Every finding on record at Life Care Center of Tullahoma

Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure dignity by exposure of a resident's bare shoulder and bra while she sat in front of the building lobby for 1 resident (Resident #10) and failed to promote dignity for residents by the continued use of disposables for resident meals for a prolonged time, potentially effecting 83 of 88 residents reviewed.The findings included: Review of the facility policy titled, Dignity, dated 9/26/2025, revealed .each resident has the right to be treated with dignity and respect .enhancing the resident's self-esteem .preferences, and choices . Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Profound Intellectual Disabilities, Bipolar Disorder, and Cognitive Communication Deficit. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 was absent of spoken words, rarely/never makes self-understood, rarely/never understand others. During an observation of Resident #10 on 5/11/2026 at 2:20 PM, revealed Resident #10 was sitting in the facility lobby with an ill-fitting blouse exposing the resident bare shoulder and bra. Continued observation revealed when surveyor attempted to talk with Resident #10 multiple staff came up and adjusted the resident blouse. During an observation with the Administrator and Director of Nursing (DON) on 5/11/ 2026 at 2:44 PM, revealed Resident #10 still in the front lobby area with the same ill-fitting blouse. During an interview with the Administrator and DON on 5/11/2026 at 2:45 PM, the Administrator confirmed the exposure of resident shoulder and bra could be a dignity concern. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Stroke, Atrial Fibrillation, Hypertension, Hemiplegia, Anxiety, and Depression. Review of a comprehensive MDS assessment dated [DATE], revealed Resident #18 scored a 15 on the BIMS (Brief Interview for Mental Status) assessment, which indicated intact cognition. Surveyor observations of facility dining conducted on 5/11/2026 to 5/13/2026 revealed the facility utilized disposables for resident meals, which included disposable cups, plates, and utensils for all meals observed. Further observations of the facility dietary department on 5/12/2026, revealed the kitchen remained under construction, with work crews present onsite on 5/12/2025. Observations revealed the facility continued to utilize a temporary mobile kitchen unit, housed in a trailer situated behind the facility, to prepare meals, which was known to the surveyor, to have been implemented after a disaster at the facility which occurred in 2023 (3 years earlier) in which a structure fire disabled the facility kitchen. Further observations of the facility food preparation process conducted on 5/12/2026 between 11:30 AM and 12:15 PM revealed the facility continued to utilize a conference room as a dry storage area and location where foods prepared in the mobile kitchen were plated for resident use. Observations showed the facility reach in coolers remained situated in the dining room. Observations inside the mobile kitchen showed it equipped with a 3-compartment sink for dishwashing, but no commercial dishwasher was available due to space limitations in the mobile unit. The dietary manager reported the facility regularly prepared around 240 meals per day from the mobile kitchen and hand washed and sanitized all cooking utensils between meals in order to prepare them for use in the next meal service. During an interview on 5/12/2026 at 2:55 PM, Resident #18 reported he had lived at the facility since 2023 and recounted the fire which had occurred and events which transpired during the facility response afterwards. Resident #18 reported since the disaster occurred in 2023 the facility had continuously used the mobile kitchen to prepare meals and served meals on disposable plates, used paper cups etc. as the kitchen repairs had yet to be completed. Resident #18 reported he attended resident council meetings and in those residents frequently questioned prior facility administrations as to when residents could expect the repairs to be complete, and normal dining with plates and non-disposable items would resume but were given various timelines or unclear responses from those questioned. Resident #18 stated he and other peers had previously expressed concerns foods prepared outside in the mobile kitchen sometimes became cold during cooler months, before they were served, which were addressed by the dietary department. Resident #18 also stated residents were patient with the facility, but didn't care for these paper utensils which remained in use daily since the disaster response was initiated. During an interview on 5/12/2026 at 4:00 PM, with the facility Regional Nurse and Regional [NAME] President (RVP), the RVP confirmed the facility used disposable items for meals since the disaster had occurred due to limitations in dish washing capacity of the mobile kitchen unit in use, which had a 3 compartment sink for cleansing items used to prepare meals and no dishwasher, in efforts to ensure meal services were timely and to minimize potential difficulties hand washing all dishes, and utensils three times daily would present to the facility dietary department. The RVP and Regional Nurse confirmed the facility had not sought waivers from the State Agency related to prolonged use of disposables nor had it pursued alternatives to mitigate the prolonged use of disposables while the kitchen remained out of service.

Based on facility policy review, observation, and interview, the facility failed to ensure chemicals were stored and secured properly on 1 of 3 housekeeping carts for 6 wandering residents of 88 residents observed for accidents and hazards. The findings include: Review of the facility's policy titled, Storage of Chemicals, dated 4/1/2026, revealed .the facility will store chemicals in accordance with manufacture's guidelines while maintaining supervision while in use . During an observation on 5/11/2026 at 2:20 PM, a housekeeping cart was observed unlocked and unattended by housekeeping staff. During an interview with Housekeeper A on 5/11/2026 at 2:22 PM, the housekeeper stated the cart with chemicals should have been locked when not in direct view. During an interview with the Housekeeping Supervisor on 5/13/2026 at 12:33 PM, that included a review of chemicals stored on the 3 housekeeping carts, the chemicals identified included one 32 fluid ounce (oz) bottle of Enzyme Treatment labeled Keep out of reach of children and one 15.5 oz spray can of Disinfectant Deodorant labeled Keep out of reach of children. Continued interview with the Housekeeping Supervisor revealed all housekeeping carts were to be locked when not in view of a housekeeper.

