Every finding on record at Lovington Healthcare LLC

Based on observation and interview, the facility failed to maintain interior surfaces. This failure had the potential to affect all residents on the 200 and 300 halls. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities. These deficient practices could likely result in residents feeling frustrated, embarrassed, and unimportant. The findings are:A. On 07/12/26 at 11:45 am, during an observation of the 300 hall, the clean utility door had two patches of missing paint that measured one foot by one foot and exposed the different colored paint underneath. B. On 07/12/26 at 12:05 pm, an observation revealed significant scuff marks and peeling paint to the bottom portions of the closet door frames for resident rooms 302, 303, 305, 307, and 309. C. On 07/12/26 at 12:15 pm, an observation of every resident room on the 200 hall revealed one wall in each room had missing paint which extended from one bed to the other. D. On 07/12/26 at 2:23 pm, during an interview and observation, R #55 sat in her room. There was a six foot line of missing paint in the middle of the wall behind the resident's bed. The corner of the wall near the bathroom door had chipped and missing paint and drywall. The bottom of the room door was separating and had chipped paint on the lower half. R #55 stated the missing and chipped paint made her room look ugly. E. On 7/16/27 at 11:40 am, during an interview, the Administrator (Admin) stated the damage to the residents' walls, the missing paint on the facility doors, the missing paint and scuff marks to closet door frames, and the condition of R #55's room was in disrepair and was not homelike. The Admin stated she expected all staff members to report environmental issues to herself or the maintenance department. The Admin stated the facility was in between maintenance personnel and only had the support from a sister facility.

Based on observation, record review, and interviews, the facility failed to accurately reflect R #5's use of dentures in the care plan for 1 (R #5) of 5 (R #5, R #7, R #8, R #10 and R #33) residents reviewed. This deficient practice is likely to result in residents' needs not being met, decreased quality of life, and avoidable decline in physical and psychosocial well-being. The findings are: A. Record review of R #5's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/12/26, revealed the following:1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact.2. R #5 was independent and required no assistance with oral hygiene. B. Record review of R #5's comprehensive care plan, revised on 05/17/26, revealed the resident had her own teeth and did not have dentures. C. On 07/15/26 at 8:39 am, observation and interview, R #5 did not have top teeth and wore partial bottom dentures. R #5 stated the dentures did not cause pain. She stated she did not like to wear the top dentures because they did not fit properly. D. On 07/15/26 at 10:30 am, during an interview, the Social Service Director (SSD) stated R #5 went to the dentist on 06/18/24 and 11/19/24 to have her teeth extracted. E. On 07/16/26 at 1:30 pm, during an interview, the Director of Nursing (DON) stated she expected the care plan to be revised during annual and quarterly assessments or when there was a significant change in a resident's plan of care. The DON stated she would have ensured the care plan was accurate, if she was aware.

Based on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment was accurate for 1 (R #16) of 5 (R #2, R #8, R #9, and R #16) residents reviewed. This deficient practice is likely to result in residents' needs not being met. The findings are:A. Record review of R #16's quarterly MDS assessment, dated 06/29/26, revealed the following:1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 14, cognitively intact.2. R #16 had the following diagnoses:Anxiety (feelings of fear or apprehension) disorder,Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),Malignant neoplasm (cancer) of left lung.3. R #16 did not take a hypnotic medication (a class of psychoactive drugs designed to promote sleep). B. Record review of R #16's physician orders, dated 02/13/25, revealed an order for 30 milligrams (mg) of temazepam (hypnotic medication). C. Record review of R #16's Medication Administration Record (MAR), dated January through June 2026, revealed staff administered the temazepam to R #16 as ordered. D. On 07/16/26 at 1:01 pm, during an interview, the MDS Coordinator stated R #16's MDS assessment did not indicate he took a hypnotic medication, even though he did. She stated she expected each resident to have an accurate MDS assessment. She stated R #16's assessment was not accurate.

Based on observation and interview, the facility failed to post nurse staffing data on a daily basis at the beginning of the shift that included the following: 1. Facility name. 2. The current date. 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: 1. Registered nurses. 2. Licensed practical nurses. 3. Certified nurse aides. 4. Resident census. This deficient practice has the potential to affect all 58 residents as identified by the census provided by the Administrator on 11/25/25 and could likely result in residents and visitors not having the staffing information readily available. The findings are: A. On 11/25/25 at 10:48 AM, during observation of the main entrance, the nurse staffing data was dated 11/24/25 and was not posted for the current day. B. On 11/25/25 at 10:50 PM, during an interview with the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) Coordinator, she confirmed the nursing staff data should be posted daily and was not.

Based on observation and interview, the facility failed to ensure the hallway in the 300 hall was accessible for residents. This deficient practice is likely to affect all 17 residents residing on the 300 hall as identified on the resident census provided by the Administrator on 11/25/25. This deficient practice could likely result in residents living in an unsafe environment, could increase their risk for injuries, and decrease their quality of life. The findings are: A. On 11/25/25 at 10:30 am, a random observation of the 300 hall revealed the following: 1. Three large boxes (one with a picture of a toilet on it) piled on top of each other with other pieces of cardboard and what appeared to be packaging material sticking out of the top and sides in the hall near room [ROOM NUMBER].2. A large box with a picture of a toilet on it, on the floor in the hall near room [ROOM NUMBER].3. A toilet on the floor in the hall near room [ROOM NUMBER]. B. On 11/25/25 at 10:41 am, during an interview with the facility payroll, she confirmed there were objects on both sides of the hall blocking residents' path. She stated that everything should be on one side of the hall, so residents had a clear path.

Based on observation and interview, the facility failed to ensure safe medication storage practices by not ensuring the medication cart was locked while unattended. This deficient practice has the potential to affect all 17 residents residing on the 300 hall as identified by the census provided by the Administrator on 11/25/25. If the facility does not ensure safe storage practices, then residents are at risk for unauthorized persons to have access to medications and adverse effects due to improper storage. The findings are: A. On 11/25/25 at 12:15 pm, during an observation of the facility, the medication cart located near the 300 hall was found unlocked and unattended.B. On 11/25/25 at 12:17 pm, during an interview with the facility scheduler, she confirmed the medication cart near nursing station was not locked and should be locked anytime it is unattended.

Based on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions when staff failed to: 1. Follow safe food handling practices. 2. Properly label food items in the refrigerator. 3. Properly wear hair nets while in the kitchen. These deficient practices are likely to affect all 59 residents listed on the resident census list provided by the Administrator on 05/03/25 and are likely lead to foodborne illnesses in residents if safe food handling practices are not adhered to and stored properly. The findings are: A. On 05/03/25 at 12:35 pm, an observation of dining revealed transportation personnel (TP) #1 improperly serving residents cups by touching the rim with his bare hands. B. On 05/03/25 at 12:40 pm, during an interview with the MDS Coordinator (MDS), she confirmed TP #1 should not handle residents cups by the rim, the expectation is that staff serve and handle cups by gasping around the sides and avoiding to touch the rim. C. On 05/03/25 at 11:00 am, an observation of the kitchen revealed a drink pitcher filled with brown liquid was in the main refrigerator and did not have a label indicating the contents or date it was prepared. D. On 05/03/25 at 11:10 am, during an interview with Dietary Aide (DA) #1, she pulled the sticker/label out of her pocket that was labeled with sweet tea and the date of 05/03/25 with a time of 10:30 am. She stated she had forgotten to place it on the pitcher before she put the pitcher back in the refrigerator. E. On 05/03/25 at 11:12 am an observation of the kitchen revealed Dishwasher (DW) #1's hair hung out of the hairnet. The hair net did not cover all of her hair. DW #1 confirmed that all of her hair should be up in the hairnet. F. On 05/05/25 at 11:53 am, a random observation of the kitchen revealed DW #1 not properly wearing hair net as evidenced by her hair hanging past the hair net. G. On 05/03/25 at 11:55 am during an interview with the Dietary Supervisor (DS) #1, she confirmed that DW #1 was not properly wearing the hairnet. She stated her expectation is for all staff to properly wear hairnets while in the kitchen or serving food. 51657

Based on observation and interview, the facility failed to ensure the hallway in the 100 hall was accessible for residents. This deficient practice is likely to affect all 22 residents residing on the 100 hall as identified on the resident census provided by the Administrator on 05/03/25. This deficient practice could likely result in residents living in an unsafe environment, could increase their risk for injuries, and decrease their quality of life. The findings are: A. On 05/03/25 at 1:00 pm during a random observation of the 100 hall revealed the following: 1. A mechanical lift on the right side of the hallway near rooms [ROOM NUMBERS], 2. A mechanical lift on the left side of the hallway near rooms [ROOM NUMBERS], 3. A housekeeping cart on the right side of the hallway near the shower room and room [ROOM NUMBER], 4. A medication cart on the left side of the hallway near rooms [ROOM NUMBERS]. B. On 05/04/25 at 9:00 am during a random observation of the 100 hall revealed the following: 1. A mechanical lift on the right side of the hallway near rooms [ROOM NUMBERS], 2. A mechanical lift on the left side of the hallway near rooms [ROOM NUMBERS], 3. A housekeeping cart on the left side of the hallway near room [ROOM NUMBER], 4. A medication cart on the left side of the hallway near rooms [ROOM NUMBERS]. C. On 05/04/25 at 9:10 am during an interview with Receptionist (REC) #1, she confirmed there were objects on both sides of the hallway blocking the residents' path. She stated that everything should be on one side of the hallway, so residents had a clear path.

Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 5 (R #4, R #10, R #14, R #15, and R #28) of 5 (R #4, R #10, R #14, R #15, and R #28) residents reviewed when staff failed to: 1. Revise R #4's care plan to include information regarding mobility bars (safety devices designed to provide additional support and stability for people with limited mobility or balance), 2. Revise R #10's care plan to include information regarding positioning rails (rails used to assist in maintaining an object's location or position), 3. Revise R #14's care plan to remove information regarding positioning rails, 4. Revise R #15's care plan to remove information regarding pain interventions, 5. Revise R #28's care plan to remove information regarding psychotropic medication when the medication was discontinued. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #4 A. Record review of R #4's admission record revealed R #4 was admitted to the facility on [DATE]. B. Record review of R #4's electronic health record (EHR) revealed the following: 1. A Safety Device Evaluation assessment completed on 04/29/25 for bed mobility bars. 2. An order entered on 04/29/25 for bed mobility bars. 3. A consent form completed on 04/29/25 for bed mobility bars. 4. The care plan did not include the use of bed mobility bars. C. Record review of R #4's care plan revised on 04/23/25, revealed R #4 did not have a care plan for bed mobility bars. D. On 05/04/25 at 1:40 pm during an observation of R #4's room, the bed contained mobility bars on both sides of the bed. E. On 05/04/25 at 1:40 pm during an interview with R #4, he stated he used the bed mobility bars for positioning. He stated he requested the mobility bars to assist him in positioning himself in bed. F. On 05/07/25 at 10:45 pm, during an interview with the Interim Director of Nursing (IDON), she confirmed R #4 currently requires the use of mobility bars. The IDON confirmed the revision of the care plan for R #4 was not revised and should have been. R #10 G. Record review of R #10's admission record revealed that she was admitted to the facility on [DATE]. H. Record review of R #10's current medical orders revealed an order dated 04/13/25 for positioning rails to both sides of R #10's bed. I. Record review of R #10's care plan dated 01/07/25 revealed the care plan did not contain any information regarding R #10's use of positioning rails. J. On 05/07/25 at 10:10 am during an interview with the Interim Director of Nursing (IDON), she confirmed that R #10 does use positioning rails on both sides of her bed. The IDON stated that R #10's care plan should have been revised when the positioning rails were added to R #10's bed. R #14 K. Record review of R #14's admission record revealed R #14 was admitted to the facility on [DATE]. L. Record review of R #14's electronic health record (EHR) revealed the following: 1. The record did not contain an assessment for repositioning bars. 2. The record did not contain an order for the repositioning bars. 3. The record did not contain a consent for the repositioning bars. M. On 05/04/25 at 9:23 am during an observation of R #14's room, there was not repositioning bars on her bed. N. Record review of R #14's care plan revised on 02/17/25, revealed R #14 had a care plan for bed mobility that stated, R #14 uses repositioning bars to maximize independence with turning and repositioning in bed. O. On 05/04/25 at 9:23 am during an interview with R #14, she stated she used to have repositioning bars but does not have them anymore. R #14 did not know why she no longer had them nor how long ago they had been removed. P. On 05/07/25 at 10:25 am, during an interview with the Interim Director of Nursing (IDON), she confirmed R #14 does not require the use of repositioning bars. The IDON confirmed the revision of the care plan for R #14 was not revised and should have been. R #15 Q. Record review of R #15's admission record revealed R #15 was admitted to the facility on [DATE]. R. Record review of R #15's care plan initiated on 01/23/25 and revised on 04/09/25, revealed a care plan for actual pain with interventions to administer pain medication as prescribed. S. Record review of R #15's Electronic Health Record (EHR) revealed there were no orders for pain medication. T. Record review of R #15's Medication Administration Record (MAR) dated February 2025, March 2025, April 2025 and May 2025, revealed: 1. Pain medication was not administered. 2. Daily pain monitoring scored at a zero (no pain). U. On 05/04/25 at 9:57 am during an interview with R #15, he stated that he sometimes has pain, but does not get any pain medication. R #15 could not confirm if he notified the facility of any pain. V. On 05/07/25 at 10:25 am during an interview with the Interim Director of Nursing (IDON), she stated the care plan was created as a preventative with the expectation that R #15 may require an order for pain medication soon after admission. R #15 has not complained of any pain since admission and therefore has not required a request for pain medications. The IDON confirmed the care plan for R #15 was not revised to remove interventions for pain medication use and should have been. R #28 W. Record review of R #28's admission record revealed she was admitted to the facility on [DATE]. X. Record review of R #28's care plan revised on 02/17/25 revealed that R #28 takes a psychotropic medication. Y. Record review of R #28's current medical orders revealed no order for a psychotropic medication. Z. On 05/07/25 at 10:10 am, during an interview with the Interim Director of Nursing (IDON) she confirmed that R #28's psychotropic medication was discontinued in April 2025. The IDON stated she expects R 28's care plan to be revised when needed to ensure it is accurate to reflect R #28's current medical needs. 51616 51657

Based on record review, observation, and interview, the facility failed to develop comprehensive a care plan for 1 (R #214) of 1 (R #214) resident reviewed when staff failed to develop a comprehensive care plan for oxygen therapy. This deficient practice is likely to result in staff not being aware of the residents' care needs and preferences, and residents not receiving the needed care. The findings are: A. Record review of R #214's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation (a progressive lung disease that makes it difficult to breathe with worsening symptoms, typically lasting for several days, requiring changes in treatment), 2. Pleural Effusion (a condition where excessive fluid accumulates the area between the lungs and the chest wall), 3. Acute And Chronic Respiratory Failure with Hypoxia (respiratory failure involving a condition where the body doesn't get enough oxygen), 4. Anxiety Disorder (excessive worry and fear that significantly interfere with daily life). B. Record review of R #214's care plan dated 05/04/25 revealed the following: 1. Focus are of The resident has oxygen therapy related to diagnosis of COPD and respiratory therapy. 2. Interventions include monitor for signs and symptoms of respiratory distress and report to provider as needed. The care plan does not include person centered interventions, baseline vital signs nor description of oxygen therapy to include frequency and indication of use of oxygen. C. On 05/06/25 at 12:55 pm, during an observation of R #214's room, an oxygen concentrator sat on the floor next to R #214's bed and she was wearing a nasal canula (a thin flexible tube used to deliver oxygen through your nose). D. Record review of R #214's electronic health records (EHR) revealed the resident did not have an order for the use of oxygen. E. On 05/06/25 at 12:55 pm, during an interview with Certified Medication Aid (CMA) #1, she confirmed R #214 was wearing a nasal canula with oxygen in use. F. On 05/07/25 at 10:25 am, during an interview with the Interim Director of Nursing (IDON), she confirmed R #214's care plan did not meet her expectations of person-centered interventions for oxygen therapy.

Based on record review, observation, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #214) of 2 (R #23, and R #214) residents reviewed for respiratory care when the facility failed to ensure there was a physician order for use of oxygen. This deficient practice is likely to result in residents' care and needs not being met if staff are not aware of the indication for use. The findings are: A. Record review of R #214's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation (a progressive lung disease that makes it difficult to breathe with worsening symptoms, typically lasting for several days, requiring changes in treatment), 2. Pleural Effusion (a condition where excessive fluid accumulates the area between the lungs and the chest wall), 3. Acute And Chronic Respiratory Failure with Hypoxia (respiratory failure involving a condition where the body doesn't get enough oxygen), 4. Anxiety Disorder (excessive worry and fear that significantly interfere with daily life). B. On 05/06/25 at 12:55 pm, during an observation of R #214's room, an oxygen concentrator sat on the floor next to R #214's bed and she wore a nasal canula (a thin flexible tube used to deliver oxygen through your nose). C. On 05/06/25 at 12:55 pm, during an interview with Certified Medication Aid (CMA) #1, she confirmed R #214 was wearing a nasal canula with oxygen in use. D. Record review of R #214's electronic health records (EHR) revealed the resident did not have an order for the use of oxygen. E. On 05/07/25 at 10:25 am, during an interview with the Interim Director of Nursing (IDON), she confirmed that R #214 uses oxygen. The IDON confirmed R #214 did not have an order for use of oxygen and should have.

Based on record review and interview, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 1 (R #36) of 2 (R #36 and R #40) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the residents not receiving the services they need. The findings are: A. Record review of R #36's face sheet revealed R #36 was admitted to the facility on [DATE] with the following diagnoses: 1. Major depressive disorder (depression; a mood disorder that causes a persistent feeling of sadness and loss of interest), 2. Post-traumatic stress disorder (PTSD; a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety), 3. Schizoaffective disorder (a mental condition that causes both psychosis and mood problems), bipolar type (a disorder associated with episodes of mood swings). B. Record review of R #36's PASRR dated 07/12/22, revealed staff documented that R #36 does not have a diagnosis or suspected mental illness. C. On 05/07/25 at 10:10 am, during an interview with the Interim Director of Nursing (IDON), she stated R #36 does has been diagnosed with major depressive disorder, PTSD, and schizoaffective disorder, bipolar type which are listed as a mental illnesses on the first question of section C on the New Mexico PASRR Level 1 Identification Screen form and confirmed that R #36's PASRR was incorrect.

Based on observation, interview, and record review, the facility failed to maintain proper infection prevention measures by not changing the oxygen tubing and cannula as ordered and having unbagged oxygen tubing and cannulas on the floor and on the back of wheelchairs for 2 (R #5 and R #21) of 3 (R #5, R #21, and R #35) residents reviewed. This deficient practice could likely cause the spread of infections and illnesses to the residents. The findings are: R #5 A. Record review of R #5's admission record revealed that he was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic Obstructive Pulmonary Disease (COPD; respiratory disease), 2. Anxiety Disorder (fear and worry that interferes with daily activities), 3. Anemia (not enough hemoglobin (a protein in red blood cells that carries oxygen to the lungs to breathe) to carry oxygen to the body's tissues. B. On 05/02/25 at 10:30 am, during an observation of R #5 the oxygen tubing date and time were missing on the concentrator tubing and the portable oxygen tubing. C. On 05/03/25 at 12:30 pm during a random observation of the lunch meal revealed R#5 in the dining area. R #5 was wearing oxygen, and the oxygen tubing and cannula were not dated or in a bag. R #21 D. Record review of R #21's admission record revealed that she was admitted to the facility on [DATE] with the following diagnoses: 1. Cerebral palsy (a disorder of movement, muscle tone, and posture), 2. Diabetes mellitus (DM; metabolic disease) 3. Seizure Disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), 4. Acute Respiratory Failure with hypoxia (condition that occurs when lungs cannot get enough oxygen into the blood or remove carbon dioxide from the blood). E. Record review of R #21's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 03/15/25, revealed the following: 1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 00, severe impairment. 2. R #21 was dependent and required the use of oxygen. F. On 05/03/25 at 11:20 am, an observation of R #21's room revealed the oxygen tubing that was connected to the oxygen concentrator that was located by R #21's bed was on the floor and dated 04/28/25 as indicated as the date written on a piece of tape. The oxygen tubing and cannula were not in a bag. G. On 05/03/25 at 12:30 pm a random observation of the lunch meal revealed R #21 in the dining area. R #21 was wearing oxygen, and the oxygen tubing and cannula were not dated or in a bag. H. On 05/03/25 at 12:56 pm, during an interview with the MDS Coordinator (MDS) she confirmed that R #5's and R #21's oxygen tubing and cannulas were not dated or placed in bags. She stated that her expectation is for all tubing and cannulas to be changed out weekly as ordered and they should be kept in bags, not on the floor or on the back of wheelchairs. 51616

Based on observation, record review, and interview, the facility failed to provide reasonable accommodation for resident needs and preferences for 1 (R #1) of 1 (R #1) resident reviewed by not ensuring R #1 had access to his call light and was able to use call light. These deficient practices are likely to result in residents being unable to request assistance, such as needing help with activities of daily living (ADL's) or other acute distress. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's Electronic Health Record (EHR), revealed R #1 was admitted with the following diagnoses: 1. Unspecified sequelae (condition which is the consequence of a previous disease or injury) of cerebral infarction (stroke). 2. Hemiplegia (condition characterized by paralysis (loss of voluntary muscle control) on one side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction affecting right dominant side 3. Muscle weakness generalized. 4. Other reduced mobility. 5. Unspecified Speech disturbance. C. Record review of R #1's care plan dated 04/01/25 revealed R #1 has ADL self-care deficit related to hemiplegia and stroke and is totally dependent on staff for toilet use and to use the call bell for assistance. D. On 04/10/25 at 10:37 am, during an observation, R #1 laid in bed and the call light was on the floor towards the back of the bed. R#1's spouse [R #1's spouse (R #2), who shares the same room with R #1] also verified the call light was on the floor behind the bed. E. On 04/10/25 at 10:40 during an observation, the call light was in R #1's hand when he attempted to demonstrate how to use the call light. R #1 attempted multiple times to press the call light button and was unable to press the button on his call light. F. On 04/10/25 at 10:45 am, during an interview with Social Services (SS), she confirmed that it is difficult for R #1 to use a press button call light and he would benefit from a different simpler call light. G. On 04/10/25 at 11:05 am, during an interview with the Director of Nursing (DON), she stated R #1's push button call light is difficult for him to use and the use of a soft touch call light would be more appropriate due to his impaired mobility.

