that CNA isn't going to be taking care of me anymore. I am scared for my life. She has really shaken me. S6CNA stated she reported the incident to S3ADON on 02/21/2024. S6CNA confirmed the incident between S5CNA and Resident #1 was verbal abuse. S6CNA confirmed S5CNA continued to work and was assigned to care for Resident #1 for the rest of the shift. On 03/07/2024 at 9:50 a.m., an interview was conducted with Resident #1. Resident #1 was unable to hold a meaningful conversation due to cognitive impairment. She stated she could not remember if any staff ever yelled at her, cursed at her, abused or neglected her in any way. She stated she couldn't remember the incident that took place between her and S5CNA on 02/20/2024. On 03/07/2024 at 10:42 a.m., an interview was conducted with S7CNA. S7CNA stated on 02/20/2024 around 4:00 p.m., Resident #1 was emotional and crying, and began walking up and down the hall with her walker. S7CNA stated S5CNA said to her I don't have time for her s*** today, referring to Resident #1's emotional state. S7CNA stated between 7:30 p.m. and 9:00 p.m. when Resident #1 returned to her room, she bumped her bedside table with her walker which had a pitcher filled with soda causing it to spill onto the floor, bed linens, and on the Resident. S7CNA stated she followed S5CNA into Resident #1's room. Resident #1 was on the floor. S5CNA repeatedly told Resident #1 Get up off the f****** floor. Shut the f***up. Get the f*** up. You are gonna get up by yourself. You're gonna lay in that mother f****** s*** and I'm not going to change s***. S7CNA stated she assisted Resident #1 off of the floor and left the room to get a change of bed linens. S7CNA stated when she was returning to the room she overheard S5CNA say to Resident #1 I'm gonna punch you in the f****** forehead. S7CNA stated she reported the incident to S3ADON on 02/21/2024. S7CNA confirmed S5CNA continued to work and was assigned to care for Resident #1 for the rest of the shift. On 03/07/2024 at 12:38 p.m., an interview was conducted with S3ADON. S3ADON stated she was made aware of the incident on the morning of 02/21/2024. She stated she immediately informed S1ADM. S3ADON stated when she asked Resident #1 about the incident, the resident did not remember anything due to her impaired cognitive status. S3ADON stated S5CNA was informed on 02/21/2024 not to return to work due to an investigation regarding an allegation of abuse on 02/20/2024. S3ADON stated if she had been made aware at the time of the incident of the allegation of verbal abuse between S5CNA and Resident #1, she would have sent S5CNA home at that time. S6CNA confirmed S5CNA continued to work and was assigned to care for Resident #1 for the rest of the shift. S3ADON confirmed the incident between S5CNA and Resident #1 was verbal abuse. On 03/07/2024 at 1:34 p.m., an interview was conducted with S1ADM. He stated S3ADON notified him on 02/21/2024 that staff witnessed S5CNA curse at Resident #1 and used foul language on the evening of 02/20/2024. S1ADM stated he substantiated the allegation of verbal abuse by S5CNA to Resident #1 because he received written statements from two credible staff witnesses. S1ADM confirmed the incident between S5CNA and Resident #1 was verbal abuse. The facility implemented the following actions to correct the deficient practice: 1. Measures implemented for action plan regarding verbal abuse staff to resident: a. Written witness statements were obtained from S6CNA and S7CNA upon discovery of the allegation of verbal abuse on 02/21/2024 b. S5CNA was suspended immediately on 02/21/2024 pending investigation and ultimately terminated on 02/23/2024. Upon termination, S1ADM reported her to the CNA registry for termination as a result of abuse to a resident c. S1ADM entered SIMS report to State Agency on 02/21/2024 at 3:43 p.m. and began facility investigation 2. Residents with potential to be affected include all residents cared for by S5CNA. 3. Measures implemented to address problem identified in corrective action plan: a. In-services began on 02/21/2024 covering the topics of types of abuse, abuse reporting requirements and timelines, the 7 points of preventing abuse including protection of the resident, abuse violation examples, and the consequences of committing abuse. In-services were completed on 03/01/2024 when 100% of staff had received inservice training related to abuse and abuse reporting. b. The facility will continue monthly abuse including the 7 points of preventing abuse, abuse reporting in-services for the next three months. 4. Monitoring of compliance will include the following: a. Facility DON or designee will interview 4 cognitive residents per hall per week for 3 months to inquire if they are being abused or have witnessed abuse by staff. Questioned if anyone had talked to them in a threatening way, forced them to give them money or took money from them, touched them without consent, or if anyone had hit or been mean to them. Any negative responses will be investigated immediately. b. Results of these audits will be discussed weekly between Administrator, DON and ADON. Any negative responses will be investigated immediately. Facility compliance date as of 03/01/2024. Throughout the survey on 03/06/2024 and 03/07/2024, observations, record reviews and staff interviews revealed staff received training on the facility's abuse policies and procedures, were knowledgeable of the types of abuse and were aware abuse should be reported to administration immediately. Observations were made throughout the survey with no abuse identified. Observations, interviews, and record review revealed monitoring had begun with no further issues identified.

Based on interviews and record reviews, the facility failed to ensure an allegation of verbal abuse was reported immediately, but not later than 2 hours after the allegation was made, to the facility Administrator and to the State Survey Agency for 1(#1) of 3 (#1, #2, and #3) residents sampled for abuse. Findings: Review of the State Agency document titled Guidance for Mandated Reporting of Allegations of Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Reportable Incidents with a revision date of 10/04/2018, revealed the following: IV. Reporting Requirements: Nursing Facilities must report to the State Agency any incidents and allegations of abuse . immediately, but no later than 2 hours after the allegation is made, if the event that caused the allegation involves abuse or results in bodily harm or injury. Reporting is to be made to the Administrator, or designee, of the facility and to other officials in accordance with state law through established procedures. Review of the facility reported incident filed for Resident #1 revealed the following: Entered: 02/21/2024 at 3:43 p.m. Occurred: 02/20/2024 at 9:30 p.m. Discovered: 02/21/2024 at 1:00 p.m. Alleged Allegation #2: Verbal Abuse Incident Investigation: On 02/20/2024, S5CNA was witnessed yelling and cursing profanities at Resident #1. S5CNA was heard by S6CNA and S7CNA telling Resident #1 If you don't stop coming in and out of that room, I am going to bash your mother f****** head, Get up off the f****** floor. Shut the f***up. Get the f*** up. You are gonna get up by yourself. You're gonna lay in that mother f****** s*** and I'm not going to change s***, and I'm gonna punch you in the f****** forehead. Following the incident, Resident #1 approached S6CNA crying and stated I hope that CNA isn't going to be taking care of me anymore. I am scared for my life. She has really shaken me. On 03/06/2024 at 11:53 a.m., an interview was conducted with S6CNA. She stated on 02/20/2024 she witnessed S5CNA verbally abuse Resident #1. S6CNA stated she not report it immediately to S3ADON. She stated she did not know the floor nurse was her direct supervisor if administration was not in the building. S6CNA confirmed she should have reported the verbal abuse allegation immediately, and she did not. On 03/07/2024 at 10:42 a.m., a telephone interview was conducted with S7CNA. S7CNA stated on 02/20/2024, she observed S5CNA yell and curse at Resident #1. S7CNA stated she did not report the incident to the nurse on duty, S8LPN. S7CNA stated on 02/21/2024, she called and spoke with S3ADON and told her what she witnessed. S7CNA stated she should have reported the verbal abuse she witnessed immediately, and she did not. On 03/07/2024 at 12:38 p.m., an interview was conducted with S3ADON. S3ADON stated any allegation of abuse should be reported immediately to the supervisor and/or administration per the facility's policy. S3ADON stated she was not made aware of the allegation of verbal abuse between S5CNA and Resident #1, which took place on 02/20/2024, until 02/21/2024. She confirmed she should have been notified immediately, and was not. On 03/07/2024 at 1:34 p.m., an interview was conducted with S1ADM. S1ADM stated S6CNA and S7CNA stated they did not inform S8LPN when they witnessed S5CNA verbally abuse Resident #1, and they should have. He confirmed the expectation of all staff was to report any allegation of abuse immediately to the nurse and/or supervisor. He stated the initial investigation of verbal abuse was not submitted to the State Agency within 2 hours of the alleged incident taking place.

Based on record review and interviews, the facility failed to initiate and resolve grievances voiced for 2 (#46 and #60) of 19 sampled residents reviewed for grievances. Findings: Review of the facility's policy titled, Grievance Policy, revealed the following, in part: If you have a complaint raise it with the person you are working with. We ask you to allow us 5 working days. We will acknowledge complaints 24 hours a day. We will formally acknowledge your complaint within 5 working days and let you know how it was resolved. Review of the facility's policy titled, Personal Items, revealed the following in part: Procedure: 5. Anytime missing items of clothing or other personal property shall be reported immediately to the Social Service Director or nurse in charge. Resident #46 Review of the Quarterly MDS with an ARD of 09/26/2023 revealed Resident #46 had a BIMS of 15 which indicated intact cognition. Review of the Grievance Log from 09/01/2023 to 12/11/2023 revealed no grievances were filed for Resident #46. On 12/11/2023 at 1:16 p.m., an interview was conducted with Resident #46. She stated her navy pull over sweater was lost a few weeks ago. She stated it was sent to laundry and was never returned to her. She stated she told the CNA's, a nurse and laundry aids and had never heard back about her missing sweater. On 12/13/2023 at 8:47 a.m., an interview was conducted with S6CNA. She stated she sent Resident #46's blue sweater to be laundered. She stated the sweater never returned. She stated S5RN was aware. On 12/13/2023 at 8:50 a.m., an interview was conducted with S7CNA. She stated Resident #46's blue sweater was sent to be laundered. She stated the sweater never returned. She stated S8ES was aware. On 12/13/2023 at 12:00 p.m., an interview was conducted with S8ES. She stated she was told yesterday by Resident #46 of a missing a blue sweater for the first time. She stated she did not initiate a grievance. On 12/13/2023 at 12:15 p.m., an interview was conducted with S5RN. He stated on 12/01/2023 Resident #46 told him she was missing a blue sweater. He stated he did not initiate a grievance and did not know the time frame to report a grievance. On 12/13/2023 at 11:10 a.m., an interview was conducted with S2ADON. She stated she was responsible for writing grievances. She confirmed she was not informed of Resident 46's missing blue sweater and should have been. On 12/13/2023 at 12:52 p.m., an interview was conducted with S1NFA. He stated he expected staff to notify the S2ADON, Social Services or himself if a resident's missing item was not found. He confirmed he was never informed of Resident 46's missing blue sweater, a grievance had not been initiated, and should have been. Resident #60 Review of the Quarterly MDS with ARD of 11/07/2023 revealed Resident #60 had a BIMS of 12 which indicated moderately impaired cognition. Review of the Grievance Log from 08/01/2023 to 12/11/2023 revealed no grievances were filed for Resident #60. Review of the Resident Council Meeting Minutes from September 2023 through December 2023 revealed the following, in part: 10/26/2023 -Resident #60 stated he had some missing clothes. 11/30/2023 -Resident #60 had a concern his clothes had not been found. He stated his purple shirt and uniform were still missing. On 12/12/2023 at 9:20 a.m., an interview was conducted with Resident #60. He stated he reported his missing clothing in the Residents' Council meeting last month. He stated no one ever talked to him concerning his missing uniform and purple shirt. On 12/12/2023 at 9:42 a.m., an interview was conducted with S4APAD. She stated she was responsible for typing Resident Council Meeting Minutes. She stated after the Resident Council Meeting, she gave all department heads and the Administrator a copy of the minutes. On 12/13/2023 at 8:35 a.m., an interview was conducted with S3ADON. She stated she expected staff to report all grievances to herself or Social Services. She stated she typed up any grievances in a memo and gave it to the Administrator. She stated the Administrator was responsible for investigating grievances. She confirmed she was not made aware of Resident #60's missing items and should have been. On 12/13/2023 at 12:31 p.m., an interview was conducted with S1NFA. He stated the process for a grievance was for a CNA to report concerns to Social Services or S3ADON. He stated if they could not resolve the issue they would report the concerns to him. He stated he read the Residents' Council Meeting Minutes. After reviewing the residents 'council meeting minutes dated 11/30/2023, he stated he was not aware of a missing uniform or purple shirt. He confirmed he did not initiate a grievance and should have. 48912

Based on record review and interviews, the facility failed to ensure a Change in Status Minimum Data Set (MDS) Assessment was completed within 14 days of a resident admitted to hospice for 1 (#56) of 3 (#52, #56, and #72) sampled residents who received hospice services. Findings: Review of Resident #56's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #56's Hospice Face Sheet revealed Resident #56 was admitted to hospice on 07/17/2023. Review of Resident #56's MDS revealed a Significant Change MDS was submitted on 08/22/2023. On 12/12/2023 at 10:00 a.m., an interview was conducted with Resident #56's hospice nurse. She said Resident #56 was admitted to hospice on 07/17/2023. On 12/12/2023 at 9:20 a.m., an interview was conducted with S2DON. She confirmed the facility had 14 days to complete a Significant Change MDS. She confirmed a Significant Change MDS for Resident #56 was not submitted within the 14 day timeframe, and should have.

