Every finding on record at Lakewood Health and Rehab, LLC

Number of residents sampled: Number of residents cited: Based on record review and interviews, the facility failed to ensure signing of the facility Arbitration Agreement was not a condition of admission and the agreement contained the stipulation that it could be rescinded within 30 days of being signed for two (Resident #19 and Resident #56) of three residents reviewed. The findings include: Resident #19 Review of an admission Record for Resident #19 indicated the facility admitted the resident on 06/07/2021 with diagnoses which included interrupted blood flow to the brain causing weakness or loss of sensation on one side of the body (stroke with hemiplegia), nerve damage throughout the body (polyneuropathy) and difficulty swallowing (dysphagia). Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/2025, indicated Resident #19 scored 10, which indicated the resident had moderate cognitive impairment, on the Brief Interview for Mental Status (BIMS). During an interview on 09/24/2025 at 2:30 PM, this surveyor asked the Administrator for copies of the arbitration agreement for Resident #19. Review of a document titled, Arbitration Agreement dated 06/07/2021 for Resident #19 indicated that signing of the Arbitration Agreement as part of the admission Agreement was a condition of admission and once signed the Arbitration Agreement governs the resolution of claims. In addition, the Arbitration Agreement did not include a statement that the agreement could be rescinded within 30 Calander days of being signed. Resident #56 Review of an admission Record for Resident #56 indicated the facility admitted the resident on 11/17/2020 with diagnoses which included diabetes mellitus, inability to voluntarily move the upper and lower body (Quadriplegia), and congenital undeveloped spinal cord (Spina Bifida). Review of a quarterly MDS with an ARD of 07/01/2025, indicated Resident #56 scored 15, which indicated the resident was cognitively intact, on the BIMS. During an interview on 09/24/2025 at 2:30 PM, this surveyor asked the Administrator for copies of the arbitration agreement for Resident #56. Review of a document titled, Arbitration Agreement dated 11/17/2020 for Resident #19 indicated that signing of the Arbitration Agreement as part of the admission Agreement was a condition of admission and once signed the Arbitration Agreement governs the resolution of claims. In addition, the Arbitration Agreement did not include a statement that the agreement could be rescinded within 30 Calander days of being signed. During an interview on 09/24/2025 at 3:56 PM, the Social Service Director confirmed that Residents #19's Arbitration agreement was signed in June of 2021 and stated signing of the agreement was a condition of admission and the agreement did not contain the statement that it could be rescinded within 30 days of being signed. The Social Services Director also confirmed Residents #56's Arbitration Agreement was signed in November of 2020 and stated signing of the agreement was a condition of admission and the agreement did not contain the statement that it could be rescinded within 30 days of being signed. In addition, the Social Services Director stated that she thought that both residents might have an updated copy of the Arbitration Agreement in their hard copy records. During an interview on 09/24/2025 at 4:15 PM, the Administrator confirmed Resident #19's and Resident #56's Arbitration Agreement did indicate signing was a condition of admission and did not contain the stipulation that the agreement could be rescinded within 30 days of being signed. The Administrator also stated she thought an updated copy of the agreement might be in the residents' financial record. During an interview on 09/25/2025 at 10:50 AM, the Administrator stated that they did not have an updated Arbitration Agreement for Resident #19 or Resident #56, and the current agreements did state signing was a condition of admission. The administrator stated that they had already corrected the agreements for these two residents and were in the process of going through all the residents' Arbitration Agreements to make sure they were the updated version that states signing was not a condition of admission and the agreement could be rescinded within 30 days of signing. The Administrator also indicated the facility does not have a policy on Arbitration Agreements.

03508 Based on observation and interview, the facility failed to ensure raw meat was thawed properly to prevent a potential foodborne illness; failed to ensure food stored in the freezer, refrigerator and dry storage area were covered, sealed and dated the day received and when opened to assure first in, first out usage to prevent potential for food bone illness, failed to ensure manufacturer specification was followed in order to prevent food spoilage, expired food items were promptly removed from stock in order to reduce the risk of food-borne illness for residents who received meal trays from 1 of 1 kitchen, dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen These failed practices had the potential to affect 72 residents who received meals from the kitchen. The findings are: On [DATE] at 9:25 AM, the surveyor entered the facility kitchen and observed a sink with raw chicken thighs and legs soaking in standing water. The water was not running, and the sink was plugged. The chicken was not in a plastic bag but lying directly in the water. At 10:04 AM, the surveyor noted the chicken was still in the sink soaking in water. The surveyor asked [NAME] #1 to check the temperature of the water the chicken was soaking in. [NAME] #1 retrieved a thermometer and checked the water temperature. The surveyor asked Dietary Aide #3 to read the thermometer and Dietary Aide #3 stated it was 63 degrees. The Dietary Manager pulled the plug on the sink and drained the water. The Dietary Manager then turned the water on and allowed it to run over the chicken pieces directly under the running water. The surveyor asked the Dietary Manager to explain the process for thawing meat. The Dietary Manager stated, It should be thawed under running water so as to not remove all the blood from the meat and it should not be left sitting in standing water. The surveyor asked how long this meat had been soaking in this water. The Dietary Manager stated, He put it in the sink when he arrived at work, and it had been in there for about 40 minutes. The surveyor asked the Dietary Manager if this chicken was safe to serve the residents. The Dietary Manager stated, Well, not like this, it is raw. We have to cook it. The surveyor asked what a safe temp for thawing chicken would be. The Dietary Manager stated, We have to cook it after it is thawed. The surveyor asked the Dietary Manager if the 63-degree temperature was a safe temperature for chicken. The Dietary Manager stated, That is the water temperature. The surveyor asked the Dietary Manager to check the temperature inside the meat. The Dietary Manager inserted the thermometer through the center of a thigh piece and Dietary Aid #3 read the temperature to be 63-degrees. The Dietary Manager stated, They have to fry it to like 160 to 180-degrees. At 10:25 AM, the surveyor noted the [NAME] #1 prepping the chicken with seasoning and flour. The surveyor asked [NAME] #1 if she was prepping the chicken that had been in the sink thawing in the standing water. [NAME] #1 stated, yes. The surveyor asked [NAME] #1 what a safe temperature for thawing chicken would be. The Dietary Manager stated, Thirty degrees too . The Dietary Manager paused his speaking and [NAME] #1 stated, 40-degrees. The surveyor asked Dietary Aid #3, who was standing nearby, what was the reading of the thermometer and Dietary Aide #3 stated, Sixty three degrees. The surveyor asked how many pieces of chicken are you preparing to cook, after being in the standing water. [NAME] #1 stated, 120 pieces. The surveyor asked if the chicken being prepared was safe to serve. [NAME] #1 stated, No. 2 On [DATE] at 9:38 AM, the milk box did not have a thermometer inside the box to monitor the temperatures. 3. On [DATE] at 10:33 AM, the following observations were made on a shelf in the freezer: a. An opened box of hamburger patties. The box was not covered or sealed. The surveyor asked the Dietary Manager why it is important to ensure items are sealed that are in the freezer. The Dietary Manager stated, To keep it from getting freezer burned. b. The surveyor observed a bag of chopped onions, and a chocolate cream pie not sealed sitting inside the freezer. The Dietary Manager stated, This should have been tossed last week. c. Two packages of pancakes that did not have any received dates. The Dietary Manager pulled a clear plastic zip bag of pancakes from the back of the freezer and tossed them stating, These have expired. d. An opened box of sausage links not covered or sealed. 4. On [DATE] at 10:38 AM, the following observations were made on a shelf above the food preparation counter: a. A half empty jar of grape jelly beside a jar of peanut butter. The manufacturer specification on the jar documented, Refrigerate after opening. The surveyor asked the Dietary Manager to read labels instructions. Dietary aide #3 read it to the Dietary Manager. The Dietary Manager then pulled the jelly and instructed the staff to discard it. b. A gallon jug of black pepper, a gallon jug of paprika, and a gallon jug of parsley sitting on the shelf did not have an open date on them, only a received date. The Dietary Manager pulled the three-gallon products and discarded them. 5. On [DATE] at 10:40 AM, the surveyor observed the water was not running over the chicken which was lying in the sink. The Dietary Manager turned the water on and stated to the staff, We need to leave this running over the frozen meat. At 10:55 AM, the surveyor observed the water was not running over the chicken lying in the sink. Again, the Dietary Manager turned the water on. At 11:00 AM, the surveyor noted the water was not running over the chicken lying in the sink. The Dietary Manager asked, Who turned the water off? The Dietary Manager stated, Leave this water running to thaw the chicken. 6. On [DATE] at 12:00 PM, the surveyor asked the Administrator for a policy on food preparation or thawing of food. The Administrator stated, We do not have one. 7. On [DATE] at 7:58 AM, an open box of low sodium dairy free mashed potatoes was on a shelf above the food preparation counter. The box was not covered. 8. On [DATE] at 9:59 AM, Dietary Aide #10 opened the refrigerator and placed a zip lock bag that contained butter logs, she removed gloves from the glove box and placed them on her hands, contaminating the gloves. Without changing gloves and washing her hands, she removed bread sticks from the bag and placed them on the pans to be heated up and served to the residents for lunch meal. 9. On [DATE] at 10:07 AM, the following observations were made on a shelf in the freezer with no received or opened dates in the kitchen areas: a. An opened box of biscuits, the box has no received or opened date on it. b. An opened box of cookies had no opened date on it. 10. On [DATE] at 10:10 AM, DC #11 took a dirty pan to the dirt dish area, she removed gloves from the glove box and placed them on her hands, contaminating the gloves. Without changing gloves and washing her hands, she removed chicken enchiladas from the original box and placed them in the oven to bake and served to the residents who dislike lasagna for lunch. 11. On [DATE] at 10:22 AM, an opened box of bacon was on a shelf in the refrigerator with no opened date on it. 12. On [DATE] at 10:31 AM, the following observations were made on a shelf in the refrigerator. a. A container of pimento cheese had an expiration date of [DATE]. b. A container of pimento cheese had an expiration date of [DATE]. c. A container of cucumber and onion salad had an expiration date of [DATE]. 13. On [DATE] at 10:39 AM, DC #11 opened the oven and placed a pan of pureed carrots on the rack. Without washing her hands, she picked up a clean blade and attached it to the base of the blender. As DC#11 was about to use the blender to puree food items to be served to the residents for lunch. The surveyor asked DC #11 what should you have done after touching dirty and or before handling clean equipment or handling food items? She stated, I should have washed my hands. 14. On [DATE] at 10:46 AM, a bag that contained 9 counts of dinner rolls was on the bread rack with an expiration date of [DATE]. 15. On [DATE] at 10:51 AM, the following observations were made on a rack leading to the food storage room: a. Three of 3 boxes of complete buttermilk pan cake with an expiration date of [DATE]. b. A box that contained bags of diced chicken was opened. c. An opened bag of diced chicken Inside the box had no open date. d. A box that contained 5 sealed bags of flour tortilla with an expiration date of [DATE]. 16. On [DATE] at 11:19 AM, the following observations were made on a shelf in the refrigerator in the day room: a. A spout to a pitcher that contained grape juice was not covered, exposing the grape juice. b. A container with slices of tomatoes. There was no name to whom it belongs to, with no date to indicate when it was stored. There was white fuzz on the tomatoes. The surveyor asked the Activities Director #19 to describe the appearance of the tomatoes. She stated probably mold not good. c. There was a banana in a bag. The banana was discolored and mushy. The Dietary Manager stated, It was cold, too mushy, and black. d. Two of the 2 expired bags of corn chips with an expiration date of [DATE]. e. A bottle of almond creamer, the bottle has no name, no received date, and no opened date on it. f. Three opened bottles of ranch dressings, the bottles had no received or opened date on them. g. An opened bottle of sandwich dressing, the bottle has no date on it. h. An opened bottle of avocado ranch dressing, the bottle has no date on it. i. An opened bottle of dill pickles, the bottle has no date on it. J. Two of two bags of watermelon were not dated when they were stored. k. A bag of spaghetti with meat sauce not dated or when it was opened or received. l. Two of two bottles of taco sauce were not dated or have an opened date.

Based on observation and interview, the facility failed to ensure resident privacy and confidentiality of personal and medical information by posting photographs of residents to the facility's social media site without the written consent of the resident or the residents designated representative. The findings are: 1. On 07/09/2024 at 2:30 PM, the surveyor interviewed the Administrator, asking if the facility had a social media site. The Administrator stated, Yes, we have a social media page that we started during Covid. The surveyor asked if the facility had consents for posting to a social media site. The Administrator stated, I'm sure we do, we had to get those during Covid. I will check and see. The Surveyor asked the Administrator who has authorization to post to the facility's social media site. The Administrator stated, The Social Director and me. 2. On 07/09/2024 at 2:50 PM, the Consultant handed the surveyor a form titled HIPAA (Health Information Accountability Act) Authorization for Release of Health Information Media and for Use or Disclosure of Resident Photographic and/or Video Images. The Administrator and the Surveyor conducted a random viewing of the social media postings. The social media site contains pictures of numerous residents and events held in the facility. The surveyor pointed out three resident's pictures and asked for the signed consent forms. The Administrator stated, We do not have any consent forms for posting on the social media site. 4. On 04/11/2024 at 1:00 PM, the Surveyor met with the Administrator and Consultant. The Surveyor asked if they had found any consents for any of the residents posted on the social media page. The Administrator and Consultant both stated, No, we do not have them.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 2 meals observed. This failed practice had the potential to affect 3 residents who received pureed diet. The findings are. 1. On 07/10/2024 at 10:16 AM, Dietary [NAME] (DC) #11 used a 4-ounce spoon to place 4 servings of lasagna into a blender and pureed. At 10:21 AM, DC #10 poured the pureed lasagna into a pan and placed it in the oven. The consistency was thick, lumpy, and was not smooth. There were pieces of pasta visible in the mixture. 2. On 07/10/2024 at 10:40 AM, DC #11 placed 3 servings of garlic bread into a blender, added a carton of whole milk and pureed. At 10:42 AM, DC #10 used a #20 scoop to portion pureed bread stick into 3 bowls. The consistency of the pureed bread was lumpy and was not smooth. 3. On 07/10/2024 at 12:30 PM, the surveyor asked the Dietary Manager to describe the consistency. of the pureed food items served to the residents on pureed diets. He stated, There were lumpy. 4. On 07/11/2024 at 1:00 PM, the following observations were made on the steam table. a. A pan of pureed orange chicken. The consistency of the pureed chicken was lumpy and not smooth. There were pieces of chicken visible in the mixture. b. A pan of pureed rice. The consistency of the pureed rice was lumpy and not smooth. There were pieces of rice in the mixture. 5. On 07/11/2024 at 1:05 PM, the surveyor asked the Dietary Manager to describe the consistency of the pureed food items served to the residents who required pureed diets. He stated, They were lumpy.

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained a palatable appearance, and at temperatures acceptable to the residents during 2 of 2 meals observed. This failed practice had the potential to affect 15 residents who receive meal trays in their rooms on the 100 Hall,10 residents who receive meal trays on the 200 hall, 15 residents who receive meal trays on 300 hall and 13 residents who receive meal trays in their room on the 400 -hall. The findings are: 1. On 07/08/2024 at 10:10 AM, the surveyor asked Resident #32, How is the food in the facility? Resident #32 stated, The food is always ice cold. 2. On 07/10/2024 at 11:53 AM, an unheated food cart that contained 15 trays for lunch was delivered to 300-hall by Staff #2. At 12:09 PM, immediately after the last resident was served in their room on 300-hall, temperature of the food items on the tray used as a test tray were taken by the and was and read by Certified Nursing Assistant (CNA)#14 with the following result: a. Milk 45 degrees Fahrenheit. 3. On 07/10/24 at 11:58 AM, an unheated food cart that contained 15 trays for lunch was delivered to 100-hall by Dish Washer #2. At 12:15 PM, immediately after the last resident was served in their room on 100-hall, temperature of the food items on the tray used as a test tray were taken by the Dietary Manager and was and read by CNA#15 with the following results: a. Milk 44 degrees Fahrenheit. b. Lasagna 110 degrees Fahrenheit. 4. On 07/10/2024 at 12:13 PM, an unheated food cart that contained 10 trays for lunch was delivered to 200-hall by Dish Washer #2. At 12:20 PM, immediately after the last resident was served in their room on 200-hall, temperature of the food items on the tray used as a test tray were taken by the Dietary Manager and was read by CNA #15 with the following results: a. Milk 44 degrees Fahrenheit. b. Lasagna 110 degrees Fahrenheit. 5. On 07/11/2024 at 7:10 AM, an unheated food cart that contained 15 trays for lunch was delivered to 300 -hall by Dietary Aide #17. At 12:20 AM, immediately after the last resident was served in their room on 300-hall, temperature of the food items on the tray used as a test tray were taken and read by CNA #16 with the following results: a. Scrambled eggs 88 degrees Fahrenheit. b. Ground sausage with gravy 89 degrees Fahrenheit. 6. On 07/11/2024 at 7:16 AM, an unheated food cart that contained 15 trays for lunch was delivered to 100-hall by Dietary Aide #17. At 7:26 AM, immediately after the last resident was served in their room on 100-hall, temperature of the food items on the tray used as a test tray were taken and read by CNA# 14 with the following results: a. Sausage 85 degrees Fahrenheit. b. Scrambled eggs 95 degrees Fahrenheit. 7. On 07/11/2024 at 7:28 AM, an unheated food cart that contained 13 trays for breakfast was delivered to 400-hall by Dietary Aide #17. At 7:26 AM, immediately after the last resident was served in their room on 400-hall, temperature of the food items on the tray used as a test tray were taken and read by Licensed Practical Nurse (LPN) #19 with the following results: a. Pureed eggs 92 degrees Fahrenheit. b. Scrambled degrees 102 degrees Fahrenheit. c. Pureed eggs 101 degrees Fahrenheit. d. Ground sausage 98 degrees Fahrenheit. e. Oatmeal 103 degrees Fahrenheit.

Based on observation, record review and interview, the facility failed to ensure nail care was consistently provided to promote good grooming and personal hygiene for 1 (Resident #39) of 2 (Resident #39 and #223) sampled residents who were reviewed for activities of daily living (ADL) care. The findings are: Resident #39 had diagnoses of abnormalities of way of walking (gait) and mobility and lack of coordination as indicated on the Order Summary. A quarterly Minimum Data Set with an Assessment Reference Date of 05/06/2024 indicated Resident #39 had a Brief Interview for Mental Status score of 4, which indicated the resident was severely impaired. Resident #39's Care Plan, initiated 05/24/2024, indicated the resident had an ADL (Activities of Daily Living) self-care performance deficit related to confusion and limited mobility and required supervision of staff with bathing/showering on Monday, Wednesday and Friday and staff were to check the resident's nail length and trim and clean on bath days and as necessary. On 07/08/2024 at 9:43 AM, Resident #39 was lying in bed. The resident's feet and the toenails on both feet were thick and discolored. On 07/09/2024 at 3:06 PM, Resident #39 was asked if anyone at the facility had provided toenail care. Resident #39 removed the right foot from a shoe and looked down at the toes and stated, They do need trimming. Resident #39 denied being diabetic. Resident #39 stated no one here has ever taken care of Resident #39's toes. Resident #39 was asked if they liked their fingernails long and Resident #39 looked at both hands and confirmed the fingernails needed trimming also because they weren't usually that long but had not been paying attention to them. Resident #39's fingernails were greater than a quarter inch in length on both hands but were clean. On 07/11/2024 at 12:55 PM, Certified Nursing Assistant (CNA) #16 confirmed Resident #39's fingernails were grown and the toenails were thick and layered. She confirmed that she provided nail care to the resident's toenails last week and that was the best she could do because they were layered and thick. On 07/11/2024 at 1:10 PM, CNA #27 confirmed Resident #39's fingernails needed to be trimmed and shaped and the toenails on the right foot were thick and the resident probably needed to see a Podiatrist. She confirmed that if a resident's fingernails and toenails were too long or ingrown, this could cause an infection, or they could scratch themselves. On 07/11/2024 at 1:40 PM, the Administrator reported they did not have a policy on nail care.

Based on record review, interview, and observation, the facility failed to ensure an assessment for siderail use was completed for Resident #60 prior to installing siderails; to ensure an assessment of the bed, mattress and siderails was completed prior to the use of the siderails; to review the risks and benefits of siderails with Resident # 60; to obtain informed consent prior to the installation of the siderails on Resident #60 bed; to attempt the use of appropriate alternatives prior to installing siderails. The findings are: 1. A review of an annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/20/2024, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment. Section GG0170 indicated Resident #60 is dependent on staff to do all the effort to complete an activity; or the assistance of 2 or more helpers is required for the resident to complete the activity of Mobility. Section P0100 indicated Resident #60 was coded, bed rail - not used. Section I-Active Diagnoses identified Resident #60 had neurological diagnoses of stroke and seizure disorder or Epilepsy. a. A review of Resident #60's Care Plan revealed an ADL (Activities of Daily Living) self-care performance deficient related to limited mobility with an intervention for bed mobility, identified Resident #60 to be totally dependent on staff for turns and repositioning while in bed, identified Resident #60 to be totally dependent on staff to be moved between surfaces, identified that Resident # 60 had impaired cognitive function or impaired thought processes as evidenced by BIMS(Brief Interview for Mental status) score of 0 (06/28/2023), and that Resident #60 was at risk for falls related to resident being unaware of safety needs. The use of side rails was not addressed in the care plan. b. A review of the Nursing Quarterly assessment dated [DATE] indicated the use of Side Rails were not indicated at this time. c. On 07/08/2024 at 1:15 PM, the surveyor observed Resident #60 lying in bed with both half-length siderails raised on the right and left sides of the bed. The siderails were positioned in the center of the bed, leaving the two ends of the bed opened on the right side with the left side of the bed pushed against the wall. d. On 07/08/2024 at 1:28 PM, the surveyor spoke with Resident #60's family member. The surveyor asked if Resident #60 used the rails for turning and positioning. Resident #60's family member stated, I've never seen (Named Resident) use the siderails for anything and (Named Resident) doesn't use them for turning or positioning. e. On 07/10/2024 at 7:52 AM, the surveyor observed Resident # 60 in a wheelchair. The Resident's bed was made with quarter length siderails up on both sides of the bed. The surveyor asked Resident # 60 if they used the siderails. Resident #60 stated I want the siderail folded down when I'm in bed. Resident #60 motioned for the quarter rail to be pulled down to the half-rail position. f. On 07/10/2024 at 9:07 AM, the surveyor conducted an interview with the Director of Nursing (DON) and asked how a determination is made for use of siderails for residents. The DON stated, The DON and nurses complete an assessment upon admission. The DON presented the surveyor with the assessment form the facility uses for assessing siderails. The surveyor asked if it is determined that siderails are to be used, would the use of siderails be care planned. The DON stated, Yes. The surveyor asked if a physician's order would be received for siderails. The DON stated, No. The surveyor asked if a resident request siderails how the facility handles that request. The DON stated, It would not be a restraint, the staff would monitor the resident and typically we will not utilize the siderail. The surveyor asked if they try other things before using a siderail and if they explain the risk vs benefits to the resident. The DON said, We usually go straight to the siderail, if that is what they want. g. On 07/10/2024 at 1:30 PM, the surveyor observed Resident #60 lying in bed with the siderail up, positioned in the center of the bed. h. On 07/10/2024 at 2:08 PM, the surveyor observed Resident #60 lying in bed with siderail up, positioned in the center of the bed. i. On 07/10/2024 at 2:30 PM, the surveyor conducted an interview with Certified Nursing Assistant (CNA) #12. The surveyor asked CNA #12 if Resident #60 uses siderails. CNA #12 stated, Yes. The surveyor asked CNA #12 why the side rails are used. CNA #12 stated, Most of the time for positioning, but [Resident #60] doesn't move in the bed. The surveyor asked CNA #12 if side rails are considered to be a restraint. CNA #12 stated, No. The surveyor asked CNA #12, How do you monitor the resident while the siderails are in use? CNA #12 stated, I check on them every 30 to 45 minutes. The surveyor asked CNA #12 if Resident's #60 care plan identifies Resident #60 to use side rails. CNA #12 stated, Yes. j. On 07/10/2024 at 2:45 PM, the surveyor conducted an interview with the DON. The surveyor asked the DON if Resident #60 used siderails. The DON stated, I will need to look because I cannot recall off the top of my head. The DON checked his computer and stated, [Resident #60's] assessment shows side rails are not indicated. The DON asked, Why? Does [Resident #60] have siderails? The surveyor confirmed the siderails were in use. The surveyor asked the DON why the siderails are used. The DON stated, I'm honestly not sure because [Resident #60] hasn't had any falls and is dependent on staff for transfers. The surveyor asked the DON if siderails are considered a restraint. The DON stated, Yes. The surveyor asked the DON how the staff monitors residents while siderails were in use. The DON stated, They should be checking [the residents] every two hours. The surveyor asked the DON if Resident #60 had been care planned for the use of siderails. The DON stated, No. k. On 07/10/2024 at 2:58 PM, the surveyor conducted an interview with the DON and Administrator. The surveyor asked the DON if they had an assessment for entrapment on the application of the side rails on Resident #60's bed. The DON stated, No. The surveyor asked for the manufactures guidelines for applying the siderails to the bed and requested to see documentation of where the installation of the siderails, with an assessment of the bed, mattress, and siderails, for the risk of entrapment was completed.