Based on record review, observation, and interview, the facility failed to ensure privacy during personal care for 1 (R #1) of 1 (R #1) residents reviewed for privacy when staff failed to pull the privacy curtain closed allowing his roommate full view of R #1's body parts. This deficient practice likely caused R #1 to feel ashamed and embarrassed. The findings are: A. Record review of R #1's care plan dated 01/24/25 revealed R #1 has a reopened pressure ulcer stage (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin), Stage 3 (full thickness skin loss that extends into deeper tissue and fat but not into muscle, tendon, or bone) to his right buttock. B. On 02/13/25 at 2:10 pm, during an interview with R #1's daughter, she stated that her father was always a proud man and would be embarrassed with other people, like his roommate, seeing his body parts. C. On 02/13/25 at 4:07 pm, a wound care observation with R #1 revealed the following: 1. Registered Nurse (RN) #1 entered R #1's room and closed the door behind her. 2. R #1's roommate was in the room, on his side of the room, in his wheelchair in full view of R #1's bed. 3. RN #1 completed personal care which involved wound care to a pressure ulcer to R #1's buttocks area without pulling the privacy curtain closed. D. On 02/13/25 at 4:20 pm, during an interview with the Administrator (ADM), she confirmed that facility staff should pull the privacy curtains closed prior to assisting residents with personal care. The ADM stated that her expectation is for staff to provide privacy by pulling curtains closed if there is a roommate or closing the door.

Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 (R #1) of 1 (R #1) residents when staff failed to: 1. Reposition R #1 in accordance with her care plan. 2. Communicate among staff and document when R #1 was repositioned. If the facility is not repositioning a resident per their care plan then residents are likely to not receive the therapeutic benefits and care needed. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. Stroke. 2. Muscle weakness. 3. Dysphagia (condition with difficulty in swallowing food or liquid). B. Record review of R #1's care plan, dated 05/15/24, revealed the following: - Focus: The resident had potential/actual impairment to skin integrity related to fragile skin. - Interventions: Educate resident/family/caregivers of causative factors and measure to prevent skin injury. Turn resident using the clock for repositioning. C. On 05/15/24 at 12:19 pm during an observation of R #1's room, a repositioning clock was located on the wall across from R #1's bed. The repositioning clock indicated the following: - At 12:00 am and pm, staff to reposition R #1 on her back. - At 2:00 am and pm, staff to reposition R #1 on her left side. - At 4:00 am and pm, staff to reposition R #1 on her right side. - At 6:00 am and pm, staff to reposition R #1 on her back. - At 8:00 am and pm, staff to reposition R #1 on her left side. - At 10:00 am and pm, staff to reposition R #1 on her right side. D. On 05/15/24 at 2:43 pm during an observation, R #1 lay on her back and was not positioned on her left side as indicated by the repositioning clock. E. On 05/16/24 at 10:19 am during an observation, R #1 lay on her back and was not positioned on her right side as indicated by the repositioning clock. F. On 05/16/24 at 10:21 am during an interview with Licensed Practical Nurse (LPN) #1, she stated staff were supposed to reposition R #1 every two hours, but she did not know how to read the repositioning clock that was on R #1's wall. LPN #1 stated the CNAs (Certified Nursing Assistants) were responsible to reposition R #1 and document it. G. On 05/16/24 at 11:21 am during an interview with CNA #1, he stated R #1 should be repositioned every two hours according to the repositioning clock on the resident's wall. CNA #1 also stated, Right now, she [R #1] should be on her right side, but she's still on her back. We should have repositioned her already. H. On 05/16/24 at 12:24 pm during an interview with the Assistant Director of Nursing (ADON), she stated R #1 should be repositioned according to the repositioning clock on R #1's wall, and nursing staff should document at the nursing station each time R #1 was repositioned. I. On 05/16/24 at 12:44 pm during an interview with Nursing Assistant (NA) #1, she stated nursing staff repositioned R #1 according to the reposition clock on R #1's wall, and they were supposed to document when R #1 was repositioned. J. On 05/16/24 at 1:19 pm during an interview with the Regional Nurse Consultant (RNC), she stated she expected the nursing staff to use the repositioning clock as a guide and reposition R #1 in the position according to the clock. The RNC also stated R #1 should be repositioned every two hours, but staff were not required to document when R #1 was repositioned.

Based on record review and interview, the facility failed to ensure the medical record was accurate for 2 (R #1 and #2) of 2 (R #1 and #2) residents reviewed, when staff failed to document when a resident's tube feeding solution was changed and when a resident was provided hydration via a tube feed. This deficient practice is likely to result in staff confusion as to the services and treatment provided. The findings are: R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. Stroke (a medical emergency that can cause brain damage and disability). 2. Muscle weakness. 3. Dysphagia (condition with difficulty in swallowing food or liquid). B. Record review of R #1's physician orders, dated 02/09/24, revealed the following: - An order for enteral (involving or passing through the intestine, either naturally via the mouth and esophagus, or through an artificial opening) feed every shift. Jevity 1.5 (specialized nutritional formula) at 55 milliliters (ml) an hour (hr) for 20 hours a day via percutaneous endoscopic gastrostomy tube (PEG; a surgery to place a feeding tube.) Hold four hours daily from 8:00 am to noon. - An order for enteral feed five times a day. Hydration flush 200 ml of water five times a day via PEG. C. Record review of R #1's Nurse Administration Record (NAR), dated 04/01/24 through 04/30/24, revealed the following: - Staff documented they administered Jevity every shift three times out of 60 opportunities. - Staff documented they administered the hydration flush five times out 150 opportunities. D. Record review of R #1's NAR, dated 05/01/24 through 05/16/24, revealed the following: - Staff documented they administered Jevity every shift 12 times out of 32 opportunities. - Staff documented they administered the hydration flush 25 times out of 80 opportunities. E. On 05/16/24 at 10:23 am during an interview with Licensed Practical Nurse (LPN) #1, she stated staff should document tube feeding and hydration via PEG in the NAR each time staff administered them. F. On 05/16/24 at 11:29 am during an interview with Registered Nurse (RN) #1, she stated staff should document tube feeding and hydration via PEG in the NAR each time staff administered them. G. On 05/16/24 at 1:25 pm during an interview with the Regional Nurse Consultant (RNC), she stated staff should document tube feeding and hydration via PEG in the NAR. The RNC stated staff did not document R #1's tube feeding and hydration in the NAR. R #2: H. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE] with the following diagnoses: 1. Acute respiratory failure with hypoxia (below-normal level of oxygen in your blood). 2. Gastrostomy status (artificial opening to stomach). 3. Dysphagia. I. Record review of R #2's physician orders, dated 04/26/24, revealed the following: - An order for enteral feed five times a day. Glucerna 1.5 (meal replacement solution) at 250 ml five times a day. - An order for enteral feed six times a day. 150 ml water flushes six times a day. J. Record review of R #2's Medication Administration Record (MAR) dated 05/01/24 through 05/16/24 revealed the following: - Staff documented they administered Glucerna five times a day 71 times out of 80 opportunities. - Staff documented they administered water flushes six times a day 36 times out of 96 opportunities. K. On 05/16/24 at 1:26 pm during an interview, the RNC stated staff should have documented R #2's tube feeding and hydration via tube feeding in the MAR each time it was performed, but they did not.

Based on record review and interview, the facility failed to effectively manage pain for 1 (R #3) of 1 (R #3) residents reviewed for pain when staff did not provide pain treatment. This deficient practice likely resulted in R #3 experiencing long periods of pain without sufficient relief. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted to the facility from the hospital on 05/09/24 at approximately 7:00 pm and was discharged home on 05/10/24 at 11:40 am. B. Record review of R #3's hospital discharge orders, dated 05/09/24 at 2:24 pm, revealed a discharge medication order for hydrocodone-acetaminophen tablet (opioid pain medication), 5-325 milligram (mg). One tablet, orally, every eight hours as needed. C. Record review of R #3's physician orders, dated 05/09/24 at 7:15 pm, revealed an order for hydrocodone-acetaminophen, 5-325 mg. Give one tablet by mouth every eight hours as needed for pain. D. Record review of R #3's pain evaluation form, dated 05/09/24 at 11:29 pm, revealed R #3's pain level (measured pain on a scale of 1-10) was a 9 (very severe pain) out of 10 (worst possible pain) and his pain intensity (how strong pain is felt) in the past 24 hours was an 8 (very severe pain) out 10 (worst possible pain). E. Record review of R #3's Treatment Administration Record (TAR), dated 05/09/24, revealed staff did not administer hydrocodone - acetaminophen to R #3 as needed for pain. F. Record review of R #3's physician orders, dated 05/10/24 at 12:21 am, revealed an order for methocarbamol oral tablet (muscle relaxer), 750 mg, methocarbamol. Give one tablet by mouth every six hours as needed for muscle spasms. G. Record review of R #3's nursing progress notes, dated 05/10/24 at 12:41 am, revealed the resident and wife wanted to leave against medical advice (AMA) multiple times related to the resident did not receive pain medication as soon as he got into the facility. H. Record review of R #3's Treatment Administration Record (TAR), dated 05/10/24, revealed staff did not administer hydrocodone - acetaminophen to R #3 as needed for pain. I. Record review of R #3's Medication Administration Record (MAR), dated 05/10/24, revealed staff did not administer methocarbamol to R #3. J. On 05/15/24 at 5:14 pm during an interview with R #3's wife, she stated the facility was not ready for R #3 when he arrived to the facility. She stated R #3 was in a lot of pain after having recent brain surgery, and staff did not give his pain medications as ordered. R #3's wife also stated they left the facility as soon as they could and went to R #3's primary care Physician. K. On 05/15/24 at 6:03 pm during an interview with Licensed Vocational Nurse (LVN) #1, she stated she knew R #3 did not receive his pain medication. She stated she offered the resident Tylenol and asked him how the pain was. LVN #1 stated R #3 and his wife wanted to leave against medical advice (AMA) because R #3 was not given hydrocodone. She said they tried to work as fast as they could to get R #3 his hydrocodone pain medication. LVN #1 stated R #3's wife was in distress, because the hospital did not administer R #3's medications before he left. LVN #1 stated staff did not administer hydrocodone to R #3 while he was at the facility because the facility did not have that medication readily available for R #3. L. On 05/16/24 at 1:29 pm during an interview with the Regional Nurse Consultant (RNC), she stated the nursing staff should have used the hydrocodone that was in the facility's medication dispensing cabinet (used for all residents with matching physician orders) for R #3. The RNC stated staff should have administered pain medication to R #3 as ordered, but they did not.