Based on observations, interviews, and record review, the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 4 (#20, #25, #43 and #56) of 84 residents residing in the facility. The facility failed to ensure: 1. S9HK, S5CNA, and S6CNA knocked and requested permission to enter Residents #20 and #25's room; 2. S10CNA knocked and requested permission to enter Resident #43's room; and 3. S5CNA knocked and requested permission to enter Resident #56's room. Findings: Resident #20 A review of Resident #20's Clinical Record revealed she was admitted to the facility on [DATE]. A review of Resident #20's quarterly MDS with an ARD of 09/01/2022 revealed Resident #20 had a BIMS of 9, which indicated she was moderately cognitively impaired. On 11/15/2022 at 1:59 p.m., an observation was made of S9HK entering Resident #20's room without knocking or asking for permission to enter. On 11/16/2022 at 9:15 a.m., an observation was made of S5CNA and S6CNA entering Resident #20's room without knocking or asking for permission to enter. On 11/16/2022 at 9:39 a.m., an interview was conducted with Resident #20. She stated it bothered her when the staff entered her room without knocking because she liked her privacy. Resident #25 On 11/15/2022 at 1:57 p.m., an observation was made of S9HK entering Resident #25's room without knocking or asking for permission to enter. On 11/16/2022 at 9:06 a.m., an observation was made of S5CNA and S6CNA entering Resident #25's room without knocking or asking for permission to enter. Resident #43 On 11/14/2022 at 9:35 a.m., an observation was made of S10CNA walking into Resident #43's room without knocking or asking permission to enter. Resident #56 A review of Resident #56's Clinical Record revealed she was admitted to the facility on [DATE]. A review of Resident #56's quarterly MDS with an ARD of 08/15/2022 revealed Resident #56 had a BIMS of 15, which indicated she was cognitively intact. On 11/14/2022 at 9:24 a.m., while conducting an interview with Resident #56, S5CNA entered Resident #56's room without knocking on the door or asking for permission to enter. Resident #56 stated the staff frequently came into the room without knocking. Resident #56 stated it really bothered her because she enjoyed her privacy. On 11/16/2022 at 2:11 p.m., an interview was conducted with S3ADON. S3ADON stated she expected staff to knock and request permission before entering a resident's room. S3ADON confirmed staff should not have walked into a resident's room without knocking or asking for permission to enter.

Based on observation and Interview, the facility failed to accurately conduct a comprehensive assessment for one resident (#236) as it relates to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one resident (#236) in a total sample of 23 residents reviewed for MDS documentation. Findings include: Resident #236 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation with Resident # 236 on 11/14/2022 at 10:41 a.m. revealed the resident had an indwelling supra pubic catheter. Review of the quarterly MDS with an ARD of 10/20/2022 revealed on Section I Active Diagnoses, I1550 [CONDITION(S)] was not assessed under active diagnosis. Further review of Section H Bladder and Bowel, H0100 Appliances- Z was marked None of the above which indicated Resident #236 was not assessed for a catheter. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with S2DON on 11/15/2022 at 12:37 p.m. She confirmed there was no documentation of an assessment for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, interviews, and record review the facility failed to maintain an infection prevention and control program and implement appropriate use of personal protective equipment to prevent the spread of COVID-19. The staff failed to wear facemasks at all times while in the facility. Findings: A review of the facility's policy titled Mask Policy and Procedure revealed, in part: Purpose: To provide facemask guidance to ensure resident and staff safety during COVID-19 pandemic. Policy: All staff must wear a facemask while in resident care areas of the facility. This includes breakrooms, bathrooms, and other spaces where they will encounter co-workers and residents. On 07/05/2022 at 9:45 a.m., an observation was made of S4LPN at NS1 without a facemask. Multiple residents were observed walking past NS1within 6 feet of S4LPN. On 07/05/2022 at 1:19 p.m., an observation was made of S4LPN at NS1 without a facemask. Multiple residents were observed sitting next to NS1 within 6 feet of S4LPN. On 07/05/2022 at 1:36 a.m., an observation was made of S4LPN at NS1 without a facemask with multiple residents observed walking by NS1. On 07/06/2022 at 10:35 a.m., an observation was made of S5WC and S3RN sitting at NS2 without a facemask. An observation was made of multiple residents walking past NS2 within 6 feet of S5WC and S3RN. On 07/06/2022 at 10:38 a.m., an observation was made of S6RN walking in corridor within 6 feet of multiple residents without a facemask. An observation was made of S6RN at NS1 with multiple residents within 6 feet. An observation was made of S6RN without a facemask speaking to a resident without a facemask within 6 feet. On 07/07/2022 at 9:05 a.m., an observation was made of S3RN sitting at NS2 without a facemask. An observation was made of a residents walking past NS2 within 6 feet of S3RN. On 07/06/2022 at 10:30 a.m., an interview was conducted with S2DON. She stated staff were expected to wear facemasks at all times while in the facility regardless of their vaccination status. She stated the facility was testing unvaccinated staff twice a week due to community transmission rate in the red zone indicating a high level transmission rate. On 07/07/2022 at 11:40 a.m., an interview was conducted with S1ADM. He stated the expectation was for all staff to wear facemask at all times while in the facility.

Based on observations and interview, the facility failed to store and prepare food under sanitary conditions by failing to ensure: 1. Food was properly stored in the walk-in-refrigerator 2. Knives and mixing bowel accessories were clean and ready for use 3. Yellow sticky substance on the mixing bowl table was removed According to the facility census, 89 residents are served food from the kitchen. Findings: Review of the facility policy titled Food Service to Prevent Risk of Cross Contamination revealed the following: Purpose: To ensure that all residents meals are cooked, stored, transported and served using methods that reduce risk of cross contamination and food borne illness. Process: 4. Opened product shall be dated as to the date opened and not kept on shelf beyond the manufacturer's recommendation. During the initial tour of the facility's kitchen with S4DM on 09/27/2021 at 9:00 a.m., the following observations were made: Walk-in-refrigerator: 1 plastic container of apple jelly opened, unlabeled with no date on the container. 1 plastic container of caramel opened, unlabeled with no date on the container. 1 plastic container of pimento cheese opened, unlabeled with no date on the container. 1 bag of hotdog buns opened, unlabeled with no date on the bag. 1 container each of apple juice, grape juice, and cherry juice opened, unlabeled with no open date on the container. 1 red bag on the floor in the corner of refrigerator containing 3 heads of cabbage. 3 packages of sliced turkey, opened, unlabeled and unsealed with no date on the packages. 1 bag of shredded cheddar cheese opened, undated and unsealed. Kitchen Area: 3 knives hanging on the wall with a dried white substance noted on the blades. 1 whip and 1 paddle accessory to the mixer with dried white substance on each accessory and yellow sticky substance on the mixing bowl table An interview was conducted with S4DM during the initial tour of the kitchen. She verified the above observations and acknowledged the facility failed to store foods under sanitary conditions. She confirmed all opened food products should be labeled with the date when it was opened. She further stated she was responsible for making sure this was done. She confirmed a white substance was on 3 knives, the whip and the paddle accessory to the mixer. She said the knives and the 2 mixer accessories were not cleaned properly. She confirmed the knives and the mixing accessories were used by the kitchen staff daily. She said the mixing bowl table had a sticky yellow substance on it. She said the staff should clean the mixing bowl table after each use. She said the kitchen was short staffed at the present time and she was trying to make it during this difficult time.

Based on observations and interviews, the facility failed to ensure infection control measures were practiced to provide a safe, sanitary environment and help prevent the development and transmission of infection for 1 (#52) of 1 (#52) residents observed with an indwelling urinary catheter. There was one resident residing in the facility with an indwelling urinary catheter. Findings: Review of the facility policy titled Catheters/Urinary Insertion/Re-Insertion revealed the following: Purpose: To provide a continuous drainage of urine from the resident's bladder Procedure: 6. Catheter drainage bags and tubing must be off the floor at all times. Review of the clinical record revealed Resident # 52 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS ARD 08/18/2021 revealed Resident #52's BIMS=14 which indicated she was cognitively intact. Section H Bowel and Bladder: Urinary continence- not rated; indwelling catheter Bowel continence- always incontinent An observation was made on 09/27/2021 at 10:00 a.m. of Resident #52. Resident #52's indwelling catheter bag was inside a trash bin next to the bed. At the time of this observation, S8HK was cleaning Resident #52's room. She said she found the indwelling catheter bag in the trash bin when she entered Resident #52's room this morning. She said she removed the indwelling catheter bag from the trash bin, replaced the trash bag and replaced the indwelling catheter bag into the trash bin. She said she was unaware who originally placed the indwelling bag in the trash bin. She said she had witnessed the bag leaking in the past and was the reason she put it in the trash bin. She confirmed she had placed the indwelling catheter bag in the trash bin in the past. She said she had not received an in-service instructing her where the indwelling catheter bag should be placed. An interview was conducted on 09/27/2021 at 10:05 a.m. with S3LPN. She said she provided care to Resident #52. At the time of the interview, S3LPN confirmed Resident #52's indwelling catheter bag was in a trash bin next to her bed. At this time, she removed the indwelling catheter bag from the trash bin and hung it on Resident #52's bed frame. She said she was unsure which staff member placed the indwelling catheter bag in the trash bin. An observation was made on 09/29/2021 11:25 a.m. of Resident #52. Residents #52's indwelling catheter bag was in a trash bin next to her bed. An interview was conducted on 09/29/2021 at 12:45 p.m. with S5CNA. She said she provided care to Resident #52. She said 30 minutes ago she went into Resident #52 room and found the indwelling catheter bag in the trash bin. She said she was unsure who put it in the trash bin but thought it may have been placed there by the housekeeping staff. An interview was conducted on 09/29/2021 at 12:50 p.m. with S6CNA. She said she provided care to Resident #52. She said she was present when S5CNA found Resident #52's indwelling catheter bag in the trash bin. She said she was unaware who put the catheter bag in the trash bin. An interview was conducted on 09/29/2021 at 1:00 p.m. with S9HK. She said she worked 6:00 a.m.-2:00 p.m. shift today. She said Resident #52's indwelling catheter bag was in the trash bin when she went into her room. She said she removed the indwelling catheter bag from the trash bin, replaced the plastic bag and put the indwelling catheter bag back into the trash bin. She said she had witnessed the bag leaking in the past and put it in the trash bin. She confirmed she had placed the indwelling catheter bag in the trash bin in the past. She said she had not received an in-service instructing her where the indwelling catheter bag should be placed. An interview was conducted on 09/29/2021 at 1:15 p.m. with S7ADON. She verified she was made aware on 09/27/2021 and 09/29/2021 by S3LPN that Resident #52's indwelling catheter bag was found in the trash bin next to the bed. She said the indwelling catheter bag should never be placed in the trash bin and should always be hung below the level of the bladder.