Based on observation, record review and interview, the facility failed to ensure an inhaler was properly stored after use for 1 (Resident #35) of 1 sampled resident who had an inhaler on an over-bed table. The findings are: Resident #35 had a diagnosis of chronic obstructive pulmonary disease (COPD) as indicated in the Medical Diagnosis section of the electronic health record (EHR) An admission Minimum Data Set with an Assessment Reference Date of 04/07/2024 revealed Resident #35 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. A review of Resident #35's Care Plan dated 04/12/2024 indicated Resident #35 had Emphysema/COPD and an intervention specified giving the resident an aerosol or bronchodilators as ordered. Review of Resident #35's Order Summary indicated an order for budesonide-formoterol (Symbicort) 160-4.5 mcg (micrograms)/actuation inhaler and to take two puffs inhale orally two times a day for COPD. There was no physician's order that indicated the inhaler could be left at the resident's bedside. Review of Resident #35's Electronic Medication Administration Record (eMAR) for July 2024 indicated an order for budesonide-formoterol (Symbicort) 160-4.5 mcg (micrograms)/actuation inhaler and to take two puffs inhale orally two times a day and the times were scheduled for 0800 (8:00 AM) and 1600 (4:00 PM). The eMAR indicated this medication was administered on 07/01/2024 - 07/10/2024 at 8:00 AM and on 07/01/2024 -07/09/2024 at 4:00 PM. On 07/08/2024 at 10:46 AM, Resident #35 was observed lying in bed on back with eyes closed. There was an inhaler, budesonide and formoterol fumarate mcg inhalation/aerosol 160 mcg / 4.5 mcg, lying on the over-bed table that was across the resident's bed. The resident did not open their eyes when their name was spoken. On 07/08/2024 at 3:25 PM, attempted to speak with Resident #35 but the resident was yet in bed with eyes closed and did not open eyes when a name was spoken. There was an inhaler, budesonide and formoterol fumarate mcg inhalation / aerosol 160 mcg / 4.5 mcg, lying on the over-bed table that was across the resident's bed. On 07/09/2024 at 8:31 AM, Resident #35 was awake, sitting up in bed opening the condiments to put on the breakfast meal that was on the over-bed table across the resident's bed. There was an inhaler, budesonide and formoterol fumarate mcg inhalation / aerosol 160 mcg / 4.5 mcg, lying on the over-bed table and Resident #35 confirmed Resident #35 was allowed to use the inhaler twice a day. On 7/11/2024 at 12:03 PM, Licensed Practical Nurse (LPN) #26 confirmed that after an inhaler has been used, it is stored in the medication cart. On 7/11/2024 at 1:20 PM, LPN #19 confirmed that after an inhaler has been used, it should be stored back in the medication cart. A Medication Storage in The Facility policy, (revised January 2018), indicated, . Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Bedside Medication Storage Policy Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team .

Based on observation, record review and interview, the facility failed to ensure enhanced barrier precautions (EBP) were consistently followed when administering medication and enteral feeding through a Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 (Resident #42) of 1 sampled resident who was on enhanced barrier precautions. The findings are: Resident #42 had a diagnosis of obstruction of the tube from the throat to the stomach (esophagus), difficulty swallowing (dysphagia) and gastrostomy status indicated on the Order Summary. A 5-day Medicare Minimum Data Set with an Assessment Reference Date of 06/16/2024 indicated Resident #42 had a Staff Assessment for Mental Status score of 3, which indicated the resident was severely impaired, and that the resident had a feeding tube. Resident #42's Order Summary indicated an enteral feeding order of (Named) 1.5 and to give a 220 cc (cubic centimeters) bolus through the PEG tube one a day. It also indicated an order for enhanced barrier precautions related to the resident's PEG tube. Resident #42's Care Plan initiated 06/11/2024 was yet in progress and did not include any focus problems or interventions regarding the resident's gastrostomy status. On 07/10/2024 at 11:53 AM, Licensed Practical Nurse (LPN) #27 entered Resident #42's room without putting on gloves or a gown. She put on gloves before she checked Resident #42's PEG tube for placement, and proceeded to administer water, medications, water, enteral formula and water again, but did not put on a gown before or during this process. On 07/11/2024 at 11:50 AM, LPN #27 confirmed Resident #42 was on EBP, a gown and gloves were to be used, and she did not put on a gown. She said she thought EBP was just for wounds. On 07/11/2024 at 12:15 PM, LPN #26 confirmed gloves and a gown were to be used for residents on EBP. On 07/11/2024 at 1:48 PM, the Administrator stated there was no policy for enhanced barrier precautions. On 07/11/2024 at 1:50 PM, the Administrator provided an Inservice form dated 06/19/2024 with the topic of enhanced barrier precautions. It indicated, .Star stickers by residents' names indicate EBP, which means gloves and gowns are to be worn when providing care .These residents either have a wound, catheter, feeding tube and or central line .

Based on observation, interview, and record review, the facility failed to follow the smoking policy of securing smoking materials for all residents. The findings are: Resident #3 had diagnoses of Unspecified psychosis and Unspecified dementia. The Annual Minimum Data Set [MDS] with an Assessment Reference Date of 11/25/2023 documented a Brief Interview of Mental Status [BIMS] of 15, which indicated the resident was cognitive. Independent with transfers, ambulated with a walker and no impairment documented to upper or lower extremities. On 03/05/24 at 11:00 AM, Resident (R) #3 was observed sitting in a wheelchair in the facility courtyard smoking area. He/she was wearing a smoking apron and was smoking a cigarette. Dietary Staff Member (DSM) #1 was heard asking R #3 if he/she had a cigarette lighter they could borrow. R #3 then removed a cigarette lighter from a pants pocket and handed it to DSM #1. DSM #1 took the lighter and lit two resident's cigarettes, then handed the lighter back to R #3, who placed it back in his/her pocket. On 03/05/2024 At 3:10 PM, DSM #1 was asked if staff normally supervised resident smoking breaks, DSM #1 replied This was my first time back taking the residents outside, the dishwashers usually take them but they weren't here yet so I took them. DSM # 1 was asked if the dietary department was responsible for supervising resident smoke breaks, and replied, The different departments are scheduled at different times. DSM #1 was then asked if they had been in-serviced and trained on supervising resident smoke breaks prior to doing it and they confirmed they had. DSM #1 was asked why residents were not supposed to have their own lighter, and replied, They could be set on fire, [a resident] could hurt him/her self. The facility smoking policy and procedure obtained from the Administrator on 03/05/2024 at 12:30 PM, documented, .All residents who smoke or use electronic cigarettes will be oriented to this policy smoking .is permitted only under the supervision of designated staff members .No smoking materials will be in any residents possession a anytime .all smoking materials will be kept in a secure area and furnished to the resident during smoking times .All residents will receive assistance with ignition sources . On 03/05/2024 at 2:45 PM, the Administrator stated he/she had searched for a smoking supervision competency for DSM #1 but since the facility had switched to electronic personnel files, they did not have a competency.

Based on observation and interview, the facility failed to ensure foods stored in the refrigerator, freezer, and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure foods were dated the day received and when opened to assure first in, first out usage to prevent potential for food bone illness, expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen, dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure 1 of 2 ice machines and 2 of 2 ice scoop holders were maintained in clean and sanitary condition to prevent contamination of airborne particles. These failed practices had the potential to affect 81 residents who received meals from the kitchen (total census: 83) as documented on a list provided by the Dietary Employee #2 on [DATE] at 10:16 a.m. The findings are: 1. On [DATE] at 10:52 AM The following observations were made on a shelf in the vegetable freezer: a. Bag of diced onion tied at the top not dated. b. Pie crusts not dated when opened. c. French toast sticks not dated when opened. 2. On [DATE] at 10:55 AM The following observations were made in an upright refrigerator: a. a pan of salad covered with clear wrap no open date. b. a container of sliced strawberry topping with no open date. c. Two clear cups of orange juice without a date. d. A clear container with a blue lid of catfish in water to thaw; no thaw date and lid is not sealed; container is partially open. e. Bag of turkey sausage patties with no open date f. Gallon container of mayonnaise with no open date g. container of steak sauce no open date 3. On [DATE] at 10:59 AM The following observations were made in the dry storage room. a. Two individual containers spilled on the floor of the storage room. b. An open 50-pound bag of long grain rice was not dated when it was opened or when received, the bag was torn exposing the rice. c. 14 individual servings of syrup with no receive date. d. An open bag of cookie pieces. e. 2 expired bags of corn chips with an expiration date of [DATE] f. An open bag of croutons g. Dented can of blackeye peas with snaps and no separate dented can area. Dietary Employee (DE) #2 stated, I don't know where we keep dented cans. I've only been here a couple of weeks and we do not have a dietary manager. h. An open and not sealed storage container of rice. i. 80 fluid ounce jar of whole sours pickles with no open date. j. 1 gallon of soy sauce with no open date. 4. On [DATE] at 11:07 AM 34 cartons of skim milk in the milk refrigerator had an expiration date of [DATE]. DE #2 stated, today is the last day - oh wait. That was yesterday. 5. On [DATE] at 11: 08 AM the following observations were made in the Ice cream freezer: a. Two individual containers of ice cream cotton candy with no receive date or open date. 6. On [DATE] at 11:10 AM two zip lock bags of sliced cheese were on a shelf in the cheese refrigerator, the bags were not dated when they were opened. 7. On [DATE] 11:11 AM the ice machine panel in the kitchen had pink and brown residue on it. The surveyor asked DE #2 to wipe the pink residue. He did so, pink residue easily transferred to the tissue. The surveyor asked DE #2, When was it cleaned? I'm not sure. 8. The ice scoop container on the wall by the ice machine had brown crusty particles at the bottom. The ice scoop was in direct contact with crusty brown residue. DE #2 was asked, can you describe that? He stated, crusty brown and was not sure when it had been cleaned. 9. On [DATE] at 08:58 AM the following observations were made on a shelf above the food preparation counter with no received or opened dates and in the kitchen area. a. An opened box of kosher salt., the box has no date on it. b. A bottle of imperial garlic salt, the bottle has no date on it. c. A bottle of ground black pepper, the bottle has no date on it. d. A bottle of lemon pepper, the has no date on it. e. A bottle of chopped onion powder, the bottle has no received or opened date on it. f. A bottle of ground mustard, the bottle has no date. g. A bottle of vegetable seasoning, the bottle has no date. h. A bottle of ground onion, there were no received or opened dates on the bottle. i. A bag of spaghetti, there was no received date on the bag. J. An opened box of complete buttermilk, the box was not covered or dated. k. An opened bag of country style gravy mix, the bag had no date. l. A container of peanut butter, the container has no date. m. An opened 80-ounce bottle of barbecue sauce, the bottle had no date on it. n. A 48-ounce bottle of concord grape jelly was on the shelf above the food counter. The manufacturer specification on the bottle document, Refrigerate after opening. o. On the utility cart, the first level through the 3rd level where clean dishes were kept, had loose food crumbs on them. A box of baker's source that contained white hoagie 8 roll dated [DATE] was on the milk refrigerator. The manufacturer specifications on the box documented, Keep frozen 0 degrees Fahrenheit or below. 10. On [DATE] at 09:00 AM DE #1 pushed a cart in the dish washing machine room. Without washing her hands, she picked up clean bowls and plates and placed them on the cart with fingers inside of them. 11. On [DATE] at 09:35 AM the air vent in the dish washing machine had rust on it. 12. On [DATE] at 09:54 AM the following observations were made around the stove and steam table. a. Vent hood was not on when pans of food items were being cooked on the stove. The manufacture specification on the facing of the hood documented, Vent -A hood fan must be on when stove or fryer is in use. b. The floor between the deep fryer and oven had greasy stains on it. A toaster on top of the counter by the steam table had loose breadcrumbs on them. c. There was a pan under the steam table almost full of greasy water in it. 13. On [DATE] at 10:19 AM an opened box of hamburger patties was on a shelf in the freezer, the box was not covered or sealed. 14. On [DATE] at 10:24 AM the ice machine panel with black spots. The surveyor asked DE #2 to wipe the area The surveyor asked DE #2 to wipe the black residue. He did so, black residue easily transferred to the tissue. The surveyor asked DE #2, How often do you clean the ice machine and who uses the ice from the ice machine? He stated, We clean it once every week. We use it to fill beverages served to the resident at mealtimes. 15. On [DATE] at 10:30 AM the scoop holder on top of the hand washing sink in the utility room had accumulation of wet black/gray residue all around the corner and the area where ice scoop was resting. The surveyor asked DE #2 to wipe the wet black/gray residue. He did so, wet black/gray residue easily transferred to the tissue. The surveyor asked DE #2, How often do you clean the ice machine and who uses the ice from the ice machine? DE #2, stated, CNA's use it The CNAs use it for the water pitchers in the residents' rooms. 16. On [DATE] at 10:35 AM the following observations were made in the freezer. a. A box that contained bags of diced chicken was opened. An opened bag of diced chicken inside the box had no date when it was opened. b. An opened box of sliced pepperoni; the box was not covered or sealed. c. A zip lock bag of fish, the bag was not dated. d. A zip lock bag that contained French fries, the bag was not dated. e. A bag of hushpuppies, the bag was not dated. f. An opened box of beef steak fritters, the box was not dated. 17. On [DATE] at 10:42 AM the following observations were made in the vegetable and dessert freezer. a. A box of [NAME] blend salad, the box was not dated. b. An opened box of garlic bread, the box was not dated when it was opened. c. Four bags of whipping topping, the bags had not been dated when they were received. d. A bag of diced potatoes, the bag was not dated when it was received. 18. On [DATE] at 10:44 AM there was an opened box on a shelf below the counter where the tea maker was kept. There was an opened bag that contained 12 loose bags of tea inside the box. The bag was not dated. 19. On [DATE] at 10:48 AM The following observations were made on the bread rack in the kitchen of bread items that had no dates when received or when opened: a. Eighteen bags of wheat bread. b. Ten of 10 bags of hamburger buns. c. Three of 3 bags of hoagie buns. d. Eight of 8 bags of white bread. 20. On [DATE] at 10:56 AM the following observations were made in the storage room: a. An opened bag of rice was on a shelf, the bag was not sealed. b. Three boxes of cornbread mix had no received dates on them. c. Six cans of instant thickener were not dated when received. d. An opened bottle of distilled white vinegar was on a shelf in the storage room. e. An opened bottle of buffalo sauce, the bottle had no date on it. 21. On [DATE] at 11:36 AM DE #2, picked up the water hose with his bare hand, used it to spray leftover food from inside of the blender, contaminating his hands. He placed the blender, a blade and the lid in the dirty racks and pushed the rack into the dish washing machine to wash. After the dishes stopped washing, he moved to the clean side of the dishwasher area and picked up a clean blade and attached it to the base of the blender to be used in pureeing foods to be served to the residents who received pureed diets for lunch. When he was about to place food items to puree. the Surveyor asked him immediately what you should have done after touching dirty objects or before handling clean equipment? He stated, I should have washed my hands. I will go and rewash them. 22. On [DATE] at 11:53 AM DE #3 turned on the hand washing sink and washed her hands. After washing her hands, she turned off the faucet with her bare hand, removed tissue papers from the dispenser and dried her hands, contaminating them. Without washing her hands, she removes gloves from the glove box and places them on her hands, contaminating the gloves. As she was assisting was on the tray line with lunch meal, she used her contaminated gloved hands to pick up glasses that contained beverages by their rims and placed them on the trays to be served to the residents for lunch. The surveyor immediately asked DE #3 what should you have done after touching dirty objects and before handling clean equipment? DE #3 stated, I should have washed my hands. 23. On [DATE] at 12:00 PM DE #1 who was on the tray line assisting with meal service wore gloves on her hands when she picked up condiments and supplement cartons and placed them on the trays. Without changing gloves and washing her hands, she picked up glasses that contained beverages by their rims and placed them on the trays to be served to the residents for lunch. 24. On [DATE] at 12:42 PM DE #1 picked up 2 cartons of ice cream from a pan of ice on a cart in the kitchen to be served to the residents. The surveyor asked her if those ice creams were still frozen. She pulled the lid off from the carton and stated, They are melted. She discarded them. 25. On [DATE] at 12:49 PM DE #4, picked up the water hose with his bare hand, used it to spray off dust from the new plates, contaminating his hands. He placed the plates in the dirty rack and pushed the rack into the dish washing machine to wash. After the dishes stopped washing, he moved to the clean side of the dishwasher area and picked up plates to be used in serving lunch meal to the residents with his finger inside the plates. The Surveyor asked him immediately what you should have done after touching dirty objects or before handling clean equipment? He stated, I should have washed my hands. I will go and rewash them. 26. The facility policy titled, Handwashing. Provided by the Administrator on [DATE] at 09:35 AM documented, Before during and after food preparation and engaging in any activity that may contaminate hands.

Based on interview and record review, the facility failed to ensure residents and family representatives were involved in care plan meetings for 3 (Resident # 21, # 28, and #32) of 3 sampled residents The findings are: 1. A review of Resident #32 Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of June 16, 2023, noted the resident scored a 3 on the Brief Interview for Mental Status (BIMS) which indicates the resident is severely cognitively impaired. a. On 08/14/23 at 12:33 PM, an interview with Resident #32's representative revealed they have not been invited to care plan meetings and were not aware of the meetings. On 08/14/23 at 12:36 PM, in an interview with Resident #28 who stated, I don't get invited and have never attended. On 08/14/23 at 12:40 PM, in an interview with Resident #21 who stated, I don't know about being invited and so I evidently haven't been. On 08/16/23 at 1:30 PM, The Social Service Director (SSD) stated in an interview that she or the MDS Coordinator will call the family representatives and stated they do not mail anything out. The SSD noted the care plan meeting is scheduled every 3 months. On 8/17/23 at 8:45 AM the Director of Nursing stated, We have no documentation of care plan meetings.

Based on observation, interview, and record review the facility failed to ensure dependent residents were provided nail care for 2 (Resident #41 and Resident #277) sampled residents and failed to ensure that 1 of 1 sampled resident (Resident #64) was free from facial hair. The findings are: 1. On 8/14/23 at 11:33 AM observed Resident #41 fingernails, were approximately 1/4 inch past the fingertip, jagged and, with black substance under the nails. The nails were yellow in color. a. On 8/16/23 at 9:40 AM observed Resident #41 fingernails, were approximately 1/4 inch past the fingertip, jagged and, with black substance under the nails. b. On 8/17/2023 at 8:30 AM observed Resident #41 fingernails, were approximately 1/4 inch past the fingertip, jagged and with black substance under the nails. c. Review of Resident #41 Care Plan for Activities of Daily Living (ADL) deficit, initiated on 8/4/21 noted for staff to check nail length and trim and clean on bath day and as necessary and noted bath days as every Monday, Wednesday, Friday and as necessary. d. During an interview on 8/17/23 at 8:30 AM Certified Nursing Assistant (CNA) # 6, confirmed Resident #41 nails need to be cut and stated the CNAs are responsible for nail care. e. During an interview on 8/17/23 at 8:38 AM with Licensed Practical Nurse (LPN) #4, who said the nurses and CNA's are responsible for nailcare. LPN #4 further stated the nurses always do nailcare for diabetics. 2. On 8/14/23 at 11:21 AM, observed Resident #64 sitting in a wheelchair next to her bed with 1/2-inch-long white chin hair. a. On 8/15/23 at 8:52 AM, observed Resident # 64 lying in bed asleep with 1/2-inch-long white chin hair. b. Review of Resident #64 care plan for ADL performance deficit, initiated on 6/28/23 noted the resident is totally dependent on staff for personal hygiene and oral care. c. On 8/16/23 at 9:15 AM, the Surveyor asked CNA #1 when residents were shaved. CNA #1 stated, as often as needed. The Surveyor asked CNA #1 to look at Resident #64 chin. CNA #1 stated, she was shaved yesterday. d. On 8/16/23 at 10:32 AM, the Surveyor asked the Director of Nursed (DON) when residents were shaved. The DON stated, every shower day or as needed. The DON stated facial hair is a dignity issue and further state the staff were told to shave Resident #64 yesterday. 3. On 8/14/23 at 11:00 AM, Resident #277 stated her toe hurts, and she is in pain from her long toenails and the nurses won't trim them or let her trim them. Resident #277 stated her family talked to staff last week about her toenails and they still have not trimmed them. Observed the residents left big toe had a thick toenail that was curved a half inch past the end of her toe and the edge was in her skin, which was red. The resident's other toenails were 1/4 to 1/2 inch past the end of her toes. a. On 8/15/23 at 8:53 AM, the Surveyor asked Resident #277 if staff trimmed her toenails. Resident #277 stated, no, but I saw clippers in her (pointing to roommate's side of room) things and borrowed them. I guess I need to do it myself. Asking them is obviously not doing anything. b. Review of the Bathing Intervention/Task report noted showers or bathing were provided on 8/9/23, 8/11/23, and 8/14/23. c. On 8/15/23 at 8:55 AM, the Surveyor asked CNA #2 if a resident should use another resident's toenail clippers. CNA #2 stated, No, it's an issue. d. On 8/15/23 at 9:01 AM, the Surveyor asked LPN #3 if Resident #277 was able to safely clip her own toenails. LPN #3 stated, She asked me earlier this morning and I told her I would come back later. She might be able if someone was watching her. The Surveyor asked if residents could use each other's clippers. LPN #3 stated, no, they cannot use each other's. e. On 8/16/23 at 10:22 AM, the Surveyor asked the DON when resident toenails were trimmed. The DON stated, It varies, but at least done on every shower day. The Surveyor asked if Resident #277 family voiced a concern about long toenails. The DON stated the family had not come to him but if she voiced a concern to a nurse, it should be documented in the progress notes. The DON stated, I am not seeing anything. The Surveyor asked if the residents could have toenail clippers or use another resident's clippers. The DON stated, No.

46868 Based on observation, interview, and record review the facility failed to ensure 1 (Resident #36) resident received the physician ordered flow rate of oxygen and the failed to ensure respiratory equipment tubing were changed and bagged in a closed container and failed to obtain a physician's order for oxygen and continuous positive airway pressure (CPAP) for 2 (Resident #21, and #276) residents, and failed to ensure portable oxygen cylinder was stored safely for 1 (Resident #276). These failed practices had the potential to affect 18 residents in the facility who received respiratory treatments as documented on a list provided by the Director of Nursing on 8/16/23 at 4:17 PM. The findings are: 1. On 08/14/2023 at 12:09 PM observed Resident #36 with oxygen via nasal cannula at 4 Liters per minute. a. On 08/15/2023 at 8:29 AM observed Resident #36 with oxygen via nasal cannula set at 2.5 Liters per minute. b. On 08/16/2023 9:45 AM observed Resident #36 with oxygen via nasal cannula set at 2.0 Liters per minute. c. Review of Resident #36 care plan with an initiation date of 08/03/2023 noted oxygen settings at 2 Liters via nasal cannula as needed. d. On 08/17/23 at 8:38 AM during an interview with Licensed Practical Nurse (LPN) #4, the Surveyor asked who is responsible for taking care of the resident's oxygen and what should happen if the oxygen is not set at the physician ordered flow rate. LPN #4 said, the nurses are responsible for the oxygen, and it should be set at the physician ordered flow rate. e. On 08/17/23 at 8:46 AM during an interview with the Director of Nurses (DON), the surveyor asked who is responsible for taking care of the resident's oxygen and what should happen if the oxygen is not set at the physician ordered flow rate? The DON said the nurses are responsible for the oxygen and it should be set at the prescribed flow rate. 2. On 08/14/23 at 10:52 AM, observed Resident #276's oxygen tubing and nasal cannula wrapped around the neck of an oxygen tank in an oxygen cart. a. On 08/15/23 at 8:42 AM, observed an oxygen tank sitting on the floor next to the bedside table while Resident #276 was lying in bed. The oxygen tank was not secured. b. On 08/15/23 at 8:49 AM, an observation with Certified Nursing Assistant (CNA) #2, while in Resident #276 room who confirmed the oxygen cylinder was not safely stored and stated she would tell the nurse. c. On 08/15/23 at 8:51 AM, during an observation with LPN #3, while in Resident #276 room who said the oxygen cylinder should be stored in the oxygen room, and confirmed it was a safety hazard. d. On 08/16/23 at 9:30 AM, during an interview with the DON, who stated, oxygen supplies should be stored in a bag with a date, oxygen tanks should be stored in a wheeled holder or in the oxygen room in a stand. 3. On 08/14/23 at 11:26 AM, Resident # 21 CPAP mask and tubing were not dated, bagged, or stored in a closed container. The oxygen cannula was dated 8/6. a. On 08/15/23 at 9:29 AM observed Resident #21's CPAP mask was not dated or bagged. The oxygen cannula was dated 8/6. b. On 08/15/23 at 02:22 PM, observed Resident #21's CPAP mask and tubing had no date and was not bagged, lying on top of a refrigerator not stored in a bag. The oxygen (O2) cannula was dated 8/6. and the humified water was dated 8/8/23. c. Review of Resident #21, Physician's Order dated, 8/15/23 noted staff to change oxygen tubing, clean filter and oxygen cabinet, date all tubing every Sunday night. d. On 8/16/23 at 9:55 AM LPN #1 stated, All the tubing's, cannulas, and nebulizer equipment should be bagged and dated. LPN #1 further stated the respiratory tubing should be changed every Sunday night. LPN #1 confirmed there was no date on the CPAP tubing, and it was not bagged. 4. During an interview on 8/16/23 at 10:40 AM the DON stated, all tubing is changed on the night shift every Sunday, and confirmed the items should be bagged when not in use. 5. Review of the facility policy titled, Oxygen, Portable, last revised on 11/22/16 noted, Oxygen cylinders should be secured or in a cart. 6. Review of the facility policy titled, Oxygen Safety, last updated on 11/22/16 noted Oxygen cylinders must be stored in rocks with chains, sturdy portable carts and/or approved stands.

