Every finding on record at Legacy Health and Rehabilitation Center

Based on observation, record review, interview, and facility policy review, the facility failed to ensure food was served after an insulin injection in a timeframe recommended by the manufacturer for one (Resident #21) of one resident reviewed. The facility also failed to ensure a resident's stated allergy to sodium hypochlorite was added to the medical record for one (Resident #4) of one resident reviewed. The findings included: Resident #21 During an observation on 08/18/2026 at 12:48 PM, Licensed Practical Nurse (LPN) #1 checked Resident #21's blood glucose level by fingerstick. At 12:48 PM, the glucometer reading showed 144. At 12:54 PM, LPN #1 administered eight units of a rapid-acting man-made insulin (Novolog) into Resident #21's abdominal area. She did not offer Resident #21 any food. This surveyor continued to observe Resident #21 after the insulin was administered. At 1:32 PM, Resident #21 was observed seated in the dining room and was given an egg roll from a staff member and began to feed self. Resident #21 received food 38 minutes after receiving an insulin injection. Review of Resident #21's admission Record revealed the facility admitted the resident on 06/29/2022 with diagnoses that included type two diabetes mellitus. Review of Resident #21's Physician's Orders revealed an order with a start date of 07/22/2026 for Novolog 100 unit/ml (milliliters) inject 6 units subcutaneous three times daily with meals for diabetes. The Physician's Orders also revealed an order with a start date of 07/02/2026 for a Novolog pen syringe inject as per sliding scale: 141-180 = 2 units subcutaneously before meals and at bedtime related to diabetes mellitus. Review of the quarterly Minimum Data Set with an Assessment Reference Date of 07/07/2026 revealed a Brief Interview for Mental Status score of 12, which indicated Resident #21 had moderate cognitive impairment. During an interview on 08/18/2026 at 2:19 PM, LPN #1 stated she administered Resident #21's insulin between 12:47 PM and 12:50 PM. She stated she did not offer Resident #21 any food but the [lunch meal] tray came shortly after. She stated Resident #21's lunch meal tray was received around 1:30 PM. She stated she was familiar with Novolog insulin, and a resident should receive food 30 minutes to an hour after receiving Novolog insulin. She stated according to the FDA (Food and Drug Administration) guidelines that this surveyor showed her regarding Novolog insulin, Resident #21 should have received food 5-10 minutes after receiving the Novolog insulin. She stated Resident #21 could have experienced lethargy, confusion or dizziness as a result of not getting food in a timely manner after receiving Novolog insulin. During an interview on 08/20/2026 at 2:53 PM, the Director of Nursing (DON) was asked when a resident should receive food after receiving Novolog insulin and she stated she would have stated 15 minutes, but she's heard the time frame is five to 10 minutes. She stated if a resident does not get food in a timely manner after receiving insulin the blood sugar could drop, and the resident could become hypoglycemic. She stated nurses should offer residents who received an insulin injection a snack if the tray was not received at the time the insulin was administered. The DON was asked to provide a policy/protocol nurses follow regarding administering insulin and when food should be given. Review of the Novolog data sheet provided by the facility indicated Novolog insulin should be injected subcutaneously within five to ten minutes before a meal. Hypoglycemia (low blood sugar) was one of the adverse reactions. Review of an article on Novolog Insulin from FDA.GOV revised in 02/2023 revealed inject subcutaneously within five to ten minutes before a meal into the abdominal area, thigh, buttocks or upper arm. Review of the Insulin Administration policy, revised September 2014, revealed the nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system (s) prior to their use. Resident #4: Review of Resident #4's Face Sheet revealed the facility admitted the resident on 05/01/2025. The latest return date was 07/10/2025 with diagnoses that included acute on chronic combined congestive heart failure and chronic obstructive pulmonary disease. The listed allergies did not include sodium hypochlorite. Review of Resident #4's quarterly Minimum Data Set with an Assessment Reference Date of 10/14/2025 revealed a Brief Interview for Medical Status score of 15, which indicated Resident #4 was cognitively intact. Review of Resident #4's Progress Notes dated 09/22/2025 at 11:00 AM, revealed notified that resident has called EMS [emergency medical services] and told EMS [they] cannot breathe. Resident stated that [Resident #4] is allergic to sodium hypochlorite and they used it to mop. Resident denied any problems and refused to [go] with EMS to ER [emergency room] . Review of Resident #4's Progress Notes dated on 10/01/2025 at 4:29 PM, revealed [Resident #4] tells me that [Resident #4] was exposed to some sort of cleaning chemical and it caused a severe allergic reaction My understanding is that it was sometime last week. [Resident #4] did not require any rescue drugs. Review of Resident #4's Progress Notes dated on 10/02/2025 at 10:31 AM, the Administrator went to resident's room and resident stated [Resident #4] could not breathe from last week from someone using cleaning supplies. During an interview on 08/20/2026 at 2:53 PM, the DON stated Resident #4 did state an allergy to a cleaning product, but she could not remember the name of the product. She stated someone one from housekeeping did speak with Resident #4 and showed Resident #4 housekeeping did not use the product Resident #4 stated. The DON stated she would have to look to see if the product was added to Resident #4's medical record as an allergy. She stated, Any one of us could have added the cleaning product to Resident #4's list of allergies and she should have added the product since she was aware of what Resident #4 stated. She stated Resident #4 could have experienced an allergic reaction to sodium hypochlorite if Resident #4 was exposed to this product. This surveyor did not ask if the facility had a policy or protocol of when to add allergies to resident's medical records. During an interview on 08/20/2026 at 5:16 PM, the Administrator stated if staff were aware that Resident #4 had stated an allergy to an item, that item should have been added to Resident #4's Medical Record. She stated, Resident #4 could have experienced hives, breathing funny, or itchiness if exposed to an item Resident #4 had an allergy to.

Based on record review, interview, and facility policy review, the facility failed to ensure a resident's right to choose an outside medical provider was honored for one (Resident #4) of one resident reviewed. The findings include: Review of Resident #4's face sheet revealed the facility admitted the resident on 05/01/2025. The latest return date was 07/10/2025 with diagnoses including acute on chronic combined congestive heart failure and hypertension (high blood pressure). Review of Resident #4's quarterly Minimum Data Set with an Assessment Reference Date of 10/14/2025 revealed a Brief Interview for Medical Status score of 15, which indicated Resident #4 was cognitively intact. Review of the progress notes revealed the following documentation: -On 07/15/2025 at 1:36 PM a medical provider spoke with Resident #4 about seeing a local cardiologist and Resident #4 stated they, WILL see [their preferred] cardiologist and someone WILL take [them]. The progress note also indicated the provider mentioned sending a referral to somewhere closer to the area so Resident #4 can still see [their] doctor as ultimately that is in [their] best interest and Resident #4 was agreeable to that idea. -On 07/15/2025 at 5:20 PM, a staff member spoke with the nurse for Resident #4's cardiologist and informed the nurse Resident #4 refused to see a local cardiologist. The progress note indicated Resident #4's cardiologist had no new orders for the resident's blood pressure at that time. The progress note did not indicate if an attempt was made to make an appointment for Resident #4 to see their cardiologist. -On 07/20/2025 at 2:00 PM, Resident #4's blood pressure reading was 178/100 and the provider was notified. The note indicated the provider wanted Resident #4 to see cardiology. -On 08/04/2025 at 1:29 PM, staff from the facility spoke with Resident #4 regarding getting resident an appointment with a cardiologist close to the area and Resident #4 refused again. The progress note indicated Resident #4 stated they needed to speak with their cardiologist. -On 09/23/2025 at 12:55 PM, new orders received for referral to [local] cardiology clinic per [medical director]. Residents RP [responsible party] notified. -On 09/23/2025 at 3:56 PM, resident has an appointment on 3/25/26 aat 10:30 AM with [local] cardiology clinic. Residents RP notified. -On 10/22/2025 at 3:19 PM, resident has an appointment on 11/6/25 at 2:38 PM with [Resident #4's Cardiologist] .Residents RP notified. During an interview on 08/20/2026 at 2:53 PM, the Director of Nursing (DON) stated Resident #4 had a high BIMS but did not provide the score. She stated Resident #4 could go to their cardiologist of choice if the facility couldn't get Resident #4 an appointment closer to the area. She stated Resident #4 did have the right to see a provider of their choosing. She was asked by the facility attempting to get Resident #4 to choose a provider closer to the area, was this honoring Resident #4's right to choose their cariologist of choice and she stated, We are not telling them that they don't have to absolutely go there, but we are trying to get them to go to someone closer. During an interview on 08/20/2026 at 5:16 PM, the Administrator stated the facility does take residents to providers out of town. She stated Resident #4 did have the right to choose their own cardiologist. The Administrator was asked if Resident #4's right to choose a cardiologist was honored by facility staff continuing to attempt to have Resident #4 change their cardiologist of choice and she stated, No. The Administrator stated Resident #4 cancelled appointments that Resident #4 made with the cardiologist, but she could not provide any documentation to support this statement. Review of the Resident Rights policy, revised February 2021, revealed federal and state laws guarantee certain basic rights to all residents of this facility. The policy indicated residents have the right to communicate with and access to people and services, both inside and outside the facility. The policy also indicated residents have the right to exercise his or her rights without interference, coercion, discrimination or reprisal from the facility.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure an allegation of abuse was reported to the state survey agency (SSA) within the required timeframe for 1 (Resident #1) of 2 sampled resident reviewed for alleged sexual abuse Based on observations, interviews, record review, and facility policy review, the facility staff failed to recognize and report indicators of sexual abuse for one (Resident #1) of two residents reviewed. The findings include: Review of an Office of Long-Term Care Incident and Accident (I&A) Report with a discovery date and time of 04/07/2025 at 11:00 AM and a submitted date and time of 04/07/2025 at 11:52 AM revealed Certified Nursing Assistant (CNA) #11 discovered Resident #13 and Resident #14 in Resident #14's room. Resident #14 was seen standing in front of Resident #13 pulling up their pants, while Resident #13 was noted sitting in a chair naked from the waist down. Review of an Office of Long-Term Care Incident and Accident (I&A) Report with a discovery date and time of 04/07/2025 at 5:00 PM and a submitted date and time of 04/10/2025 at 5:23 PM revealed CNA #11 had reported to facility administration during the current investigation of the incident dated 04/07/2025 at 11:00 AM that they (CNA #11) had witnessed Resident #14 wander into Resident #1's room two or three months ago. When CNA #11 walked into the room, the residents were one to two feet apart, both had their pants off, with their hands by their sides. CNA #11 dressed Resident #14 and removed the resident from the room but did not report the incident at the time. Review of CNA #11's orientation paperwork revealed a signed acknowledgement of receipt of abuse training upon hire in October 2024. This surveyor attempted contact, was unable to interview CNA #11. Review of nursing note dated 04/10/2025 at 5:39 PM, written by Licensed Practical Nurse (LPN) #12 indicated call placed to RP (Responsible Party) about encounter with another resident, no concerns voiced. During an interview on 08/20/2026 at 2:45 PM, the Director of Nursing (DON) acknowledged that CNA #11 did not immediately report the suspicion of resident-to-resident suspected sexual contact between Resident # 14 and Resident # 1 as their abuse policy stated but rather waited until a second alleged incident occurred with the same alleged perpetrator (Resident #14) two to three months later. During an interview on 08/20/2026 at 4:27 PM, the Administrator stated she did not remember an incident between Resident #14 and Resident #1. The Administrator stated that her expectation of staff, if resident to resident abuse was suspected, was to immediately separate the residents involved, alert the nurse, who would in turn alert her. She provided an abuse policy with an in-service dated 04/10/2025. She stated it was important to report abuse immediately to ensure that other residents were not put in potential danger. Resident #1 Review of an admission Record revealed Resident #1 was readmitted on [DATE] with diagnoses that included bipolar disorder, post-traumatic stress disorder, and major depressive disorder. Review of an annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/13/2026 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. During an interview on 08/18/2026 at 2:14 PM, Resident #1 stated they did not remember being touched in a sexual way since they have been in the facility. They did not remember a time from April of 2025 when they were found undressed from the waist down with Resident# 14, as reported by CNA #11. Resident #13 Review of a discharge MDS with an ARD of 04/14/2025 revealed Resident #13 received a BIMS score of 00, indicating severe cognitive impairment. The MDs revealed diagnoses that included anxiety disorder, psychotic disorder, Alzheimer's disease, and dementia. Review of a Care Plan revealed Resident #13 had an identified problem of disrobes at times, start date of 04/07/2026. It was identified that Resident #13 was at risk for mood distress and impaired psychological well-being. Resident #14 Review of a discharge MDS with an ARD of 10/08/2025 revealed Resident #14 received a BIMS score of 4, indicating severe cognitive impairment. The MDS revealed diagnoses that included dementia, psychoactive substance use, and mood disorder. Review of a Care Plan revealed Resident #14 had an identified problem involving behavioral symptoms, specifically that the resident was at risk for injury to self and others related to aggressive behavior. Review of an undated in-service with signature page indicated for [staff] to notify nurse or management with any change in behaviors that might need to be addressed, or care planned such as wandering into other resident's rooms, disrobing in front of others, or other unusual behaviors. Review of a facility policy titled Abuse, Neglect, Misappropriation, of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, dated 04/10/2025, revealed it was the facility's policy that all instances of abuse, neglect, exploitation and misappropriation be reported to the state agency.

Based on record review, observation and interview, the facility failed to ensure that menus were followed and that the alternatives presented were available in one of one facility kitchen. Specifically, residents and staff in the facility reported the posted menus were not followed for all residents, with alternatives being served to parts of the population due to the facility kitchen running out of the menu meal option. Alternative choices that were presented to residents were not provided due to a lack of product. The findings include: During a concurrent tour and interview of the facility kitchen on 08/17/2026 at 8:44 AM, the Dietary Manager (DM) reported the kitchen's freezers contained enough food for a minimum of three days, and a food truck was expected tomorrow morning. The DM reported receiving deliveries every Tuesday and Thursday from a local food distribution company. During an observation of the lunch meal service on 8/17/2026 at 12:19 PM, the first five trays went out to early dinners. Snickerdoodle cookies that were the menu dessert had to be substituted with gelatin cup due to shortage of product. During an interview on 8/19/2026 at 10:41 AM, Resident #18 reported being a resident of the facility for four years and that they recalled asking for alternative meal options on multiple occasions that were not available despite the menu saying there were. Resident #18 reported asking for additional food on occasion and not receiving it. During an interview on 8/19/2026 at 11:08 AM, Resident #20 reported the meals they were provided were not always what was on the menu. During an interview on 8/19/2026 at approximately 11:15, Resident #19 stated the food they received was not always what was ordered, or on the menu. Resident #19 confirmed the South Hall in the facility received alternate menu items without ordering them. During an interview on 8/20/2026 at 10:46 AM, a family member of Resident #22 stated, Meals are not provided as ordered and they run out of the alternates trying to get everyone fed. The CNAs ask every morning what the resident wanted then it does not ever come to the room correctly. No diabetic options and the items requested have run out. During an interview on 8/20/2026 at 10:58 AM, Resident #22 confirmed what their family member had shared with the surveyor. They often run out of meal choices. One day we were expecting herbed rice and asparagus, when it got here it was orzo pasta and mixed veggies, sometimes it has changed more than once in a single day. The other morning, I got a hard-boiled egg and a piece of sausage. I don't eat boiled eggs, sometimes I get one piece of bacon as a serving. I am diabetic and I get trays with two carbohydrate choices on it. During an interview on 8/19/2026 at 1:39 PM, CNA #8 stated, I have seen a time when the meals don't look enough to fill someone up. We will go back to see if there was more food available from dietary. We give snacks but each resident can only have one snack. Some residents just need more. They do run out a lot on South Hall and they (the residents residing there) only get substitutes. During an interview on 8/19/2026 at 2:22 PM, CNA #6 reporting remembering a time when there has not been enough food on resident trays, and that the facility runs out of the primary meal option before South Hall is served often. I have had them also run out of an alternate. I sometimes have to come back and fill out a new ticket because the alternative they are requesting was already gone. During an interview on 8/19/2026 at 2:39 PM, CNA/MA #4 revealed South Hall residents get their trays last, so the primary option runs our a lot and the residents have to receive substitutes. During an interview on 8/20/2026 at 9:50 AM, LPN#1 reported observing the South Hall residents do not have all the items they should have on their tray. I have not heard this complaint on any other hall. LPN #1 reported there were currently 18 residents on the South Hall. During an interview on 8/20/2026 at 1:11 PM, the DM reported the kitchen had run out of menu items before meal service was completed before. The DM confirmed South Hall residents were always served last. The Administrator has asked me before why we are running out of food for a hall. No diabetic diet here, all diabetics get regular food, we provide sugar substitutes if it was known or if they ask it or yogurt for an option when they request it. They can have peanut butter crackers, fruits, and options like that if they request. During an interview on 8/20/2026 at 3:02 PM, the Director of Nursing (DON) revealed that the portions are smaller now, but they were the correct portions for the menu. During an interview on 8/20/2026 at 4:18 PM, the Administrator reported expecting the DM to ensure the menu was being served and with appropriate serving sizes, what the resident wants, and that it is palatable. The Administrator voiced an expectation that the alternate menu should be there and be available. Yes, I have seen an alternative instead of the regular menu item because it has run out. She [the DM] is purchasing for the number of residents we have. She should have at least ten more extra. I am the one reviewing the resident council minutes and I have seen this mentioned before.

Based on observation, interview, and record review, it was determined that the facility failed to keep residents free from abuse and neglect for 2 residents (Residents #68 and #84) who received physical abuse from another resident. The findings include: A review of a policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, stated, residents have the right to be free from abuse, neglect, exploitation, and misappropriation of property. An in-service on Abuse/Neglect/Misappropriation to all staff was provided dated 10/16/2024 specifically keeping residents free from resident-to-resident abuse where a cognitive resident intentionally and willfully hits another resident. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/2024 revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. A review of an Incident and Accident report dated 11/11/2024 at 2:30 PM, revealed Resident #68 was hit on the side of the head when another resident (Resident #109) walked past and stated to Resident #68 to move out of the way. Certified Nursing Assistant (CNA) #22 separated the residents and reported the incident to the nurse. Registered Nurse (RN) #13 assessed Resident #68 and no injuries were noted. An in-service on abuse, neglect, and misappropriation, specifically resident-to-resident abuse where a cognitive resident intentionally and willfully hits another resident, was initiated on 11/11/2024 along with a copy of the facility's policy and procedures on abuse. Witness statements were collected, Resident #109 was placed on 1:1 supervision with staff. The quarterly MDS with an ARD of 11/25/2024 revealed Resident #84 had a BIMS score of 15, which indicated the resident was cognitively intact. A review of an Incident and Accident report dated 11/24/2025 at 8:20 PM, revealed Resident #84 was hit on the leg while outside on smoke break by Resident #109. Resident #109 became upset because the resident ' s cigarette was not lit first. The residents were separated, and Resident #109 was placed on 1:1 supervision. A body audit was done on Resident #84 with no negative findings. The police and physician were notified, and witness statements were collected. The quarterly MDS with an ARD of 09/10/2024 revealed Resident #109 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #109's care plan dated 10/29/2024 indicated, Resident #109 had the potential for behaviors of aggression and agitation towards others, and staff were to monitor the resident while awake. Listed interventions were 1:1 staff supervision, approach resident in a calm manner, do not argue with resident, and reach out to family for their input. On 01/28/2025 at 12:20 PM, during an interview CNA #23 indicated she had witnessed resident-to-resident aggressions, but none that had caused injuries. CNA #23 stated any resident-to-resident aggression is reported to the charge nurse at the time the incident occurred. On 01/28/2025 at 12:35 PM, during an interview, CNA #22 confirmed she had witnessed the resident-to-resident aggression and reported it to the nurse. CNA #22 also confirmed that the aggressor was no longer in the facility and stated that the resident who was hit did not sustain any injuries. On 01/28/2025 at 2:35 PM, during an interview, Licensed Practical Nurse (LPN) #16 confirmed resident-to-resident aggression had happened and when it did, the residents were immediately separated and the charge nurse, administration, physician, and family were all notified. The severity of the incident determined the interventions taken. The aggressor may be placed on 1:1 supervision, lab work may be ordered, or the resident may require a psychiatric evaluation. On 01/31/2025 at 2:10 PM, during an interview the Administrator stated that when the resident-to-resident interactions occurred the residents were separated, body audits performed, police, family, and the physician were notified, and an investigation was initiated. Staff and resident interviews were conducted. The Administrator confirmed the aggressor was cognitive and did hit other residents. When the incidents occurred, residents were separated, and interventions were put in place. On 01/31/2025 at 2:21 PM, during an interview the Director of Nursing (DON) stated, when resident-to-resident aggressions occurred, the staff intervened by separation and resident redirection. The Administrator was notified and was also the facility's Abuse Coordinator. The DON confirmed Resident #109 hit Resident #68 and Resident #84 but did not remember Resident #109's cognition. The DON confirmed the aggressor was transferred to a facility which conducted psychiatric interventions to decrease behaviors.

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. The findings are: 1. The 01/27/2025 lunch menu documented the residents who required pureed diets were to receive 3 ounces of pureed breaded pork patty, 4 ounces (1/2 cup) of pureed vegetables, 2 ounces of gravy, and 2 ounces of pureed dinner roll. 2. A facility recipe titled, recipe for pureed Breaded Pork Patty not dated and provided by the Dietary Manager on 01/28/2025 indicated; .Notes: 1. For pureed measure desired # (number) of servings into food processor. Blend until smooth and add broth or gravy if product needs thinning . a. On 01/27/2025 at 11:37 AM, Dietary [NAME] (DC) #11 placed 7 servings of breaded fried pork into a blender, added 2 cups of water from the food preparation sink, instead of broth or gravy. At 11:40 AM, DC #11 was interviewed and was asked how much water she added to the meat, and she estimated it was about 3/4 cup. When DC #11 was asked to measure the amount of water precisely, DC #11 removed the pork patties from the blender, poured the water into a measuring cup and confirmed she had used 2 cups of water. DC #11 then placed the 7 servings of fried breaded pork patties into the blender, added 2 cups of water and continued pureeing it. On 01/28/2025 at 12:09 PM, DC #11 was interviewed and asked how fried breaded pork patties pureed with water would taste, and she stated it will taste bland. 3. On 01/27/2025 at 12:46 PM, the following observations were made during the noon meal service: a. Dietary [NAME] (DC) #11 used a #20 scoop, equivalent to 1.5 ounces, to serve 2 servings of pureed cut green beans, totaling 1/3 cup, to each resident who received pureed alternative cut green beans, instead of using a number #8 scoop, which is equivalent to 1/2 cup. b. There was no gravy served to the residents who required pureed diets with their meal. c. There was no pureed bread served to the residents who required pureed diets. There were no substitutions served in place of the dinner roll. d. On 01/27/2025 at 1:06 PM, DC #11 was interviewed and asked what scoop size she had used to serve the pureed cut greens, and how many servings she gave to each resident who received pureed cut green beans. She stated she used a #20 scoop which is equivalent to 1.5 ounces and gave 2 servings of pureed cut green beans each, totaling 1/3 cup, instead of 1/2 cup. DC #11 was asked the reason residents on pureed diets did not receive gravy and a pureed dinner roll. She stated she was unaware they were supposed to receive gravy, and she forgot to fix pureed dinner rolls.

Based on observation, interview, and facility policy review, the facility failed to ensure food items in the refrigerator, freezer and storage room were covered or sealed; 1 of 2 ice machines was maintained in clean and sanitary condition; dietary staff washed their hands before handling food or clean equipment; ceiling tiles, air vents, dish washer wall, kitchen door frames were free of, debris, dirt, rust, stains; baseboards were secured; and hot food items were maintained at temperature of 135 degrees or above for 2 of 2 meals observed. The findings are: 1. On 01/27/2025 at 11:28 AM, an observation of the inside back panel of the ice machine in the kitchen as well as the area where ice formed before dropping into the ice collector had wet pink residue on it. The areas were pointed out to the Dietary Manager (DM) #1 and during an interview she was asked if the residue build up could be wiped off, how often she cleans the ice machine, and who used the ice from the machine. She used tissue papers and wiped the wet pink residue off. The wet pink residue easily transferred to the tissue, and she confirmed there was wet pink residue in the area. DM #1 instructed Dietary Aide (DA) #10 to use tissue papers and wipe down the inside back panel of the ice machine. When DA #10 did, a black residue easily transferred to the tissue paper. DM #1 stated the maintenance man cleaned it once a month. The kitchen staff used it to fill beverages served to the residents at mealtimes and CNAs [Certified Nursing Assistants] used it for the water pitchers in the residents' rooms. 2. On 01/27/2025 at 11:45 AM, the following observations were made in the freezer: a. An opened box of vegetable blend was on a shelf in the freezer. The box was not covered or sealed. b. An opened box of cookies was on a shelf in the freezer. The box was not covered or sealed. c. An opened box of hamburger patties was on a shelf in the freezer. The box was not covered or sealed. d. An open box of dinner rolls was on a shelf in the refrigerator. The box was not covered or sealed. 3. On 01/27/2025 at 11:51 AM, an opened bag of coffee was on a counter where the coffee machine was located. The opened coffee bag was pointed out to Dietary Manager #1, and she confirmed that the coffee bag should not have been left out and should have been kept in a sealed bag. 4. On 01/27/2025 at 11:54 PM, an opened box of sausage was on a shelf in the refrigerator. The box was not covered or sealed. 5. On 01/27/2025 at 12:12 PM, the temperatures of the food items when checked and read on the steam table by the DC #11 were: a. Breaded fried pork steak - 119 degrees Fahrenheit. b. Ground breaded fried pork steak - 125 degrees Fahrenheit. c. Macaroni and cheese - 126 degrees Fahrenheit. d. Pureed cut green - 116 degrees Fahrenheit. The above food items were not reheated before being served to the residents. 6. On 01/27/2025 at 12:15 PM, the following observations were made in the kitchen areas: a. The wall above the door frames leading to the outside; the wall between the door leading to the outside; the hand washing sink; the wall above the thermostat leading to the dishwashing machine room; and above the rack by the walk-in refrigerator where storage containers were kept had cobwebs hanging down from them. b. The door behind the rack by the walk-in refrigerator where clean containers were kept had sage color stains on it. c. The wall by the janitor's closet leading to the storage room and the walls in the dishwashing machine room were chipped and exposed the concrete. d. The door frames leading to the dining room, outside, janitor's closet, storage room, and dishwashing machine were chipped, the chipped areas were covered with rust. e. The wooden shelves where clean pans were kept had loose food crumbs on them. f. The (brand name) countertop covering above the counter where clean pans were kept was chipped which exposed the wood. g. The baseboard below the dishwashing machine had sage residue on it. h. The floor tiles in the dishwashing machine were missing; the areas where tiles were missing were covered with black dirt. There was loose salt, pepper, pink sugar and regular sugar packets on it. i. The floor between the ice machine and the 2-compartment sink had a wet accumulation of black residue on it. The pipes attached to the ice machine had black stains on them. The wall above this area had brown stripes of residue on it. 7. On 01/27/2025 at 12:25 PM, the following observations were made in the storage room: a. A bottle of lemon juice, on a rack in the storage room, was opened and partially used. Dietary Manager #1 was interviewed and was asked what she used the lemon juice for, and she stated kitchen staff use it when baking various desserts and that she was unaware it needed to be stored in the refrigerator after being opened. The manufacturer specification on the bottle indicated to refrigerate after opening. b. An opened box of chicken fried steak was on a shelf in the storage room freezer. c. An opened bag of chips was on a shelf in the freezer. The bag was not sealed. 8. On 01/28/2025 at 11:27 PM, DC #11 picked up a box of mashed potato flakes, emptied it into a pan of hot water on the stove, and mixed it with a whisk, contaminating her hands in the process. Without washing her hands, DC #11 picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets for lunch. DC #11 was interviewed and was asked what she should have done after touching dirty objects and before handling clean equipment and stated she should have washed her hands. 9. On 01/28/2025 at 11:58 AM, Dietary [NAME] (DC) #12 was wearing gloves on his hands when he removed a block of butter from the refrigerator and placed it on the counter, in the process, his gloved hands were contaminated. DC #12 then unwrapped the butter, picked up a knife, cut a piece, and placed it on the noodles in a pan on the steamtable mixing it before serving it to the residents. DC #12 was interviewed and was asked what he should have done after touching dirty objects and before handling clean equipment and he stated he should have removed the gloves and washed his hands. 10. A review of facility policy titled, Handwashing Guidelines, initiated 1/2002, provided by Dietary Manager #1 on 01/28/2025 indicated, hands should wash every time an employ enters the kitchen, at the beginning of the shift, their hands before starting work, and after touching anything unsanitary.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to ensure (1) hand hygiene was performed between residents during medication administration observation for Resident #21; (2) clean personal protective equipment (PPE) was used during medication administration for Resident #17 who was on enhanced barrier precautions (EBP); (3) transmission based precautions (TBP) were posted outside a secure unit when a parasitic infestation was identified; (4) and provide re-education to staff when infection trends were identified during a review of the facility's infection control practices. The findings include: 1. A review of a facility pharmacy policy book titled, Policy and Procedure Manual for Nursing Facilities contained a policy titled, Medication Administration, Medication Administration-General Guidelines Policy 6.2, dated April 2020 indicated 6. Cleanse hands with antimicrobial soap and water or facility approved hand sanitizer before handling medication and before and after direct contact with resident. A review of a facility policy titled, Hand Hygiene, dated 06/11/2020, indicated, Hand hygiene continues to be the primary means of preventing the transmission of infection. Hand Hygiene is required upon and after coming into contact with a resident/guest intact skin. During an observation on 01/29/2025 at 8:05 AM, Licensed Practical Nurse (LPN) #18 administered oral medications to Resident #5 and left the room without performing hand hygiene. LPN #18 returned to the medication cart and prepared insulin for an unidentified resident. LPN #18 entered the resident's room and administered the insulin without performing hand hygiene. LPN #18 returned to the medication cart without performing hand hygiene and prepared insulin for Resident #21. LPN #18 entered Resident #21's room and administered two insulin injections without performing hand hygiene. During an interview on 01/29/2025 at 8:15 AM, LPN #18 was asked about infection control practices. LPN #18 stated he forgot to perform hand hygiene between residents. 2. A review of the facility's policy titled, Enhanced Barrier Precautions, dated 04/29/2024 indicated, Multi drug-resistant organisms (MDRO) transmission is common in [Long-term Care] LTC, contributing to substantial resident morbidity and mortality. Enhanced barrier precautions are approach to the use of PPE as a strategy to decrease transmission of CDC [Centers for Disease Control] targeted MDROs when contact precautions do not apply. EBP are indicated for residents with indwelling medical devices including feeding tubes and PPE should be utilized during high contact care. During a concurrent observation and interview on 01/29/2025 at 11:50 AM, LPN #18 entered Resident #17's room and donned personal protective equipment (PPE) including a gown and gloves for enhanced barrier precaution (EBP) related to Resident #17's feeding tube. An extra gown fell on the floor, LPN #18 picked up the now dirty gown and placed it on top of a dresser in the resident's room. After LPN #18 administered Resident #17's medication he took off the PPE, threw it away, and returned to the cart. LPN #18 retrieved Resident #17's sliding scale insulin, then donned PPE including the dirty gown from the dresser. Resident #17's insulin was administered in their exposed abdomen while wearing the dirty gown which touched the resident's bed and linens. Resident #17 had a percutaneous endoscopic gastrostomy (PEG) tube which was the access for feedings/medication administration and a colostomy present on their abdomen. LPN #18 stated, this is the gown I dropped on the floor, I should not have done that when he was informed he was wearing the dirty gown. During an interview on 01/29/2025 at 2:52 PM, the Director of Nursing (DON) stated hand hygiene should performed when going in between residents and providing care. PPE should be put on prior to direct resident care, we use it with anyone who has an open area from a line or device with a compromised immune system. A gown on the floor would be considered dirty and should be thrown away and not used. 3. A review of a facility policy titled Scabies and Lice with an effective date of May 11, 2017, was reviewed and read in part, to prevent the spread of scabies and lice. Process 1. A) implement contact precaution, B) change the resident ' s linen daily for seven days, use water soluble and red bags for all laundry .General lice information, head lice are transmitted through personal contact and by objects such as hats, combs, and brushes ., sources of infestation, hats, clothing, or bedding should be cleaned through laundering. Combs and brushes should be disinfected with germicidal solution and hot water then soak for 15 minutes in isopropyl alcohol. A review of Resident #36 's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 11/13/2024 revealed, Resident #36 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A review of Resident #36 ' s Care Plan revised on 01/20/2025 revealed Resident #36 had diagnoses of schizoaffective disorder, bipolar, major depressive disorder, mental disorder, and cognitive communication deficit. Interventions included assistance of one staff with all activities of daily living, provide simple cues, prompts and reminders as needed, encourage safe decisions, encourage to keep focused on task or subject at hand, use reminders, prompts or cues to keep on task and when attention wanders guide her gently back to what she is doing. A review of a Prescription Order for Resident #36 with a received and start date of 01/27/2025 revealed (Name Brand) solution one application, one time. The order was received on 01/29/2025 after LPN #25 was questioned regarding the physician' s order for treatment Resident #36 received on 01/27/2025. On 01/27/2025 at 12:32 PM during initial rounds on the secure unit, Resident #36 was observed with haircare being performed by CNA #24 with a nit comb. CNA #24 was asked if resident #36 had head lice and the response was yes. No signage for Transmission Based Precautions was observed either in the secure unit or on the door to enter the secure unit. No Personal Protective Equipment (PPE) was available on entry to the secure unit. 01/27/2025 12:35 PM 10 residents and 2 staff members were observed in the dining room. Resident #36 was without any type of hair covering, ambulatory, and moving freely through the room with the other residents. 01/27/2025 at 01:01 PM Resident #36 was observed without any hair covering, sitting in the dining room at the table with 2 other residents. A review of Resident #36's progress notes revealed a documented late entry dated 01/29/2025 at 10:31 AM for 1/27/2025 that read in part, resident head was itching, when checked by staff live head lice were present. During an interview on 01/29/2025 at 10:01 AM LPN #25, reported the first resident was infested with head lice and treated on Friday 01/24/2025. Resident #36 was found to have live head lice on Monday 1/27/2024. LPN #25 confirmed the whole unit should have been placed on isolation when the first resident was identified 01/24/2025. LPN #25 stated there were no precautions put into place initially when the first resident was identified on 01/24/2025. LPN #25 reported all the residents who resided on the secure unit were being treated, but none were identified as being infested with head lice, they were being treated as a precaution. LPN #25 stated the residents, and the staff were wearing hair coverings. LPN #25 confirmed transmission-based precautions were put into place on 01/29/2025, five days after the initial case. During an interview on 01/29/2025 at 10:11 AM the Infection Preventionist (IP) identified head lice as being considered transmission-based precautions because it can be transferred from person to person. The IP reported the whole secure unit should have been placed on isolation due to the identified infestation of head lice. The IP reported the first resident was identified on Friday 01/24/2025 and was treated. Resident #36 was identified on Monday 01/27/2025 and treated. The IP was asked to explain the facility policy regarding head lice. The IP denied knowing what the facility policy was regarding residents identified as infested with head lice. The IP indicated no precautions had been taken for the residents ' laundry or personal items due to the outbreak, but the laundry should have been isolated and personal items that would not be able to be laundered should have been bagged for isolation. The IP confirmed responsibility for ensuring precautions were taken to prevent the spread of head lice was hers. On 01/29/2025 at 01:19 PM, the secure unit residents were observed being treated for head lice. LPN #25 confirmed the secure unit residents were being treated, but there were no further confirmed cases. The staff and residents were observed wearing hair coverings. There was PPE available at the entry of the secure unit, with instructions on the door to contact the nurse for further information. 4. A review of a facility policy titled Infection Prevention and Control Program Overview with an effective date of September 14, 2020, was reviewed and read in part, the goals of the infection prevention and control program are to reduce the risk of infection to residents by breaking the chain of infection, preventing development and transmission of communicable diseases. To monitor the occurrence of and implement control measures including isolation if necessary. To identify and correct problems related to infection control practices. To provide a safe, comfortable and sanitary environment. II A. There should be ongoing monitoring and preventative measures in place to prevent the spread of infections. Preventing the spread of infections would be accomplished by using standard precautions, barriers, and treatments. Staff education to focus on the risk of infection and decreasing the risk for prevention of infection. B. Systems should be in place to identify an increase in infections as well as trends or outbreaks. D. Staff Education, staff should be trained during new staff orientation and retrained as needed according to the incidence of infections. III A. The DON is ultimately responsible for the Infection Prevention and Control Program. A review of a facility policy titled Antibiotic Stewardship Program with an effective date of September 1, 2017 was reviewed and read in part, to educate and follow protocol for appropriate treatment of infections During an interview on 01/29/2025 at 10:11 AM the IP reviewed the infection control tracking and trending logs. The IP identified trends that involved wounds, urinary tract infections and respiratory infections. The analysis was documented weekly. A Weekly Infection Analysis form dated 8/26-9/1/24 (08/26/2024-09/01/2024) was reviewed by the IP, who identified 4 urinary tract infections, 2 skin, 1 mouth, and 1 conjunctival infection recorded for the week with no re-education reported in the log. A Weekly Infection Analysis form dated 10/10-10/20/24 (10/10/2024-10/20/2024) was reviewed by the Infection Preventionist, who identified 6 wound infections, 3 urinary tract infections, 3 respiratory infections and 2 other infections recorded for the week with no re-education reported in the log. A Weekly Infection Analysis form dated 12/12-12/22/24 (12/12/2024-12/22/2024) was reviewed by the Infection Preventionist, who identified 3 urinary tract infections, 3 respiratory infections, 1 skin, 1 mouth and 1 conjunctival infection recorded for the week with no re-education reported in the log. A Weekly Infection Analysis form dated 1/6-1/12/2025 (01/06/2025-01/12/2025) was reviewed by the Infection Preventionist, who identified 2 urinary tract infections, 8 respiratory infections and 1 wound infection recorded for the week with no re-education reported in the log. During an interview on 01/29/2025 at 10:11 AM the Infection Preventionist confirmed the tracking and trending of the infections identified as being a trend and denied having provided any re-education to staff for the identified trends in infections. The Infection Preventionist was asked if re-education should have been provided when the trend was identified. The Infection Preventionist confirmed retraining should have been provided to staff related to what the concern had identified.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure a resident was not exploited for money from a staff member for 1 (Resident #42) of 10 residents reviewed for abuse. Specifically, the staff member accepted money from the resident for personal favors and borrowed money from the resident. The findings include: A review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, dated 05/01/2023, indicated, All of our resident/guest(s) have the right to be free from abuse, neglect, exploitation, and misappropriation of resident/guest property. Exploitation is defined as taking advantage of a resident/guest for personal gain through use of manipulation, intimidation, threats, or coercion. An example is monetary assistance provided to staff after informing resident/guest that they are in a financial crisis, gifts to staff by resident/guest(s) based on staff persuasion. A review of the Employee Handbook, contained the Code of Conduct Guidelines which indicated, Employees should always conduct themselves in a manner that will protect the interests and safety of fellow employees, residents, and the facility ensuring orderly operations and the best possible work environment. Employee should Report abuse, neglect, misappropriation/handling of resident property or other concerns to the abuse coordinator, or Administrator. The Behavior Guidelines stated, Type A Violations will result in disciplinary actions up to and including immediate discharge without prior warning. 8. Inappropriate behavior with the public, residents or staff. 12. Abuse, destruction or waste of company, resident or employee property. 17. Resident abuse. 21. Failure to report any observed abusive and/or negligent conduct through designated reporting channels. A review of CNA #17's employee file revealed CNA #17 acknowledged the Abuse, Neglect, Misappropriation of resident property, injuries of unknown source was reviewed and a copy provided at the time of orientation. The Employee Handbook Acknowledgement was torn from the back of the handbook and was present in the employee file signed. CNA #17 was hired in 08/2023. On 10/09/2024, CNA #17 received a verbal warning from the Director of Nursing (DON) listed as a Type A Violation with the offense cited as Violation of Company Policy (specify) and Other: Failure to report allegation of Abuse, the Description of Infraction was listed as On 10/08/2024 you failed to report an allegation of Abuse to the Abuse coordinator who is the Administrator. The Plan for Improvement was Any allegations to be reported to the Admin [Administrator]/Abuse Coordinator immediately. It was signed and dated by both CNA #17 and the DON on 10/09/2024. CNA #17 remained an active employee. A review of the Face Sheet, indicated the facility admitted Resident #42 with diagnoses that included cerebrovascular disease, repeated falls, hemiplegia and hemiparesis, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, anxiety disorder, and depression. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2024 revealed Resident #42 had a Brief Interview of Mental Status score of 15 which indicated the resident was cognitively intact. A review of Resident #42's Care Plan, revised 01/24/2025, revealed the resident had a potential for impaired cognition/decision making ability related to a past CVA (cerebral vascular accident) which required staff to anticipate their needs. During an interview on 01/29/2025 at 3:44 PM, Resident #42 stated Certified Nursing Assistant (CNA) #17 had taken them to town in her private vehicle so Resident #42 could get a manicure. Resident #42 reported, when this occurred the resident would give CNA #17 $20 [dollars] for gas money. After one occasion, CNA #17 asked to borrow some money from Resident #42 stating she had an issue at home and was attempting to get custody of her children which required a drug test. Resident #42 stated $40 cash was loaned to CNA #17. Resident #42 stated they had received a back check from federal benefits and CNA #17 was aware the money was available. Resident #42 stated the resident had loaned money a second time to CNA #17 in the amount of $30 cash, CNA #17 borrowed a total of $70.00 dollars from Resident #42. Resident #42 stated, CNA #17 would no longer drive the resident to get a manicure and when Resident #42 attempted to get the money, CNA #17 stated she did not have it. Resident #42 reported the plan was to use the money owed to call a cab for transportation to the nail salon. A review of an Incident and Accidents (I&A) report for Resident #42 contained a written statement dated 01/13/2025 from CNA #17 indicated that she had taken Resident #42 to the nail salon on three occasions by private vehicle. On two occasions CNA #17 accepted $20.00, but not on the third occasion. CNA #17 stated she had discussed her situation regarding her children and a hair follicle drug test to obtain custody but denied borrowing money from the resident. CNA #17 stated she did tell Resident #42 she couldn't take her to the nail salon following the third occasion. During an interview on 01/29/2025 at 4:11 PM, the Financial Specialist Assistant (FSA) stated she was the employee who handled the resident trust accounts. FSA stated Resident #42's federal benefits check was deposited in the resident trust account every month, then the resident would come and withdraw her balance after expenses in cash. It was usually the standard $40.00, except for one occurrence. On 08/26/2024, a deposit of $1916.00 was deposited for Resident #42, after a back balance was settled with the facility and a petty cash settlement for a manicure, a balance of $1605.24 remained and Resident #42 withdrew the full amount on 09/16/2024. A review of an I&A report for Resident #42 contained an in-service titled, You cannot accept gifts or money from resident/guests. This is policy and doing so is a breach of the Code of Conduct. You may not take resident's money to go to the store or buy something for them with their money. There are only 2 people allowed to do that (activities & social) dated 01/09/2025 and signed by 58 employees. A second in-service titled, Misappropriation of resident/guest property on 01/09/2025 was signed by 55 employees. During an interview on 01/29/2025 at 3:56 PM, the Director of Nursing (DON) stated, Resident #42 was their own legal representative and could sign out of the facility, but it was not the facility's policy to take a resident out in an employee's private vehicle or accept money from them. The DON stated CNA #17 reported to her they no longer took the resident for manicures because the resident was missing showers. The DON stated an investigation was completed and no other residents reported any money issues with CNA #17, but CNA #17 admitted to taking gas money from Resident #42 however, denied borrowing money. The DON stated CNA #17 was terminated from the facility for taking money from Resident #42 and not following company policy. A review of CNA #17's employee file revealed she was terminated on 01/13/2025 for a Type A Violation, Description of Infraction was #8 Inappropriate behavior with the public, residents, or staff. Using a personal vehicle to take resident to nail appointments. Accepting tip from resident. It was signed and dated by CNA #17, the DON, and the Administrator on 01/13/2025.