Based on observation, interview, and record review the facility failed to ensure a resident was not subjected to any form of abuse for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) residents reviewed for abuse. The facility failed to: 1.) Protect a resident (Resident #4) from deliberate disparaging remarks and disrespectful attitudes of staff. 2.) Immediately report and thoroughly investigate an allegation of abuse. 3.) Implement written policies and procedures that prohibit abuse of a resident (Resident #4). This deficient practice resulted in actual harm when Resident #4 exhibited [MEDICAL CONDITION] following a CNA not giving her donuts because Resident #4 is a diabetic. The CNA then started making fun of her for getting snacks out of the machine. The CNA said I love donuts and was playing like she was popping a donut in her mouth . The resident stated to facility staff she wanted to leave the facility. When told that she would be struck by a vehicle in the road she stated that she did not care. The resident verbalized these ideations to the hospital staff on 10/10/15 when transferred to the ER for attempting to elope from the facility. The resident verbalized wanting to suffocate herself in her pillow or roll herself into traffic following the nursing home staff verbally abusing her. Findings: A review of the facility ' s document titled (Nursing Home) Policy and Procedure for Reporting of Abuse, Neglect, and/or Misappropriation of Resident Property revealed the following: A. Procedure: Nursing facilities and administrators are mandated by federal regulation to have evident that all alleged violations by nurse aides are thoroughly investigated and that the results of all investigations verified, to take appropriate corrective action, 42 CFR 483-13 (c)(3)(4). 1. Description of the investigation: a. date/time of the incident b. statement that the allegation was found to be valid or not valid c. must be signed by the facility administrator or his designee d. identify the resident. 2. Written statements for all persons who have knowledge about the incident or were witnesses to the abuse, neglect mistreatment or misappropriation of a resident ' s property. a. statement must have date/time of incident, shift occurred b. detail account to the incident. Verbal abuse (profanity), physical abuse, psychological abuse, mistreatment, neglect. (Use actual words used by the abuser) c. signature of witness, title, and date of statement, this includes visitors. 3. Written statements should be descriptive and outline the incident in detail. 4. If only oral information can be obtained: a. must be at least two (2) persons present to receive the information. b. document the statement, sign and date (both parties) c. the reporter must also have the statement read back to him/her d. resident must agree with the statement e. must sign his/her name or mark his/her mark on the document f. the recorder and the witness to the statement must sign/dated and title the statement. 5. The report must be accompanied by the NAT-7 (employment/termination) form, a copy of the time card to validate that the employee in question was indeed on duty that day and also a copy of the abuse policy the employee signs when first employed. B. Policy 1. Description of Abuses Resident abuse occurs when a resident is hurt physically or emotionally . * . * Emotional Abuse refers to making fun of a resident, scolding a resident, calling a resident names or doing anything in order to humiliate the resident. It is also emotionally abusive to ignore residents who need assistance, or not talk with residents when helping them. Even residents who are senile can have their feelings hurt. * . 3. Examples of Violations: *Refusing to care for patient. Resident #4 A review of the clinical record revealed the following: Resident #4 was initially admitted to the nursing home on 10/24/12. The resident was recently admitted to an acute care facility on 10/10/15 and was readmitted to the Nursing Home on 10/23/15 with the following Diagnosis: [REDACTED]. A review of the Discharge MDS (Minimum Data Set) with an assessment date of 10/10/15 revealed Resident #4 had a BIMS (Brief Interview for Mental Status) score of 15 indicating she was cognitively intact. A review of Resident #4 ' s care plan revealed the following: Problem onset date 10/23/15- Resident Problem or Needs: Pt tried to leave building; Goals: Pt will not leave building trying to go to somewhere she should not go by 10/30/15 Approaches: 1. Monitor q (every) 1 hour prn (as needed) when trying to leave building or suicidal thoughts. A review of the facility ' s grievance/complaint tracking log with results from the last 90 days was reviewed. The log documented on 10/12/15 resident #4 filed a grievance that S4CNA was rude to her. The report further revealed there were no witnesses and the validity of the complaint was unknown. The S3SSD spoke with the resident ' s family, and the resolution was documented as ADON/Admin in serviced aid. 10/27/15 at 11:40 a.m. an interview was conducted with the ADON. The ADON was asked to provide the facility ' s investigation into Resident #4 ' s grievance from 10/10/15 regarding S4CNA. The ADON stated that all investigation notes were in the grievance log folder. A review of the incident folder revealed hand written notes on a blank sheet of paper regarding an incident involving Resident #4 on 10/10/15 as follows: S3SSD documented the following: Resident #4 ' s mother called today 10/12/15. She told S3SSD the Ambulance Service worker called her to say the way the aids at the nursing home talked to and about (Resident #4) was awful. S3SSD told Resident #4 ' s mother she would report this. Signed by S3SSD. The S3SSD documented a conversation with the EMS Employee: Resident #4 told her: Aids in room telling me I ' m a loser and no one wants me here. They won ' t give me my call light they aren ' t changing me like they are supposed to. S4CNA ' Well, well, well, what do we have here, going for a ride huh? ' Antagonizing her. ' You won ' t be coming back for a long time. ' All aids laughing. Called per pt request to let mom know where she was going and why. An attached 2nd page documented the following staff interview with S2ADON: 11/12/15 Spoke with S4CNA-Says I did not say anything like that . She called me a [***] . I told her next time get nurse-let her handle situation. She told me she told her she was going to go out-and told her couple of time. Told her let nurse handle situation. Signed by S2DON. An attached 3rd page documented the following hand written note from S1ADM: I spoke with EMS Company Supervisor on 10/13/15 concerning complaint to get details. EMS Company Supervisor spoke with staff member who was involved. Stated employee continually having conversation with resident stating ' you see I told you if you didn ' t act right going to send you out ' . EMS Employee stated could have been handled better. Thought Facility employee was antagonizing Resident #4 with language. Stated as soon as she got in Ambulance Resident #4 calmed down. Signed by S1ADM and dated 10/13/15. Further down on the same page was the following addendum by S1ADM. Will in service employee and monitor for further complaints. Attached was a document noting a video titled Managing Difficult Resident Behavior and signed by S4CNA on 10/11/15. These documents completed the facilities investigation into the events of 10/10/15, prior to the resident being sent to the ER. The Hospital records were reviewed and revealed the following: A review of the ED triage notes documented the following. Psychiatric Evaluation: History Chief Complaint: The history is provided by the patient and the EMS personnel: History of present illness: Patient sent by the nursing home for apparent psychiatric evaluation. According to paramedics when they arrived at the nursing home, there apparently were multiple aides, and in paramedics view point felt like they were antagonizing the patient, making however, at one point the patient did get upset and called one of the aides a name, apparently the paramedics notified the charge nurse of the behavior of the aides, patient told paramedics she wants to leave the nursing home, she did try to leave in the past. Stated that she is not treated fairly, patient says she does feel depressed and has some [MEDICAL CONDITION]. She has tried to get family to take her back home, however has not been able work it out. Nurses Notes from the hospital documented the following: 10/10/15 at 9:00 p.m.: Per Ambulance Service pt. brought here from Nursing Home, staff sent her for psy eval (Psychiatric Evaluation) r/t (related to) her trying to leave and yelling at staff, pt calm cooperative at this time, Ambulance Service states they were appalled at the staff and how unprofessional they were acting toward the patient, they were antagonizing her denies SI (Suicidal Ideation). 10/10/15 at 9:39 p.m.: Pt reports SI directly related to the aids at Nursing Home picking on her. States she does not like living there and only has those feelings when they are mean to her. Pt does not want to go back to Nursing Home. Pt requested family be contacted to have someone here with her. Pts mother and daughter were contacted and are aware that pt is here. Both state that they are unable to come to see her. A review of the Social Workers Notes from the hospital dated 10/10/15 documented the following: Consult for sw (Social Worker). Per nurse and physician, EMS reported that aides at nursing home seemed to antagonize patient making her more upset. EMS reported they felt aides at Nursing Home were rude to patient and unprofessional. Met with patient who admitted she did not like living at Nursing Home and had been there for 3 years. Per patient, she stated the aides ' don ' t like me because I report them ' . Patient stated she has been depressed lately due to the aides and having to live at Nursing Home. Patient expressed some SI (Suicidal Ideation). Particularly when the aides ' are mean ' . Patient stated she has thought about suffocating herself with a pillow or rolling her wheelchair into traffic. Again, patient indicated she has these thoughts only after she and the aides have been arguing. Patient said she currently attends (Behavioral Facility) outpatient program and has been hospitalized at (Behavioral Facility) X2. Awaiting physician ' s evaluation. A review of the hospital physician notes dated 10/11/15 at 12:35 a.m. revealed the following: Social service consult obtained, on further investigation and discussion with the patient with a social worker and nursing staff, the patient does state she has had [MEDICAL CONDITION], she expressed this more to them than she did to me initially. She has these thoughts including tonight when she feels she is ridiculed or antagonized by staff at the nursing home, patient knows she has some family issues as well as no one can really help her or take care of her and this upsets her as well. The patient admits to trying to leave the nursing home in the past Patient admits to me that she does not want to go back to the nursing home Diagnosis: [REDACTED]. Signed by ER Physician. A review of the hospital flow sheets revealed the following: 10/10/15 at 10:04 p.m. Suicide Risk: Does the patient verbalize or display characteristics of impaired judgment or suicide risk? Yes Suicide Risk Assessment: Expressing suicidal/self-harm thoughts without intent? Yes. Notified MD, Social Worker and Security immediately of potential Suicide risk: Yes. Psychosocial Safety Checks were documented on 10/10/15 at 11:11 p.m.: Behavioral Precautions Minimal Q Shift: Is the patient PEC/CEC or Suicidal: Yes The following hospital report were of the events leading up to admit as told to hospital staff by the EMS personnel: The EMS personnel stated they were called to the nursing home regarding a resident with altered mental status who was trying to leave the facility. Upon their arrival the EMS Personnel found Resident #4 seated in a wheelchair, awake and oriented X4. Resident #4 appeared in no distress but stated she was very upset with this staff . She was calm and cooperative with the EMS personnel. Resident #$ stated that the aid had just told her ' that I am a loser and nobody wants me ' . Resident #4 also said that the aids refuse to give her the call button and when she informed them she has a soiled diaper that ' they will leave me in it it for hours ' . ' They also refuse to give me snack too ' . When Resident #4 told EMS Personnel that a staff member told Resident #4 ' we not going to give you no donut. Resident #4 stated to the EMS Personnel that is why she was ' very upset, because they antagonize me ' . Resident #4 stated to EMS Personnel that she wanted to leave and go to another place but cannot because ' no one will believe me ' . After loading Resident #4 into truck the EMS Personnel found her very pleasant with no complaints. EMS Personnel took Resident #4 to the hospital without incident and reported to staff RN. A review of the Behavioral Health Hospital records where Resident #4 was PEC (Physician Emergency Certificate) revealed the following: Psychiatric Evaluation Dated 10/14/15 Chief Complaint: Tried to run away. ' History of Present Illness: This is a Caucasian female with a history of depression who has been admitted after she was sent to the emergency room for an evaluation from the nursing home. Patient reportedly has been depressed lately due to aids being ' mean ' to her. She had thoughts of suffocating herself with a pillow and rolling her wheel chair into traffic. She indicated these thoughts only after because of the way the staff has been treating her and she does not want to return to the nursing home, however, she has very poor family support and is unable to live anywhere else. She has suffered a stroke 3 years ago and since then she has been in the nursing home. Patient has been attending Behavioral Health Hospital Day Program which she finds to be very helpful. Again she has very poor family support and she cannot recall the last time family has come to visit her. On 10/27/15 at 3:10 p.m. an interview was conducted with Resident #4. The resident was sitting upright in a wheelchair in her room. She was alert and oriented. The resident requested that the door to the room be closed for privacy. She was asked to recall the events of 10/10/15 prior to being sent to the hospital. She stated that earlier in the day she had requested cigarettes from the staff which were refused and this upset her. She stated later that day S4CNA was passing out donut snacks. She stated S4CNA would not give her donuts