Based on record review, observations, and interview the facility failed to: 1. Update the staffing sheets at the beginning of each shift or in a timely manner to reflect the staff working that day. This deficient practice could likely prevent the public as well at the 56 residents identified on the facility census list provided by the Administrator on 03/25/24 from having access to accurate, current, and previous staffing information. The findings are: A. Record review of the posted staffing sheet, on 03/25/24 at 3:49 PM, revealed the following: - Staff documented RN-1 LPN -1 CMA-1 CNA-5 for the day shift; - The data was not in a clear and readable format; -Staff did not update the document with the evening shift staff. B. On 03/26/24 at 8:03 AM, 12:20 PM, and 5:07 PM, record review of the posted staffing sheet remained the same as the staffing sheet on 03/25/24, and the evening shift was not filled out. The staffing post sheet was not updated to reflect the current date. C. On 03/27/24 at 8:00 AM, record review of the posted staff sheet revealed it was dated 03/26/24. D. On 03/28/24 at 3:30 PM, record review of the Posting Nurse Staffing Information and Report policy and procedure revealed the staff will post the following information daily, at the beginning of each shift, day, night and weekend shift. 1. Registered Nurses, 2. Licensed Vocational Nurses, 3. Certified Medication Aides, 4. Certified Nurse's Aides and Nursing Assistants. E. On 03/29/24 at 11:30 AM during an interview with Director of Nursing (DON) and the Administrator, they stated staff should complete the posted staffing sheet each day and post the staffing sheet daily at the beginning of the shift.

Based on observation and interviews the facility failed to: 1. Ensure opened and accessed (has been used) insulin flex pens (an injectable diabetes medicine that helps control blood sugar levels. This medication helps the pancreas produce insulin more efficiently) were dated as to when they were initially opened by nursing staff. 2. Ensure all expired supplies were not kept with unexpired supplies. These deficient practices are likely to result in all 56 residents, identified on the census list provided by the Executive Director (ED) on [DATE], receiving expired medication that may have lost their potency or effectiveness. The findings are: Findings for Insulin Pens A. On [DATE] at 3:42 pm, an observation of medication cart 100 revealed the following: - A Basagler flex pen (a long-acting insulin that starts to work several hours after injection and keeps working evenly for 24 hours), 100 unit/milliliter (ML) was ,d+[DATE] full and belonged to R #7. The insulin pen did not have an open date written on it. - An Ozempic prefilled syringe (a prescription drug for type 2 diabetes that lowers blood sugar and heart risks) 2 MG/3 milliliter (ML) was almost empty. The syringe did not have an open date written on it. B. On [DATE] at 3:46 pm during an interview with LPN #2, she confirmed staff did not write an open date on either medications, and both medications were used. C. On [DATE] at 10:05 am during an interview with the Director of Nursing (DON), she confirmed staff should write the dates on all insulin pens. Findings for expired supplies D On [DATE] at 3:42 pm, an observation of the 100-medication cart revealed the following: 1. Assure Dose, level 1, normal dose (a glucose control test used to check the meter and strips work optimally to deliver accurate and precise results) was opened and did not have an open by date. The test expired within 90 days of opening. 2. Assure Dose, level 2, normal dose was opened did not have an open by date. The test expired within 90 days of opening. E. On [DATE] at 3:33 pm LPN #2 stated staff should have dated the two open bottles of Assure Dose, the glucose control testing, with an open date.