Based on facility policy review, medical record review, and interview, the facility failed to report an allegation of staff to resident verbal abuse for 1 resident (Resident #5) and an allegation of staff to resident physical abuse for 1 resident (Resident#16) of 10 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse - Reporting and Response - Suspicion of a Crime, dated 5/7/2025 revealed, .The facility will ensure reporting .against a resident or individual receiving care from the facility within prescribed timeframes to the appropriate entities . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Persistive Vegetative State, Dysphagia, Anxiety Disorder, and Autistic Disorder. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was dependent on staff for all activities of daily living. Review of the comprehensive care plan for Resident #5 revealed .[Resident #5] .has impaired communication r/t (related to) dx (diagnosis) Persistent vegetative state. She does smile appropriately when spoke to . Review of a facility investigation dated 5/8/2025 revealed .On 5/8/2025 .[CNA (Certified Nursing Assistant) A] made a statement that some inappropriate things were said in front of one of the patients [Resident #5]; she made this statement to the Director of Nursing (DON) .this alleged incident took place on 5/2/2025. The issues involved .[Resident #5] having her period and the amount of blood that was at the site . Review of a coaching session for (CNA B and CNA C) dated 5/8/2025 revealed .this document shall serve to verify that a conversation took place with [CNA C] .regarding an allegation on 5/8/2025 .It was suggested in the allegation that [CNA C] may have made inappropriate comments in front of a resident [Resident #5] . During an interview with CNA C on 5/12/2026 at 8 AM, CNA C stated she normally didn't work on the west hallway (the hallway Resident #5 was on) she did remember the incident about a year ago. CNA C stated Resident #5 was having her menstrual cycle and it caused CNA C to have anxiety with her having to step out of room. Continued interview revealed CNA C stated she was questioned by facility staff about inappropriate comments and was suspended pending an investigation by the Administrator and DON. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis, Cognitive Communication Deficit, Irritable Bowel Syndrome, and Diverticulitis of Intestine. Review of an admission MDS dated [DATE] revealed Resident #16 had a Brief Interview of Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Review of the comprehensive care plan for Resident #16 revealed .[Resident #16] .has an ADL (activity of daily living) self-care performance deficit r/t (related to) weakness .dx (diagnosis) multiple sclerosis) . Review of a facility investigation dated 5/2/2026 revealed .on 5/2/2206 .received a call from my unit manager .that a resident [Resident #16] had some concerns about her ADL care .The resident stated, I called for help on Friday because I had a bowel movement and .[CNA D] came to help .she stated the care was harsh when he was cleaning her .[CNA D] was removed from all care areas . During an interview with CNA D on 5/12/2026 at 4:30 PM, CNA D stated when questioned about a separate investigation if he has had any other allegations of abuse against him with the CNA stating, yes about a month ago Continued interview revealed the CNA was accused by Resident #16 of abuse. The CNA stated he was pulled off the unit and told to wait, with the CNA off work 1 day following the allegation. Further interview revealed the CNA was told not to go into Resident #16 room after the allegation. During an interview with the DON on 5/13/2026 at 7:08 Am, the DON stated she felt it has a customer service issue is the reason the allegation concerning Resident #5 was not reported, the DON also stated she failed to report the allegation concerning Resident #16. Continued interview with the DON confirmed it was the facility policy to report any allegation of abuse to state entities.

Based on facility policy review, observation and interview, the facility failed to ensure proper infection control practices during the medication administration for 1 resident (Resident #17) of 9 residents reviewed for medication administration. The findings include: Review of the facility policy titled Medication Administration .,dated 9/15/2025, revealed .The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment . Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Encounter for Attention to Gastrostomy, Adult Failure to Thrive, and Dysphagia. Review of the current physician's recapitalization orders for Resident #17 revealed, .Buspirone (medication to treat anxiety) 10 mg (milligram) .via (by) G (gastrostomy) tube three times a day .Dicyclomine (medication to treat irritable bowel syndrome) 20 mg .via G tube four times a day .Ferrous Sulfate (Iron) oral solution 300 mg .give 5 ml (milliliters) via G tube one time a day every other day .Magnesium Oxide (used as antacid) 400 mg .via G tube two times a day .Polyethylene Glycol (medication used as laxative) .17 grams via G tube one time a day .Senna 8.6-50 mg ( medication used as laxative) give 1 tablet via G tube two times a day . During observation of a medication administration on 5/12/2026 at 7:25 AM, Licensed Practical Nurse (LPN) A prepared medications for Resident #17, failed to cover prepared medications while carrying throughout the facility to obtain a feeding tube syringe, returned to Resident #17 room, failed to wash the hands prior to donning gloves, administered the medications via G tube, and failed to clean the residents tube feeding prior to restarting tube feeding which had been hanging exposed over the residents tube feeding pole. During an interview on 5/12/2026 at 2:48 PM, LPN A stated hands should be cleaned prior to placing gloves, medications should not be uncovered while carrying throughout facility, and Resident #17's tube feeding should have been cleaned prior to restarting. During an interview on 5/13/2026 at 6:40 AM, the Director of Nursing (DON) confirmed it was her expectation for hands to be washed prior to donning gloves, exposed medications to be covered while carrying through facility, and exposed tube feeding to be cleaned prior to restarting

Based on facility policy review, medical record review, and interview, the facility failed to thoroughly investigate an allegation of staff to resident verbal abuse for 1 resident (Resident #5) and an allegation of staff to resident physical abuse for 1 resident (Resident#16) of 10 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse - Conducting an Investigation, dated 4/1/2026 revealed, .It is the policy of this facility that allegations .are promptly and thoroughly investigated . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Persistive Vegetative State, Dysphagia, Anxiety Disorder, and Autistic Disorder. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was dependent on staff for all activities of daily living. Review of the comprehensive care plan for Resident #5 revealed .[Resident #5] .has impaired communication r/t (related to) dx (diagnosis) Persistent vegetative state. She does smile appropriately when spoke to . Review of a facility investigation dated 5/8/2025 revealed .On 5/8/2025 .[CNA (Certified Nursing Assistant) A] made a statement that some inappropriate things were said in front of one of the patients (Resident #5); she made this statement to the Director of Nursing (DON) .this alleged incident took place on 5/2/2025. The issues involved .[Resident #5] having her period and the amount of blood that was at the site . Continued review of the facility investigation dated 5/8/2025 revealed additional residents other than Resident #5 were asked the flowing question: Are you treated with respect at this facility? Continued review of the facility investigation revealed 2 residents on interview stated no (indicating they were not treated with respect at the facility) without any documentation of follow up investigation. During an interview with Social Services Director (SSD) A on 5/13/2026 at 9:30 AM, SSD A stated she was the interviewer of the patient questioner as the documentation suggested. Continued interview and record review revealed no documentation the 2 residents answering no were followed up on. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis, Cognitive Communication Deficit, Irritable Bowel Syndrome, and Diverticulitis of Intestine. Review of an admission MDS dated [DATE] revealed Resident #16 had a Brief Interview of Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Review of the comprehensive care plan for Resident #16 revealed .[Resident #16] .has an ADL (activity of daily living) self-care performance deficit r/t (related to) weakness .dx (diagnosis) multiple sclerosis) . Review of a facility investigation dated 5/2/2026 revealed .on 5/2/2206 .received a call from my unit manager .that a resident [Resident #16] had some concerns about her ADL care .The resident stated, I called for help on Friday because I had a bowel movement and .[CNA D] came to help .she stated the care was harsh when he was cleaning her .[CNA D] was removed from all care areas . Continued review of the facility investigation revealed no further residents were interviewed regarding the allegation of physical abuse. During an interview with CNA D on 5/12/2026 at 4:30 PM, CNA D stated when questioned about a separate investigation if he has had any other allegations of abuse against him, CNA D stated, yes about a month ago. Continued interview revealed CNA D was accused by Resident #16 of abuse. CNA D stated he was pulled off the unit and told to wait, with CNA D off work 1 day following the allegation. Further interview revealed CNA D was told not to go into Resident #16 room after the allegation. During an interview with the DON on 5/13/2026 at 7:08 Am, the DON confirmed thorough investigations had not been completed for Resident #5 and Resident #16 after allegations of abuse.