Based on observation, record review and interview the facility medication error rate was 15.38%. The failed practice had the potential to affect 28 residents who received medications from the 300 hall Medication Cart, as documented on a list provided by the Director of Nursing (DON) on 8/17/23 at 8:45 a.m. The findings are: During the medication pass observation, 26 opportunities were observed, with 4 errors. Error #1 Resident #25 had a Physician's Order dated 8/12/23 for fexofenadine 180 milligram (mg) tablet daily. On 8/16/23 at 7:53 AM, Licensed Practical Nurse (LPN) #1 stated, I am not going to give this medication because we don't have it. The Surveyor asked if it was in the building or on another cart. The nurse stated, No. It's not available but it's just an over-the-counter medication. There was no physician notification. Error #2 Resident #25 had a Physician's Order dated 8/12/23 for Pantoprazole Sodium Oral Tablet Delayed Release 40 MG daily. On 8/16/23 at 7:53 Am during medication pass observation, LPN #1 did not administer Pantoprazole to Resident #25. Error #3 On 8/16/23 at 7:53 AM during medication pass observation, LPN #1 administered one multivitamin with minerals tablet to resident #25. A review of Resident #25 Physicians order failed to reveal an order for a multivitamin with minerals tablet. Error #4 On 8/16/23 at 8:18 AM, during medication pass observation, LPN #1 administered ferrous sulfate 325 mg tablet through Resident #175 Percutaneous Endoscopic Gastrostomy (PEG) tube. A review of Resident #175 Physician's Order dated 8/14/23 noted an order for Ferrous Sulfate Oral Liquid via the PEG tube. On 6/18/23 9:11AM during interview with LPN #1 she stated, the fexofenadine was not available, and the pantoprazole was a new order, and it wasn't given. LPN #1 reviewed Resident #25 orders and confirmed there was no order for the multivitamin with mineral, and stated she had one before going to the hospital. LPN #1 confirmed the orders for ferrous sulfate was liquid, and she provided a tablet. On 8/16/23 at 1:40 PM during an interview, the Director of Nurses (DON) was asked if nurses were expected to follow the Physicians orders while administering medications. The DON said yes.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 4 residents who received pureed diets and 10 residents who received regular diets diets from the kitchen according to a list provided by the Assistant Dietary Supervisor on 08/16/2023. The findings are: 1. The facility menu for lunch provided by the Administrator on 08/15/23 at 11:30 AM, documented that each resident on regular diets were to receive 3-ounces of ground herb pork loin and each resident on pureed diets were to receive a #16 scoop (1/4-cup) of pureed bread and a -#10 scoop (1/3 cup) of pureed buttermilk pie each. 2. The following observations were made during the noon meal preparation and meal service. a. On 8/07/23 at 11:45 AM there was no pureed bread or pureed buttermilk pie prepared. b. On 08/16/23 at 12:42 PM the residents on pureed diets did not receive pureed bread and pureed buttermilk pie. They were served apple sauce, instead of pureed bread and pureed buttermilk pie. At 1:12 PM an interview with Dietary Employee (DE) #2, revealed DE #2 forgot to puree bread, so DE #2 gave applesauce. 3. On 08/16/23 at 12:52 PM the kitchen ran out of food items. Ten residents on regular diets received mashed potatoes, hamburger steak, brussels sprouts, and dinner roll instead of herb pork lion and sweet potatoes. Four residents were served mashed potatoes, hamburger steak and dinner roll, instead of herb pork lion, brussels sprouts, and sweet potatoes. At 1:12 PM the surveyor asked DE #2, how many residents received Brussels sprouts. He stated, ten residents received mashed potatoes, hamburger steak, brussels sprouts and dining roll. Four residents received mashed potatoes, hamburger steak and dinner roll. 4. On 08/17/23 at 10:09 AM The surveyor asked the DE #1 the reason buttermilk pie was not prepared and served to the residents on pureed diets. She stated, Because I could never get to the machine.

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained a palatable appearance, and at temperatures that were acceptable to the residents during 2 of 2 meals observed. This failed practice had the potential to affect 12 residents who receive meal trays in their rooms on the 100 Hall, 16 residents who receive meal trays on the 300 hall, and 17 residents who receive meal trays in their room on the 400 hall, as documented on a list provided by the Administrator on 8/17/2023 at 12:20 PM. The findings are: 1. On 8/14/23 at 1:15 PM the surveyor asked Resident #18 if your hot food stays hot and your cold food cold? The residents stated, I never get hot food especially breakfast. 2. On 8/14/23 at 11:58 AM the surveyor asked Resident #51 if your hot food stays hot and your cold food cold? The residents stated, food not always hot enough is my only complaint. 3. On 8/14/23 at 12:06 PM the surveyor asked Resident #33 if your hot food stays hot and your cold food cold? The Resident stated, No hot food. 4. 8/15/23 at 8:40 AM the surveyor asked Resident #6 if the hot food stays hot and cold food stays cold? Resident #6 stated that he eats his food even though its cold because he gets hungry; cold food is better than no food. He picked at his food and ate snacks the family had brought in. 5. On 8/16/23 at 12:06 PM an unheated food cart that contained 16 trays for lunch was delivered to the 300 hall by Dietary Employee (DE) #4. At 12:19 PM the unheated food cart that was pushed to the dining room on 400 Hall by the Certified Nursing Assistant #4. There were 3 food trays left in the cart. Certified Nursing Assistant #4, stated, the remaining trays belong to the residents who eat in the dining room. At 12:38 PM CNA #5 removed the last tray from the cart and took it to the dining room to serve the resident. The surveyor asked CNA #5 to check the temperatures of the food items on the plate. CNA #3 checked the temperatures and stated, Pork roast 107.2 degrees Fahrenheit, brussels sprouts 109.6 degrees Fahrenheit. The surveyor asked CNA #3 to describe the ice cream. She stated, It was melted. 6. On 08/16/23 at 12:13 PM an unheated food cart that contained 12 trays for lunch was delivered to 100 hall by DE #4. At 12:28 PM immediately after the last resident was served in their room on 100 hall, temperature of the food items on the tray used as a test tray were taken and read by CNA #3 with the following results: a. Pork roast 109.2 degrees Fahrenheit. b. Ground meat with gravy 106.5 degrees Fahrenheit. 7. On 8/16/23 at 12:25 PM an unheated food cart that contained 17 trays for lunch was delivered to the dining room on 400 Hall by DE #4. At12:35 PM immediately after the last resident received their tray in their room on 400 hall, the temperatures of food items on a test tray were checked and read by CNA #3 with the following results: Regular pork roast 109.1 degrees Fahrenheit. 8. On 8/17/23 at 7:15 AM an unheated food cart that contained 20 trays for breakfast was delivered to 300 Hall by DE #5. At 7:25 AM the first tray was served on the 300 hall. At 07:35 immediately after the last residents received their tray in the room on 300 Hall CNA #7 pushed the food cart that contained 4 breakfast trays to the 100 Hall. After the last resident received their tray in their room on 100 hall, at 07:36 AM the temperatures of food items on the tray used as a test tray was checked and read by the Administrator with the following results: a. Ground sausage 80 degrees Fahrenheit. b. Scrambled eggs 90 degrees Fahrenheit. c. Sausage 72 degrees Fahrenheit. d. The surveyor asked the Director of Nursing if he could feel the sausage and the plate. He felt the sausage and stated, It's lukewarm. He touched the plate and stated, It was cold. 6. On 8/17/23 at 7:21 AM an unheated food cart that contained 12 trays for breakfast was delivered to the 100 Hall by DE #4. At 07:36 PM immediately after the last resident received their tray in their room on 100 hall, the temperatures of food items on a test tray were checked and read by CNA #8 with the following results: a. Grits 105 degrees Fahrenheit. b. Pureed eggs 102 degrees Fahrenheit. c. Pureed sausage 90 degrees Fahrenheit. d. Pureed sausage 90 degrees Fahrenheit. e. Scrambled eggs 92 degrees Fahrenheit.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 3 of 3 meals observed. This failed practice had the potential to affect 4 residents who received pureed diets, as documented on the Diet List provided by the Dietary Employee #2 on 08/17/2023. The findings are: 1. On 08/16/23 at 11:24 AM Dietary Employee (DE) #2 placed 5 servings of pork roast into a blender, added broth and pureed. At 11:28 AM DE #2 poured the pureed meat into a pan, covered the pan with foil and placed it in the oven. The consistency of the pureed pork loin was gritty and was not smooth. At 1:14 PM The surveyor asked DE #6 to describe the consistency of the pureed meat served to the residents on pureed diets. She stated, It was gritty. Pureed should be pudding consistency. 2. On 08/17/23 at 7:25 AM the pureed grits served to the residents on pureed diets was gritty and not smooth. At 7:29 AM the surveyor asked DE #2 to describe the consistency of the grits served to the residents on pureed diets. He stated, It was gritty, and it was not smooth. 3. On 08/18/23 at 8:12 AM The pureed oatmeal served to the residents on pureed diets was runny. The surveyor asked Certified Nursing Assistant #10 who was assisting residents with their meals, to describe the consistency of the pureed oatmeal served to the residents on pureed diets. She stated, It was runny.

Based on observation, record review, and interview, the facility failed to ensure licensed nurses demonstrated competency with administering medications through a gastrostomy tube and providing respiratory services. This failed practice had the potential to affect all 83 residents in the facility as documented on the Resident Census and Conditions of Residents which was provided by the MDS Coordinator on 8/15/23 at 9:49 a.m. The Findings are: 1. On 8/16/23 at 7:53 AM, during medication pass observation for Resident #25, Licensed Practical Nurse (LPN) #1 stated, I am not going to give this medication because we don't have it. The medication was fexofenadine (an antihistamine). The Surveyor asked if it was in the building or on another cart she stated, No, it's not available. It's just over the counter. a. On 8/16/23 at 7:53 AM during medication pass observation for Resident #25 Pantoprazole (a medication used for gastroesophageal reflux disease) was not administered. b. On 8/16/23 at 7:53AM during medication pass observation for Resident #25, a multivitamin with minerals was administered. c. Review of Resident #25's Physician's Order, dated 8/12/23 noted an order for fexofenadine daily for allergic rhinitis. d. Review of Resident #25's Physician's Order dated 8/12/23, noted an order for pantoprazole sodium delayed release tablet daily for gastroesophageal reflux disease. e. Review of Resident #25's Physician's Orders failed to reveal an order for multivitamin with minerals. 2. On 8/16/23 at 8:18 AM, during medication pass observation for Resident #175 a ferrous sulfate 325 mg tablet was administered by LPN #1. b. Review of Resident #175's Physicians Order dated 8/14/23 noted an order for ferrous sulfate oral liquid through the percutaneous endoscopic gastrostomy (PEG) tube. 3. On 8/16/23 at 10:25 AM during an interview with LPN #1 who stated, she did not administer Resident #25 fexofenadine because it was not available. She stated the pantoprazole was a new order and was unable to locate the medication in the medication cart. LPN #1 stated she would have to strike that one out, because she did not give it, but documented it as given. LPN #1 confirmed there was no physician order for the multivitamin with minerals for Resident #25. She stated the resident was on the medication prior to going to the hospital. LPN #1 confirmed she gave Resident #175 a table of ferrous sulfate, instead of the ordered liquid. 4. On 8/16/23 at 8:18 AM during medication pass observation for Resident #25, observed LPN #1 drew 60 milliliters of water into a syringe and inserted the syringe into the (percutaneous endoscopic gastrostomy) PEG tube. The nurse pushed the plunger until the water flushed. LPN #1 then withdrew medication mixed with water into the syringe and pushed the plunger until the syringe was emptied. This process was repeated 3 more times. a. On 08/16/23 at 10:30 AM during an interview, LPN #1 was asked when giving medications through a PEG tube how should the medications be allowed to enter the stomach. The LPN stated, I crushed the med (Medications) then added water, sucked it into the syringe then pushed the plunger until it's all gone. e. On 8/16/23 at 11:10 AM during an interview with the Director of Nurses (DON) was asked to explain how to administer medications/liquids through a Gastrostomy tube. The DON stated it should be allowed to flow through gravity. 5. On 8/16/23 at 1:40 PM during an interview with the DON who stated he expects the nurses to follow the physician's orders while administering medications and stated the nurses receive training on medication administration quarterly, and the pharmacist observes monthly. 6. A review of LPN #1 training and competency documentation revealed LPN #1 completed a medication posttest on 5/7/20, 5/11/21, 5/10/22 and 5/10/23. 7. A review of the procedure titled, Medication, General Administration of, last updated on 11/22/16 noted .Should there be any doubt concerning the administering of medications, the physician's order must be verified before the medication is administered . 8. A review of the facility policy titled Enteral Feedings, Administration via Gastrostomy noted under initiate feedings to allow the syringe to empty gradually.

Based on observation and interview, the facility failed to ensure privacy and confidentiality of personal and medical information was maintained for 1 of 2 medication carts observed. The findings are: 1. On 08/15/23 at 7:58 AM, observed a medication cart on Hall 300 unattended with a laptop screen open and unlocked and residents name, medication information, and photo visible. 2. On 08/15/23 at 08:08 AM during an interview with Licensed Practical Nurse (LPN) #1 who confirmed the computer should have been locked, when the medication cart was unattended. 3. During an interview on 08/17/23 at 11:06 AM, the Director of Nursing (DON) confirmed the computer screen should be locked when the medication cart is unattended to hide any resident information. 4. On 8/17/23 at 11:53 AM the DON stated they do not have a privacy policy.

Based on record review and interview, the facility failed to ensure a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Resident (R) #1 was admitted to the facility on [DATE] from an acute care hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Baseline Plan of Care dated 12/22/21 and signed by Licensed Practical Nurse (LPN) #1 documented, . Medications resident is taking . Insulin . Medication list reconciled by: Resident . b. Hospital Discharge Orders dated 12/22/21 documented, .Medications to be continued at [Facility] . Insulin detemir 20 units at bedtime . Active Outpatient medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject 20 units under the skin at bedtime for diabetes . Accu-check [blood glucose test] guide test strip. Use one strip four times a day . Insulin [MEDICATION(S)], Hum [human] 100 unt/mL [units per milliliter] Novolog inject 8 units under the skin before breakfast and inject 8 units before lunch and inject 8 units before dinner for diabetes . c. The December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Order date 12/22/21 1402 [2:02 p.m.] . D/C [discontinue] Date 12/27/21 1448 [2:48 p.m.]. Check marks were documented to indicate the Insulin Detemir 80-unit injections were administered to the resident on 12/22/21, 12/25/21 and 12/26/21. The order for Insulin Detemir 20 mg had been incorrectly transcribed on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . d. A Progress Note dated 12/23/21 at 9:19 p.m. documented, .Orders Administration Note . Insulin Detemir Solution Inject 80 unit subcutaneously at bedtime . 80 u [units] given blood sugar checked and is 509 . e. A Progress Note dated 12/24/21 at 9:31 p.m. documented, .Orders Administration Note . Insulin Detemir Solution Inject 80 unit subcutaneously at bedtime . resident refused r/t [related to] fsbs [fingerstick blood sugar] 132 . f. A Progress Noted dated 12/27/21 at 8:20 a.m. documented, .Nsg [Nursing] - General Note . during regular rounds this morning resident was very lethargic and was not responding verbally. This nurse checked resident's blood sugar and the result was 33. Got order from [Advanced Practice Nurse (APN) #1] to give oral [MEDICATION(S)]. Resident also drank 2 cups of orange juice. Resident's blood sugar increased to 65 then dropped back down into the 40s. Order given by [APN #1] to send resident to hospital . g. The facility's documented investigation dated as initiated on 12/27/21 documented, Problem Identified: On 12-27-21 [at] 0730 [7:30 a.m.] resident presented with a blood sugar of 33 mg/dL. [Rechecked] x [times] 4 [with] range still below normal. [MEDICATION(S)] and orange juice administered [and] resident transferred via ambulance to [hospital] . Admission order from [hospital on 12-21-21 compare to transcribed orders on [facility's electronic health record software] for 12/21 . 1. Transcribed order for insulin and blood sugar do not match hospital dc [discharge] orders. 2. No prompt 2nd check to assure meds transcribed correctly. MR [Medical Records employee] on vacation. 3. 20 units of HS [bedtime] insulin transcribed as 80 units. 4. No transcription for blood sugar checks. 5. Before meal insulin administered 12-22-21 to 12-27-21 TID [3 times daily] without consistent blood sugar checks . h. On 1/5/22 at 11:15 a.m., the Administrator and Director of Nursing (DON) entered the room where the surveyors were working and provided a list of residents who received insulin. The DON stated she knew why the surveyors were at the facility and confirmed that the resident had been given 80 units of insulin. i. The Weights and Vitals Summary provided by the Nurse Consultant on 1/6/22 at 10:02 a.m. documented the resident's blood glucose readings were as follows: 12/23/21 at 9:08 p.m. - 298 milligrams per deciliter (mg/dL) 12/26/21 at 11:56 p.m. - 138 mg/dL 12/27/21 at 7:30 a.m. - 33 mg/dL 12/27/21 at 7:45 a.m. - 42 mg/dL 12/27/21 at 8:17 a.m. - 58 mg/dL 12/27/21 at 8:30 a.m. - 65 mg/dL 12/27/21 at 8:42 a.m. - 47 mg/dL j. These medication errors were significant based on the classification of the medication (insulin), the frequency of the error, and the condition of the resident. k. The facility removed the immediate jeopardy and corrected the failed practices on 12/27/21 prior to the complaint investigation survey, as evidenced by the following: 1.) The facility's written investigation dated 12/27/21 documented, .Normal process is med regimen review by medical records to assure proper transcription 2nd review by provider with signature . Inservice all nurses should be alert to giving insulin [without] checking BS [blood sugar]. Before meal insulin should not be given until BS checked . 2.) The facility's written corrective actions dated 12/27/21 documented, 1. Pull all current insulin orders, compare with original or most current insulin order for accurate transcription. Confirm all with provider. 2. Compare all orders to be certain blood sugar check ordered, transcribed as ordered and being obtained and documented as ordered. 3. Beginning immediately, all nursing staff to be inserviced shift to shift on necessity of confirmation of correct transcription of insulin and blood sugars order to MAR by second licensed nurse before administration of first dose. 4. All admission from previous 24 hours and 48 hours on weekends will be brought to each weekday morning meeting for a complete med review comparing hospital DC [discharge] orders to [electronic health record software] transcribed orders for accuracy. To include insulin and all other medication orders . 5. Inservice: 1.) Standard of checking any blood sugars on any resident receiving insulin. 2.) Clarification of orders if needed to include how often timing and blood sugar parameter of blood sugar for contacting MD [Medical Doctor] purpose . 3.) Inservice Records dated 12/27/21 and 12/28/21 documented, Topic: Transcribing Insulin Orders. Transcription of insulin orders will be checked and verified by a second nurse on admission and with any change of insulin orders prior to administration of the first dose . All insulin orders pulled and verified between 2 nurses to ensure accurate transcription. All insulin orders then verified with provider. All insulin and finger stick blood sugar orders pulled to ensure that blood sugar check was also ordered, obtained and being documented . If a resident is admitted on insulin but there are no fingerstick blood sugar orders the nurse must clarify and obtain FSBS [fingerstick blood sugar] orders from the provider. Blood sugars < [less than] 60 and > [greater than] 400 must be called to the provider . A nurse should be concerned if they have an insulin order and no order for fingersticks. Always confirm any concerns immediately with provider for clarification of frequency, timing and blood sugar parameters for contacting MD. The signatures of 12 nurses were documented on the signature sections of the inservice forms. 4.) On 1/7/22 at 10:35 a.m., LPN #2 was asked, Can you tell me how you administer insulin? She stated, I check the order x [times] 2, check the resident's blood sugar, verify the order and insulin drawn up with another nurse before I give it. The LPN was asked, When you receive a new admission, can you explain to me how MD orders are processed and if you are unsure, what do you do? She stated, I verify the orders that come with the resident being admitted with the doctor and a second nurse and, after verifying and they are agreed upon, I enter the orders into the computer on the MAR. If I am unsure or have any doubts, I will call the doctor back. 5.) On 1/7/22 at 10:50 a.m., LPN #3 was asked, Can you tell me how you administer insulin? She stated, I check the order, make sure it's correct, verify the insulin with another nurse before I give the insulin. The LPN was asked, When you receive a new admission, can you explain to me how MD orders are processed and if you are unsure, what do you do? She stated, If a new admit comes in, I verify the orders that came with the resident. I check the name, dose, amount, time, and route. I have another nurse verify the order with me. I call the doctor to go over the orders and I make sure the doctor agrees with the orders before I put them in the computer. I have another nurse to verify the orders as well. If I have concerns or question myself on what the doctor said, I will call them back to clarify the orders again.