Based on record review, observation, and interview the facility failed to ensure comprehensive care plans were reviewed and revised for 2 (R #s 16 and 37) of 2 (R #s 16 and 37) residents reviewed for falls with accidents. This deficient practice likely caused R#16 to sustain 9 falls from (MONTH) (YEAR) to 09/06/18. Falls occurred on 01/04/18, 01/18/18 (twice), 02/10/18, 02/20/18, 04/05/18, 04/13/18, 07/21/18, 09/06/18. The fall on 02/20/18 resulted in a 8 inch laceration to the top of R #16's head. The fall on 09/06/18 resulted in a laceration to the left top of head and a contusion to the left side of head. Record review revealed R #37 had 6 falls from (MONTH) (YEAR) to (MONTH) (YEAR). Falls occurred on 01/16/18, 04/19/18, 05/07/18, 05/27/18, 06/20/18, 08/04/18. The fall dated 08/04/18 resident fell from a standing position and fractured the right femur (thigh bone) and right arm. The findings are: Resident # 16 - A. Record review of the facility face sheet for R #16 indicated the resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. B. Record review of nursing progress notes for R #16 indicated the following: 1. 01/04/18 at 12:03 pm, this nurse was called to TV room where resident was found sitting on the floor on her buttocks with her walker beside her. 2. 01/18/18 at 5:15 am., Called to Resident's room by staff. Upon entering Resident's room, observed resident sitting on buttock's on the floor in front of the closet door close to the exit door to the hallway. 3. 01/18/18 at 7:02 pm, Nurse was alerted that resident was on the floor in TV room sitting in front of her wheelchair and a recliner. 4. 02/10/18 at 10:16 pm, Resident was observed lying on floor in TV room. Resident was attempting to transfer from w/c (wheelchair) to recliner, unassisted. 5. 02/20/18 at 10:37 pm Resident was found sitting on floor with legs sticking out of the door of the room. Blood was all over the floor next to bed. It Is believed that resident may have rolled out of the bed and hit head on bed side table. Has a laceration to left side of forehead that goes into top of head about 8 inches in length. 6. 04/5/18 at 4:30 pm Resident wheeling herself in the wheelchair out of the activity room. She attempted to stand up from chair and slid down to the floor. She complained of right hip pain. Sent to ER (emergency room ). 7. 04/13/18 at 8:40 am Resident was sitting in her w/c when she tried to get up holding on to the rails outside of dinning room. Resident stood up and legs buckled and twisted still holding the rails fell on floor on her butt did hit head on rail. 8. 07/21/18 at untimed, Found on Floor, another resident informed the DON (Director of Nursing) and this nurse that resident was on floor in another residents room. 9. 09/6/18 at 9:14 pm, Resident was in her w/c(wheelchair) staff was fixing her bed and turned back around to see resident attempting to self transfer and slipped out of w/c to her left side and fell hitting her head and causing a skin tear to left arm, laceration to left mid side of her head and contusion to left side of head as well. C. Record review of R#16's care plan dated 12/20/16 indicated four of the nine falls had new interventions added to the resident's fall risk related to deconditioning. Those dates and interventions were: 1. 01/05/18-monitor resident for significant changes in mobility, sitting balance and lower extremity joint function, keep fall mat in place. 2. 01/05/18-review as indicated for significant changes in cognition, safety awareness and decision-making capacity. 3. 02/21/18-review status of any medical conditions that predispose to falls or that could increase the risk of injury from falls. 4. 07/21/18-dycem (non slip product) placed between wheelchair and wheelchair cushion to prevent cushion from sliding out of wheelchair. Continue with anti rollback (As the occupant begins to stand, the unit is automatically activated and a pair of brake arms grab the tires to prevent the chair from rolling back and away) on wheelchair, place corner guards on bedside table. 5. There was no documentation to indicate that the R #16's care plan was updated to include new or revised approaches for falls on 01/18/18, 02/10/18, 04/05/18, 04/13/18, or 09/6/18. D. Observations of R #16 on 09/12/18 indicated the following: 1. 11:30 am resident sitting in her wheelchair in the TV room alone, taking off shoes, The resident appeared as she could fall forward from the wheelchair at any moment. No staff were observed in the general area, redirecting R#16. 2. 12:20 pm no dycem observed in wheelchair 3. 12:40 pm resident has propelled wheelchair with feet to end of hallway by therapy room, skin tear on left arm is bleeding 4. 12:50 pm pushing self with feet down hallway, no supervision or redirection 4. 1:12 PM no plastic corner guards on two sides of bedside table 5. 1:20 pm wheeling self down 300 hall, no supervision or re-direction 6. 1:46 PM wheeling down 100 hallway, no supervision or redirection 7. 2:14 PM lying in bed, fall mat not by side of bed. E. On 09/12/18 at 2:30 pm with the interim Director of Nursing (DON) #2 she stated and confirmed that the R #16's wheelchair did not have the dycem, the guards were not on two corners of the nightstand, and the fall mat was not down beside the bed while the resident was in bed. She also stated that facility policy is that after each and every fall there should have been an analysis of why the resident fell and new approaches added to the R #16's fall care plan. Resident #37 - F. Record review of facility face sheet date 01/12/17 revealed R #37 was admitted on this date. Admission [DIAGNOSES REDACTED].-related [MEDICAL CONDITION] (weakening of the bones), wedge compression [MEDICAL CONDITION] vertebra (compression fracture is a collapse of a vertebra), wedge compression fracture of the [MEDICATION NAME] vertebra (compression fracture is a collapse of a vertebra - middle back), [MEDICAL CONDITION], (a medical condition that disrupts the way the brain works. AD affects the parts of the brain that control thought, memory, and language), and [MEDICAL CONDITION] (long-term lung diseases). G. Record review of Care Plans for R #37 dated 07/10/18 with Focus, measurable Goals and Interventions include, has an ADL (activities of daily living) self care performance deficit, has bowel and bladder incontinence, is on antidepressant medication therapy, has a mood problem, has potential for elopement with behaviors, is at risk for falls, resident uses psychopharmacological (the scientific study of the effects of drugs on the mind and behavior) medications, has chronic pain. H. Record review of Progress Notes for R #37 dated 01/16/18 2:28 pm revealed, .Resident was sitting in dining room eating cookies and drinking coffee. Resident stated she tried to get up, other visitor stated she just got up and fell to the floor. Called daughter, (name of physician) and informed them of fall started on neuro checks (an assessment made by a medical professional on someone with a head injury, cervical injury, nerve function in injury/surgery, or stroke). Does have bump to back of her head. Informed Director of Nursing (DON) and administrator of fall was able to move all extremities without complications . I. Record review of a facility incident reported dated 04/19/18 indicated R #37 was found lying on her back on dining room floor, head facing the kitchen, feet facing doorway going into dining area. Resident alert, had her shoes on, w/c (wheelchair) upright behind her, unlocked. Resident stated she was trying to clean up the mess. Assessed for injuries and none noted. Resident denies any pain, and is able to move all extremities without c/o (complaint of) pain or change of facial expression. Neuro checks (an assessment made by a medical professional on someone with a head injury) started. (name of DON) was present during assessment . J. Record review of Progress Notes for R #37 dated 5/7/18 at 6:25 pm revealed, .resident found sitting on her bottom on the floor in her room, back towards the bed, feet facing out into room, w/c upright across from her, resident was in her sock feet. Assessed for injuries and none noted, resident able to move all extremities and stand and bear wt (weight) with assist without c/o pain or change of facial expression. resident denied any pain. Neuro checks started. Resident stated she tried to get up and slipped . K. Record review of Progress Note date 5/27/18 at 2:04 pm Nutritional Status Note Text: Pt (patient) observed lying on floor near, Near locked w/c. Pt appears to have tried to walk w/o (without) assistance. Oxygen in place. Pt assessed, No visible injury. Unable to roll d/t (due to) c/o excruciating pain. On call MD (medical doctor) called, Informed of change in position. New orders reading send to ED (emergency department) for eval (evaluation) and tx (treatment). Pt representative aware. L. Record review of Progress Notes for R #37 dated 6/20/18 at 3:21 pm revealed, .resident found sitting on her bottom on the floor in the family room, w/c upright behind her, shoes on feet. resident stated she was leaving, going home to see (name of spouse). assessed for injuries and none noted, resident able to move all extremities without c/o pain or change of facial expression. resident denied pain anywhere . M. Record review of Progress Notes for R #37 dated 08/04/18 at 12:01 pm revealed, . Resident fell on floor by front door; (name of physician) notified; sent to ER for c/o rt (right) hip and rt arm pain. N. Record review of facility Incident Report dated 08/04/18 revealed, .CNA (certified nursing assistant) saw resident walking toward front door; her O2 (oxygen) tubing caught and she fell on to floor by front door. Resident c/o rt hip pain, rt arm pain and back .Stated she wanted out and door was locked; she got out of w/c and fell when O2 tubing caught .Assessed resident and got vital signs. Kept resident on floor while ER (emergency room ) and EMT (emergency medical technicians) notified and upon arrival of EMT's. (name of physician), (name of DON) and (name of daughter) were notified. O. Record review of Progress Notes for R #37 dated 8/8/18 at 10:30 am revealed, . Resident returned to facility at 10:30 am via ambulance, transported per stretcher. Transferred onto bed, pain evident with any movement. Sling on Rt. arm, 3 border dressings (soft, non-stick dressing with an adhesive border) intact to rt. hip. No drainage noted. Resident alert and oriented x (times) 2. Color pale/warm/dry. Phone message left for (name of physician) to return call to notify of residents return and med orders. P. Record review of Progress Notes for R #37 dated 8/9/18 at 2:23 am revealed, .Returned to this facility on 8/8/2018 after hospital stay for fall resulting in fractures of right hip and right arm. She is resting quietly in bed at this time. Responds to staff during care and assessment but appears to be lethargic with minimal conversation and keeping eyes closed. Unable to follow any directions or participate in care. Right arm has severe discoloration from bruising and 2 plus [MEDICAL CONDITION] (the term used to describe [MEDICAL CONDITION] (swelling) when pressure applied to the skin of the swollen area is released and an indentation is left behind) in elbow area. Stabilized with sling. Left arm has 1-2 plus [MEDICAL CONDITION] also in elbow area. 3 dressings on right hip are intact clean and dry. Signs of pain--crying out and facial grimace when right leg is moved. 2 person assistance to change Attends undergarment and provide routine incontinence care. Oral fluids offered but refused to take water at this time . Q. Record review of Fall Care Plan for R #37 dated 07/10/18 revealed, Focus: The resident is at risk for falls R/T (related to) actual fall on . 1/16/18, 5/8/18, 6/20/2018 no injury, 08/04/18 - injury. Goal: Resident will be free of minor injury r/t falls through the review date. Interventions: Dated 02/25/18 - Remind (name of resident) to assist for assistance when transferring. Dated 02/25/18 - Remind (name of resident) to mobilize in w/c and not to try walking. Dated 01/13/17 - fall mats on both sides of the bed, and bed In low position for safety. Dated 05/01/17 - Ensure that Resident is wearing appropriate footwear slip resistant shoes, when mobilizing in w/c. Dated - 05/01/18 - Anti-roll backs (As the occupant begins to stand, the unit is automatically activated and a pair of brake arms grab the tires to prevent the chair from rolling back and away) to wheelchair. Dated 02/25/18 - Monitor resident for significant changes in mobility, sitting balance and lower extremity joint function. Dated 10/31/17 - Ensure/provide a safe environment. Encourage and educate the husband to ask for assistance from staff members when needing to transfer resident. Dated 01/16/18 - Review as indicated for significant changes in cognition, safety awareness and decision-making capacity. Dated 02/25/18 - Review new or progressive neurological impairments. R. Record review of the Fall Care plans for R #37 revealed, the falls dated 04/19/18 and 05/27/18 revealed there is no evidence of this fall on the care plan and no up-date to the care plan. Falls dated 05/08/18, 06/20/18 and 08/04/18 there is no evidence of a up-date to the care plan for these falls. S. ON 09/12/18 at 2:24 pm, Director of Nursing (DON) #2 stated, From what I've been told the facility has not had a Minimum Data Set Coordinator (MDSC) for at least the last year and a half. I was informed that the DON has been doing the MDS's/care plans and up-dates to care plans. When asked if there were any staff currently that were doing care plans that could answer questions about past care plans the DON responded, No.