Based on facility policy, medical record review and interview, the facility failed to refer 2 residents (Residents #67 and #50), of 8 residents reviewed for Pre-Admission Screening and Resident Review (PASRR), to the state-designated authority for a Level II PASRR after the residents were identified with new mental health diagnoses. The findings include: Review of the facility policy titled Pre-admission Screening and Resident Review [PASRR] dated 8/7/2021, showed .requires that .applicants .be evaluated for a serious mental disorder .be offered the most appropriate setting .Referring all level II residents and all residents with newly evident or possible serious mental disorder .A negative Level I screen permits admission to proceed and ends the .process unless a possible serious mental disorder .arises later . Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Notice of PASRR Level I Screen Outcome dated 5/20/2020, showed Resident #67's screening diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment dated [DATE], showed Resident #67 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/27/2022 at 2:05 PM, the MDS Coordinator confirmed a new PASRR had not been submitted to the state-designated authority for Resident #67 after a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a PASRR Level I for Resident #50 dated 7/22/2021 prior to admission to the facility showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #50 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/27/2022 at 12:28 PM, the Minimum Data Set (MDS) Nurse confirmed a new PASRR had not been submitted to the state-designated authority for Resident #50 when the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on facility policy review, medical record review, observation and interview, the facility failed to provide a clean and homelike environment for 2 residents (Residents #370 and #1) of 10 resident rooms observed for homelike environment. The findings include: Review of the facility policy titled Keeping a Resident's Room in Order, dated 7/28/2022, showed .resident has a right to a safe, clean .homelike environment .Housekeeping .services necessary to maintain a sanitary .interior .Place frequently used items within resident' [resident's] reach .water cups should be within reach . Resident #370 was admitted to the facility on [DATE] with diagnoses including Aftercare Following Joint Replacement Surgery, Depression, and Anxiety Disorder. During an observation and interview on 9/26/2022 at 9:31 AM, in Resident #370's room, the resident stated concerns about the cleanliness of the bathroom. Observation of the bathroom revealed a dirty drinking glass on a shelf above the sink, dirty linen hung over the edge of the sink, dirty linen was on the floor, a brown dried substance on the toilet seat, and the garbage from the waste container overflowed onto the floor. Resident #1 was admitted to the facility on [DATE] with diagnoses including Surgical Aftercare Following Surgery on the Skin, Unspecified Dementia, and Hypertensive Heart and [CONDITION(S)]. During an observation and interview in Residents #1 and #370's bathroom on 9/26/2022 at 10:24 AM, LPN #1 confirmed there was a dirty drinking glass on a shelf above the sink, dirty linen hung over the edge of the sink and in the floor, feces on the toilet seat, and the garbage from the waste container overflowed onto the floor. During an observation and interview on 9/26/2022 at 10:27 AM, the Infection Preventionist confirmed a sanitary and homelike environment had not been maintained in Resident #1 and Resident #370's bathroom. During an interview on 9/26/22 at 10:30 AM, Resident #1 stated the bathroom in the room was .terribly unclean . During an interview on 9/28/2022 at 10:08 AM, the Housekeeping Supervisor stated housekeepers were expected to clean every resident room and bathrooms daily. The Certified Nursing Assistants (CNA)s should remove dirty linen from the room and place in the appropriate receptacle. The nurses and CNAs were expected to do light cleaning when necessary to maintain a clean environment in resident rooms.

Based on facility policy review, observation, and interview, the facility failed to provide showers as scheduled for 3 residents (#1, #2, and #3) of 9 residents reviewed for bathing. The findings included: Review of the facility's policy titled Activity of Daily Living (ADLs) reviewed on 7/17/2021 showed .A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's 5-day Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The resident required extensive assistance of two or more persons for toilet use and extensive assistance of one-person for personal hygiene. The resident was always incontinent of bowel and bladder. Review of Resident #1's ADL-Bathing Shower report dated 10/18/2021-11/15/2021 showed the resident was to receive 3 showers weekly and her shower days were Tuesday, Thursday, and Saturday. Continued review showed during the period of 10/18/2021 - 11/15/2021 the resident only received a shower on 11/1/2021 (Monday) and on 11/9/2021 (Tuesday). Observation of Resident #1 on 11/17/2021 at 8:00 AM, in her room, showed the resident to be in bed in an upright position, visible areas of her body were clean and no odor or signs of incontinence were observed. During an interview on 11/17/2021 at 8:00 AM Resident #1 stated .when I ask about a shower, they tell me I will have to wait. Showers are really bad .one week I went a whole week without a shower. I finally got one on Sunday . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's 5-day MDS dated [DATE] showed a BIMS score of 15 indicating the resident was cognitively intact. The resident required extensive assist of two persons for toileting and total dependent of two-person assist with personal hygiene. The resident was occasionally incontinent of bladder and was always incontinent of bowel. Review of Resident #2's ADL-Bathing Shower report dated 10/18/2021-11/15/2021 showed the resident was to receive 3 showers weekly and his shower days were Tuesday, Thursday, and Saturday. Continued review showed during the period of 10/18/2021 - 11/15/2021 the resident only received a shower on 10/28/2021 (Thursday) and on 11/2/2021 (Tuesday). Observation of Resident #2 on 11/17/2021 at 8:15 AM, in his room, showed the resident lying in bed awake and alert. No odors or signs of incontinence were observed and the resident appeared to be well groomed. During an interview on 11/17/2021 at 8:15 AM Resident #2 stated .would like to have a shower every other day .lucky to get one a week . The resident stated he was not offered a bed bath. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's quarterly MDS dated [DATE] showed a BIMS score of 15 indicating the resident was cognitively intact. The resident required extensive assistance of one person for toileting and personal hygiene. The resident was always incontinent of bladder and frequently incontinent of bowel. Review of Resident #1's ADL-Bathing Shower report dated 10/18/2021-11/15/2021 showed the resident was to receive 3 showers weekly and her shower days were Tuesday, Thursday, and Saturday. Continued review showed during the period of 10/18/2021 - 11/15/2021 the resident only received a shower on 10/18/2021 (Monday), 10/25/2021 (Monday), and 11/3/2021 (Wednesday). Observation of Resident #3 on 11/17/2021 at 8:30 AM showed the resident to be lying in bed awake and alert. The resident was well groomed and no odors or signs of incontinence were noted. During an interview on 11/17/2021 at 8:30 AM Resident #3 stated .I don't get a shower .there is always something going on so I can't get it. I don't get a bed bath either they are always in a hurry . During an interview with on 11/17/2021 at 1:40 PM the Director of Nursing (DON) stated .Residents are scheduled for 3 showers per week unless they request more often. Showers are to be offered on the scheduled shower days, with the expectation that the resident will receive a shower or complete bed bath at minimum 2 times per week. The DON confirmed the facility failed to provide showers as scheduled and for Resident #1, Resident #2, and Resident #3. During an interview with the on 11/17/2021 at 2:15 PM, the Administrator stated .it is my expectation that all residents receive a minimum of 2 showers or complete bed baths weekly .

Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to ensure 1 resident (Resident #2) was free from abuse of 4 residents reviewed for abuse. The findings include: Review of facility policy Protection of Residents: Reducing the Threat of Abuse and Neglect, last revised 1/21/19, revealed .Position Statement and Guidelines: Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms .Residents must not be subjected to abuse by anyone. This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was not available for interview due to going home with his family over the holiday weekend and aspirated and was taken to and admitted to the hospital. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 scored a 11 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS). Review of the resident's functional status showed the resident was independent with activities of daily living except for eating and required physical assistance of one person. Review of the resident's care plan dated 8/24/2020 revealed: [NAME] verbalizes inappropriate sexual remarks to staff at times, May self-isolate when upset or angry, may be argumentative, or curse staff, ambulating by rooms and stopping and looking into rooms, may resist care by refusing vital signs being taken or may refuses his meal tray, hx physical aggression; Goal: The resident will cooperate with care through 5/18/2021; Interventions: Allow the resident to make decisions about treatment regime, to provide sense of control, Counsel as needed for inappropriate comments, Encourage as much participation/interaction by the resident as possible during care activities, Give clear explanation of all care activities prior to and as they occur during each contact, Praise the resident when behavior is appropriate, Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing ADLs, caregivers, and routine, as much as possible, Team Health psych services as needed. Review of a psychiatric consult dated 4/17/18 revealed Resident #2 had behaviors including yelling out, verbal aggression towards female staff, and reports of physical aggression at times. Review of a facility investigation dated 7/15/2020 revealed administration received a report of an allegation of physical abuse by Licensed Practical Nurse (LPN) #1 directed toward Resident #2. Continued review revealed LPN #1 was finishing her medication pass on 7/15/2020at 7:30 PM when Resident #2 came from behind her and hit her in the shoulder shouting BOO. LPN #1 reacted by moving the resident's hand out of the way to prevent him from hitting her again and after recovering turned around and told the resident never touch me again touching the resident's shoulder with her finger with every word. LPN #1 called the unit supervisor to tell her she had been hit by the resident and the unit manager came to the facility to relieve LPN #1. The unit manager assessed Resident #2 and found no injuries, took over for LPN #1 and had her call the Director of Nursing (DON) and explain to her what had happened, was dismissed from the facility pending investigation of the incident and the investigation was initiated. The facility investigation was thorough and Substantiated Abuse. The investigation followed the facility's Abuse policy and LPN #1 was eventually terminated for the incident. Interview with the unit manager LPN #2 on 6/2/2021 at 8:30 AM in the Administrator's office revealed she was the manager on call on 7/15/2020 at 7:30 when LPN #1 called her about being hit by Resident #2, came in to the facility to relieve her and had her call the DON and start filling out an incident report, it was unclear at first that she had touched the resident inappropriately only that she had been hit but after further questioning . I realized LPN #1 had abused the resident and told her to leave the building pending an investigation . LPN #2 stated she assessed Resident #2 and he had no injuries and was laughing and thought it was just horseplay. LPN #2 called the HR director in to help investigate the incident. Interview with the HR Director on 6/2/2021 at 9:15 AM in the Administrator's office revealed she had been called to come to the facility and help with the investigation on 7/15/2020 around 8:00 PM. The HR director stated the police were in the facility when she got there, and they investigated and left, and no report was written. The HR director stated she had spoken with LPN #1 and she told her she had poked him in the chest after she recovered from his hitting her in her shoulder. The HR director stated she gave guidance to the other staff on how to do the investigation and the rules for questioning cognitive resident about abuse. Interview with the Director of Nursing (DON) on 6/2/2021 at 10:15 AM in the Administrator's office confirmed the facility failed to protect Resident #2 from abuse per the facility investigation of the incident. Continued interview revealed LPN #1 had been terminated by the facility because of the investigation. Telephone interview with LPN #1 on 6/2/2021 at 11:00 AM revealed she has just finished her medication pass on 7/15/2020 at 7:30 PM when Resident #2 came up from behind her and hit her hard in her shoulder, the LPN stated it hurt bad and she went to the floor and she knocked away the resident's arm so he wouldn't do it again. The LPN stated after she recovered, she told the resident .don't do that again . and poked him in his shoulder with her finger while she was saying it. The LPN stated she called the unit manager to report that the resident had hit her and did not realize she would be accused of abuse toward the resident. The LPN stated the DON suspended her pending an investigation and eventually terminated her for code of conduct violation.