because Resident #4 is a diabetic. Resident #4 stated she then went to the snack machine to get her own snack. Resident #4 stated that is when S4CNA started in on me . She stated S4CNA started making fun of her for getting snacks out of the machine. She stated S4CNA was saying I love donuts and was playing like she was popping a donut in her mouth . Resident #4 stated she started going out the front door of the facility. She stated she was headed toward the street. The street in front of the facility is identified as a highway and heavily trafficked. She stated I was just trying to go home. The way the aids treat me I just wanted to go home . Resident #4 further stated the ambulance drivers saw how S4CNA was making fun of her. She stated that when she was on the EMS stretcher being wheeled to the ambulance S4CNA followed her and as she was being placed into the ambulance S4CNA stated Well, well, well, what do we have here. Going for ride huh? You won ' t be coming back for a long time. S4CNA continued to taunt Resident #4 in front of EMS staff stating I love donuts and playing like she was popping a donut in her mouth as she was being wheeled out by the EMS. On 10/28/15 at 11:40 a.m. an interview was conducted with S2ADON. She was asked to recall the incident between S4CNA and Resident #4 on 10/10/15. S2ADON stated she found out about the incident on Monday, 10/12/15 after it took place. S2ADON was asked if S4CNA worked on the 200 Hall with Resident #4. She stated that evening S4CNA was assigned the 100 Hall. She stated that S4CNA can be pulled to the 200 Hall to assist breaks and passing snacks. S2ADON stated Resident #4 had requested cigarettes earlier in the day on 10/10/15 but the nurse had refused to give her any. S2ADON stated the resident was sent to the hospital around 6 p.m. for trying to leave the facility . She was asked if she knew what had occurred between 2 p.m. when she was refused cigarettes and 6 p.m. when she was sent out. S2ADN stated she knew of no events that had occurred during that time. She was asked if S4CNA had been written up recently for any resident complaints. She stated all the events of the facility ' s investigation can be found in the incident log folder. On 10/29/15 at 11:45 a.m. an interview was conducted with S2ADON. The ADON was given a copy of the facility ' s written investigation and asked if they had any other documentation regarding the incident. The ADON said no that ' s everything. She stated she didn ' t really know what all happened with that . S2ADON stated she spoke with S4CNA about the incident. She stated S4CNA denied saying anything. She stated Resident #4 was trying to go out of the facility that night. She stated the facility sent Resident #4 to the hospital because she kept trying to leave the facility and go towards the road. S2ADON stated there was not an investigation of that timeframe. She was asked if the written notes on the pages in the incident folder was the only investigation regarding the incident between S4CNA and Resident #4.She stated that was all the facility had regarding their investigation. On 10/29/15 at 11:49 a.m. during an interview with S2ADON she stated her note dated 10/10/15 documented the events prior to Resident #4 being sent to the ER. Documented on a blank nursing note was the following: 10/10/15 6pm Pt. has attempted to leave and go out door X2. Monitoring pt. 1 on 1 CNA with patient at present until behavior is app (appropriate). Call phoned to Dr. New order: [MEDICATION NAME] 2 mg shot if no result send to hospital . 7:00 PM monitoring pt. Trying to leave. Ambulance Service notified to transfer to hospital. Signed by S2DON. 7:30 pm AAS here. Resident in room. CNA w/her 1:1.Referto go to hospital. Informed will be PEC: but she needs to go to the hospital. discharged to go to hospital. RP Mother notified of transfer. Notified hospital ER of transfer. BP 110/80-80-20 T 98.6. No skin Dec (decubitus) no rash upon transfer. 9 pm Call placed to hospital informed resident admitted 10/13/15 8 a.m. Continue to be in hospital. On 10/28/15 S4CNA personnel record was reviewed. The date of hire was documented as 7/7/15. The record contained the following note: dated 9/25/15 Written up for sitting in resident ' s room on cell phone. Told you cannot be on cell phone, you cannot be sitting in resident ' s room. This is a warning - another incident of this - will result in disciplinary action. On 10/28/15 at 12:15 p.m. an interview was conducted with S1ADM. He was asked about the incident which occurred on 10/10/15 regarding S4CNA and Resident #4. He stated he spoke with the EMS Supervisor the following week. The EMS Supervisor told S1ADM that he had spoken to the EMS staff regarding the events. The EMS Supervisor told S1ADM the situation was handled poorly but in his opinion was not verbal abuse. He was asked if he did an investigation about what led to the incident he stated he did not. He stated Resident #4 is a chronic complainer. He stated Resident #4 gets upset if she does not get enough ice or is out of cigarettes. He stated Resident #4 has a long history of filing complaints against staff members. He stated if Resident #4 does not get what she wants when she wants it she will complain. S1ADM was asked if he spoke to the EMS employee who witnessed the incident regarding Resident #4. S1ADM stated No I didn ' t . S1ADM was asked if he did an investigation about what led to the incident and he stated he had not. S1ADM was asked if he had filed an OTIS (Online Tracking Incident System) as required by the state. S1ADM stated No I didn ' t file an OTIS report . On 10/28/15 at 2:30 p.m. a telephone interview was conducted with the EMS Company Supervisor. He stated he is the liaison between the ambulance service and the nursing homes. He was asked about the incident which occurred at the facility on 10/10/15. He stated the EMS Employee had communicated with him what she had witnessed at the facility on 10/10/15. He stated the EMS Employee informed him she had been called to pick up a resident from the facility. He further stated the EMS Employee informed him that one of the aids at the facility had been antagonizing Resident #4. The EMS Company Supervisor stated it was certainly verbally inappropriate. He stated he discussed the incident with the nursing home administrator (S1ADM). On 10/28/15 at 3:30 p.m. an interview was conducted with S4CNA. She was asked how long she had been working at the facility. She stated 3 months. S4CNA was asked if she could recall the events prior to the resident being sent to the hospital on [DATE]. S4CNA stated she was assigned to hand out snacks that night to the residents. She stated resident #4 requested donuts that were being handed out. She told Resident #4 she could not have donuts because Resident #4 is diabetic. S4CNA stated Resident #4 became upset because she could not have a donut. She stated Resident #4 kept trying to leave the facility that evening. She stated Resident #4 stated she was going to the road and trying to go home. She stated Resident #4 was sent to the hospital because she kept trying to leave the facility. S4CNA was asked if she had directly said to the resident Well, well, well, what do we have here, going for a ride huh? You won ' t be coming back for a long time . S4CNA denied having made that statement. S4CNA was asked if she had made any remarks to the resident that evening regarding Resident #4 getting snacks form the snack machine. S4CNA denied making any comment. On 10/29/15 at 09:30 a.m. a telephone interview was conducted with the EMS Employee. She was asked if she answered the call to pick up the resident from the nursing home on 10/10/15 around 6:00 p.m. She stated she responded to a call regarding a resident with altered mental status trying to leave the facility. She stated she arrived at the nursing home around 6 p.m. She stated Resident #4 was aggravated and wanted to go outside to smoke a cigarette. She stated that while Resident #4 was getting on the stretcher S4CNA was antagonizing her. The EMS Employee stated S4CNA was saying Well, well, well look what you got yourself into now. Remember, don ' t eat donuts. The EMS Employee stated Resident #4 ' s roommate said see you tomorrow and S4CNA responded by saying Oh no, you won ' t be back for a long time . She stated all the aides were laughing. The EMS Employee stated she thought the staff at the facility were antagonizing Resident #4. The EMS Employee further stated she had been working as an EMT for 2 years and had never witnessed anything like that in a nursing home. She stated after leaving the facility Resident #4 was very pleasant and relieved to be out of the facility. She further stated she notified her supervisor a couple of days later of the incident and she explained it to him just as she was explaining it to the surveyors. The EMS Employee was asked if she thought the actions by S4CNA were willful and abusive. The EMS Employee stated Yes. No doubt in my mind. Absolutely they were being verbally abusive. If they can do that to my face what do you think they do when no one is around.

Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse were reported immediately to officials in accordance with state law through established procedures. The facility further failed to ensure: 1. An alleged violation of abuse that occurred on 10/12/15 involving a CNA and Resident #4 was thoroughly investigated. 2. Actions were taken to protect Resident #4 from further potential abuse from the person Resident identified as the alleged perpetrator. 3. The State agency was notified through the Online Tracking Incident System (OTIS) of the results of all investigations within 5 working days of the incident. This deficient practice resulted in harm when Resident #4 exhibited [MEDICAL CONDITION] following a CNA not giving her donuts because Resident #4 is a diabetic. The CNA then started making fun of her for getting snacks out of the machine. The CNA said I love donuts and was playing like she was popping a donut in her mouth . The resident stated to facility staff she wanted to leave the facility. When told that she would be struck by a vehicle in the road she stated that she did not care. The resident verbalized these ideations to the hospital staff on 10/10/15 when transferred to the ER for attempting to elope from the facility. The resident verbalized wanting to suffocate herself in her pillow or roll herself into traffic following the nursing home staff verbally abusing her. The resident ' s mother reported on 10/12/15 to the social service staff that Resident #4 was verbally abused. The social service staff spoke with the EMS employee ' s and verified that a CNA was verbally abusive prior to transporting Resident #4 to the ER. The alleged perpetrator was not reassigned from caring for or being in contact with Resident #4 while an investigation was in progress. The state agency was not made aware of the alleged abuse. Findings: A review of the facility ' s document (Nursing Home) Policy and Procedure for Reporting of Abuse, Neglect, and/or Misappropriation of Resident Property revealed the following: A. Procedure: Nursing facilities and administrators are mandated by federal regulation to have evidence that all alleged violations by nurse aides are thoroughly investigated and that the results of all investigations verified, to take appropriate corrective action, 42 CFR 483-13 (c)(3)(4). 1. Description of the investigation: a. date/time of the incident b. statement that the allegation was found to be valid or not valid c. must be signed by the facility administrator or his designee d. identify the resident. 2. Written statements for all persons who have knowledge about the incident or were witnesses to the abuse, neglect mistreatment or misappropriation of a resident ' s property. a. statement must have date/time of incident, shift occurred b. detail account to the incident. Verbal abuse (profanity), physical abuse, psychological abuse, mistreatment, neglect. (Use actual words used by the abuser) c. signature of witness, title, and date of statement, this includes visitors. 3. Written statements should be descriptive and outline the incident in detail. 4. If only oral information can be obtained: a. must be at least two (2) persons present to receive the information. b. document the statement, sign and date (both parties) c. the reporter must also have the statement read back to him/her d. resident must agree with the statement e. must sign his/her name or mark his/her mark on the document f. the recorder and the witness to the statement must sign/date and title the statement. 5. The report must be accompanied by the NAT-7 (employment/termination) form, a copy of the time card to validate that the employee in question was indeed on duty that day and also a copy of the abuse policy the employee signs when first employed. B. Policy 1. Description of Abuses Resident abuse occurs when a resident is hurt physically or emotionally . * . * Emotional Abuse refers to making fun of a resident, scolding a resident, calling a resident names or doing anything in order to humiliate the resident. It is also emotionally abusive to ignore residents who need assistance, or not talk with residents when helping them. Even residents who are senile can have their feelings hurt. * . 3. Examples of Violations: * . *Refusing to care for patient. Resident #4 A review of the clinical record revealed the following: The resident was recently admitted to an acute care facility on 10/10/15 and was readmitted to the Nursing Home on 10/23/15 with the following Diagnosis: [REDACTED]. A review of the MDS (Minimum Data Set) with an (ARD) assessment reference date of 10/04/15 revealed Resident #4 had a BIMS (Brief Interview for Mental Status) score of 15 indicating she was cognitively intact. A review of the facility ' s grievance/complaint tracking log with results from the last 90 days was reviewed. The log documented on 10/12/15 resident #4 filed a grievance that S4CNA was rude to her. The report further revealed there were no witnesses and the validity of the complaint was unknown. The S3SSD spoke with the resident ' s family, and the resolution was documented as ADON/Admin in serviced aid. 10/27/15 at 11:40 a.m. an interview was conducted with the ADON. The ADON was asked to provide the facility ' s investigation into Resident #4 ' s grievance from 10/10/15 regarding S4CNA. The ADON stated that all investigation notes were in the grievance log folder. A review of the incident folder revealed hand written notes on a blank sheet of paper regarding an incident involving Resident #4 on 10/10/15 as follows: S3SSD documented the following: Resident #4 ' s mother called today, 10/12/15. She told S3SSD the Ambulance Service worker called her to say the way the aids at the nursing home talked to and about (Resident #4) was awful. S3SSD told Resident #4 ' s mother she would report this. The S3SSD documented a conversation with the EMS Employee: Resident #4 told her: Aids in room telling me I ' m a loser and no one wants me here. They won ' t give me my call light they aren ' t changing me like they are supposed to. 