Based on observation, interview, and record review, it was determined that the facility failed to ensure residents were free from accidents and hazards for 1 (Resident #68) of 6 sampled residents reviewed for accidents and hazards, by not ensuring cleaning agents were kept locked up and out of the resident's reach. The findings include: A review of the facility's policy titled, I&A Policy dated 11/10/2014, indicated the facility was to remain as free of accidents and hazards as possible. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/05/2024 revealed, Resident #68 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Resident #68's care plan dated 12/04/2025 indicated Resident #68 required partial/moderate assistance with daily living activities, was unable to walk 10 feet without partial/moderate assistance, and was able to self-propel a manual wheelchair for independent mobility. The resident required supervision or touching assistance for meals. Review of an email from the regional ombudsman, dated 12/17/2024, indicated staff reported Resident #68 ingested a liquid cleaning agent. Review of the facility's internal investigation report confirmed Resident #68 was found by Certified Nursing Assistant (CNA) #14 in the resident's room with an open bottle of cleaning agent up to their mouth and appeared to be drinking from it. CNA #14 intervened and took the bottle of cleaner from resident #68's hand and then reported the incident to Registered Nurse (RN) #13. Resident #68 was assessed and transferred to the hospital emergency department for evaluation and treatment. The facility initiated an in-service to all staff titled, Any cleaning liquid or cleaning product labelled Keep out of Reach of Children must be kept locked and out of resident's reach for their safety. A review of the hospital records dated 12/16/2024 indicated Resident #68 was seen at the hospital because staff believed the resident may have ingested a cleaning agent left in the resident's room by family. A physical exam was performed, which indicated the resident did not have any coughing, choking, shortness of breath, abdominal pain, nausea, or vomiting. Resident #68 was transferred back to the facility and monitored by staff; anti-nausea medication was prescribed if the resident began showing symptoms. Review of Resident #68's progress notes indicated, the resident did not develop gastrointestinal pain or discomfort from ingesting the cleaning agent. During an interview on 01/28/2025 at 2:39 PM Licensed Practical Nurse (LPN) #16 confirmed, Resident #68 was found drinking from an open bottle of cleaning agent in their room. LPN #16 wasn't sure what the date was but stated it was about a month or so ago. LPN #16 was not sure who left the cleaning agent in the resident's room. LPN #16 stated Resident #68 had a family member that visited often, and they could have left it. During an interview on 01/29/2025 at 1:29 PM, the Housekeeping Supervisor (HS) acknowledged the incident and indicated that the housekeeping staff used a similar type of cleaner in the mop buckets as the one found in the resident's room. The HS did not believe the housekeepers left chemicals in the resident's room, because the one found was much smaller than what was kept in the supply closet. The HS gave this surveyor a tour of the cleaning closets and only a very large bottle of the cleaning agent was observed in the closet. During an interview on 01/29/2025 at 2:51 PM, Licensed Practical Nurse (LPN) #8 acknowledged the incident occurred but was not working when it happened. LPN #8 remembered the in-service that instructed to keep chemicals locked up and away from residents. LPN #8 did not know how the cleaning agent got left in the resident's room but stated, Anybody that knows the resident knows not to leave liquids laying around because [resident] will try to drink it. During an interview on 01/29/2025 at 3:01 PM, Registered Nurse (RN) #13 confirmed, a CNA had intervened and reported the incident. RN #13 assessed the resident and called for an ambulance to transport the resident to the hospital emergency department for evaluation and treatment. Resident #68 did not show any signs or symptoms of ingestion, and the bottle of cleaning agent had a very small amount missing. RN #13 also confirmed the resident was known for behaviors of taking beverages and attempting to drink them. During an interview on 01/30/25 at 8:59 AM, Housekeeping Technician (HT) #20 indicated housekeepers use the same type of cleaning chemical in the mop buckets which was found in the Resident #68's room. HT #20 confirmed leaving a cleaning agent in a resident's room or unlocked would be considered an accident and hazard. During an interview on 01/30/25 at 9:37 AM, Resident #68's family representative confirmed notification had been given of the incident and the resident had been transferred to the hospital for ingesting a cleaning agent but did not get ill from the ingestion. Resident #68's representative denied bringing cleaning agents to the facility and stated, Lord no. Anybody that knows [resident] knows that [pronoun] will pick anything up and try to drink it. During an interview with CNA #22 on 01/31/2025 at 2:50 PM, the CNA indicated that the cleaner was most likely left by staff on the evening shift because the staff on that shift had mentioned that resident rooms were cleaned on the evening shifts and supplies were brought from home (by staff). A review of the facility's staff in-service dated 12/17/2024 indicated, Do not keep or place any of your personal belongings in resident's rooms.

Based on observations, interviews, record review, facility document review and facility policy review, it was determined that the facility failed to ensure an accurate account of a controlled medication for 1 of 3 medication carts reviewed for controlled medication reconciliation. Findings include: A review of a facility pharmacy policy book titled, Policy and Procedure Manual for Nursing Facilities contained a policy titled, Medication Administration Procedures Controlled Medication Administration Policy 7.1, dated April 2020 indicated, medication included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal and state law regulations. When a controlled medication is to be administered, the licensed nurse removing the medication immediately enters the following information on the controlled drug record, A. Date and time of removal, B. Amount removed, C. Signature. A review of the Physician Order Report, indicated Resident #107 had an active order for (Brand Name antianxiety medication) 0.5 milligram (mg) scheduled every eight hours to be administered at 9:00 AM, 5:00 PM, and 1:00 AM. During a concurrent observation and interview on 01/29/2025 at 1:41 PM, Licensed Practical Nurse (LPN) #9 removed Resident #107 ' s (brand name antianxiety medication) card from the locked box of the medication cart and revealed a count of 63 tablets. The controlled medication book was open to the corresponding controlled medication page labeled 24. The reconciliation count in the controlled medication book was 64 and the last entry was on 01/29/2025 at 1:00 AM, about 12-hour prior. LPN #9 immediately stated, I forgot to sign out the dose I gave. LPN #9 stated she administered the controlled medication at 9:00 AM, almost 5 hours prior and the reason it should be signed out immediately was to keep an accurate count of controlled medications in the facility. During an interview on 01/29/2025 at 2:52 PM, the Director of Nursing (DON) stated, the nurses should sign a controlled medication out in the controlled medication book at the time of administration.

Based on observations, interviews, record review, and facility document review, it was determined the facility failed to serve and offer double portions as ordered for 1 (Resident #73) of 1 resident reviewed for therapeutic diet. The findings include: A review of a facility's, Admission Agreement, dated 11/2016, indicated, E. Dietary Services. The Facility maintains a food service program monitored by a registered dietician. The Facility shall provide you regular meals and will use its best efforts to provide you with therapeutic diets and snacks prescribed by your attending physician. A review of the Face Sheet, indicated the facility admitted Resident #73 with diagnoses which included Huntington ' s disease, major depressive disorder, nausea with vomiting, disease of salivary glands, and pain. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/13/2025 revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. Resident #73 was recorded as a weight of 88 pounds (lbs). Resident #73 was identified with weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and not on a physician-prescribed weight loss regimen. Which is defined in the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 Manual Page K-8 as a significant weight loss. No swallowing disorders were identified. A review of a dietary physician order started 10/10/2024 revealed Resident #73 had a Regular diet order with pureed consistency and special instructions Double Portions. A review of a flowsheet titled, Vitals, revealed Resident #73 consumed 76-100% of the breakfast meal on 01/30/2025 at 7:15 AM. During an observation on 01/30/2025 at 8:17 AM, Resident #73 was eating breakfast with the assistance of Certified Nursing Assistant (CNA) #29 and the meal card on the resident's plate indicated the resident should be receiving double portions. Double portions were not observed. During an interview on 01/30/2025 at 8:27 AM, CNA #29 stated, Resident #73 was not served double portions. CNA #29 stated she let the resident tell her if the resident wanted more and the resident did not. CNA #29 stated Resident #73 had a supplemental shake prior to breakfast. During an interview on 01/30/2025 at 3:14 PM, Licensed Practical Nurse (LPN) #8 stated, Resident #73 was ordered a regular, pureed diet with double portions and supplement shakes. LPN # 8 stated because the resident moved around a lot and burned calories the resident had lost weight. The CNA should have gotten the other portions and offered them, we are required to serve what is ordered and it is up to the resident if they choose to eat it. LPN #8 utilized the Electronic Health Record (EHR) and reported Resident #73's current weight was 76 lbs. During an interview on 01/30/2025 at 11:30 AM, the Dietary Manager (DM) #1 stated she was also the cook for breakfast and prepared Resident #73's breakfast tray. DM #1 reviewed Resident #73's meal card and stated double portions should be served but had not served double portions to Resident #73 as ordered. DM #1 stated she was not aware if Resident #73 had a weight loss or not, but it was important the residents were served what was ordered because it was ordered for a reason. During an interview on 01/31/2025 at 8:15 AM, the Director of Nursing (DON) stated, if double portions were ordered by the physician they should be served. It was important because it may be an intervention or a resident request. The DON stated the CNA should have returned to the kitchen and obtained another plate to equal double portions, not offering double portions could lead to weight loss.

According to observation, interview, and record review, the facility failed to ensure the dignity of 3 (Resident #61, #72, and #304) sampled residents by not pulling the curtain or closing the door, leaving them exposed for any visitors to see from the hallway. The findings are: 1. Resident #72 had diagnoses of Parkinson's without fluctuations and Dementia without behavioral disturbances. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/2024 revealed the resident received a score of 3 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), and that the resident is dependent for transfers. A. On 03/19/2024 at 08:52 AM, the Surveyor observed the shower room door open with Resident #72 sitting fully naked in a shower chair, curtain and door not pulled. Resident #72 was fully visible from the hallway. B. On 03/20/2024 at 09:30 AM, the Surveyor asked Certified Nursing Assistant (CNA) #4, When transferring Resident #72 yesterday to the shower, should the curtain have been pulled and the door closed? CNA #4 said, Yes it should have been. The Surveyor asked why this could be an issue. CNA #4 said, For the resident's privacy. C. On 03/20/2024 at 09:32 AM, the Surveyor asked CNA #3, When transferring Resident #72 yesterday to the shower, should the curtain have been pulled and the door closed? CNA #3 said, Yes it should have been. The Surveyor asked why this could be an issue. CNA #4 said, Dignity. 2. Resident #304 had diagnoses of Alzheimer's disease early onset, Generalized anxiety disorder, and Depression. According to the MDS with an ARD 01/31/2024 revealed the resident scored a 4 BIMS. 3. Resident #61 had a diagnosis of Dementia with unspecified severity with agitation and a history of falling. The MDS with an ARD of 01/15/2024 revealed the resident scored a 3 BIMS and that the resident is an independent/supervision with transfers. A. On 03/19/2024 at 02:39 PM, the Surveyor observed two CNA's changing Resident #61 and Resident #304 in the resident women's bathroom for the secure unit. The Surveyor observed CNA #2 changing Resident #61 in the right stall with the door open. Surveyor observed that CNA #2 was changing Resident #61's clothes, while CNA #2 was pulling up teal-colored pants on Resident #61 the surveyor observed that you can see the resident naked and fully visible from the hall, as the main door was left opened to the resident's women bathroom as well. The Surveyor observed CNA #2 pulling a pink shirt with flowers over Resident #61's head. Surveyor observed that CNA #1 was changing Resident #304 in the left most stall with the door open as they began to walk out of the room when finished with care. CNA #1 was telling CNA #2 that Resident #304 also had a bowel movement that required clothes to be changed. B. On 03/19/2024 at 02:45 PM, the Surveyor asked CNA #1, Should the door have been closed to the bathroom and stalls while residents were undressed? The CNA said, Well, there is not much room in there to work in but yes, I should have. The Surveyor asked CNA #1, Why is that an issue for the resident? CNA #1 said, Well like I said, there is not much room in this bathroom to work with, but yes, for privacy. C. On 03/19/2024 at 02:48 PM, the Surveyor asked CNA #2, Should the door have been closed to the bathroom and stalls while residents were undressed? CNA #2 said, Yes, they should have been. The Surveyor asked, Why is that an issue for the resident? CNA #2 said, For their privacy. D. On 03/21/2024 at 08:30 AM, the Surveyor asked the Director of Nursing (DON), When transferring residents or providing care should the curtain be pulled, and the door closed? The DON said, Yes it should be pulled closed. The Surveyor asked the DON why this is an issue for the residents. DON said, For their privacy and dignity. E. On 03/20/2024 at 04:45 PM, the Administrator provided a policy titled Federal Rights of Resident/Guest(s) that states (e) Respect and dignity: The resident/guest has a right to be treated with respect and dignity.

Based on observation, interview, and record review, the facility failed to ensure care plan interventions were implemented for 1 (Resident #36) of 1 sampled resident who were at risk for falls, to prevent falls and possible injury. The findings are: A review of a Face Sheet indicated Resident #36 had a diagnosis of dementia. The annual Minimum Data Set (MDS), dated [DATE], revealed Resident #36 had a Staff Assessment for Mental Status (SAMS) score of 1, which indicated a memory problem. Review of Resident #36's Care Plan. reviewed 02/09/2023, revealed the resident had potential for falls. Interventions included: encourage clutter free environment and path to bathroom, initiated 12/17/2022; encourage use of handrails/appropriate assistive devices, initiated 12/17/2022; wear non-slip footwear while out of bed, initiated 12/17/2022. The resident was at risk for poor safety awareness. Interventions included: place resident in area where frequent observation is possible, initiated 03/06/2019. On 03/18/2024 at 11:46 AM, Resident #36 observed sitting in a chair alone in the room. Resident #36 attempted to get up out of the chair by lifting bottom and scooting toward the front of the chair. Resident # 36 ' s chair is stuck on the fall mat on the side of the A bed. A fall mat was observed on the floor in front of the B bed. Resident #36 had regular socks on. On 03/18/2024 at 01:39 PM, Resident #36 was observed alone in their room in the chair. The chair was observed on the fall mat near the bed. Resident #36 was unable to move self in the chair while on the fall mat. On 03/18/2024 at 02:29 PM, Resident # 36 was observed in their room alone and sitting on the edge of the chair in the doorway of room. Resident #36 was unable to self-propel/ambulate in the chair. Resident #36 had regular socks on. On 03/19/2024 at 02:48 PM, Resident # 36 was observed sitting in a chair in room alone. The chair is next to the resident ' s bed, on the fall mat, and the brake is locked on the right wheel. Resident #36 was not able to ambulate in the chair. On 03/19/2024 at 02:51 PM, Certified Nursing Assistant (CNA) #10 was asked why Resident #17 ' s brake was locked on their chair. CNA #10 stated, We can't leave it locked. CNA #10 was asked if locking Resident #17 brake would be considered a restraint. CNA #10 stated, Yes, it's a restraint. On 03/19/2024 at 02:52 PM, CNA #11 stated, I locked it when I changed her earlier, I forgot to unlock it. CNA #11 stated, We are short staffed every day, I was in a hurry. CNA #11 was asked how long the facility had been short staffed. CNA #11 stated, it's been going on for quite a while, night shift comes in to help day shift. CNA #10 stated, We have 21 residents on this hall, there's a lot of lifts, we don't even have time to chart. CNA #10 was asked, Do you have a shower team or do you do your own shower? CNA#10 stated, We do our own, we had 7 showers today and 5 on the other days. On 03/19/2024 at 04:30 PM, Resident #36 was observed alone in room sitting in a chair going around in circles. On 03/20/2024 at 06:25 AM, Resident #36 was observed in a chair at the nurses ' station with eyes closed. On 03/20/2024 at 01:38 PM, Resident #36 was observed alone in room sitting up in a chair with eyes closed. The brake on the right side of Resident #36's chair is locked. On 03/20/2024 at 01:45 PM, the Director of Nursing (DON) was asked, Is Resident #36 supposed to be left alone in the room? The DON stated, I will find out. The DON was asked, Why is the locked brake on Resident #36 ' s chair considered a restraint? The DON stated, Because she can't move. The DON stated, The resident could not move being left on the fall mat, nothing will roll on the fall mat. On 03/21/2024 at 09:39 AM, CNA #10 was asked, What are the fall interventions for Resident # 36? CNA #10 stated, Use a gait belt to transfer, 2 person assist, fall mat, and they just told us we are to remove the fall mats off the floor when she is in the chair. CNA #10 was asked, Is Resident #36 supposed to be observed at all times? CNA #10 stated, I always left her in her room, she can't defend herself. CNA #10 was asked, Is Resident #36 supposed to wear special footwear? CNA #10 stated, No, special socks. CNA #10 was asked, Why should resident ' s care plan be followed and interventions implemented for residents at high risk for falls? CNA #10 stated, For their safety. On 03/21/2024 at 10:04 AM, Licensed Practical Nurse (LPN) #3 was asked, What are the fall interventions for Resident #36? LPN #3 stated, Fall mat at bedside while in the bed, wheelchair brakes have to be unlocked so she can move around, non-skid socks, and out so we can observe her. LPN #3 was asked, How do you know how to take care of Resident #36? LPN stated, The care plan, any special needs pop up on the Medication Administration Record (MAR), and in report. LPN #3 was asked, Why is Resident #36 supposed to be supervised? LPN #3 stated, Because she will get hung on stuff and it prevents the chair from moving, and it scoots her closer to the edge of the chair. LPN #3 was asked, Why is Resident #36 supposed to have non-skid socks on while up in the chair? LPN #3 stated, It helps to grip the floor and helps to move. LPN #3 was asked, Why should resident ' s care plan be followed, and interventions implemented for residents at high risk for falls? LPN #3 stated, To maintain a safe environment.

Based on observation, interview, and record review, the facility failed to ensure that 1 (Resident #78) of 17 residents who reside on the hall had nails cleaned and trimmed to promote good hygiene, cleanliness, and a sense of well being, and that 1 (Resident #41) of 29 residents who reside on the hall had facial hair removed. The findings are: A. On 03/18/2024 at 11:31AM, the Surveyor observed Resident #78 to have 1/3 to 1/2 inch long fingernails on both hands, with a dark brown substance under the nails. The Surveyor asked R #78, Do you like your nails this long? Resident #78 stated, Just my thumb on this left hand, so I can scratch with it, the rest of them need cleaned and trimmed. 1. On 03/19/2024 at 09:34 AM, Resident #78 had long 1/3 to1/2, inch nails on both hands with a brown substance under the nails of both hands. 2. On 03/20/2024 at 04:19 PM, Certified Nursing Assistant (CNA) #6, Who is responsible for trimming a resident's fingernails? CNA #6 confirmed, The CNAs are, unless they are diabetic, then the nurses do. CNA #6 was asked, How often do the residents get their nails trimmed? CNA #6 stated, On their bath days or when they are needed. CNA #6 was asked, Should there be brown substance under a resident nails? The CNA stated, No there should not, that is nasty. 3. On 03/21/2024 at 09:50 AM, Licensed Practical Nurse (LPN) #2 was asked, How often should a residents nails be trimmed? LPN #2 stated, When the resident asks you to, or when the staff notice they are growing out. Some of the residents have it on their medical chart when to trim them. The LPN was asked, Who can trim nails? LPN #2 stated, The CNA is, if the resident is not diabetic, and the nurse trims the nails if the resident is diabetic. LPN #2 was asked, Should there be brown substance under a resident nails? LPN #2 confirmed there should not be and if there is, the staff should clean them immediately. B. On 03/18/2024 at 01:51 PM, the Surveyor observed Resident #41to have 1/4 to 1/2 inch chin hair. 1. On 03/19/2024 at 09:42 AM, Resident #41 had 1/4 to 1/2 inch chin hair. 2. On 03/20/2024 at 04:14 PM, CNA #8, was asked, Why should a female resident be free of facial hair? CNA #8 stated, Self-esteem and self-appearance. The CNA was asked, How often should a female have facial hair removed? CNA #8 stated, On shower days. The Surveyor took CNA #8 into Resident #41 ' s room to observe the resident ' s facial hair, and then the Surveyor and CNA stepped out of room. The Surveyor asked CNA #8 to describe what the facial hair looked like. CNA #8 confirmed, She has a mini beard and mustache. 3. On 03/21/2024 at 09:50 AM, LPN #2 was asked, Why should a female resident be free of facial hair? LPN #2 stated, Dignity. The LPN was asked, How often should a female facial hair be trimmed? LPN#2 stated, On shower days. 4. On 03/20/2024 at 04:45 PM, the Surveyor received policy titled Nursing Procedure Manual that documented, .Purpose: Good hygiene, and grooming help prevent the spread of infection and promote the resident feelings of self-worth and dignity .Standard .shaving daily or as needed .Process .Female residents may prefer to have underarms and legs shaved frequently. Facial hair should be tended to as needed .e) Nail care is a part of grooming. Female residents may prefer to use nail polish .

49689 Based on observation, interview, and record review, the facility failed to ensure residents at risk for falls were supervised and fall prevention interventions were implemented for 1 (Resident #36) of 1 sampled residents, to prevent falls and possible serious injury; failed to ensure 3 of 3 clothes dryers remained free of lint build-up to decrease the potential for fire and loss of laundry services for 1 of 1 laundry room; and failed to ensure the safety of a resident by transferring 2 (Residents #87 and #304 ) sampled residents without a gait belt. The findings are: 1. A review of a Face Sheet indicated Resident #36 had a diagnosis of Dementia. a. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/2024 revealed Resident #36 had a Staff Assessment for Mental Status (SAMS) score of 1, which indicated a memory problem. b. Resident #36's Care Plan with a review date 02/09/2023 revealed the resident had a potential for falls. Interventions included: encourage clutter free environment and path to bathroom, initiated 12/17/2022; encourage use of handrails/appropriate assistive devices, initiated 12/17/2022; wear non-slip footwear while out of bed, initiated 12/17/2022. The resident was at risk for poor safety awareness. Interventions included: place resident in area where frequent observation is possible, initiated 03/06/2019. c. On 03/18/2024 at 11:46 AM, Resident #36 was observed sitting in an adjustable chair alone in their room. Resident #36 attempted to get up out of the chair by lifting bottom and scooting toward the front of the chair. Resident #36 ' s chair is stuck on the fall mat on the side of the A bed. A fall mat was observed on the floor in front of the B bed. Resident #36 had regular socks on. d. On 03/18/2024 at 01:39 PM, Resident #36 was observed alone in their room in an adjustable chair. The chair was sitting on the fall mat near the bed. Resident #36 was unable to move the chair while on the fall mat. e. On 03/18/2024 at 02:29 PM, Resident #36 was observed alone in their room and sitting on the edge of the chair in the doorway of room. Resident #36 was unable to self-propel in the chair. Resident #36 had regular socks on. f. On 03/19/2024 at 02:48 PM, Resident #36 was observed sitting in an adjustable chair in their room alone. The chair is next to the resident ' s bed, on the fall mat, and the brake is locked on the right wheel. Resident #36 was not able to in the chair. g. On 03/19/2024 at 02:51 PM, Certified Nursing Assistant (CNA) #10 was asked why Resident #17 ' s brake was locked on their chair. CNA #10 stated, We can't leave it locked. CNA #10 was asked if locking Resident #17 brake would be considered a restraint. CNA #10 stated, Yes, it's a restraint. h. On 03/19/2024 at 02:52 PM, CNA #11 stated, I locked it when I changed [him/her] earlier, I forgot to unlock it. CNA #11 stated, We are short staffed every day, I was in a hurry. CNA #11 was asked how long the facility had been short staffed. CNA #11 stated, It's been going on for quite a while, night shift comes in to help day shift. CNA #10 stated, We have 21 residents on this hall, there's a lot of lifts, we don't even have time to chart. CNA #10 was asked, Do you have a shower team, or do you do your own showers? CNA#10 stated, We do our own, we had 7 showers today and 5 on the other days. i. On 03/19/2024 at 04:30 PM, Resident #36 was observed alone in their room sitting in an adjustable chair going around in circles. j. On 03/20/2024 at 06:25 AM, Resident #36 was observed in a chair at the nurses ' station with eyes closed. k. On 03/20/2024 at 01:38 PM, Resident #36 was observed alone in room sitting up in an adjustable chair with eyes closed. The brake on the right side of Resident #36 ' s chair was locked. l. On 03/20/2024 at 01:45 PM, the Director of Nursing (DON) was asked, Is Resident #36 supposed to be left alone in their room? The DON stated, I will find out. The DON was asked, Why is the locked brake on Resident #36 adjustable chair considered a restraint? The DON stated, Because [he/she] can't move the resident could not move being left on the fall mat, nothing will roll on the fall mat. m. On 03/21/2024 at 09:39 AM, CNA #10 was asked, What are the fall interventions for Resident # 36? CNA #10 stated, Use a gait belt to transfer, 2 person assist, fall mat, and they just told us we are to remove the fall mats off the floor when [he/she] is in the chair. CNA #10 was asked, Is Resident #36 supposed to be observed at all times? CNA #10 stated, I always left [the resident in their] room, [he/she] can't defend [his/herself]. CNA #10 was asked, Is Resident #36 supposed to wear special footwear? CNA #10 stated, No, special socks. CNA #10 was asked, Why should residents care plan be followed, and interventions implemented for at high risk for falls? CNA #10 stated, For their safety. n. On 03/21/2024 at 10:04 AM, Licensed Practical Nurse (LPN) #3 was asked, What are the fall interventions for Resident # 36? LPN #3 stated, Fall mat at bedside while in the bed, wheelchair brakes have to be unlocked so [he/she] can move around, non-skid socks, and out so we can observe [him/her]. LPN #3 was asked, How do you know how to take care of Resident #36? LPN #3 stated, The care plan, any special needs pop up on the Medication Administration Record (MAR), and in report. LPN #3 was asked, Why is Resident #36 supposed to be supervised? LPN #3 stated, Because [he/she] will get hung on stuff and it prevents the chair from moving, and it scoots [him/her] closer to the edge of the chair. LPN #3 was asked, Why is Resident #36 supposed to have non-skid socks on while up in the chair? LPN #3 stated, It helps to grip the floor and helps to move. LPN #3 was asked, Why should residents care plan be followed, and interventions implemented for at high risk for falls? LPN #3 stated, To maintain safe environment. 2. On 03/19/2024 at 02:25 PM, during the Infection Control tour of the Laundry Department, the following observations were made: a. There were 3 electric dryers in the clean area of the laundry room on the outside the facility. The Surveyor opened the bottom drawer to Dryer #1. The Surveyor observed 1.0 cm lint build up on the lint screen and a ball of lint on the floor inside the dryer in a ball the size of a soccer ball. The Surveyor opened the lint trap for Dryer #2 and identified 0.5 cm of lint-on-lint trap. The Surveyor opened the bottom drawer of Dryer #3 to find 0.5 cm of lint-on-lint trap and 4 popcorn size balls of lint in the bottom of dryer. The Surveyor asked the Laundry Aide #1, How often are the lint traps cleaned out? Laundry Aide #1 stated, Every 4 hours, or every other load give or take. The Surveyor asked, Have you cleaned it out today? Laundry Aide #1 stated, I have not yet I just came in this afternoon. b. On 03/20/2024 at 04:02 PM, the Surveyor asked the Administrator, How often should the dryer lint trap be cleaned? The Assistant Administrator stated, Our policy states every 2 hours. c. On 03/20/2024 at 08:57 AM, the Assistant Administrator provided a copy of the Lint Filter Cleaning Log from the 03/16/2024-03/20/2024 at 07:00 AM that documented the lint trap had been cleaned every 2 hours. d. On 03/20/2024 at 08:57 AM, the Assistant Administrator provided a policy titled, Laundry-Cleaning outside of dryers that documented, .Every 2 hours, clean the filter and filter area. Check burner area for lint build up. Wipe all areas that are easily accessible . 3. Resident #87 had diagnoses of Autistic disorder and Intellectual disabilities. The Significant Change MDS with a ARD of 02/16/2024 documented the resident scored 3 (indicates severe impairment) on a Staff Assessment for Mental Status (SAMS), and was a maximal assistance dependent with two people assist for transfers. a. The Care Plan for Resident #87 documented, .Potential for falls .start date 1/31/2024 .care plan goal . I don't want to fall x 90 days .Intervention .Staff to check resident during rounds . b. On 03/21/2024 at 09:30 AM, the resident was observed sitting on the floor at the front nurse's station by his wheelchair. Registered Nurse (RN) #1 and #2 were assessing the resident. The Surveyor observed CNA #3 and #5 place their hands in the resident arm pits on each side. They lifted the resident from the floor into the chair. The Administrator was standing at the nurse's station and observed the incident. c. On 03/21/2024 at 09:35 AM, RN #1 was asked, How did the staff lift the resident from the floor? RN #1 said, They picked him up. The Surveyor asked, What should the staff use when lifting a resident? RN #1 stated, We should probably use a gait belt. d. On 03/21/2024 at 09:38 AM, the Administrator was asked, Did the staff use a gait belt when lifting the resident from the floor? The Administrator stated, No. 4. Resident #304 had diagnoses of Alzheimer's disease early onset, Generalized anxiety disorder, and Depression. According to the MDS with an ARD of 01/31/2024 revealed the resident scored a 4 (0-7 indicates severe impaired cognition) on the Brief Interview for Mental Status (BIMS). a. On 03/19/2024 at 02:45 PM, the Surveyor observed CNA #1 walking with Resident #304 by hand with no gait belt in use. Resident #304 lost their footing and fell backwards. CNA #1 caught the resident from behind, while another CNA held the Resident #304 ' s hands while the CNA #1 helped Resident #304 up. CNA #1 then attempted to walk Resident #304 with the other CNA behind them. Resident #304 kept having trouble with footing and almost fell again. CNA #1 instructed the CNA walking behind Resident #304 to hold onto their upper arms while they go get Resident #304's walker; no gait belt was in use. Both CNAs then helped Resident #304 to sit on their rolling walker. CNA #1 took Resident #304 to their room, then proceeded to wrap their arms around Resident #304's chest and asked the resident to hold on. The Surveyor observed the transfer being made with no gait belt. Resident #304's legs were shaking, and their arms lifted up completely vertical during the transfer. b. On 03/19/2024 at 02:58 PM, the Surveyor asked CNA #1, Should any safety devices be in use while transferring? CNA #1 said, Yes, because they could fall or get hurt. c. On 03/21/2024 at 08:40 AM, the Surveyor asked the Director of Nursing (DON), Should any safety devices be in use while transferring residents? The DON said, Yes, they should be in use. The Surveyor asked, Why could this be an issue with the residents? The DON said, They could get injured. The Surveyor asked DON about the level of transfer for Resident #304. The DON said that right now the resident is charted as independent but had a recent change with the resident being added on hospice, and the transfers can change from day to day. d. On 03/21/2024 at 09:00 AM, a policy titled Ambulation Belt/Gait Belt provided by the DON documented, Process: 1. Apply the belt around the residents waist snugly enough to eliminate the possibility of sliding up on the ribs, 3. The belt should be used during ambulation to stabilize the resident, by grasping the belt firmly in the middle of the resident's back.