Based on record review, observation and interview, the facility failed to ensure a safe environment free from accidents for for 2 (R #16 and R #37) of 2 (R #16 and R #37) residents reviewed for accidents by: 1. failing to prevent serious injury from falls, 2. failing to follow care plan interventions as they related to fall risk, 3. failing to update care plans after falls, and 4. failing to provide supervision necessary to prevent serious injury. This deficient practice likely resulted in actual harm to R #16, lacerations to the head, and R #37 right femur (thigh bone) and right humerus (upper arm) fractures. The findings are: Resident #16 A. Record review of the facility face sheet for R #16 indicated the resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. B. Record review of nursing progress notes for R #16 indicated the following: 1. 01/04/18 at 12:03 pm, this nurse was called to TV room where resident was found sitting on the floor on her buttocks with her walker beside her. 2. 01/18/18 at 5:15 am, Called to Resident's room by staff. Upon entering Resident's room, observed resident sitting on buttock's on the floor in front of the closet door close to the exit door to the hallway. 3. 01/18/18 at 7:02 pm, Nurse was alerted that resident was on the floor in TV room sitting in front of her wheelchair and a recliner. 4. 02/10/18 at 10:16 pm, Resident was observed lying on floor in TV room. Resident was attempting to transfer from w/c (wheelchair) to recliner, unassisted. 5. 02/20/18 at 10:37 pm Resident was found sitting on floor with legs sticking out of the door of the room. Blood was all over the floor next to bed It Is believed that resident may have rolled out of the bed and hit head on bed side table. Has a laceration to left side of forehead that goes into top of head about 8 inches in length. 6. 04/5/18 at 4:30 pm Resident wheeling herself in the wheelchair out of the activity room. She attempted to stand up from chair and slid down to the floor. She complained of right hip pain. Sent to ER (emergency room ). 7. 04/13/18 at 8:40 am Resident was sitting in her w/c when she tried to get up holding on to the rails outside of dinning room. Resident stood up and legs buckled and twisted still holding the rails fell on floor on her butt did hit head on rail. 8. 07/21/18 untimed, Found on Floor, another resident informed the DON (Director of Nursing) and this nurse that resident was on floor in another residents room. 9. 09/6/18 at 9:14 pm, Resident was in her w/c(wheelchair) staff was fixing her bed and turned back around to see resident attempting to self transfer and slipped out of w/c to her left side and fell hitting her head and causing a skin tear to left arm, laceration to left mid side of her head and contusion to left side of head as well. C. Record review of R#16's care plan dated 12/20/16 indicated four of the nine falls had new interventions added to the resident's fall risk related to deconditioning. Those dates and interventions were: 1. 01/05/18-monitor resident for significant changes in mobility, sitting balance and lower extremity joint function. 2. 01/05/18-review as indicated for significant changes in cognition, safety awareness and decision-making capacity. 3. 02/21/18-review status of any medical conditions that predispose to falls or that could increase the risk of injury from falls. 4. 07/21/18-dycem (non slip product) placed between wheelchair and wheelchair cushion to prevent cushion from sliding out of wheelchair. Continue with anti rollback (As the occupant begins to stand, the unit is automatically activated and a pair of brake arms grab the tires to prevent the chair from rolling back and away) on wheelchair. 5. There was no documentation to indicate that the R #16's care plan was updated to include new or revised approaches for falls on 01/18/18, 02/10/18, 04/05/18, 04/13/18, or 09/6/18. D. Observations of R #16 on 09/12/18 indicated the following: 1. 11:30 am resident in TV room alone, taking off shoes, The resident appeared as she could fall forward out of the wheelchair and there were no staff re-directing or supervising the resident. 2. 12:20 pm, no dycem observed in wheelchair, 3. 12:40 pm resident has propelled with feet to end of hallway by therapy room, skin tear on left arm is bleeding, 4. 12:50 pm pushing self with feet down hallway, no supervision or redirection 4. 1:12 PM no plastic corner guards on two sides of bedside table 5. 1:20 pm wheeling self down 300 hall, no supervision or re-direction, 6. 1:46 PM wheeling down 100 hallway, no supervision or redirection, 7. 2:14 PM lying in bed, fall mat not by side of bed. E. On 09/12/18 at 2:30 pm with the interim Director of Nursing (DON) #2 she stated and confirmed that the R #16's wheelchair did not have the dycem, the guards were not on two corners of the nightstand, and the fall mat was not down beside the bed while the resident was in bed. She also stated that facility policy was that after each and every fall there should have been an analysis of why the resident fell and new approaches added to the care plan. DON #2 stated that had not occurred with the falls regarding R #16. Resident #37 - F. Record review of facility face sheet date 01/12/17 revealed R #37 was admitted on this date with a re-admission date of [DATE]. Re-admission [DIAGNOSES REDACTED].-related [MEDICAL CONDITION] (weakening of the bones), wedge compression [MEDICAL CONDITION] vertebra (compression fracture is a collapse of a vertebra), wedge compression fracture of the [MEDICATION NAME] vertebra (compression fracture is a collapse of a vertebra - middle back), and [MEDICAL CONDITION] (long-term lung diseases). G. Record review of Care Plans for R #37 dated 07/10/18 with Focus, measurable Goals and Interventions include, has an ADL (activities of daily living) self care performance deficit, has bowel and bladder incontinence, is on antidepressant medication therapy, has a mood problem, has potential for elopement with behaviors, is at risk for falls, resident uses psychopharmacological (the scientific study of the effects of drugs on the mind and behavior) medications, has chronic pain. H. Record review of Progress Notes for R #37 dated 01/16/18 2:28 pm revealed, .Resident was sitting in dining room eating cookies and drinking coffee. Resident stated she tried to get up, other visitor stated she just got up and fell to the floor. Called daughter, (name of physician) and informed them of fall started on neuro checks (an assessment made by a medical professional on someone with a head injury) , does have bump to back of her head. Informed Director of Nursing (DON) and administrator of fall was able to move all extremities without complications . I. Record review of Progress Notes for R #37 dated 04/19/18 at 05:27 pm revealed .resident found lying on her back on dining room floor, head facing the kitchen, feet facing doorway going into dining area. Resident alert, had her shoes on, w/c (wheelchair) upright behind her, unlocked. Resident stated she was trying to clean up the mess. Assessed for injuries and none noted. Resident denies any pain, and is able to move all extremities without c/o (complaint of) pain or change of facial expression. Neuro checks (an assessment made by a medical professional on someone with a head injury) started. (name of DON) was present during assessment . J. Record review of Progress Notes for R #37 dated 5/7/18 at 06:25 pm revealed, .resident found sitting on her bottom on the floor in her room, back towards the bed, feet facing out into room, w/c upright across from her, resident was in her sock feet. Assessed for injuries and none noted, resident able to move all extremities and stand and bear wt (weight) with assist without c/o pain or change of facial expression. resident denied any pain. Neuro checks started. Resident stated she tried to get up and slipped . K. Record review of Progress Note date 5/27/18 at 2:04 pm Nutritional Status Note Text: Pt (patient) observed lying on floor near, Near locked w/c. Pt appears to have tried to walk w/o (without) assistance. Oxygen in place. Pt assessed, No visible injury. Unable to roll d/t (due to) c/o excruciating pain. On call MD (medical doctor) called, Informed of change in position. New orders reading send to ED (emergency department) for eval (evaluation) and tx (treatment). Pt representative aware. L. Record review of Progress Notes for R #37 dated 6/20/18 at 3:21 pm revealed, .resident found sitting on her bottom on the floor in the family room, w/c upright behind her, shoes on feet. resident stated she was leaving, going home to see (name of spouse). assessed for injuries and none noted, resident able to move all extremities without c/o pain or change of facial expression. resident denied pain anywhere . M. Record review of Progress Notes for R #37 dated 08/04/18 at 12:01 pm revealed, . Resident fell on floor by front door; (name of physician) notified; sent to ER for c/o rt (right) hip and rt arm pain. N. Record review of facility Incident Report for R #37 dated 08/04/18 revealed, .CNA (certified nursing assistant) saw resident walking toward front door; her O2 (oxygen) tubing caught and she fell on to floor by front door. Resident c/o rt hip pain, rt arm pain and back .Stated she wanted out and door was locked; she got out of w/c and fell when O2 tubing caught .Assessed resident and got vital signs. Kept resident on floor while ER (emergency room ) and EMT (emergency medical technicians) notified and upon arrival of EMT's. (name of physician), (name of DON) and (name of daughter) were notified. O. Record review of Progress Notes for R #37 dated 8/8/18 at 10:30 am revealed, . Resident returned to facility at 10:30 am via ambulance, transported per stretcher. Transferred onto bed, pain evident with any movement. Sling on Rt. arm, 3 border dressings (soft, non-stick dressing with an adhesive border) intact to rt. hip. No drainage noted. Resident alert and oriented x (times) 2. Color pale/warm/dry. Phone message left for (name of physician) to return call to notify of residents return and med orders. P. Record review of Progress Notes for R #37 dated 8/9/18 at 2:23 am revealed, .Returned to this facility on 8/8/18 after hospital stay for fall resulting in fractures of right hip and right arm. She is resting quietly in bed at this time. Responds to staff during care and assessment but appears to be lethargic with minimal conversation and keeping eyes closed. Unable to follow any directions or participate in care. Right arm has severe discoloration from bruising and 2 plus [MEDICAL CONDITION] (the term used to describe [MEDICAL CONDITION] (swelling) when pressure applied to the skin of the swollen area is released and an indentation is left behind) in elbow area. Stabilized with sling. Left arm has 1-2 plus [MEDICAL CONDITION] also in elbow area. 3 dressings on right hip are intact clean and dry. Signs of pain--crying out and facial grimace when right leg is moved. 2 person assistance to change Attends undergarment and provide routine incontinence care. Oral fluids offered but refused to take water at this time . Q. Record review of Fall Care Plan for R #37 dated 07/10/18 revealed, Focus: The resident is at risk for falls R/T (related to) actual fall on . 1/16/18, 5/8/18, 6/20/2018 no injury, 08/04/18 - injury. Goal: Resident will be free of minor injury r/t falls through the review date. Interventions: Dated 02/25/18 - Remind (name of resident) to assist for assistance when transferring. Dated 02/25/18 - Remind (name of resident) to mobilize in w/c and not to try walking. Dated 01/13/17 - fall mats on both sides of the bed, and bed In low position for safety. Dated 05/01/17 - Ensure that Resident is wearing appropriate footwear slip resistant shoes, when mobilizing in w/c. Dated - 05/01/18 - Anti-roll backs (As the occupant begins to stand, the unit is automatically activated and a pair of brake arms grab the tires to prevent the chair from rolling back and away) to wheelchair. Dated 02/25/18 - Monitor resident for significant changes in mobility, sitting balance and lower extremity joint function. Dated 10/31/17 - Ensure/provide a safe environment. Encourage and educate the husband to ask for assistance from staff members when needing to transfer resident. Dated 01/16/18 - Review as indicated for significant changes in cognition, safety awareness and decision-making capacity. Dated 02/25/18 - Review new or progressive neurological impairments. R. Record review of the Fall Care plans for R #37 revealed, falls dated 04/19/18 and 05/27/18 revealed there is no evidence of these falls on the care plan. Falls dated 05/08/18, 06/20/18 and 08/04/18 there is no evidence of an up-date to the care plan with new interventions for these falls. S. On 09/12/18 at 2:30 pm during an interview, the current Interim Director of Nursing (DON #2) stated, What I have read, I was not working at this facility when this incident occurred, (name of resident) tried several times to exit the front of the facility, (name of resident) stood up, got caught up in the oxygen tubing, became unbalanced and fell , breaking her right femur and humerus bones. If (name of R #37) had been supervised, this fall probably would not have happened.

Based on record review and interview the facility failed to prevent a pressure ulcer (localized damage to the skin and/or underlying soft tissue resulting from intense and/or prolonged pressure) from becoming infected for one (R#19) of one (R #19) residents reviewed for pressure ulcer care. This failure likely resulted in a pressure ulcer on R #19's right buttock progressing from a Stage 2 (partial thickness loss of skin presenting as an intact or open blister) to an ulcer that became larger, blacker, painful, and with a foul odor. The findings are: A. Record review of the facility face sheet for R #19 indicated the resident was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. AD affects the parts of the brain that control thought, memory, and language, [MEDICAL CONDITIONS](gastro-[MEDICAL CONDITION] reflux disease), and major [MEDICAL CONDITION]. B. Record review of facility nursing progress notes for R #19 indicated the following: 1. 08/26/18 at 10 pm, Change in condition, Skin open area to rt (right) buttock. This started on 08/26/18 Area cleaned and dressing applied to area. 2. 08/29/18 at 12:37 pm, Resident had wound care done by wound care nurse this shift. This nurse did notice a stage 2 to right buttocks. Was cleaned and dressed will do wound care daily until healed. 3. 09/5/18 at 1:52 pm, Resident had wound care this shift no signs or symptoms (s/s) of infection noted. 4. 09/10/18 at 2:05 pm, This nurse called daughter due to resident appeared to not feel well. Wound care was done to right buttocks has a foul odor to it. Daughters were both notified and power of attorney (POA) was very upset. Stated she has been telling people all weekend about wound to buttocks smelling bad. Informed daughters may want to send resident out to ER (emergency room ). Wound to buttocks is necrotic (death of tissue in response to disease or injury) and has odor. C. Record review of the facility weekly wound data collection form dated 08/29/18 for R #19 indicated the following: 1. Pressure ulcer to right buttock measuring 1 centimeter (cm) long, 1.5 cm wide. 2. The wound was 50 percent [MEDICATION NAME] (thin layer of skin cells) tissue and 50 percentage granulation ( pink-red moist tissue that fills an open wound ) and 0 percent eschar (dead tissue that is black, and appear scab-like). D. Record review of the facility weekly wound data collection sheet dated 09/06/18 indicated the R #19, pressure ulcer to R #19's right buttock measured 2.5 cm length, 2.5 cm wide, and .1 cm deep and is 100 percent slough (non-viable yellow, tan, gray, green or brown tissue) and 0 percent eschar. E. Record review of the facility weekly wound data collection sheet dated 09/10/18 indicated the pressure ulcer to R #19's right buttock was 4 cm long and 4 cm wide, and was 100% eschar. F. On 09/10/18 at 2:15 pm during an interview with R#19's family member (FM) #1, the family stated (name of R #19) was very ill and he smelled. FM #1 ask the surveyors to go to R #19's bedroom. Upon entering the room, a strong, foul odor was present upon approaching the resident who was lying in his bed. FM #1 stated that the pressure sore had started out small and grew really fast and that she had been telling staff during the previous weekend (09/08/18 and 09/09/18) that her father (R #19) was sick and that a smell was coming from the sore. She stated nursing staff would give her no response. G. Record review of R #19's care plan dated 01/05/18 indicated no new approaches or strategies were implemented after R #19 developed the Stage 2 pressure ulcer to his right buttock on 08/26/18 or as it became worse. The care plan was not updated until 09/13/18, three days after the resident left the facility H. On 09/13/18 at 2:18 pm during an interview, the interim Director of Nursing (DON) #2 stated R #19's care plan was not reviewed or updated to reflect the development and worsening of the resident's pressure ulcer care on the right buttocks. I. On 09/17/18 at 1:33 PM during an interview with Licensed Practical Nurse (LPN) #1 she stated the pressure ulcer to R #19's right buttock had gotten worse from 09/06/18 until 09/10/18. She stated the wound had gotten bigger, was soft, and black. She stated it had an odor like an infection a foul odor you didn't even have to get close to. It was inflamed around the edges and was painful to the resident when the surrounding skin was touched. Before I went on my days off, I told the DON (name of DON #1) that the wound needed a new type of dressing. When I came back it was the same type as when I left. J. Further observations of R #19 were not available as the resident was sent to a higher level of care on 09/10/18 at 6:00 pm.