Complaint # (AR 970) was substantiated (all or in part) in these findings: Based on record review and interview, the facility failed to ensure blood sugar levels were monitored prior to the administration of insulin for 1 (Resident #5) of 4 (Residents #1, #2, #3 and #5) case mix residents who received insulin. The failure to monitor blood sugars prior to the administration of insulin resulted in Past Immediate Jeopardy which caused or could have caused serious harm, injury or death for Resident #5 who had a decreased level of consciousness and a blood sugar reading of 33 following the administration of scheduled insulin and had the potential to affect 15 residents who received insulin, according to a list provided by the Nurse Consultant on 2/9/16. The facility was informed of the Past Immediate Jeopardy on 2/9/16 at 2:50 p.m. The findings are: Resident #5 had [DIAGNOSES REDACTED]. The Initial Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/15 documented the resident scored a 9 (8 - 12 indicates moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS), required supervision with eating and received insulin injections 7 of the last 7 days. a. The admission orders [REDACTED].Insulin Detemir ([MEDICATION NAME]) . 13 units . (at) bed time . Insulin [MEDICATION NAME] (Humalog) . 6 units . 3 times daily before meals . There were no orders documented for blood sugar monitoring or any parameters for consultation with physician regarding highs/lows. b. The November 2015 Med (Medication) Sheet Notes, the Daily/24 Hour Report Sheet, and/or the November 2015 Medication Administration Record [REDACTED] 1) (Med Sheet Notes) Humalog . inject 6 units sq (subcutaneous) ac (before meals) . (Date / Time) 11/14/2015 (5:19 p.m.) (Given By) (Licensed Practical Nurse (LPN) #12) . (Notes) Held due to FSBS (finger stick blood sugar) 143. The Daily / 24 Hour Report Sheet dated 11/14/15 signed by LPN #12 .(Resident #5) - Please clarify insulin order. Held 6 (units) insulin (at) lunch (and) dinner due to FSBS. 2) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/15/2015 (11:23 a.m.) (Given By) (LPN #12) . (Notes) Held insulin due to FSBS 132 . (Date / Time) 11/15/15 (4:45 p.m.) (Given By) (LPN #12) . (Notes) Held due to FSBS being under 150. 3) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/18/2015 (6:55 a.m.) (Given By) (LPN #13) . (Notes) BS (blood sugar) 72. (MAR) (11/18/15) (6:30 a.m.) . H (medication held). 4) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/19/2015 (6:57 a.m.) (Given By) (LPN #13) . (Notes) BS 74. (MAR) (11/19/15) (6:30 a.m.) H (medication held). 5) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/20/15 (6:52 a.m.) (Given By) (LPN #13) . (Notes) BS 69. (MAR) (11/20/15) (6:30 a.m.) H (medication held). 6) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/21/15 (4:51 p.m.) (Given By) (LPN #12) . (Notes) Hold due to FSBS (less than) 150. 7) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/22/15 (4:38 p.m.) (Given By) (LPN #12) . (Notes) Held due to FSBS (less than) 150. 8) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/25/15 (6:45 a.m.) Given By: (LPN #13) . (Notes) Hold. There was no reason why the Humalog was held and there was no blood sugar documented. The laboratory report dated 11/25/15 documented, .Date Collected . 11/25/2015 (7:15 a.m.) . CMP (Comprehensive Metabolic Panel) . Glucose 59 L (low) . (Reference Range) 70-99 . This report was signed by the Advanced Practice Nurse (APN), but had no date of review. There was no documentation the physician was consulted regarding the abnormal glucose level. 9) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/28/15 (6:36 a.m.) (Given By) (LPN #13) . (Notes) BS 72. (MAR) (11/28/15) (6:30 a.m.) H (medication held). (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/28/15 (12:28 p.m.) (Given By) (LPN #12) . (Notes) Held due to FSBS 112. (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/28/15 (5:15 p.m.) (Given By) (LPN #12) . (Notes) Held due to FSBS below 150. c. On 2/10/16 at 9:55 a.m., Registered Nurse (RN) #2 was asked, Did you give (Resident #5) any insulin? RN #2 stated, Yes, I did. The November 2015 eMAR (electronic Medication Administration Record) documented 6 units of [MEDICATION NAME] / Humalog was administered by RN #2 on 11/11/15 at 8:00 a.m., 12:00 p.m. and 4:00 p.m.; on 11/12/15 at 8:00 a.m. and 12:00 p.m.; on 11/16/15 at 11:30 a.m.; on 11/17/15 at 11:30 a.m.; on 11/18/15 at 11:30 a.m.; on 11/19/15 at 11:30 a.m.; on 11/20/15 at 11:30 a.m.; on 11/23/15 at 11:30 a.m.; on 11/24/15 at 11:30 a.m.; on 11/25/15 at 11:30 a.m.; on 11/26/15 at 11:30 a.m.; on 11/27/15 at 11:30 a.m.; and on 11/30/15 at 11:30 a.m. and 4:30 p.m. There were no documented blood sugar results on the dates and times RN #2 administered 6 units of Humalog insulin. d. As of 2/10/16 at 10:28 a.m., the November 2015 eMAR documented 6 units of Humalog was administered by LPN #10 on 11/27/15 at 4:30 p.m. There was no blood sugar result documented. LPN #10 was asked, Did you give (Resident #5) any insulin? LPN #10 stated, I did at 4:30 p.m., but not at 8:00 p.m.No I did not check FSBS, as there was no order for FSBS. LPN #10 was asked, Is Humalog a short acting insulin? LPN #10 stated, Yes. LPN #10 was asked, Should you give Humalog without checking a blood sugar? LPN #10 stated, No. e. The December 2015 Med (Medication) Sheet Notes, the Daily/24 Hour Report Sheet, and/or the December 2015 Medication Administration Record [REDACTED] 1) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 12/3/15 (6:07 a.m.) (Given By) (LPN #13) . (Notes) Hold BS 65. The laboratory report dated 12/4/15 documented, .Date Collected: 12/4/2015 (7:05 a.m.) . CMP . Glucose 68 L (low) . (Reference Range) 70-99 . The report was signed by the APN, but had no date of review. There was no documentation the physician was consulted regarding the abnormal glucose level. 2) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 12/8/15 (6:17 a.m.) (Given By) (LPN #13) . (Notes) Hold BS 62. The laboratory report dated 12/11/15 documented, .Date Collected . 12/11/2015 (7:05 a.m.) . CMP . Glucose 49 L (low) . (Reference Range) 70-99 . This report was signed by the APN, but had no date of review. There was no documentation the physician was consulted regarding the abnormal glucose level. 3) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 12/12/2015 (1:30 p.m.) (Given By) (LPN #12) . (Notes) Held due to FSBS of 184. (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 12/12/15 (4:37 p.m.) (Given By) (LPN #12) . (Notes) Held due to FSBS 172. 4) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 12/15/15 (6:24 a.m.) (Given By) (LPN #13) . (Notes) BS 80. (MAR) (12/15/15) (6:30 a.m.) H (medication held). 5) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 12/17/15 (6:27 a.m.) (Given By) (LPN #13) . (Notes) Held BS 62. f. The December 2015 eMAR documented 6 units of [MEDICATION NAME] / Humalog was administered by RN #2 on 12/1/15 at 11:30 a.m.; on 12/2/15 at 11:30 a.m.; on 12/3/15 at 11:30 a.m.; on 12/4/15 at 11:30 a.m.; on 12/7/15 at 11:30 a.m.; on 12/8/15 at 11:30 a.m.; on 12/9/15 at 11:30 a.m.; on 12/10/15 at 11:30 a.m.; on 12/14/15 at 11:30 a.m.; on 12/15/15 at 11:30 a.m. and 4:30 p.m.; on 12/16/15 at 11:30 a.m.; and on 12/17/15 at 11:30 a.m. There were no documented blood sugar results on the dates and times RN #2 administered 6 units of Humalog insulin. RN #2 was asked, Prior to insulin administration, did you check her (Resident #5) blood sugar? RN #2 stated, Not always. RN #2 was asked, Did you chart it (blood sugars)? RN #2 stated, No. RN #2 was asked, Why not? RN #2 stated, I was moving along. g. Nursing Notes from 11/14/15 through 12/17/15 were reviewed. As of 2/8/16 at 1:55 p.m., there was no documentation regarding consultation with the physician when the Humalog insulin was held or of notification of the finger stick blood sugars or laboratory blood sugar / glucose results. h. The Nurses Notes dated 12/20/15 at 8:15 a.m. documented, CNA (Certified Nursing Assistant) reports to writer resident would not wake up for morning meal. (8:30 a.m.) writer entered resident's room noted resident lying in bed eyes closed, resp (respirations) even and unlabored, no response to verbal or touch stimuli, skin cool and clammy, gown was wet around the neck area. (8:35 a.m.) BS was 33 when checked at this time, (8:36 a.m.) Supervisor notified to bring [MEDICATION NAME] emergency kit, (8:40 a.m.) [MEDICATION NAME] 1 mg (milligram) administered, (8:48 a.m.) BS 31 (ambulance) notified, (9:00 a.m.) BS 35 (9:15 a.m.) (ambulance) here . i. On 2/10/16 at 11:00 a.m., LPN #12 was asked, Did you give (Resident #5) any insulin? LPN #12 stated, In the beginning no. She had an order to give 6 units of insulin and I was not comfortable with giving insulin without checking her blood sugar. LPN #12 was asked, You held the insulin? LPN #12 stated, Yes. LPN #12 was asked, Did you notify the doctor? LPN #12 stated, No. I wrote on the 24-hour sheet that we needed to get a clarification from the doctor regarding if he wanted blood sugars and no one ever did. LPN #12 was asked, Was there any reason you did not follow up and ask if the doctor wanted her blood sugar checked? LPN #12 stated, No, she wasn't in an emergency and when I talked with the daughters they said if it was under 200 they held the insulin. j. On 2/9/16 at 10:58 a.m., the APN who signed the resident's lab reports was observed signing lab reports. The APN was asked, What is your process for reviewing labs? The APN stated, I come on Tuesday and Wednesday. On Tuesday I review all the labs in my lab folder that have been placed there since I left on Wednesday. Every Wednesday when I leave my lab folder is empty. The APN was asked to look at the lab reports dated 11/25/15, 12/4/15 and 12/11/15 for Resident #5. The APN was asked, Did you review these labs? The APN stated, Yes. I've signed them but I couldn't say when. The APN was asked, Were you notified of low glucose levels? The APN stated, No. If I had been they would have written it on the lab report for me to sign later. I did look at them, but I don't recall noting the glucose levels. The APN was asked, Were you notified of the resident's Humalog insulin being held? The APN stated, No. k. On 2/9/16 at 10:10 a.m., the Director of Nursing (DON) was asked, Did anyone call the physician to question if they wanted blood sugars done prior to administering Humalog insulin or to monitor the resident's response to short and long acting insulin she was receiving? The DON stated Not that I'm aware of. On 2/9/16 at 11:10 a.m., the DON and Administrator were asked, When you reviewed (Resident #5)'s medical record, did you know the nurses were holding the resident's insulin? The Administrator stated, We noticed it on 12/20/15. The DON and Administrator were asked, What did you do about all the insulin that was held without physician notification? The DON stated, We counseled all of the nurses. The DON was asked, Is there anything on the counseling form about notifying the physician when insulin is held? The DON stated, No. It's in our in-service we did on 12/20/15. l. On 2/8/15 at 1:55 p.m., the Administrator presented hand written documentation of the facility's corrective actions following the 12/20/15 hospitalization of Resident #5. 1) (At) (1:00 p.m.) met (with) family (December) 20th, 2015. Brought to my attention by family member of (Resident #5) was sent to ER (emergency room ) for low blood sugar. (Administrator) met (with) (Family Member #1) to review (resident) chart. During review of chart (no) documented results of FSBS. Noted no MD (medical doctor) order for scheduled FSBS. (Resident) in fact had an order (for) scheduled (regular) insulin. Spoke (with) nurse who cared for (resident) the a.m. of (December) 20 (and) nurse (LPN #2) reported (resident) (with) a FSBS of 102 (and) insulin given as ordered (at) (6:30 a.m.) on 12/20(/15). -Pulled Nurse's Notes for (resident) Reviewed orders. On 12/20/15 Nurse (LPN #2) called in to facility (and) completed 1 on 1 training / inservicing (with) DON (Director of Nursing) Diabetes education (and) administration of insulin. Employee counseled - prior to start of next shift - All nurses inserviced Diabetes (and) insulin administration. - any nurse that admin (administered) insulin counseled / inserviced. December 20 - 21st audit completed of all (residents( (with) [DIAGNOSES REDACTED]. Charts (checked), ensured all necessary had order to (check) FSBS - No others identified. 12-20-15 Spoke (with) (LPN #2) (complaint of) FSBS results for (Resident #5). (LPN #2) reports giving 6 (units) of insulin as ordered (at) approximately (6:30 a.m.). States FSBS was checked prior to (administration) (and) result was 102. (LPN #2) reports FSBS for (Resident #5) on previous night (12-19-15) (at) HS (hour of sleep) was 210. [MEDICATION NAME] given as ordered. Reviewed facility camera. Observed nurse (LPN #2) in (resident) room (at) approx. (approximately) (6:35 a.m.) CNA (CNA #1) entered room (7:15 a.m.) - (resident) sleeping. (CNA #2) took tray in room, (resident) asleep (7:30 a.m.). (CNA #3) in room (8:00 a.m.) left room, talked to nurse (8:10 a.m.). (LPN #3) in room (8:20 a.m.) 2) On 2/8/16 at 2:07 p.m., the facility presented an in-service dated 12/20/15 that documented, .Know your different insulin actions (and) onsets . Never (administer) insulin (without) knowing (blood sugar) . it is very important to follow the appropriate guidelines (and) procedures when taking blood sugars (and) (administering) insulin . As licensed nurse know that you are able to use your nursing judgement (and) hold a medication (and) notify MD (with) any concerns . The in-service was signed by 15 nurses. 3) On 2/9/16 at 10:12 a.m., the DON provided a copy of Counseling Reports done with 7 nurses who had administered insulin to Resident #5. The Counseling Reports were dated 12/20/15 through 12/29/15. 4) The Administrator was asked, On 12/20/15 you did an audit of what? The Administrator stated, Residents with [DIAGNOSES REDACTED]. I pulled them all up on the computer, looked at the [DIAGNOSES REDACTED]. what she did with it. Since then, in morning meeting we bring in all admits, readmits and newly diagnosed diabetic charts. We go through the chart to verify if the resident is Diabetic, if insulin is administered, and if there is an order to check the blood sugars. 5) On 2/10/16 at 11:30 a.m., the DON and Administrator were asked, Did you do any in-services other than 12/20/15 regarding insulin and finger stick blood sugars? The DON stated, Yes, on 1/26/16 we did a repeat of the 12/20/15 in-service for all staff, including all new staff. They are supposed to check blood sugars before giving short acting insulin and the onset and duration of the insulin. On 1/26/16, we talked to staff about reporting abnormal labs per the physician's parameters . in the 24 hour report book the nurses have access to. On 1/26/16, we covered they are to ensure they give the resident something substantial to eat - cereal and milk, etcetera that they have or can get starting at 5:30 a.m. dietary gets here. We also did a follow up audit checking residents with [DIAGNOSES REDACTED].

Complaint # (AR 970) was substantiated (all or in part) in these findings: Based on record review and interview, the facility failed to ensure the physician was consulted regarding decreases in blood sugar readings and to ensure scheduled insulin was not held without physician consultation in order to provide the physician with necessary information to guide treatment and decrease the potential for complications related to hypo and [MEDICAL CONDITION] for 1 (Resident #5) of 4 (Residents #1, #2, #3 and #5) case mix residents who received insulin. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious injury, harm, or death for Resident #5 who had a decreased level of consciousness and a blood sugar reading of 33 following the administration of scheduled insulin. The Immediate Jeopardy was removed by the facility on 12/20/15 when the facility identified the issue and initiated corrective action, however the facility had not corrected the underlying deficient practice at the time of the survey. On 2/9/16 at 2:50 p.m., the facility was informed of the Immediate Jeopardy removed. The facility failed to ensure the physician was consulted regarding elevated blood sugars in order to provide the physician with necessary information to guide treatment and decrease the potential for hyperglycemic related complications for 1 (Resident #1) of 3 (Residents #1, #2 and #3) case mix residents with physician orders [REDACTED]. This failed practice had the potential to cause more than minimal harm for 18 residents who had physician orders [REDACTED]. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Initial Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/15 documented the resident scored a 9 (8 - 12 indicates moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS), required supervision with eating and received insulin injections 7 of the last 7 days. a. The admission orders [REDACTED].Insulin Detemir ([MEDICATION NAME]) . 13 units . (at) bed time . Insulin [MEDICATION NAME] (Humalog) . 6 units . 3 times daily before meals . There were no orders documented for blood sugar monitoring or any parameters for consultation with physician regarding highs/lows. b. The November 2015 Med (Medication) Sheet Notes, the Daily/24 Hour Report Sheet, and/or the November 2015 Medication Administration Record [REDACTED] 1) (Med Sheet Notes) Humalog . inject 6 units sq (subcutaneous) ac (before meals) . (Date / Time) 11/14/2015 (5:19 p.m.) (Given By) (Licensed Practical Nurse (LPN) #12) . (Notes) Held due to FSBS (finger stick blood sugar) 143. The Daily / 24 Hour Report Sheet dated 11/14/15 signed by LPN #12 .(Resident #5) - Please clarify insulin order. Held 6 (units) insulin (at) lunch (and) dinner due to FSBS. 2) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/15/2015 (11:23 a.m.) (Given By) (LPN #12) . (Notes) Held insulin due to FSBS 132 . (Date / Time) 11/15/15 (4:45 p.m.) (Given By) (LPN #12) . (Notes) Held due to FSBS being under 150. 3) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/18/2015 (6:55 a.m.) (Given By) (LPN #13) . (Notes) BS (blood sugar) 72. (MAR) (11/18/15) (6:30 a.m.) . H (medication held). 4) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/19/2015 (6:57 a.m.) (Given By) (LPN #13) . (Notes) BS 74. (MAR) (11/19/15) (6:30 a.m.) H (medication held). 5) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/20/15 (6:52 a.m.) (Given By) (LPN #13) . (Notes) BS 69. (MAR) (11/20/15) (6:30 a.m.) H (medication held). 6) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/21/15 (4:51 p.m.) (Given By) (LPN #12) . (Notes) Hold due to FSBS (less than) 150. 7) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/22/15 (4:38 p.m.) (Given By) (LPN #12) . (Notes) Held due to FSBS (less than) 150. 8) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/25/15 (6:45 a.m.) Given By: (LPN #13) . (Notes) Hold. There was no reason why the Humalog was held and there was no blood sugar documented. The laboratory report dated 11/25/15 documented, .Date Collected . 11/25/2015 (7:15 a.m.) . CMP (Comprehensive Metabolic Panel) . Glucose 59 L (low) . (Reference Range) 70-99 . This report was signed by the Advanced Practice Nurse (APN), but had no date of review. There was no documentation the physician was consulted regarding the abnormal glucose level. 9) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/28/15 (6:36 a.m.) (Given By) (LPN #13) . (Notes) BS 72. (MAR) (11/28/15) (6:30 a.m.) H (medication held). (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/28/15 (12:28 p.m.) (Given By) (LPN #12) . (Notes) Held due to FSBS 112. (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 11/28/15 (5:15 p.m.) (Given By) (LPN #12) . (Notes) Held due to FSBS below 150. c. The December 2015 Med (Medication) Sheet Notes, the Daily/24 Hour Report Sheet, and/or the December 2015 Medication Administration Record [REDACTED] 1) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 12/3/15 (6:07 a.m.) (Given By) (LPN #13) . (Notes) Hold BS 65. The laboratory report dated 12/4/15 documented, .Date Collected: 12/4/2015 (7:05 a.m.) . CMP . Glucose 68 L (low) . (Reference Range) 70-99 . The report was signed by the APN, but had no date of review. There was no documentation the physician was consulted regarding the abnormal glucose level. 2) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 12/8/15 (6:17 a.m.) (Given By) (LPN #13) . (Notes) Hold BS 62. The laboratory report dated 12/11/15 documented, .Date Collected . 12/11/2015 (7:05 a.m.) . CMP . Glucose 49 L (low) . (Reference Range) 70-99 . This report was signed by the APN, but had no date of review. There was no documentation the physician was consulted regarding the abnormal glucose level. 3) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 12/12/2015 (1:30 p.m.) (Given By) (LPN #12) . (Notes) Held due to FSBS of 184. (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 12/12/15 (4:37 p.m.) (Given By) (LPN #12) . (Notes) Held due to FSBS 172. 4) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 12/15/15 (6:24 a.m.) (Given By) (LPN #13) . (Notes) BS 80. (MAR) (12/15/15) (6:30 a.m.) H (medication held). 5) (Med Sheet Notes) Humalog . inject 6 units sq ac . (Date / Time) 12/17/15 (6:27 a.m.) (Given By) (LPN #13) . (Notes) Held BS 62. d. Nursing Notes from 11/14/15 through 12/17/15 were reviewed. As of 2/8/16 at 1:55 p.m., there was no documentation regarding consultation with the physician when the Humalog insulin was held or of notification of the finger stick blood sugars or laboratory blood sugar / glucose results. e. The Nurses Notes dated 12/20/15 at 8:15 a.m. documented, CNA (Certified Nursing Assistant) reports to writer resident would not wake up for morning meal. (8:30 a.m.) writer entered resident's room noted resident lying in bed eyes closed, resp (respirations) even and unlabored, no response to verbal or touch stimuli, skin cool and clammy, gown was wet around the neck area. (8:35 a.m.) BS was 33 when checked at this time, (8:36 a.m.) Supervisor notified to bring [MEDICATION NAME] emergency kit, (8:40 a.m.) [MEDICATION NAME] 1 mg (milligram) administered, (8:48 a.m.) BS 31 (ambulance) notified, (9:00 a.m.) BS 35 (9:15 a.m.) (ambulance) here . f. On 2/10/16 at 11:00 a.m., LPN #12 was asked, Did you give (Resident #5) any insulin? LPN #12 stated, In the beginning no. She had an order to give 6 units of insulin and I was not comfortable with giving insulin without checking her blood sugar. LPN #12 was asked, You held the insulin? LPN #12 stated, Yes. LPN #12 was asked, Did you notify the doctor? LPN #12 stated, No. I wrote on the 24-hour sheet that we needed to get a clarification from the doctor regarding if he wanted blood sugars and no one ever did. LPN #12 was asked, Was there any reason you did not follow up and ask if the doctor wanted her blood sugar checked? LPN #12 stated, No, she wasn't in an emergency and when I talked with the daughters they said if it was under 200 they held the insulin. g. On 2/9/16 at 10:58 a.m., the APN who signed the resident's lab reports was observed signing lab reports. The APN was asked, What is your process for reviewing labs? The APN stated, I come on Tuesday and Wednesday. On Tuesday I review all the labs in my lab folder that have been placed there since I left on Wednesday. Every Wednesday when I leave my lab folder is empty. The APN was asked to look at the lab reports dated 11/25/15, 12/4/15 and 12/11/15 for Resident #5. The APN was asked, Did you review these labs? The APN stated, Yes. I've signed them but I couldn't say when. The APN was asked, Were you notified of low glucose levels? The APN stated, No. If I had been they would have written it on the lab report for me to sign later. I did look at them, but I don't recall noting the glucose levels. The APN was asked, Were you notified of the resident's Humalog insulin being held? The APN stated, No. h. On 2/9/16 at 11:10 a.m., the DON and Administrator were asked, When you reviewed (Resident #5)'s medical record, did you know the nurses were holding the resident's insulin? The Administrator stated, We noticed it on 12/20/15. The DON and Administrator were asked, What did you do about all the insulin that was held without physician notification? The DON stated, We counseled all of the nurses. The DON was asked, Is there anything on the counseling form about notifying the physician when insulin is held? The DON stated, No. It's in our in-service we did on 12/20/15. i. The facility removed the Immediate Jeopardy on 12/20/15 and reduced the scope/severity to H when the facility implemented the following: (On 2/8/15 at 1:55 p.m., the Administrator presented hand written documentation of the facility's actions following the 12/20/15 hospitalization of Resident #5.) 1) (At) (1:00 p.m.) met (with) family (December) 20th, 2015. Brought to my attention by family member of (Resident #5) was sent to ER (emergency room ) for low blood sugar. (Administrator) met (with) (Family Member #1) to review (resident) chart. During review of chart (no) documented results of FSBS. Noted no MD (medical doctor) order for scheduled FSBS. (Resident) in fact had an order (for) scheduled (regular) insulin. Spoke (with) nurse who cared for (resident) the a.m. of (December) 20 (and) nurse (LPN #2) reported (resident) (with) a FSBS of 102 (and) insulin given as ordered (at) (6:30 a.m.) on 12/20(/15). -Pulled Nurse's Notes for (resident) Reviewed orders. On 12/20/15 Nurse (LPN #2) called in to facility (and) completed 1 on 1 training / inservicing (with) DON (Director of Nursing) Diabetes education (and) administration of insulin. Employee counseled - prior to start of next shift - All nurses inserviced Diabetes (and) insulin administration. - any nurse that admin (administered) insulin counseled / inserviced. December 20 - 21st audit completed of all (residents( (with) [DIAGNOSES REDACTED]. Charts (checked), ensured all necessary had order to (check) FSBS - No others identified. 12-20-15 Spoke (with) (LPN #2) (complaint of) FSBS results for (Resident #5). (LPN #2) reports giving 6 (units) of insulin as ordered (at) approximately (6:30 a.m.). States FSBS was checked prior to (administration) (and) result was 102. (LPN #2) reports FSBS for (Resident #5) on previous night (12-19-15) (at) HS (hour of sleep) was 210. [MEDICATION NAME] given as ordered. Reviewed facility camera. Observed nurse (LPN #2) in (resident) room (at) approx. (approximately) (6:35 a.m.) CNA (CNA #1) entered room (7:15 a.m.) - (resident) sleeping. (CNA #2) took tray in room, (resident) asleep (7:30 a.m.). (CNA #3) in room (8:00 a.m.) left room, talked to nurse (8:10 a.m.). (LPN #3) in room (8:20 a.m.) 2) On 2/8/16 at 2:07 p.m., the facility presented an in-service dated 12/20/15 that documented, .Know your different insulin actions (and) onsets . Never (administer) insulin (without) knowing (blood sugar) . it is very important to follow the appropriate guidelines (and) procedures when taking blood sugars (and) (administering) insulin . As licensed nurse know that you are able to use your nursing judgement (and) hold a medication (and) notify MD (with) any concerns . The in-service was signed by 15 nurses. 3) On 2/9/16 at 10:12 a.m., the DON provided a copy of Counseling Reports done with 7 nurses who had administered insulin to Resident #5. The Counseling Reports were dated 12/20/15 through 12/29/15. 4) The Administrator was asked, On 12/20/15 you did an audit of what? The Administrator stated, Residents with [DIAGNOSES REDACTED]. I pulled them all up on the computer, looked at the [DIAGNOSES REDACTED]. what she did with it. Since then, in morning meeting we bring in all admits, readmits and newly diagnosed diabetic charts. We go through the chart to verify if the resident is Diabetic, if insulin is administered, and if there is an order to check the blood sugars. 2. Resident #1 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/15 documented the resident had modified independence in cognitive skills for daily decision making per a Staff Assessment for Mental Status, required supervision for eating and received insulin injections 7 of the last 7 days. a. A physician's orders [REDACTED]. 350 - 399 (equals) 8 (units), (greater than) 400 (equals) 10 (units) and notify MD (medical doctor) . b. The Overall Plan of Care dated 12/23/15 documented, .Risk for Hyper or Hypoglycemic episode secondary to Diabetes . Monitor medications and labs and report any abnormal results to physician . Accuchecks as ordered . c. The December 2015 Med Sheet Notes documented, Accuchecks AC / HS . (with) (sliding scale) using regular insulin . 350 - 399 (equals) 8 (units), (greater than) 400 (equals) 10 (units) and notify MD (medical doctor) . (Date) . 12/22/2015 (4:09 p.m.) (Given By) (LPN #2) . (Notes) 400 (Accucheck result). There was no documentation regarding administration of regular insulin in the Med Sheet Notes or on the December 2015 Medication Administration Record. There were no Nurses Notes documented by LPN #2 on 12/22/15. There was no documentation of physician consultation regarding the blood sugar of 400. The December 2015 Med Sheet Notes documented, Accucheck . Date . 12/22/15 7:47 p.m. Given By: (LPN # 2) Notes: 139 (Accucheck result). d. The January 2016 Med Sheet Notes documented, Accuchecks AC / HS . (with) (sliding scale) using regular insulin . 350 - 399 (equals) 8 (units), (greater than) 400 (equals) 10 (units) and notify MD (medical doctor) . (Date) . 01/09/2016 (10:29 p.m.) (Given By) (LPN #2) (Notes) 400 (Accucheck result). There was no documentation regarding administration of insulin. There were no documented Nurses Notes dated 1/9/16 and no documentation of physician notification of the blood sugar of 400. e. The January 2016 Med Sheet Notes documented, Accucheck . (Date) . 01/10/2016 (6:51 a.m.) (Given By) (LPN #2) Notes: 136 (Accucheck result). f. On 2/9/16 at 11:10 a.m., the Director of Nursing (DON) was asked, For the Accucheck of 400 on 1/9/16, how much insulin was given? The DON stated, I don't know. The DON was asked, If you were giving insulin for a blood sugar of 400, what would you do based on the sliding scale order? The DON stated, Give 10 units and notify the physician and get a clarification order. The DON was asked, For the Accucheck of 400 on 12/22/15, how much insulin was given, is it documented? The DON stated, No. The DON was asked, On 12/22/15 can you find documentation that the physician was notified of the blood sugar of 400? The DON stated, No. The DON was asked, On 1/9/16 can you find documentation that the physician was notified of the blood sugar of 400? The DON stated No. g. On 2/10/16 at 4:20 p.m., LPN #2 was asked, On 12/22/15 and 1/9/16 you documented the resident had a finger stick blood sugar of 400. How much insulin did you give the resident? LPN #2 stated, I have to think back. I think I gave her 10 units, that's the sliding scale order. LPN #2 was asked, Did you notify the physician? LPN #2 stated, I thought I did. Didn't I document it? They've been having problems with things you type in (the electronic medical record) not showing up later. But I thought I called the doctor and I documented it.