Based on observation, interview, and record review, the facility failed to ensure a securement device was used for residents with urinary inswelling catheters in place for 1 (Resident #68) of 5 sampled residents who had a catheter The findings are: 1. Resident (R) #68 had a diagnosis of Neuromuscular dysfunction of bladder, unspecified. The Minimum Data Set with an Assessment Reference Date of 01/01/2024 documented a Brief Interview for Mental Status score of 14 (13-15 indicates cognitively intact). 2. A Physician ' s Order with an Order Date of 01/25/2024 documented, (Indwelling) catheter may use leg band . 3. On 03/18/2024 at 02:11 PM, the Surveyor observed that R #68 did not have any securement device to hold their indwelling catheter tubing in place to prevent tubing from being pulled and causing trauma. 4. On 03/19/2024 at 09:40 AM, the Surveyor observed that R #68 did not have a securement device to hold their inswelling catheter tubing in place. 5. On 03/21/2024 at 08:32 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, How should a catheter be secured to prevent pulling? LPN #1 stated, A leg strap. The Surveyor asked, Who is responsible for making sure an indwelling security device is on the resident? LPN#1 stated, Myself, the nurses, and the aides should be looking and come and tell the nurses. 6. On 03/21/2024 at 08:36 AM, the Surveyor interviewed Certified Nursing Assistant (CNA) #5, How should a indwelling catheter be secured? CNA #5 stated, By a leg strap. The Surveyor asked, Who is responsible for making sure an indwelling catheter security device is on the resident? CNA #5 stated, The CNAs or the nurses. 7. On 03/21/2024 at 08:50 AM, the Surveyor asked the Director of Nurses (DON), How should a catheter be secured? The DON stated, By using a [named brand of securement device] or coil hook and securing it to the bed. The Surveyor asked, Who is responsible for making sure a resident with a [urinary catheter] has this in place? The DON stated, The charge nurse. 8. On 03/20/2024 at 04:45 PM, a policy titled Nursing Procedure [NAME] .Urinary Catheter Care was provided. It documented, .Secure the catheter with a leg band or loop to the bed sheet in a comfortable position for the resident/guest .

Based on observations, interview, and record review, the facility failed to (1) ensure medications were readily available at all times for 1 (Resident #28) of 1 sampled resident, who was on scheduled pain medication, to prevent possible increase in pain or further decline in status, (2) ensure that staff performed hand hygiene while providing incontinence care for 1 (Resident #32) sampled resident, (3) ensure that staff utilized adjustable chairs in a manner that avoided causing a restraint for 1 (Resident #36) sampled resident, (4) ensure that privacy was maintained while providing bathing and incontinence care for 3 (Residents #61, #72, and #304) sampled residents, and (5) ensure that safety devices were utilized while lifting and transferring for 2 (Residents #87 and #304) sampled residents. The findings are: Resident #28 had diagnoses of Chronic pain and Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/2024 documented a Brief Interview for Mental Status (BIMS) score of 10 (8-12 indicates moderate cognitive impairment). Resident #28's Physician Orders documented an order, dated 02/02/2024, for Lyrica (a medication that can treat nerve and muscle pain) 150 milligram (mg), one capsule twice daily for pain. Resident 28's Care Plan, initiated 09/27/2022, revealed the resident will not have unrelieved pain times (x) 90 days as evidenced by (AEB) no moaning, groaning, or facial grimaces. Interventions included coordinating with physician to manage pain medication for optimum control of pain. The Approved Emergency Medication List 2024 dated 2024, revealed no Lyrica in the emergency kit. A nursing Progress Notes, dated 03/15/2024 at 03:44 PM, revealed scheduled for 03/15/2024 04:00 PM, needs new script (rx), doctor (name) aware per day shift nurse. Resident #28's Medication Administration Record (MAR) dated March 2024, revealed Lyrica was administered to Resident #28 on 03/15/2024 at 08:00 AM, 03/16/2024 at 08:00 AM and at 04:00 PM, on 03/17/2024 at 08:00 AM and at 04:00 PM. Lyrica was not administered on 03/18/2024 at 08:00 AM or at 04:00 PM. On 03/20/2024 at 10:37 AM, in the medication cart for South East and East Hall a bubble card for, Resident #28 was found that was labeled, Lyrica 150 mg give 1 tablet twice a day (BID) . The bubble card documented a 0 balance, with the last dose given 3/15/2024 at 08:00 AM. Registered Nurse (RN) #1 stated, We've ordered it and it didn't come in, and I called the pharmacy and they said they were waiting on a script. I asked if they had called/faxed the doctor, this was the day before yesterday I think, it might have been yesterday, they said no, they we're waiting on us to contact the doctor, I asked them if the send out request for that, for the script, and they said yes they would do that, so they were going to send it to the doctor, and I talked to the Assistant Director of Nursing (ADON) and she was going to contact the doctor too. RN #1 stated, [The resident] has not complained of pain or asked for pain meds. RN #1 was asked what do you normally do if you run out of meds for a resident? RN #1 stated, Normally call the pharmacy, normally we don't call the doctor for scripts. I would think the pharmacy would be responsible for it. RN #1 was asked, Have you been trained on ordering medications when the script runs out? RN #1 stated, I had 3 days of training, and I had to learn it on my own because they were shorthanded. RN #1 was asked, How long have you worked here? RN #1 stated, I started February 5, I left for vacation, and came back on the 25th. On 03/20/2024 at 12:00 PM, the Director of Nursing (DON) stated, We don't have it (Lyrica) in the E-kit. The DON was asked, Is there any documentation that the nurse contacted the pharmacy or physician about being out of Resident #28 ' s Lyrica? The DON stated, I was just made aware of this, the ADON said she called the doctor yesterday. The DON was asked, What about the resident not receiving the scheduled medication? The DON said, [His/her] pain had not increased and [he/she] had PRN Norco. On 03/20/2024 at 02:02 PM, RN #1 was asked, On 03/19/2024 did you document that you administered Lyrica to Resident #28? RN #1 stated, I accidentally checked it. RN #1 was asked, Did you take the Lyrica from the ER box? RN #1 stated, I didn't check the ER box, I gave the last dose of Lyrica on March 15th, which made it zero. RN #1 was asked, What does a check mark on the MAR mean? RN #1 stated, I assume it was given. After assessing the Narcotic book with RN #1, the nurse marked the date of 3/15/2024 at 04:00 PM instead of 03/14/2024 at 04:00 PM. RN #1 was asked, How do you ensure medication/narcotics are documented for accurate counts? RN #1 stated, Sign out in the (narcotic) book, each shift counts, oncoming and outgoing, and if there are any discrepancies, we look into it. RN #1 was asked, Why should medications/narcotic records be accurate when documenting administration of the medications? RN #1 stated, To show the resident is getting the correct medication, the right dose, follow the 5 rights, right resident, right medication, right dosage, right time, and right route. RN #1 was asked, Why should the doctor be notified if a resident runs out of medication, and they need more? RN #1 stated, So they know they are out and need more. RN #1 was asked, Who is responsible for ensuring the doctor is notified? RN #1 stated, I'm not sure, everywhere I've worked it's always been me. On 03/20/2024 at 03:12 PM, the ADON was asked to explain the situation regarding Resident #28's Lyrica 150 mg BID that ran out on March 15, 2024. The ADON stated, The night nurse showed me the empty card when I took over and did the count yesterday morning, I called the on-call for doctor (name), I never got a call from on-call, so I called doctor (name), and I had to leave a voicemail because he didn't answer. I called a second time with no answer, then I called Doctor (name he's our medical director, and he said I could go ahead and call the Lyrica to the pharmacy under him, because I'm an agent under him. The ADON was asked, Why did it take 5 days before someone said anything or ordered the meds? The ADON stated, That's the first I had heard about it, doesn't make any sense to me. The ADON was asked, Why should the nurse contact the physician when a resident runs out of medication or needs a new script? The ADON stated, So the resident doesn't run out. That tells me they weren't paying attention to what they were giving or paying attention to the MAR. The ADON was asked, How do you ensure medications/narcotics are documented for accurate counts? The ADON stated, Nurses count each shift and any discrepancies we contact unit manager. The ADON was asked, Why should medication/narcotic records be accurate when documenting administration of the medications? The ADON stated, So you know the resident got the medication and it's not diverted. A Face Sheet indicated the facility admitted Resident #32 with diagnoses of Hemiplegia and Dementia. The Quarterly MDS with an ARD of 03/15/2024, revealed Resident #32 had a BIMS score of 15 (13-15 indicates cognitively intact). The resident required partial/moderate assistance for toileting and was always incontinent of bowel and bladder. Resident #32's Care Plan, reviewed 12/06/2022, revealed the resident was incontinent of bowel and bladder. Interventions included perineal care after each incontinent episode, initiated 05/15/2018; disposable brief program, initiated 05/15/2018. A facility policy titled, Hand Hygiene, dated June 11, 2020, specified, To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. Hand washing should be performed between procedures with the resident/guest(s) based upon the principle that all blood, body fluids, secretions, excretions (except swear), non-intact skin, and mucus membranes may contain transmissible infectious agents. If hands are not visible soiled, use an alcohol-based hand sanitizer for routinely decontaminating hands in all clinical situations other than those listed under Handwashing above. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: when hands are visibly soiled (hand washing with soap and water); before and after direct resident/guest contact (for which hand hygiene is indicated by acceptable professional practice). Before and after assisting a resident/guest with personal care (e.g. oral care, bathing). After contact with a resident/guest(s) mucous membranes and body fluids or excretions. After handling soiled or used linens, dressings, bedpans, catheters, and urinals. After handling soiled equipment or utensils. After removing gloves or aprons. Consistent us by staff of proper hygienic practices and techniques is critical to preventing the spread of infections. On 03/21/2024 at 11:04 AM, Certified Nursing Assistants (CNA) #10 and #11 entered Resident #32 ' s room. CNA #10 and CNA #11 did not perform hand hygiene. Both CNAs applied gloves. CNA #11 moved Resident #32 ' s bed away from the wall and positioned him/herself between the bed and wall. CNA #11 did not perform hand hygiene and did not change gloves. CNA #10 pulled the privacy curtain with gloved hands. CNA #10 did not change gloves and did not perform hand hygiene. CNA #10 obtained two plastic bags and placed at the head of Resident #32 bed and near Resident #32 ' s head. CNA #10 obtained a package of premoistened wipes from the nightstand and placed them on Resident #32 ' s bed. CNA #10 performed incontinence care, during which they did not change gloves and did not perform hand hygiene. CNA #10 picked up the premoistened wipe package with both gloved hands, placed the package on the nightstand. CNA #11 rolled Resident #32 toward the wall. CNA #11 placed a clean brief under the dirty brief and under Resident #32, then removed the dirty brief using the same dirty gloves. CNA #10 stated, I'm in a rush, I need to slow down. Using the same dirty gloves, CNA #11 obtained the package of premoistened wipes from the nightstand, placed on the bed, and using the left hand, held the premoistened package of wipes, while removing wipes from the package using the right hand. CNA #10 continued performing incontinence care, during which they did not change dirty gloves and did not perform hand hygiene. CNA #10 placed the package of premoistened wipes in a basket on the nightstand. The CNAs rolled Resident #32 toward CNA #10, with Resident #32 ' s face near the plastic bags with the dirty brief and wipes. CNA #10 removed a package of skin protectant from the basket using the same dirty gloves used to provide incontinence care, then opened the package of skin protectant, squeezed the package with the left hand, and placed the skin protectant into the right hand. CNA #10 applied skin protectant to Resident #32 genitals and in between both legs on the front side. CNA #10 removed their used gloves and placed into the trash, then stated, I forgot to change gloves, you are supposed to change gloves when doing perineal care. e. On 03/21/2024 at 12:03 PM, CNA #10 was asked, When should hand hygiene be performed? CNA #10 stated, Before, during, and after care. CNA #10 was asked, When should gloves be changed when doing perineal care? CNA #10 stated, Before, during, and after. CNA #10 was asked, Why should hand hygiene/gloves be changed during perineal care? CNA #10 stated, To keep from transferring germs. f. On 03/21/2024 at 12:05 PM, the ADON was asked, When should hand hygiene be performed? The ADON stated, Anytime you enter or leave the room, before providing care, when you complete care for a resident, when gloves become soiled. You should sanitize before putting clean gloves on. The ADON was asked, When should gloves be changed when doing perineal care? The ADON stated, Change gloves before going to a different area and if they become soiled. The ADON was asked, Why should hand hygiene/glove changes be performed during perineal care? The ADON stated, To prevent infection, to prevent the staff from giving anything to a resident or transferring anything from a resident. g. On 03/21/2024 at 12:16 PM, the DON was asked, When should hand hygiene be performed? The DON stated, Prior to entering the room, in between tasks, when visibly soiled and dirty. The DON was asked, When should gloves be changed when doing perineal care? The DON stated, When visibly soiled. The DON was asked, Why should hand hygiene/glove changes be performed during perineal care? The DON stated, To prevent infection. 3. A Face Sheet indicated Resident #36 had a diagnosis of Dementia. a. The Annual MDS with an ARD of 01/23/2024, revealed Resident #36 had a Staff Assessment for Mental Status (SAMS) score of 1, which indicated a memory problem. b. Resident #36's Care Plan, reviewed 02/09/2023, revealed the resident had a potential for falls. Interventions included: encourage clutter free environment and path to bathroom, initiated 12/17/2022; encourage use of handrails/appropriate assistive devices, initiated 12/17/2022; wear non-slip footwear while out of bed, initiated 12/17/2022. The resident was at risk for poor safety awareness. Interventions included: place resident in area where frequent observation is possible, initiated 03/06/2019. c. On 03/18/2024 at 11:46 AM, Resident #36 was observed sitting in an adjustable chair alone in their room. Resident #36 attempted to get up from the chair by lifting bottom and scooting toward the front of the chair. Resident # 36 ' s chair is stuck on the fall mat on the side of the A bed. A fall mat was observed on the floor in front of the B bed. Resident #36 had regular socks on. d. On 03/18/2024 at 01:39 PM, Resident #36 was observed alone in their room seated in an adjustable chair. The chair was sitting on the fall mat near the bed. Resident #36 was unable to move self in the chair while on the fall mat. e. On 03/18/2024 at 02:29 PM, Resident #36 was observed alone in their room, sitting on the edge of their chair in the doorway of room. Resident #36 was unable to self-propel in the chair. Resident #36 had regular socks on. f. On 03/19/2024 at 02:48 PM, Resident #36 was observed sitting in a chair in their room alone. The chair was next to the resident ' s bed, on the fall mat, and the brake was locked on the right wheel. Resident #36 was not able to self-propel the chair. g. On 03/19/2024 at 02:51 PM, Certified Nursing Assistant (CNA) #10 was asked why Resident #36 ' s brake was locked on their chair. CNA #10 stated, We can't leave it locked. CNA #10 asked CNA #11 if she had locked Resident #36 brake. CNA #10 was asked if locking Resident #36 brake would be considered a restraint. CNA #10 stated, Yes, it's a restraint. h. On 03/19/2024 at 02:52 PM, CNA #11 stated, I locked it when I changed [him/her] earlier, I forgot to unlock it. CNA #11 stated, We are short staffed every day, I was in a hurry. CNA #11 was asked how long the facility has been short staffed. CNA #11 stated, It's been going on for quite a while, night shift comes in to help day shift. CNA #10 stated, We have 21 residents on this hall, there's a lot of lifts, we don't even have time to chart. CNA #10 was asked, Do you have a shower team, or do you do your own showers? CNA#10 stated, We do our own, we had 7 showers today and 5 on the other days. i. On 03/19/2024 at 04:30 PM, Resident #36 was observed alone in their room sitting in a chair going around in circles. j. On 03/20/2024 at 06:25 AM, Resident #36 was observed in their chair at the nurses ' station with eyes closed. k. On 03/20/2024 at 01:38 PM, Resident #36 was observed alone in their room sitting up in a chair with eyes closed. The brake on the right side of Resident # 36 chair is locked. l. On 03/20/2024 at 01:45 PM, the Director of Nursing (DON) was asked, Is Resident # 36 supposed to be left alone in the room? The DON stated, I will find out. The DON was asked, Why is the locked brake on Resident #36 chair considered a restraint? The DON stated, Because she can't move. The DON stated, The resident could not move being left on the fall mat, nothing will roll on the fall mat. m. On 03/21/2024 at 09:39 AM, CNA #10 was asked, What are the fall interventions for Resident #36? CNA #10 stated, Use a gait belt to transfer, 2 person assist, fall mat, and they just told us we are to remove the fall mats off the floor when [he/she] is in the chair. CNA #10 was asked, Is Resident #36 supposed to be observed at all times? CNA #10 stated, I always left [the resident in their] room, [he/she] can't defend [his/herself]. CNA #10 was asked, Is Resident #36 supposed to wear special footwear? CNA #10 stated, No, special socks. CNA #10 was asked, Why should residents care plan be followed, and interventions implemented for at high risk for falls? CNA #10 stated, For their safety. n. On 03/21/2024 at 10:04 AM, Licensed Practical Nurse (LPN) #3 was asked, What are the fall interventions for Resident #36? LPN #3 stated, Fall mat at bedside while in the bed, wheelchair brakes have to be unlocked so she can move around, non-skid socks, and out so we can observe [him/her]. LPN #3 was asked, How do you know how to take care of Resident #36? LPN stated, The care plan, any special needs pop up on the Medication Administration Record (MAR), and in report. LPN #3 was asked, Why is Resident #36 supposed to be supervised? LPN #3 stated, Because [he/she] will get hung on stuff and it prevents the chair from moving, and it scoots [him/her] closer to the edge of the chair. LPN #3 was asked, Why is Resident #36 supposed to have non-skid socks on while up in their chair? LPN #3 stated, It helps to grip the floor and helps to move. LPN #3 was asked, Why should residents care plan be followed, and interventions implemented for at high risk for falls? LPN #3 stated, To maintain safe environment. 4. Resident #72 had diagnoses of Parkinson's without fluctuations and Dementia without behavioral disturbances. The MDS with an ARD of 02/19/2024 revealed the resident received a score of 3 (0-7 indicates severe cognitive impairment) on the BIMS. The MDS with an ARD of 02/19/2024 on section GG documented that the resident is dependent for transfers. a. On 03/19/2024 at 08:52 AM, the Surveyor observed the door open with Resident #72 sitting fully naked in a shower chair, with the curtain and door not closed. Resident #72 was fully visible from the hallway. b. On 03/20/2024 at 09:30 AM, the Surveyor asked CNA #4, When transferring Resident #72 yesterday to the shower, should the curtain have been pulled and the door closed? CNA #4 said, Yes it should have been. The Surveyor asked why this could be an issue. CNA #4 said, For the resident's privacy. c. On 3/20/2024 at 09:32 AM, the Surveyor asked CNA #3, When transferring Resident #72 yesterday to the shower, should the curtain have been pulled and the door closed? CNA #3 said, Yes it should have been. The Surveyor asked why this could be an issue. CNA #3 said, Dignity. 5. Resident #87 had diagnoses of Autistic disorder and Intellectual disabilities. The Significant Change MDS with an ARD of 02/16/2024 documented the resident scored 3 (3 indicates severely impairment) on a (SAMS) and was a maximal assistance dependent with two people assist for transfers. The Care Plan documented, .Potential for falls .start date 01/31/2024 .care plan goal .I don't want to fall x 90 days .Intervention .Staff to check resident during rounds . On 03/21/2024 at 09:30 AM, the resident was observed sitting on the floor at the front nurse's station by his/her wheelchair. Observed Certified Nursing Assistant (CNA) #3 and #5 place their hands in the resident arm pits on each side. They lifted the resident from the floor into the chair. The Administrator was standing at the nurse's station observing the incident. On 03/21/2024 at 09:35 AM, the Surveyor asked RN #1, How did the staff lift the resident from the floor? RN #1 said, They picked him up. The Surveyor asked, What should the staff use when lifting a resident? RN #1 stated, We should probably use a gait belt. On 03/21/2024 at 09:38 AM, the Surveyor asked the Administrator, Did the staff use a gait belt when lifting the resident from the floor? They replied, No. Resident #61 had a diagnosis of dementia with unspecified severity with agitation and a history of falling. The MDS with an ARD of 01/15/2024 revealed the resident scored a 3 on the BIMS, and that the resident is an independent/supervision with transfers. Resident #304 had diagnoses of Alzheimer's disease early onset, Generalized anxiety disorder, and Depression. According to the MDS with an ARD 01/31/2024 revealed the resident scored a 4 on the BIMS. On 03/19/2024 at 2:45 PM, the Surveyor observed CNA #1 walking with Resident #304 with no gait belt in use. Resident #304 lost their footing and fell backwards. CNA #1 caught him/her from behind, while another CNA held Resident #304 hands while CNA #1 helped stand Resident #304 up. CNA #1 then attempted to walk Resident #304 with the other CNA behind them. Resident #304 continued having trouble with footing and almost fell again. Both CNAs then helped Resident #304 to sit on their rolling walker with basket. CNA #1 took Resident #304 to their room, parked the rolling walker at the end of the bed, locking both brakes, then proceeded to wrap their arms around Resident #304's chest and asked the resident to hold on. Surveyor observed the transfer occur with no gait belt. Resident #304's legs were shaky, and their arms lifted up completely vertical during the transfer. b. On 03/19/2024 at 02:58 PM, the Surveyor asked CNA #1, Should any safety devices be in use while transferring? CNA #1 said, Yes, because they could fall or get hurt. c. On 03/21/2024 at 08:40 AM, the Surveyor asked the DON, Should any safety devices be in use while transferring residents? The DON said, Yes, they should be in use. The Surveyor asked why could this be an issue with the residents. The DON said, They could get injured. The Surveyor asked the DON about the level of transfer for Resident #304. The DON said that right now [Resident #304] is charted as independent but had a recent change with the resident being added on hospice, and the transfers can change from day to day. d. On 03/19/2024 at 02:39 PM, the Surveyor observed two CNA's changing Resident #61 and Resident #304 in the resident women's bathroom for the secure unit. The Surveyor observed CNA #2 changing Resident #61 in the right stall with the door opened. Surveyor observed that CNA #2 was changing Resident #61's clothes, while CNA #2 was pulling up teal-colored pants on Resident #61 the surveyor observed that you can see the resident naked and fully visible from the hall, as the main door was left opened to the resident's women bathroom as well. The Surveyor observed CNA #2 pulling a pink shirt with flowers over Resident #61's head. Surveyor observed that CNA #1 was changing Resident #304 in the left most stall with the door open as they began to walk out of the room when finished with care. CNA #1 was telling CNA #2 that Resident #304 also had a bowel movement that required clothes to be changed. e. On 03/19/2024 at 02:45 PM, the Surveyor asked CNA #1, Should the door have been closed to the bathroom and stalls while residents were undressed? The CNA said, Well, there is not much room in there to work in but yes, I should have. The Surveyor asked CNA #1, Why is that an issue for the resident? CNA #1 said, Well like I said, there is not much room in this bathroom to work with, but yes, for privacy. f. On 03/19/2024 at 02:48 PM, the Surveyor asked CNA #2, Should the door have been closed to the bathroom and stalls while residents were undressed? CNA #2 said, Yes, they should have been. The Surveyor asked, Why is that an issue for the resident? CNA #2 said, For their privacy. g. On 03/21/2024 at 08:30 AM, the Surveyor asked the DON, When transferring residents or providing care should the curtain be pulled and the door closed? The DON said, Yes it should be pulled closed. The Surveyor asked the DON why this is an issue for the residents. The DON said, For their privacy and dignity. h. On 03/20/2024 at 04:45 PM, the Administrator provided a policy titled Federal Rights of Resident/Guest(s) that states (e) Respect and dignity: The resident/guest has a right to be treated with respect and dignity. 49689

Based on observation, interview, and record review, the facility failed to ensure medications were readily available at all times for 1 (Resident #28) of 1 sampled resident, who was on scheduled pain medication, to prevent possible increase in pain or further decline in status. The findings are: A Face Sheet indicated the facility admitted Resident #28 with diagnoses of Chronic pain and Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/2024 revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. A review of Resident #28's Physician Orders, for the month of 03/2024, revealed an order, dated 02/02/2024, for Lyrica (a medication given for pain) 150 milligram (mg), one capsule twice daily for pain. Review of Resident 28's Care Plan, initiated 09/27/2022, revealed the resident will not have unrelieved pain times (x) 90 days as evidenced by (AEB) no moaning, groaning, or facial grimaces. Interventions included coordinate with physician to manage pain medication for optimum control of pain, initiated 09/27/2022. A review of the Approved Emergency Medication List 2024 dated 2024, revealed no Lyrica in the emergency kit. A review of a nursing Progress Notes, dated 03/15/2024 at 03:44 PM, revealed scheduled for 03/15/2024 04:00 PM, needs new script (rx), doctor (name) aware per day shift nurse. A review of Resident #28 ' s Medication Administration Record dated March 2024 revealed Lyrica was administered to Resident #28 on 03/15/2024 at 08:00 AM, 03/16/2024 at 08:00 AM and at 04:00 PM, on 03/17/2024 at 08:00 AM and at 04:00 PM. Lyrica was not administered on 03/18/2024 at 08:00 AM or at 04:00 PM. On 03/20/2024 at 10:37 AM, a bubble card was observed for Lyrica 150 mg give 1 tablet twice a day (BID) with a zero balance with a last dose given 3/15/2024 at 08:00 AM. It documented the card was for Resident #28. RN #1 stated, We've ordered it and it didn't come in, and I called the pharmacy and they said they were waiting on a script. I asked if they had called/faxed the doctor, this was day before yesterday I think, it might have been yesterday, they said no, they we're waiting on us to contact the doctor, I asked them if the send out request for that, for the script, and they said yes they would do that, so they were going to send it to the doctor, and I talked to the Assistant Director of Nursing (ADON) and she was going to contact the doctor too. RN #1 stated, [Resident #28] has not complained of pain or asked for pain meds. RN #1 was asked, What do you normally do if you run out of meds for a resident? RN #1 stated, Normally call the pharmacy, normally we don't call the doctor for scripts. I would think the pharmacy would be responsible for it. RN #1 was asked, Have you been trained on ordering medications when the script runs out? RN #1 stated, I had 3 days of training, and I had to learn it on my own because they were shorthanded. RN #1 was asked, How long have you worked here? RN #1 stated, I started February 5, I left for vacation, and came back on the 25th. On 03/20/2024 at 12:00 PM, the Director of Nursing (DON) stated, We don't have it (Lyrica) in the E-kit. The DON was asked, Is there any documentation that the nurse/nurses contacted the pharmacy or physician about being out of Resident #28 ' s Lyrica? The DON stated, The ADON (Assistant Director of Nurses) said she called the doctor yesterday. The DON was asked, What about the resident not receiving the scheduled medication? The DON said, [His/her] pain had not increased and [he/she] had PRN Norco. On 03/20/2024 at 02:02 PM, RN #1 was asked, On 03/19/2024 did you document that you administered Lyrica to Resident #28? RN #1 stated, I accidentally checked it. RN #1 was asked, Did you take the Lyrica from the ER box? RN #1 stated, I didn't check the ER box, I gave the last dose of Lyrica on March 15th, which made it zero. RN #1 was asked, What does a check mark on the MAR mean? RN #1 stated, I assume it was given. After assessing the Narcotic book with RN #1, the nurse marked the date of 03/15/2024 at 04:00 PM instead of 3/14/2024 at 04:00 PM. RN #1 was asked, How do you ensure medication/narcotics are documented for accurate counts? RN #1 stated, Sign out in the (narcotic) book, each shift counts, oncoming and outgoing, and if there are any discrepancies, we look into it. RN #1 was asked, Why should medications/narcotic records be accurate when documenting administration of the medications? RN #1 stated, To show the resident is getting the correct medication, the right dose, follow the 5 rights, right resident, right medication, right dosage, right time, and right route. RN #1 was asked why should the doctor be notified if a resident runs out of medication, and they need more? RN #1 stated, So they know they are out and need more. RN #1 was asked who is responsible for ensuring the doctor is notified. RN #1 stated, I'm not sure, everywhere I've worked it's always been me. On 03/20/2024 at 03:12 PM, the ADON was asked to elaborate about Resident #28's Lyrica 150 mg BID that ran out on March 15, 2024. The ADON stated, The night nurse showed me the empty card when I took over and did the count yesterday morning, I called the on-call for doctor (name), I never got a call from on-call, so I called doctor (name), and I had to leave a voicemail because he didn't answer. I called a second time with no answer, then I called Doctor (name he's our medical director, and he said I could go ahead and call the Lyrica to the pharmacy under him, because I'm an agent under him. The ADON was asked, Why did it take 5 days before someone said anything or ordered the meds. The ADON stated, That's the first I had heard about it, doesn't make any sense to me. The ADON was asked, Why should the nurse contact the physician when a resident runs out of medication or needs a new script? The ADON stated, So the resident doesn't run out. That tells me they weren't paying attention to what they were giving or paying attention to the MAR. The ADON was asked, How do you ensure medications/narcotics are documented for accurate counts? The ADON stated, Nurses count each shift and any discrepancies we contact unit manager. The ADON was asked, Why should medication/narcotic records be accurate when documenting administration of the medications? The ADON stated, So you know the resident got the medication and it's not diverted.

Based on observation, interview, and record review, the facility failed to ensure staff washed and/or sanitized their hands during meal service in the facility's dining room to prevent cross-contamination which had the potential to affect the 23 residents residing in the dining area, that the laundry workers handled resident garments in a manner that avoided contamination, and that The findings are: 1. On 03/18/2024 at 12:19 PM, the Surveyor observed a Registered nurse (RN) get a soft drink out of the vending machine for a resident. The RN then picked up a tray to deliver to a resident at a table, then while going back to get another tray placed his/her hands in their pocket. The RN then touched his/her face before picking up another tray to deliver to a resident without sanitizing their hands. a. On 03/18/2024 at 12:32 PM, the Surveyor observed a Certified Nursing Assistant (CNA) pick up a chair, move it over to the table, move their hair away from their face, and begin feeding a resident without sanitizing hands. b. On 03/18/2024 at 12:32 PM, the Surveyor observed a CNA sit down to feed a resident. After feeding a few bites, the CNA removed a cell phone from her pocket and used it while feeding the resident without ever sanitizing hands. c. On 03/18/2024 at 12:39 PM, the Surveyor observed a CNA sitting between 2 residents feeding them. The CNA did not sanitize hands in between feeding each of them a bite. 5. On 03/21/2024 at 10:48 AM, RN #2 was asked, What should happen after passing out a tray, and before passing out another tray? RN #2 replied, Wash your hands. The Surveyor asked, What should happen after passing out trays before starting to feed a resident? RN #2 replied, Wash your hands. The Surveyor asked, What could the outcome be for not sanitizing/washing hands in between residents? RN #2 replied, Cross contamination. d. On 03/21/2024 at 10:53 AM, CNA #5 was asked, What should occur when sitting in between 2 residents and feeding them both? CNA #5 stated, Sanitize your hands. The Surveyor asked, What can occur from not sanitizing your hands in between feeding 2 residents? CNA #5 stated, Pass infections or bacteria to them both. e. On 03/21/2024 at 10:58 AM, CNA #10 was asked, What should happen before starting to feed a resident? CNA #10 stated, Sanitize your hands. The Surveyor asked, Should a staff member be on their phone while feeding a resident? CNA #10 stated, No, but I play music for them. The CNA was asked, Should a staff member sanitize their hands after touching the phone before starting to feed again? CNA #10 confirmed they should. The Surveyor asked, What can occur from not sanitizing hands? CNA #10 stated, Spread germs. 2. On 03/19/2024 at 03:57 PM, the Surveyor observed a laundry worker folding clean sheets. The sheets were touching the ground and he/she was folding them by holding them against their uniform. a. On 03/19/2024 at 04:00 PM, the Surveyor observed laundry worker pick up a white sweatshirt off the floor and place it in the clean clothes basket. b. On 03/19/2024 at 04:07 PM, the Surveyor asked the Laundry Aide, Can you explain how the proper way to fold laundry? The Laundry Aide stated, Just fold it. The Laundry Aide was asked, Is it proper for the sheets to touch the ground and your uniform? The Laundry Aide stated, No, but it is hard for them not to. The Surveyor asked, Can you explain what you should do with a clean clothing item that falls on the floor? The Laundry Aide stated, Place it in the dirty barrel to be rewashed. c. On 02/21/2024 at 10:52 AM, a policy was provided titled Infection Prevention and Control Manual that documented, .Hand Hygiene .Before and after assisting a resident/guest with meals . d. On 11/08/2023 at 09:32 AM, the Infection Preventionist (IP) was asked, What should happen between passing out trays from one resident to another? The IP replied, Wash your hands. The IP was asked, What should happen after passing trays before starting to feed a resident? The IP stated, Wash your hands. e. On 11/08/2023 at 11:30 AM, the (Director of Nurses) DON provided a policy titled Handwashing/Hand Hygiene that documented, Purpose: this facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 3. A Face Sheet indicated the facility admitted Resident #32 with diagnoses of Hemiplegia and Dementia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/2024 revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact. The resident required partial/moderate assistance for toileting and was always incontinent of bowel and bladder. Resident #32's Care Plan, reviewed 12/06/2022, revealed the resident was incontinent of bowel and bladder. Interventions included peri care after each incontinent episode, initiated 05/15/2018; disposable brief program, initiated 05/15/2018. On 03/21/2024 at 11:04 AM, CNA #10 and CNA #11 entered Resident #32 ' s room. CNA #10 and CNA #11 did not perform hand hygiene. The CNAs applied gloves. CNA #11 moved Resident #32 ' s bed away from the wall and positioned self between the bed and wall. CNA #11 did not perform hand hygiene and did not change gloves. CNA #10 pulled the privacy curtain with gloved hands. CNA #10 did not change gloves and did not perform hand hygiene. CNA #10 obtained two plastic bags and placed at the head of Resident #32 ' s bed and near Resident #32 ' s head. CNA #10 obtained a package of premoistened wipes from the nightstand and placed them on Resident #32 ' s bed. CNA #10 performed incontinence care, during which they did not change gloves and did not perform hand hygiene. CNA #10 picked up the premoistened wipe package with both gloved hands, placed the package on the nightstand. CNA #11 rolled Resident #32 toward the wall. CNA #11 placed a clean brief under the dirty brief and under Resident #32, then removed the dirty brief using the same dirty gloves. CNA #10 stated, I'm in a rush, I need to slow down. Using the same dirty gloves, CNA #11 obtained the package of premoistened wipes from the nightstand, placed on the bed, and using the left hand, held the premoistened package of wipes, while removing wipes from the package using the right hand. CNA #10 continued performing incontinence care, during which they did not change dirty gloves and did not perform hand hygiene. CNA #10 removed a package of skin protectant from the basket using the same dirty gloves. CNA #10 opened the package of skin protectant, squeezed the package with the left hand, and placed the skin protectant into the right hand. CNA #10 applied skin protectant to Resident #32 ' s genitals and in between both legs on the anterior side. CNA #10 removed the used gloves and placed into the trash, then stated, I forgot to change gloves, you are supposed to change gloves when doing perineal care. On 03/21/2024 at 12:03 PM, CNA #10 was asked, When should hand hygiene be performed? CNA #10 stated, Before, during, and after care. CNA #10 was asked, When should gloves be changed when doing perineal care? CNA #10 stated, Before, during, and after. CNA #10 was asked, Why should hand hygiene / change gloves be performed during perineal care? CNA #10 stated, To keep from transferring germs. On 03/21/2024 at 12:05 PM, the Assistant Director of Nursing (ADON) was asked, When should hand hygiene be performed? The ADON stated, Anytime you enter or leave the room, before providing care, when you complete care for a resident, when gloves become soiled. You should sanitize before putting clean gloves on. The ADON was asked, When should gloves be changed when doing perineal care? The ADON stated, Change gloves before going to a different area and if they become soiled. The ADON was asked, Why should hand hygiene/changing gloves be performed during perineal care? The ADON stated, To prevent infection, to prevent the staff from giving anything to a resident or transferring anything from a resident. On 03/21/2024 at 12:16 PM, the DON was asked, When should hand hygiene be performed? The DON stated, Prior to entering the room, in between tasks, when visibly soiled and dirty. The DON was asked, When should gloves be changed when doing perineal care? The DON stated, When visibly soiled. The DON was asked, Why should hand hygiene/changing gloves be performed during perineal care? The DON stated, To prevent infection. A facility policy titled, Hand Hygiene, dated June 11, 2020, specified, To provide guidelines to employees for proper and appropriate hand washing techniques that will aid in the prevention of the transmission of infections. Hand washing should be performed between procedures with the resident/guest(s) based upon the principle that all blood, body fluids, secretions, excretions (except swear), non-intact skin, and mucus membranes may contain transmissible infectious agents. If hands are not visible soiled, use an alcohol-based hand sanitizer for routinely decontaminating hands in all clinical situations other than those listed under Handwashing above. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: when hands are visibly soiled (hand washing with soap and water); before and after direct resident/guest contact (for which hand hygiene is indicated by acceptable professional practice). Before and after assisting a resident/guest with personal care (e.g. oral care, bathing). After contact with a resident/guest(s) mucous membranes and body fluids or excretions. After handling soiled or used linens, dressings, bedpans, catheters, and urinals. After handling soiled equipment or utensils. After removing gloves or aprons. Consistent us by staff of proper hygienic practices and techniques is critical to preventing the spread of infections.