'Well, well, well, what do we have here, going for a ride huh? ' Antagonizing her. 'You won ' t be coming back for a long time. ' All aids laughing. Called per pt. request to let mom know where she was going and why. An attached 2nd page documented the following staff interview with S2ADON: 11/12/15 Spoke with S4CNA. Says I did not say anything like that . She called me a [***] . I told her next time get nurse-let her handle situation. She told me she told her she was going to go out-and told her couple of time. Told her let nurse handle situation. An attached 3rd page documented a statement by S1ADM. The hand written note contained the following: I spoke with EMS Company Supervisor on 10/13/15 concerning complaint to get details. EMS Company Supervisor spoke with staff member who was involved. Stated employee continually having conversation with resident stating ' you see I told you if you didn ' t act right going to send you out ' . EMS Employee stated could have been handled better. Thought Facility employee antagonizing Resident #4 with language. Stated as soon as she got in Ambulance Resident #4 calmed down. Signed by S1ADM and dated 10/13/15. Further down on the same page was the following addendum by S1ADM. Will in service employee and monitor for further complaints. Attached was a document noting a video titled Managing Difficult Resident Behavior and signed by S4CNA on 10/11/15. These documents completed the facilities investigation into the events of 10/10/15, prior to the resident being sent to the ER. The facility ' s investigation of the incident on 10/10/15 between Resident #4 and S4CNA did not contain written statements from Resident #4, Resident #4 ' s roommate, S4CNA, EMS Personnel, Ward Clerk, or any other witnesses to the incident. There were no written statements from anyone directly involved in the incident between Resident #4 and S4CNA. The Hospital records were reviewed and revealed the following: History of present illness: Patient, sent by the nursing home for apparent psychiatric evaluation. According to paramedics when they arrived at the nursing home, there apparently were multiple aides, and in paramedics view point felt like they were antagonizing the patient, at one point the patient did get upset and called one of the aides a name, apparently the paramedics notified the charge nurse of the behavior of the aides, patient told paramedics she wants to leave the nursing home, she did try to leave in the past. Stated that she is not treated fairly, patient says she does feel depressed and has some [MEDICAL CONDITION]. She has tried to get family to take her back home, however has not been able work it out. Nurses Notes from the hospital documented the following: 10/10/15 at 9:00 p.m.: Per (Ambulance Service pt. brought here from Nursing Home, staff sent her for psy eval (Psychiatric Evaluation) r/t (related to) her trying to leave and yelling at staff, pt. calm cooperative at this time, Ambulance Service states they were appalled at the staff and how unprofessional they were acting toward the patient, they were antagonizing her denies SI (Suicidal Ideation). 10/10/15 at 9:39 p.m.: Pt. reports SI directly related to the aids at Nursing Home picking on her. States she does not like living there and only has those feelings when they are mean to her. Pt. does not want to go back to Nursing Home. Social Worker Notes from the hospital dated 10/10/15 at 9:41 p.m. revealed the following: Consult for sw (Social Worker). Per nurse and physician, EMS reported that aides at nursing home seemed to antagonize patient making her more upset. EMS reported they felt aides at Nursing Home were rude to patient and unprofessional. Met with patient who admitted she did not like living at Nursing Home and had been there for 3 years. Per patient, she stated the aides ' don ' t like me because I report them ' . Patient stated she has been depressed lately due to the aides and having to live at Nursing Home. Patient expressed some SI Suicidal Ideation particularly when the aides ' are mean ' The following hospital report titled Encounter Flowsheets were of the events leading up to admit as told to hospital staff by the EMS personnel: The EMS personnel stated they were called to the nursing home regarding a resident with altered mental status who was trying to leave the facility. Upon their arrival the EMS Personnel found Resident #4 seated in a wheelchair, awake and oriented X4. Resident #4 appeared in no distress but stated she was very upset with this staff . She was calm and cooperative with the EMS personnel. Resident #4 stated that the aid had just told her ' that I am a loser and nobody wants me ' . Resident #4 also said that the aids refuse to give her the call button and when she informed them she has a soiled diaper that ' they will leave me it for hours ' . ' They also refuse to give me snack too ' . When Resident #4 told EMS Personnel that a staff member told Resident #4 ' we not going to give you no donut ' . The EMS Personnel witnessed staff laughing at her as they were wheeling away saying ' you not coming back for a while, have fun where you ' . Resident #4 stated to the EMS Personnel that is why she was ' very upset, because they antagonize me ' . Resident #4 stated to EMS Personnel that she wanted to leave and go to another place but cannot because ' no one will believe me ' . After loading Resident #4 into truck the EMS Personnel found her very pleasant with no complaints. EMS Personnel took Resident #4 to the hospital without incident and reported to staff RN. On 10/27/15 at 3:10 p.m. an interview was conducted with Resident #4. The resident was sitting upright in a wheelchair in her room. She was alert and oriented. The resident requested that the door to the room be closed for privacy. She was asked to recall the events of 10/10/15 prior to being sent to the hospital. She stated that earlier in the day she had requested cigarettes from the staff which were refused and this upset her. She stated later that day S4CNA was passing out donut snacks. She stated S4CNA would not give her donuts because Resident #4 is a diabetic. Resident #4 stated she then went to the snack machine to get her own snack. Resident #4 stated that is when S4CNA started in on me . She stated S4CNA started making fun of her for getting snacks out of the machine. She stated S4CNA was saying I love donuts and was playing like she was popping a donut in her mouth . Resident #4 stated she started going out the front door of the facility. She stated she was headed toward the street. The street in front of the facility is identified as a highway and heavily trafficked. She stated I was just trying to go home. The way the aids treat me I just wanted to go home . Resident #4 further stated the ambulance drivers saw how S4CNA was making fun of her. She stated that when she was on the EMS stretcher being wheeled to the ambulance CNA S4CNA followed her and as she was being placed into the ambulance S4CNA stated Well, well, well, what do we have here. Going for ride huh? You won ' t be coming back for a long time. S4CNA continued to taunt the Resident #4 in front of EMS staff stating I love donuts and playing like she was popping a donut in her mouth as she was being wheeled out by the EMS. On 10/28/15 at 11:40 a.m. an interview was conducted with S2ADON. She was asked to recall the incident between S4CNA and Resident #4 on 10/10/15. S2ADON stated she found out about the incident on 10/12/15. S2ADON was asked if S4CNA worked on the 200 Hall with Resident #4. She stated that evening S4CNA was assigned the 100 Hall. She stated that S4CNA can be pulled to the 200 Hall to assist with breaks and passing snacks. S2ADON that earlier in the day on 10/10/5 there was an incident when Resident #4 had requested cigarettes and refused. S2ADON stated the resident was sent to the hospital around 6 p.m. for trying to leave the facility. She was asked if she knew what had occurred between 2 p.m. when she was refused cigarettes and 6 p.m. when she was sent out. S2ADN stated she knew of no events that had occurred during that time. She was asked if the facility had any other documentation regarding the incident. S2ADON stated all of the documentation regarding the incident is in the incident log folder. On 10/29/15 at 11:45 a.m. an interview was conducted with S2ADON. She was asked about the incident on 10/10/15 between S4CNA and Resident #4. S2ADON stated she didn't really know what all happened with that. She was shown a copy of the paper the facility filled out regarding the incident between Resident #4 and S4CNA. S2ADON was asked if the facility had any other documentation regarding the incident. S2ADON stated there was no other documentation. S2ADON stated she spoke with S4CNA about the incident. She stated S4CNA denied saying anything to Resident #4. S2ADON stated Resident #4 was trying to go out of the facility that night. She stated the facility sent Resident #4 to the hospital because she kept trying to leave the facility and go towards the road. She was asked if there was any investigation of what occurred between 2:00 p.m. and 6:00 p.m.to explain why Resident #4 was so upset. S2ADON stated there was not an investigation of that timeframe. She was asked if the written notes on the pages in the incident folder was the only investigation regarding the incident between S4CNA and Resident #4. S2ADON stated that was all the facility had regarding their investigation. On 10/28/15 at 12:15 p.m. an interview was conducted with S1ADM. He was asked about the incident which occurred on 10/10/15 regarding S4CNA and Resident #4. He stated he spoke with the EMS Supervisor the following week. The EMS Supervisor told S1ADM that he had spoken to the EMS staff regarding the events. The EMS Supervisor told S1ADM the situation was handled poorly but in his opinion was not verbal abuse. He was asked if he did an investigation about what led to the incident he stated he did not. He stated Resident #4 is a chronic complainer. He stated Resident #4 gets upset if she does not get enough ice or is out of cigarettes. He stated Resident #4 has a long history of filing complaints against staff members. He stated if Resident #4 does not get what she wants when she wants it she will complain. S1ADM was asked if he spoke to the EMS employee who witnessed the incident regarding Resident #4. S1ADM stated No I didn ' t . S1ADM was asked if he did an investigation about what led to the incident and he stated he had not. S1ADM was asked if he had filed an OTIS (Online Tracking Incident System) as required by the state. He stated No, I didn't On 10/28/15 at 2:30 p.m. a telephone interview was conducted with the EMS Company Supervisor. He stated he is the liaison between the ambulance service and the nursing homes. He was asked about the incident which occurred at the facility on 10/10/15. He stated the EMS Employee had communicated with him what she had witnessed at the facility on 10/10/15. He stated the EMS Employee informed him she had been called to pick up a resident from the facility. He further stated the EMS Employee informed him that one of the aids at the facility had been antagonizing Resident #4. The EMS Company Supervisor stated it was certainly verbally inappropriate. He stated he discussed the incident with the nursing home administrator. On 10/28/15 at 3:30 p.m. an interview was conducted with S4CNA. She was asked how long she had been working at the facility. She stated 3 months. S4CNA was asked if she could recall the events prior to the resident being sent to the hospital on [DATE]. S4CNA stated she was assigned to hand out snacks that night to the residents. She stated resident #4 requested donuts that were being handed out. She told Resident #4 she could not have donuts because Resident #4 is diabetic. S4CNA stated Resident #4 became upset because she could not have a donut. She stated R4 kept trying to leave the facility that evening. She stated Resident #4 stated she was going to the road and trying to go home. She stated Resident #4 was sent to the hospital because she kept trying to leave the facility. S4CNA was asked if she had directly said to the resident Well, well, well, what do we have here, going for a ride huh? You won ' t be coming back for a long time . S4CNA denied having made that statement. S4CNA was asked if she had made any remarks to the resident that evening regarding Resident #4 getting snacks form the snack machine. S4CNA denied making any comment. On 10/29/15 at 09:30 a.m. a telephone interview was conducted with the EMS Employee. She was asked if she answered the call to pick up the resident from the nursing home on 10/10/15 around 6:00 p.m. She stated she responded to a call regarding a resident with altered mental status trying to leave the facility. She stated she arrived at the nursing home around 6 p.m. She stated Resident #4 was aggravated and wanted to go outside to smoke a cigarette. She stated that while Resident #4 was getting on the stretcher S4CNA was antagonizing her. The EMS Employee stated S4CNA was saying Well, well, well look what you got yourself into now. Remember, don ' t eat donuts. The EMS Employee stated Resident #4 ' s roommate said see you tomorrow and S4CNA responded by saying Oh no, you won ' t be back for a long time . She stated all the aides were laughing. The EMS Employee stated she thought the staff at the facility were antagonizing Resident #4. The EMS Employee further stated she had been working as an EMT for 2 years and had never witnessed anything like that in a nursing home. She stated after leaving the facility Resident #4 was very pleasant and relieved to be out of the facility. She further stated she notified her supervisor a couple of days later of the incident and she explained it to him just as she was explaining it to the surveyors. The EMS Employee was asked if she thought the actions by S4CNA were willful and abusive. The EMS Employee stated Yes. No doubt in my mind. Absolutely they were being verbally abusive. If they can do that to my face what do you think they do when no one is around.