Based on review of facility policies, review of a facility investigation, review of a police report, medical record review, observation, and interviews, the facility failed to report abuse timely for 2 residents (#7 and #8) of 11 residents reviewed for abuse. The findings included: Review of facility policy, Protection of Residents: Reducing the Threat of Abuse & Neglect revised 2/2018, revealed .To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse .REPORTING AND RESPONSE .All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative .All alleged or suspected violations involving mistreatment, abuse, neglect .will be immediately reported to the administrator and/or director of nursing .Facilities must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made . Review of facility policy, Social Media revised on 9/1/16, revealed .social media policy is designed to protect .patients (residents) .This prohibition includes photos and video where the patient is not easily identifiable (e.g. a close-up photo of any part of a patient's body) .It also includes photos or video where the patient is easily identifiable . Review of a facility investigation dated 2/13/19 at 10:50 AM, revealed the police department notified the Human Resource Director of an incident which occurred on 2/12/19. Further review revealed .an employee (Certified Nursing Assistant (CNA) #1) had participated in a video chat with an incarcerated male in a patient care area (shower room) and breached the privacy of the resident (residents) . Continued review of a witness statement from CNA #2 revealed .(CNA #2) walked in the shower room where .(CNA #1) was doing showers she was facetiming her boyfriend .I do not remember if a patient was in the room at the time . Further review of a witness statement from Licensed Practical Nurse (LPN) #3 revealed .Shower Tech-yelled out for a CNA to assist .I went to the shower room to help .entered to help .I did know (CNA #1) had the phone over by the sink .I was not aware that someone could actually see the resident . Further review of a witness statement from CNA #3 revealed .I walked into the shower room on west wing .(CNA #1) was on the phone. I did advise her to hang up the phone numerous times and let her know .(Interim DON) was down the hall .hoping she (CNA #1) would hang up the phone . Review of a Police Department Incident Report dated 2/13/19 revealed .On (MONTH) 12, 2019 I was monitoring video visitations (video chat) made from .(named) County Jail when I observed a recording which was made by inmate The recording showed the female recipient of the video chat appearing to be working .I did observe the phone was placed on a sink or counter allowing the video chat to continue I observed an older female (residents) in a wheel chair in the room which appeared to be a bathroom. The video which lasted twenty-five minutes, showed the female in the wheelchair being undressed and dressed and several times completely naked. When the video chat was terminated due to time .(inmate) initiated another video chat call to the same recipient as the first. In this recording, the recipient is talking with .(inmate) and there is another older female in the video chat completely naked. The recipient did place the phone on the counter by the sink again and allowed the video chat to continue. Several times in both recordings the recipient states I am working or I am trying to work but continues to allow the video chat call to proceed. This recording is approximately thirty minutes long .I discovered the name of video chat recipient was (CNA #1) .discovered .(CNA#1) is currently working at .(the facility). I contacted the facility and spoke with Director of Human Resources (HR) .who confirmed that .(CNA #1) is employed .(HR Director) assured me they have Zero Tolerance for the usage of cell in the work area .(HR Director) and Interim Director of Nursing .came to the .Police Department to view the video. Upon viewing the video .(CNA #1) was identified as the recipient of the video chat .(Interim DON) also stated the room where the video chat occurred is called the shower room and .(CNA #1)'s responsibility that day was Shower Tech .(Interim DON) recognized three other employees .(Interim DON) did provide me with information on the female victims (Resident #7 and Resident #8) that were in the shower room . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #7's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive impairment). Continued review revealed the resident required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and was always incontinent of both bowel and bladder. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #8's Quarterly MDS dated [DATE] revealed a BIMS score of 6 (severe cognitive impairment). Continued review revealed the resident required extensive assistance with bed mobility, transfer, dressing toilet use, personal hygiene, and was frequently incontinent of both bowel and bladder. Interview with the Interim Director of Nursing (DON) on 2/21/19 at 10:10 AM, in the conference room, revealed .the police detective contacted the facility .to inquire about employment of a CNA .(police detective) viewed a video chat involving an inmate at the county jail and a health care employee .attempting to identify what nursing facility the employee was employed by. She was identified as one of our CNA's (CNA #1) .we (DON and Human Resources Manager) went to the police station and viewed the video .we were able to identify two residents (Resident #8 and Resident #9) .In addition to (CNA #1) two CNA's (CNA#2 and CNA #3) and a LPN (Licensed Practical Nurse #3) were viewed entering the patient care area during the video chat . Telephone interview with CNA #3 on 2/21/19 at 3:05 PM revealed .I walked in (the shower room) with a patient (resident) .I saw she (CNA #1) was on the phone .I didn't realize it was a video chat. I did tell her to get off the phone . Continued interview confirmed staff was not to have a cellphone in a resident care area and she failed to report the incident. Interview with the Interim DON on 2/22/19 at 2:30 PM, in the conference room, confirmed the facility failed to report an allegation of abuse timely for Resident #7 and Resident #8 and the facility failed to follow facility policy. Refer to F-600