Based on record review and interview the facility failed to ensure Care Plan interventions were in place to prevent a fall for 1 (Resident #1) of 1 (R #1) sampled resident. The failed practice resulted in past non-compliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #1, who was at risk for falls and was left without the bed alarm that was Care Planned. This failed practice had the potential to cause more than minimal harm to 1 resident who was at risk for falls and had a fall that resulted in an ankle fracture as documented on a list provided by the Medical Records Clerk on 12/16/22. The Administrator was informed of the past immediate jeopardy condition on 12/15/22 at 12:21 PM. The Findings are: 1. R #1 had Diagnoses of Urinary Tract Infection, Alzheimer's Disease, Anxiety, and Hypertension, Admission MDS (Minimum Data Set) with an ARD (Assessment reference Date of 11/29/22 documented a BIMs (Brief Interview for Mental Status score of 4 (Severely cognitively impaired), required extensive assist with bed mobility, transfers, dressing, and personal hygiene, toileting, and bathing. a. R#1 was discharged from facility per discharge list provided by the Director of Nursing (DON) on 12/14/22. b. A Nurse's note dated 12/2/2022 documented, 2:51 PM Resident (R #1) got herself out of her bed, lost balance and fell to floor. Able to do ROM (Range of Motion) within Resident's usual range. No apparent injuries. Assisted back to bed. Notified Dr. (Doctor) [name] with orders for neuro checks x72 hrs [hours]. Daughter [named] notified. The electronic charting was signed by Licensed Practical Nurse (LPN) #1. c. A Nurse's note dated 12/2/22 at 11:24 PM documented, .Resident's [R #1] daughter here at 3:30 PM asked for Tylenol and ice pack for resident [R#1] states resident is C/O (complaining of) pain to right lower leg. Upon examining right lower leg large, raised area noted, no discoloration or heat noted from area, but resident screamed out in pain with light palpitation. Dr. [name] notified new order received to send to ER [emergency room ] via [by way of] EMS [Emergency Medical Service]. EMS notified here at 4:05 PM for transport. Resident in severe pain, EMTs [Emergency Medical Technician] applied splint to leg before transfer to gurney resident was combative due to pain. Resident left facility at 4:25 PM Daughter to meet at hospital. d. On 12/15/22 at 8:28 AM, the Surveyor asked LPN #1, Tell me about [R #1's] fall on 12/2/22. LPN #1 stated she was working on 12/2/22 when an assistant, not sure which one, came and told me that they found [R #1] on the floor. It was just before the end of my shift when she fell . I went immediately to assess her. She thought she was ambulatory, but she wasn't well she wasn't safe. She was confused and was yelling 'get me up', 'get me up'. She told me she was trying to walk to the bed side commode and fell . I assessed her range of motion and her vital signs. She was fine. We assisted her back to bed, and she didn't complain of anything bothering her. I asked her if her hips were hurting, and she said no. She calmed down and wasn't yelling after we got her back in bed. I notified the doctor and he ordered neuro checks every 15 minutes. I can't remember if I or [LPN #2] notified her daughter. It was change of shift, so I gave report to [LPN #2], who works the second shift. The Surveyor asked LPN #1, How often do you do neuro checks after an unwitnessed fall? She stated, We do them every 15 min [minutes] for 4 hours then every 30 minutes for 4 hours then every hour for four hours. She stated, [R#1] was usually confused and hollers sometimes . I was off a few days. When I returned, I found out she was in the hospital with a fractured ankle. e. On 12/15/22 at 9:08 AM, the Director of Nursing (DON) stated, We don't have the neuro check documentation for [R #1]. The Surveyor asked the DON, What is a potential negative outcome if the neuro checks are not completed/documented when a physician has ordered them for a resident after a fall? The DON stated, If something was going on they couldn't watch it. f. On 12/15/22 at 9:17 AM, R #1's Care Plan dated 11/29/22 was reviewed. The Care Plan documented, .At risk for falls .Tab alarm while in bed .tab alarm while in chair .PT (Physical Therapy) for eval .Night light .Nonskid footwear . g. On 12/15/22 at 9:45 AM, the Surveyor asked LPN #1, Was [R #1's] bed alarm sounding when she fell ? LPN #1 stated, No, we don't use alarms. The Surveyor asked, Was she wearing nonskid socks? LPN #1 stated, She had socks on, but I can't tell you if they were nonskid or not. h. On 12/15/22 at 9:47 AM, the Surveyor asked the DON, Did [R #1] have a bed/chair alarm? She stated, I don't know why that is on her care plan. We don't use alarms. i. On 12/15/22 at 9:47 AM, the DON stated, We use the Incident policy as our fall policy. We don't have fall Assessment's in our computer system. When she was asked for R #1's Fall Assessment and the facility's fall policy. j. An I&A (Incident and Accident) report provided by the DON dated 12/2/22 documented, R #1 .Immediate Post-Incident Action: FALL MAT NEXT TO BED . k. Nursing Management Manual policy provided by the DON on 12/15/22, titled: Incidents and Accidents documents, .when an accident occurs, prompt response and reporting occur. Process: assess resident . Access neurological signs, notify family, Notify physician. Remember, fractures in the elderly, .cannot readily be detected visually. Frequently, the elderly does not experience pain .Interventions should be documented in the nurse's notes .initiate investigation . l. The [named] hospital document received from the DON on 12/15/22 documented, 12/2/22 .R #1 .closed fracture of right lower leg . m. On 12/15/22 at 10:57 AM, The Surveyor asked CNA #1 (Certified Nursing Assistant) who was working the South Hall on 12/2/22, Will you tell me about [R #1's] fall on December 2nd [second]? CNA #1 stated, She was down on the floor. I think she had Dementia because she was talking about a plane crash. The nurse came in and made sure she was okay, and we put her to bed. The Surveyor asked CNA #1,, Did you see anything unusual? She stated, Nothing we could see. n. On 12/15/22 at 11:44 AM, the Surveyor asked the DON, Should the bed alarm have been in place for [R #1] since it was care planned? She stated, No, because it is considered a restraint and we don't use them. o. On 12/15/22 at 11:44 AM, the Surveyor asked the DON, Should the neuro checks been done since they were ordered by the physician after [R #1] was found on the floor? She stated, Yes. p. On 12/15/22 at 12:20 PM, the Surveyor asked the Administrator, Who is responsible for ensuring the Care Plan interventions are correct and being followed? The Administrator stated, The Care Unit Manager and the nursing sub committees discuss those throughout the week.

Based on observation, record review, and interview, the facility failed to ensure the resident environment was as free of accident fire hazards as possible, as evidenced by failure to immediately remove electrical power strips and extension cords that were improperly used in the facility before and after an incident where a power strip malfunctioned. This failed practice resulted in noncompliance at the level of Immediate Jeopardy that had the potential to cause serious injury, harm, or death to all 94 residents residing in the facility according to a Resident Census List provided by the Director of Nursing (DON) on 12/1/22. The Administrator was informed of the Immediate Jeopardy condition on 12/1/22 at 5:25 PM. The findings are: 1. During a facility tour on 12/1/22 between 11:25 AM and 12:45 PM, The Surveyor asked the Maintenance Director (MD) to enter each resident room and identify if there was an electrical power strip or electrical extension cord in the room and if he could identify what was plugged into it. The following observations were made: a. At 11:28 AM in [named] resident room the MD stated, There is an extension cord with a [oxygen] concentrator. The extension cord with an oxygen concentrator was plugged into the power strip that was plugged into an electrical outlet. b. At 11:30 AM in [named] resident room the MD stated, a power strip with a bed. the resident's bed was plugged into an electrical power strip that was plugged into an electrical outlet. c. At 11:31 AM in [named] resident room the MD stated, A power strip with a [electric] wheelchair charge box .a power strip with a bed and phone charger .I try not to overload them [power strips]. The resident bed and phone charger were plugged into an electrical power strip that was plugged into an electrical outlet. d. At 11:35 AM in [named] resident room the MD stated, A power strip with a concentrator, C-Pap machine, phone charger and updraft machine. An oxygen concentrator, Continuous Positive Airway Pressure (C-Pap) machine, phone charger and an [oxygen] updraft machine was plugged into a power strip that was plugged into an electrical outlet. e. At 11:36 AM in [named] resident room the MD stated, A big one [power strip] oxygen concentrator, humidifier, updraft, C-pap, they have one plugged up from this big one to another one to go to that one .I guarantee you I didn't put it like that .they have her bed plugged in . A large power strip with an oxygen concentrator, humidifier, updraft, C-pap, and a second power strip was plugged into the first one and a third plugged into the second power strip. The third power strip had a small refrigerator and a tablet charger plugged into it; a power strip with a resident bed plugged into it. The power strips were plugged into an electrical outlet. f. At 11:40 AM in [named] resident room the MD stated, Power strip with phone charger, cooler, fan. An electrical power strip with a phone charger, small refrigerator cooler and a fan were plugged into the power strip that was plugged into an electrical outlet. g. At 11:41 AM in [named] resident room the MD stated, Power strip with phone charger, bed, tablet charger. A phone charger, resident bed, and tablet charger were plugged into an electrical power strip that was plugged into and electrical outlet. h. At 11:43 AM in [named] resident room the MD stated, Power strip with [phone] charger and bed. A phone charger and resident bed were plugged into an electrical power strip that was plugged into an electrical outlet. i. At 11:44 AM in [named] resident room the MD stated, Power strip with o2 [oxygen] concentrator and refrigerator. An oxygen concentrator and small refrigerator were plugged into an electrical power strip that was plugged into an electrical outlet. j. At 11:45 AM, Certified Nursing Assistant (CNA) #1 approached the MD and stated, .I wanted to say something about the extension cords .I didn't think she should have one plugged into another one . The MD stated, You should have said something, that is a fire hazard. Next time, say something. k. At 11:53 AM in [Named] resident room the MD stated, a breathing machine .not safe .exposed wire . An oxygen updraft machine with exposed wire connectors connected the original power cord coming from the machine to another piece of power cord. The machine was not connected to a power source at the time and the MD removed it from the resident room. l. At 12:01 PM in [Named] resident room the MD stated, Power strip with o2 concentrator, fan, refrigerator An oxygen concentrator, fan and small refrigerator were plugged into an electrical power strip that was plugged into an electrical outlet. m. At 12:08 PM in [Named] resident room the MD stated, That shouldn't be here .a regular extension cord with a TV. A small brown regular household extension cord without a ground prong with a tv plugged into it. The extension cord was plugged into an electrical outlet. n. At 12:28 PM in [Named] resident room the MD stated, A brown extension cord with the ground cut off .there is a clock and a power strip plugged in the extension cord with a phone charger. A small brown regular household extension cord with the ground plug removed-a clock and a power strip plugged in, the power strip had a phone charger plugged into it. The extension cord was plugged into an electrical outlet until the MD unplugged it from the outlet. p. At 12:37 PM in [Named] resident room the MD stated, Power strip and bed. A small refrigerator and a resident bed were plugged into an electrical power strip that was plugged into an electrical outlet. q. At 12:42 PM in [Named] resident room the MD stated, Power strip going into the other, into the wall, computer modem, bed, not that is the mattress, and a power strip, it has a charger, bed, computer charger. There was a power strip plugged into an electrical outlet with a computer modem, low air loss mattress, and 2nd [second] power strip. The 2nd power strip had a phone charger, resident bed, and computer charger plugged into it. r. At 12:46 PM, the MD stated, .Extension cords shouldn't be in play, and we found 2-3 power strips plugged into each other .concentrators shouldn't be in a power strip because they pull a lot .or anything like a C-Pap . The Surveyor asked if any kind of medical equipment should be plugged into an electrical power strip or extension cord. He stated, I do know that that can be an issue. 2. On 12/1/22 at 12:53 PM, the Surveyor asked the MD if knew of any incidents that occurred with power strips. He stated, .got a call the fire alarm went off .a power strip that faulted and all they had in it was a TV [television] .I came and did an inspection on that hallway and reported it to The Administrator. The Surveyor asked when this occurred. He stated, Maybe 2 weeks ago. 3. On 12/1/22 at 3:12 PM, The Surveyor asked The Administrator, What the policy is for the use of extension cords and power strips in the facility? She stated, .We are not supposed to use them. We have .has 4 plugs on them, an adapter rather than extension cords .I haven't done an audit, but I will . The Surveyor asked, Was there an incident with a power strip? She stated, .We had a spark .Maintenance came in and handled it. I asked him if it was an approved plug, he said he thought so, if any resident was harmed, if there was smoke, he said everything was cleared The Surveyor asked, Should power strips be plugged into another power strip for use? She stated, absolutely not. The Surveyor asked if medical equipment such as an oxygen concentrator, should be plugged into a power strip. She stated, no The Surveyor asked if a non-grounded extension cord be used. She stated, no. The Surveyor asked the Administrator, Do you have any documentation about the incident with the power strip? She stated, I don't know, I'll have to look. I don't think I did a soft file on it. The Surveyor asked the Administrator for a policy and procedure for the use of electrical power cords and electrical extension cords. 4. On 12/1/22 at 3:30 PM, the Surveyor asked the Administrator, When did the incident with the power strip occur? She stated, .Saturday October 29th, the strip itself is what sparked. It only had a television plugged into it, so we threw it away. About 3:30 in the afternoon, He [Maintenance] checked the plug, he said it was fine. It was on the secure unit, no one was in the room. We put up the window, there was not smoke, but you could smell a plasticky smell so the windows were opened. The resident across the hall smelled it and alerted the staff . 5. On 12/1/11 at 3:39 PM, the Surveyor asked the MD, Just to clarify, did the power strip catch on fire, spark, smell? If the alarm went off, did the fire department come? He stated, .It was heating up the plastic of the power strip. A nurse called me to let me know, I could hear the alarm in the background. The fire department did come and cleared it before I got here .I came in and checked the room and every other room [on that hall] to make sure everything was ok .to make sure that nothing else was happening and the residents were safe and that there was no other reoccurrence in another room . 6. On 12/1/22 at 6:08 PM, The Administrator handed The Surveyor a document and stated, This is the only policy I could find. It is old. The Policy documented, .Electrical Equipment .Power Cords/Extension Cords .To verify National Health Service (NHS) Facilities utilize power cords and extension cords per Centers for Medicare and Medicaid Services (CMS) and adopted National Fire Protection Association (NFPA) requirements . The Surveyor asked the Administrator if the facility had any other policy or resident instruction at admit that addressed the use of power strips or extension cords. She stated she would look. The Immediate Jeopardy was removed on 12/1/22 when the facility implemented the following Plan of Removal: POC Legacy: 1. On 12/1/22, upon learning of the IJ facility in-serviced all staff present how to properly utilize power strips for residents in the facility. 2. Facility will in-service all other nursing staff prior to the start of their shift how to properly utilize power strips for residents in the facility. 3. Facility will immediately audit patient room to ensure there is no unsafe utilization of power strips and remove any possible hazards immediately. 4. Facility will have all hazardous power strip situations removed by 7:00pm. 5. Administrator/designee will monitor for any hazardous power strip situations daily in each resident room for at least 7 days, and then weekly thereafter.

Based on record review and interview the facility failed to ensure pain management consistent with professional standards of practice was provided for one resident (resident #1) of six (R#1, R#2, R#3, R#4, R#5, R#6) residents reviewed who were admitted with Physician Orders for pain medication. This failed practice had the potential to affect 1 resident who was at risk of pain due to fracture and resulted in past immediate jeopardy that caused or was likely to cause serious harm, injury, or death to Resident #1. The Administrator, Director of Nursing (DON) and the Consultant were notified of the Past Immediate Jeopardy (IJ) on 10/12/22 at 9:38 AM. This failed practice had the potential to affect 1 resident who was at risk of lack of pain medication due to fracture. The findings are: 1.R#1 was admitted to the facility on [DATE] at 6:30 pm with Diagnoses of closed three (3) part fracture of proximal end of right Humerus post repair for aftercare. Acute midline back pain, and frequent falls. A 5-day Medicare Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/04/22 documented a scored 15(13-15: Cognitively Intact) on the brief interview of mental status (BIMS), required extensive one-person physical assistance for bed mobility, toileting, dressing, two-person extensive physical assistance for transfer, and limited one person assistance for eating. Section J documented received as needed (PRN) pain medication per resident interview. J0400 frequency 2. Frequent. J0500B limited daily activities J0600 verbal descriptor scale 2. Moderate and Received Antidepressant and Opioids 5 of the 7-day look back period. a. On 10/11/22 at 8:42 am, Record Review of resident # 1's Physician Order dated 09/28/22 documented . Percocet 7.5/325 MG (milligram) tablet give one tablet by mouth every four hours as needed. (Do not exceed more than 3 grams of Acetaminophen in 24-hour period. Dx [Diagnosis] pain . b. On 10/11/22 at 8:42 am, Record Review of resident # 1's September 2022 Medication Administration Record (MAR) documented .Percocet 7.5/325 mg tablet give one tablet by mouth every 4 hours as needed. Order date 09/28/22 . The MAR documented the first dose of pain medication was given on 09/29/22 at 9:28 pm. 27 hours after admission to facility. c. On 10/11/22 at 8:42 am, Record Review of resident # 1's progress note dated 09/29/22 at 3:15 pm .called Omnicare pharmacy to follow up on Percocet Pharmacy did not fill, unable to read signed script faxed when resident arrived 09/28/22, had called and spoke with staff earlier that day and was refaxed to backup pharmacy in town and driver would deliver at 7 pm. At 10:39 pm it had not arrived; driver had gone to back up pharmacy to pick up medication and it was not filled because only one tablet on hand. Medication arrived at 9:25 pm, resident medicated at 9:28 pm for pain . d. On 10/11/22 at 8:42 am, Record Review of resident # 1's Physical Therapy Treatment Encounter Note dated 09/29/22 at 12:51 pm documented . Pt.[patient] in bed. The Pt was unable to tolerate sitting up fully or transferring out of bed due to no pain meds given since hospital discharge and she was in excruciating pain. Nursing was working on getting pain meds for patient and is aware of issue . e. On 10/11/22 at 2:20 pm, OT # 1 was interviewed and asked to tell surveyor about OT (Occupational Therapy) services provided for R # 1 on 09/29/22. OT # 1 stated, I did the evaluation, resident # 1 came in with a total shoulder repair. She was very pain affected, had a terrible night, for the first 24 hours. She didn't want to get out of bed. f. On 10/11/22 at 2:30 pm, a phone interview was completed with PT #1. The Surveyor asked PT # 1 to tell about PT (Physical Therapy) services provided for R# 1 on 09/29/22. She stated, R#1 couldn't tolerate anything much at all that day. I would say pain level was an 8 out of 10. Resident # 1's facial expression was so that you could see the pain in her face, tired, and kept verbalizing how bad she was hurting. I went to the nurse, she said they were waiting on the pharmacy. That seems to happen quite a bit, more than once. Once she got the pain meds, she worked with me fine. g. On 10/11/22 at 2:40 pm, The Surveyor interviewed and asked Licensed Practical Nurse (LPN) # 1 if resident # 1 had any pain on 09/29/22 and if any pain medication or Sertraline was given that day. LPN#1 said yes, I didn't give any pain medication or Sertraline. h. On 10/11/22 at 3:30 pm, The Surveyor interviewed and asked Registered Nurse (RN)#1, What the facility admission process was and if she completed R#1's admission? She stated, yes, I did. Resident # 1 came with a hard script for Percocet from the hospital. I got all the orders sent to the Pharmacy before 10:00 pm. I worked until 1:00 am that day. The next day I worked the 3:00 pm to 11:00 pm shift as medication nurse. When the narcotic count was done, I asked if we hadn't received Resident # 1's pain medication and I called the Pharmacy, Medical Records had refaxed to backup pharmacy, they only had one pill and didn't fill it. I contacted the pharmacy, as soon as it came in, I logged it in the narcotic log and gave it immediately. The Surveyor asked, if the order sent to the pharmacy on admission on 06/28/22 had been confirmed as received by fax or phone call to the pharmacy? She stated, I usually should but they usually call within thirty (30) minutes if they can't read it, or allergy information isn't listed. i. On 10/11/22 at 4:00 pm, an interview with the Administrator and RN # 2 was completed. Both were asked for the policy and procedure for Admission medication ordering and if it was acceptable for a post-surgical resident to not have pain medications available until 27 hours after admission. RN# 2 stated there was a policy and would look for it. Both stated it was not acceptable. The facility should have medications for new admissions in the building within four hours of admission. j. On 10/11/22 at 5:02 pm, a phone interview was completed with R#1. The Surveyor asked, how was the care received at the facility? She stated, The first two days were really bad. The evening I went over there I was post op and it was 36 (thirty-six) hours before I got any pain medication. My pain level was an 8 (eight) out of 10 (ten). k. On 10/12/22 at 9:20 am, The Surveyor asked LPN # 2 why resident # 1's Physician was not notified that the pain medication had not been received or order requested for alternate pain medication? LPN # 2 stated, I don't know, I wasn't aware, I don't know why usually the admit nurse checks on it. The Surveyor asked LPN # 2 if a pain assessment was completed on resident #1? LPN # 2 stated, There is a pop-up assessment, I don't know if resident # 1's came up for completion. Requested copy of any pain assessment at 9:20 am. l. On 10/12/22 at 12:10 pm, the Assistant Director of Nursing (ADON) stated If the pain assessment isn't on the MAR it wasn't done. 2. On 10/12/22 at 12:20 pm the Policy and Procedure titled Admission of a Resident documented .V 2. Notify pharmacy of new admission, medication and treatment orders and any allergies . The Quality-of-Care Change in Medical Condition of Residents documented .PURPOSE: To keep the Physician, who is in charge of medical care, and family members/legal representatives, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed. STANDARD: Notification of the physician, legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident's condition. Change in condition is defined as: A change in the resident's physical, mental or psychosocial status (i.e., a deterioration in health, mental or psychosocial status in either life-threatening condition or clinical complications) a need to alter treatment (i.e., a need to discontinue an existing form of treatment due to adverse consequences, of or to commence a new form of treatment . m. On 10/12/22 at 9:38 AM, the Surveyor notified the Administrator, Director of Nursing (DON) and the Consultant of the Past IJ. Timeline sent to office for review for what level tag, email response past IJ, Administrator and Registered Nurse Consultant notified at 9:23 am and case mix expanded. Requested additional information on policy and procedure, in services to staff of admissions, pharmacy med orders. Requested additional pain scale assessments if any on R # 1- R # 3 expanded sample to include three more residents admitted in the last 60 days with pain medication orders. Administrator notified past IJ at 9:38 AM on 10/12/22-------

Based on observation, record review and interview, the facility failed to ensure a resident who was at risk for elopement and was actively exhibiting exit-seeking behaviors was redirected in accordance with the plan of care to prevent elopement, when staff observed the resident heading toward the front of the facility unattended for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents who had exit-seeking behaviors. The failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who exited the facility undetected by staff, and had the potential to cause more than minimal harm to 9 residents who were at risk for elopement, as documented on a list provided by the Administrator on 10/1/21 at 9:00 AM. The Administrator was notified of the past immediate jeopardy situation on 10/1/21 at 1:55 PM. The findings are: 1. Resident #1 was admitted to the facility on [DATE] and had a diagnosis of Alzheimer's Disease. The Admission Minimum Data Set (MDS) was not yet completed at the time of the survey. An Admission assessment dated [DATE] at 12:24 PM by the Assistant Director of Nursing (ADON) documented, .Ambulated into facility with steady gait. Alert and oriented to self only . Wanderguard placed to left ankle . a. A Nurse's Note dated 9/28/21 at 3:18 PM documented, Resident is alert and oriented to self. Resident is very confused and exit seeking. Resident gets around on his own . b. An Elopement Risk Review dated 9/28/21 at 3:19 PM documented, .Risk Factor of Elopement (pick all that apply): Short-term Memory Problem, Alzheimer's or other Dementias, New Admission . Other Risk Factors (check all that apply): Has symptoms of confusion and can ambulate or propel wheelchair or other mobility device without assistance, Resident has packed his / her belongings in a suitcase, carryall or sack . Wandering: risk of getting to dangerous place: Yes . Resident is at risk related to: Intervention(s) in place to minimize risk of elopement . c. The Care Plan dated 9/28/21 documented, Potential for Elopement . Intervention . Listen and observe for potential signs of elopement . Redirect with conversation, activities, food, fluid, toilet, ambulation, appropriate exercise when observed exit seeking . Contact family / responsible party to sit with resident when exit seeking / exit attempts are observed . Alarm bracelet at all times - to left ankle . d. A Nurse's Note dated 9/29/21 at 2:54 PM documented, Resident is alert and oriented to self. Some confusion noted. Resident mood has be [been] calm, and somber. Resident has been sitting down by the back door, with his bags packed . e. A Nurse's Note dated 9/29/21 at 4:26 PM documented, 3:10 PM during shift change resident noted to be outside the facility. Resident was ambulating with no problems with his overnight bag in his hand. Resident's wanderguard was in place and in working condition at this time. Resident was seen at the SE [Southeast] door just prior to being found outside the building . f. On 10/1/21 at 11:55 AM, Certified Nursing Assistant (CNA) #1 was asked, Can you tell me what transpired when you found [Resident #1] outside the facility? She stated, I had clocked out going home at 3:11 PM and went down the sidewalk in front of the facility. I was parked just across the alleyway between the facility and parking lot, where I was parked. He was standing in the alleyway approximately 122 feet from the front door. The CNA took the Surveyor to the area where the resident was found. Main Street was approximately 40 feet from where the resident was found. CNA #1 stated, It was also time for school to be let out, active, cars going both ways up and down 50th Street. He was dressed in street clothes carrying a floral tote bag. It was bigger than a purse but not bigger than a suitcase. I didn't recognize him as a resident. I suspected he was here to visit his wife and didn't know where to go. So, I started asking him if I could help, and he answered, but I was unable to understand him. He was confused. I asked him if we could go in and possibly find somebody that could help, and he came willingly. We went into the front door, and I told him to wait right there in the sitting area. It was shift change, and there were several residents with Wanderguards in the sitting area, so when I brought him through the front door, his or other residents Wanderguards could have set off alarms. I went to 3 nurses that were counting meds [medications] and asked if he was a resident or a resident's spouse or family. By this time, he was right behind me. One of the nurses told me he was a resident, and his room was on the Southeast Hall. I told her I had found him in the alleyway next to the street. They immediately went to the Administrator and started investigating what had happened and had me fill out a witness statement. I then went out with [Nurse Educator] and showed her like I did you. She took pictures of all different directions he could have come from, because no one, to my knowledge, knew what door he went out of. I suspect since he resided on Southeast Hall, he exited Southeast door into the alley. I was in- serviced on elopement the very next morning, then we all had an elopement drill yesterday afternoon. g. On 10/1/21 at 12:52 PM, Licensed Practical Nurse (LPN) #1 was asked, What do you know about the elopement of [Resident #1]? She stated, I was here the day he was admitted on [DATE]. He was assigned to my hall. We placed a Wanderguard on him at the time, because his wife told me he had really bad Sundowner's. The day he got out; I had been watching him all day. He had his bags packed all day, but not at the back Southeast exit door until 2:30 PM. That day, he was sitting in a chair. At 3:00 [PM], I heard the Southeast door alarm. I went to check on him, but he was in his room. I saw him immediately after this, heading up East Hall toward the front with his bag. We were in the middle of shift change. I was talking to one of the other nurses, and that's the last time I saw him. She was asked, What did you do when you saw him going toward the front of the facility? She stated, I did nothing, because there was a lot going on - shift change - I was also aware that he had been pushing on the Southeast door, because a CNA told me he had been pushing on that Southeast door. He'd been pretty depressed since he'd been here. He told me his wife did not love him anymore. 2. The facility removed the immediate jeopardy and corrected the failed practices on 9/29/21, prior to the survey, as evidenced by the following: a. A Care Plan revision dated 9/29/21 documented, Resident to be a 1:1. b. A Quality Issue / Problem form dated 9/29/21 and provided by the Director of Nursing (DON) on 10/1/21 at 1:49 PM documented, .Quality Issue/Problem: Resident [Resident #1] was found 150 feet from the front door of the facility at about 3:10 PM. Action: Resident was brought back into the facility and placed 1:1 [one-on-one supervision]. ADON [Assistant Director of Nursing] performed body audit with no negative findings found. Maintenance Director checked all doors to assure the Wanderguard system is in good working order. Residents who reside in the facility and have a Wanderguard in place were checked to assure their Wanderguard is in place and in good working order. Staff will be educated on elopement policy, elopement book and door alarms. DON / Designee will conduct random Elopement drills daily for seven days, then three times a week for four weeks, then weekly until substantial compliance is met . c. A Policy and Procedure for Elopements and Wandering Residents, provided by the Nurse Educator on 10/1/21 at 1:42 PM, documented the procedure for the Elopement drill on 9/30/21. d. An Inservice sheet dated 10/1/21 documented, AT ANY TIME YOU SEE A RESIDENT PACKING BAGS, STANDING BY DOORS, ATTEMPTING TO OPEN DOORS, TALKING OF LEAVING BUILDING YOU MUST NOTIFY DON ADMIN [ADMINISTRATOR] CHARGE NURSE. THESE ARE SIGNS OF RESIDENT ATTEMPTING TO LEAVE. RESIDENT MUST BE PLACED ON ONE-ON-ONE AT THAT TIME TILL FURTHER NOTICE. THERE IS AN ELOPEMENT BOOK AT FRONT NURSE STATION WITH PICTURES OF OUR RESIDENTS AT RISK. PLEASE REVIEW DAILY FOR NEW ADMITS OR CHANGES IN RESIDENTS.