Complaint # (AR 766) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure necessary treatment and services were provided to promote the healing of pressure ulcers for Resident #3. The facility failed to ensure the physician was promptly consulted regarding deterioration of pressure ulcers and need for treatment changes for 1 of 1 (Resident #3) case mix resident who had a pressure ulcer. The failed practice resulted in a pattern of harm for Resident #3 whose pressure ulcers continued to deteriorate and had the potential to affect 6 residents in the facility who had a pressure ulcer. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an Assessment Reference Date of 9/27/15 documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status, required extensive assistance from staff for bed mobility and had 2 Stage IV and 4 unstageable pressure ulcers. a. The Care Plan dated 10/1/15 documented, Resident is at risk for skin breakdown due to need for extensive assist in bed and wheel chair mobility. Incontinent of bladder and bowel. b. A Weekly Wound Assessment sheet dated 8/25/15 documented, Right lateral ankle. How acquired: In house. Wound type: Pressure. New area to right ankle . Cleanse, cover with foam 3 x week. The section that included wound measurements was blank. c. A Weekly Wound Assessment sheet dated 9/1/15 documented, Coccyx/left sacrum. 4.5 cm (centimeter) x 5.2 cm x purple. No exudate. Purple DTI (deep tissue injury). Cleanse, cover with foam dressing . d. A physician's Re-admit History and Physical dated 9/2/15 documented, (Resident #3) was readmitted to (Nursing Home) on 9/1/15 (after) admittance to (Hospital) on 8/26/15 for surgical debridement (and) IV (intravenous) abx (antibiotics) for her (left) foot [MEDICAL CONDITION]; she underwent BKA ([MEDICAL CONDITION]) of LLE (left lower extremity) instead.Pressure sores right foot, left and right sacral ulcers healed . continue treatments and nutritional optimization . e. Lab work collected on 9/3/15 documented the resident's total protein as 4.8 (reference range: 6-8.5) and the [MEDICATION NAME] as 2.0 (reference range: 3.5-5.2). f. A Weekly Wound Assessment sheet dated 9/7/15 documented, Coccyx 1.3 cm x 0.6 cm x 0.1 cm. Scant serous exudate, no odor. Cleanse and cover with foam dressing. A Weekly Wound Assessment sheet dated 9/7/15 documented, Right ankle 1.4 cm x 1.1 cm x slough. Moderate serosanguineous exudate present, no odor. Cleanse, cover with silver alginate and foam 3 x week. A Wound Progress Note dated 9/7/15 documented, Dressing change and measurements today. Right foot wounds have decreased in size and appear improved. Large DTI sacral/coccyx has faded leaving two smaller wounds with slough. #1 coccyx is 1.3 x 0.6 with white adherent slough. #2 left sacrum is 0.7 x 0.5 with white adherent slough. Will cont (continue) foam dressing to offload. g. A Weekly Wound Assessment sheet dated 9/14/15 documented, Coccyx 2.2 cm x 0.6 cm x 0.1 cm. Scant serous exudate present. No odor. Continue foam dressing 3x/week. A Weekly Wound Assessment sheet dated 9/14/15 documented, Right lateral ankle 1.7 cm x 0.8 cm x slough. Moderate serosanguinous exudate present, no odor. Cleanse, cover with foam and silver. A Wound Progress Note dated 9/14/15 documented, Left sacrum has resolved whereas coccyx is a little worse. Showing discoloration. Ankle and heel seems better. There was no documentation found in the clinical record to indicate the physician was notified of the deterioration in the wound on the coccyx noted on the Wound Progress Note dated 9/14/15. h. A Telephone Order dated 9/14/15 documented, admitted to Hospice per family wish related to disease process of dementia. i. A Weekly Wound Assessment sheet dated 9/21/15 documented, Coccyx 2.7 cm x 1.9 cm x slough. Moderate purulent exudate present with foul odor. Cleanse, cover with foam. Will contact Hospice for parameters i.e. wound clinic. A Weekly Wound Assessment sheet dated 9/21/15 documented, Right ankle 2.8 cm x 1.7 cm x slough. Moderate serosanguinous exudate present, no odor. Continue silver alginate and foam. There was no documentation in the clinical record that the primary physician was consulted regarding the continued deterioration of the pressure sore on the coccyx and the increase in size of the pressure sore on the right ankle. j. A Wound Progress Note dated 9/22/15 documented, Coccyx has declined .Hospice informed me wound clinic out. Will cont to pad and offload. k. A Quality Assurance Meeting note dated 9/23/15 documented, (Resident #3) with decline . coccyx wound increased size . Hospice . l. A Weekly Wound Assessment sheet dated 9/28/15 documented, Coccyx 6.9 cm x 3.1 cm x UTD (unable to determine). Eschar wound bed. Scant foul exudate present. Cleanse, cover with foam. Wound has rapidly declined. Called RN (Registered Nurse) with Hospice for ABT (antibiotic) order. There was no documentation to indicate the primary physician was notified of the further deterioration in the wound. A Weekly Wound Assessment sheet dated 9/28/15 documented, Right ankle 2.2 cm x 1.5 cm x slough. Moderate serosanguinous exudate present, no odor. Continue silver and foam. Edges pink epith ([MEDICATION NAME]), slough still present in center. m. A Wound Progress Note dated 9/29/15 documented, Spoke with Hospice RN about coccyx wound rapid decline. Will start ABT (antibiotic therapy) and (physician) wants to start [MEDICATION NAME] 3x/week. Wound assessments documented declines in pressure on coccyx since 9/14/15. A Telephone Order dated 9/30/15 documented, [MEDICATION NAME] 100 mg 1 PO (by mouth) BID (twice daily) x 10 days. Change dressing (coccyx), cleanse, cover with [MEDICATION NAME] and dry dressing Monday, Wednesday, Friday. n. A Weekly Wound Assessment sheet dated 10/5/15 documented, Coccyx 9.8 cm x 3.9 cm x eschar. Large amount of exudate present. Foul odor. Cleanse, apply [MEDICATION NAME] to eschar, cover with foam. There was no documentation to indicate the physician was notified of further deterioration of the wound. A Weekly Wound Assessment sheet dated 10/5/15 documented, Right ankle 1.8 cm x 1.4 cm x slough. Scant amount serosanguinous exudate, no odor. Cleanse, cover with silver alginate and foam. o. A Wound Progress Note dated 10/6/15 documented, Spoke with . Hospice nurse again for new orders due to coccyx wound rapid decline. New orders for Dakins 1/2 strength and [MEDICATION NAME] 500 mg (milligrams) sprinkled in wound every day. A Physician order [REDACTED]. Cleanse unstageable coccyx with Sea Cleanse, pat dry, pack lightly with Dakins 1/2, cover with dry dressing every day. p. A Weekly Wound Assessment sheet dated 10/12/15 documented, Coccyx 8.7 cm x 6.8 cm x 1.5 cm. Granular, slough, eschar. Large purulent exudate present. Foul odor. Cleanse, apply Dakins and [MEDICATION NAME] every day x 14. A Weekly Wound Assessment sheet dated 10/12/15 documented, Right lateral ankle 1.7 cm x 1.2 cm x slough. Scant serosanguinous exudate present, no odor. Continue silver alginate and foam 3 x week. q. A Weekly Wound Assessment sheet dated 10/19/15 documented, Coccyx 9.4 cm x 4.1 cm x 1.5 cm. Granular, slough. Large amount of serosanguinous exudate present. No odor. Continue Dakins and [MEDICATION NAME]. A Weekly Wound Assessment sheet dated 10/19/15 documented, Right ankle 1.7 cm x 1.4 cm x slough. Scant serosanguinous exudate present, no odor. Silver alginate and foam 3 x week. A Wound Progress Note dated 10/19/15 documented, Wound (coccyx) has improved as far as smell/odor. Still strip of slough and wound base . r. A Physician's Progress Note dated 10/21/15 documented, .Per nurse she is a Hospice patient. She currently has a Stage 4 pressure ulcer to sacrum and is getting [MEDICATION NAME] sprinkles in it. Dressing intact and was not removed . She does not eat but will drink some Ensure . She is followed by wound clinic and treatment nurse. She's on [MEDICATION NAME], Zinc, Vit (vitamin) C daily but it is not healing. Wt (Weight) loss - Juven and Prostat were stopped but she is still on [MEDICATION NAME] 45 mg daily. Wt loss continues and is inevitable . s. A Weekly Wound Assessment sheet dated 10/26/15 documented, Coccyx 9.4 cm x 4.1 cm x 1.7 cm. Granular, slough. Large amount serous exudate present. No odor. Dakins every day. A Weekly Wound Assessment sheet dated 10/26/15 documented, Right ankle 2.4 cm x 1.9 cm x 0.3 cm. 30% slough. Moderate amount of serosanguinous exudate present. No odor. Silver alginate and foam. There was no documentation in the clinical record to indicate the physician was consulted since the start of treatment for [REDACTED]. t. On 11/3/15 at 9:45 a.m., Licensed Practical Nurse (LPN) #1 provided wound care for the resident. A large dressing was removed from the coccyx area to reveal a pressure ulcer that measured 9.0 cm x 4.8 cm x 1.8 cm. There was a small area of white slough in the base of the wound with 1.7 cm undermining at 6 o'clock. LPN #1 stated, She had a deep tissue injury(DTI) when she returned from the hospital, but it actually got to looking better. Then it quickly deteriorated and just sort of . fell out. I was shocked. It happened so fast I thought maybe it was a Kennedy ulcer. I thought she maybe needed to go to the wound clinic, but she's on Hospice and they don't allow that. The wound was cleaned with Sea Cleanse and 4x4s. Gauze soaked with 1/2 Dakins was packed into the wound and then covered with a large [MEDICATION NAME] dressing. A pressure relieving boot was removed from the resident's right foot. A dressing to the right outer ankle was removed and revealed a pressure ulcer that measured 2.7 cm x 2.1 cm. The wound bed was yellow slough and the peri wound was bright red. The wound was cleaned with Sea Cleanse and 4x4s. Silver Alginate was placed in the wound bed and it was covered with a dressing. LPN #1 stated, She's on Hospice so I can't be real aggressive on treating these. 2. On 11/3/15 at 4:00 p.m., the Director of Nursing (DON) was asked if Resident #3 had gone to the wound clinic as it was written in the physician progress notes [REDACTED]. 3. On 11/4/15 at 9:25 a.m., LPN #1 was asked why the physician wasn't notified of the deterioration in the wounds and why the treatments weren't changed sooner when the wounds failed to improve. He stated, I have learned a lot since yesterday with this. It's my fault and it won't happen again. 4. The Policy titled Dressing Change received from the Administrator on 11/4/15 contained an attachment titled Other Common Wound Etiologies that documented, treatment for [REDACTED].Improvement should be seen in 2-4 weeks. If not consider a change in plan.

Complaint # was substantiated (all or in part) in these findings: Complaint # was substantiated (all or in part) in these findings: Complaint # was substantiated (all or in part) in these findings: Based on record review and interview, the facility Administration failed to ensure the immediate reporting of alleged incidents of abuse to the proper authorities in accordance with State law; failed to thoroughly investigate the alleged violations, and failed to protect the resident from further potential abuse during an investigation for 1 of 1 (Resident #2) case mix resident who experienced verbal, mental, and physical abuse from a private sitter. This failed practice resulted in Immediate Jeopardy at a pattern due to length of time, which caused or could have caused serious harm, injury, or death for Resident #2 who had a private sitter who staff witnessed verbally/mentally abusing the resident. The facility was notified of the Immediate Jeopardy on [DATE] at 4:25 p.m. The failed practice had the potential to affect one resident who had a private sitter, according to an interview with the Administrator on [DATE] at 10:00 a.m. The findings are: 1. The Job Description for the Administrator documented, "Purpose of Your Job Position: The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents at all times. ...Major Duties and Responsibilities: Administrative Functions: Plan, develop, organize, evaluate, and direct the facility's programs and activities. Develop and maintain written policies and procedures for the operation of the facility. ...Interpret the facility's policies and procedures to employees, residents, family members, visitors, government agencies, etc., as necessary. Review the facility's policies and procedures periodically, at least annually, and make changes as necessary to assure continued compliance with current regulations. Assure that all employees, residents, visitors, and the general public follow established policies and procedures. ...Maintain an adequate liaison with families and residents. ...Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed. ...Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility..." 2. The Facility's Abuse Investigation & Reporting Policy was provided by the Administrator on [DATE] at 9:30 a.m. and documented, "Definitions: ...Abuse. Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish to an endangered or impaired person. Any intentional or demeaning act that a reasonable person would believe subjects an endangered or impaired person, regardless of age, ability to comprehend, or disability, to ridicule or psychological injury in a manner likely to provoke fear or alarm. Any intentional threat that a reasonable person would find credible and non-frivolous to inflict pain on or cause injury to an endangered or impaired person except in the course of medical treatment or for justifiable cause. 1. Verbal Abuse. Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within hearing distance. ...3. Physical Abuse. Includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. 4. Mental Abuse. Includes humiliation, harassment, threats of punishment or deprivation that are likely to provoke fear or alarm. ...Identifying, Investigating, & Reporting: General policy. All reports of patient maltreatment, including neglect and abuse, injuries, of unknown origin, or misappropriation of resident property, shall be promptly reported to Administrator or immediate supervisor and investigated by facility management. 2. Immediate Reporting. ALL incidents of alleged or suspected patient maltreatment, including mistreatment, neglect, or abuse, and misappropriation of patient property must be reported immediately to the Administrator or the Administrative Designee by a Facility employee or immediate supervisor, who will report incidents as required by State law or regulation. ...4. Identification and investigation. a. The Administrator or Administrative Designee will conduct an immediate investigation of all alleged or actual incidents of abuse (verbal, mental, sexual, physical, mental), neglect, involuntary seclusion or misappropriation of property. The investigation should determine whether an incident has occurred, to what extent the patient was mistreated, by whom, and the measures needed to protect patients from further incidents. If the patient is able to communicate, the Administrator or Administrative designee shall document, in thorough detail, the patient's account of the incident, including a description of the perpetrator. b. Identification and investigation of abuse, neglect, involuntary seclusion or misappropriation of property should include interviews with those persons the investigator determines are related to allegation or incident ... ...10. Reporting ALL alleged or suspected incidents must be reported according to state and federal law, according to the time restrictions required by law. The following persons or entities will be notified by Facility personnel (Administrator or Administrator Designee): a. Administrator. b. State Survey Agency. c. Local law enforcement. d. Physician. e. Family members. ...11. Time for completing I&A (Incident and Accident) Reports. An Incident and Accident intake Form (form DMS (Department of Medical Services)-7734) form will be completed by the Administrator or Administrator Designee within 24 hours or no later than 11:00 on the next business day of the incident's discovery ... ... Patient, Family Member or Visitor Suspected of Maltreatment of [REDACTED]. Reporting and investigation procedures will be used by the Facility to address abuse or neglect allegedly committed by a family member, patient, or other visitors in the same manner as for alleged, suspected, or actual employee abuse situations. ...2. isolating perpetrator. If the alleged or suspected perpetrator is still in the Facility, he or she will be asked to leave the patient's room, or area of the Facility where the patient is located. If the alleged perpetrator will not leave the area, then a staff person will stay with the patient until law enforcement officials arrive at the Facility. 3. Supervised visits. Persons suspected of abuse will not be allowed unsupervised visits with patients, unless otherwise ordered by a 'court of law'..." 3. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 9 (,[DATE] indicates moderate cognitive impairment) on the Brief Interview for Mental Status and had behavioral symptoms directed toward others that occurred 1 to 3 days out of the last 7 days. a. On [DATE] at 9:15 a.m. the Administrator provided documentation of 1 alleged violation that had been reported to the Office of Long Term Care since their last annual survey on ,[DATE]. This allegation was not related to any incident with Resident #2. b. The Nurse's Notes dated [DATE] at 3:40 p.m. and signed by LPN #1 documented, "CNA (Certified Nursing Assistant #1) rushes up to nurse's station saying, 'I need help now.' As we rush down the hall she says that (Resident #2)'s sitter (Sitter #1) was in (Resident #2)'s face yelling and cursing (at) (Resident #2). As we make it to (Resident), (Resident #2) is in the hallway. (Resident #2's) sitter is in (Resident #2's) room talking very loudly on her cell phone saying, '(Resident #2) is not going to call me a '(derogatory racial word)' (Registered Nurse #1) and this LPN (Licensed Practical Nurse) (LPN #1) in hallway. (RN #1) tells sitter that she needs to get her stuff and go home. This LPN asked (Resident #2) what happened. (Resident #2) states that (Sitter #1) called her a white (expletive) (and) was in her face yelling (at) her. (Resident) walked up to nurse's station (with) this LPN while (RN #1) gets sitter out of building. (Resident) states that she was afraid (Sitter #1) was going to hit her (and) that she does not want her back here. Assured (Resident) that the situation will be handled and we will not allow (Sitter #1) to harm her. Sitter escorted out of building by (RN #1). (Administrator) notified by (RN #1). (Director of Nursing) notified by this LPN. (Resident)'s husband (Spouse's name) called (and) spoke (with) (RN #1). (Resident) states she is (all right), just glad (Sitter #1) is gone. Will cont (continue) to monitor." c. The Nurse's Notes dated [DATE] to [DATE] were reviewed on [DATE]. There were notations that there was a sitter at the resident's bedside on [DATE], [DATE] and [DATE]. Further notations documented, " ...sitters during the day ..." " ...visiting with the sitter..." on [DATE], [DATE], [DATE], [DATE] and [DATE]. d. The Resident Progress Notes dated [DATE] at 2:19 p.m. and signed by RN #2 documented, "Resident C/O (complained) to (CNA #1) that her private sitter grabbed and twisted her (left) upper arm; slight redness to area indicated; Resident stated that when she was going into DR (dining room) before it was time, sitter grabbed her arm and twisted it. Administrator was notified as well as Husband (Spouse's name). Resident was kept by nurse's station until investigation was done. (Resident #2's Spouse) stated that his wife always makes accusations against (Sitter #1) the private sitter and that he does not believe them and does not want to pursue accusation. Will continue to monitor (left) upper arm." e. On [DATE] at 10:00 a.m., RN #1 was asked if she was aware of any abuse in the facility. The RN stated, "No, I haven't seen it myself, but it was reported to me. A CNA came up and told me the sitter was being verbally abusive to (Resident #2). I immediately removed (the) sitter from the situation and asked her to leave during the investigation, I escorted her out. I went to the resident who was already calming down. I did not approach (the) subject due to she was calming down. I did call (her) husband. He told me it was not the first time his wife accused sitters, before coming here, (until) she caused them to leave. I called the Administrator and told her what I'd done. She told me I did good and she would take care of it tomorrow. I did not talk with any other staff or residents about the situation." f. On [DATE] at 11:40 a.m., CNA #1 was asked if she was aware of anyone abusing a resident. She stated, "Yes... her sitter, (Resident #2), (Sitter #1) don't know (the) sitter's last name." The CNA did not know exactly when the sitter worked, but knew she worked on weekends. The CNA continued, "There were two different times. She didn't hit her in front of me. (Sitter #1) was standing and bent down to eye level with (Resident #2), pointing in her face, screaming, touching (her) face with (a) finger at resident. She said (Resident #2) called her a name was why she was screaming. (Resident #2) said she was scared and she was crying. So, I took her to the nurses' station and got the supervisor, the weekend supervisor, (RN #1) and floor nurse, (LPN #1) ...I had asked (Sitter #1) to leave. She was on the cell phone, she told me she was calling (Resident #2's spouse). My supervisor walked her outside and she did not come back while I was there that day (until) 7 (7:00 p.m.) Recently last week, I'm wanting to say Monday ...I did not see this. (Resident #2) said she was walking to the dining room with the walker and she said the sitter grabbed her arm and squeezed it cause she had gone to lunch too early. I passed her when she was walking back to the room and she told me about it. I went and got the charge nurse, (RN #2) and reported it. ...(RN #2) said let's take her to the bath room. There was redness on the arm and she complained of it hurting. It was just red. We let her sit at the nurses' station and stayed with her most of the time. I would not call it one-on-one, but we checked on her often... I saw (Sitter #1) one time in the hall and she said something ugly. She said if she wanted to whip (Resident #2)'s ass, she would have done it when she was the sitter at home. I just said, 'Yes ma'am' and walked off. I reported this to (RN #2)." The CNA was asked if she had seen (Sitter #1) in the nursing home since. She stated, "Yes, she still sits with her. I think on weekends." g. On [DATE] at 12:35 p.m., RN #2 stated, "We had some reported abuse over the weekend a while back. I heard about the sitter in her face calling her a name. The sitter was removed. I was kind of upset she was allowed to come back. We monitored her (Sitter #1) closely after the first situation. About 2 weeks ago, a CNA reported to me that the sitter (Sitter #1) had twisted her (Resident #2) arm. I went and talked with (Resident #2), examined her arm, did not find anything but slight redness. She said she was going to the dining room too early when the sitter grabbed her and twisted her arm. Kept her sitter and her separate during the investigation. (Sitter #1) doesn't go into the room anymore, only out in hall. She mainly works weekends and Fridays and usually leaves at 3:00 p.m. I reported it to the Administrator, DON (Director of Nursing), the husband. I've never seen her back in the room since the first incident." h. On [DATE] at 12:50 p.m., the DON was asked about the alleged abuse concerning the resident). She stated, "I'm not a personal witness to any of it. I know that (Resident #2)'s sitter got loud and yelled at, got verbally abusive, got in her face. The nurse reported to me that day. (Administrator) is in charge. I don't make any decisions regarding that kind of thing. She takes care of all of that. I do know the nurses separated them. She (Sitter #1) was sent home but was back the next day. We were appalled she was allowed back in. She's not been back in her (Resident #2) room since, usually sits in the hall. I watch her like a hawk when she's here. I don't know of any other allegations of abuse regarding (Resident #2)." i. On [DATE] at 1:20 p.m., the Administrator was asked about an incident with Resident #2 and her sitter. She stated, "Yes, the first time was about 12 to 18 months ago with (Resident #2)'s sitter (Sitter #1), a black sitter that had worked for them at their home, employed for greater than 3 years. (Resident #2) had made racial remarks to (Sitter #1) while (Sitter #1) was trying to get her to do something, care or some treatment. (Resident #2) got mad at her called her a black... then (Sitter #1) yelled back at her, 'This is not what we do, I'm not going to put up with this kind of talk.' I was here and it was brought to my attention. I don't remember which CNA over heard. We sent sitter home ...I contacted the husband, he said that was the way she (Resident #2) is when she is told something she doesn't want to do. She lashes out at them. I talked with the husband and he did not want me to turn it in as an allegation of abuse. I did not interview other interviewable residents. At that time, we had a policy in place that we were asking the residents every day, 'is everybody being nice to you today?' I did talk to other staff regarding (Resident #2)'s sitter. ...I did not talk to (Resident #2) about the incident. She wasn't scared. She was mad per staff and her husband. He came up that same day and talked with his wife and me. (Sitter #1) has been here since the day after the incident. She is never in the room alone with the resident. She makes (her)self visible. The next incident was about 2 weeks ago. It was prior to lunch. She (Resident #2) was going up the hallway with (CNA #1). She was wearing a fleece jacket. The CNA told me (Sitter #1) grabbed (Resident #2)'s arm and twisted it. I told her to take (Resident #2) to (RN #2) to have a look at her arm. I called the sitter to my office to find out what was going on. She told me she did not twist her arm. She (Resident #2) was trying to go to the dining room too early. Dining room was closed. She reached out to resident, touching resident's arm telling her it was too early to go to the dining room and the resident jerked her arm back from the sitter. (Resident #2) told (RN #2) that she was trying to stop her from going to the dining room too early and 'I jerked my arm back'." The Administrator further stated, "We have abuse in-services regularly." She was asked for copies of the in-services for the last 4 months. She stated, "There is no large portion of time that the sitters are in the room with (Resident #2). I see her mainly in the hallway with (Resident #2). The sitter is quite visible while here with (Resident #2). I have not told staff to monitor while the sitter is here." The Administrator was asked if she considered each incident an allegation of abuse. She stated, "I treated each incident as an allegation of abuse by immediately separating them. I did talk to every staff involved. There were no witness statements done." The Administrator was asked if this had been reported to the Office of Long Term Care (OLTC) as an allegation of abuse. She stated, "No." She further stated, "In hindsight, I probably could have done more investigation to thoroughly investigate." The Administrator was asked if there were cameras in the hallways. She said, "There weren't during the first incident, but there was with the second." She was asked if she had viewed the second incident. She stated, "I should have, but I got busy and did not. I did separate the sitter from the resident both incidents." The Administrator left the room to view the camera from the date of [DATE], the last incident. The Surveyor also viewed the video from the time of the alleged incident; there was nothing conclusive observed due to the sitter and the resident being inside the dining room door during the incident. j. On [DATE] at 2:00 p.m. LPN #1 was asked about the incident in [DATE] with the resident. The LPN stated, "It was around 3:00 p.m. because the ,[DATE] (3:00 p.m. to 11:00 p.m.) shift was there, (CNA #1) and (RN #1) weekend supervisor, and LPN (#2), who no longer works here, were at the nurses station. I heard (CNA #1) say 'We've got to get (Sitter #1) out of here. She was yelling in (Resident #2)'s face.' I heard (Sitter #1) in the resident's room on the cell phone. I knew she was talking with (Resident's spouse) because I heard her say (Resident's spouses' name). She said 'She's not gonna talk to me like that, you know how she is' and I heard her complaining about (CNA #1). (Resident #2) reported to me that (Sitter #1) had called her a 'white (expletive)'. (Resident #6) who was also in the hall, said 'she would have never got in my face like that. She wouldn't have done that to me.' She has expired since then. I filled out witness statements. (RN #1) told (Sitter #1) she needed to leave. (CNA #1) and I took (Resident #2) to the nurses station (until) (Sitter #1) left. (CNA #2) also saw it, but she no longer works here. ...I talked to a few residents and (Resident #2) and filled out witness statements and was told to put under the Administrator's door. No other residents, other than(Resident #6), said they heard anything. (Resident #2) looked like a whooped puppy. She said, she and her husband pay her and she can't treat me like that. She looked frightened and said she did not want her to be back around her. (Sitter #1) said the resident called her a '(derogatory racial word)', but the resident said she didn't. (CNA #1) was saying 'You've got to stop and you can't be doing this', when (Sitter #1) was yelling at the resident. (RN #1) called (Administrator) and spoke with (Resident's spouse). I put a hand full of witness statements under the door to (Administrator's) office. (Administrator) did not come up there. I had not heard of anything happening before this. When I came back the next day for an in-service for the nurses, I saw (Sitter #1) sitting in the hall. I asked (RN #1) why she was here. She said, 'Yea, (Administrator)'s aware and she is not allowed to have unsupervised interaction with the resident.' The ,[DATE] (7:00 a.m. to 3:00 p.m. shift) nurse, who is no longer here, (LPN #3), said the aides were watching closely. (Sitter #1) was not allowed to be alone with (Resident #2) until (Administrator) finished the investigation. I work on Saturdays and Sundays, 7a to 7p (7:00 a.m. to 7:00 p.m.). (Sitter #1) is here on Sundays, but I haven't seen her lately. I read the nurses notes from the incident on Monday, the 14th, and checked (Resident #2)'s arm on Saturday, no marks. I asked (RN #2) if there were any instructions concerning the resident and the sitter. She said everything had been worked out." LPN #1 was asked if she had seen (Sitter #1) in the room, alone with (Resident #2) since the first incident. She stated, "Yes." k. On [DATE] at 2:45 p.m., the Administrator was again asked about the incident on [DATE]. At first the Administrator did not remember that the incident was in [DATE]. She stated, "I was out of the office 4 of 5 days a week with the computer training in January." After reading the nurses notes of [DATE], she stated, "Well, wait a minute." She was asked if it was coming back to her. She stated, "Yes." She was asked if it had happened before this and she stated, "I honestly don't know." The Administrator was asked if she told the staff to get witness statements. She stated, "I don't remember." She was asked, "What if this had been one of your CNAs?" The Administrator stated, "They would be gone, fired." l. On [DATE] at 3:20 p.m., the Administrator provided witness statements from the incident on [DATE]. She stated, "I'm sorry, I didn't remember this January (2014) was so crazy." 1) The Witness Statement dated [DATE] from CNA #1 documented, "...heard someone screaming. I looked up and (Resident #2)'s personal assistant was screaming at her. She was bent over the wheel chair with her finger in (Resident #2)'s face. I heard her call (Resident #2) an 'old white (expletive)'. I made the personal assistant stop and told her that was resident abuse. She started arguing with me saying that it was not abuse because (Resident #2) had called her a (derogatory racial word).' I told her that she had to leave the facility or I would have to call the police..." 2) The Witness Statement dated [DATE] from CNA #2 documented, "When I, (CNA #2) came out of a room on two hundred hall, I witness the care giver of (Resident #2) was in her face screaming at her telling her that she will not call her anything but her name. (Resident #2) never said anything back, even when she asked her do you hear me. ...At this time the lead CNA (CNA #1) came down the hall and told the care giver that what she was doing wasn't right and that she needs to stop. The care giver told her, yes it is right what she was doing and that she couldn't tell her anything because she don't work for (Name of Nursing Home). And as (CNA #1) walked off she called her a (expletive) and that she was only going to do what her boss told her to do. Because her boss knows how she is. I (CNA #2) feel like (CNA #1) did the right thing to make sure (Resident #2) was safe. If she didn't step in I feel like it would have got even more out of hand ...for (Resident #2) was afraid..." 3) The Witness Statement dated [DATE] from LPN #1 documented, "(CNA #1) came to nurses station saying I need you down the hall now! She stated that (Resident #2) of facilities' sitter was yelling in (resident's) face. I rushed down the hall with (RN #1). (Resident) was sitting in hallway in chair with hands in lap (and) looking down. (Resident) appeared upset. Sitter was in (Resident's) room on cell phone speaking very loudly saying she wasn't putting up with this, that (Resident #2) would not talk to her like that (and) that she was not abusing (Resident). She told the person on the phone that (Resident #2) had called her a (derogatory racial word). I addressed (Resident) and asked her what happened, while (RN #1) told sitter (Sitter #1) that she needed to get her stuff (and) go home for the day. (Sitter #1), the sitter said 'when I get off the phone.' ...(Resident told me that (Sitter #1) was in her face yelling at her (and) calling her a white (expletive). ...(Resident) said we pay her to help me, she can't treat me this way. Assured (Resident) that she would not be treated that way... Resident stated that she was alright, but asked that we never let (Sitter #1) back here. Assured (Resident) that the situation will be handled (and) that she will not be treated in such a manner. (Resident) stated, 'I thought she was going to hit me.' ...(Sitter #1) was escorted out by (RN #1). (Resident's) husband called (and) spoke (with) (RN #1). (RN #1) notified (Administrator). I notified DON." 4) Resident #2's statement was dated [DATE] and signed by LPN #1; the statement documented, "(Resident) stated that her sitter (Sitter #1) called her a white (expletive), got in her face, was leaning over her yelling (at) her. Incident was witnessed by multiple staff members. Sitter was escorted out of building." 5) Resident #6's witness statement was dated [DATE] and signed by LPN #1; the statement documented, "(Resident) asked if she witnessed the incident that took place in hallway where (resident) was sitting. She stated, yes that resident (Resident #2) called the sitter (Sitter #1) a Black son of a (expletive) (and) that the sitter called (Resident) a white son of a (expletive) (and) then got up out of her seat (and) started yelling in (Resident #2)'s face. (Resident) states it upset her (and) made her nervous seeing (and) hearing the incident. (Resident) assured that the situation was being handled (and) would not happen again." 6) CNA #3's witness statement was dated [DATE] and documented, "I witnessed (Sitter #1) tell the resident to not call her anything else but her name. She stated her name was (Sitter #1) and to not call her anything else." m. On [DATE] at 10:00 a.m., the Administrator provided Sitter #1's full name. The Administrator stated that the sitter was employed 3 days a week, Sunday, Mondays, and Tuesdays by the spouse of the resident and that this was the only resident with sitters in the facility. The Administrator further stated, "My mistake was not reading the witness statements and just going by what was verbally told to me about the incident. In January (2014), when this occurred, I was doing computer training for new software 4 days a week." n. The Immediate Jeopardy was removed and the scope and severity was lowered to a "H" on [DATE] at 3:35 p.m. when the following Plan of Removal was initiated: 1) At 3:35 p.m. on [DATE], the sitter was not working today and not in the building. After that the administrator tried to call the husband and could not get him. At 3:53 p.m., the Administrator was able to contact the Grandson and informed him of the abuse reporting and that the sitter was not allowed back in the building. At 3:59 p.m., the husband spoke with the Administrator. The Administrator informed him of the abuse reporting and that the sitter was not allowed back in the building and for him to notify the sitter. 2) At 3:40 p.m. on [DATE] abuse in-service was initiated by the Administrator or her designees for ALL staff prior to beginning their shift. No one will be allowed to work on the floor until in-service is done. 3) On [DATE], the ADON (Assistant Director of Nursing) and staff RN asked residents if the residents had been abused or seen abuse. This began at 4:30 p.m. and was finished 5:30 p.m. No resident reported abuse or seeing abuse. 4) On [DATE] at 4:30 p.m., staff was asked by the ADON and staff RN if they had any knowledge of abuse. No staff reported abuse or seeing abuse. All staff will be interviewed by Administrator or designees prior to beginning shift. Any negative outcomes will be addressed immediately. 5) On [DATE] at 4:30 p.m. DON initiated body audits on residents by DON or her designees and no signs of abuse or injuries of unknown origin were found. Completion was at [DATE] at 9:00 a.m. 6) On [DATE] at 5:00 p.m., the Administrator began a book that staff are to sign at the end of the shift: "On your shift have you seen any signs of abuse "yes or no". "If yes, who did you report this to?" Any negative outcomes will be addressed immediately. On [DATE] at 5:00 p.m., the Administrator began a book "Has everyone been nice to you?" that will be done by the social designee or her designee on a daily basis. This book is for the purpose of identifying if a resident has experienced abuse. Any negative outcomes will be addressed immediately. 7) On [DATE] at 5:30 p.m. the Administrator was in-serviced on abuse including reporting by the executive director. 8) On [DATE] at 5:00 p.m., the Administrator made a plan that current private sitters of residents will be in-serviced by Administrator or her designee on what constitutes abuse, abuse reporting requirements of Long Term Care Facilities, and to whom to report abuse. No sitters were on duty. At this time there is only one sitter being utilized by one resident. The Administrator in-serviced her at 7:15 a.m. on [DATE] as she came on duty. 9) Any negative outcomes identified by audits, interviews, etc. will be addressed immediately by the Administrator or her designee.