Based on review of facility policies, review of a facility investigation, review of a police report, medical record review, observation, and interviews, the facility failed to prevent abuse for 2 residents (#7and #8) of 11 residents reviewed for abuse. The findings included: Review of facility policy, Protecting Patient Privacy and Prohibiting Mental Abuse: Photography and Social Media dated 8/30/16, revealed .This facility will ensure that an environment as home-like as possible will be provided to all patients which will include an environment that treats each resident with respect and dignity. All forms of abuse are prohibited .Taking photographs with camera-equipped cell phones or any other photographic device .is strictly prohibited anywhere in the facility without the express permission of the Executive Director .Associates are prohibited from taking photographs or recordings on any personal electronic devices .when working with or near residents . Review of facility policy, Social Media revised on 9/1/16, revealed .social media policy is designed to protect .patients (residents) .This prohibition includes photos and video where the patient is not easily identifiable (e.g. a close-up photo of any part of a patient's body) .It also includes photos or video where the patient is easily identifiable . Review of a facility investigation dated 2/13/19 at 10:50 AM, revealed the police department notified the Human Resource Director of an incident which occurred on 2/12/19. Further review revealed .an employee (Certified Nursing Assistant (CNA) #1) had participated in a video chat with an incarcerated male in a patient care area (shower room) and breached the privacy of the resident (residents) . Continued review of a witness statement from CNA #2 revealed .(CNA #2) walked in the shower room where .(CNA #1) was doing showers she was facetiming her boyfriend .I do not remember if a patient was in the room at the time . Further review of a witness statement from Licensed Practical Nurse (LPN) #3 revealed .Shower Tech-yelled out for a CNA to assist .I went to the shower room to help .entered to help .I did know (CNA #1) had the phone over by the sink .I was not aware that someone could actually see the resident . Further review of a witness statement from CNA #3 revealed .I walked into the shower room on west wing .(CNA #1) was on the phone. I did advise her to hang up the phone numerous times and let her know .(Interim DON) was down the hall .hoping she (CNA #1) would hang up the phone . Review of a Police Department Incident Report dated 2/13/19 revealed .On (MONTH) 12, 2019 I was monitoring video visitations (video chat) made from .(named) County Jail when I observed a recording which was made by inmate The recording showed the female recipient of the video chat appearing to be working .I did observe the phone was placed on a sink or counter allowing the video chat to continue I observed an older female (residents) in a wheel chair in the room which appeared to be a bathroom. The video which lasted twenty-five minutes, showed the female in the wheelchair being undressed and dressed and several times completely naked. When the video chat was terminated due to time .(inmate) initiated another video chat call to the same recipient as the first. In this recording, the recipient is talking with .(inmate) and there is another older female in the video chat completely naked. The recipient did place the phone on the counter by the sink again and allowed the video chat to continue. Several times in both recordings the recipient states I am working or I am trying to work but continues to allow the video chat call to proceed. This recording is approximately thirty minutes long .I discovered the name of video chat recipient was (CNA #1) .discovered .(CNA#1) is currently working at .(the facility). I contacted the facility and spoke with Director of Human Resources (HR) .who confirmed that .(CNA #1) is employed .(HR Director) assured me they have Zero Tolerance for the usage of cell in the work area .(HR Director) and Interim Director of Nursing .came to the .Police Department to view the video. Upon viewing the video .(CNA #1) was identified as the recipient of the video chat .(Interim DON) also stated the room where the video chat occurred is called the shower room and .(CNA #1)'s responsibility that day was Shower Tech .(Interim DON) recognized three other employees .(Interim DON) did provide me with information on the female victims (Resident #7 and Resident #8) that were in the shower room . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #7's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive impairment). Continued review revealed the resident required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and was always incontinent of both bowel and bladder. Observation of Resident #7 on 2/21/19 at 12:05 PM, in the dining room, revealed the resident was seated at a dining room table with three other residents. Continued observation revealed the resident was feeding herself without difficulty and no signs of anxiety or fearful behavior were observed. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #8's Quarterly MDS dated [DATE] revealed a BIMS score of 6 (severe cognitive impairment). Continued review revealed the resident required extensive assistance with bed mobility, transfer, dressing toilet use, personal hygiene, and was frequently incontinent of both bowel and bladder. Observation of Resident #8 on 2/21/19 at 12:10 PM, in the dining room, revealed the resident was seated at a dining room table with two other residents. Continued observation revealed the resident was feeding herself and no signs of anxiety or fearful behavior were observed. Interview with the Interim Director of Nursing (DON) on 2/21/19 at 10:10 AM, in the conference room, revealed .the police detective contacted the facility .they (police detective) had viewed a video chat involving an inmate at the county jail and a health care employee. They were attempting to identify what nursing facility the employee was employed by. She (employee) was identified as one of our CNA's (CNA #1) .we (DON and Human Resources Manager went to the police station and viewed the video .we were able to identify two residents (Resident #7 and Resident #8) .it was identified there were two calls from the inmate .one lasted 25 minutes and then he called back and the conversation was approximately 30 minutes .we were able to see the inmate .two screens were viewable one was of him and the other was of the patient care area .at this point we were only able to identify one resident (Resident #7). The patient is seen seated on a shower chair draped with a sheet .(CNA #1) goes to the door and asked the nurse to send another CNA in to assist her. The next view I see of the patient (Resident #7) is a side view .the sheet has been removed, I was able to see her (Resident #7's) right breast .(LPN #3) and (CNA #2) both enter the patient care area, I could see .(LPN #3) and (CNA 3) lift the patient (Resident #7) up and the brief (adult undergarment) slide out, but I was not able to see her bottom or full view of her buttocks area .(CNA #3) is viewed entering the patient care area with the second resident (Resident #8) .(Resident #8) has her own personal gown on .(CNA #3) comes back in the patient care area with the sit to stand lift .(CNA #1) is back at the counter top talking to him (inmate) I am able to view .(Resident #8) .(CNA #3) removed her (Resident #8's) gown .It wasn't until she was being dried and dressed that I was able to see a full front view of her breast, her abdominal fold, and umbilicus area. I was not able to see her peri (perineal) area .the screen is blank and we were not able to see any patient care, when the video came back on .(CNA #1) said take her (Resident #7) out so I can argue some more. The resident was taken out of the patient care area .and the video is ended . Telephone interview with the Police Detective on 2/21/19 at 1:00 PM revealed .I saw the actual video chat .the inmates know they are being taped. The way the video works is if a face is not in the screen the screen should go blank, if the recipient moves her face away they can still see for a few seconds before the screen goes blank. It is possible he (inmate) was able to view the resident . Interview with Resident #8 on 2/21/19 at 2:30 PM, in her room, revealed the resident was unable to recall the incident. Interview with Resident #7 on 2/22/19 at 8:35 AM, in her room, revealed the resident was unable to recall the incident. Interview with the Social Service Director on 2/22/19 at 10:30 AM, in the conference room, revealed .not seen any changes in the residents .no change in their emotional psychosocial wellbeing .neither of the residents have any recall of the incident . Interview with the Interim DON on 2/22/19 at 2:30 PM, in the conference room, confirmed the facility failed to prevent abuse to Resident #7 and Resident #8 and the facility failed to follow facility policy.

Based on review of facility policies, review of a facility investigation, medical record review, observation, and interviews, the facility failed to ensure privacy was maintained during a shower for 2 residents (#7and #8) of 11 residents reviewed for privacy. The findings included: Review of facility policy, Preservation of Resident Rights revised 11/19/16, revealed .All associates are responsible for the preservation of resident's rights .Privacy during medical treatments and personal care . Review of facility policy, Protecting Patient Privacy and Prohibiting Mental Abuse: Photography and Social Media dated 8/30/16, revealed .This facility will ensure that an environment as home-like as possible will be provided to all patients .treats each resident with respect and dignity. All forms of abuse are prohibited .Taking photographs with camera-equipped cell phones or any other photographic device .is strictly prohibited anywhere in the facility without the express permission of the Executive Director .Associates are prohibited from taking photographs or recordings on any personal electronic devices .when working with or near residents . Review of facility policy, Social Media revised on 9/1/16, revealed .social media policy is designed to protect .patients (residents) .This prohibition includes photos and video where the patient is not easily identifiable (e.g. a close-up photo of any part of a patient's body) .It also includes photos or video where the patient is easily identifiable . Review of a facility investigation dated 2/13/19 at 10:50 AM, revealed the police department notified the Human Resource Director of an incident which occurred on 2/12/19. Further review revealed .an employee (Certified Nursing Assistant (CNA) #1) had participated in a video chat with an incarcerated male in a patient care area (shower room) and breached the privacy of the resident (residents) . Continued review of a witness statement from CNA #2 revealed .(CNA #2) walked in the shower room where .(CNA #1) was doing showers she was facetiming her boyfriend .I do not remember if a patient was in the room at the time . Further review of a witness statement from Licensed Practical Nurse (LPN) #3 revealed .Shower Tech-yelled out for a CNA to assist .I went to the shower room to help .entered to help .I did know (CNA #1) had the phone over by the sink .I was not aware that someone could actually see the resident . Further review of a witness statement from CNA #3 revealed .I walked into the shower room on west wing .(CNA #1) was on the phone. I did advise her to hang up the phone numerous times and let her know .(Interim DON) was down the hall .hoping she (CNA #1) would hang up the phone . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #7's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive impairment). Continued review revealed the resident required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and was always incontinent of both bowel and bladder. Observation of Resident #7 on 2/21/19 at 12:05 PM, in the dining room, revealed the resident was seated at a dining room table with three other residents. Continued observation revealed the resident was feeding herself without difficulty and no signs of anxiety or fearful behavior were observed. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Medical record review of Resident #8's Quarterly MDS dated [DATE] revealed a BIMS score of 6 (severe cognitive impairment). Continued review revealed the resident required extensive assistance with bed mobility, transfer, dressing toilet use, personal hygiene, and was frequently incontinent of both bowel and bladder. Observation of Resident #8 on 2/21/19 at 12:10 PM, in the dining room, revealed the resident was seated at a dining room table with two other residents. Continued observation revealed the resident was feeding herself and no signs of anxiety or fearful behavior were observed. Interview with the Interim Director of Nursing (DON) on 2/21/19 at 10:10 AM, in the conference room, revealed .the police detective contacted the facility .to inquire about employment of a CNA .They (police detective) had viewed a video chat involving an inmate at the county jail and a health care employee. They were attempting to identify what nursing facility the employee was employed by. She (employee) was identified as one of our CNA's (CNA #1) .we (DON and Human Resources Manager) went to the police station and viewed the video .we were able to identify two residents (Resident #7 and Resident #8) .We were able to see the inmate .two screens were viewable one was of him (inmate) and the other was of the patient care area .at this point we were only able to identify one resident (Resident #7) .(Resident #7) is seen seated on a shower chair draped with a sheet .(CNA #1) goes to the door and asked the nurse to send another CNA in to assist her. The next view I see of the patient (Resident #7) is a side view .the sheet has been removed .I was able to see her (Resident #7's) right breast .(LPN #3) and (CNA #2) both enter the patient care area, I could see .(LPN #3) and (CNA #3) lift the patient (Resident #7) up and the brief (adult undergarment) slide out, but I was not able to see her bottom or full view of her buttocks area .(CNA #3) is viewed entering the patient care area with the second resident (Resident #8) .(Resident #8) .has her own personal gown on .(CNA #1) is back at the counter top (where phone was lying) talking to him (inmate) .I am able to view .(Resident #8) .(CNA #3) removed her (Resident #8's) gown .It wasn't until she was being dried and dressed that I was able to see a full front view of her breast, her abdominal fold, and umbilicus area. I was not able to see her peri (perineal) area . Interview with the Interim DON on 2/22/19 at 2:30 PM, in the conference room, confirmed the facility failed to ensure privacy during personal care for Resident #7 and Resident #8 and the facility failed to follow facility policy. Refer to F-600