Based on record review and interview, the facility failed to ensure residents were free from staff-to-resident abuse and neglect, by failing to ensure immediate protective measures were implemented to prevent further abuse, after a resident and multiple staff members made allegations of physical abuse and neglect against Licensed Practical Nurse (LPN #1). The facility failed to ensure an allegation of physical abuse against LPN #1 was immediately investigated, protective measures were implemented to prevent further potential abuse, and that staff did not attempt to pressure the resident to keep quiet about the allegation for 1 (Resident #7); and failed to ensure allegations of neglect were investigated and immediate protective measures were implemented after staff alleged that LPN #1 failed to promptly respond when informed that residents had fallen and were on the floor for 2 (Residents #6 and #2) of 9 (Residents #1 - 9) case mix residents who received care from LPN #1. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Residents #7, #6 and #2, and had the potential to cause more than minimal harm to 101 residents who received care from LPN #1, as verified by the Director of Nursing on 4/26/18. The Administrator, Regional Administrator and Director of Nursing were informed of the immediate jeopardy condition on 4/10/18 at 7:00 a.m. The findings are: 1. Resident #7 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a brief interview for mental status (BIMS). On 4/4/18, the Office of Long Term Care (OLTC) was informed, by an anonymous source, that LPN #1 had been physically abusive to Resident #7 during a capillary blood glucose (CBG) test. The OLTC staff person reported the allegation to the Administrator via telephone call on 4/4/18. a. On 4/10/18 at 1:00 a.m., the resident was awake, in bed. The resident was asked if she was diabetic and stated, Yes. She was asked if she had to have Capillary Blood Glucose (CBG) testing to check her blood sugar and stated, Yes. She was asked if any of the nurses had been rough with her when checking her CBGs and stated, You're talking about Licensed Practical Nurse (LPN) #1) aren't you? The resident was asked what happened with LPN #1 and stated, She (LPN #1) got this finger (the resident held up the ring finger on her right hand), and she grabbed this finger and twisted it and bent it around to use it. I told her that she was hurting me, but she just kept doing it. It hurt when she got ahold and twisted my finger. I refuse to have her as my nurse. The resident was asked if anyone from the facility had come to talk to her about the incident and stated, The Social Worker came and talked to me about it. They came, the Social Worker and someone else, and talked to me and didn't want this to be reported to the state. b. On 4/10/18 at 1:10 a.m., LPN #2 was asked if she had ever received any complaints from residents regarding rough treatment by staff during CBG testing. The LPN stated, Yes, what do you want to know? Ask (Resident #7). They (facility administration) just cover for her - it's (LPN #1) - she's new. Residents and families have complained a lot about her, and they just protect her, because she's a new nurse. c. On 4/10/18 at 1:35 a.m., Certified Nursing Assistant (CNA) #2 was asked if she was aware of any complaints regarding a nurse being rough when checking a resident's CBG and stated, Yes, (Resident #7) was sitting up here at the back nurses' station, and she told me and 2 other CNAs that (LPN #1) came into her room to do her CBG the previous morning, on (3/11/18), and she (LPN #1) grabbed her (Resident #7's) finger and pulled it back. (LPN #1) continued to grab her finger and twisted her finger and wrist and took the CBG. She told us that it hurt when she twisted her finger and wrist, and also told us she didn't want (LPN #1) back in her room. All 3 of us got (LPN #3); she was in the medication room just behind the nurses' station. We told her exactly what the resident had told us. We all filled out witness statements and slid them under the Administrator's door. We were never talked to by anyone about this incident. I don't know what happened. d. On 4/10/18 at 2:05 a.m., CNA #6 was asked if she was aware of any nurse being rough with residents when checking their CBGs and stated, I've heard she bent (Resident #7's) finger and twisted it when she did her CBG. The nurse was (LPN #1). e. On 4/10/18 at 2:18 a.m., LPN #2 was asked if she was aware of any nurse being rough with residents when checking their CBG and stated, I heard the DON (Director of Nursing) say she had to talk (Resident #7) into not making a state reportable out of it, regarding (LPN #1) bending and twisting her finger. f. On 4/10/18 at 2:50 a.m., LPN #1 was asked about Resident #7's allegation that the LPN had hurt her finger while obtaining a CBG and stated, I don't recall (Resident #7) saying I hurt her finger when taking a CBG. She said after I poked her finger, she told me that wasn't the finger she wanted me to use. After the incident, after I chose a finger she didn't want me to use, (DON) and (Staff Development Nurse) gave me an in-service on (Resident #7) as a resident and how she likes things done and to be slower and make sure to ask her which finger she wants me to use. g. On 4/10/18 at 5:20 a.m., the Administrator was asked about the incident with Resident #7 and LPN #1 that took place on 3/11/18 and stated, I've never spoken with (Resident #7) about (LPN #1) hurting her. My knowledge is that Social Services went to the resident to take a statement. I told Social Services to let me know what she said. The Administrator was asked for this documentation and stated, I never asked for it. The Administrator was asked if the staff who had written witness statements regarding the incident had been interviewed in an effort to investigate the resident's allegations and stated, No, they haven't. She was asked why not and did not answer. The Administrator stated, I was aware that (Resident #7) didn't want (LPN #1) back in her room, because she went too fast. It just made sense not to let (LPN #1) back in there. The Administrator was then asked for the witness statements the staff had placed underneath her door on 3/13/18 and for her investigation of the incident. h. On 4/10/18 at 6:30 a.m., the Administrator provided the surveyors with 4 witness statements and a report sent to OLTC on 4/4/18. The OLTC Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated 4/4/18 documented, .Date and time of Discovery 4/4/18 at 10:30 a.m., date and time submitted : 4/4/18 at 5:00 p.m., Type of Incident: Physical Abuse. The Summary of Incident documented: On 4/4/18 (Name of person from OLTC) with the Office of Long Term Care phone administrator to inform that there was an allegation that a facility nurse had bent back a resident's finger during a CBG check Steps taken to Prevent Continued Abuse or Neglect During the Investigation . Nurse named in incident immediately suspended pending investigation. In-service started on Abuse, Neglect, and misappropriation of resident personal belongings along with facility policy/protocol. Collected witness/character statements from staff and alert/oriented residents. Administrator, DON, Police, and Responsible Party notified of allegation pending investigation. Investigation is ongoing. 1.) An OLTC Witness Statement Form dated 3/12/18 at 11:40 p.m. documented, .Witness Full Name: (CNA #1) . Shift: 11-7 (11:00 p.m. to 7:00 a.m.) . I witness (Resident #7) telling my co-worker (CNA #3) that a nurse (LPN #1) had got on to her and had jerked her finger while getting her CBG. I was not working on the day (Resident #7) claims this incident happened . 2.) An OLTC Witness Statement Form dated 3/12/18 at 11:45 p.m. documented, .Witness Full Name: (LPN #3) .(Resident #7) was sitting by the nurse's desk, and she spoke up, saying 'I don't like (LPN #1), she wrestled me down and twisted my fingers trying to get blood from it'. I reminded her (LPN #1) was a new nurse and didn't know how she liked things done yet. (Resident #7) replied 'I don't care I don't like her'. I personally did not witness the situation and do not know what happened, but I had worked with the nurse, (LPN #1) for a double shift and had not seen anything objectionable from her . 3.) An OLTC Witness Statement Form dated 3/13/18 at 12:10 a.m. documented, .Witness Full Name: (CNA #2) . Shift: 11-7 . (Resident #7) reported to this aide and co-aides that the nurse (LPN #1) walked into her room to check her blood sugar and tried to poke a certain finger. (Resident #7) told her not that one. Jerked away and nurse (LPN #1) yanked and twisted her finger to poke the one (Resident #7) told her not to .This was reported to nurse (LPN #3) . 4.) An OLTC Witness Statement Form dated 3/13/18 at 12:10 a.m. documented, .Witness Full Name: (CNA #3) Shift: 11-7 . (Resident #7) told us that she does not like the new nurse (LPN #1). I asked why and she said that she jumped all over her and twisted her finger and was very hateful . These Witness Statements were all dated during the night shift beginning at 11:00 p.m. on 3/12/18 and ending at 7:00 a.m. on 3/13/18; however, the report to OLTC was not completed until 4/4/18, after the OLTC staff person contacted the facility to report the allegation to the Administrator. i. On 4/10/18 at 6:30 a.m., CNA #2 was asked if Resident #7, when describing what LPN #1 had done during the CBG incident, had specified the date when the incident occurred and stated, The date of our Witness Statements is the date (Resident #7) told us about it. She said it had happened the morning before, which would have been the a.m. of the 11th (3/11/18). When we told (LPN #3), she said she had to call the Administrator about the allegation. We pulled the Witness Statements and filled them out and put them under the Administrator's door. I was never talked to by anyone in administration, and I don't believe the others have been either. If they had been, I'm pretty sure they would have told me. j. On 4/10/18 at 8:35 a.m., the Social Service Director (SSD) was asked about the Witness Statements for 3/12/18 and 3/13/18 regarding Resident #7 and LPN #1. The SSD stated, I don't believe I ever saw those Witness Statements. I went and spoke with (Resident #7) on 3/5/18 after the DON (Director of Nursing) told me about her finger. The Social Service Director was informed that the incident occurred on 3/11/18 and was reported to staff by the resident on the night of 3/12/18. The Social Service Director stated, The DON told me, after OLTC called on the 4th of April, that I needed to write up my interview I had with (Resident #7) on 3/5/18. I looked for paper copies of my interview and there are none. The Social Service Director was asked if a previous incident had occurred involving Resident #7 and LPN #1 on 3/5/18, since the surveyors were only aware of the incident that occurred on 3/11/18. The Social Service Director stated, I was told by the DON that it occurred on 3/5/18. k. On 4/10/18 at 8:55 a.m., the DON was informed of the SSD's statement that she was asked to document an incident on 3/5/18, involving Resident #7. The DON was then asked if an incident occurred with Resident #7 and LPN #1 on 3/5/18. The DON stated, She (SSD) got the 3/5/18 from me, because I believed the incident occurred on (Saturday) 3/3/18, because I had it in my head it was the weekend of (LPN #1's) second day of work. She was asked, if a nurse had worked 2 days, would she be caring for residents on her own? The DON stated, No, I guess I had the dates wrong. I thought it was 3/3/18 when I got the call (from staff regarding the incident). After me and the Social Service Director talked to (Resident #7), neither of us wrote anything up prior to OLTC notifying us on 4/4/18. The DON was asked when she first saw the witness statements dated 3/12/18 and 3/13/18 from the staff and stated, Honestly, I believe today is the first time I saw them. I knew we had gotten some witness statements, but I had not seen them. The Administrator had them, and I asked if there were any negative findings, as in something we needed to follow-up on, and she said, after talking with (Resident #7), that we had resolved it. I don't remember the exact wording. Me and (Social Service Director) talked to her (Resident #7) together once, and then I went down later that afternoon to make sure her story didn't change. She told us the nurse just went too fast. The DON was asked if she had documentation of any of their conversations with the resident and stated, There is no documentation of any of these conversations with the resident. She was asked if, during their investigation, they talked with the staff who initially reported the resident's allegations via witness statements dated 3/12/18 and 3/13/18 and stated, No. l. On 4/10/18 at 9:17 a.m., the Administrator was asked when she first received the Witness Statements dated 3/12/18 and 3/13/18 and stated, When I first got these statements, I had the Social Service and DON go talk to (Resident #7). I don't remember if I gave the Witness Statements to the Social Service Director or not. I may have just told her about it and had her talk to the resident. I'm sure I asked for the documentation from the Social Service Director and DON. I've never received any documentation after they talked with the resident. m. On 4/10/18 at 9:24 a.m., the Regional Nurse Consultant was asked when she was initially made aware of the Witness Statements dated 3/12/18 and 3/13/18 for (Resident #7) and stated, The first time I was aware of the Witness Statements for 3/12/18 and 3/13/18 was today, when you surveyors showed them to me. n. On 4/10/18 at 9:28 a.m., the Administrator was asked if the staff who had written the Witness Statements regarding the incident with Resident #7 had been interviewed after she received the call from OLTC on 4/4/18 and stated, When the reportable was initiated on 4/4/18, after the call from OLTC, none of the CNAs or the nurse who the resident initially reported the incident were interviewed. o. On 4/10/18 at 10:02 a.m., the Staff Development Nurse was asked if she was involved with the investigation regarding Resident #7's allegation of abuse from a nurse and stated, I don't know the dates, but it was brought to our attention. (DON) said there was an allegation that (Resident #7's) finger was bent back during a CBG. I was told about it before the phone call from OLTC on 4/4/18. I was told that they had gone down and spoke with the resident. I don't know if it was both (DON) and (Social Service Director). (DON) told me they felt that it was just hurried by the nurse, after speaking with the resident. (DON) and myself talked to (LPN #1) about slowing down and explaining what she was doing. I never saw any Witness Statements from staff who initially received the information from the resident. p. On 4/11/18 at 11:34 a.m., CNA #3 was asked about his witness statement dated 3/13/18 at 12:10 a.m. regarding Resident #7 and stated, When I came in at 11:00 p.m. on 3/12/18, she wanted out of bed. I told her to give us a bit, we were in the middle of shift exchange. We got her up and she wanted a cup of ice and I got her a cup of ice and she said, 'Boy (CNA #3) I tell ya', I don't know nothing about that new nurse, but I don't like her. I asked who she was talking about and she said, (LPN #1's name). I asked her why and she said (LPN #1) wanted to poke her finger and I told her, 'all the nurses have to poke your finger to check your sugar'. She said, 'Oh no, not the way she did it; she jumped all over me.' I said, 'jumped all over you?', and she said, 'Oh yeah, she pretty much straddled me and grabbed my finger.' I asked her what she meant and she said, 'She grabbed my finger, twisted it and poked it anyway and she hurt me.' After that, I went and got (LPN #3) from the medication room that is behind the nurses' station. She came out and asked (Resident #7) what was going on, and (Resident #7) told her the exact same thing. I asked her when this happened, and she said the morning before . that would have been the 11th of March. The nurse called (DON), and (DON) said we would have to do Witness Statements. We got Witness Statements out of the drawer and filled them out. CNA #3 was asked if anyone from administration had ever talked to him about the incident and stated, No one ever came and asked me anything. I was wondering why she came back to work. (Resident #7) has her right mind. I know when allegations like this are made, until they complete their investigation, the person named is suspended, but (LPN #1) came back to work and (Resident #7) saw her and said, 'I knew she would be back', because (DON) and another lady came into her room and tried to talk her out of what she said had happened. After she told us about the incident, I was off the next 2 nights. When I came back in, (LPN #1) was here, and that's when (Resident #7) told me this. I told (LPN #3), and she said, 'That's out of our hands; we did what we were supposed to do. We reported it by our chain of command.' After that, (LPN #1) worked back there (on Resident #7's hall) a couple of nights, and then she started working up front. q. On 4/11/18 at 12:28 p.m., LPN #3 was asked about Resident #7's allegation of abuse from LPN #1 and stated, When the CNAs told me what (Resident #7) told them, I told them I would have to call the Administrator and DON. I called them both. I can't remember who I called first. I must have called (Administrator) first, because she said to call (DON). She told me she would be up here. We waited, and she never showed up on our shift. I knew she would have to talk to them (CNA staff who documented the Witness Statements), so I had them to wait. They finally left, with no one talking to them. (DON) said to get Witness Statements. We did write Witness Statements. I heard that someone had talked to her. (Resident #7) told me someone came and talked to her. I heard people saying they tried to get her to change her story. The CNAs said, '(Resident #7) just told us that (LPN #1) bent her finger back.' So I went to talk to (Resident #7). She told me, '(LPN #1) wrangled me down and bent my finger back to check my sugar.' I didn't think to ask her when it happened. If they said she told them it happened the morning before, that's when it happened. (DON) told me I didn't write the date (of the incident on the Witness Statement). I asked her, 'I didn't write the date?' She said, 'You didn't write the date it happened'. This happened on 3/11/18 in the morning, is what (Resident #7) had told the CNAs. I was never asked anything about this until yesterday. To my knowledge, none of the CNAs were talked to either. r. On 4/11/18 at 12:50 p.m., CNA #1 was asked if Resident #7 told her when the incident she reported had occurred and stated, (Resident #7) told us that the incident where (LPN #1) bent her finger happened the morning before she told us, which would have been (MONTH) the 11th. (Resident #7) told me, I can't remember the exact day, but I was putting her to bed after I came on, and she told me, 'You won't believe what they are trying to do to me . I asked her 'what is it?' She said (DON) and the other lady (SSD) were trying to talk her out of the bending of her finger because (LPN #1) was a new nurse and that she could lose her job and it would be a state reportable. I asked her what happened, and she said, 'I don't know what they are going to do'. No one ever came and talked to me or anyone else that I know of about this incident. I heard that (DON) had said that she was going to have to go down and talk (Resident #7) out of this reportable. I heard this from (LPN #2) and (CNA #2). s. On 4/11/18 at 3:34 p.m., the Regional Nurse Consultant was asked what the Administrator had reported to her after she had received the witness statements regarding Resident #7 and stated, When we talked to the Administrator, she told us she didn't really remember looking at the witness statements on (Resident #7) on 3/12/18 and 3/13/18. On 4/13/18 at 10:35 a.m., the Regional Nurse Consultant provided the surveyors with an Addendum to the reportable regarding Resident #7 that documented, (MONTH) 14, (YEAR) Addendum: (Resident #7) . On 4/10/18 it was determined during a complaint survey the date and time of the incident was 3/12/18, not 3/3/18. Also, it was determined at the time of the actual incident the DON or Administrator did not investigate the allegation after interviews with staff and resident. Based on this information, the facility has substantiated the allegation. DON and Administrator were both suspended on 4/10/18 and relieved of their duties on 4/13/18. LPN (LPN #1) was also relieved of her duties on 4/13/18 . 2. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/15/18 documented the resident scored 3 (0 - 7 indicates severely impaired) on a BIMS, required extensive assistance of 2 plus person for bed mobility, transfers and locomotion on and off of the unit and had two falls with no injuries since the last assessment. a. The Plan of Care dated 11/7/17 documented, ADLs (Activities of Daily Living) . Start Date: 11/7/17 . Intervention: Transfers - 2 person assistance . Potential for falls: Safety . Start Date: 6/16/17 . Fall 12/15/17 . Staff to assist with transfers: Fall 12/15/17 . Staff to assist Resident to bed at time of choice: Fall 12/26/17 . Staff to assist resident with toileting after evening meal: Fall 1/7/18 . Staff to assist resident with toileting prior to bedtime: Fall 1/16/18 . Use call light for assist with transfers for safety: Fall 1/6/18 . Staff to assist resident into wheelchair after breakfast: Fall 2/14/18 . Staff to encourage resident to wear non-skid socks/shoes for transfers/ambulation: Fall 3/3/18 .Visual reminder placed on wall in room to ask for assistance: Fall 3/11/18 .Resident places self in floor at times: Fall 4/5/18 . Continue Plan of Care . b. An Incident Report dated 4/1/18 and signed by LPN #1 documented, Incident Type: Fall no head injury . Date/Time: 4/1/18 at 6:30 a.m . Type of Injury: None Apparent . Location: Resident room . Activity at time: From chair w/o (without) asst (assistance) . Associate involved: (CNA #1) . Incident reported by: (CNA #1) . Report prepared by: (LPN #1) . Non-Witnessed . Narrative of Incident and description of injuries: CNA reported to this Nurse (LPN #1) that Pt (Patient) was transferring self from chair to bed without assistance and fell on her bottom. Performed neuro (neurological) check on Pt WNL (within normal limits). No injuries or bruises apparent. No c/o (complaints of) pain or discomfort at this time. Incident took place in Pt room while Pt was transferring herself from the chair to the bed without assistance. Immediate Actions taken: Neuro check performed WNL, V/S (vital signs) & (and) skin evaluation performed no apparent injuries . c. On 4/10/18 at 1:20 a.m., CNA #4 was asked about the resident's fall on 4/1/18 and stated, I heard the resident fell , and (LPN #1) left her in the floor at least 40 to 45 minutes before assessing her and had left another resident in the floor after a fall for approximately 20 to 25 minutes before having the aides get her up prior to her assessing her . d. On 4/10/18 at 1:25 a.m., CNA #5 was asked about the resident's fall on 4/1/18 and stated, I heard (Resident #6) was in the floor and it took (LPN #1) a while for her to check on her. e. On 4/10/18 at 1:35 a.m., CNA #2 was asked about the resident's fall on 4/1/18 and stated, .I heard (CNA #1) hollering out of (Resident #6's) room. She had found (Resident #6) on the floor. She told me that she needed (LPN #1) in there now. I was heading to another resident who thought she was having a stroke. (CNA #1) found (LPN #1) on the Southeast Hall (back hall) passing medications and told her she needed her in (Resident #6's) room because she had fallen. (LPN #1) continued getting a routine medication for another resident on that hall. After I finished with my resident, I saw (LPN #1) entering another resident's room, passing routine medications, and was about to ask her if she had been to (Resident #6's) room, when (CNA #1) came back out into hall out of (Resident #6's) room asking me if anybody had seen (LPN #1) because she still hadn't assessed her. She went on to say that it had been 30 minutes since the fall at that time. I told her she (LPN #1) was in another resident's room passing routine medications. (CNA #1) then went into the other resident's room that (LPN #1) was in, passing medications, to once again tell her she needed her in (Resident #6's) room, due to fall. She had been trying to get her to come and assess her since approximately 30 minutes ago. I don't know if (LPN #1) went to (Resident #6's) room after that, because I had to go again to help (LPN #4) with another resident who had a fall on the back hall with a pretty good skin tear after assisting him earlier with the resident with stroke symptoms. The CNA was asked if she documented any of this on a witness statement and stated, Yes and they were given to the DON. f. On 4/10/18 at 2:05 a.m., CNA #6 was asked about the resident's fall on 4/1/18 and stated, .I wasn't working that night but (Resident #6) was left on the floor for 45 minutes and (LPN #1) was the nurse. (CNA #1) was the CNA working that night, and she told me she had left the room [ROOM NUMBER] times to get (LPN #1). All I heard was she was doing her med pass. I have never been questioned or asked to write a witness statement about anything involving (LPN #1). g. On 4/10/18 at 2:18 a.m., LPN #2 was asked about the resident's fall on 4/1/18 and stated, I wasn't here, but I heard (LPN #1) left (Resident #6) in the floor after a fall for 45 minutes and left (Resident #2) in the floor after a fall for approximately 40 minutes. I'm sure (CNA #1) told the Administrator about the falls . h. On 4/10/18 at 2:50 a.m., LPN #1 was asked about the resident being left on the floor for approximately 45 minutes after falling during her shift on 4/1/18 and stated, I don't know anything about any resident being left in the floor for 45 minutes before assessing them. I was across the hall from (Resident #7's) room when she fell . passing scheduled narcotics when (CNA #1) told me (Resident #6) had fallen. I told her to give me a minute and I'd be right in there. It took me approximately 10 minutes to get there. She did come to me twice to get me to come in there; not three times. i. On 4/10/18 at 3:11 a.m., the DON was asked about the resident's fall on 4/1/18 and stated, (LPN #1) called me the night (Resident #6) fell and told me she had fallen and that she had already pulled out another resident's narcotics and was waiting to administer her meds when (CNA #1) came out into the hallway to holler at her about (Resident #6's) fall. She said she told her to let her give the other resident's narcotic and she would be right in there. (LPN #1) was upset because it took her no longer than 5 - 10 minutes before she got in there to assess (Resident #6), but (CNA #1) was telling everyone that it took her 45 minutes to get in there. They both requested a meeting with me and Staff Development, because they have had a lot of issues since working together (approximately 1 month). I never questioned (LPN #1) or (CNA #1) about the discrepancy in the length of time it took (LPN #1) to get to (Resident #6's) room to assess her after the fall. I also didn't question anyone else working that night to get their statements of what occurred that night either. I don't remember receiving any witness statements regarding this incident. I do remember (CNA #1) telling me what happened though. I don't have any reason to believe that (CNA #1) was lying to me; she's a good aide. I don't know why I didn't investigate further what really happened that night. I guess I thought (LPN #1) just needed some more re-education because she was a new LPN and a new employee. The DON was asked to provide copies of the witness statements that were submitted by staff on the night of Resident #6' fall; she was unable to locate any of them during the survey. j. On 4/10/18 at 3:56 a.m., CNA #1 was asked about the resident's fall on 4/1/18 and stated, I was changing another resident when I heard someone hollering for help. I went toward the help sound and found (Resident #6) sitting in the floor between the over bed table and the side of her bed. She didn't appear to have sustained any injuries. I asked her what happened, and she told me she was trying to get to her bed and fell . I went to her doorway and asked (CNA #2) if she knew where (LPN #1) was and told her if she saw her to tell her I need her in (Resident #6's) room to assess her, because she had fallen on the floor. I initially couldn't find her, so I went directly back to (Resident #6's) room and asked her if she was alright, and she told me, 'yes but get me out of this floor'. I told her I would as soon as the nurse came to check her out and make sure she was alright. She again told me to get her out of the floor. I stepped out once again and saw the med cart outside another resident's room and went in and told (LPN #1) I needed her in (Resident #6's) room, because she had fallen and she told me okay, she'll be right there. I then went back to (Resident #6's) room and sat down in the floor next to her (resident), because she was so upset. At this time, (Resident #6) had been in the floor for about 10 minutes. I sat there with her for about 5 - 10 more minutes. I got up and stepped back into the hallway and saw (LPN #1) going into yet another resident's room, when I stopped her and told her, again, that I needed her to come check on (Resident #6) after her fall. She did not respond as she entered the other resident's room, so I stood at (Resident #6's) doorway. When she (LPN #1) came out of that resident's room, I told her (Resident #6) was still on the floor, and I was going to get her up, since (Resident #6) was so upset wanting up out of the floor and into her bed, and she could assess her when she had time. She told me, 'No, I'll be there in a minute'. By this time, (Resident #6) had been on the floor approximately 15 - 20 minutes, and (LPN #1) had not laid eyes on her yet. (LPN #1) left again and I saw her go down to the Southeast (back) hall. I don't know what she was doing. I went back into (Resident #6's) room and told her that I would be right back. I was going to try and get (LPN #4), but he was busy with another resident who had fallen and suffered a bad skin tear and at the same time, another aide was telling him that another resident was having stroke-like symptoms, so I left, and while I was heading back to (Resident #6's) room, I saw (LPN #1) and again I told her if she couldn't get to (Resident #6's) room, I was going to get her off of that cold floor. She again told me, 'no, I'll be right there'. She then went into another resident's room. At this time, it had been about 30 minutes since (Resident #6) had fallen onto the floor. After about 4 more minutes, I saw her come out of that resident's room and go to the med cart and again into the other resident's room for another 5 minutes. At this time, (Resident #6) had been on the floor for about 40 minutes. After (LPN #1) had come out of that resident's room, she went to the med cart and took out her vital sign equipment and then came to assess (Resident #6), and the resident screamed at her 'get me out of this damn floor'. At this time, she had been on the floor for about 45 minutes. After the incident was under control, I took it upon myself to fill out a fall witness statement and took the non-witness statement (TRUNCATED)

Based on record review and interview, the facility failed to ensure the facility abuse prohibition policies and procedures were implemented, by failing to ensure immediate protective measures were implemented to prevent further abuse, after a resident and multiple staff members made allegations of physical abuse and neglect against Licensed Practical Nurse (LPN #1). The facility failed to ensure an allegation of physical abuse against LPN #1 was immediately investigated, protective measures were implemented to prevent further potential abuse, and that staff did not attempt to pressure the resident to keep quiet about the allegation for 1 (Resident #7); and failed to ensure allegations of neglect were investigated and immediate protective measures were implemented after staff alleged that LPN #1 failed to promptly respond when informed that residents had fallen and were on the floor for 2 (Residents #6 and #2) of 9 (Residents #1 - 9) case mix residents who received care from LPN #1. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Residents #7, #6 and #2, and had the potential to cause more than minimal harm to 101 residents who received care from LPN #1, as verified by the Director of Nursing on 4/26/18. The Administrator, Regional Administrator and Director of Nursing were informed of the immediate jeopardy condition on 4/10/18 at 7:00 a.m The findings are: 1. The facility's policy and procedure titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation provided by the Nurse Consultant on 4/13/18, documented, .d) Each employee has an obligation to immediately report any incident or allegation that could constitute an instance of abuse or neglect, an injury of unknown origin, exploitation or misappropriation of resident/guest property to the Administrator, Director of Nursing (DON) or the Department Supervisor .v. Protection of Resident/Guest(s) during the investigation a) The facility will take all reasonable measures to protect a resident/guest during an investigation .VI. Investigations and Facility Response to Incidents or Accidents .b .the Administrator /Designee will report to the State Agency and all other required agencies, per regulations. All allegations of abuse and instances that result in serious bodily injury must be reported within 2 hours .The Administrator is responsible for conducting a thorough investigation and obtaining witness statements . 2. Resident #7 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a brief interview for mental status (BIMS). On 4/4/18, the Office of Long Term Care (OLTC) was informed, by an anonymous source, that LPN #1 had been physically abusive to Resident #7 during a capillary blood glucose (CBG) test. The OLTC staff person reported the allegation to the Administrator via telephone call on 4/4/18. a. On 4/10/18 at 1:00 a.m., the resident was awake, in bed. The resident was asked if she was diabetic and stated, Yes. She was asked if she had to have Capillary Blood Glucose (CBG) testing to check her blood sugar and stated, Yes. She was asked if any of the nurses had been rough with her when checking her CBGs and stated, You're talking about (Licensed Practical Nurse (LPN) #1) aren't you? The resident was asked what happened with LPN #1 and stated, She (LPN #1) got this finger (the resident held up the ring finger on her right hand), and she grabbed this finger and twisted it and bent it around to use it. I told her that she was hurting me, but she just kept doing it. It hurt when she got ahold and twisted my finger. I refuse to have her as my nurse. The resident was asked if anyone from the facility had come to talk to her about the incident and stated, The Social Worker came and talked to me about it. They came, the Social Worker and someone else, and talked to me and didn't want this to be reported to the state. b. On 4/10/18 at 1:10 a.m., LPN #2 was asked if she had ever received any complaints from residents regarding rough treatment by staff during CBG testing. The LPN stated, Yes, what do you want to know? Ask (Resident #7). They (facility administration) just cover for her - it's (LPN #1) - she's new. Residents and families have complained a lot about her, and they just protect her, because she's a new nurse. c. On 4/10/18 at 1:35 a.m., Certified Nursing Assistant (CNA) #2 was asked if she was aware of any complaints regarding a nurse being rough when checking a resident's CBG and stated, Yes, (Resident #7) was sitting up here at the back nurses' station, and she told me and 2 other CNAs that (LPN #1) came into her room to do her CBG the previous morning, on (3/11/18), and she (LPN #1) grabbed her (Resident #7's) finger and pulled it back. (LPN #1) continued to grab her finger and twisted her finger and wrist and took the CBG. She told us that it hurt when she twisted her finger and wrist, and also told us she didn't want (LPN #1) back in her room. All 3 of us got (LPN #3); she was in the medication room just behind the nurses' station. We told her exactly what the resident had told us. We all filled out witness statements and slid them under the Administrator's door. We were never talked to by anyone about this incident. I don't know what happened. d. On 4/10/18 at 2:05 a.m., CNA #6 was asked if she was aware of any nurse being rough with residents when checking their CBGs and stated, I've heard she bent (Resident #7's) finger and twisted it when she did her CBG. The nurse was (LPN #1). e. On 4/10/18 at 2:18 a.m., LPN #2 was asked if she was aware of any nurse being rough with residents when checking their CBG and stated, I heard the DON (Director of Nursing) say she had to talk (Resident #7) into not making a state reportable out of it, regarding (LPN #1) bending and twisting her finger. f. On 4/10/18 at 2:50 a.m., LPN #1 was asked about Resident #7's allegation that the LPN had hurt her finger while obtaining a CBG and stated, I don't recall (Resident #7) saying I hurt her finger when taking a CBG. She said after I poked her finger, she told me that wasn't the finger she wanted me to use. After the incident, after I chose a finger she didn't want me to use, (DON) and (Staff Development Nurse) gave me an in-service on (Resident #7) as a resident and how she likes things done and to be slower and make sure to ask her which finger she wants me to use. g. On 4/10/18 at 5:20 a.m., the Administrator was asked about the incident with Resident #7 and LPN #1 that took place on 3/11/18 and stated, I've never spoken with (Resident #7) about (LPN #1) hurting her. My knowledge is that Social Services went to the resident to take a statement. I told Social Services to let me know what she said. The Administrator was asked for this documentation and stated, I never asked for it. The Administrator was asked if the staff who had written witness statements regarding the incident had been interviewed in an effort to investigate the resident's allegations and stated, No, they haven't. She was asked why not and did not answer. The Administrator stated, I was aware that (Resident #7) didn't want (LPN #1) back in her room, because she went too fast. It just made sense not to let (LPN #1) back in there. The Administrator was then asked for the witness statements the staff had placed underneath her door on 3/13/18 and for her investigation of the incident. h. On 4/10/18 at 6:30 a.m., the Administrator provided the surveyors with 4 witness statements and a report sent to OLTC on 4/4/18. The OLTC Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated 4/4/18 documented, .Date and time of Discovery 4/4/18 at 10:30 a.m., date and time submitted : 4/4/18 at 5:00 p.m., Type of Incident: Physical Abuse. The Summary of Incident documented: On 4/4/18 (Name of person from OLTC) with the Office of Long Term Care phone administrator to inform that there was an allegation that a facility nurse had bent back a resident's finger during a CBG check Steps taken to Prevent Continued Abuse or Neglect During the Investigation . Nurse named in incident immediately suspended pending investigation. In-service started on Abuse, Neglect, and misappropriation of resident personal belongings along with facility policy/protocol. Collected witness/character statements from staff and alert/oriented residents. Administrator, DON, Police, and Responsible Party notified of allegation pending investigation. Investigation is ongoing. 1.) An OLTC Witness Statement Form dated 3/12/18 at 11:40 p.m. documented, .Witness Full Name: (CNA #1) . Shift: 11-7 (11:00 p.m. to 7:00 a.m.) . I witness (Resident #7) telling my co-worker (CNA #3) that a nurse (LPN #1) had got on to her and had jerked her finger while getting her CBG. I was not working on the day (Resident #7) claims this incident happened . 2.) An OLTC Witness Statement Form dated 3/12/18 at 11:45 p.m. documented, .Witness Full Name: (LPN #3) .(Resident #7) was sitting by the nurse's desk, and she spoke up, saying 'I don't like (LPN #1), she wrestled me down and twisted my fingers trying to get blood from it'. I reminded her (LPN #1) was a new nurse and didn't know how she liked things done yet. (Resident #7) replied 'I don't care I don't like her'. I personally did not witness the situation and do not know what happened, but I had worked with the nurse, (LPN #1) for a double shift and had not seen anything objectionable from her . 3.) An OLTC Witness Statement Form dated 3/13/18 at 12:10 a.m. documented, .Witness Full Name: (CNA #2) . Shift: 11-7 . (Resident #7) reported to this aide and co-aides that the nurse (LPN #1) walked into her room to check her blood sugar and tried to poke a certain finger. (Resident #7) told her not that one. Jerked away and nurse (LPN #1) yanked and twisted her finger to poke the one (Resident #7) told her not to .This was reported to nurse (LPN #3) . 4.) An OLTC Witness Statement Form dated 3/13/18 at 12:10 a.m. documented, .Witness Full Name: (CNA #3) Shift: 11-7 . (Resident #7) told us that she does not like the new nurse (LPN #1). I asked why and she said that she jumped all over her and twisted her finger and was very hateful . These Witness Statements were all dated during the night shift beginning at 11:00 p.m. on 3/12/18 and ending at 7:00 a.m. on 3/13/18; however, the report to OLTC was not completed until 4/4/18, after the OLTC staff person contacted the facility to report the allegation to the Administrator. i. On 4/10/18 at 6:30 a.m., CNA #2 was asked if Resident #7, when describing what LPN #1 had done during the CBG incident, had specified the date when the incident occurred and stated, The date of our Witness Statements is the date (Resident #7) told us about it. She said it had happened the morning before, which would have been the a.m. of the 11th (3/11/18). When we told (LPN #3), she said she had to call the Administrator about the allegation. We pulled the Witness Statements and filled them out and put them under the Administrator's door. I was never talked to by anyone in administration, and I don't believe the others have been either. If they had been, I'm pretty sure they would have told me. j. On 4/10/18 at 8:35 a.m., the Social Service Director (SSD) was asked about the Witness Statements for 3/12/18 and 3/13/18 regarding Resident #7 and LPN #1. The SSD stated, I don't believe I ever saw those Witness Statements. I went and spoke with (Resident #7) on 3/5/18 after the DON (Director of Nursing) told me about her finger. The Social Service Director was informed that the incident occurred on 3/11/18 and was reported to staff by the resident on the night of 3/12/18. The Social Service Director stated, The DON told me, after OLTC called on the 4th of April, that I needed to write up my interview I had with (Resident #7) on 3/5/18. I looked for paper copies of my interview and there are none. The Social Service Director was asked if a previous incident had occurred involving Resident #7 and LPN #1 on 3/5/18, since the surveyors were only aware of the incident that occurred on 3/11/18. The Social Service Director stated, I was told by the DON that it occurred on 3/5/18. k. On 4/10/18 at 8:55 a.m., the DON was informed of the SSD's statement that she was asked to document an incident on 3/5/18, involving Resident #7. The DON was then asked if an incident occurred with Resident #7 and LPN #1 on 3/5/18. The DON stated, She (SSD) got the 3/5/18 from me, because I believed the incident occurred on (Saturday) 3/3/18, because I had it in my head it was the weekend of (LPN #1's) second day of work. She was asked, if a nurse had worked 2 days, would she be caring for residents on her own? The DON stated, No, I guess I had the dates wrong. I thought it was 3/3/18 when I got the call (from staff regarding the incident). After me and the Social Service Director talked to (Resident #7), neither of us wrote anything up prior to OLTC notifying us on 4/4/18. The DON was asked when she first saw the witness statements dated 3/12/18 and 3/13/18 from the staff and stated, Honestly, I believe today is the first time I saw them. I knew we had gotten some witness statements, but I had not seen them. The Administrator had them, and I asked if there were any negative findings, as in something we needed to follow-up on, and she said, after talking with (Resident #7), that we had resolved it. I don't remember the exact wording. Me and (Social Service Director) talked to her (Resident #7) together once, and then I went down later that afternoon to make sure her story didn't change. She told us the nurse just went too fast. The DON was asked if she had documentation of any of their conversations with the resident and stated, There is no documentation of any of these conversations with the resident. She was asked if, during their investigation, they talked with the staff who initially reported the resident's allegations via witness statements dated 3/12/18 and 3/13/18 and stated, No. l. On 4/10/18 at 9:17 a.m., the Administrator was asked when she first received the Witness Statements dated 3/12/18 and 3/13/18 and stated, When I first got these statements, I had the Social Service and DON go talk to (Resident #7). I don't remember if I gave the Witness Statements to the Social Service Director or not. I may have just told her about it and had her talk to the resident. I'm sure I asked for the documentation from the Social Service Director and DON. I've never received any documentation after they talked with the resident. m. On 4/10/18 at 9:24 a.m., the Regional Nurse Consultant was asked when she was initially made aware of the Witness Statements dated 3/12/18 and 3/13/18 for (Resident #7) and stated, The first time I was aware of the Witness Statements for 3/12/18 and 3/13/18 was today, when you surveyors showed them to me. n. On 4/10/18 at 9:28 a.m., the Administrator was asked if the staff who had written the Witness Statements regarding the incident with Resident #7 had been interviewed after she received the call from OLTC on 4/4/18 and stated, When the reportable was initiated on 4/4/18, after the call from OLTC, none of the CNAs or the nurse who the resident initially reported the incident were interviewed. o. On 4/10/18 at 10:02 a.m., the Staff Development Nurse was asked if she was involved with the investigation regarding Resident #7's allegation of abuse from a nurse and stated, I don't know the dates, but it was brought to our attention. (DON) said there was an allegation that (Resident #7's) finger was bent back during a CBG. I was told about it before the phone call from OLTC on 4/4/18. I was told that they had gone down and spoke with the resident. I don't know if it was both (DON) and (Social Service Director). (DON) told me they felt that it was just hurried by the nurse, after speaking with the resident. (DON) and myself talked to (LPN #1) about slowing down and explaining what she was doing. I never saw any Witness Statements from staff who initially received the information from the resident. p. On 4/11/18 at 11:34 a.m., CNA #3 was asked about his witness statement dated 3/13/18 at 12:10 a.m. regarding Resident #7 and stated, When I came in at 11:00 p.m. on 3/12/18, she wanted out of bed. I told her to give us a bit, we were in the middle of shift exchange. We got her up and she wanted a cup of ice and I got her a cup of ice and she said, 'Boy (CNA #3) I tell ya', I don't know nothing about that new nurse, but I don't like her. I asked who she was talking about and she said, (LPN #1's name). I asked her why and she said (LPN #1) wanted to poke her finger and I told her, 'all the nurses have to poke your finger to check your sugar'. She said, 'Oh no, not the way she did it; she jumped all over me.' I said, 'jumped all over you?', and she said, 'Oh yeah, she pretty much straddled me and grabbed my finger.' I asked her what she meant and she said, 'She grabbed my finger, twisted it and poked it anyway and she hurt me.' After that, I went and got (LPN #3) from the medication room that is behind the nurses' station. She came out and asked (Resident #7) what was going on, and (Resident #7) told her the exact same thing. I asked her when this happened, and she said the morning before . that would have been the 11th of March. The nurse called (DON), and (DON) said we would have to do Witness Statements. We got Witness Statements out of the drawer and filled them out. CNA #3 was asked if anyone from administration had ever talked to him about the incident and stated, No one ever came and asked me anything. I was wondering why she came back to work. (Resident #7) has her right mind. I know when allegations like this are made, until they complete their investigation, the person named is suspended, but (LPN #1) came back to work and (Resident #7) saw her and said, 'I knew she would be back', because (DON) and another lady came into her room and tried to talk her out of what she said had happened. After she told us about the incident, I was off the next 2 nights. When I came back in, (LPN #1) was here, and that's when (Resident #7) told me this. I told (LPN #3), and she said, 'That's out of our hands; we did what we were supposed to do. We reported it by our chain of command.' After that, (LPN #1) worked back there (on Resident #7's hall) a couple of nights, and then she started working up front. q. On 4/11/18 at 12:28 p.m., LPN #3 was asked about Resident #7's allegation of abuse from LPN #1 and stated, When the CNAs told me what (Resident #7) told them, I told them I would have to call the Administrator and DON. I called them both. I can't remember who I called first. I must have called (Administrator) first, because she said to call (DON). She told me she would be up here. We waited, and she never showed up on our shift. I knew she would have to talk to them (CNA staff who documented the Witness Statements), so I had them to wait. They finally left, with no one talking to them. (DON) said to get Witness Statements. We did write Witness Statements. I heard that someone had talked to her. (Resident #7) told me someone came and talked to her. I heard people saying they tried to get her to change her story. The CNAs said, '(Resident #7) just told us that (LPN #1) bent her finger back.' So I went to talk to (Resident #7). She told me, '(LPN #1) wrangled me down and bent my finger back to check my sugar.' I didn't think to ask her when it happened. If they said she told them it happened the morning before, that's when it happened. (DON) told me I didn't write the date (of the incident on the Witness Statement). I asked her, 'I didn't write the date?' She said, 'You didn't write the date it happened'. This happened on 3/11/18 in the morning, is what (Resident #7) had told the CNAs. I was never asked anything about this until yesterday. To my knowledge, none of the CNAs were talked to either. r. On 4/11/18 at 12:50 p.m., CNA #1 was asked if Resident #7 told her when the incident she reported had occurred and stated, (Resident #7) told us that the incident where (LPN #1) bent her finger happened the morning before she told us, which would have been (MONTH) the 11th. (Resident #7) told me, I can't remember the exact day, but I was putting her to bed after I came on, and she told me, 'You won't believe what they are trying to do to me . I asked her 'what is it?' She said (DON) and the other lady (SSD) were trying to talk her out of the bending of her finger because (LPN #1) was a new nurse and that she could lose her job and it would be a state reportable. I asked her what happened, and she said, 'I don't know what they are going to do'. No one ever came and talked to me or anyone else that I know of about this incident. I heard that (DON) had said that she was going to have to go down and talk (Resident #7) out of this reportable. I heard this from (LPN #2) and (CNA #2). s. On 4/11/18 at 3:34 p.m., the Regional Nurse Consultant was asked what the Administrator had reported to her after she had received the witness statements regarding Resident #7 and stated, When we talked to the Administrator, she told us she didn't really remember looking at the witness statements on (Resident #7) on 3/12/18 and 3/13/18. t. On 4/13/18 at 10:35 a.m., the Regional Nurse Consultant provided the surveyors with an Addendum to the reportable regarding Resident #7 that documented, (MONTH) 14, (YEAR) Addendum: (Resident #7) . On 4/10/18 it was determined during a complaint survey the date and time of the incident was 3/12/18, not 3/3/18. Also, it was determined at the time of the actual incident the DON or Administrator did not investigate the allegation after interviews with staff and resident. Based on this information, the facility has substantiated the allegation. DON and Administrator were both suspended on 4/10/18 and relieved of their duties on 4/13/18. LPN (LPN #1) was also relieved of her duties on 4/13/18 . 3. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/15/18 documented the resident scored 3 (0 - 7 indicates severely impaired) on a BIMS, required extensive assistance of 2 plus person for bed mobility, transfers and locomotion on and off of the unit and had two falls with no injuries since the last assessment. a. The Plan of Care dated 11/7/17 documented, ADLs (Activities of Daily Living) . Start Date: 11/7/17 . Intervention: Transfers - 2 person assistance . Potential for falls: Safety . Start Date: 6/16/17 . Fall 12/15/17 . Staff to assist with transfers: Fall 12/15/17 . Staff to assist Resident to bed at time of choice: Fall 12/26/17 . Staff to assist resident with toileting after evening meal: Fall 1/7/18 . Staff to assist resident with toileting prior to bedtime: Fall 1/16/18 . Use call light for assist with transfers for safety: Fall 1/6/18 . Staff to assist resident into wheelchair after breakfast: Fall 2/14/18 . Staff to encourage resident to wear non-skid socks/shoes for transfers/ambulation: Fall 3/3/18 .Visual reminder placed on wall in room to ask for assistance: Fall 3/11/18 .Resident places self in floor at times: Fall 4/5/18 . Continue Plan of Care . b. An Incident Report dated 4/1/18 and signed by LPN #1 documented, Incident Type: Fall no head injury . Date/Time: 4/1/18 at 6:30 a.m . Type of Injury: None Apparent . Location: Resident room . Activity at time: From chair w/o (without) asst (assistance) . Associate involved: (CNA #1) . Incident reported by: (CNA #1) . Report prepared by: (LPN #1) . Non-Witnessed . Narrative of Incident and description of injuries: CNA reported to this Nurse (LPN #1) that Pt (Patient) was transferring self from chair to bed without assistance and fell on her bottom. Performed neuro (neurological) check on Pt WNL (within normal limits). No injuries or bruises apparent. No c/o (complaints of) pain or discomfort at this time. Incident took place in Pt room while Pt was transferring herself from the chair to the bed without assistance. Immediate Actions taken: Neuro check performed WNL, V/S (vital signs) & (and) skin evaluation performed no apparent injuries . c. On 4/10/18 at 1:20 a.m., CNA #4 was asked about the resident's fall on 4/1/18 and stated, I heard the resident fell , and (LPN #1) left her in the floor at least 40 to 45 minutes before assessing her and had left another resident in the floor after a fall for approximately 20 to 25 minutes before having the aides get her up prior to her assessing her . d. On 4/10/18 at 1:25 a.m., CNA #5 was asked about the resident's fall on 4/1/18 and stated, I heard (Resident #6) was in the floor and it took (LPN #1) a while for her to check on her. e. On 4/10/18 at 1:35 a.m., CNA #2 was asked about the resident's fall on 4/1/18 and stated, .I heard (CNA #1) hollering out of (Resident #6's) room. She had found (Resident #6) on the floor. She told me that she needed (LPN #1) in there now. I was heading to another resident who thought she was having a stroke. (CNA #1) found (LPN #1) on the Southeast Hall (back hall) passing medications and told her she needed her in (Resident #6's) room because she had fallen. (LPN #1) continued getting a routine medication for another resident on that hall. After I finished with my resident, I saw (LPN #1) entering another resident's room, passing routine medications, and was about to ask her if she had been to (Resident #6's) room, when (CNA #1) came back out into hall out of (Resident #6's) room asking me if anybody had seen (LPN #1) because she still hadn't assessed her. She went on to say that it had been 30 minutes since the fall at that time. I told her she (LPN #1) was in another resident's room passing routine medications. (CNA #1) then went into the other resident's room that (LPN #1) was in, passing medications, to once again tell her she needed her in (Resident #6's) room, due to fall. She had been trying to get her to come and assess her since approximately 30 minutes ago. I don't know if (LPN #1) went to (Resident #6's) room after that, because I had to go again to help (LPN #4) with another resident who had a fall on the back hall with a pretty good skin tear after assisting him earlier with the resident with stroke symptoms. The CNA was asked if she documented any of this on a witness statement and stated, Yes and they were given to the DON. f. On 4/10/18 at 2:05 a.m., CNA #6 was asked about the resident's fall on 4/1/18 and stated, .I wasn't working that night but (Resident #6) was left on the floor for 45 minutes and (LPN #1) was the nurse. (CNA #1) was the CNA working that night, and she told me she had left the room [ROOM NUMBER] times to get (LPN #1). All I heard was she was doing her med pass. I have never been questioned or asked to write a witness statement about anything involving (LPN #1). g. On 4/10/18 at 2:18 a.m., LPN #2 was asked about the resident's fall on 4/1/18 and stated, I wasn't here, but I heard (LPN #1) left (Resident #6) in the floor after a fall for 45 minutes and left (Resident #2) in the floor after a fall for approximately 40 minutes. I'm sure (CNA #1) told the Administrator about the falls . h. On 4/10/18 at 2:50 a.m., LPN #1 was asked about the resident being left on the floor for approximately 45 minutes after falling during her shift on 4/1/18 and stated, I don't know anything about any resident being left in the floor for 45 minutes before assessing them. I was across the hall from (Resident #7's) room when she fell . passing scheduled narcotics when (CNA #1) told me (Resident #6) had fallen. I told her to give me a minute and I'd be right in there. It took me approximately 10 minutes to get there. She did come to me twice to get me to come in there; not three times. i. On 4/10/18 at 3:11 a.m., the DON was asked about the resident's fall on 4/1/18 and stated, (LPN #1) called me the night (Resident #6) fell and told me she had fallen and that she had already pulled out another resident's narcotics and was waiting to administer her meds when (CNA #1) came out into the hallway to holler at her about (Resident #6's) fall. She said she told her to let her give the other resident's narcotic and she would be right in there. (LPN #1) was upset because it took her no longer than 5 - 10 minutes before she got in there to assess (Resident #6), but (CNA #1) was telling everyone that it took her 45 minutes to get in there. They both requested a meeting with me and Staff Development, because they have had a lot of issues since working together (approximately 1 month). I never questioned (LPN #1) or (CNA #1) about the discrepancy in the length of time it took (LPN #1) to get to (Resident #6's) room to assess her after the fall. I also didn't question anyone else working that night to get their statements of what occurred that night either. I don't remember receiving any witness statements regarding this incident. I do remember (CNA #1) telling me what happened though. I don't have any reason to believe that (CNA #1) was lying to me; she's a good aide. I don't know why I didn't investigate further what really happened that night. I guess I thought (LPN #1) just needed some more re-education because she was a new LPN and a new employee. The DON was asked to provide copies of the witness statements that were submitted by staff on the night of Resident #6' fall; she was unable to locate any of them during the survey. j. On 4/10/18 at 3:56 a.m., CNA #1 was asked about the resident's fall on 4/1/18 and stated, I was changing another resident when I heard someone hollering for help. I went toward the help sound and found (Resident #6) sitting in the floor between the over bed table and the side of her bed. She didn't appear to have sustained any injuries. I asked her what happened, and she told me she was trying to get to her bed and fell . I went to her doorway and asked (CNA #2) if she knew where (LPN #1) was and told her if she saw her to tell her I need her in (Resident #6's) room to assess her, because she had fallen on the floor. I initially couldn't find her, so I went directly back to (Resident #6's) room and asked her if she was alright, and she told me, 'yes but get me out of this floor'. I told her I would as soon as the nurse came to check her out and make sure she was alright. She again told me to get her out of the floor. I stepped out once again and saw the med cart outside another resident's room and went in and told (LPN #1) I needed her in (Resident #6's) room, because she had fallen and she told me okay, she'll be right there. I then went back to (Resident #6's) room and sat down in the floor next to her (resident), because she was so upset. At this time, (Resident #6) had been in the floor for about 10 minutes. I sat there with her for about 5 - 10 more minutes. I got up and stepped back into the hallway and saw (LPN #1) going into yet another resident's room, when I stopped her and told her, again, that I needed her to come check on (Resident #6) after her fall. She did not respond as she entered the other resident's room, so I stood at (Resident #6's) doorway. When she (LPN #1) came out of that resident's room, I told her (Resident #6) was still on the floor, and I was going to get her up, since (Resident #6) was so upset wanting up out of the floor and into her bed, and she could assess her when she had time. She told me, 'No, I'll be there in a minute'. By this time, (Resident #6) had been on the floor approximately 15 - 20 minutes, and (LPN #1) had not laid eyes on her yet. (LPN #1) left again and I saw her go down to the Southeast (back) hall. I don't know what she was doing. I went back into (Resident #6's) room and told her that I would be right back. I was going to try and get (LPN #4), but he was busy with another resident who had fallen and suffered a bad skin tear and at t (TRUNCATED)