Complaint # was substantiated (all or in part) in these findings: Complaint # was substantiated (all or in part) in these findings: Complaint # was substantiated (all or in part) in these findings: Based on record review and interview, the facility failed to ensure the facility's written policies and procedures for prohibition of mistreatment and abuse of residents were promptly implemented to address allegations of verbal, mental and physical abuse as evidenced by the failure to immediately report the alleged violations to the proper authorities in accordance with State law, failure to thoroughly investigate the alleged violations, and the failure to protect the resident from further potential abuse during an investigation for 1 of 1 (Resident #2) case mix resident who experienced verbal, mental, and physical abuse from a private sitter. This failed practice resulted in Immediate Jeopardy at a pattern due to length of time, which caused or could have caused serious harm, injury, or death for Resident #2 who had a private sitter who staff witnessed verbally/mentally abusing the resident. The facility was notified of the Immediate Jeopardy on [DATE] at 4:25 p.m. The failed practice had the potential to affect one resident who had a private sitter, according to an interview with the Administrator on [DATE] at 10:00 a.m. The findings are: 1. The Facility's Abuse Investigation & Reporting Policy was provided by the Administrator on [DATE] at 9:30 a.m. and documented, "Definitions: ...Abuse. Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish to an endangered or impaired person. Any intentional or demeaning act that a reasonable person would believe subjects an endangered or impaired person, regardless of age, ability to comprehend, or disability, to ridicule or psychological injury in a manner likely to provoke fear or alarm. Any intentional threat that a reasonable person would find credible and non-frivolous to inflict pain on or cause injury to an endangered or impaired person except in the course of medical treatment or for justifiable cause. 1. Verbal Abuse. Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within hearing distance. ...3. Physical Abuse. Includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. 4. Mental Abuse. Includes humiliation, harassment, threats of punishment or deprivation that are likely to provoke fear or alarm. ...Identifying, Investigating, & Reporting: General policy. All reports of patient maltreatment, including neglect and abuse, injuries, of unknown origin, or misappropriation of resident property, shall be promptly reported to Administrator or immediate supervisor and investigated by facility management. 2. Immediate Reporting. ALL incidents of alleged or suspected patient maltreatment, including mistreatment, neglect, or abuse, and misappropriation of patient property must be reported immediately to the Administrator or the Administrative Designee by a Facility employee or immediate supervisor, who will report incidents as required by State law or regulation. ...4. Identification and investigation. a. The Administrator or Administrative Designee will conduct an immediate investigation of all alleged or actual incidents of abuse (verbal, mental, sexual, physical, mental), neglect, involuntary seclusion or misappropriation of property. The investigation should determine whether an incident has occurred, to what extent the patient was mistreated, by whom, and the measures needed to protect patients from further incidents. If the patient is able to communicate, the Administrator or Administrative designee shall document, in thorough detail, the patient's account of the incident, including a description of the perpetrator. b. Identification and investigation of abuse, neglect, involuntary seclusion or misappropriation of property should include interviews with those persons the investigator determines are related to allegation or incident ... ...10. Reporting ALL alleged or suspected incidents must be reported according to state and federal law, according to the time restrictions required by law. The following persons or entities will be notified by Facility personnel (Administrator or Administrator Designee): a. Administrator. b. State Survey Agency. c. Local law enforcement. d. Physician. e. Family members. ...11. Time for completing I&A (Incident and Accident) Reports. An Incident and Accident intake Form (form DMS (Department of Medical Services)-7734) form will be completed by the Administrator or Administrator Designee within 24 hours or no later than 11:00 on the next business day of the incident's discovery ... ... Patient, Family Member or Visitor Suspected of Maltreatment of [REDACTED]. Reporting and investigation procedures will be used by the Facility to address abuse or neglect allegedly committed by a family member, patient, or other visitors in the same manner as for alleged, suspected, or actual employee abuse situations. ...2. isolating perpetrator. If the alleged or suspected perpetrator is still in the Facility, he or she will be asked to leave the patient's room, or area of the Facility where the patient is located. If the alleged perpetrator will not leave the area, then a staff person will stay with the patient until law enforcement officials arrive at the Facility. 3. Supervised visits. Persons suspected of abuse will not be allowed unsupervised visits with patients, unless otherwise ordered by a 'court of law'..." 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 9 (,[DATE] indicates moderate cognitive impairment) on the Brief Interview for Mental Status and had behavioral symptoms directed toward others that occurred 1 to 3 days out of the last 7 days. a. On [DATE] at 9:15 a.m. the Administrator provided documentation of 1 alleged violation that had been reported to the Office of Long Term Care since their last annual survey on ,[DATE]. This allegation was not related to any incident with Resident #2. b. The Nurse's Notes dated [DATE] at 3:40 p.m. and signed by LPN #1 documented, "CNA (Certified Nursing Assistant #1) rushes up to nurse's station saying, 'I need help now.' As we rush down the hall she says that (Resident #2)'s sitter (Sitter #1) was in (Resident #2)'s face yelling and cursing (at) (Resident #2). As we make it to (Resident), (Resident #2) is in the hallway. (Resident #2's) sitter is in (Resident #2's) room talking very loudly on her cell phone saying, '(Resident #2) is not going to call me a '(derogatory racial word)' (Registered Nurse #1) and this LPN (Licensed Practical Nurse) (LPN #1) in hallway. (RN #1) tells sitter that she needs to get her stuff and go home. This LPN asked (Resident #2) what happened. (Resident #2) states that (Sitter #1) called her a white (expletive) (and) was in her face yelling (at) her. (Resident) walked up to nurse's station (with) this LPN while (RN #1) gets sitter out of building. (Resident) states that she was afraid (Sitter #1) was going to hit her (and) that she does not want her back here. Assured (Resident) that the situation will be handled and we will not allow (Sitter #1) to harm her. Sitter escorted out of building by (RN #1). (Administrator) notified by (RN #1). (Director of Nursing) notified by this LPN. (Resident)'s husband (Spouse's name) called (and) spoke (with) (RN #1). (Resident) states she is (all right), just glad (Sitter #1) is gone. Will cont (continue) to monitor." c. The Nurse's Notes dated [DATE] to [DATE] were reviewed on [DATE]. There were notations that there was a sitter at the resident's bedside on [DATE], [DATE] and [DATE]. Further notations documented, " ...sitters during the day ..." " ...visiting with the sitter..." on [DATE], [DATE], [DATE], [DATE] and [DATE]. d. The Resident Progress Notes dated [DATE] at 2:19 p.m. and signed by RN #2 documented, "Resident C/O (complained) to (CNA #1) that her private sitter grabbed and twisted her (left) upper arm; slight redness to area indicated; Resident stated that when she was going into DR (dining room) before it was time, sitter grabbed her arm and twisted it. Administrator was notified as well as Husband (Spouse's name). Resident was kept by nurse's station until investigation was done. (Resident #2's Spouse) stated that his wife always makes accusations against (Sitter #1) the private sitter and that he does not believe them and does not want to pursue accusation. Will continue to monitor (left) upper arm." e. On [DATE] at 10:00 a.m., RN #1 was asked if she was aware of any abuse in the facility. The RN stated, "No, I haven't seen it myself, but it was reported to me. A CNA came up and told me the sitter was being verbally abusive to (Resident #2). I immediately removed (the) sitter from the situation and asked her to leave during the investigation, I escorted her out. I went to the resident who was already calming down. I did not approach (the) subject due to she was calming down. I did call (her) husband. He told me it was not the first time his wife accused sitters, before coming here, (until) she caused them to leave. I called the Administrator and told her what I'd done. She told me I did good and she would take care of it tomorrow. I did not talk with any other staff or residents about the situation." f. On [DATE] at 11:40 a.m., CNA #1 was asked if she was aware of anyone abusing a resident. She stated, "Yes... her sitter, (Resident #2), (Sitter #1) don't know (the) sitter's last name." The CNA did not know exactly when the sitter worked, but knew she worked on weekends. The CNA continued, "There were two different times. She didn't hit her in front of me. (Sitter #1) was standing and bent down to eye level with (Resident #2), pointing in her face, screaming, touching (her) face with (a) finger at resident. She said (Resident #2) called her a name was why she was screaming. (Resident #2) said she was scared and she was crying. So, I took her to the nurses' station and got the supervisor, the weekend supervisor, (RN #1) and floor nurse, (LPN #1) ...I had asked (Sitter #1) to leave. She was on the cell phone, she told me she was calling (Resident #2's spouse). My supervisor walked her outside and she did not come back while I was there that day (until) 7 (7:00 p.m.) Recently last week, I'm wanting to say Monday ...I did not see this. (Resident #2) said she was walking to the dining room with the walker and she said the sitter grabbed her arm and squeezed it cause she had gone to lunch too early. I passed her when she was walking back to the room and she told me about it. I went and got the charge nurse, (RN #2) and reported it. ...(RN #2) said let's take her to the bath room. There was redness on the arm and she complained of it hurting. It was just red. We let her sit at the nurses' station and stayed with her most of the time. I would not call it one-on-one, but we checked on her often... I saw (Sitter #1) one time in the hall and she said something ugly. She said if she wanted to whip (Resident #2)'s ass, she would have done it when she was the sitter at home. I just said, 'Yes ma'am' and walked off. I reported this to (RN #2)." The CNA was asked if she had seen (Sitter #1) in the nursing home since. She stated, "Yes, she still sits with her. I think on weekends." g. On [DATE] at 12:35 p.m., RN #2 stated, "We had some reported abuse over the weekend a while back. I heard about the sitter in her face calling her a name. The sitter was removed. I was kind of upset she was allowed to come back. We monitored her (Sitter #1) closely after the first situation. About 2 weeks ago, a CNA reported to me that the sitter (Sitter #1) had twisted her (Resident #2) arm. I went and talked with (Resident #2), examined her arm, did not find anything but slight redness. She said she was going to the dining room too early when the sitter grabbed her and twisted her arm. Kept her sitter and her separate during the investigation. (Sitter #1) doesn't go into the room anymore, only out in hall. She mainly works weekends and Fridays and usually leaves at 3:00 p.m. I reported it to the Administrator, DON (Director of Nursing), the husband. I've never seen her back in the room since the first incident." h. On [DATE] at 12:50 p.m., the DON was asked about the alleged abuse concerning the resident). She stated, "I'm not a personal witness to any of it. I know that (Resident #2)'s sitter got loud and yelled at, got verbally abusive, got in her face. The nurse reported to me that day. (Administrator) is in charge. I don't make any decisions regarding that kind of thing. She takes care of all of that. I do know the nurses separated them. She (Sitter #1) was sent home but was back the next day. We were appalled she was allowed back in. She's not been back in her (Resident #2) room since, usually sits in the hall. I watch her like a hawk when she's here. I don't know of any other allegations of abuse regarding (Resident #2)." i. On [DATE] at 1:20 p.m., the Administrator was asked about an incident with Resident #2 and her sitter. She stated, "Yes, the first time was about 12 to 18 months ago with (Resident #2)'s sitter (Sitter #1), a black sitter that had worked for them at their home, employed for greater than 3 years. (Resident #2) had made racial remarks to (Sitter #1) while (Sitter #1) was trying to get her to do something, care or some treatment. (Resident #2) got mad at her called her a black... then (Sitter #1) yelled back at her, 'This is not what we do, I'm not going to put up with this kind of talk.' I was here and it was brought to my attention. I don't remember which CNA over heard. We sent sitter home ...I contacted the husband, he said that was the way she (Resident #2) is when she is told something she doesn't want to do. She lashes out at them. I talked with the husband and he did not want me to turn it in as an allegation of abuse. I did not interview other interviewable residents. At that time, we had a policy in place that we were asking the residents every day, 'is everybody being nice to you today?' I did talk to other staff regarding (Resident #2)'s sitter. ...I did not talk to (Resident #2) about the incident. She wasn't scared. She was mad per staff and her husband. He came up that same day and talked with his wife and me. (Sitter #1) has been here since the day after the incident. She is never in the room alone with the resident. She makes (her)self visible. The next incident was about 2 weeks ago. It was prior to lunch. She (Resident #2) was going up the hallway with (CNA #1). She was wearing a fleece jacket. The CNA told me (Sitter #1) grabbed (Resident #2)'s arm and twisted it. I told her to take (Resident #2) to (RN #2) to have a look at her arm. I called the sitter to my office to find out what was going on. She told me she did not twist her arm. She (Resident #2) was trying to go to the dining room too early. Dining room was closed. She reached out to resident, touching resident's arm telling her it was too early to go to the dining room and the resident jerked her arm back from the sitter. (Resident #2) told (RN #2) that she was trying to stop her from going to the dining room too early and 'I jerked my arm back'." The Administrator further stated, "We have abuse in-services regularly." She was asked for copies of the in-services for the last 4 months. She stated, "There is no large portion of time that the sitters are in the room with (Resident #2). I see her mainly in the hallway with (Resident #2). The sitter is quite visible while here with (Resident #2). I have not told staff to monitor while the sitter is here." The Administrator was asked if she considered each incident an allegation of abuse. She stated, "I treated each incident as an allegation of abuse by immediately separating them. I did talk to every staff involved. There were no witness statements done." The Administrator was asked if this had been reported to the Office of Long Term Care (OLTC) as an allegation of abuse. She stated, "No." She further stated, "In hindsight, I probably could have done more investigation to thoroughly investigate." The Administrator was asked if there were cameras in the hallways. She said, "There weren't during the first incident, but there was with the second." She was asked if she had viewed the second incident. She stated, "I should have, but I got busy and did not. I did separate the sitter from the resident both incidents." The Administrator left the room to view the camera from the date of [DATE], the last incident. The Surveyor also viewed the video from the time of the alleged incident; there was nothing conclusive observed due to the sitter and the resident being inside the dining room door during the incident. j. On [DATE] at 2:00 p.m. LPN #1 was asked about the incident in [DATE] with the resident. The LPN stated, "It was around 3:00 p.m. because the ,[DATE] (3:00 p.m. to 11:00 p.m.) shift was there, (CNA #1) and (RN #1) weekend supervisor, and LPN (#2), who no longer works here, were at the nurses station. I heard (CNA #1) say 'We've got to get (Sitter #1) out of here. She was yelling in (Resident #2)'s face.' I heard (Sitter #1) in the resident's room on the cell phone. I knew she was talking with (Resident's spouse) because I heard her say (Resident's spouses' name). She said 'She's not gonna talk to me like that, you know how she is' and I heard her complaining about (CNA #1). (Resident #2) reported to me that (Sitter #1) had called her a 'white (expletive)'. (Resident #6) who was also in the hall, said 'she would have never got in my face like that. She wouldn't have done that to me.' She has expired since then. I filled out witness statements. (RN #1) told (Sitter #1) she needed to leave. (CNA #1) and I took (Resident #2) to the nurses station (until) (Sitter #1) left. (CNA #2) also saw it, but she no longer works here. ...I talked to a few residents and (Resident #2) and filled out witness statements and was told to put under the Administrator's door. No other residents, other than(Resident #6), said they heard anything. (Resident #2) looked like a whooped puppy. She said, she and her husband pay her and she can't treat me like that. She looked frightened and said she did not want her to be back around her. (Sitter #1) said the resident called her a '(derogatory racial word)', but the resident said she didn't. (CNA #1) was saying 'You've got to stop and you can't be doing this', when (Sitter #1) was yelling at the resident. (RN #1) called (Administrator) and spoke with (Resident's spouse). I put a hand full of witness statements under the door to (Administrator's) office. (Administrator) did not come up there. I had not heard of anything happening before this. When I came back the next day for an in-service for the nurses, I saw (Sitter #1) sitting in the hall. I asked (RN #1) why she was here. She said, 'Yea, (Administrator)'s aware and she is not allowed to have unsupervised interaction with the resident.' The ,[DATE] (7:00 a.m. to 3:00 p.m. shift) nurse, who is no longer here, (LPN #3), said the aides were watching closely. (Sitter #1) was not allowed to be alone with (Resident #2) until (Administrator) finished the investigation. I work on Saturdays and Sundays, 7a to 7p (7:00 a.m. to 7:00 p.m.). (Sitter #1) is here on Sundays, but I haven't seen her lately. I read the nurses notes from the incident on Monday, the 14th, and checked (Resident #2)'s arm on Saturday, no marks. I asked (RN #2) if there were any instructions concerning the resident and the sitter. She said everything had been worked out." LPN #1 was asked if she had seen (Sitter #1) in the room, alone with (Resident #2) since the first incident. She stated, "Yes." k. On [DATE] at 2:45 p.m., the Administrator was again asked about the incident on [DATE]. At first the Administrator did not remember that the incident was in [DATE]. She stated, "I was out of the office 4 of 5 days a week with the computer training in January." After reading the nurses notes of [DATE], she stated, "Well, wait a minute." She was asked if it was coming back to her. She stated, "Yes." She was asked if it had happened before this and she stated, "I honestly don't know." The Administrator was asked if she told the staff to get witness statements. She stated, "I don't remember." She was asked, "What if this had been one of your CNAs?" The Administrator stated, "They would be gone, fired." l. On [DATE] at 3:20 p.m., the Administrator provided witness statements from the incident on [DATE]. She stated, "I'm sorry, I didn't remember this January (2014) was so crazy." 1) The Witness Statement dated [DATE] from CNA #1 documented, "...heard someone screaming. I looked up and (Resident #2)'s personal assistant was screaming at her. She was bent over the wheel chair with her finger in (Resident #2)'s face. I heard her call (Resident #2) an 'old white (expletive)'. I made the personal assistant stop and told her that was resident abuse. She started arguing with me saying that it was not abuse because (Resident #2) had called her a (derogatory racial word).' I told her that she had to leave the facility or I would have to call the police..." 2) The Witness Statement dated [DATE] from CNA #2 documented, "When I, (CNA #2) came out of a room on two hundred hall, I witness the care giver of (Resident #2) was in her face screaming at her telling her that she will not call her anything but her name. (Resident #2) never said anything back, even when she asked her do you hear me. ...At this time the lead CNA (CNA #1) came down the hall and told the care giver that what she was doing wasn't right and that she needs to stop. The care giver told her, yes it is right what she was doing and that she couldn't tell her anything because she don't work for (Name of Nursing Home). And as (CNA #1) walked off she called her a (expletive) and that she was only going to do what her boss told her to do. Because her boss knows how she is. I (CNA #2) feel like (CNA #1) did the right thing to make sure (Resident #2) was safe. If she didn't step in I feel like it would have got even more out of hand ...for (Resident #2) was afraid..." 3) The Witness Statement dated [DATE] from LPN #1 documented, "(CNA #1) came to nurses station saying I need you down the hall now! She stated that (Resident #2) of facilities' sitter was yelling in (resident's) face. I rushed down the hall with (RN #1). (Resident) was sitting in hallway in chair with hands in lap (and) looking down. (Resident) appeared upset. Sitter was in (Resident's) room on cell phone speaking very loudly saying she wasn't putting up with this, that (Resident #2) would not talk to her like that (and) that she was not abusing (Resident). She told the person on the phone that (Resident #2) had called her a (derogatory racial word). I addressed (Resident) and asked her what happened, while (RN #1) told sitter (Sitter #1) that she needed to get her stuff (and) go home for the day. (Sitter #1), the sitter said 'when I get off the phone.' ...(Resident told me that (Sitter #1) was in her face yelling at her (and) calling her a white (expletive). ...(Resident) said we pay her to help me, she can't treat me this way. Assured (Resident) that she would not be treated that way... Resident stated that she was alright, but asked that we never let (Sitter #1) back here. Assured (Resident) that the situation will be handled (and) that she will not be treated in such a manner. (Resident) stated, 'I thought she was going to hit me.' ...(Sitter #1) was escorted out by (RN #1). (Resident's) husband called (and) spoke (with) (RN #1). (RN #1) notified (Administrator). I notified DON." 4) Resident #2's statement was dated [DATE] and signed by LPN #1; the statement documented, "(Resident) stated that her sitter (Sitter #1) called her a white (expletive), got in her face, was leaning over her yelling (at) her. Incident was witnessed by multiple staff members. Sitter was escorted out of building." 5) Resident #6's witness statement was dated [DATE] and signed by LPN #1; the statement documented, "(Resident) asked if she witnessed the incident that took place in hallway where (resident) was sitting. She stated, yes that resident (Resident #2) called the sitter (Sitter #1) a Black son of a (expletive) (and) that the sitter called (Resident) a white son of a (expletive) (and) then got up out of her seat (and) started yelling in (Resident #2)'s face. (Resident) states it upset her (and) made her nervous seeing (and) hearing the incident. (Resident) assured that the situation was being handled (and) would not happen again." 6) CNA #3's witness statement was dated [DATE] and documented, "I witnessed (Sitter #1) tell the resident to not call her anything else but her name. She stated her name was (Sitter #1) and to not call her anything else." m. On [DATE] at 10:00 a.m., the Administrator provided Sitter #1's full name. The Administrator stated that the sitter was employed 3 days a week, Sunday, Mondays, and Tuesdays by the spouse of the resident and that this was the only resident with sitters in the facility. The Administrator further stated, "My mistake was not reading the witness statements and just going by what was verbally told to me about the incident. In January (2014), when this occurred, I was doing computer training for new software 4 days a week." n. The Immediate Jeopardy was removed and the scope and severity was lowered to a "H" on [DATE] at 3:35 p.m. when the following Plan of Removal was initiated: 1) At 3:35 p.m. on [DATE], the sitter was not working today and not in the building. After that the administrator tried to call the husband and could not get him. At 3:53 p.m., the Administrator was able to contact the Grandson and informed him of the abuse reporting and that the sitter was not allowed back in the building. At 3:59 p.m., the husband spoke with the Administrator. The Administrator informed him of the abuse reporting and that the sitter was not allowed back in the building and for him to notify the sitter. 2) At 3:40 p.m. on [DATE] abuse in-service was initiated by the Administrator or her designees for ALL staff prior to beginning their shift. No one will be allowed to work on the floor until in-service is done. 3) On [DATE], the ADON (Assistant Director of Nursing) and staff RN asked residents if the residents had been abused or seen abuse. This began at 4:30 p.m. and was finished 5:30 p.m. No resident reported abuse or seeing abuse. 4) On [DATE] at 4:30 p.m., staff was asked by the ADON and staff RN if they had any knowledge of abuse. No staff reported abuse or seeing abuse. All staff will be interviewed by Administrator or designees prior to beginning shift. Any negative outcomes will be addressed immediately. 5) On [DATE] at 4:30 p.m. DON initiated body audits on residents by DON or her designees and no signs of abuse or injuries of unknown origin were found. Completion was at [DATE] at 9:00 a.m. 6) On [DATE] at 5:00 p.m., the Administrator began a book that staff are to sign at the end of the shift: "On your shift have you seen any signs of abuse "yes or no". "If yes, who did you report this to?" Any negative outcomes will be addressed immediately. On [DATE] at 5:00 p.m., the Administrator began a book "Has everyone been nice to you?" that will be done by the social designee or her designee on a daily basis. This book is for the purpose of identifying if a resident has experienced abuse. Any negative outcomes will be addressed immediately. 7) On [DATE] at 5:30 p.m. the Administrator was in-serviced on abuse including reporting by the executive director. 8) On [DATE] at 5:00 p.m., the Administrator made a plan that current private sitters of residents will be in-serviced by Administrator or her designee on what constitutes abuse, abuse reporting requirements of Long Term Care Facilities, and to whom to report abuse. No sitters were on duty. At this time there is only one sitter being utilized by one resident. The Administrator in-serviced her at 7:15 a.m. on [DATE] as she came on duty. 9) Any negative outcomes identified by audits, interviews, etc. will be addressed immediately by the Administrator or her designee.