Based on record review, interview the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable physical and mental wellbeing of its residents. The facility failed to have a system in place to ensure that residents' directives were honored for 1(#2) of 51 residents wanting life saving measure done in the case of an emergent situation out of a facility census of 112 . The facility failed to: 1. Have a policy and procedure in place for residents who wished to have CPR performed. 2. Ensure staff honored the client's CPR Directive for residents (#2) on [DATE] 3. Ensure staff initiated CPR (cardiopulmonary resuscitation) on a resident found pulseless and not breathing (#2) on [DATE] 4. Immediately call 911 emergency services when a resident was found pulseless and not breathing (#2) on [DATE] 5. Have a system in place to ensure staff honored resident's directives for provision of CPR in the event of no pulse or not breathing (#1, #3, #6 - #54) Resident #2 was in Immediate Jeopardy on [DATE] at 5:55 a.m. when found in bed, pulseless and not breathing by S5LPN and CPR was not initiated and 911 was not called. S5LPN called the MD and told her the resident was dead but she did not inform the MD that no CPR was attempted to try to revive the resident. The Immediate Jeopardy ended on [DATE] for Resident #2 when he died . The Immediate Jeopardy continued for the 51 residents (#1, #3, #6 - #54) identified by the facility as wanting life saving measures in an emergency situation on [DATE] when CPR was not initiated on a resident who wanted life saving measures in an emeregency situation. The plan of removal was submitted by the facility on [DATE] at 11:30 am which stated: Effectively Immediately, in the event that a resident exhibits signs of no longer having vitals essential to maintain life and has signed a declaration to maintain life, or has given an oral declaration nursing personnel should do the following: 1. Begin immediate CPR on the resident, periodically checking resident for indication of vitals. 2. Notify ambulance. 3. Phone physician or physician on call, giving all available information as to time of discovery, vitals as well as other visible conditions (eye fixation) and attempts to resuscitate resident. 4. Follow physician orders. 5. If resident has further instructions indicated for life sustaining procedures notify emergency services. Document time of discovery, condition at discovery, attempts made to resuscitate resident as well as physician orders [REDACTED]. The Immediate Jeopardy ended on [DATE] for the remaining 51 residents (#1, #3, #6 - #54) when the facility implemented the policy/procedure for immediately providing CPR for resident with no vital signs and ensured that staff were inserviced regarding the initiation of CPR if resident is found pulseless and not breathing. The Immediate Jeopardy was lowered to actual harm for Resident #2 on [DATE] when he expired. The deficient practice remains at a potential for more than minimal harm for all 51 residents (#1, #3, #6 - #54) identified by the facility as having a directive to have all possible measures taken to revive them if their heart stops beating. Findings: Resident #2 was a [AGE] year old admitted to the nursing home on [DATE]. His diagnose included Pacemaker, [MEDICAL CONDITION], Acute Pancreatitis, status [REDACTED]. Review of Resident #2's CPR Direction revealed the following: I have discussed with my doctor the probable effect and results of cardiopulmonary resuscitation (CPR) for someone with my health situation. After thinking, deeply about whether CPR would be right for my situation, I have concluded that: I do want all possible measures taken to revive me if my heart stops beating. Initialed and signed by the client and the client's wife on [DATE]. There were no other updated CPR Directives on the resident's chart. Review of Resident #2 clinical record revealed the following Nurses' notes at the nursing home: "[DATE] - 2:00 a.m. Wanting to go to E.R. Call placed to Dr. on call for Dr.- BP: ,[DATE], T 100.2, P 78, R 18 - Order to give [MEDICATION NAME] for nausea & Tylenol for Temp & if c/o continue send to ER." "2:10 a.m. [MEDICATION NAME] & Tylenol given - pt. c/o nausea, burning up & dizziness - laying with head down and feet up - Pt. advised to --- & put head up; his air on high - advised pt. only had a slight Temp & I will check back. Will monitor." "3:00 a.m. - Asleep - No Acute Distress noted. Will monitor" "5:30 a.m. - Pt. talking with CNA's in room - has had no further c/o - No emesis has been seen." "5:55 a.m. - Spoke with pt. asked if he was o.k. - no response - asked if he was o.k. - no response - asked again if he was ok. Again no response. Went to bedside and touched pt., cold to touch - No breathing, no pulse. Called Dr. informed Dr. - states to call coroner - coroner called." "6:30 a.m. Coroner here; unable to reach next of kin (brother)" "7:00 a.m. - Coroner unable to reach brother" On [DATE] at 1:40 p.m. a telephone interview was held with S3CNA. She stated that she worked the morning of [DATE]. She stated that she made several rounds/checks to the resident's room between 11 p.m. and 6:00 a.m. She said that the resident had been throwing up clear fluids and that she had taken his vital signs, most of which were in the normal range, but that the resident had a low grade temp of 100.2 and complained of feeling hot. She stated that he wanted to go to the hospital. She stated that she informed the nurse. She stated that the nurse called the doctor and got an order to give him [MEDICATION NAME] and Tylenol for his fever. She said that shortly after he took the meds, Resident #2 went to sleep. She stated that at around 5:30 a.m., she and S4CNA, was in Resident #2's room taking care of his roommate. She stated that the resident had his feet up and head down as he was lying in his bed. She said that he talked to her and the other CNA and told them he was feeling better and he never asked to go back to the hospital. She stated that after the nurse gave him the meds, Resident #2 didn't complain anymore. She stated that she was in a state of shock when she was told that the resident had died because she had just talked to him. A telephone interview was held with S5LPN on [DATE]/at 3:25 p.m. She stated that Resident #2 wasn't feeling well, but later said he felt better. She stated that the last time she checked on him he felt better but still had a little nausea. She stated that 1 hour later she went back to check on him and he voiced no complaints. She said she went back at 5 minutes to 6 minutes later and asked him if he was okay twice. She said she touched him and immediately went to get her stethoscope. She said that the resident had no pulse or heartbeat. She said that the resident's body was cold and he had begun to get stiff. When asked why she didn't administer CPR, she stated that if he had been warm and it would have been a chance for him to be revived, she would have. She also stated that the resident had a lot of heart problems. She stated that she knew he was a full code. She stated she had called the Doctor earlier and reported that the resident had said he had been vomiting clear liquid. She stated that she did not see the resident throwing up. She said the doctor gave an order to give the resident [MEDICATION NAME] and 2 Tylenols for his temp of 100.2. She said the Doctor informed her that if the resident continued to throw up and did not get any better to send him to the ER. She said that the resident did not go to the ER because he was not vomiting and he said that he felt better and that he voiced no complaints after taking the medications. On [DATE] at 4:15 p.m., an interview was held with S1Administrator. He stated that he does not have a policy on administering CPR or a DNR policy. He spoke with someone at Ambulance Service regarding when to administer CPR. He stated that he was told that if the resident has all symptoms of death, they would not be sent to the ER, but that the coroner would be called. He further stated that he was told that the American Heart Association recommends not performing CPR on an individual that is known to be dead. An interview was held with S2ADON on [DATE] at 5:10 p.m. When asked what would she have done if she had a found a resident who did not have a pulse or heart rate, she stated that she would have initiated CPR. She said that S5LPN told her that because the resident was cold and because he didn't have a heart rate or a pulse she did not do CPR. She said at that point it was the nurse's judgment and the nurse's call. When asked what was the facility's policy with honoring a resident's wish that all measures be taken to revive his/her life, she didn't respond. She said that they probably needed a policy on that and that they probably would be working on one. On [DATE] at 5:45 p.m., a call was received from the on-call doctor on [DATE]. She stated that on [DATE] the nurse had called stating that the resident had wanted to go the ER. She said she stated that the resident had reported that he had been throwing up clear liquids, but she had not witnessed him throwing up and that he had a low grade temp. She said that she gave an order for [REDACTED]. When asked if she had given an order to not perform CPR to the nurse, she said she did not give an order to not perform CPR. An interview was held with S1Administrator on [DATE] at 11:00 a.m. He confirmed that they did not have a policy to address what to do if a resident was found unresponsive in regards to administering CPR. An interview was held with S6 RN on [DATE] at 11:25 a.m. She said that she was on duty at 6:30 a.m. on [DATE]. She said she asked S5 LPN what had happened. She said she told her that the resident had died , he was cold, and she could not feel no pulse and his eyes were fixed. She stated that if she had found the resident, she would have checked the carotid pulse and would have definitely done CPR. S6RN stated that she did not ask the nurse if she had performed CPR. She also stated that she was there when the coroner came. She also stated that the facility does have a policy on what nurses are to do in case of residents that wished to be resuscitated, if they are gone. She said that they are to perform CPR even if they're gone. She was told that nurses were to perform their duties and to comply with all directives and consents related to patient care. In an interview with S8LPN on [DATE] at 12:05 p.m. she stated that she worked the front Nurse's Station on the ,[DATE] shift on [DATE]. As an LPN, if she would have found a resident unresponsive, S8LPN stated that she would have called the resident by name and if she knew they had a directive for CPR she would have started CPR immediately and then called the doctor. She said that the procedure is to make sure that they are not a DNR. On [DATE] at 12:20 p.m. an interview was held with S9RN via telephone. She said that she was at the facility around 6:30 a.m. She said that she was told by the aides that Resident #2 had expired. The coroner had been called and arrived shortly after she arrived. As an RN, she stated that she would have checked the resident for a pulse and would have immediately started CPR. In an interview with S2ADON on [DATE] she was asked how the facility ensured that their staff maintained proficiency in training of emergency care/training. She stated that she did not know because the former DON took care of all of that with the nurse's training/in-services. S2ADON was asked if Resident #2's blood sugars were being monitored and she stated the resident did not have an order for [REDACTED]. An interview was held with S10DietaryWorker on [DATE] at 1:10 p.m. She stated that on the morning of [DATE], she clocked in at 6:02 a.m. and that she checked on Resident #2 on a regular basis. She stated that she was told that Resident #2 had died . She said that she went to his room, looked at him and his eyes were opened, She stated that she tried to close his eyes and they wouldn't close. S10DietaryWorker stated that he was slightly warm and wasn't cold all the way. She stated that this was between 6:08 and 6:10 a.m. and that he was slightly warm. She stated that she did not see the nurse doing CPR. She also said that she went down the hall, but saw S5LPN go into the room. A return telephone call was received from the on-call physician on [DATE] at 5:49 p.m. She stated that "at no time did the nurse state to her that she had not performed CPR on the resident." She said that the nurse told her that the resident had died . She also said that she was not given any time span but was only informed by the nurse that the resident was dead.