Based on record review and interview, the facility failed to ensure allegations of physical abuse and neglect against Licensed Practical Nurse (LPN) #1 were immediately reported to the Office of Long Term Care (OLTC) and other agencies within 2 hours to allow these agencies to promptly provide the necessary oversight to ensure residents were protected from abuse and neglect for 1 (Resident #7) of 1 case mix resident who made an allegation of physical abuse against LPN #1 and for 2 (Residents #6 and #2) of 2 case mix residents for whom staff alleged neglect against LPN #1 after these residents experienced falls and were not immediately assessed for injury by LPN #1. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Residents #7, #6 and #2, and had the potential to cause more than minimal harm to 101 residents who received care from LPN #1, as documented by the Director of Nursing on 4/26/18. The Administrator, Regional Administrator and Director of Nursing were informed of the immediate jeopardy condition on 4/10/18 at 7:00 a.m. The findings are: 1. Resident #7 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a brief interview for mental status (BIMS). On 4/4/18, the Office of Long Term Care (OLTC) was informed, by an anonymous source, that LPN #1 had been physically abusive to Resident #7 during a capillary blood glucose (CBG) test. The OLTC staff person reported the allegation to the Administrator via telephone call on 4/4/18. a. On 4/10/18 at 1:00 a.m., the resident was awake, in bed. The resident was asked if she was diabetic and stated, Yes. She was asked if she had to have Capillary Blood Glucose (CBG) testing to check her blood sugar and stated, Yes. She was asked if any of the nurses had been rough with her when checking her CBGs and stated, You're talking about (Licensed Practical Nurse (LPN) #1) aren't you? The resident was asked what happened with LPN #1 and stated, She (LPN #1) got this finger (the resident held up the ring finger on her right hand), and she grabbed this finger and twisted it and bent it around to use it. I told her that she was hurting me, but she just kept doing it. It hurt when she got ahold and twisted my finger. I refuse to have her as my nurse. The resident was asked if anyone from the facility had come to talk to her about the incident and stated, The Social Worker came and talked to me about it. They came, the Social Worker and someone else, and talked to me and didn't want this to be reported to the state. b. On 4/10/18 at 1:10 a.m., LPN #2 was asked if she had ever received any complaints from residents regarding rough treatment by staff during CBG testing. The LPN stated, Yes, what do you want to know? Ask (Resident #7). They (facility administration) just cover for her - it's (LPN #1) - she's new. Residents and families have complained a lot about her, and they just protect her, because she's a new nurse. c. On 4/10/18 at 1:35 a.m., Certified Nursing Assistant (CNA) #2 was asked if she was aware of any complaints regarding a nurse being rough when checking a resident's CBG and stated, Yes, (Resident #7) was sitting up here at the back nurses' station, and she told me and 2 other CNAs that (LPN #1) came into her room to do her CBG the previous morning, on (3/11/18), and she (LPN #1) grabbed her (Resident #7's) finger and pulled it back. (LPN #1) continued to grab her finger and twisted her finger and wrist and took the CBG. She told us that it hurt when she twisted her finger and wrist, and also told us she didn't want (LPN #1) back in her room. All 3 of us got (LPN #3); she was in the medication room just behind the nurses' station. We told her exactly what the resident had told us. We all filled out witness statements and slid them under the Administrator's door. We were never talked to by anyone about this incident. I don't know what happened. d. On 4/10/18 at 2:05 a.m., CNA #6 was asked if she was aware of any nurse being rough with residents when checking their CBGs and stated, I've heard she bent (Resident #7's) finger and twisted it when she did her CBG. The nurse was (LPN #1). e. On 4/10/18 at 2:18 a.m., LPN #2 was asked if she was aware of any nurse being rough with residents when checking their CBG and stated, I heard the DON (Director of Nursing) say she had to talk (Resident #7) into not making a state reportable out of it, regarding (LPN #1) bending and twisting her finger. f. On 4/10/18 at 2:50 a.m., LPN #1 was asked about Resident #7's allegation that the LPN had hurt her finger while obtaining a CBG and stated, I don't recall (Resident #7) saying I hurt her finger when taking a CBG. She said after I poked her finger, she told me that wasn't the finger she wanted me to use. After the incident, after I chose a finger she didn't want me to use, (DON) and (Staff Development Nurse) gave me an in-service on (Resident #7) as a resident and how she likes things done and to be slower and make sure to ask her which finger she wants me to use. g. On 4/10/18 at 5:20 a.m., the Administrator was asked about the incident with Resident #7 and LPN #1 that took place on 3/11/18 and stated, I've never spoken with (Resident #7) about (LPN #1) hurting her. My knowledge is that Social Services went to the resident to take a statement. I told Social Services to let me know what she said. The Administrator was asked for this documentation and stated, I never asked for it. The Administrator was asked if the staff who had written witness statements regarding the incident had been interviewed in an effort to investigate the resident's allegations and stated, No, they haven't. She was asked why not and did not answer. The Administrator stated, I was aware that (Resident #7) didn't want (LPN #1) back in her room, because she went too fast. It just made sense not to let (LPN #1) back in there. The Administrator was then asked for the witness statements the staff had placed underneath her door on 3/13/18 and for her investigation of the incident. h. On 4/10/18 at 6:30 a.m., the Administrator provided the surveyors with 4 witness statements and a report sent to OLTC on 4/4/18. The OLTC Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated 4/4/18 documented, .Date and time of Discovery 4/4/18 at 10:30 a.m., date and time submitted : 4/4/18 at 5:00 p.m., Type of Incident: Physical Abuse. The Summary of Incident documented: On 4/4/18 (Name of person from OLTC) with the Office of Long Term Care phone administrator to inform that there was an allegation that a facility nurse had bent back a resident's finger during a CBG check Steps taken to Prevent Continued Abuse or Neglect During the Investigation . Nurse named in incident immediately suspended pending investigation. In-service started on Abuse, Neglect, and misappropriation of resident personal belongings along with facility policy/protocol. Collected witness/character statements from staff and alert/oriented residents. Administrator, DON, Police, and Responsible Party notified of allegation pending investigation. Investigation is ongoing. 1.) An OLTC Witness Statement Form dated 3/12/18 at 11:40 p.m. documented, .Witness Full Name: (CNA #1) . Shift: 11-7 (11:00 p.m. to 7:00 a.m.) . I witness (Resident #7) telling my co-worker (CNA #3) that a nurse (LPN #1) had got on to her and had jerked her finger while getting her CBG. I was not working on the day (Resident #7) claims this incident happened . 2.) An OLTC Witness Statement Form dated 3/12/18 at 11:45 p.m. documented, .Witness Full Name: (LPN #3) .(Resident #7) was sitting by the nurse's desk, and she spoke up, saying 'I don't like (LPN #1), she wrestled me down and twisted my fingers trying to get blood from it'. I reminded her (LPN #1) was a new nurse and didn't know how she liked things done yet. (Resident #7) replied 'I don't care I don't like her'. I personally did not witness the situation and do not know what happened, but I had worked with the nurse, (LPN #1) for a double shift and had not seen anything objectionable from her . 3.) An OLTC Witness Statement Form dated 3/13/18 at 12:10 a.m. documented, .Witness Full Name: (CNA #2) . Shift: 11-7 . (Resident #7) reported to this aide and co-aides that the nurse (LPN #1) walked into her room to check her blood sugar and tried to poke a certain finger. (Resident #7) told her not that one. Jerked away and nurse (LPN #1) yanked and twisted her finger to poke the one (Resident #7) told her not to .This was reported to nurse (LPN #3) . 4.) An OLTC Witness Statement Form dated 3/13/18 at 12:10 a.m. documented, .Witness Full Name: (CNA #3) Shift: 11-7 . (Resident #7) told us that she does not like the new nurse (LPN #1). I asked why and she said that she jumped all over her and twisted her finger and was very hateful . These Witness Statements were all dated during the night shift beginning at 11:00 p.m. on 3/12/18 and ending at 7:00 a.m. on 3/13/18; however, the report to OLTC was not completed until 4/4/18, after the OLTC staff person contacted the facility to report the allegation to the Administrator. i. On 4/10/18 at 6:30 a.m., CNA #2 was asked if Resident #7, when describing what LPN #1 had done during the CBG incident, had specified the date when the incident occurred and stated, The date of our Witness Statements is the date (Resident #7) told us about it. She said it had happened the morning before, which would have been the a.m. of the 11th (3/11/18). When we told (LPN #3), she said she had to call the Administrator about the allegation. We pulled the Witness Statements and filled them out and put them under the Administrator's door. I was never talked to by anyone in administration, and I don't believe the others have been either. If they had been, I'm pretty sure they would have told me. j. On 4/10/18 at 8:35 a.m., the Social Service Director (SSD) was asked about the Witness Statements for 3/12/18 and 3/13/18 regarding Resident #7 and LPN #1. The SSD stated, I don't believe I ever saw those Witness Statements. I went and spoke with (Resident #7) on 3/5/18 after the DON (Director of Nursing) told me about her finger. The Social Service Director was informed that the incident occurred on 3/11/18 and was reported to staff by the resident on the night of 3/12/18. The Social Service Director stated, The DON told me, after OLTC called on the 4th of April, that I needed to write up my interview I had with (Resident #7) on 3/5/18. I looked for paper copies of my interview and there are none. The Social Service Director was asked if a previous incident had occurred involving Resident #7 and LPN #1 on 3/5/18, since the surveyors were only aware of the incident that occurred on 3/11/18. The Social Service Director stated, I was told by the DON that it occurred on 3/5/18. k. On 4/10/18 at 8:55 a.m., the DON was informed of the SSD's statement that she was asked to document an incident on 3/5/18, involving Resident #7. The DON was then asked if an incident occurred with Resident #7 and LPN #1 on 3/5/18. The DON stated, She (SSD) got the 3/5/18 from me, because I believed the incident occurred on (Saturday) 3/3/18, because I had it in my head it was the weekend of (LPN #1's) second day of work. She was asked, if a nurse had worked 2 days, would she be caring for residents on her own? The DON stated, No, I guess I had the dates wrong. I thought it was 3/3/18 when I got the call (from staff regarding the incident). After me and the Social Service Director talked to (Resident #7), neither of us wrote anything up prior to OLTC notifying us on 4/4/18. The DON was asked when she first saw the witness statements dated 3/12/18 and 3/13/18 from the staff and stated, Honestly, I believe today is the first time I saw them. I knew we had gotten some witness statements, but I had not seen them. The Administrator had them, and I asked if there were any negative findings, as in something we needed to follow-up on, and she said, after talking with (Resident #7), that we had resolved it. I don't remember the exact wording. Me and (Social Service Director) talked to her (Resident #7) together once, and then I went down later that afternoon to make sure her story didn't change. She told us the nurse just went too fast. The DON was asked if she had documentation of any of their conversations with the resident and stated, There is no documentation of any of these conversations with the resident. She was asked if, during their investigation, they talked with the staff who initially reported the resident's allegations via witness statements dated 3/12/18 and 3/13/18 and stated, No. l. On 4/10/18 at 9:17 a.m., the Administrator was asked when she first received the Witness Statements dated 3/12/18 and 3/13/18 and stated, When I first got these statements, I had the Social Service and DON go talk to (Resident #7). I don't remember if I gave the Witness Statements to the Social Service Director or not. I may have just told her about it and had her talk to the resident. I'm sure I asked for the documentation from the Social Service Director and DON. I've never received any documentation after they talked with the resident. m. On 4/10/18 at 9:24 a.m., the Regional Nurse Consultant was asked when she was initially made aware of the Witness Statements dated 3/12/18 and 3/13/18 for (Resident #7) and stated, The first time I was aware of the Witness Statements for 3/12/18 and 3/13/18 was today, when you surveyors showed them to me. n. On 4/10/18 at 9:28 a.m., the Administrator was asked if the staff who had written the Witness Statements regarding the incident with Resident #7 had been interviewed after she received the call from OLTC on 4/4/18 and stated, When the reportable was initiated on 4/4/18, after the call from OLTC, none of the CNAs or the nurse who the resident initially reported the incident were interviewed. o. On 4/10/18 at 10:02 a.m., the Staff Development Nurse was asked if she was involved with the investigation regarding Resident #7's allegation of abuse from a nurse and stated, I don't know the dates, but it was brought to our attention. (DON) said there was an allegation that (Resident #7's) finger was bent back during a CBG. I was told about it before the phone call from OLTC on 4/4/18. I was told that they had gone down and spoke with the resident. I don't know if it was both (DON) and (Social Service Director). (DON) told me they felt that it was just hurried by the nurse, after speaking with the resident. (DON) and myself talked to (LPN #1) about slowing down and explaining what she was doing. I never saw any Witness Statements from staff who initially received the information from the resident. p. On 4/11/18 at 11:34 a.m., CNA #3 was asked about his witness statement dated 3/13/18 at 12:10 a.m. regarding Resident #7 and stated, When I came in at 11:00 p.m. on 3/12/18, she wanted out of bed. I told her to give us a bit, we were in the middle of shift exchange. We got her up and she wanted a cup of ice and I got her a cup of ice and she said, 'Boy (CNA #3) I tell ya', I don't know nothing about that new nurse, but I don't like her. I asked who she was talking about and she said, (LPN #1's name). I asked her why and she said (LPN #1) wanted to poke her finger and I told her, 'all the nurses have to poke your finger to check your sugar'. She said, 'Oh no, not the way she did it; she jumped all over me.' I said, 'jumped all over you?', and she said, 'Oh yeah, she pretty much straddled me and grabbed my finger.' I asked her what she meant and she said, 'She grabbed my finger, twisted it and poked it anyway and she hurt me.' After that, I went and got (LPN #3) from the medication room that is behind the nurses' station. She came out and asked (Resident #7) what was going on, and (Resident #7) told her the exact same thing. I asked her when this happened, and she said the morning before . that would have been the 11th of March. The nurse called (DON), and (DON) said we would have to do Witness Statements. We got Witness Statements out of the drawer and filled them out. CNA #3 was asked if anyone from administration had ever talked to him about the incident and stated, No one ever came and asked me anything. I was wondering why she came back to work. (Resident #7) has her right mind. I know when allegations like this are made, until they complete their investigation, the person named is suspended, but (LPN #1) came back to work and (Resident #7) saw her and said, 'I knew she would be back', because (DON) and another lady came into her room and tried to talk her out of what she said had happened. After she told us about the incident, I was off the next 2 nights. When I came back in, (LPN #1) was here, and that's when (Resident #7) told me this. I told (LPN #3), and she said, 'That's out of our hands; we did what we were supposed to do. We reported it by our chain of command.' After that, (LPN #1) worked back there (on Resident #7's hall) a couple of nights, and then she started working up front. q. On 4/11/18 at 12:28 p.m., LPN #3 was asked about Resident #7's allegation of abuse from LPN #1 and stated, When the CNAs told me what (Resident #7) told them, I told them I would have to call the Administrator and DON. I called them both. I can't remember who I called first. I must have called (Administrator) first, because she said to call (DON). She told me she would be up here. We waited, and she never showed up on our shift. I knew she would have to talk to them (CNA staff who documented the Witness Statements), so I had them to wait. They finally left, with no one talking to them. (DON) said to get Witness Statements. We did write Witness Statements. I heard that someone had talked to her. (Resident #7) told me someone came and talked to her. I heard people saying they tried to get her to change her story. The CNAs said, '(Resident #7) just told us that (LPN #1) bent her finger back.' So I went to talk to (Resident #7). She told me, '(LPN #1) wrangled me down and bent my finger back to check my sugar.' I didn't think to ask her when it happened. If they said she told them it happened the morning before, that's when it happened. (DON) told me I didn't write the date (of the incident on the Witness Statement). I asked her, 'I didn't write the date?' She said, 'You didn't write the date it happened'. This happened on 3/11/18 in the morning, is what (Resident #7) had told the CNAs. I was never asked anything about this until yesterday. To my knowledge, none of the CNAs were talked to either. r. On 4/11/18 at 12:50 p.m., CNA #1 was asked if Resident #7 told her when the incident she reported had occurred and stated, (Resident #7) told us that the incident where (LPN #1) bent her finger happened the morning before she told us, which would have been (MONTH) the 11th. (Resident #7) told me, I can't remember the exact day, but I was putting her to bed after I came on, and she told me, 'You won't believe what they are trying to do to me . I asked her 'what is it?' She said (DON) and the other lady (SSD) were trying to talk her out of the bending of her finger because (LPN #1) was a new nurse and that she could lose her job and it would be a state reportable. I asked her what happened, and she said, 'I don't know what they are going to do'. No one ever came and talked to me or anyone else that I know of about this incident. I heard that (DON) had said that she was going to have to go down and talk (Resident #7) out of this reportable. I heard this from (LPN #2) and (CNA #2). s. On 4/11/18 at 3:34 p.m., the Regional Nurse Consultant was asked what the Administrator had reported to her after she had received the witness statements regarding Resident #7 and stated, When we talked to the Administrator, she told us she didn't really remember looking at the witness statements on (Resident #7) on 3/12/18 and 3/13/18. t. On 4/13/18 at 10:35 a.m., the Regional Nurse Consultant provided the surveyors with an Addendum to the reportable regarding Resident #7 that documented, (MONTH) 14, (YEAR) Addendum: (Resident #7) . On 4/10/18 it was determined during a complaint survey the date and time of the incident was 3/12/18, not 3/3/18. Also, it was determined at the time of the actual incident the DON or Administrator did not investigate the allegation after interviews with staff and resident. Based on this information, the facility has substantiated the allegation. DON and Administrator were both suspended on 4/10/18 and relieved of their duties on 4/13/18. LPN (LPN #1) was also relieved of her duties on 4/13/18 . 2. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/15/18 documented the resident scored 3 (0 - 7 indicates severely impaired) on a BIMS, required extensive assistance of 2 plus person for bed mobility, transfers and locomotion on and off of the unit and had two falls with no injuries since the last assessment. a. The Plan of Care dated 11/7/17 documented, ADLs (Activities of Daily Living) . Start Date: 11/7/17 . Intervention: Transfers - 2 person assistance . Potential for falls: Safety . Start Date: 6/16/17 . Fall 12/15/17 . Staff to assist with transfers: Fall 12/15/17 . Staff to assist Resident to bed at time of choice: Fall 12/26/17 . Staff to assist resident with toileting after evening meal: Fall 1/7/18 . Staff to assist resident with toileting prior to bedtime: Fall 1/16/18 . Use call light for assist with transfers for safety: Fall 1/6/18 . Staff to assist resident into wheelchair after breakfast: Fall 2/14/18 . Staff to encourage resident to wear non-skid socks/shoes for transfers/ambulation: Fall 3/3/18 .Visual reminder placed on wall in room to ask for assistance: Fall 3/11/18 .Resident places self in floor at times: Fall 4/5/18 . Continue Plan of Care . b. An Incident Report dated 4/1/18 and signed by LPN #1 documented, Incident Type: Fall no head injury . Date/Time: 4/1/18 at 6:30 a.m . Type of Injury: None Apparent . Location: Resident room . Activity at time: From chair w/o (without) asst (assistance) . Associate involved: (CNA #1) . Incident reported by: (CNA #1) . Report prepared by: (LPN #1) . Non-Witnessed . Narrative of Incident and description of injuries: CNA reported to this Nurse (LPN #1) that Pt (Patient) was transferring self from chair to bed without assistance and fell on her bottom. Performed neuro (neurological) check on Pt WNL (within normal limits). No injuries or bruises apparent. No c/o (complaints of) pain or discomfort at this time. Incident took place in Pt room while Pt was transferring herself from the chair to the bed without assistance. Immediate Actions taken: Neuro check performed WNL, V/S (vital signs) & (and) skin evaluation performed no apparent injuries . c. On 4/10/18 at 1:20 a.m., CNA #4 was asked about the resident's fall on 4/1/18 and stated, I heard the resident fell , and (LPN #1) left her in the floor at least 40 to 45 minutes before assessing her and had left another resident in the floor after a fall for approximately 20 to 25 minutes before having the aides get her up prior to her assessing her . d. On 4/10/18 at 1:25 a.m., CNA #5 was asked about the resident's fall on 4/1/18 and stated, I heard (Resident #6) was in the floor and it took (LPN #1) a while for her to check on her. e. On 4/10/18 at 1:35 a.m., CNA #2 was asked about the resident's fall on 4/1/18 and stated, .I heard (CNA #1) hollering out of (Resident #6's) room. She had found (Resident #6) on the floor. She told me that she needed (LPN #1) in there now. I was heading to another resident who thought she was having a stroke. (CNA #1) found (LPN #1) on the Southeast Hall (back hall) passing medications and told her she needed her in (Resident #6's) room because she had fallen. (LPN #1) continued getting a routine medication for another resident on that hall. After I finished with my resident, I saw (LPN #1) entering another resident's room, passing routine medications, and was about to ask her if she had been to (Resident #6's) room, when (CNA #1) came back out into hall out of (Resident #6's) room asking me if anybody had seen (LPN #1) because she still hadn't assessed her. She went on to say that it had been 30 minutes since the fall at that time. I told her she (LPN #1) was in another resident's room passing routine medications. (CNA #1) then went into the other resident's room that (LPN #1) was in, passing medications, to once again tell her she needed her in (Resident #6's) room, due to fall. She had been trying to get her to come and assess her since approximately 30 minutes ago. I don't know if (LPN #1) went to (Resident #6's) room after that, because I had to go again to help (LPN #4) with another resident who had a fall on the back hall with a pretty good skin tear after assisting him earlier with the resident with stroke symptoms. The CNA was asked if she documented any of this on a witness statement and stated, Yes and they were given to the DON. f. On 4/10/18 at 2:05 a.m., CNA #6 was asked about the resident's fall on 4/1/18 and stated, .I wasn't working that night but (Resident #6) was left on the floor for 45 minutes and (LPN #1) was the nurse. (CNA #1) was the CNA working that night, and she told me she had left the room [ROOM NUMBER] times to get (LPN #1). All I heard was she was doing her med pass. I have never been questioned or asked to write a witness statement about anything involving (LPN #1). g. On 4/10/18 at 2:18 a.m., LPN #2 was asked about the resident's fall on 4/1/18 and stated, I wasn't here, but I heard (LPN #1) left (Resident #6) in the floor after a fall for 45 minutes and left (Resident #2) in the floor after a fall for approximately 40 minutes. I'm sure (CNA #1) told the Administrator about the falls . h. On 4/10/18 at 2:50 a.m., LPN #1 was asked about the resident being left on the floor for approximately 45 minutes after falling during her shift on 4/1/18 and stated, I don't know anything about any resident being left in the floor for 45 minutes before assessing them. I was across the hall from (Resident #7's) room when she fell . passing scheduled narcotics when (CNA #1) told me (Resident #6) had fallen. I told her to give me a minute and I'd be right in there. It took me approximately 10 minutes to get there. She did come to me twice to get me to come in there; not three times. i. On 4/10/18 at 3:11 a.m., the DON was asked about the resident's fall on 4/1/18 and stated, (LPN #1) called me the night (Resident #6) fell and told me she had fallen and that she had already pulled out another resident's narcotics and was waiting to administer her meds when (CNA #1) came out into the hallway to holler at her about (Resident #6's) fall. She said she told her to let her give the other resident's narcotic and she would be right in there. (LPN #1) was upset because it took her no longer than 5 - 10 minutes before she got in there to assess (Resident #6), but (CNA #1) was telling everyone that it took her 45 minutes to get in there. They both requested a meeting with me and Staff Development, because they have had a lot of issues since working together (approximately 1 month). I never questioned (LPN #1) or (CNA #1) about the discrepancy in the length of time it took (LPN #1) to get to (Resident #6's) room to assess her after the fall. I also didn't question anyone else working that night to get their statements of what occurred that night either. I don't remember receiving any witness statements regarding this incident. I do remember (CNA #1) telling me what happened though. I don't have any reason to believe that (CNA #1) was lying to me; she's a good aide. I don't know why I didn't investigate further what really happened that night. I guess I thought (LPN #1) just needed some more re-education because she was a new LPN and a new employee. The DON was asked to provide copies of the witness statements that were submitted by staff on the night of Resident #6' fall; she was unable to locate any of them during the survey. j. On 4/10/18 at 3:56 a.m., CNA #1 was asked about the resident's fall on 4/1/18 and stated, I was changing another resident when I heard someone hollering for help. I went toward the help sound and found (Resident #6) sitting in the floor between the over bed table and the side of her bed. She didn't appear to have sustained any injuries. I asked her what happened, and she told me she was trying to get to her bed and fell . I went to her doorway and asked (CNA #2) if she knew where (LPN #1) was and told her if she saw her to tell her I need her in (Resident #6's) room to assess her, because she had fallen on the floor. I initially couldn't find her, so I went directly back to (Resident #6's) room and asked her if she was alright, and she told me, 'yes but get me out of this floor'. I told her I would as soon as the nurse came to check her out and make sure she was alright. She again told me to get her out of the floor. I stepped out once again and saw the med cart outside another resident's room and went in and told (LPN #1) I needed her in (Resident #6's) room, because she had fallen and she told me okay, she'll be right there. I then went back to (Resident #6's) room and sat down in the floor next to her (resident), because she was so upset. At this time, (Resident #6) had been in the floor for about 10 minutes. I sat there with her for about 5 - 10 more minutes. I got up and stepped back into the hallway and saw (LPN #1) going into yet another resident's room, when I stopped her and told her, again, that I needed her to come check on (Resident #6) after her fall. She did not respond as she entered the other resident's room, so I stood at (Resident #6's) doorway. When she (LPN #1) came out of that resident's room, I told her (Resident #6) was still on the floor, and I was going to get her up, since (Resident #6) was so upset wanting up out of the floor and into her bed, and she could assess her when she had time. She told me, 'No, I'll be there in a minute'. By this time, (Resident #6) had been on the floor approximately 15 - 20 minutes, and (LPN #1) had not laid eyes on her yet. (LPN #1) left again and I saw her go down to the Southeast (back) hall. I don't know what she was doing. I went back into (Resident #6's) room and told her that I would be right back. I was going to try and get (LPN #4), but he was busy with another resident who had fallen and suffered a bad skin tear and at the same time, another aide was telling him that another resident was having stroke-like symptoms, so I left, and while I was heading back to (Resident #6's) room, I saw (LPN #1) and again I told her if she couldn't get to (Resident #6's) room, I was going to get her off of that cold floor. She again told me, 'no, I'll be right there'. She then went into another resident's room. At this time, it had been about 30 minutes since (Resident #6) had fallen onto the floor. After about 4 more minutes, I saw her come out of that resident's room and go to the med cart and again into the other resident's room for another 5 minutes. At this time, (Resident #6) had been on the floor for about 40 minutes. After (LPN #1) had come out of that resident's room, she went to the med cart and took out her vital sign equipment and then came to assess (Resident #6), and the resident screamed at her 'get me out of this damn floor'. At this time, she had been on the floor for about 45 minutes. After the incident was under control, I took it upon myself to fill out a fall witness statement and took the non-witness statement around to all the other staff that worked that night to get their signatures too. I put mine under the DON's door and gave (LPN #1) the non-witness statement. I don't know what she did with that . I had stayed over one morning, 4/2/18, to talk to the DON, because usually when something like this happens, they come an (TRUNCATED)