Based on facility policy review, observation, and interview, the facility failed to use proper hand washing/hand sanitizing techniques between resident care functions in 1 of 4 dining areas observed. The findings included: Review of the facility policy, Hand Washing, revised 11/16 revealed .Staff washes hands as necessary to remove contamination .handling soiled equipment .after engaging in other activities that contaminate the hands . Observation on 5/24/17 at 7:50 AM, in the East Wing Day Room revealed Certified Nursing Assistant #1 (CNA) feeding a resident. Continued observation revealed CNA #1 left the resident she was feeding and walked over to another resident. Continued observation revealed CNA #1 reached down and adjusted the electric wheel chair pedal to the down position, then returned to feeding the first resident without washing or sanitizing her hands. Observation of the wheel chair pedal revealed a large amount of unidentified debris. Interview on 5/24/17 at 7:55 AM with CNA #1 in the East Wing Day Room confirmed she should have washed her hands after touching the pedal and before returning to feeding the resident. Interview with the Director of Nursing on 5/24/17 at 8:30 AM, in the conference room confirmed the CNA should have washed her hands after adjusting the wheel chair pedal. Continued interview confirmed the facility had not maintained infection control practices during the meal service.

Based on medical record review and interview, the facility failed to notify the physician to obtain orders for follow up, parameters for limitations, and care of a walking boot for 1 resident (#1) of 3 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Continued medical record review revealed Resident #1 was admitted to the facility in a walker boot. Medical record review of admission orders [REDACTED]. Medical record review of the facility's Physician's Progress Note dated 4/10/16 revealed, .Pt (patient) was placed in a boot .(follow up with) Ortho (Orthopedic) in 2 weeks . Medical record review of the facility's Physician's Progress Note dated 5/11/16 revealed, .Pt came (with) boot S/P (status [REDACTED]. Interview with the Physician's Assistant (PA) on 9/14/16 at 10:30 AM in the conference room stated, We totally dropped the ball with no ortho (orthopedic) orders on admission. Interview with Licensed Practical Nurse (LPN) #1 on 9/14/16 at 11:00 AM in the conference room revealed the nursing staff thought Physical Therapy (PT) would call for orders for Resident #1 related to follow up with an Orthopedic Physician and parameters for the walker boot usage, and PT thought nursing was following up on the orders. Continued interview with the LPN revealed the LPN stated, We dropped the ball there. Interview with the PT Director on 9/14/16 at 1:40 PM in the PT office revealed when a resident was admitted with a cast, splint, or boot they usually come with orders relating to the limitations, follow up, and weight bearing status. Continued interview revealed the PT Director stated the resident had a walking boot and they are usually weight bearing. We wouldn't have called Ortho because she wasn't surgical. Usually the Admission Nurse will call and clarify any missing orders. Interview with the Director of Nursing (DON) on 9/14/15 at 2:25 PM in the conference room revealed, when asked who was responsible for obtaining additional orders from the physician when a resident was admitted with a boot to their leg, the DON stated, The Admission Nurse or PT would clarify orders for the boot. Continued interview revealed the DON confirmed the facility failed to notify the physician to obtain physician orders [REDACTED].#1's fracture, follow up care, and walking boot until 5/11/16.

Based on observation and interview, the facility dietary department failed to maintain sanitary food related equipment; failed to dispose expired frozen food stored in the dietary freezer; failed to label and date frozen food prepared by a resident's family and ensure an approved food provider was utilized. The findings included: Observation on 8/17/15 at 9:30 AM in the dietary department, with the Certified Dietary Manager (CDM) present, revealed white dried debris on the underside of the floor model mixer arm, and sticky blackened debris on the can opener blade, base and the interior slot on the base. Further observation of the leftover freezer located in the dietary department revealed 8 4-ounce (oz) cartons of orange sherbet with an expiration date of 7/7/15 and 11 chicken patties in a clear zip lock bag with a Use by date of 8/3/15. Further observation revealed 28 unlabeled and undated zip lock bags containing approximately 4 oz of white rice and light brown sauce. Interview with the CDM on 8/17/15, beginning at 9:33 AM in the dietary department, confirmed the orange sherbet and chicken patties were available for resident use and were out of date. Further interview revealed the bags of rice and sauce were for a resident. They were brought in by the resident's family and 1 bag was served to the resident daily at lunch. Continued interview revealed the family made 6-8 weeks of soup and provided it to the facility to serve the resident daily. Observation and interview on 8/18/15 at 8:11 AM, with the CDM in the dietary department, confirmed the underside of the floor model mixer arm had dried white debris and the can opener base and interior of the slot on the base had sticky blackened debris present. Interview with the facility Registered Dietitian and CDM on 8/18/15 at 11:32 AM in the CDM's office confirmed the dietary department accepted, stored, re-heated and served food prepared off-site by a resident's family. Further interview revealed the family provided the facility dietary department up to a 6 week supply of individually bagged portions. Further interview confirmed the facility failed to obtain food from an approved and inspected provider source.