The following deficiency was cited as a result of a Complaint survey that was initiated on 03/17/17. An immediate jeopardy was identified on 04/12/17 and a plan of removal was accepted on 04/12/17. Based on record review and interview the facility failed to provide immediate assessment and treatment for one (R #1) of one (R#1) residents reviewed for neglect. The failure to assess and provide treatment after R #1 told staff he had inserted a pencil in his rectum and then began complaining of severe abdominal pain, likely resulted in R #1 sustaining a perforated (pierce and make a hole or holes in) bowel that required surgical intervention. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of J, identified at the facility on 04/12/17 at 1:00 pm. The interim facility administrator was notified at this time. The facility provided an acceptable Plan of removal on 04/12/17 at 9:00 pm. Based on the Plan of Removal, the interventions included: 1. Staff education on recognizing changes in a resident and improved communication between staff members, 2. Licensed nurses educated on completing the pain data collection tool, 3. Education on behavior monitoring, 4. Training for licensed nurses to use communication tool in the electronic medical record and 24 hour nursing report, 5. Education on proper reporting for abuse/neglect, to include the placement of binders at nursing locations in the facility, 6. Update of resident care plans as needed after review of assessments, behavior, pain, etc. 7. Training to occur for each staff member before working the next shift/day, etc. Based on the Plan of Removal and observation, the Immediate Jeopardy was lifted on 04/12/17 at 9:00 pm. This resulted in the scope and severity being reduced from a scope and severity of J to a scope and severity of G. Based on record review and interview the facility failed to seek prompt medical attention for (R #1) after he stated to facility staff that he had inserted a pencil into his rectum and was experiencing abdominal pain. This failure likely caused R #1's bowel to perforate requiring surgical repair. The findings are: A. Review of R #1's admission record indicated an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. The admission record indicates R #1 was discharged from the facility on 1/24/17. B. On 04/04/17 at 9:30 am during an interview, a family member (FM#1) of R #1 stated she was at the facility visiting R #1 on 01/18/17 when the resident told her I was constipated and I used a pencil in my rectum to relieve myself. FM #1 stated a certified nursing assistant (CNA) was changing the sheets on R #1's bed during this visit because there was blood on the sheets and the CNA also told FM #1 that the resident had inserted a pencil in his rectum. FM#1 stated she left the faciity on [DATE] assuming the situation was going to be handled by the facility. FM#1 stated she received a call from the facility on 01/24/17 and sure enough, there was a pencil in his rectum. He had a pencil in his rectum for a week before anyone would do anything about it. FM #1 stated R #1 was transported by ambulance to an out of state hospital for surgery. C. Review of the local acute care hospital admission record dated 01/24/17 indicates R #1 arrived to the Emergency Department via ambulance on 01/24/17 at 2:55 pm for evaluation of abdominal pain. Physician documentation indicates the following: 1. Patient appears to be in moderate painful distress and is mildly toxic appearing; 2. Body temperature of 101.2 degrees Fahrenheit; 3. The abdomen is distended, with tenderness and pain; 4. Computerized Tomography (CT ) Scan report reflects a perforation of the bowel with free air in the abdomen, foreign body thought to be a pencil in the right side of the abdomen extending from top to bottom of the abdomen. An abscess is associated with this. 5. Pain was treated with [MEDICATION NAME] (an opioid pain reliever for moderate to severe pain), consult with physician at accepting hospital for surgical evaluation and treatment. D. Review of the hospital CT scan report for R #1 dated 01/24/17 at 3:30 pm indicated: there is a foreign body lying over the right aspect of the abdomen that measure approximately 20 centimeters (cm) in length. The overall shape and density of this is most suspicious for a graphite filled pencil. Suspect that this has perforated the bowel. There is developing abscess seen along the right pericolic gutter (open area between the wall of the abdomen and colon) adjacent to this foreign body. E. Review of the hospital hematology (blood) report dated 01/24/17 indicated R #1 had an elevated white blood count, [DIAGNOSES REDACTED]s (predominant cells in pus), and was positive for the growth of staphylococcus warneri (bacteria). Review of the Emergency Department (ED) triage record indicates R #1 was begun on intravenous [MEDICATION NAME] (antibiotic for moderate to severe infections). F. Review of facility nursing progress notes for R #1 dated 01/24/17 indicated the following: 1. 9:30 am-resident has uncontrollable abdominal pain. States last bowel movement was this morning, 2. 9:50 am-resident sitting in wheelchair complaining of severe abdominal pain, states he is unable to lay down, 3. 11:00 am-resident lying in bed, complaining of abdominal pain, 4. 11:45 am-complaining of severe abdominal pain 5. 1:00 pm-resident laying on bed, agitated, cursing, wants to go to the hospital, says he will call 911 if facility doesn't. G. Review of the (name of local fire department) Emergency Medical Services Report dated 01/24/17 indicated the facility did not call for transport of R #1 to the hospital until 2:15 pm. The reason for transport is indicated as: complaint of abdominal pain all day, since about 9:45 am. H. Review of the facility communication and progress note form completed by Registered Nurse (RN) #1 dated 01/24/17 at 2:56 pm indicated the following: 1. Abdominal distention, pain, and tenderness 2. repetitive calling out and requests for attention, constant complaining or whining 3. Abrupt onset of severe pain or distention, 4. Pain is acute and resident states the pain is severe I. On 04/06/17 at 11:30 am during an interview, the interim Director of Nursing (DON) stated she had been employed at the facility since mid February 2017 and R #1's bowel perforation had occurred before her arrival. She stated that on 02/24/17she began trying to investigate the incident/injury involving R #3 from 01/18/17 until transport to the hospital on [DATE]. The interim DON stated several of the staff to include the previous DON, administrator, staff development, etc were no longer working at the facility by the time she was able to begin the investigation. She stated an investigation of the incident did not occur on or within 5 days of 01/18/17. The interim DON stated there was no documentation in R #1's medical record for the days immediately leading up to 01/24/17. She stated what she was able to reconstruct was that neglect had occurred and that R #1 had inserted a pencil into his rectum and had told staff that he had done this, at least 3-4 days prior to 01/24/17. When ask if the facility investigation had been completed, summarized, and appropriate corrective action taken to prevent incidents/neglect from happening again, the interim DON stated, No. J. Review of statements from facility staff regarding the injury/incident for R #1 dated 02/24/17 indicated the following: 1. R #1 stated to CNA #3 on either 01/20/17 or 01/21/17 that his stomach was hurting. CNA #3's statement indicates she forgot to tell anyone. 2. R #1 stated to CNA #1 on 01/21/17, guess what I did, I shoved a pencil up my butt. CNA #1 states she reported this to Registered Nurse (RN) #1 and RN #2 3. CNA #4 received report from CNA #1 and CNA #4 on 01/23/17 that R #1 had stuck a pencil up his butt. Further review of this statement indicates CNA #4 reported this to RN #2. K. Review of the Hosptial Surgical Assessment/Plan for R #1 dated 01/25/17 at 1:15 am indicated the following: patient needs exploration to remove forgein body from his right lower abdomen, this did not happen acutely and more than likely is a week old.