Based on record review and interview, the facility failed to ensure allegations of physical abuse and neglect against Licensed Practical Nurse (LPN) #1 were immediately reported to the Office of Long Term Care (OLTC) and other officials in accordance with state law, that the allegations were promptly and thoroughly investigated, and that protective measures were implemented to prevent further potential abuse or neglect, for 1 (Resident #7) of 1 case mix resident who made an allegation of physical abuse against LPN #1 and for 2 (Residents #6 and #2) of 2 case mix residents for whom staff alleged neglect against LPN #1 after the residents experienced falls and were not immediately assessed for injury by LPN #1. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Residents #7, #6 and #2, and had the potential to cause more than minimal harm to 101 residents who received care from LPN #1, as verified by the Director of Nursing on 4/26/18. The Administrator, Regional Administrator and Director of Nursing were informed of the immediate jeopardy condition on 4/10/18 at 7:00 a.m. The findings are: 1. Resident #7 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a brief interview for mental status (BIMS). On 4/4/18, the Office of Long Term Care (OLTC) was informed, by an anonymous source, that LPN #1 had been physically abusive to Resident #7 during a capillary blood glucose (CBG) test. The OLTC staff person reported the allegation to the Administrator via telephone call on 4/4/18. a. On 4/10/18 at 1:00 a.m., the resident was awake, in bed. The resident was asked if she was diabetic and stated, Yes. She was asked if she had to have Capillary Blood Glucose (CBG) testing to check her blood sugar and stated, Yes. She was asked if any of the nurses had been rough with her when checking her CBGs and stated, You're talking about (Licensed Practical Nurse (LPN) #1) aren't you? The resident was asked what happened with LPN #1 and stated, She (LPN #1) got this finger (the resident held up the ring finger on her right hand), and she grabbed this finger and twisted it and bent it around to use it. I told her that she was hurting me, but she just kept doing it. It hurt when she got ahold and twisted my finger. I refuse to have her as my nurse. The resident was asked if anyone from the facility had come to talk to her about the incident and stated, The Social Worker came and talked to me about it. They came, the Social Worker and someone else, and talked to me and didn't want this to be reported to the state. b. On 4/10/18 at 1:10 a.m., LPN #2 was asked if she had ever received any complaints from residents regarding rough treatment by staff during CBG testing. The LPN stated, Yes, what do you want to know? Ask (Resident #7). They (facility administration) just cover for her - it's (LPN #1) - she's new. Residents and families have complained a lot about her, and they just protect her, because she's a new nurse. c. On 4/10/18 at 1:35 a.m., Certified Nursing Assistant (CNA) #2 was asked if she was aware of any complaints regarding a nurse being rough when checking a resident's CBG and stated, Yes, (Resident #7) was sitting up here at the back nurses' station, and she told me and 2 other CNAs that (LPN #1) came into her room to do her CBG the previous morning, on (3/11/18), and she (LPN #1) grabbed her (Resident #7's) finger and pulled it back. (LPN #1) continued to grab her finger and twisted her finger and wrist and took the CBG. She told us that it hurt when she twisted her finger and wrist, and also told us she didn't want (LPN #1) back in her room. All 3 of us got (LPN #3); she was in the medication room just behind the nurses' station. We told her exactly what the resident had told us. We all filled out witness statements and slid them under the Administrator's door. We were never talked to by anyone about this incident. I don't know what happened. d. On 4/10/18 at 2:05 a.m., CNA #6 was asked if she was aware of any nurse being rough with residents when checking their CBGs and stated, I've heard she bent (Resident #7's) finger and twisted it when she did her CBG. The nurse was (LPN #1). e. On 4/10/18 at 2:18 a.m., LPN #2 was asked if she was aware of any nurse being rough with residents when checking their CBG and stated, I heard the DON (Director of Nursing) say she had to talk (Resident #7) into not making a state reportable out of it, regarding (LPN #1) bending and twisting her finger. f. On 4/10/18 at 2:50 a.m., LPN #1 was asked about Resident #7's allegation that the LPN had hurt her finger while obtaining a CBG and stated, I don't recall (Resident #7) saying I hurt her finger when taking a CBG. She said after I poked her finger, she told me that wasn't the finger she wanted me to use. After the incident, after I chose a finger she didn't want me to use, (DON) and (Staff Development Nurse) gave me an in-service on (Resident #7) as a resident and how she likes things done and to be slower and make sure to ask her which finger she wants me to use. g. On 4/10/18 at 5:20 a.m., the Administrator was asked about the incident with Resident #7 and LPN #1 that took place on 3/11/18 and stated, I've never spoken with (Resident #7) about (LPN #1) hurting her. My knowledge is that Social Services went to the resident to take a statement. I told Social Services to let me know what she said. The Administrator was asked for this documentation and stated, I never asked for it. The Administrator was asked if the staff who had written witness statements regarding the incident had been interviewed in an effort to investigate the resident's allegations and stated, No, they haven't. She was asked why not and did not answer. The Administrator stated, I was aware that (Resident #7) didn't want (LPN #1) back in her room, because she went too fast. It just made sense not to let (LPN #1) back in there. The Administrator was then asked for the witness statements the staff had placed underneath her door on 3/13/18 and for her investigation of the incident. h. On 4/10/18 at 6:30 a.m., the Administrator provided the surveyors with 4 witness statements and a report sent to OLTC on 4/4/18. The OLTC Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated 4/4/18 documented, .Date and time of Discovery 4/4/18 at 10:30 a.m., date and time submitted : 4/4/18 at 5:00 p.m., Type of Incident: Physical Abuse. The Summary of Incident documented: On 4/4/18 (Name of person from OLTC) with the Office of Long Term Care phone administrator to inform that there was an allegation that a facility nurse had bent back a resident's finger during a CBG check Steps taken to Prevent Continued Abuse or Neglect During the Investigation . Nurse named in incident immediately suspended pending investigation. In-service started on Abuse, Neglect, and misappropriation of resident personal belongings along with facility policy/protocol. Collected witness/character statements from staff and alert/oriented residents. Administrator, DON, Police, and Responsible Party notified of allegation pending investigation. Investigation is ongoing. 1.) An OLTC Witness Statement Form dated 3/12/18 at 11:40 p.m. documented, .Witness Full Name: (CNA #1) . Shift: 11-7 (11:00 p.m. to 7:00 a.m.) . I witness (Resident #7) telling my co-worker (CNA #3) that a nurse (LPN #1) had got on to her and had jerked her finger while getting her CBG. I was not working on the day (Resident #7) claims this incident happened . 2.) An OLTC Witness Statement Form dated 3/12/18 at 11:45 p.m. documented, .Witness Full Name: (LPN #3) .(Resident #7) was sitting by the nurse's desk, and she spoke up, saying 'I don't like (LPN #1), she wrestled me down and twisted my fingers trying to get blood from it'. I reminded her (LPN #1) was a new nurse and didn't know how she liked things done yet. (Resident #7) replied 'I don't care I don't like her'. I personally did not witness the situation and do not know what happened, but I had worked with the nurse, (LPN #1) for a double shift and had not seen anything objectionable from her . 3.) An OLTC Witness Statement Form dated 3/13/18 at 12:10 a.m. documented, .Witness Full Name: (CNA #2) . Shift: 11-7 . (Resident #7) reported to this aide and co-aides that the nurse (LPN #1) walked into her room to check her blood sugar and tried to poke a certain finger. (Resident #7) told her not that one. Jerked away and nurse (LPN #1) yanked and twisted her finger to poke the one (Resident #7) told her not to .This was reported to nurse (LPN #3) . 4.) An OLTC Witness Statement Form dated 3/13/18 at 12:10 a.m. documented, .Witness Full Name: (CNA #3) Shift: 11-7 . (Resident #7) told us that she does not like the new nurse (LPN #1). I asked why and she said that she jumped all over her and twisted her finger and was very hateful . These Witness Statements were all dated during the night shift beginning at 11:00 p.m. on 3/12/18 and ending at 7:00 a.m. on 3/13/18; however, the report to OLTC was not completed until 4/4/18, after the OLTC staff person contacted the facility to report the allegation to the Administrator. i. On 4/10/18 at 6:30 a.m., CNA #2 was asked if Resident #7, when describing what LPN #1 had done during the CBG incident, had specified the date when the incident occurred and stated, The date of our Witness Statements is the date (Resident #7) told us about it. She said it had happened the morning before, which would have been the a.m. of the 11th (3/11/18). When we told (LPN #3), she said she had to call the Administrator about the allegation. We pulled the Witness Statements and filled them out and put them under the Administrator's door. I was never talked to by anyone in administration, and I don't believe the others have been either. If they had been, I'm pretty sure they would have told me. j. On 4/10/18 at 8:35 a.m., the Social Service Director (SSD) was asked about the Witness Statements for 3/12/18 and 3/13/18 regarding Resident #7 and LPN #1. The SSD stated, I don't believe I ever saw those Witness Statements. I went and spoke with (Resident #7) on 3/5/18 after the DON (Director of Nursing) told me about her finger. The Social Service Director was informed that the incident occurred on 3/11/18 and was reported to staff by the resident on the night of 3/12/18. The Social Service Director stated, The DON told me, after OLTC called on the 4th of April, that I needed to write up my interview I had with (Resident #7) on 3/5/18. I looked for paper copies of my interview and there are none. The Social Service Director was asked if a previous incident had occurred involving Resident #7 and LPN #1 on 3/5/18, since the surveyors were only aware of the incident that occurred on 3/11/18. The Social Service Director stated, I was told by the DON that it occurred on 3/5/18. k. On 4/10/18 at 8:55 a.m., the DON was informed of the SSD's statement that she was asked to document an incident on 3/5/18, involving Resident #7. The DON was then asked if an incident occurred with Resident #7 and LPN #1 on 3/5/18. The DON stated, She (SSD) got the 3/5/18 from me, because I believed the incident occurred on (Saturday) 3/3/18, because I had it in my head it was the weekend of (LPN #1's) second day of work. She was asked, if a nurse had worked 2 days, would she be caring for residents on her own? The DON stated, No, I guess I had the dates wrong. I thought it was 3/3/18 when I got the call (from staff regarding the incident). After me and the Social Service Director talked to (Resident #7), neither of us wrote anything up prior to OLTC notifying us on 4/4/18. The DON was asked when she first saw the witness statements dated 3/12/18 and 3/13/18 from the staff and stated, Honestly, I believe today is the first time I saw them. I knew we had gotten some witness statements, but I had not seen them. The Administrator had them, and I asked if there were any negative findings, as in something we needed to follow-up on, and she said, after talking with (Resident #7), that we had resolved it. I don't remember the exact wording. Me and (Social Service Director) talked to her (Resident #7) together once, and then I went down later that afternoon to make sure her story didn't change. She told us the nurse just went too fast. The DON was asked if she had documentation of any of their conversations with the resident and stated, There is no documentation of any of these conversations with the resident. She was asked if, during their investigation, they talked with the staff who initially reported the resident's allegations via witness statements dated 3/12/18 and 3/13/18 and stated, No. l. On 4/10/18 at 9:17 a.m., the Administrator was asked when she first received the Witness Statements dated 3/12/18 and 3/13/18 and stated, When I first got these statements, I had the Social Service and DON go talk to (Resident #7). I don't remember if I gave the Witness Statements to the Social Service Director or not. I may have just told her about it and had her talk to the resident. I'm sure I asked for the documentation from the Social Service Director and DON. I've never received any documentation after they talked with the resident. m. On 4/10/18 at 9:24 a.m., the Regional Nurse Consultant was asked when she was initially made aware of the Witness Statements dated 3/12/18 and 3/13/18 for (Resident #7) and stated, The first time I was aware of the Witness Statements for 3/12/18 and 3/13/18 was today, when you surveyors showed them to me. n. On 4/10/18 at 9:28 a.m., the Administrator was asked if the staff who had written the Witness Statements regarding the incident with Resident #7 had been interviewed after she received the call from OLTC on 4/4/18 and stated, When the reportable was initiated on 4/4/18, after the call from OLTC, none of the CNAs or the nurse who the resident initially reported the incident were interviewed. o. On 4/10/18 at 10:02 a.m., the Staff Development Nurse was asked if she was involved with the investigation regarding Resident #7's allegation of abuse from a nurse and stated, I don't know the dates, but it was brought to our attention. (DON) said there was an allegation that (Resident #7's) finger was bent back during a CBG. I was told about it before the phone call from OLTC on 4/4/18. I was told that they had gone down and spoke with the resident. I don't know if it was both (DON) and (Social Service Director). (DON) told me they felt that it was just hurried by the nurse, after speaking with the resident. (DON) and myself talked to (LPN #1) about slowing down and explaining what she was doing. I never saw any Witness Statements from staff who initially received the information from the resident. p. On 4/11/18 at 11:34 a.m., CNA #3 was asked about his witness statement dated 3/13/18 at 12:10 a.m. regarding Resident #7 and stated, When I came in at 11:00 p.m. on 3/12/18, she wanted out of bed. I told her to give us a bit, we were in the middle of shift exchange. We got her up and she wanted a cup of ice and I got her a cup of ice and she said, 'Boy (CNA #3) I tell ya', I don't know nothing about that new nurse, but I don't like her. I asked who she was talking about and she said, (LPN #1's name). I asked her why and she said (LPN #1) wanted to poke her finger and I told her, 'all the nurses have to poke your finger to check your sugar'. She said, 'Oh no, not the way she did it; she jumped all over me.' I said, 'jumped all over you?', and she said, 'Oh yeah, she pretty much straddled me and grabbed my finger.' I asked her what she meant and she said, 'She grabbed my finger, twisted it and poked it anyway and she hurt me.' After that, I went and got (LPN #3) from the medication room that is behind the nurses' station. She came out and asked (Resident #7) what was going on, and (Resident #7) told her the exact same thing. I asked her when this happened, and she said the morning before . that would have been the 11th of March. The nurse called (DON), and (DON) said we would have to do Witness Statements. We got Witness Statements out of the drawer and filled them out. CNA #3 was asked if anyone from administration had ever talked to him about the incident and stated, No one ever came and asked me anything. I was wondering why she came back to work. (Resident #7) has her right mind. I know when allegations like this are made, until they complete their investigation, the person named is suspended, but (LPN #1) came back to work and (Resident #7) saw her and said, 'I knew she would be back', because (DON) and another lady came into her room and tried to talk her out of what she said had happened. After she told us about the incident, I was off the next 2 nights. When I came back in, (LPN #1) was here, and that's when (Resident #7) told me this. I told (LPN #3), and she said, 'That's out of our hands; we did what we were supposed to do. We reported it by our chain of command.' After that, (LPN #1) worked back there (on Resident #7's hall) a couple of nights, and then she started working up front. q. On 4/11/18 at 12:28 p.m., LPN #3 was asked about Resident #7's allegation of abuse from LPN #1 and stated, When the CNAs told me what (Resident #7) told them, I told them I would have to call the Administrator and DON. I called them both. I can't remember who I called first. I must have called (Administrator) first, because she said to call (DON). She told me she would be up here. We waited, and she never showed up on our shift. I knew she would have to talk to them (CNA staff who documented the Witness Statements), so I had them to wait. They finally left, with no one talking to them. (DON) said to get Witness Statements. We did write Witness Statements. I heard that someone had talked to her. (Resident #7) told me someone came and talked to her. I heard people saying they tried to get her to change her story. The CNAs said, '(Resident #7) just told us that (LPN #1) bent her finger back.' So I went to talk to (Resident #7). She told me, '(LPN #1) wrangled me down and bent my finger back to check my sugar.' I didn't think to ask her when it happened. If they said she told them it happened the morning before, that's when it happened. (DON) told me I didn't write the date (of the incident on the Witness Statement). I asked her, 'I didn't write the date?' She said, 'You didn't write the date it happened'. This happened on 3/11/18 in the morning, is what (Resident #7) had told the CNAs. I was never asked anything about this until yesterday. To my knowledge, none of the CNAs were talked to either. r. On 4/11/18 at 12:50 p.m., CNA #1 was asked if Resident #7 told her when the incident she reported had occurred and stated, (Resident #7) told us that the incident where (LPN #1) bent her finger happened the morning before she told us, which would have been (MONTH) the 11th. (Resident #7) told me, I can't remember the exact day, but I was putting her to bed after I came on, and she told me, 'You won't believe what they are trying to do to me . I asked her 'what is it?' She said (DON) and the other lady (SSD) were trying to talk her out of the bending of her finger because (LPN #1) was a new nurse and that she could lose her job and it would be a state reportable. I asked her what happened, and she said, 'I don't know what they are going to do'. No one ever came and talked to me or anyone else that I know of about this incident. I heard that (DON) had said that she was going to have to go down and talk (Resident #7) out of this reportable. I heard this from (LPN #2) and (CNA #2). s. On 4/11/18 at 3:34 p.m., the Regional Nurse Consultant was asked what the Administrator had reported to her after she had received the witness statements regarding Resident #7 and stated, When we talked to the Administrator, she told us she didn't really remember looking at the witness statements on (Resident #7) on 3/12/18 and 3/13/18. t. On 4/13/18 at 10:35 a.m., the Regional Nurse Consultant provided the surveyors with an Addendum to the reportable regarding Resident #7 that documented, (MONTH) 14, (YEAR) Addendum: (Resident #7) . On 4/10/18 it was determined during a complaint survey the date and time of the incident was 3/12/18, not 3/3/18. Also, it was determined at the time of the actual incident the DON or Administrator did not investigate the allegation after interviews with staff and resident. Based on this information, the facility has substantiated the allegation. DON and Administrator were both suspended on 4/10/18 and relieved of their duties on 4/13/18. LPN (LPN #1) was also relieved of her duties on 4/13/18 . 2. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/15/18 documented the resident scored 3 (0 - 7 indicates severely impaired) on a BIMS, required extensive assistance of 2 plus person for bed mobility, transfers and locomotion on and off of the unit and had two falls with no injuries since the last assessment. a. The Plan of Care dated 11/7/17 documented, ADLs (Activities of Daily Living) . Start Date: 11/7/17 . Intervention: Transfers - 2 person assistance . Potential for falls: Safety . Start Date: 6/16/17 . Fall 12/15/17 . Staff to assist with transfers: Fall 12/15/17 . Staff to assist Resident to bed at time of choice: Fall 12/26/17 . Staff to assist resident with toileting after evening meal: Fall 1/7/18 . Staff to assist resident with toileting prior to bedtime: Fall 1/16/18 . Use call light for assist with transfers for safety: Fall 1/6/18 . Staff to assist resident into wheelchair after breakfast: Fall 2/14/18 . Staff to encourage resident to wear non-skid socks/shoes for transfers/ambulation: Fall 3/3/18 .Visual reminder placed on wall in room to ask for assistance: Fall 3/11/18 .Resident places self in floor at times: Fall 4/5/18 . Continue Plan of Care . b. An Incident Report dated 4/1/18 and signed by LPN #1 documented, Incident Type: Fall no head injury . Date/Time: 4/1/18 at 6:30 a.m . Type of Injury: None Apparent . Location: Resident room . Activity at time: From chair w/o (without) asst (assistance) . Associate involved: (CNA #1) . Incident reported by: (CNA #1) . Report prepared by: (LPN #1) . Non-Witnessed . Narrative of Incident and description of injuries: CNA reported to this Nurse (LPN #1) that Pt (Patient) was transferring self from chair to bed without assistance and fell on her bottom. Performed neuro (neurological) check on Pt WNL (within normal limits). No injuries or bruises apparent. No c/o (complaints of) pain or discomfort at this time. Incident took place in Pt room while Pt was transferring herself from the chair to the bed without assistance. Immediate Actions taken: Neuro check performed WNL, V/S (vital signs) & (and) skin evaluation performed no apparent injuries . c. On 4/10/18 at 1:20 a.m., CNA #4 was asked about the resident's fall on 4/1/18 and stated, I heard the resident fell , and (LPN #1) left her in the floor at least 40 to 45 minutes before assessing her and had left another resident in the floor after a fall for approximately 20 to 25 minutes before having the aides get her up prior to her assessing her . d. On 4/10/18 at 1:25 a.m., CNA #5 was asked about the resident's fall on 4/1/18 and stated, I heard (Resident #6) was in the floor and it took (LPN #1) a while for her to check on her. e. On 4/10/18 at 1:35 a.m., CNA #2 was asked about the resident's fall on 4/1/18 and stated, .I heard (CNA #1) hollering out of (Resident #6's) room. She had found (Resident #6) on the floor. She told me that she needed (LPN #1) in there now. I was heading to another resident who thought she was having a stroke. (CNA #1) found (LPN #1) on the Southeast Hall (back hall) passing medications and told her she needed her in (Resident #6's) room because she had fallen. (LPN #1) continued getting a routine medication for another resident on that hall. After I finished with my resident, I saw (LPN #1) entering another resident's room, passing routine medications, and was about to ask her if she had been to (Resident #6's) room, when (CNA #1) came back out into hall out of (Resident #6's) room asking me if anybody had seen (LPN #1) because she still hadn't assessed her. She went on to say that it had been 30 minutes since the fall at that time. I told her she (LPN #1) was in another resident's room passing routine medications. (CNA #1) then went into the other resident's room that (LPN #1) was in, passing medications, to once again tell her she needed her in (Resident #6's) room, due to fall. She had been trying to get her to come and assess her since approximately 30 minutes ago. I don't know if (LPN #1) went to (Resident #6's) room after that, because I had to go again to help (LPN #4) with another resident who had a fall on the back hall with a pretty good skin tear after assisting him earlier with the resident with stroke symptoms. The CNA was asked if she documented any of this on a witness statement and stated, Yes and they were given to the DON. f. On 4/10/18 at 2:05 a.m., CNA #6 was asked about the resident's fall on 4/1/18 and stated, .I wasn't working that night but (Resident #6) was left on the floor for 45 minutes and (LPN #1) was the nurse. (CNA #1) was the CNA working that night, and she told me she had left the room [ROOM NUMBER] times to get (LPN #1). All I heard was she was doing her med pass. I have never been questioned or asked to write a witness statement about anything involving (LPN #1). g. On 4/10/18 at 2:18 a.m., LPN #2 was asked about the resident's fall on 4/1/18 and stated, I wasn't here, but I heard (LPN #1) left (Resident #6) in the floor after a fall for 45 minutes and left (Resident #2) in the floor after a fall for approximately 40 minutes. I'm sure (CNA #1) told the Administrator about the falls . h. On 4/10/18 at 2:50 a.m., LPN #1 was asked about the resident being left on the floor for approximately 45 minutes after falling during her shift on 4/1/18 and stated, I don't know anything about any resident being left in the floor for 45 minutes before assessing them. I was across the hall from (Resident #7's) room when she fell . passing scheduled narcotics when (CNA #1) told me (Resident #6) had fallen. I told her to give me a minute and I'd be right in there. It took me approximately 10 minutes to get there. She did come to me twice to get me to come in there; not three times. i. On 4/10/18 at 3:11 a.m., the DON was asked about the resident's fall on 4/1/18 and stated, (LPN #1) called me the night (Resident #6) fell and told me she had fallen and that she had already pulled out another resident's narcotics and was waiting to administer her meds when (CNA #1) came out into the hallway to holler at her about (Resident #6's) fall. She said she told her to let her give the other resident's narcotic and she would be right in there. (LPN #1) was upset because it took her no longer than 5 - 10 minutes before she got in there to assess (Resident #6), but (CNA #1) was telling everyone that it took her 45 minutes to get in there. They both requested a meeting with me and Staff Development, because they have had a lot of issues since working together (approximately 1 month). I never questioned (LPN #1) or (CNA #1) about the discrepancy in the length of time it took (LPN #1) to get to (Resident #6's) room to assess her after the fall. I also didn't question anyone else working that night to get their statements of what occurred that night either. I don't remember receiving any witness statements regarding this incident. I do remember (CNA #1) telling me what happened though. I don't have any reason to believe that (CNA #1) was lying to me; she's a good aide. I don't know why I didn't investigate further what really happened that night. I guess I thought (LPN #1) just needed some more re-education because she was a new LPN and a new employee. The DON was asked to provide copies of the witness statements that were submitted by staff on the night of Resident #6' fall; she was unable to locate any of them during the survey. j. On 4/10/18 at 3:56 a.m., CNA #1 was asked about the resident's fall on 4/1/18 and stated, I was changing another resident when I heard someone hollering for help. I went toward the help sound and found (Resident #6) sitting in the floor between the over bed table and the side of her bed. She didn't appear to have sustained any injuries. I asked her what happened, and she told me she was trying to get to her bed and fell . I went to her doorway and asked (CNA #2) if she knew where (LPN #1) was and told her if she saw her to tell her I need her in (Resident #6's) room to assess her, because she had fallen on the floor. I initially couldn't find her, so I went directly back to (Resident #6's) room and asked her if she was alright, and she told me, 'yes but get me out of this floor'. I told her I would as soon as the nurse came to check her out and make sure she was alright. She again told me to get her out of the floor. I stepped out once again and saw the med cart outside another resident's room and went in and told (LPN #1) I needed her in (Resident #6's) room, because she had fallen and she told me okay, she'll be right there. I then went back to (Resident #6's) room and sat down in the floor next to her (resident), because she was so upset. At this time, (Resident #6) had been in the floor for about 10 minutes. I sat there with her for about 5 - 10 more minutes. I got up and stepped back into the hallway and saw (LPN #1) going into yet another resident's room, when I stopped her and told her, again, that I needed her to come check on (Resident #6) after her fall. She did not respond as she entered the other resident's room, so I stood at (Resident #6's) doorway. When she (LPN #1) came out of that resident's room, I told her (Resident #6) was still on the floor, and I was going to get her up, since (Resident #6) was so upset wanting up out of the floor and into her bed, and she could assess her when she had time. She told me, 'No, I'll be there in a minute'. By this time, (Resident #6) had been on the floor approximately 15 - 20 minutes, and (LPN #1) had not laid eyes on her yet. (LPN #1) left again and I saw her go down to the Southeast (back) hall. I don't know what she was doing. I went back into (Resident #6's) room and told her that I would be right back. I was going to try and get (LPN #4), but he was busy with another resident who had fallen and suffered a bad skin tear and at the same time, another aide was telling him that another resident was having stroke-like symptoms, so I left, and while I was heading back to (Resident #6's) room, I saw (LPN #1) and again I told her if she couldn't get to (Resident #6's) room, I was going to get her off of that cold floor. She again told me, 'no, I'll be right there'. She then went into another resident's room. At this time, it had been about 30 minutes since (Resident #6) had fallen onto the floor. After about 4 more minutes, I saw her come out of that resident's room and go to the med cart and again into the other resident's room for another 5 minutes. At this time, (Resident #6) had been on the floor for about 40 minutes. After (LPN #1) had come out of that resident's room, she went to the med cart and took out her vital sign equipment and then came to assess (Resident #6), and the resident screamed at her 'get me out of this damn floor'. At this time, she had been on the floor for about 45 minutes. After the incident was under control, I took it upon myself to fill out a fall witness statement and took the non-witness statement around to all the other staff that worked that night to get their signatures too. I put mine under the DON's door and gave (LPN #1) the non-witness statement. I don't know what she did with that . I had stayed over one morning, 4/2/18, to talk to the DON, because usually (TRUNCATED)