Based on record review and interview the facility failed to ensure that staff provided services that met professional standards of quality in the care of 1(#2) of 5 residents reviewed. The facility failed to ensure that staff honored the Directives that the facility had on file in the residents' clinical record regarding life sustaining measures once pulselessness and cessation of breathing had occurred for 1(#2) out of a census of 51 residents. The facility failed to ensure that: 1. Staff initiated CPR (Cardiopulmonary Resuscitation) on a resident found pulseless and not breathing (#2)on [DATE]. 2. Immediately call 911 emergency services when a resident found pulseless and not breathing (#2) 3. Contact Physician to notify her that CPR had not been started on a resident found pulseless and not breathing (#2) Resident #2 was in Immediate Jeopardy on [DATE] at 5:55 a.m. when found in bed, pulseless and not breathing by S5LPN and CPR was not initiated and 911 was not called. S5LPN called the MD and told her the resident was dead but she did not inform the MD that no CPR was attempted to try to revive the resident. The Immediate Jeopardy ended on [DATE] for Resident #2 when he died . The Immediate Jeopardy continued for the 51 residents (#1, #3, #6 - #54) identified by the facility as wanting life saving measures in an emergency situation [DATE] when CPR was not initiated on a resident who wanted life saving measures in an emeregency situation. The plan of removal was submitted by the facility on [DATE] at 11:30 am which stated: Effectively Immediately, in the event that a resident exhibits signs of no longer having vitals essential to maintain life and has signed a declaration to maintain life, or has given an oral declaration nursing personnel should do the following: 1. Begin immediate CPR on the resident, periodically checking resident for indication of vitals. 2. Notify ambulance. 3. Phone physician or physician on call, giving all available information as to time of discovery, vitals as well as other visible conditions (eye fixation) and attempts to resuscitate resident. 4. Follow physician orders. 5. If resident has further instructions indicated for life sustaining procedures notify emergency services. Document time of discovery, condition at discovery, attempts made to resuscitate resident as well as physician orders [REDACTED]. The Immediate Jeopardy ended on [DATE] for the remaining 51 residents (#1, #3, #6 - #54) when the facility implemented the policy/procedure for immediately providing CPR for resident with no vital signs and ensured that staff were inserviced regarding the initiation of CPR if resident is found pulseless and not breathing. The Immediate Jeopardy was lowered to actual harm for Resident #2 on [DATE] when he expired. The deficient practice remains at a potential for more than minimal harm for all 51 residents (#1, #3, #6 - #54) identified by the facility as having a directive to have all possible measures taken to revive them if their heart stops beating. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2009) Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part ..."3. development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self- awareness, sound judgment, prudence, ethical thinking and behaviors, problem solving and critical thinking abilities...7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team..." Resident #2 was a [AGE] year old admitted to the nursing home on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #2's CPR Direction revealed the following: I have discussed with my doctor the probable effect and results of cardiopulmonary resuscitation (CPR) for someone with my health situation. After thinking, deeply about whether CPR would be right for my situation, I have concluded that: "I do want all possible measures taken to revive me if my heart stops beating." The document was initialed and signed by the client and the client's wife on [DATE]. There were no other updated CPR Directives on the resident's chart. Review of Resident #2 clinical record revealed the facility Nurses' notes on [DATE] as follows:: 2:00 a.m.- Wanting to go to E.R. Call placed to Dr. on call for Dr.- BP: ,[DATE], T 100.2, P 78, R 18 - Order to give [MEDICATION NAME] for nausea & APHP for Temp & if c/o continue send to ER. 2:10 a.m.- [MEDICATION NAME] & Tylenol given - pt. c/o nausea, burning up & dizziness - laying with head down and feet up - Pt. advised to --- & put head up; his air on high - advised Pt. only had a slight Temp and I will check back. Will monitor. 3:00 a.m. - Asleep - No Acute Distress noted. Will monitor. 5:30 a.m. - Pt. talking with CNA's in room - has had no further c/o - No emesis has been seen. 5:55 a.m. - Spoke with pt. asked if he was o.k. - no response - asked if he was o.k. - no response - asked again if he was ok. Again no response. Went to bedside and touched Pt., cold to touch - No breathing, no pulse. Called Dr. informed Dr. - states to call coroner - coroner called. 6:30 a.m- Coroner here; unable to reach next of kin (brother) 7:00 a.m. - Coroner unable to reach brother On [DATE] at 1:40 p.m. a telephone interview was held with S3CNA. She stated that she worked the morning of [DATE]. She stated that she made several rounds/checks to the resident's room between 11p.m. and 6:00 a.m. She said that the resident had been throwing up clear fluids and that she had taken his vital signs, most of which were in the normal range. She also said that the resident had a low grade temp of 100.2 and complained of feeling hot. S3CNA stated that the resident wanted to go to the hospital. She stated that she informed the nurse. She also stated that the nurse called the doctor and got an order to give him [MEDICATION NAME] and Tylenol for his fever. S3CNA said that shortly after he took the meds, Resident #2 went to sleep. She stated that at around 5:30 a.m., she and S4CNA, was in Resident #2's room taking care of his roommate. She also stated that the resident had his feet up and head down as he was lying in his bed. S3CNA said that he talked to her and the other CNA and told them he was feeling better and he never asked to go back to the hospital. S3CNA stated that after the nurse gave him the meds, Resident #2 didn't complain anymore. She stated that she was in a state of shock when she was told that the resident had died because she had just talked to him. A telephone interview was held with S5LPN on [DATE]/at 3: 25 p.m. She stated that Resident #2 wasn't feeling well, but later said he felt better. She stated that the last time she checked on him he felt better but still had a little nausea. S5LPN stated that 1 hour later she went back to check on him and he voiced no complaints. She said she went back at 5:55 a.m. and asked him if he was okay twice. She also said she touched him and immediately went to get her stethoscope. S5LPN said that the resident had no pulse or heartbeat and contacted the Doctor. She also said that the resident's body was cold and he had begun to get stiff. When asked why she didn't administer CPR, S5LPN stated that if he had been warm and it would have been a chance for him to be revived, she would have. She also stated that the resident had a lot of heart problems. S5LPN stated that she knew he was a full code. She stated she had called the Doctor earlier and reported that the resident had said he had been vomiting clear liquids. She also stated that she did not see the resident throwing up. S5LPN said the doctor gave an order to give the resident [MEDICATION NAME] and 2 Tylenols for his temp of 100.2. She said the Doctor informed her that if the resident continued to throw up and did not get any better to send him to the ER. She said that the resident did not go to the ER because he was not vomiting and he said that he felt better and that he voiced no complaints after taking the medications. On [DATE] at 4:15 p.m., an interview was held with S1Administrator. He stated that he does not have a policy on administering CPR or a DNR policy. He spoke with someone at the Ambulance Service regarding when to administer CPR. He stated that he was told that if the resident has all symptoms of death, they would not be sent to the ER, but that the coroner would be called. S1Administrator further stated that he was told that the American Heart Association recommends not performing CPR on an individual that is known to be dead. An interview was held with S2ADON on [DATE] at 5:10 p.m. When asked what would she have done if she had a found a resident who did not have a pulse or heart rate, she stated that she would have initiated CPR. She said that S5LPN told her that because the resident was cold and because he didn't have a heart rate or a pulse she did not do CPR. She said at that point it was the nurse's judgment and the nurse's call. When asked what was the facility's policy with honoring a resident's wishes regarding advance directives, she didn't respond. She said that they probably needed a policy on that and that they probably would be working on one. On [DATE] at 5:45 p.m., a call was received from the on-call doctor on [DATE]. She stated that on [DATE] the nurse had called stating that the resident had wanted to go the ER. She said she stated that the resident had reported that he had been throwing up clear liquids, but she had not witnessed him throwing up and that he had a low grade temp. She said that she gave an order for [REDACTED]. When asked if she had given an order to not perform CPR to the nurse, she said she did not give an order to not perform CPR. An interview was held with S1Administrator on [DATE] at 11:00 a.m. He confirmed that they did not have a policy to address what to do if a resident was found unresponsive in regards to administering CPR. An interview was held with S6RN on [DATE] at 11:25 a.m. She said that she was on duty at 6:30 a.m. on [DATE]. She said she asked S5 LPN what had happened. She said she told her that the resident had died , he was cold, and she could not feel no pulse, and his eyes were fixed. S6RN stated that if she had found the resident, she would have checked the carotid pulse and would have definitely done CPR. S6RN stated that she did not ask the nurse if she had performed CPR. She stated that she was there when the coroner came. She also stated that the facility does have a policy on what nurses are to do in case of residents that wished to be resuscitated, if they are gone. S6RN said that they are to perform CPR even if they're gone. She was told that nurses were to perform their duties and to comply with all directives and consents related to patient care. In an interview with S8LPN on [DATE] at 12:05 p.m. she stated that she worked the front Nurse's Station on the ,[DATE] shift on [DATE]. As an LPN, if she would have found a resident unresponsive, S8LPN stated that she would have called the resident by name and if she knew they had a directive for CPR she would have started CPR immediately and then called the doctor. She said that the procedure is to make sure that they are not a DNR. On [DATE] at 12:20 p.m. an interview was held with S9RN via telephone. She said that she was at the facility around 6:30 a.m. She said that she was told by the aides that Resident #2 had expired. The coroner had been called and arrived shortly after she arrived. As an RN, she stated that she would have checked the resident for a pulse and would have immediately started CPR. In an interview with S2ADON on [DATE] she was asked how the facility ensured that their staff maintained proficiency in training of emergency care/training. She stated that she did not know because the former DON took care of all of that with the nurse's training/in-services. S2ADON was asked if Resident #2's blood sugars were being monitored and she stated the resident did not have an order for [REDACTED]. An interview was held with S10DietaryWorker on [DATE] at 1:10 p.m. She stated that on the morning of [DATE], she clocked in at 6:02 a.m. and that she checked on Resident #2 on a regular basis. She stated that she was told that Resident #2 had died . She said that she went to his room, looked at him and his eyes were opened. S10DietaryWorker stated that she tried to close his eyes and they wouldn't close. She stated that he was slightly warm and wasn't cold all the way. She stated that this was between 6:08 a.m. and 6:10 a.m. and that he was slightly warm. S10DietaryWorker stated that she did not see the nurse doing CPR. She also said that she went down the hall, but saw S5LPN go into the room. A return telephone call was received from the on-call physician on [DATE] at 5:49 p.m. She stated that "at no time did the nurse state to her that she had not performed CPR on the resident." She said that the nurse told her that the resident had died . She also said that she was not given any time span but was only informed by the nurse that the resident was dead.