Complaint # was substantiated (all or in part) in these findings: Complaint # was substantiated (all or in part) in these findings: Complaint # was substantiated (all or in part) in these findings: Based on record review and interview, the facility failed to ensure allegations of verbal, mental, and physical abuse were immediately reported to the required officials in accordance with State law through established procedures (including to the State survey and certification agency), failed to thoroughly investigate the alleged violations of abuse and failed to protect the resident from further potential abuse during an investigation for 1of 1 (Resident #2) case mix resident who experienced verbal, mental, and physical abuse from a private sitter. This failed practice resulted in Immediate Jeopardy at a pattern due to length of time, which caused or could have caused serious harm, injury, or death for Resident #2 who had a private sitter who staff witnessed verbally/mentally abusing the resident. The facility was notified of the Immediate Jeopardy on [DATE] at 4:25 p.m. The failed practice had the potential to affect one resident who had a private sitter, according to an interview with the Administrator on [DATE] at 10:00 a.m. The findings are: Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 9 (,[DATE] indicates moderate cognitive impairment) on the Brief Interview for Mental Status and had behavioral symptoms directed toward others that occurred 1 to 3 days out of the last 7 days. a. The Nurse's Notes dated [DATE] at 3:40 p.m. and signed by LPN #1 documented, "CNA (Certified Nursing Assistant #1) rushes up to nurse's station saying, 'I need help now.' As we rush down the hall she says that (Resident #2)'s sitter (Sitter #1) was in (Resident #2)'s face yelling and cursing (at) (Resident #2). As we make it to (Resident), (Resident #2) is in the hallway. (Resident #2's) sitter is in (Resident #2's) room talking very loudly on her cell phone saying, ' (Resident #2) is not going to call me a '(derogatory racial word)' (Registered Nurse #1) and this LPN (Licensed Practical Nurse) (LPN #1) in hallway. (RN #1) tells sitter that she needs to get her stuff and go home. This LPN asked (Resident #2) what happened. (Resident #2) states that (Sitter #1) called her a white (expletive) (and) was in her face yelling (at) her. (Resident) walked up to nurse's station (with) this LPN while (RN #1) gets sitter out of building. (Resident) states that she was afraid (Sitter #1) was going to hit her (and) that she does not want her back here. Assured (Resident) that the situation will be handled and we will not allow (Sitter #1) to harm her. Sitter escorted out of building by (RN #1). (Administrator) notified by (RN #1). (Director of Nursing) notified by this LPN. (Resident)'s husband (Spouse's name) called (and) spoke (with) (RN #1). (Resident) states she is (all right), just glad (Sitter #1) is gone. Will cont (continue) to monitor." b. The Nurse's Notes dated [DATE] to [DATE] were reviewed on [DATE]. There were notations that there was a sitter at the resident's bedside on [DATE], [DATE] and [DATE]. Further notations documented, " ...sitters during the day ..." " ...visiting with the sitter..." on [DATE], [DATE], [DATE], [DATE] and [DATE]. c. The Resident Progress Notes dated [DATE] at 2:19 p.m. and signed by RN #2 documented, "Resident C/O (complained) to (CNA #1) that her private sitter grabbed and twisted her (left) upper arm; slight redness to area indicated; Resident stated that when she was going into DR (dining room) before it was time, sitter grabbed her arm and twisted it. Administrator was notified as well as Husband (Spouse's name). Resident was kept by nurse's station until investigation was done. (Resident #2's Spouse) stated that his wife always makes accusations against (Sitter #1) the private sitter and that he does not believe them and does not want to pursue accusation. Will continue to monitor (left) upper arm." d. On [DATE] at 10:00 a.m., RN #1 was asked if she was aware of any abuse in the facility. The RN stated, "No, I haven't seen it myself, but it was reported to me. A CNA came up and told me the sitter was being verbally abusive to (Resident #2). I immediately removed (the) sitter from the situation and asked her to leave during the investigation, I escorted her out. I went to the resident who was already calming down. I did not approach (the) subject due to she was calming down. I did call (her) husband. He told me it was not the first time his wife accused sitters, before coming here, (until) she caused them to leave. I called the Administrator and told her what I'd done. She told me I did good and she would take care of it tomorrow. I did not talk with any other staff or residents about the situation." e. On [DATE] at 11:40 a.m., CNA #1 was asked if she was aware of anyone abusing a resident. She stated, "Yes... her sitter, (Resident #2), (Sitter #1) don't know (the) sitter's last name." The CNA did not know exactly when the sitter worked, but knew she worked on weekends. The CNA continued, "There were two different times. She didn't hit her in front of me. (Sitter #1) was standing and bent down to eye level with (Resident #2), pointing in her face, screaming, touching (her) face with (a) finger at resident. She said (Resident #2) called her a name was why she was screaming. (Resident #2) said she was scared and she was crying. So, I took her to the nurses' station and got the supervisor, the weekend supervisor, (RN #1) and floor nurse, (LPN #1) ...I had asked (Sitter #1) to leave. She was on the cell phone, she told me she was calling (Resident #2's spouse). My supervisor walked her outside and she did not come back while I was there that day (until) 7 (7:00 p.m.) Recently last week, I'm wanting to say Monday ...I did not see this. (Resident #2) said she was walking to the dining room with the walker and she said the sitter grabbed her arm and squeezed it cause she had gone to lunch too early. I passed her when she was walking back to the room and she told me about it. I went and got the charge nurse, (RN #2) and reported it. ...(RN #2) said let's take her to the bath room. There was redness on the arm and she complained of it hurting. It was just red. We let her sit at the nurses' station and stayed with her most of the time. I would not call it one-on-one, but we checked on her often... I saw (Sitter #1) one time in the hall and she said something ugly. She said if she wanted to whip (Resident #2)'s ass, she would have done it when she was the sitter at home. I just said, 'Yes ma'am' and walked off. I reported this to (RN #2)." The CNA was asked if she had seen (Sitter #1) in the nursing home since. She stated, "Yes, she still sits with her. I think on weekends." f. On [DATE] at 12:35 p.m., RN #2 stated, "We had some reported abuse over the weekend a while back. I heard about the sitter in her face calling her a name. The sitter was removed. I was kind of upset she was allowed to come back. We monitored her (Sitter #1) closely after the first situation. About 2 weeks ago, a CNA reported to me that the sitter (Sitter #1) had twisted her (Resident #2) arm. I went and talked with (Resident #2), examined her arm, did not find anything but slight redness. She said she was going to the dining room too early when the sitter grabbed her and twisted her arm. Kept her sitter and her separate during the investigation. (Sitter #1) doesn't go into the room anymore, only out in hall. She mainly works weekends and Fridays and usually leaves at 3:00 p.m. I reported it to the Administrator, DON (Director of Nursing), the husband. I've never seen her back in the room since the first incident." g. On [DATE] at 12:50 p.m., the DON was asked about the alleged abuse concerning the resident). She stated, "I'm not a personal witness to any of it. I know that (Resident #2)'s sitter got loud and yelled at, got verbally abusive, got in her face. The nurse reported to me that day. (Administrator) is in charge. I don't make any decisions regarding that kind of thing. She takes care of all of that. I do know the nurses separated them. She (Sitter #1) was sent home but was back the next day. We were appalled she was allowed back in. She's not been back in her (Resident #2) room since, usually sits in the hall. I watch her like a hawk when she's here. I don't know of any other allegations of abuse regarding (Resident #2)." h. On [DATE] at 1:20 p.m., the Administrator was asked about an incident with Resident #2 and her sitter. She stated, "Yes, the first time was about 12 to 18 months ago with (Resident #2)'s sitter (Sitter #1), a black sitter that had worked for them at their home, employed for greater than 3 years. (Resident #2) had made racial remarks to (Sitter #1) while (Sitter #1) was trying to get her to do something, care or some treatment. (Resident #2) got mad at her called her a black... then (Sitter #1) yelled back at her, 'This is not what we do, I'm not going to put up with this kind of talk. ' I was here and it was brought to my attention. I don't remember which CNA over heard. We sent sitter home ...I contacted the husband, he said that was the way she (Resident #2) is when she is told something she doesn't want to do. She lashes out at them. I talked with the husband and he did not want me to turn it in as an allegation of abuse. I did not interview other interviewable residents. At that time, we had a policy in place that we were asking the residents every day, 'is everybody being nice to you today?' I did talk to other staff regarding (Resident #2)'s sitter. ...I did not talk to (Resident #2) about the incident. She wasn't scared. She was mad per staff and her husband. He came up that same day and talked with his wife and me. (Sitter #1) has been here since the day after the incident. She is never in the room alone with the resident. She makes (her)self visible. The next incident was about 2 weeks ago. It was prior to lunch. She (Resident #2) was going up the hallway with (CNA #1). She was wearing a fleece jacket. The CNA told me (Sitter #1) grabbed (Resident #2)'s arm and twisted it. I told her to take (Resident #2) to (RN #2) to have a look at her arm. I called the sitter to my office to find out what was going on. She told me she did not twist her arm. She (Resident #2) was trying to go to the dining room too early. Dining room was closed. She reached out to resident, touching resident's arm telling her it was too early to go to the dining room and the resident jerked her arm back from the sitter. (Resident #2) told (RN #2) that she was trying to stop her from going to the dining room too early and 'I jerked my arm back'." The Administrator further stated, "We have abuse in-services regularly." She was asked for copies of the in-services for the last 4 months. She stated, "There is no large portion of time that the sitters are in the room with (Resident #2). I see her mainly in the hallway with (Resident #2). The sitter is quite visible while here with (Resident #2). I have not told staff to monitor while the sitter is here." The Administrator was asked if she considered each incident an allegation of abuse. She stated, "I treated each incident as an allegation of abuse by immediately separating them. I did talk to every staff involved. There were no witness statements done." The Administrator was asked if this had been reported to the Office of Long Term Care (OLTC) as an allegation of abuse. She stated, "No." She further stated, "In hindsight, I probably could have done more investigation to thoroughly investigate." The Administrator was asked if there were cameras in the hallways. She said, "There weren't during the first incident, but there was with the second." She was asked if she had viewed the second incident. She stated, "I should have, but I got busy and did not. I did separate the sitter from the resident both incidents." The Administrator left the room to view the camera from the date of [DATE], the last incident. The Surveyor also viewed the video from the time of the alleged incident; there was nothing conclusive observed due to the sitter and the resident being inside the dining room door during the incident. i. On [DATE] at 2:00 p.m. LPN #1 was asked about the incident in [DATE] with the resident. The LPN stated, "It was around 3:00 p.m. because the ,[DATE] (3:00 p.m. to 11:00 p.m.) shift was there, (CNA #1) and (RN #1) weekend supervisor, and LPN (#2), who no longer works here, were at the nurses station. I heard (CNA #1) say 'We've got to get (Sitter #1) out of here. She was yelling in (Resident #2)'s face.' I heard (Sitter #1) in the resident's room on the cell phone. I knew she was talking with (Resident's spouse) because I heard her say (Resident's spouses' name). She said 'She's not gonna talk to me like that, you know how she is' and I heard her complaining about (CNA #1). (Resident #2) reported to me that (Sitter #1) had called her a 'white (expletive)'. (Resident #6) who was also in the hall, said 'she would have never got in my face like that. She wouldn't have done that to me.' She has expired since then. I filled out witness statements. (RN #1) told (Sitter #1) she needed to leave. (CNA #1) and I took (Resident #2) to the nurses station (until) (Sitter #1) left. (CNA #2) also saw it, but she no longer works here. ...I talked to a few residents and (Resident #2) and filled out witness statements and was told to put under the Administrator's door. No other residents, other than(Resident #6), said they heard anything. (Resident #2) looked like a whooped puppy. She said, she and her husband pay her and she can't treat me like that. She looked frightened and said she did not want her to be back around her. (Sitter #1) said the resident called her a '(derogatory racial word)', but the resident said she didn't. (CNA #1) was saying 'You've got to stop and you can't be doing this', when (Sitter #1) was yelling at the resident. (RN #1) called (Administrator) and spoke with (Resident's spouse). I put a hand full of witness statements under the door to (Administrator's) office. (Administrator) did not come up there. I had not heard of anything happening before this. When I came back the next day for an in-service for the nurses, I saw (Sitter #1) sitting in the hall. I asked (RN #1) why she was here. She said, 'Yea, (Administrator)'s aware and she is not allowed to have unsupervised interaction with the resident.' The ,[DATE] (7:00 a.m. to 3:00 p.m. shift) nurse, who is no longer here, (LPN #3), said the aides were watching closely. (Sitter #1) was not allowed to be alone with (Resident #2) until (Administrator) finished the investigation. I work on Saturdays and Sundays, 7a to 7p (7:00 a.m. to 7:00 p.m.). (Sitter #1) is here on Sundays, but I haven't seen her lately. I read the nurses notes from the incident on Monday, the 14th, and checked (Resident #2)'s arm on Saturday, no marks. I asked (RN #2) if there were any instructions concerning the resident and the sitter. She said everything had been worked out." LPN #1 was asked if she had seen (Sitter #1) in the room, alone with (Resident #2) since the first incident. She stated, "Yes." j. On [DATE] at 2:45 p.m., the Administrator was again asked about the incident on [DATE]. At first the Administrator did not remember that the incident was in [DATE]. She stated, "I was out of the office 4 of 5 days a week with the computer training in January." After reading the nurses notes of [DATE], she stated, "Well, wait a minute." She was asked if it was coming back to her. She stated, "Yes." She was asked if it had happened before this and she stated, "I honestly don't know." The Administrator was asked if she told the staff to get witness statements. She stated, "I don't remember." She was asked, "What if this had been one of your CNAs?" The Administrator stated, "They would be gone, fired." k. On [DATE] at 3:20 p.m., the Administrator provided witness statements from the incident on [DATE]. She stated, "I'm sorry, I didn't remember this January (2014) was so crazy." 1) The Witness Statement dated [DATE] from CNA #1 documented, "...heard someone screaming. I looked up and (Resident #2)'s personal assistant was screaming at her. She was bent over the wheel chair with her finger in (Resident #2)'s face. I heard her call (Resident #2) an 'old white (expletive). I made the personal assistant stop and told her that was resident abuse. She started arguing with me saying that it was not abuse because (Resident #2) had called her a (derogatory racial word).' I told her that she had to leave the facility or I would have to call the police..." 2) The Witness Statement dated [DATE] from CNA #2 documented, "When I, (CNA #2) came out of a room on two hundred hall, I witness the care giver of (Resident #2) was in her face screaming at her telling her that she will not call her anything but her name. (Resident #2) never said anything back, even when she asked her do you hear me. ...At this time the lead CNA (CNA #1) came down the hall and told the care giver that what she was doing wasn't right and that she needs to stop. The care giver told her, yes it is right what she was doing and that she couldn't tell her anything because she don't work for (Name of Nursing Home). And as (CNA #1) walked off she called her a (expletive) and that she was only going to do what her boss told her to do. Because her boss knows how she is. I (CNA #2) feel like (CNA #1) did the right thing to make sure (Resident #2) was safe. If she didn't step in I feel like it would have got even more out of hand ...for (Resident #2) was afraid..." 3) The Witness Statement dated [DATE] from LPN #1 documented, "(CNA #1) came to nurses station saying I need you down the hall now! She stated that (Resident #2) of facilities' sitter was yelling in (resident's) face. I rushed down the hall with (RN #1). (Resident) was sitting in hallway in chair with hands in lap (and) looking down. (Resident) appeared upset. Sitter was in (Resident's) room on cell phone speaking very loudly saying she wasn't putting up with this, that (Resident #2) would not talk to her like that (and) that she was not abusing (Resident). She told the person on the phone that (Resident #2) had called her a (derogatory racial word). I addressed (Resident) and asked her what happened, while (RN #1) told sitter (Sitter #1) that she needed to get her stuff (and) go home for the day. (Sitter #1), the sitter said 'when I get off the phone.' ...(Resident told me that (Sitter #1) was in her face yelling at her (and) calling her a white (expletive). ...(Resident) said we pay her to help me, she can't treat me this way. Assured (Resident) that she would not be treated that way... Resident stated that she was alright, but asked that we never let (Sitter #1) back here. Assured (Resident) that the situation will be handled (and) that she will not be treated in such a manner. (Resident) stated, 'I thought she was going to hit me.' ...(Sitter #1) was escorted out by (RN #1). (Resident's) husband called (and) spoke (with) (RN #1). (RN #1) notified (Administrator). I notified DON." 4) Resident #2's statement was dated [DATE] and signed by LPN #1; the statement documented, "(Resident) stated that her sitter (Sitter #1) called her a white (expletive), got in her face, was leaning over her yelling (at) her. Incident was witnessed by multiple staff members. Sitter was escorted out of building." 5) Resident #6's witness statement was dated [DATE] and signed by LPN #1; the statement documented, "(Resident) asked if she witnessed the incident that took place in hallway where (resident) was sitting. She stated, yes that resident (Resident #2) called the sitter (Sitter #1) a Black son of a (expletive) (and) that the sitter called (Resident) a white son of a (expletive) (and) then got up out of her seat (and) started yelling in (Resident #2)'s face. (Resident) states it upset her (and) made her nervous seeing (and) hearing the incident. (Resident) assured that the situation was being handled (and) would not happen again." 6) CNA #3's witness statement was dated [DATE] and documented, "I witnessed (Sitter #1) tell the resident to not call her anything else but her name. She stated her name was (Sitter #1) and to not call her anything else." l. On [DATE] at 10:00 a.m., the Administrator provided Sitter #1's full name. The Administrator stated that the sitter was employed 3 days a week, Sunday, Mondays, and Tuesdays by the spouse of the resident and that this was the only resident with sitters in the facility. The Administrator further stated, "My mistake was not reading the witness statements and just going by what was verbally told to me about the incident. In January (2014), when this occurred, I was doing computer training for new software 4 days a week." m. The Immediate Jeopardy was removed and the scope and severity was lowered to a "H" on [DATE] at 3:35 p.m. when the following Plan of Removal was initiated: 1) At 3:35 p.m. on [DATE], the sitter was not working today and not in the building. After that the administrator tried to call the husband and could not get him. At 3:53 p.m., the Administrator was able to contact the Grandson and informed him of the abuse reporting and that the sitter was not allowed back in the building. At 3:59 p.m., the husband spoke with the Administrator. The Administrator informed him of the abuse reporting and that the sitter was not allowed back in the building and for him to notify the sitter. 2) At 3:40 p.m. on [DATE] abuse in-service was initiated by the Administrator or her designees for ALL staff prior to beginning their shift. No one will be allowed to work on the floor until in-service is done. 3) On [DATE], the ADON (Assistant Director of Nursing) and staff RN asked residents if the residents had been abused or seen abuse. This began at 4:30 p.m. and was finished 5:30 p.m. No resident reported abuse or seeing abuse. 4) On [DATE] at 4:30 p.m., staff was asked by the ADON and staff RN if they had any knowledge of abuse. No staff reported abuse or seeing abuse. All staff will be interviewed by Administrator or designees prior to beginning shift. Any negative outcomes will be addressed immediately. 5) On [DATE] at 4:30 p.m. DON initiated body audits on residents by DON or her designees and no signs of abuse or injuries of unknown origin were found. Completion was at [DATE] at 9:00 a.m. 6) On [DATE] at 5:00 p.m., the Administrator began a book that staff are to sign at the end of the shift: "On your shift have you seen any signs of abuse "yes or no". "If yes, who did you report this to?" Any negative outcomes will be addressed immediately. On [DATE] at 5:00 p.m., the Administrator began a book "Has everyone been nice to you?" that will be done by the social designee or her designee on a daily basis. This book is for the purpose of identifying if a resident has experienced abuse. Any negative outcomes will be addressed immediately. 7) On [DATE] at 5:30 p.m. the Administrator was in-serviced on abuse including reporting by the executive director. 8) On [DATE] at 5:00 p.m., the Administrator made a plan that current private sitters of residents will be in-serviced by Administrator or her designee on what constitutes abuse, abuse reporting requirements of Long Term Care Facilities, and to whom to report abuse. No sitters were on duty. At this time there is only one sitter being utilized by one resident. The Administrator in-serviced her at 7:15 a.m. on [DATE] as she came on duty. 9) Any negative outcomes identified by audits, interviews, etc. will be addressed immediately by the Administrator or her designee.