Based on record review and interview, the facility's administration and nursing administration failed to take the necessary measures to ensure residents were free from staff-to-resident abuse and neglect, by failing to ensure immediate protective measures were implemented to prevent further abuse, after a resident and multiple staff members made allegations of physical abuse and neglect against Licensed Practical Nurse (LPN #1). The facility failed to ensure an allegation of physical abuse against LPN #1 was immediately investigated, protective measures were implemented to prevent further potential abuse, and that staff did not attempt to pressure the resident to keep quiet about the allegation for 1 (Resident #7); failed to ensure allegations of neglect were investigated and immediate protective measures were implemented after staff alleged that LPN #1 failed to promptly respond when informed that residents had fallen and were on the floor for 2 (Residents #6 and #2) of 9 (Residents #1 - 9) case mix residents who received care from LPN #1; and failed to ensure that all 3 of the incidents were immediately reported to the Office of Long Term Care (OLTC) and other agencies in accordance with State law to enable these agencies to promptly provide the necessary oversight to ensure residents were protected from abuse. The failed practices resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death to Residents #7, #6 and #2, and had the potential to cause more than minimal harm to 101 residents who received care from LPN #1, verified by the Director of Nursing on 4/26/18. The Administrator, Regional Administrator and Director of Nursing were informed of the immediate jeopardy condition on 4/10/18 at 7:00 a.m. The findings are: 1. The Job Description for the Administrator provided by the Nurse Consultant on 4/11/18 documented, General Purpose: To direct the day-to-day functions of the facility in accordance with current Federal, State and local standards governing long-term care facilities to ensure that the highest practicable level of care is provided to the residents .Resident's Rights Functions: .6. Monitor, investigate and report all allegations of resident abuse in compliance with regulatory guidelines . 2. The Job Description for the Director of Nursing provided by the Nurse Consultant on 4/11/18 documented, General Purpose: Under the direction of the administrator plans, organizes, develops and directs the overall operation of the Nursing Services Department in accordance with current federal, state and local standards governing the facility. Ensure that the highest practicable level of quality care is maintained at all times .Essential Job Functions .6. Ensure compliance with Federal/state and company requirements are met for all incidents/accidents and reportable allegations, including conducting investigations as required . 3. Resident #7 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a brief interview for mental status (BIMS). On 4/4/18, the Office of Long Term Care (OLTC) was informed, by an anonymous source, that LPN #1 had been physically abusive to Resident #7 during a capillary blood glucose (CBG) test. The OLTC staff person reported the allegation to the Administrator via telephone call on 4/4/18. a. On 4/10/18 at 1:00 a.m., the resident was awake, in bed. The resident was asked if she was diabetic and stated, Yes. She was asked if she had to have Capillary Blood Glucose (CBG) testing to check her blood sugar and stated, Yes. She was asked if any of the nurses had been rough with her when checking her CBGs and stated, You're talking about (Licensed Practical Nurse (LPN) #1) aren't you? The resident was asked what happened with LPN #1 and stated, She (LPN #1) got this finger (the resident held up the ring finger on her right hand), and she grabbed this finger and twisted it and bent it around to use it. I told her that she was hurting me, but she just kept doing it. It hurt when she got ahold and twisted my finger. I refuse to have her as my nurse. The resident was asked if anyone from the facility had come to talk to her about the incident and stated, The Social Worker came and talked to me about it. They came, the Social Worker and someone else, and talked to me and didn't want this to be reported to the state. b. On 4/10/18 at 1:10 a.m., LPN #2 was asked if she had ever received any complaints from residents regarding rough treatment by staff during CBG testing. The LPN stated, Yes, what do you want to know? Ask (Resident #7). They (facility administration) just cover for her - it's (LPN #1) - she's new. Residents and families have complained a lot about her, and they just protect her, because she's a new nurse. c. On 4/10/18 at 1:35 a.m., Certified Nursing Assistant (CNA) #2 was asked if she was aware of any complaints regarding a nurse being rough when checking a resident's CBG and stated, Yes, (Resident #7) was sitting up here at the back nurses' station, and she told me and 2 other CNAs that (LPN #1) came into her room to do her CBG the previous morning, on (3/11/18), and she (LPN #1) grabbed her (Resident #7's) finger and pulled it back. (LPN #1) continued to grab her finger and twisted her finger and wrist and took the CBG. She told us that it hurt when she twisted her finger and wrist, and also told us she didn't want (LPN #1) back in her room. All 3 of us got (LPN #3); she was in the medication room just behind the nurses' station. We told her exactly what the resident had told us. We all filled out witness statements and slid them under the Administrator's door. We were never talked to by anyone about this incident. I don't know what happened. d. On 4/10/18 at 2:05 a.m., CNA #6 was asked if she was aware of any nurse being rough with residents when checking their CBGs and stated, I've heard she bent (Resident #7's) finger and twisted it when she did her CBG. The nurse was (LPN #1). e. On 4/10/18 at 2:18 a.m., LPN #2 was asked if she was aware of any nurse being rough with residents when checking their CBG and stated, I heard the DON (Director of Nursing) say she had to talk (Resident #7) into not making a state reportable out of it, regarding (LPN #1) bending and twisting her finger. f. On 4/10/18 at 2:50 a.m., LPN #1 was asked about Resident #7's allegation that the LPN had hurt her finger while obtaining a CBG and stated, I don't recall (Resident #7) saying I hurt her finger when taking a CBG. She said after I poked her finger, she told me that wasn't the finger she wanted me to use. After the incident, after I chose a finger she didn't want me to use, (DON) and (Staff Development Nurse) gave me an in-service on (Resident #7) as a resident and how she likes things done and to be slower and make sure to ask her which finger she wants me to use. g. On 4/10/18 at 5:20 a.m., the Administrator was asked about the incident with Resident #7 and LPN #1 that took place on 3/11/18 and stated, I've never spoken with (Resident #7) about (LPN #1) hurting her. My knowledge is that Social Services went to the resident to take a statement. I told Social Services to let me know what she said. The Administrator was asked for this documentation and stated, I never asked for it. The Administrator was asked if the staff who had written witness statements regarding the incident had been interviewed in an effort to investigate the resident's allegations and stated, No, they haven't. She was asked why not and did not answer. The Administrator stated, I was aware that (Resident #7) didn't want (LPN #1) back in her room, because she went too fast. It just made sense not to let (LPN #1) back in there. The Administrator was then asked for the witness statements the staff had placed underneath her door on 3/13/18 and for her investigation of the incident. h. On 4/10/18 at 6:30 a.m., the Administrator provided the surveyors with 4 witness statements and a report sent to OLTC on 4/4/18. The OLTC Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated 4/4/18 documented, .Date and time of Discovery 4/4/18 at 10:30 a.m., date and time submitted : 4/4/18 at 5:00 p.m., Type of Incident: Physical Abuse. The Summary of Incident documented: On 4/4/18 (Name of person from OLTC) with the Office of Long Term Care phone administrator to inform that there was an allegation that a facility nurse had bent back a resident's finger during a CBG check Steps taken to Prevent Continued Abuse or Neglect During the Investigation . Nurse named in incident immediately suspended pending investigation. In-service started on Abuse, Neglect, and misappropriation of resident personal belongings along with facility policy/protocol. Collected witness/character statements from staff and alert/oriented residents. Administrator, DON, Police, and Responsible Party notified of allegation pending investigation. Investigation is ongoing. 1.) An OLTC Witness Statement Form dated 3/12/18 at 11:40 p.m. documented, .Witness Full Name: (CNA #1) . Shift: 11-7 (11:00 p.m. to 7:00 a.m.) . I witness (Resident #7) telling my co-worker (CNA #3) that a nurse (LPN #1) had got on to her and had jerked her finger while getting her CBG. I was not working on the day (Resident #7) claims this incident happened . 2.) An OLTC Witness Statement Form dated 3/12/18 at 11:45 p.m. documented, .Witness Full Name: (LPN #3) .(Resident #7) was sitting by the nurse's desk, and she spoke up, saying 'I don't like (LPN #1), she wrestled me down and twisted my fingers trying to get blood from it'. I reminded her (LPN #1) was a new nurse and didn't know how she liked things done yet. (Resident #7) replied 'I don't care I don't like her'. I personally did not witness the situation and do not know what happened, but I had worked with the nurse, (LPN #1) for a double shift and had not seen anything objectionable from her . 3.) An OLTC Witness Statement Form dated 3/13/18 at 12:10 a.m. documented, .Witness Full Name: (CNA #2) . Shift: 11-7 . (Resident #7) reported to this aide and co-aides that the nurse (LPN #1) walked into her room to check her blood sugar and tried to poke a certain finger. (Resident #7) told her not that one. Jerked away and nurse (LPN #1) yanked and twisted her finger to poke the one (Resident #7) told her not to .This was reported to nurse (LPN #3) . 4.) An OLTC Witness Statement Form dated 3/13/18 at 12:10 a.m. documented, .Witness Full Name: (CNA #3) Shift: 11-7 . (Resident #7) told us that she does not like the new nurse (LPN #1). I asked why and she said that she jumped all over her and twisted her finger and was very hateful . These Witness Statements were all dated during the night shift beginning at 11:00 p.m. on 3/12/18 and ending at 7:00 a.m. on 3/13/18; however, the report to OLTC was not completed until 4/4/18, after the OLTC staff person contacted the facility to report the allegation to the Administrator. i. On 4/10/18 at 6:30 a.m., CNA #2 was asked if Resident #7, when describing what LPN #1 had done during the CBG incident, had specified the date when the incident occurred and stated, The date of our Witness Statements is the date (Resident #7) told us about it. She said it had happened the morning before, which would have been the a.m. of the 11th (3/11/18). When we told (LPN #3), she said she had to call the Administrator about the allegation. We pulled the Witness Statements and filled them out and put them under the Administrator's door. I was never talked to by anyone in administration, and I don't believe the others have been either. If they had been, I'm pretty sure they would have told me. j. On 4/10/18 at 8:35 a.m., the Social Service Director (SSD) was asked about the Witness Statements for 3/12/18 and 3/13/18 regarding Resident #7 and LPN #1. The SSD stated, I don't believe I ever saw those Witness Statements. I went and spoke with (Resident #7) on 3/5/18 after the DON (Director of Nursing) told me about her finger. The Social Service Director was informed that the incident occurred on 3/11/18 and was reported to staff by the resident on the night of 3/12/18. The Social Service Director stated, The DON told me, after OLTC called on the 4th of April, that I needed to write up my interview I had with (Resident #7) on 3/5/18. I looked for paper copies of my interview and there are none. The Social Service Director was asked if a previous incident had occurred involving Resident #7 and LPN #1 on 3/5/18, since the surveyors were only aware of the incident that occurred on 3/11/18. The Social Service Director stated, I was told by the DON that it occurred on 3/5/18. k. On 4/10/18 at 8:55 a.m., the DON was informed of the SSD's statement that she was asked to document an incident on 3/5/18, involving Resident #7. The DON was then asked if an incident occurred with Resident #7 and LPN #1 on 3/5/18. The DON stated, She (SSD) got the 3/5/18 from me, because I believed the incident occurred on (Saturday) 3/3/18, because I had it in my head it was the weekend of (LPN #1's) second day of work. She was asked, if a nurse had worked 2 days, would she be caring for residents on her own? The DON stated, No, I guess I had the dates wrong. I thought it was 3/3/18 when I got the call (from staff regarding the incident). After me and the Social Service Director talked to (Resident #7), neither of us wrote anything up prior to OLTC notifying us on 4/4/18. The DON was asked when she first saw the witness statements dated 3/12/18 and 3/13/18 from the staff and stated, Honestly, I believe today is the first time I saw them. I knew we had gotten some witness statements, but I had not seen them. The Administrator had them, and I asked if there were any negative findings, as in something we needed to follow-up on, and she said, after talking with (Resident #7), that we had resolved it. I don't remember the exact wording. Me and (Social Service Director) talked to her (Resident #7) together once, and then I went down later that afternoon to make sure her story didn't change. She told us the nurse just went too fast. The DON was asked if she had documentation of any of their conversations with the resident and stated, There is no documentation of any of these conversations with the resident. She was asked if, during their investigation, they talked with the staff who initially reported the resident's allegations via witness statements dated 3/12/18 and 3/13/18 and stated, No. l. On 4/10/18 at 9:17 a.m., the Administrator was asked when she first received the Witness Statements dated 3/12/18 and 3/13/18 and stated, When I first got these statements, I had the Social Service and DON go talk to (Resident #7). I don't remember if I gave the Witness Statements to the Social Service Director or not. I may have just told her about it and had her talk to the resident. I'm sure I asked for the documentation from the Social Service Director and DON. I've never received any documentation after they talked with the resident. m. On 4/10/18 at 9:24 a.m., the Regional Nurse Consultant was asked when she was initially made aware of the Witness Statements dated 3/12/18 and 3/13/18 for (Resident #7) and stated, The first time I was aware of the Witness Statements for 3/12/18 and 3/13/18 was today, when you surveyors showed them to me. n. On 4/10/18 at 9:28 a.m., the Administrator was asked if the staff who had written the Witness Statements regarding the incident with Resident #7 had been interviewed after she received the call from OLTC on 4/4/18 and stated, When the reportable was initiated on 4/4/18, after the call from OLTC, none of the CNAs or the nurse who the resident initially reported the incident were interviewed. o. On 4/10/18 at 10:02 a.m., the Staff Development Nurse was asked if she was involved with the investigation regarding Resident #7's allegation of abuse from a nurse and stated, I don't know the dates, but it was brought to our attention. (DON) said there was an allegation that (Resident #7's) finger was bent back during a CBG. I was told about it before the phone call from OLTC on 4/4/18. I was told that they had gone down and spoke with the resident. I don't know if it was both (DON) and (Social Service Director). (DON) told me they felt that it was just hurried by the nurse, after speaking with the resident. (DON) and myself talked to (LPN #1) about slowing down and explaining what she was doing. I never saw any Witness Statements from staff who initially received the information from the resident. p. On 4/11/18 at 11:34 a.m., CNA #3 and he was asked about his witness statement dated 3/13/18 at 12:10 a.m. regarding Resident #7 and stated, When I came in at 11:00 p.m. on 3/12/18, she wanted out of bed. I told her to give us a bit, we were in the middle of shift exchange. We got her up and she wanted a cup of ice and I got her a cup of ice and she said, 'Boy (CNA #3) I tell ya', I don't know nothing about that new nurse, but I don't like her. I asked who she was talking about and she said, (LPN #1's name). I asked her why and she said (LPN #1) wanted to poke her finger and I told her, 'all the nurses have to poke your finger to check your sugar'. She said, 'Oh no, not the way she did it; she jumped all over me.' I said, 'jumped all over you?', and she said, 'Oh yeah, she pretty much straddled me and grabbed my finger.' I asked her what she meant and she said, 'She grabbed my finger, twisted it and poked it anyway and she hurt me.' After that, I went and got (LPN #3) from the medication room that is behind the nurses' station. She came out and asked (Resident #7) what was going on, and (Resident #7) told her the exact same thing. I asked her when this happened, and she said the morning before . that would have been the 11th of March. The nurse called (DON), and (DON) said we would have to do Witness Statements. We got Witness Statements out of the drawer and filled them out. CNA #3 was asked if anyone from administration had ever talked to him about the incident and stated, No one ever came and asked me anything. I was wondering why she came back to work. (Resident #7) has her right mind. I know when allegations like this are made, until they complete their investigation, the person named is suspended, but (LPN #1) came back to work and (Resident #7) saw her and said, 'I knew she would be back', because (DON) and another lady came into her room and tried to talk her out of what she said had happened. After she told us about the incident, I was off the next 2 nights. When I came back in, (LPN #1) was here, and that's when (Resident #7) told me this. I told (LPN #3), and she said, 'That's out of our hands; we did what we were supposed to do. We reported it by our chain of command.' After that, (LPN #1) worked back there (on Resident #7's hall) a couple of nights, and then she started working up front. q. On 4/11/18 at 12:28 p.m., LPN #3 was asked about Resident #7's allegation of abuse from LPN #1 and stated, When the CNAs told me what (Resident #7) told them, I told them I would have to call the Administrator and DON. I called them both. I can't remember who I called first. I must have called (Administrator) first, because she said to call (DON). She told me she would be up here. We waited, and she never showed up on our shift. I knew she would have to talk to them (CNA staff who documented the Witness Statements), so I had them to wait. They finally left, with no one talking to them. (DON) said to get Witness Statements. We did write Witness Statements. I heard that someone had talked to her. (Resident #7) told me someone came and talked to her. I heard people saying they tried to get her to change her story. The CNAs said, '(Resident #7) just told us that (LPN #1) bent her finger back.' So I went to talk to (Resident #7). She told me, '(LPN #1) wrangled me down and bent my finger back to check my sugar.' I didn't think to ask her when it happened. If they said she told them it happened the morning before, that's when it happened. (DON) told me I didn't write the date (of the incident on the Witness Statement). I asked her, 'I didn't write the date?' She said, 'You didn't write the date it happened'. This happened on 3/11/18 in the morning, is what (Resident #7) had told the CNAs. I was never asked anything about this until yesterday. To my knowledge, none of the CNAs were talked to either. r. On 4/11/18 at 12:50 p.m., CNA #1 was asked if Resident #7 told her when the incident she reported had occurred and stated, (Resident #7) told us that the incident where (LPN #1) bent her finger happened the morning before she told us, which would have been (MONTH) the 11th. (Resident #7) told me, I can't remember the exact day, but I was putting her to bed after I came on, and she told me, 'You won't believe what they are trying to do to me . I asked her 'what is it?' She said (DON) and the other lady (SSD) were trying to talk her out of the bending of her finger because (LPN #1) was a new nurse and that she could lose her job and it would be a state reportable. I asked her what happened, and she said, 'I don't know what they are going to do'. No one ever came and talked to me or anyone else that I know of about this incident. I heard that (DON) had said that she was going to have to go down and talk (Resident #7) out of this reportable. I heard this from (LPN #2) and (CNA #2). s. On 4/11/18 at 3:34 p.m., the Regional Nurse Consultant was asked what the Administrator had reported to her after she had received the witness statements regarding Resident #7 and stated, When we talked to the Administrator, she told us she didn't really remember looking at the witness statements on (Resident #7) on 3/12/18 and 3/13/18. t. On 4/13/18 at 10:35 a.m., the Regional Nurse Consultant provided the surveyors with an Addendum to the reportable regarding Resident #7 that documented, (MONTH) 14, (YEAR) Addendum: (Resident #7) . On 4/10/18 it was determined during a complaint survey the date and time of the incident was 3/12/18, not 3/3/18. Also, it was determined at the time of the actual incident the DON or Administrator did not investigate the allegation after interviews with staff and resident. Based on this information, the facility has substantiated the allegation. DON and Administrator were both suspended on 4/10/18 and relieved of their duties on 4/13/18. LPN (LPN #1) was also relieved of her duties on 4/13/18 . 3. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 3/15/18 documented the resident scored 3 (0 - 7 indicates severely impaired) on a BIMS, required extensive assistance of 2 plus person for bed mobility, transfers and locomotion on and off of the unit and had two falls with no injuries since the last assessment. a. The Plan of Care dated 11/7/17 documented, ADLs (Activities of Daily Living) . Start Date: 11/7/17 . Intervention: Transfers - 2 person assistance . Potential for falls: Safety . Start Date: 6/16/17 . Fall 12/15/17 . Staff to assist with transfers: Fall 12/15/17 . Staff to assist Resident to bed at time of choice: Fall 12/26/17 . Staff to assist resident with toileting after evening meal: Fall 1/7/18 . Staff to assist resident with toileting prior to bedtime: Fall 1/16/18 . Use call light for assist with transfers for safety: Fall 1/6/18 . Staff to assist resident into wheelchair after breakfast: Fall 2/14/18 . Staff to encourage resident to wear non-skid socks/shoes for transfers/ambulation: Fall 3/3/18 .Visual reminder placed on wall in room to ask for assistance: Fall 3/11/18 .Resident places self in floor at times: Fall 4/5/18 . Continue Plan of Care . b. An Incident Report dated 4/1/18 and signed by LPN #1 documented, Incident Type: Fall no head injury . Date/Time: 4/1/18 at 6:30 a.m . Type of Injury: None Apparent . Location: Resident room . Activity at time: From chair w/o (without) asst (assistance) . Associate involved: (CNA #1) . Incident reported by: (CNA #1) . Report prepared by: (LPN #1) . Non-Witnessed . Narrative of Incident and description of injuries: CNA reported to this Nurse (LPN #1) that Pt (Patient) was transferring self from chair to bed without assistance and fell on her bottom. Performed neuro (neurological) check on Pt WNL (within normal limits). No injuries or bruises apparent. No c/o (complaints of) pain or discomfort at this time. Incident took place in Pt room while Pt was transferring herself from the chair to the bed without assistance. Immediate Actions taken: Neuro check performed WNL, V/S (vital signs) & (and) skin evaluation performed no apparent injuries . c. On 4/10/18 at 1:20 a.m., CNA #4 was asked about the resident's fall on 4/1/18 and stated, I heard the resident fell , and (LPN #1) left her in the floor at least 40 to 45 minutes before assessing her and had left another resident in the floor after a fall for approximately 20 to 25 minutes before having the aides get her up prior to her assessing her . d. On 4/10/18 at 1:25 a.m., CNA #5 was asked about the resident's fall on 4/1/18 and stated, I heard (Resident #6) was in the floor and it took (LPN #1) a while for her to check on her. e. On 4/10/18 at 1:35 a.m., CNA #2 was asked about the resident's fall on 4/1/18 and stated, .I heard (CNA #1) hollering out of (Resident #6's) room. She had found (Resident #6) on the floor. She told me that she needed (LPN #1) in there now. I was heading to another resident who thought she was having a stroke. (CNA #1) found (LPN #1) on the Southeast Hall (back hall) passing medications and told her she needed her in (Resident #6's) room because she had fallen. (LPN #1) continued getting a routine medication for another resident on that hall. After I finished with my resident, I saw (LPN #1) entering another resident's room, passing routine medications, and was about to ask her if she had been to (Resident #6's) room, when (CNA #1) came back out into hall out of (Resident #6's) room asking me if anybody had seen (LPN #1) because she still hadn't assessed her. She went on to say that it had been 30 minutes since the fall at that time. I told her she (LPN #1) was in another resident's room passing routine medications. (CNA #1) then went into the other resident's room that (LPN #1) was in, passing medications, to once again tell her she needed her in (Resident #6's) room, due to fall. She had been trying to get her to come and assess her since approximately 30 minutes ago. I don't know if (LPN #1) went to (Resident #6's) room after that, because I had to go again to help (LPN #4) with another resident who had a fall on the back hall with a pretty good skin tear after assisting him earlier with the resident with stroke symptoms. The CNA was asked if she documented any of this on a witness statement and stated, Yes and they were given to the DON. f. On 4/10/18 at 2:05 a.m., CNA #6 was asked about the resident's fall on 4/1/18 and stated, .I wasn't working that night but (Resident #6) was left on the floor for 45 minutes and (LPN #1) was the nurse. (CNA #1) was the CNA working that night, and she told me she had left the room [ROOM NUMBER] times to get (LPN #1). All I heard was she was doing her med pass. I have never been questioned or asked to write a witness statement about anything involving (LPN #1). g. On 4/10/18 at 2:18 a.m., LPN #2 was asked about the resident's fall on 4/1/18 and stated, I wasn't here, but I heard (LPN #1) left (Resident #6) in the floor after a fall for 45 minutes and left (Resident #2) in the floor after a fall for approximately 40 minutes. I'm sure (CNA #1) told the Administrator about the falls . h. On 4/10/18 at 2:50 a.m., LPN #1 was asked about the resident being left on the floor for approximately 45 minutes after falling during her shift on 4/1/18 and stated, I don't know anything about any resident being left in the floor for 45 minutes before assessing them. I was across the hall from (Resident #7's) room when she fell . passing scheduled narcotics when (CNA #1) told me (Resident #6) had fallen. I told her to give me a minute and I'd be right in there. It took me approximately 10 minutes to get there. She did come to me twice to get me to come in there; not three times. i. On 4/10/18 at 3:11 a.m., the DON was asked about the resident's fall on 4/1/18 and stated, (LPN #1) called me the night (Resident #6) fell and told me she had fallen and that she had already pulled out another resident's narcotics and was waiting to administer her meds when (CNA #1) came out into the hallway to holler at her about (Resident #6's) fall. She said she told her to let her give the other resident's narcotic and she would be right in there. (LPN #1) was upset because it took her no longer than 5 - 10 minutes before she got in there to assess (Resident #6), but (CNA #1) was telling everyone that it took her 45 minutes to get in there. They both requested a meeting with me and Staff Development, because they have had a lot of issues since working together (approximately 1 month). I never questioned (LPN #1) or (CNA #1) about the discrepancy in the length of time it took (LPN #1) to get to (Resident #6's) room to assess her after the fall. I also didn't question anyone else working that night to get their statements of what occurred that night either. I don't remember receiving any witness statements regarding this incident. I do remember (CNA #1) telling me what happened though. I don't have any reason to believe that (CNA #1) was lying to me; she's a good aide. I don't know why I didn't investigate further what really happened that night. I guess I thought (LPN #1) just needed some more re-education because she was a new LPN and a new employee. The DON was asked to provide copies of the witness statements that were submitted by staff on the night of Resident #6' fall; she was unable to locate any of them during the survey. j. On 4/10/18 at 3:56 a.m., CNA #1 was asked about the resident's fall on 4/1/18 and stated, I was changing another resident when I heard someone hollering for help. I went toward the help sound and found (Resident #6) sitting in the floor between the over bed table and the side of her bed. She didn't appear to have sustained any injuries. I asked her what happened, and she told me she was trying to get to her bed and fell . I went to her doorway and asked (CNA #2) if she knew where (LPN #1) was and told her if she saw her to tell her I need her in (Resident #6's) room to assess her, because she had fallen on the floor. I initially couldn't find her, so I went directly back to (Resident #6's) room and asked her if she was alright, and she told me, 'yes but get me out of this floor'. I told her I would as soon as the nurse came to check her out and make sure she was alright. She again told me to get her out of the floor. I stepped out once again and saw the med cart outside another resident's room and went in and told (LPN #1) I needed her in (Resident #6's) room, because she had fallen and she told me okay, she'll be right there. I then went back to (Resident #6's) room and sat down in the floor next to her (resident), because she was so upset. At this time, (Resident #6) had been in the floor for about 10 minutes. I sat there with her for about 5 - 10 more minutes. I got up and stepped back into the hallway and saw (LPN #1) going into yet another resident's room, when I stopped her and told her, again, that I needed her to come check on (Resident #6) after her fall. She did not respond as she entered the other resident's room, so I stood at (Resident #6's) doorway. When she (LPN #1) came out of that resident's room, I told her (Resident #6) was still on the floor, and I was going to get her up, since (Resident #6) was so upset wanting up out of the floor and into her bed, and she could assess her when she had time. She told me, 'No, I'll be there in a minute'. By this time, (Resident #6) had been on the fl (TRUNCATED)

Complaint # (AR 104) was substantiated, all or in part, in these findings: A. Based on record review, and interview, the facility failed to ensure necessary care and services were provided for management of a suprapubic catheter, as evidenced by failure to ensure the suprapubic catheter was changed by the facility's nursing staff when needed, in accordance with physician orders [REDACTED]. to identify and address any potential urological complications; failure to ensure the facility's licensed nurses were familiar with the indications for catheter changes and with the suprapubic catheter change procedure to meet the needs of the resident; failure to ensure an assessment of urinary elimination status was conducted and documented when the catheter exhibited signs / symptoms of possible obstruction to prevent pain / discomfort; and failure to ensure urine culture and sensitivity (C&S) results were promptly obtained and communicated to the physician to prevent a potential delay in treatment for [REDACTED].#5) of 2 (Residents #5 and #7) case mix residents who had suprapubic catheters. These failed practices resulted in a pattern of actual harm to Resident #5, whose suprapubic catheter was not managed in accordance with physician orders, resulting in a hospitalization for UTI [MEDICAL CONDITION], and had the potential to cause more than minimal harm to 2 residents who had suprapubic catheters, according to a list provided by the Director of Nursing (DON) on 6/14/17. The findings are: Resident #5 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set with an Assessment Reference Date of 3/8/17 documented the resident scored 3 (0 - 7 indicates severe cognitive impairment) on a Brief Interview for Mental Status, required extensive assistance of 2-plus persons for transfer, bed mobility, and personal hygiene, had an indwelling catheter, and was always incontinent of bowel. a. The Plan of Care dated as initiated on 4/18/13 documented, .Follow physician orders [REDACTED]. resolved . 3/22/17 . Suprapubic cath to be changed at Doctor's office at scheduled times, bag and band to be changed at facility once monthly . resolved . foley / suprapubic catheter may use leg band . Change catheter per physician orders [REDACTED].>b. A physician's orders [REDACTED].Order Date 1/13/16 . Suprapubic catheter . may use leg band . 20 FR (French) / 10 cc (cubic centimeter) bulb to GU ([MEDICAL CONDITION]) bag . Change catheter with insertion tray / GU bag (and) band PRN (as needed). Lifetime . Order Date . 1/13/16 . Suprapubic cath (catheter) to be changed at Doctor's office at scheduled times . bag and band to be changed at facility once monthly . The order for the suprapubic catheter to be changed at the doctor's office at scheduled times, bag and band to be changed at facility once monthly was documented as currently in effect on the June 2017 Physician order [REDACTED]. c. The Urologist's Notes dated 9/14/16 at 10:15 a.m. documented, .Pt returns for follow-up for [MEDICAL CONDITION] bladder. He states that he is doing well. He does not have any complaints at this time . Suprapubic Catheter Change . This patient presents today for a suprapubic catheter change . This note was signed by the Urologist's Physician Assistant (PA). There were no further notes from the Urologist's office until March 2017. d. A physician's orders [REDACTED].Obtain STAT (immediate) UA (urinalysis) for elevated temp (temperature), increased confusion, and decreased urinary output . e. A Urinalysis Report dated 3/16/17 documented, .Collected Date . 3/16/2017 13:45 (1:45 p.m.) .reported to facility on 3/17/17 with results of UA (urine) color pale yellow .appearance .turbid .Protein 75 (normal negative) . Blood 250 (normal negative) .Leukocytes 500 (normal negative) .WBC (white blood cells) greater than 50 (normal negative) .RBC (red blood cells) 20 to 50 (normal 0 to 2) [MEDICATION NAME] cells Many .Bacteria Many (normal none seen) . f. A Nurse's Note dated 3/21/17 at 5:28 p.m. documented, Weekly Summary . Resident alert with confusion noted . Needs anticipated and met per staff. Decline Noted. Over past few days resident has required increased assist (assistance) with feeding. Complains of pain when gotten out of bed. Suprapubic cath (catheter) for urination . Has appointment on 3/22/17 to replace suprapubic cath . A Nurse's Note dated 3/22/17 at 7:41 p.m. documented, Late entry for Wednesday March 15 . During Routine AM (morning) Med (medication) Pass, noted that Suprapubic cath (catheter) had been pulled out. Resident was still in bed. I talked with (former) DON (Director of Nursing) and asked if I should get order to send him to ER (emergency room ). She said 'no,' to get the cath and bulb size and she would replace it. Gave her the information and no further problems were noted that day. On Thursday (3/16/17) no problems reported to this nurse. On Friday (3/17/17) I did not work on this resident's hall and was off on Sat (Saturday), Sun (Sunday), and Monday. When I returned to work on Tuesday morning (3/21/17) CNAs (Certified Nursing Assistants) immediately reported that resident was completely wet, but Foley (catheter) was intact. Contacted transport who does scheduling for appointments to see if resident had appt (appointment) for cath (catheter) change scheduled. Was told resident was going in at 10:00 (a.m.) to Urology today 3/22/17. Told staff to check on resident as if he were an incontinent patient. Resident was alert at that time and took meds (medications) and talked with this LPN (Licensed Practical Nurse). This a.m. (morning of 3/22/17) when giving resident his routine medication he was not as alert and oriented as usual . This note was signed by LPN #1. There was no documentation the physician was consulted on 3/21/17 regarding the decline over past few days noted by the nurse, the pain voiced by the resident on 3/21/17 and the change described by the nurse on 3/22/17 as not as alert and oriented as usual. There was no documentation the LPN assessed the resident's suprapubic catheter when it began leaking, to determine if it might be obstructed and in need of an as-needed catheter change prior to the scheduled urology appointment time. g. The Urology Notes dated 3/22/17 at 10:30 a.m. documented, .Chief Complaint . [MEDICAL CONDITION] Bladder . Problems . Problems not reviewed (last reviewed 9/14/16) . Pt (patient) returns for follow-up for retention and SP (suprapubic) tube exchange. He has not been here in several months and was to have his SP tube exchanged once a month at (Nursing Facility) where he lives. He did not have it exchanged for several months per the transporter here with him, that said there was a miscommunication there. He did finally have it exchanged in the last few weeks and again in the last 2 days. He did have a UA (urinalysis) sent out for a culture after it was found that he had a discharge around the SP tube and low grade temp (temperature). He is complaining of pain here in the clinic today and points to his head. He did yell in pain when his pants were pulled down some to get to his SP tube. He is not very talkative today and is noticeably not feeling well . Patient instructions . Pt (patient) will return in 1 month for follow-up. His transporter was encouraged to take him to the ER (emergency room ). She then called the (former) DON (Director of Nursing) and was advised to take him on to the ER. He did not have good color, his heart rate was elevated. He had a very raspy cough and breathing. His blood pressure was low here in the clinic. He was not his usual self. I then called the DON at (Nursing Home) and explained to her that it is unacceptable to leave the SP tube in place for 3 months without having it exchanged. I also informed her of his status here in the clinic and that I was very concerned for him. She then called back later in the day to explain their protocol in the NH (Nursing Home). She did have a UA sent last week that returned today (6 days after the specimen was collected) and was positive. He has been admitted to the hospital . This note was signed by the Urologist's PA. h. A Laboratory Report dated 3/22/17 documented, .Culture Urine Final . Updated Result . 3/22/17 10:35 a.m . Source Urine . Catheterized . CU (culture urine) . 50,000 to 100,000 CFU/ML (colony-forming units per milliliter) ESBL (Extended Spectrum Beta Lactamase) producing Escherichia coli . i. A Hospital History and Physical Report dated 3/22/17 documented, .3/22/2017 17:12 (5:12 p.m.) . Chief Complaint . coming from Urology clinic due to SOB (shortness of breath), headache, and confusion/combative . Patient had urinalysis done recently on 3/16/2017 that showed UTI (Urinary Tract Infection) and grew Serratia and E-coli with sensitive to Imipenem and resistant to majority of drugs. Patient was found to be septic and patient was given 2.5 L (liters) IV (intravenous) NS (normal saline) bolus and was started on [MEDICATION NAME] and 2 gm (grams) of [MEDICATION NAME] and was admitted to Medicine Team . Assessment/Plan . [MEDICAL CONDITION] secondary to UTI and possible Pneumonia . UTI since 3/16/2017 . UA positive for UTI . urine culture on 3/16/2016 grew Serratia and E-coli (not treated) . patient has suprapubic catheter . The hospital Discharge Documentation sheet dated 3/28/17 documented, .Hospital Course . Patient admitted from urology clinic . BP (blood pressure) 73/66, HR (heart rate) 125 . Vanc ([MEDICATION NAME]) and meropenem were started [MEDICAL CONDITION], believed to be (secondary) to UTI . The discharge date on the hospital records indicated the resident remained hospitalized through 3/28/17. j. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities, Division of Medical Services (DMS) form 762 dated 3/22/17 documented, .(Former) DON received a call from (Urology PA) at (Name) Urology Group on 3/22/17. (Urology PA) asked (DON) how long she had been DON and then told her that our resident, (Resident #5) was there for his follow-up and that his suprapubic catheter hadn't been changed in 3 months. (Urology PA) stated that he (Resident #5) was in pain and his urine had a bad odor and that if 'the facility' had taken care of the resident, he wouldn't have this pain. DON, (Name) told (Urology PA) that she had changed his suprapubic catheter last week on 3/15/17. All residents with catheters were assessed and orders reviewed with no negative findings . There was no documentation the facility identified the failure to consult with the physician on 3/21/17 regarding the decline in the resident's condition and the complaints of pain, and no documentation regarding the lack of urinary assessment information in the Nurses' Notes dated 3/22/17, prior to the urology appointment. 1.) On 6/13/17 at 10:52 a.m., the Urologist's PA was contacted via telephone and was asked to describe Resident #5's condition and symptoms when he visited the clinic on 3/22/17. The PA stated, .I didn't have any problems with them changing out the suprapubic catheters over there (at facility). It just needed to be done on a monthly basis. It was 3 to 4 months since I had seen him. It went some time without being changed, frustrating to me, so I inquired a little more. (Resident #5) was tachy ([MEDICAL CONDITION] - rapid heart rate), he had a temperature, low blood pressure. He was Septic. He went straight to the hospital from my clinic. I don't know who I talked to, the old DON or the new DON. I just knew something was going on. They said they were going to get it straightened out. (Resident #5's) urine was foul-smelling. I don't know how they couldn't tell. That is inappropriate; according to my Physician, the (catheter) needs to be changed out on a monthly basis. They deteriorate, easier to get infections, sets up stones if not exchanged out . I heard they had obtained a UA . usually only takes 48 hours to run a culture . 2.) On 6/13/17 at 11:50 a.m., Registered Nurse (RN #1) was asked if Resident #5 was having any signs or symptoms of a Urinary Tract Infection in March 2017 or if the suprapubic site looked infected. RN #1 was also asked if she had any recent training on how to insert a suprapubic catheter. RN #1 stated, No, if there were any problems, I would put it in a Nursing Note. I have not had any training here. No one has changed out a suprapubic catheter here that I know of. 3.) On 6/13/17 at 1:10 p.m., LPN #4 was asked if Resident #5 was having any signs or symptoms of a UTI in March 2017. LPN #4 was also asked if she had any recent training on how to insert a suprapubic catheter. LPN #4 stated, Not any training in the last year that I know of. I know he had been going to the (Urology) clinic. I can't really answer why he was going to the clinic, as to why the catheter was not being changed here. I helped the old DON put in the catheter, just me and her (on 3/15/17). I didn't check his temperature. He was talking and joking like he normally does. We did an adequate job regarding sterile technique. Maybe, some pressure when pushing on his abdomen, it had leaked some on him. I didn't smell anything different. He always has a strong urine smell. It (urine) was a little dark. The procedure was finished, we had (urine) return, and we left the room. 4.) On 6/13/17 at 1:20 p.m., Licensed Practical Nurse (LPN) #2 was asked if Resident #5 was having any signs or symptoms of a UTI in March 2017. LPN #2 was also asked if she had any recent training on how to insert a suprapubic catheter. LPN #2 stated, I have been told that (suprapubic catheter change) was done by RNs (Registered Nurses) . He usually goes out to the doctor. I have never been to a class on suprapubics, never trained here. I don't remember any symptoms, but I haven't been on that hall for over a year . 5.) On 6/13/17 at 1:29 p.m., LPN #3 was asked if Resident #5 was having any signs or symptoms of a UTI in March 2017. LPN #3 was also asked if she had any recent training on how to insert a suprapubic catheter. LPN #3 stated, A while back, his mental status seemed altered, and every time, we ended up giving him antibiotics. I think he did have a UTI. No pain at his suprapubic site, no foul odor. I wasn't here when she (former DON) put in the suprapubic. No training here. I have never put in a suprapubic (catheter). 6.) On 6/13/17 at 1:49 p.m., RN #2 was asked if Resident #5 was having any signs or symptoms of a Urinary Tract Infection [MEDICAL CONDITION] in March 2017. RN #2 was also asked if she had any recent training on how to insert a suprapubic catheter. RN #2 stated, .No training here. Personally, I have never put one in. I know (former DON) did once. I know he (Resident #5) was confused. I know he had monthly appointments with the Urologist. We sent him there. 7.) On 6/13/17 at 3:30 p.m., Certified Nursing Assistant (CNA #1) was asked if Resident #5 was acting or behaving differently when he was taken to the Urologist on 3/22/17. CNA #1 stated, I usually go back with them. I know his last Urology visit (prior to 3/22/17) was in November (2016), because I take them (residents). The DON at that time told (Urologist's PA) that we could do them (catheter changes) at (Facility Name). I don't know what happened. I didn't take him for like 3 months. I took him over there to get his catheter changed. They thought he was septic. He didn't act the same, was hollering out. He would normally cut up with me. I smelled an odor, stronger than usual, that urine smell. When they were mashing down on his stomach, he was hollering out. k. A Laboratory Report dated 5/10/17 documented urine culture results as, > (greater than) 100,000 cfu/ml Escherichia coli; 10,000 - 50,000 cfu/ml Pseudomonas aeruginosa; 10,000 - 50,000 cfu/ml [MEDICATION NAME] faecium VRE ([MEDICATION NAME] Resistant [MEDICATION NAME]); 10,000 - 50,000 cfu/ml [MEDICAL CONDITION] . 1.) On 5/10/17 at 2:45 p.m. the resident was seen by the Urology clinic. The Urology notes dated 5/10/17 documented, .Patient returns for follow-up for [MEDICAL CONDITION] Bladder and recurrent UTIs (Urinary Tract Infections). The staff at the nursing home state that he has been leaking from below into his adult briefs and around his suprapubic catheter tube. The have noticed that he did not have much output from his catheter in his bag. He also had new sediment in there. He has not had a fever that they are aware of. He states that he did vomit after lunch today. He does not feel well. His blood pressure is low but his heart rate is normal and his temperature is normal .presents today for a suprapubic catheter change .The caretaker reports recent obstruction of the catheter .The old catheter was removed .A 20 FR (French) Foley was inserted into the bladder .Urine on return was cloudy .Urine culture was sent .Assessment / Plan .[MEDICATION NAME] 50 mg capsule .Take one capsule twice a day by oral route for 10 days .Patient was sent a script (prescription) for [MEDICATION NAME] that he has taken previously until his culture can be returned. His aide was instructed to watch him closely and take him to ER (emergency room ) if he shows any signs of worsening or has any fever. He will return in one month or sooner if needed. signed by Urology clinic PA (Physician's Assistant) . 2.) A physician's orders [REDACTED]. 3.) A Nurse's Note dated 5/10/17 at 6:18 p.m. documented, .Resident left facility to Urology appointment at 2:15 p.m. and returned at 4:00 p.m. with no new skin issues . 4.) A Nurse's Note dated 5/10/17 at 10:08 p.m. documented, .New orders received from (Physician's Name) Urology for [MEDICATION NAME] 50 mg tab po BID for 10 days . l. On 6/11/17 at 5:20 p.m., the resident was lying in bed with the catheter bag hanging at the bedside. There were no odors detected. m. A written Corrective Action Plan, provided by the Administrator on 6/13/17, documented all residents with suprapubic catheters were reviewed by the former DON and that physician orders [REDACTED]. B. Based on record review and interview, the facility failed to ensure neurological assessments were performed following accidents with known or suspected head injury to enable nursing staff to promptly identify and address any potential deterioration in neurological status for 1 (Resident #3) of 3 (Residents #1, #3 and #4) case mix residents who had falls in the last 6 months. This failed practice had the potential to affect 61 residents who required neurological examinations after a fall or accident in the last 6 months, according to a list provided by the DON on 6/14/17. The findings are: Resident #3 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 3/9/17 documented the resident scored 4 (0-7 indicates severe cognitive impairment), and was dependent on staff for activities of daily living. a. An Incident Report dated 3/29/17 at 2:20 p.m. documented, .Narrative of incident and description of injuries . Resident lying on his back in the floor on the landing strip . Immediate Actions Taken . Assessed Resident for injuries, none apparent . Vital signs obtained . Notified Physician, new orders . perform neuro (neurological) checks (every) 4 hours (times) 72 h (hours) . Notify MD (Medical Doctor) of any negative findings . b. The Nursing Notes dated from 3/29/17 to 3/31/17 contained only assessments of vital signs. There was no documentation of neurological checks related to the unwitnessed fall. c. A Resident Incident Report dated 4/21/17 at 5:25 p.m. documented, .Narrative of Incident and description of injuries . Upon arrival resident was lying next to bed and in front of wheelchair (Physician) notified with new orders received to perform neuro checks (every) 4 hours (times) 72 hrs . d. A Nurses Note dated 4/21/17 at 10:19 p.m. documented, .Vitals .(Blood Pressure) . 136/80 . (Pulse) . 80 . (Respirations) . 20 . (Temperature) .97.3 . Identical vital signs results were documented on the Incident and Accident Report at 5:26 p.m. The Nurses Note contained no documentation of neurological checks. e. A Nurses Note dated 4/22/17 at 3:01 a.m. documented, .(Blood Pressure)122/66 . (Pulse) . 64 . (Respirations) . 16 (Temperature) . 98 . There was no documentation of neurological checks. f. A Nurses Note dated 4/22/17 at 10:52 a.m. documented, .Weekly Summary . VS (Vital Signs) . BP (Blood Pressure) 140/84 . P (pulse) 86 . R (respirations) 20 . T (temperature) 97.2 . There was no documentation of neurological checks. g. A Nurses Note dated 4/22/17 at 5:53 p.m. documented, .VS (vital signs) . BP (blood pressure) 100/52 . P (pulse) 72 . R (respirations) 19 . T (temperature) 97.7 . Resident has no new injuries noted . There was no documentation of neurological checks. h. A Resident Incident Report dated 5/3/17 at 12:45 p.m. documented, .Narrative of incident and description of injuries . Reported to this nurse by CNA (Certified Nursing Assistant) resident stood up out of wheelchair in doorway of room. Resident lost balance fell in floor in hallway hitting left side of forehead . Immediate Actions Taken . Assess for injury, vital signs taken . There was no documentation that indicated neurological checks were initiated. i. A Resident Incident Report dated 5/12/17 at 12:05 p.m. documented, .Narrative of incident and description of injuries . While putting resident to bed after feeding lunch, resident started falling. Sat resident on side of bed and he fell backward hitting his head on the wall . Immediate Actions Taken . Resident assessed for any noted injuries with none found and no c/o (complaints of) pain or discomfort . There was no documentation that indicated neurological checks were initiated. j. On 6/14/17 at 8:53 a.m., the Director of Nursing (DON) was asked to provide documentation of neurological checks related to the above listed incidents. The DON provided only the Nurses Notes, which documented vital signs and no neurological checks. The DON was asked if vital signs were equivalent to conducting neurological checks. The DON stated, No, the documentation is incomplete.