Based on record review and interview the facility failed to ensure that necessary care and services to attain or maintain the highest practical and physical well being when they failed to perform CPR on a resident that was found pulseless and not breathing (#2). The facility had a total of 51 residents (#1, #3, #6 - #54) out of a census of 112 residents that wanted life saving measures done in a emergency situation. The facility failed to: 1. Ensure staff honored the client's CPR Directive that indicated he wanted all possible measures taken to revive him if his heart stopped beating that was signed and dated on [DATE] (#2) 2. Ensure staff immediately initiated CPR (cardiopulmonary resuscitation) on a resident found pulseless and not breathing (#2) on [DATE] 3. Immediately call 911 emergency services when a resident was found pulseless and not breathing (#2) on [DATE] 4. Contact Physician to notify her that CPR had not been started on a resident found pulseless and not breathing (#2) 5. Have procedures in place for residents found pulseless and not breathing who wanted life saving measures performed in an emergency situation (#1, #3, #6 - #54) . 6. Ensure staff were aware of procedure for providing life saving measures in an emergency situation (#1, #3, #6 - #54) . Resident #2 was in Immediate Jeopardy on [DATE] at 5:55 a.m. when found in bed, pulseless and not breathing by S5LPN and CPR was not initiated and 911 was not called. S5LPN called the MD and told her the resident was dead but she did not inform the MD that no CPR was attempted to try to revive the resident. The Immediate Jeopardy ended on [DATE] for Resident #2 when he died . The Immediate Jeopardy continued for the 51 residents (#1, #3, #6 - #54) identified by the facility as wanting life saving measures in an emergency situation [DATE] when CPR was not initiated on a resident who wanted life saving measures in an emeregency situation. The plan of removal was submitted by the facility on [DATE] at 11:30 am which stated: Effectively Immediately, in the event that a resident exhibits signs of no longer having vitals essential to maintain life and has signed a declaration to maintain life, or has given an oral declaration nursing personnel should do the following: 1. Begin immediate CPR on the resident, periodically checking resident for indication of vitals. 2. Notify ambulance. 3. Phone physician or physician on call, giving all available information as to time of discovery, vitals as well as other visible conditions (eye fixation) and attempts to resuscitate resident. 4. Follow physician orders. 5. If resident has further instructions indicated for life sustaining procedures notify emergency services. Document time of discovery, condition at discovery, attempts made to resuscitate resident as well as physician orders [REDACTED]. The Immediate Jeopardy ended on [DATE] for the remaining 51 residents (#1, #3, #6 - #54) when the facility implemented the policy/procedure for immediately providing CPR for resident with no vital signs and ensured that staff were inserviced regarding the initiation of CPR if resident is found pulseless and not breathing. The Immediate Jeopardy was lowered to actual harm for Resident #2 on [DATE] when he expired. The deficient practice remains at a potential for more than minimal harm for all 51 residents (#1, #3, #6 - #54) identified by the facility as having a directive to have all possible measures taken to revive them if their heart stops beating. Findings: Resident #2 was a [AGE] year old admitted to the nursing home on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #2's CPR Directive intialed and signed by the resident and the resident's wife on [DATE] read in part as follows: I have discussed with my doctor the probable effect and results of cardiopulmonary resuscitation (CPR) for someone with my health situation. After thinking, deeply about whether CPR would be right for my situation, I have concluded that: I do want all possible measures taken to revive me if my heart stops beating. There were no other updated CPR Directives on the resident's chart. The resident returned to the facility from the hospital on [DATE]. A review of the local Hospital Emergency Services Note dated [DATE] listed the complaint as [DIAGNOSES REDACTED] and Hypothermia. History of Present Illness in part: This morning he was noted to have a blood sugar of 57 and was sent to the ER for further evaluation. The patient is not diabetic and not on any diabetic medication. The patient was also found to have lactic acidosis. The patient was also hypothermic. Denies any other complaints - no chest pain, no shortness of breath, no cough or sputum. The patient does [MEDICAL CONDITION] with ejection fraction less than 15% and also has history of [MEDICAL CONDITION]. The patient is admitted to the hospital for further evaluation and treatment. Since admission the patient was started on D5 half - normal and blood sugar is still only around 108. The patient was also significantly hypothermic with temperature of 93 though it has improved to 97.3 this morning. Patient has no specific complaints. He is not on any hypoglycemic agents or insulin. He does have a long-standing history of [MEDICAL CONDITION] and [MEDICAL CONDITION]. The Local Hospital emergency room Nurses' notes dated [DATE] reads in part: Nursing Triage and Assessment Triage Information: arrived per Ambulance at 1110 HPI: report called from nursing home that patient has been nauseated and vomiting since last night and this am, given [MEDICATION NAME]. Patient glucose check found at 58. On arrival per ambulance patient had glucose of 27, one amp D50 given IV which increased capillary blood glucose to 127. Symptoms: BP initially ,[DATE], enroute dropped to ,[DATE], co2 19, cardiac monitor showing 280 in lead 2, but 60's in other leads and carotid 60. Patient skin ice cold and body temp low. Mental Status: oriented times three, answers questions appropriately, easily falls asleep The patient doesn't demonstrate behaviors, mental status characteristics or conditions for suicide risk which include: -acute signs of depression, anxiety, agitation, [MEDICAL CONDITION], and dementia; or -medical or psychological problems that significantly impact judgment, including intoxication with alcohol or drugs. Review of Resident #2 clinical record revealed the following Nurses' notes at the nursing home: "[DATE] - 12:14 a.m. Returned from Leave of Absence in good condition at 10:30 p.m." "1035 PM c/o feeling nauseated; clear emesis noted. VS ,[DATE], P89, R 20, T 98.1; in bed resting at this time. Call bell in reach." "[DATE] - 2:00 a.m. Wanting to go to E.R. Call placed to Dr. on call for Dr.- BP: ,[DATE], T 100.2, P 78, R 18 - Order to give [MEDICATION NAME] for nausea & Tylenol for Temp & if c/o continue send to ER." "2:10 a.m. [MEDICATION NAME] & Tylenol given - Pt. c/o nausea, burning up & dizziness - laying with head down and feet up - Pt. advised to --- & put head up; his air on high - advised pt. only had a slight Temp & I will check back. Will monitor." "3:00 a.m. - Asleep - No Acute Distress noted. Will monitor" "5:30 a.m. - Pt. talking with CNA's in room - has had no further c/o - No emesis has been seen." "5:55 a.m. - Spoke with pt. asked if he was o.k. - no response - asked if he was o.k. - no response - asked again if he was ok. Again no response. Went to bedside and touched pt., cold to touch - No breathing, no pulse. Called Dr. informed Dr. - states to call coroner - coroner called." "6:30 a.m. Coroner here; unable to reach next of kin (brother)" "7:00 a.m. - Coroner unable to reach brother" On [DATE] at 1:40 p.m. a telephone interview was held with S3CNA. She stated that she worked the morning of [DATE]. She stated that she made several rounds/checks to the resident's room between 11 p.m. and 6:00 a.m. She said that the resident had been throwing up clear fluids and that she had taken his vital signs, most of which were in the normal range, but that the resident had a low grade temp of 100.2 and complained of feeling hot. She stated that he wanted to go to the hospital. She stated that she informed the nurse. She stated that the nurse called the doctor and got an order to give him [MEDICATION NAME] and Tylenol for his fever. She said that shortly after he took the meds, Resident #2 went to sleep. She stated that at around 5:30 a.m., she and S4CNA, was in Resident #2's room taking care of his roommate. She stated that the resident had his feet up and head down as he was lying in his bed. She said that he talked to her and the other CNA and told them he was feeling better and he never asked to go back to the hospital. She stated that after the nurse gave him the meds, Resident #2 didn't complain anymore. She stated that she was in a state of shock when she was told that the resident had died because she had just talked to him. A telephone interview was held with S5LPN on [DATE]/at 3:25 p.m. She stated that Resident #2 wasn't feeling well, but later said he felt better. She stated that the last time she checked on him he felt better but still had a little nausea. She stated that 1 hour later she went back to check on him and he voiced no complaints. She said she went back at 5 minutes to 6 minutes later and asked him if he was okay twice. She said she touched him and immediately went to get her stethoscope. She said that the resident had no pulse or heartbeat. She said that the resident's body was cold and he had begun to get stiff. When asked why she didn't administer CPR, she stated that if he had been warm and it would have been a chance for him to be revived, she would have. She also stated that the resident had a lot of heart problems. She stated that she knew he was a full code. She stated she had called the Doctor earlier and reported that the resident had said he had been vomiting clear liquid. She stated that she did not see the resident throwing up. She said the doctor gave an order to give the resident [MEDICATION NAME] and 2 Tylenols for his temp of 100.2. She said the Doctor informed her that if the resident continued to throw up and did not get any better to send him to the ER. She said that the resident did not go to the ER because he was not vomiting and he said that he felt better and that he voiced no complaints after taking the medications. On [DATE] at 4:15 p.m., an interview was held with S1Administrator. He stated that he does not have a policy on administering CPR or a DNR policy. He spoke with someone at Ambulance Services regarding when to administer CPR. He stated that he was told that if the resident has all symptoms of death, they would not be sent to the ER, but that the coroner would be called. He further stated that he was told that the American Heart Association recommends not performing CPR on an individual that is known to be dead. An interview was held with S2ADON on [DATE] at 5:10 p.m. When asked what would she have done if she had a found a resident who did not have a pulse or heart rate, she stated that she would have initiated CPR. She said that S5LPN told her that because the resident was cold and because he didn't have a heart rate or a pulse she did not do CPR. She said at that point it was the nurse's judgment and the nurse's call. When asked "what was the facility's policy with honoring a resident's wish that all measures be taken to revive his/her life", she didn't respond. She said that they probably needed a policy on that and that they probably would be working on one. On [DATE] at 5:45 p.m., a call was received from the on-call doctor on [DATE]. She stated that on [DATE] the nurse had called stating that the resident had wanted to go the ER. She said she stated that the resident had reported that he had been throwing up clear liquids, but she had not witnessed him throwing up and that he had a low grade temp. She said that she gave an order for [REDACTED]. When asked if she had given an order to not perform CPR to the nurse, she said she did not give an order to not perform CPR. An interview was held with S1Administrator on [DATE] at 11:00 a.m. He confirmed that they did not have a policy to address what to do if a resident was found unresponsive in regards to administering CPR. An interview was held with S6RN on [DATE] at 11:25 a.m. She said that she was on duty at 6:30 a.m. on [DATE]. She said she asked S5LPN what had happened. She said she told her that the resident had died , he was cold, and she could not feel no pulse and his eyes were fixed. She stated that if she had found the resident, she would have checked the carotid pulse and would have definitely done CPR. S6RN stated that she did not ask the nurse if she had performed CPR. She also stated that she was there when the coroner came. She also stated that the facility does have a policy on what nurses are to do in case of residents that wished to be resuscitated, if they are gone. She said that they are to perform CPR even if they're gone. According to S6RN, the nurse that trained her went through the policy and procedures with CPR, the ambu bag, O2 and everything for nurse training during orientation. She was told that nurses were to perform their duties and to comply with all directives and consents related to patient care. On [DATE] at 11:45 a.m. an interview was held with S7CNA. She said that she took his vital signs. She said the next time S3CNA came and said that Resident #2 was dead and I said "oh no, he's not dead". She said she shook him on the shoulder and that his eyes and mouth were opened and his hands were up at his chest. She said that at around 5:30 a.m., she was making rounds and went to his room. She said she asked him if he was okay and he stated, "yeah, okay". In an interview with S8LPN on [DATE] at 12:05 p.m. she stated that she worked the front Nurse's Station on the ,[DATE] shift on [DATE]. She said that she did not go on the back hall when the resident died . She stated that she heard the aides saying that they couldn't believe Resident #2 was dead. She stated that she asked S5LPN about it and she confirmed it. As an LPN, if she would have found a resident unresponsive, S8LPN stated that she would have called the resident by name and if she knew they had an order she would have started CPR immediately and then called the doctor. She said that the procedure is to make sure that they are not a DNR. On [DATE] at 12:20 p.m. an interview was held with S9RN via telephone. She said that she was at the facility around 6:30 a.m. She said that she was told by the aides that Resident #2 had expired. The coroner had been called and arrived shortly after she arrived. As an RN, she stated that she would have checked the resident for a pulse and would have immediately started CPR. In an interview with S2ADON on [DATE] at 12:45 p.m. she was asked how the facility ensured that their staff maintained proficiency in training of emergency care/training. She stated that she did not know because the former DON took care of all of that with the nurse's training/in-services. S2ADON was asked if Resident #2's blood sugars were being monitored and she stated the resident did not have an order for [REDACTED]. Another interview was held with S1Administrator on [DATE] at 1:00 p.m. He stated that S 10 DietaryWorker had talked to him concerning the morning of [DATE] and Resident #2. He stated that S10DietaryWorker said that she tried shutting the resident's eyes and that his eyes would not shut. He said that S10DietaryWorker frequently visited Resident #2. An interview was held with S10DietaryWorker on [DATE] at 1:10 p.m. She stated that on the morning of [DATE], she clocked in at 6:02 a.m. and that she checked on Resident #2 on a regular basis. She stated that she was told that Resident #2 had died . She said that she went to his room, looked at him and his eyes were opened, She stated that she tried to close his eyes and they wouldn't close. S10DietaryWorker stated that he was slightly warm and wasn't cold all the way. She stated that this was between 6:08 and 6:10 a.m. and that he was slightly warm. She stated that she did not see the nurse doing CPR. She also said that she went down the hall, but saw S5LPN go into the room. During the exit interview on [DATE] at 2:45 p.m. S1Administrator stated that he was working on a policy/procedure. A return telephone call was received from the on-call physician on [DATE] at 5:49 p.m. She stated that "at no time did the nurse state to her that she had not performed CPR on the resident." She said that the nurse told her that the resident had died . She also said that she was not given any time span but was only informed by the nurse that the resident was dead.