Complaint # was substantiated (all or in part) in these findings: Complaint # was substantiated (all or in part) in these findings: Complaint # was substantiated (all or in part) in these findings: Based on record review and interview, the facility failed to ensure Resident #2 was free from verbal, mental and physical abuse. The facility failed to ensure interventions were immediately developed and implemented to prevent verbal, mental and physical abuse for 1 of 1 (Resident #2) case mix resident who was witnessed to be verbally/mentally abused by her private sitter on one occasion and who also made an allegation of physical abuse by the sitter on another occasion. This failed practice resulted in Immediate Jeopardy at a pattern due to length of time, which caused or could have caused serious harm, injury, or death for Resident #2 who had a private sitter who staff witnessed verbally / mentally abusing the resident. The facility was notified of the Immediate Jeopardy on [DATE] at 4:25 p.m. The failed practice had the potential to affect one resident who had a private sitter, according to an interview with the Administrator on [DATE] at 10:00 a.m. The findings are: Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 9 (,[DATE] indicates moderate cognitive impairment) on the Brief Interview for Mental Status and had behavioral symptoms directed toward others that occurred 1 to 3 days out of the last 7 days. a. The Nurse's Notes dated [DATE] at 3:40 p.m. and signed by LPN #1 documented, "CNA (Certified Nursing Assistant #1) rushes up to nurse's station saying, 'I need help now.' As we rush down the hall she says that (Resident #2)'s sitter (Sitter #1) was in (Resident #2)'s face yelling and cursing (at) (Resident #2). As we make it to (Resident), (Resident #2) is in the hallway. (Resident #2's) sitter is in (Resident #2's) room talking very loudly on her cell phone saying, ' (Resident #2) is not going to call me a '(derogatory racial word)' (Registered Nurse #1) and this LPN (Licensed Practical Nurse) (LPN #1) in hallway. (RN #1) tells sitter that she needs to get her stuff and go home. This LPN asked (Resident #2) what happened. (Resident #2) states that (Sitter #1) called her a white (expletive) (and) was in her face yelling (at) her. (Resident) walked up to nurse's station (with) this LPN while (RN #1) gets sitter out of building. (Resident) states that she was afraid (Sitter #1) was going to hit her (and) that she does not want her back here. Assured (Resident) that the situation will be handled and we will not allow (Sitter #1) to harm her. Sitter escorted out of building by (RN #1). (Administrator) notified by (RN #1). (Director of Nursing) notified by this LPN. (Resident)'s husband (Spouse's name) called (and) spoke (with) (RN #1). (Resident) states she is (all right), just glad (Sitter #1) is gone. Will cont (continue) to monitor." b. The Nurse's Notes dated [DATE] to [DATE] were reviewed on [DATE]. There were notations that there was a sitter at the resident's bedside on [DATE], [DATE] and [DATE]. Further notations documented, " ...sitters during the day ..." " ...visiting with the sitter..." on [DATE], [DATE], [DATE], [DATE] and [DATE]. c. The Resident Progress Notes dated [DATE] at 2:19 p.m. and signed by RN #2 documented, "Resident C/O (complained) to (CNA #1) that her private sitter grabbed and twisted her (left) upper arm; slight redness to area indicated; Resident stated that when she was going into DR (dining room) before it was time, sitter grabbed her arm and twisted it. Administrator was notified as well as Husband (Spouse's name). Resident was kept by nurse's station until investigation was done. (Resident #2's Spouse) stated that his wife always makes accusations against (Sitter #1) the private sitter and that he does not believe them and does not want to pursue accusation. Will continue to monitor (left) upper arm." d. On [DATE] at 10:00 a.m., RN #1 was asked if she was aware of any abuse in the facility. The RN stated, "No, I haven't seen it myself, but it was reported to me. A CNA came up and told me the sitter was being verbally abusive to (Resident #2). I immediately removed (the) sitter from the situation and asked her to leave during the investigation, I escorted her out. I went to the resident who was already calming down. I did not approach (the) subject due to she was calming down. I did call (her) husband. He told me it was not the first time his wife accused sitters, before coming here, (until) she caused them to leave. I called the Administrator and told her what I'd done. She told me I did good and she would take care of it tomorrow. I did not talk with any other staff or residents about the situation." e. On [DATE] at 11:40 a.m., CNA #1 was asked if she was aware of anyone abusing a resident. She stated, "Yes... her sitter, (Resident #2), (Sitter #1) don't know (the) sitter's last name." The CNA did not know exactly when the sitter worked, but knew she worked on weekends. The CNA continued, "There were two different times. She didn't hit her in front of me. (Sitter #1) was standing and bent down to eye level with (Resident #2), pointing in her face, screaming, touching (her) face with (a) finger at resident. She said (Resident #2) called her a name was why she was screaming. (Resident #2) said she was scared and she was crying. So, I took her to the nurses' station and got the supervisor, the weekend supervisor, (RN #1) and floor nurse, (LPN #1) ...I had asked (Sitter #1) to leave. She was on the cell phone, she told me she was calling (Resident #2's spouse). My supervisor walked her outside and she did not come back while I was there that day (until) 7 (7:00 p.m.) Recently last week, I'm wanting to say Monday ...I did not see this. (Resident #2) said she was walking to the dining room with the walker and she said the sitter grabbed her arm and squeezed it cause she had gone to lunch too early. I passed her when she was walking back to the room and she told me about it. I went and got the charge nurse, (RN #2) and reported it. ...(RN #2) said let's take her to the bath room. There was redness on the arm and she complained of it hurting. It was just red. We let her sit at the nurses' station and stayed with her most of the time. I would not call it one-on-one, but we checked on her often... I saw (Sitter #1) one time in the hall and she said something ugly. She said if she wanted to whip (Resident #2)'s ass, she would have done it when she was the sitter at home. I just said, 'Yes ma'am' and walked off. I reported this to (RN #2)." The CNA was asked if she had seen (Sitter #1) in the nursing home since. She stated, "Yes, she still sits with her. I think on weekends." f. On [DATE] at 12:35 p.m., RN #2 stated, "We had some reported abuse over the weekend a while back. I heard about the sitter in her face calling her a name. The sitter was removed. I was kind of upset she was allowed to come back. We monitored her (Sitter #1) closely after the first situation. About 2 weeks ago, a CNA reported to me that the sitter (Sitter #1) had twisted her (Resident #2) arm. I went and talked with (Resident #2), examined her arm, did not find anything but slight redness. She said she was going to the dining room too early when the sitter grabbed her and twisted her arm. Kept her sitter and her separate during the investigation. (Sitter #1) doesn't go into the room anymore, only out in hall. She mainly works weekends and Fridays and usually leaves at 3:00 p.m. I reported it to the Administrator, DON (Director of Nursing), the husband. I've never seen her back in the room since the first incident." g. On [DATE] at 12:50 p.m., the DON was asked about the alleged abuse concerning the resident). She stated, "I'm not a personal witness to any of it. I know that (Resident #2)'s sitter got loud and yelled at, got verbally abusive, got in her face. The nurse reported to me that day. (Administrator) is in charge. I don't make any decisions regarding that kind of thing. She takes care of all of that. I do know the nurses separated them. She (Sitter #1) was sent home but was back the next day. We were appalled she was allowed back in. She's not been back in her (Resident #2) room since, usually sits in the hall. I watch her like a hawk when she's here. I don't know of any other allegations of abuse regarding (Resident #2)." h. On [DATE] at 1:20 p.m., the Administrator was asked about an incident with Resident #2 and her sitter. She stated, "Yes, the first time was about 12 to 18 months ago with (Resident #2)'s sitter (Sitter #1), a black sitter that had worked for them at their home, employed for greater than 3 years. (Resident #2) had made racial remarks to (Sitter #1) while (Sitter #1) was trying to get her to do something, care or some treatment. (Resident #2) got mad at her called her a black... then (Sitter #1) yelled back at her, 'This is not what we do, I'm not going to put up with this kind of talk. ' I was here and it was brought to my attention. I don't remember which CNA over heard. We sent sitter home ...I contacted the husband, he said that was the way she (Resident #2) is when she is told something she doesn't want to do. She lashes out at them. I talked with the husband and he did not want me to turn it in as an allegation of abuse. I did not interview other interviewable residents. At that time, we had a policy in place that we were asking the residents every day, 'is everybody being nice to you today?' I did talk to other staff regarding (Resident #2)'s sitter. ...I did not talk to (Resident #2) about the incident. She wasn't scared. She was mad per staff and her husband. He came up that same day and talked with his wife and me. (Sitter #1) has been here since the day after the incident. She is never in the room alone with the resident. She makes (her)self visible. The next incident was about 2 weeks ago. It was prior to lunch. She (Resident #2) was going up the hallway with (CNA #1). She was wearing a fleece jacket. The CNA told me (Sitter #1) grabbed (Resident #2)'s arm and twisted it. I told her to take (Resident #2) to (RN #2) to have a look at her arm. I called the sitter to my office to find out what was going on. She told me she did not twist her arm. She (Resident #2) was trying to go to the dining room too early. Dining room was closed. She reached out to resident, touching resident's arm telling her it was too early to go to the dining room and the resident jerked her arm back from the sitter. (Resident #2) told (RN #2) that she was trying to stop her from going to the dining room too early and 'I jerked my arm back'." The Administrator further stated, "We have abuse in-services regularly." She was asked for copies of the in-services for the last 4 months. She stated, "There is no large portion of time that the sitters are in the room with (Resident #2). I see her mainly in the hallway with (Resident #2). The sitter is quite visible while here with (Resident #2). I have not told staff to monitor while the sitter is here." The Administrator was asked if she considered each incident an allegation of abuse. She stated, "I treated each incident as an allegation of abuse by immediately separating them. I did talk to every staff involved. There were no witness statements done." The Administrator was asked if this had been reported to the Office of Long Term Care (OLTC) as an allegation of abuse. She stated, "No." She further stated, "In hindsight, I probably could have done more investigation to thoroughly investigate." The Administrator was asked if there were cameras in the hallways. She said, "There weren't during the first incident, but there was with the second." She was asked if she had viewed the second incident. She stated, "I should have, but I got busy and did not. I did separate the sitter from the resident both incidents." The Administrator left the room to view the camera from the date of [DATE], the last incident. The Surveyor also viewed the video from the time of the alleged incident; there was nothing conclusive observed due to the sitter and the resident being inside the dining room door during the incident. i. On [DATE] at 2:00 p.m. LPN #1 was asked about the incident in [DATE] with the resident. The LPN stated, "It was around 3:00 p.m. because the ,[DATE] (3:00 p.m. to 11:00 p.m.) shift was there, (CNA #1) and (RN #1) weekend supervisor, and LPN (#2), who no longer works here, were at the nurses station. I heard (CNA #1) say 'We've got to get (Sitter #1) out of here. She was yelling in (Resident #2)'s face.' I heard (Sitter #1) in the resident's room on the cell phone. I knew she was talking with (Resident's spouse) because I heard her say (Resident's spouses' name). She said 'She's not gonna talk to me like that, you know how she is' and I heard her complaining about (CNA #1). (Resident #2) reported to me that (Sitter #1) had called her a 'white (expletive)'. (Resident #6) who was also in the hall, said 'she would have never got in my face like that. She wouldn't have done that to me.' She has expired since then. I filled out witness statements. (RN #1) told (Sitter #1) she needed to leave. (CNA #1) and I took (Resident #2) to the nurses station (until) (Sitter #1) left. (CNA #2) also saw it, but she no longer works here. ...I talked to a few residents and (Resident #2) and filled out witness statements and was told to put under the Administrator's door. No other residents, other than(Resident #6), said they heard anything. (Resident #2) looked like a whooped puppy. She said, she and her husband pay her and she can't treat me like that. She looked frightened and said she did not want her to be back around her. (Sitter #1) said the resident called her a '(derogatory racial word)', but the resident said she didn't. (CNA #1) was saying 'You've got to stop and you can't be doing this', when (Sitter #1) was yelling at the resident. (RN #1) called (Administrator) and spoke with (Resident's spouse). I put a hand full of witness statements under the door to (Administrator's) office. (Administrator) did not come up there. I had not heard of anything happening before this. When I came back the next day for an in-service for the nurses, I saw (Sitter #1) sitting in the hall. I asked (RN #1) why she was here. She said, 'Yea, (Administrator)'s aware and she is not allowed to have unsupervised interaction with the resident.' The ,[DATE] (7:00 a.m. to 3:00 p.m. shift) nurse, who is no longer here, (LPN #3), said the aides were watching closely. (Sitter #1) was not allowed to be alone with (Resident #2) until (Administrator) finished the investigation. I work on Saturdays and Sundays, 7a to 7p (7:00 a.m. to 7:00 p.m.). (Sitter #1) is here on Sundays, but I haven't seen her lately. I read the nurses notes from the incident on Monday, the 14th, and checked (Resident #2)'s arm on Saturday, no marks. I asked (RN #2) if there were any instructions concerning the resident and the sitter. She said everything had been worked out." LPN #1 was asked if she had seen (Sitter #1) in the room, alone with (Resident #2) since the first incident. She stated, "Yes." j. On [DATE] at 2:45 p.m., the Administrator was again asked about the incident on [DATE]. At first the Administrator did not remember that the incident was in [DATE]. She stated, "I was out of the office 4 of 5 days a week with the computer training in January." After reading the nurses notes of [DATE], she stated, "Well, wait a minute." She was asked if it was coming back to her. She stated, "Yes." She was asked if it had happened before this and she stated, "I honestly don't know." The Administrator was asked if she told the staff to get witness statements. She stated, "I don't remember." She was asked, "What if this had been one of your CNAs?" The Administrator stated, "They would be gone, fired." k. On [DATE] at 3:20 p.m., the Administrator provided witness statements from the incident on [DATE]. She stated, "I'm sorry, I didn't remember this January (2014) was so crazy." 1) The Witness Statement dated [DATE] from CNA #1 documented, "...heard someone screaming. I looked up and (Resident #2)'s personal assistant was screaming at her. She was bent over the wheel chair with her finger in (Resident #2)'s face. I heard her call (Resident #2) an 'old white (expletive). I made the personal assistant stop and told her that was resident abuse. She started arguing with me saying that it was not abuse because (Resident #2) had called her a (derogatory racial word).' I told her that she had to leave the facility or I would have to call the police..." 2) The Witness Statement dated [DATE] from CNA #2 documented, "When I, (CNA #2) came out of a room on two hundred hall, I witness the care giver of (Resident #2) was in her face screaming at her telling her that she will not call her anything but her name. (Resident #2) never said anything back, even when she asked her do you hear me. ...At this time the lead CNA (CNA #1) came down the hall and told the care giver that what she was doing wasn't right and that she needs to stop. The care giver told her, yes it is right what she was doing and that she couldn't tell her anything because she don't work for (Name of Nursing Home). And as (CNA #1) walked off she called her a (expletive) and that she was only going to do what her boss told her to do. Because her boss knows how she is. I (CNA #2) feel like (CNA #1) did the right thing to make sure (Resident #2) was safe. If she didn't step in I feel like it would have got even more out of hand ...for (Resident #2) was afraid..." 3) The Witness Statement dated [DATE] from LPN #1 documented, "(CNA #1) came to nurses station saying I need you down the hall now! She stated that (Resident #2) of facilities' sitter was yelling in (resident's) face. I rushed down the hall with (RN #1). (Resident) was sitting in hallway in chair with hands in lap (and) looking down. (Resident) appeared upset. Sitter was in (Resident's) room on cell phone speaking very loudly saying she wasn't putting up with this, that (Resident #2) would not talk to her like that (and) that she was not abusing (Resident). She told the person on the phone that (Resident #2) had called her a (derogatory racial word). I addressed (Resident) and asked her what happened, while (RN #1) told sitter (Sitter #1) that she needed to get her stuff (and) go home for the day. (Sitter #1), the sitter said 'when I get off the phone.' ...(Resident told me that (Sitter #1) was in her face yelling at her (and) calling her a white (expletive). ...(Resident) said we pay her to help me, she can't treat me this way. Assured (Resident) that she would not be treated that way... Resident stated that she was alright, but asked that we never let (Sitter #1) back here. Assured (Resident) that the situation will be handled (and) that she will not be treated in such a manner. (Resident) stated, 'I thought she was going to hit me.' ...(Sitter #1) was escorted out by (RN #1). (Resident's) husband called (and) spoke (with) (RN #1). (RN #1) notified (Administrator). I notified DON." 4) Resident #2's statement was dated [DATE] and signed by LPN #1; the statement documented, "(Resident) stated that her sitter (Sitter #1) called her a white (expletive), got in her face, was leaning over her yelling (at) her. Incident was witnessed by multiple staff members. Sitter was escorted out of building." 5) Resident #6's witness statement was dated [DATE] and signed by LPN #1; the statement documented, "(Resident) asked if she witnessed the incident that took place in hallway where (resident) was sitting. She stated, yes that resident (Resident #2) called the sitter (Sitter #1) a Black son of a (expletive) (and) that the sitter called (Resident) a white son of a (expletive) (and) then got up out of her seat (and) started yelling in (Resident #2)'s face. (Resident) states it upset her (and) made her nervous seeing (and) hearing the incident. (Resident) assured that the situation was being handled (and) would not happen again." 6) CNA #3's witness statement was dated [DATE] and documented, "I witnessed (Sitter #1) tell the resident to not call her anything else but her name. She stated her name was (Sitter #1) and to not call her anything else." l. On [DATE] at 10:00 a.m., the Administrator provided Sitter #1's full name. The Administrator stated that the sitter was employed 3 days a week, Sunday, Mondays, and Tuesdays by the spouse of the resident and that this was the only resident with sitters in the facility. The Administrator further stated, "My mistake was not reading the witness statements and just going by what was verbally told to me about the incident. In January (2014), when this occurred, I was doing computer training for new software 4 days a week." m. The Immediate Jeopardy was removed and the scope and severity was lowered to a "H" on [DATE] at 3:35 p.m. when the following Plan of Removal was initiated: 1) At 3:35 p.m. on [DATE], the sitter was not working today and not in the building. After that the administrator tried to call the husband and could not get him. At 3:53 p.m., the Administrator was able to contact the Grandson and informed him of the abuse reporting and that the sitter was not allowed back in the building. At 3:59 p.m., the husband spoke with the Administrator. The Administrator informed him of the abuse reporting and that the sitter was not allowed back in the building and for him to notify the sitter. 2) At 3:40 p.m. on [DATE] abuse in-service was initiated by the Administrator or her designees for ALL staff prior to beginning their shift. No one will be allowed to work on the floor until in-service is done. 3) On [DATE], the ADON (Assistant Director of Nursing) and staff RN asked residents if the residents had been abused or seen abuse. This began at 4:30 p.m. and was finished 5:30 p.m. No resident reported abuse or seeing abuse. 4) On [DATE] at 4:30 p.m., staff was asked by the ADON and staff RN if they had any knowledge of abuse. No staff reported abuse or seeing abuse. All staff will be interviewed by Administrator or designees prior to beginning shift. Any negative outcomes will be addressed immediately. 5) On [DATE] at 4:30 p.m. DON initiated body audits on residents by DON or her designees and no signs of abuse or injuries of unknown origin were found. Completion was at [DATE] at 9:00 a.m. 6) On [DATE] at 5:00 p.m., the Administrator began a book that staff are to sign at the end of the shift: "On your shift have you seen any signs of abuse "yes or no". "If yes, who did you report this to?" Any negative outcomes will be addressed immediately. On [DATE] at 5:00 p.m., the Administrator began a book "Has everyone been nice to you?" that will be done by the social designee or her designee on a daily basis. This book is for the purpose of identifying if a resident has experienced abuse. Any negative outcomes will be addressed immediately. 7) On [DATE] at 5:30 p.m. the Administrator was in-serviced on abuse including reporting by the executive director. 8) On [DATE] at 5:00 p.m., the Administrator made a plan that current private sitters of residents will be in-serviced by Administrator or her designee on what constitutes abuse, abuse reporting requirements of Long Term Care Facilities, and to whom to report abuse. No sitters were on duty. At this time there is only one sitter being utilized by one resident. The Administrator in-serviced her at 7:15 a.m. on [DATE] as she came on duty. 9) Any negative outcomes identified by audits, interviews, etc. will be addressed immediately by the Administrator or her designee.