Based on observation, review of the Material Safety Data Sheet (MSDS), facility policy review and interview, the facility failed to ensure potentially hazardous chemicals were stored in a safe, secure manner; and failed to ensure equipment was safe for one resident (#96) of thirty-seven residents reviewed. The findings included: Observation of the Biohazard Room on the North Wing on May 19, 2014, at 10:20 a.m., revealed the door was unlocked, and a quart-size spray bottle labeled "MPC Flashback Spray Buff", one-third full of clear liquid, was hanging on the handle of the floor buffer, stored in the Bio-Hazard Room. Review of the MSDS for Flashback FS revealed, the product was classified as a cleaning compound that could pose an immediate (acute) health hazard. Continued review revealed storage and handling information included, "...Keep out of reach of children...Avoid contact with eyes, skin, and clothing. Avoid breathing vapors..." Review of the facility's policy, Hazardous Materials Management Plan, revealed, "...The purpose and objectives of the Hazardous Materials and Waste Management Program are:...Minimizing risks to patients, visitors, personnel and the environment..." Interview on May 19, 2014, at 10:25 a.m., with the Housekeeping/Floor Technician, who came to retrieve the buffer, confirmed the Bio-Hazard Room had been left unlocked, and the chemical spray had been left unsecured. Resident #96 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on May 19, 2014, at 1:50 p.m. revealed the resident seated in a wheelchair in the resident's room. Continued observation revealed the left side of the wheelchair skirt guard below the arm rest was loose with duct tape applied and a sharp edge was present on the top of the wheelchair skirt guard, and the right side of the wheelchair skirt below the arm rest was loose. Interview and observation on May 19, 2014, at 1:55 p.m., with Licensed Practical Nurse #2 (LPN) Unit Manager, in the resident's room, confirmed the wheelchair was in need of repair and was a safety hazard.

Based on medical record review and interview, the facility failed to issue the facility's Bed Hold Policy, upon hospital transfer, for one resident (#221), of three residents reviewed for admission, transfer, and discharge rights. The findings included: Resident #221 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review revealed no documentation the resident had been issued a copy of the facility's Bed Hold Policy. Review of the facility's Bed Hold Policy revealed "...At the time the Resident is to leave the Facility for a temporary stay in a hospital...the Resident/Legal Representative will be given a written copy of the Bed Hold Policy and may elect to hold open the Resident's room and bed until the Resident returns..." Interview on May 20, 2014, at 3:00 p.m., with the Administrator, in the Administrator's office, confirmed the facility did not issue the bed hold policy to the resident, at the time of discharge on November 7, 2013. c/o #

Based on medical record review and interview, the facility failed to issue a thirty day notice prior to discharge for one resident (#221) of three residents reviewed for admission, transfer, and discharge rights. The findings included: Resident #221 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Certificate of Need for Involuntary admitted d November 7, 2013, revealed "...I am a licensed physician...In my professional opinion, based on the examination and the information provided, I certify that this person is subject to Involuntary care and treatment...has a mental illness or serious emotional disturbance...antisocial behavior, Paranoia...roomate fears for life and had to be removed...intoxication - refused blood tests, refused psychiatric evaluations...violent outbreaks + (plus) actions to staff & employee. Inappropriate letters to staff. Paranoid ideations...threat to self and others...help refused multiple times...Requires direct transportation to an admitting psychiatric facility for a second certificate of need (CON) examination..." Interview on May 20, 2014, at 3:00 p.m., with the Administrator, in the Administrator's office, confirmed the facility had refused to readmit the resident and did not issue a thirty day letter of discharge to the resident. Telephone interview on May 21, 2014, at 3:15 p.m., with the psychiatric hospital's Social Worker, revealed the Social Worker had contacted the facility on November 15, 2013, as the resident was stabilized, and the facility had refused to readmit the resident to the facility. c/o #

Based on medical record review, facility policy review, observation, and interview, the facility failed to ensure dignity was maintained by a staff member standing, not sitting beside, while assisting a resident to eat, for one resident (#162) of thirty-seven residents reviewed. The findings included: Resident #162 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance of one person for eating. . Review of the policy, Feeding A Resident, revealed, "...Sit to feed the resident..." Observation on May 19, 2014, at 11:55 a.m., revealed the resident seated in a gerichair at the nursing station. Continued interview revealed Certified Nursing Assistant (CNA) #1 standing beside the resident feeding the resident lunch. Interview on May 19, 2014, at 1:10 p.m., with Licensed Practical Nurse (LPN) #1, at the nursing station, confirmed the CNA was not to feed the resident while standing over the resident.

Based on medical record review, facility policy review, observation and interview, the facility failed to develop a care plan to address the fluid restriction for one resident (#36) of thirty-seven residents reviewed. The findings included: Resident #36 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Nutrition Data Collection/Assessment, dated April 19, 2014, revealed the resident received a regular consistency, concentrated carbohydrate diet, with a 1200 milliliters (ml) fluid restriction. Review of the physician's orders [REDACTED]...1200 ml/ (per) 24 hour fluid restriction..." Observation on May 20, 2014, at 3:30 p.m., in the resident's room revealed a thirty-two ounce water pitcher, half-full, on the over-bed table near the bed, and two six ounce cups partially filled with clear liquid. Review of the facility's policy, Fluid Restriction, revealed, "Fluid restrictions are coordinated between Nursing Services and Food and Nutrition Services. Diets are adjusted to comply with fluid restrictions..." Interview with the Director of Nursing on May 20, 2014, at 3:40 p.m., in the day room on the East Wing confirmed the fluid restriction should have been divided between shifts, including the fluids provided by dietary. Interview with the Registered Dietician via telephone on May 21, 2014, at 8:45 a.m., from the Human Resources office, confirmed the resident had been reviewed in the Resident At Risk meeting for non-compliance with fluid restriction. Continued interview confirmed the 1200 ml fluid restriction should have been on the care plan for guidance of who should have provided what amount of fluid in a specific timeframe. Continued interview confirmed the facility failed to develop a care plan to address the fluid restriction for resident #36.