Based on observation, record review, and interview, the facility failed to ensure 2 (#1, 2) of 4 (1, 2, 3, 4) residents were free from verbal abuse and free from sexual abuse. This was evidenced by: 1. Resident #1, who was in a coma, was verbally abused with derogatory language and had genitals intentionally exposed to a family member. 2. Resident #2 was sexually and verbally abused. The findings are: A. Observation of Resident #1 on 11/09/11 at 9:00 am, revealed the resident was in a coma and unable to respond to commands. 1. Record review of Resident #1's History and physical dated 09/06/11 revealed, "...involved in motor vehicle accident in 2009 leaving ... with severe [MEDICAL CONDITION], ...noncommunicative..." 2. Review of the Comprehensive Care Plan dated 08/17/11 revealed, "Self care deficit related to vegetative state manifested by needs total assistance with all ADLs (activities of daily living)." B. Record review of witness statements taken by the facility on 10/19/11 and 10/20/11 revealed a statement from FM #2 dated 10/19/11, "(FM #2) stated that she was cleaning (Resident #1)'s room...when (CNA #1) and another CNA either (CNA #4) or (CNA #5) wheeled (Resident #1) back into the room after a shower. (FM #2) turned her head, cause (FM #2) does not like to see (Resident #1) like that. FM #2 stated that (CNA #1) told (FM #2) they were done, then when (FM #2) turned her head back, stated that (CNA #1) moved the diaper, showing (Resident #1)'s privates to (FM #2). (FM #2) said that (CNA #1) stated to (FM #2), 'Does it make you feel uncomfortable to see (Resident #1)'s 'junk'? (FM #2) stated that she heard (CNA #1) say 'Wake up nigger' to (Resident #1). (FM #2) stated she would protest to (CNA #1) and (CNA #1) would tell (FM #2) that maybe if we call him 'nigger' it will wake him up." C. On 11/09/11 at 11:50 am, an interview was conducted with FM #2. When FM #2 was asked about Resident #1's genitals being exposed to FM #2, FM #2 stated, "I worked in (Resident #1)'s room as the housekeeper and was cleaning the room, CNA #4 and CNA #5 had taken (Resident #1) to the shower and brought (Resident #1) back to the room. They were positioning (Resident #1) with the lift, (CNA #1) walked in the room after they had brought (Resident #1) back. FM #2 stated that she was at the foot of the bed. She stated that the CNAs' were bringing (Resident #1) down with the lift and the resident had a incontinent pad covering the genitals which came loose. FM #2 stated, "I saw his privates, ... turned away, and (Name of CNA #1) saw that I was embarrassed. FM #2 stated that when she looked back, (CNA #1) pulled his diaper back and exposed his genitals to FM #2 and said, "Does it make you uncomfortable to see your (Resident #1's relation) 'junk'. FM #2 stated, "I told (CNA #1), 'That's not right.' I was embarrassed." FM #2 stated that Resident #1 was very modest and FM #2 did not even see (Resident #1) without a shirt but once. FM #2 was asked if this was an intentional act by (CNA #1) to flash (Resident #1)'s privates, FM #2 stated, "Yes. It really upset me." FM #2 also stated that (CNA #1) would say to (Resident #1), "What's up 'nigger'." FM #2 stated that she told CNA #1 that (Resident #1) can hear you. FM #2 stated that CNA #1 continued saying it several times." FM #2 also stated that CNA #1 told Resident #1 that his grandchildren were black. FM #2 stated that this upset her because the resident had a car accident and was in a coma prior to the baby being born and that Resident #1 never got to see the grandchild. FM #2 stated that they were not prejudiced, but that it was wrong for CNA #1 to say that. FM #2 stated that she told CNA #1 that it was not right for her to do this. FM #2 was observed crying during the interview. D. Record review of the Facility's policy's and procedures "Procedure Abuse and Neglect' issued May 2003 and revised 01/11 revealed, "Procedure 1. If a staff member receives an allegation of abuse, neglect or misappropriation of resident property or witnesses suspected abuse, neglect...the staff member will immediately report this to a supervisor and ... 2. a. If this is an allegation of staff to resident abuse, the staff person will be removed from providing direct care to all residents. Additionally, the staff person will be placed on suspension pending the results of the internal investigation..5. Notification Procedures: a. Notify the center administrator immediately of any incidents of resident abuse..Notify the designated agencies in accordance with state law, including the state survey and certification agency. You may need to notify more than one state agency in order to fulfill federal and state regulations..." 1. Record review revealed a pamphlet located in the lobby of the facility dated 3/07 and titled, "We Don't Tolerate Abuse" In the Abuse Definitions on the back side of the pamphlet was written, "Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability." E. On 11/09/11 at 5:30 pm, FM #2 was interviewed. When given the (Corporate Organization) pamphlet "We Don't Tolerate Abuse", FM #2 was asked if Resident #1 had been subjected to verbal abuse, FM #2 stated, "After reading this, I understand better what it is. The part about oral language and derogatory terms to residents or their families, or within their hearing distance is really what happened and so that would be verbal abuse." 1. On 11/10/11 at 1:35 pm, CNA #4 was interviewed. When asked if she heard CNA #1 use derogatory or abusive language to residents, CNA # stated, "No but I did hear her use the slang term "niggah" but she did not call (Resident #1) that. (CNA #1) did ask (FM #2) if her (name of relation) was told she was going to marry a 'niggah' if he would wake up (from the coma). (CNA #1) used that just like a quirky teenager would." 2. On 11/10/11 at 1:55 pm, CNA # 5 was interviewed. When asked if she was present when the exposure incident occurred with Resident #1 to FM #2. She stated that she was in the room at that time and CNA #1 asked FM #2 if it embarrassed her to see her (name of relation's) privates. She stated that CNA #1 also asked FM #2 in front of Resident #1 that if CNA #1 told Resident #1 that FM #2 was married to a black man, would he wake up because Resident #1 did not like blacks. CNA # 5 was asked if this was verbal abuse to the resident, CNA #5 stated, "Yes, it was abuse for Resident #1 to have to hear that. I did not report it, but I think it would be abuse, and I would report it because I think he can hear. " F. Record review revealed a State Agency (SA) intake dated 10/24/11 alleged that CNA #1 was verbally abusive to Resident #2 by pushing him down a hallway and loudly stating, "That is the last time I'm toileting him-he can[***]on himself." Visitor #1 (V#1) alleged that this happened in front of her and Licensed Practical Nurse (LPN) #1. 1. Review of the facility's witness statements dated 10/19/11 at 1:45 pm obtained from the Business Office Manager (BOM) revealed, "I stated that this was an official investigation of allegations of inappropriate behavior against C.N.A #1. I stated that V #1 made a statement of an incident where C.N.A #1 was pushing Resident #2 down the hall after toileting him saying in a loud voice that she was not going to toilet Resident #2 again. ...LPN #1 said, 'I can't remember. I slept since then' ...Q: (Question) Has any inappropriate behavior been reported to you? LPN #1 stated no. LPN #1 stated that V #1 had come to her and said--I want to apologize to you if you have any trouble. I went to Administrator about CNA#1 and Resident #2 the other day. LPN #1 stated that she told V#1 that she did not have a memory of this." 2. Review of the facility's witness statements dated 10/25/11 obtained from the BOM revealed, "Present: CNA #3, 10-25-11 at 10:35 am ...I stated that I have a question about the incident you told us about in your interview, in the bathroom with Resident #2 when you were toileting him. Q: Do you feel like CNA #1 sexually abused Resident #2? CNA #3 stated, Physically, no. Verbally, it was between us. Q: When you say us, who do you mean? You and CNA #1? CNA #3 stated, yes me and CNA #1. Q: Was Resident #2 present? CNA #3 stated yes." 3. On 11/04/11 at 1:15 pm, Visitor #1 (V#1) was interviewed. V#1 was asked if V #1 was witness to anything inappropriate being said to Resident #2. V #1 stated that, unknown date, CNA #1 came out of a bathroom pushing Resident #2 in the wheelchair and stated in a loud voice, "That's the last time I will toilet him. He can[***]himself as far as I'm concerned." V#1 stated that Licensed Practical Nurse (LPN) #1 was witness to the verbal abuse. 4. LPN #1 was on medical leave and was not available for interview. 5. On 11/09/11 at 3:10 pm, CNA #3 was interviewed. CNA #3 was asked if she was witness to any inappropriate behaviors by CNA #1 during resident care. CNA #3 stated, "When (CNA #1) and I were assisting (Resident #2) after he went to the toilet, CNA #1 would pull on his penis to clean it, which is not the right thing to do. While (CNA #1) cleaned (Resident #2), (CNA #1) would say things like, 'You sure do have a big penis, I bet you really did made your wife happy,' and things like that. I told her not to say things like that in front of him." When given the definition of verbal abuse as defined on the pamphlet by the (Corporate Organization), "We Don't Tolerate Abuse, "Abuse Definitions...," CNA #3 stated, "By that definition, then that was definitely verbal abuse." G. On 11/09/11 at 10:05 am, an interview was conducted with the Administrator (ADM). When asked when he was notified of the allegation, he stated, "I was notified on 10/18/11. When I was notified I assigned the Business Office Manager (BOM) to conduct interviews related to this allegation. I assigned the BOM because the Social Worker (SW) was on vacation." When asked if an internal Incident Report was generated, he stated, "No, it was not done." When asked if the facility's policy was to begin an internal Incident Report immediately, he stated, "I know, but it wasn't done. When asked if a SA Incident was generated when he was notified of the allegation or when the investigation began, he stated, "No, we didn't at the time. We felt reporting to APS was enough." When the key elements of the SA Incident Management System Guide were reviewed with the ADM that stated, "...Abuse, neglect, misappropriation of property (i.e., exploitation), and injuries of unknown origin shall be reported to (The State Agency) within 24 hours", the ADM stated, "If the Social Worker had been here, it would have been done." When asked if he was aware that all facility staff should be trained in Abuse reporting procedures, he stated, "Yes, I am but, it wasn't done." H. On 11/10/11 at 3:00 pm, the Director of Nurses (DON) was interviewed. The DON stated that on 10/14/11 she was leaving the building, was on her way home, when FM #1 came to her. She stated that FM#1 was screaming, alleging that Resident #1 had been inappropriately touched by CNA #1 along with other complaints. The DON stated that she thought FM #1 was "wishy washy and venting." 1. When asked if she thought to protect Resident #1, the DON stated that she thought it was something she needed to look into. 2. When asked what protections were done for Resident #1 such as suspending CNA #1, the DON stated that she did not suspend CNA #1 for that day because she was already gone for the day and CNA #1 was off for the weekend. The DON stated, "On Monday morning, (CNA #1) came into work at 6:30 am, and I came in about 6:45 am. When I asked her if she had any inappropriate contact with (Resident #1) or any other resident or had given (Resident #1) a cold shower to get a reaction from him, (CNA #1) said 'why do you ask, who said I did that.' (CNA #1) denied everything." The DON stated that CNA #1 was upset and got up and left the building. 3. When asked if the DON had suspended CNA #1, the DON stated, "No, she was upset and left." The DON stated that CNA #1 was off work on 10/18/11 and came back to work on 10/19/11 at 6:30 am. When asked what happened on the morning of 10/19/11, the DON stated that she (the DON) was in Care Plan meetings and she was called out of the meetings when the Ombudsman came in to talk to the Administrator and her (about the allegations of abuse.) When they completed talking to the Ombudsman, the DON called CNA #1 into her office at 11:15 am, and did suspend her pending an investigation. 4. When the DON was asked if she had ever heard CNA #1 call anyone "Nigger" or that CNA #1 had been inappropriate to a resident or to staff, the DON stated she had never heard a staff complaint related to any sexual touching. 5. The DON stated that she did not think CNA #1 was guilty of any resident abuse but she did have inappropriate behavior with some staff. 6. When the DON was asked what the facility policy was when there is an allegation of abuse, the DON stated, "If anyone is accused, they should be suspended immediately. I did not do that." 7. When asked if CNA #1 should have been sent home immediately on 10/17/11, the DON stated, "Yes, I should have sent her home on suspension then, but I did not, she just left because she was upset." 8. The DON was asked if (CNA #1) worked with the residents on 10/19/11 from 6:30 am to 11:15 am, the DON stated, "Yes, she did."

Based on record review, and interview the facility failed to report to the State Agency an allegation of verbal and physical abuse for 2 (Resident #1, 2) of 4 sampled residents (#1, 2, 3, 4) within the time frame required. The facility also failed to prevent further potential abuse while the investigation was in progress by not suspending the alleged perpetrator and allowing the alleged perpetrator to work with residents. These failures were evidenced by: 1. A sexual abuse allegation was made on 10/14/11 and the facility did not file a notice with the State Agency until 10/24/11. 2. The alleged perpetrator was not suspended until 10/19/11 and worked with residents from 6:30 am until 11:15 am on 10/19/11. This is a repeat deficiency from 04/01/11. The findings are: A. Record review of the Facility's policy's and procedures "Procedure Abuse and Neglect' issued May 2003 and revised 01/11 revealed, "Procedure 1. If a staff member receives an allegation of abuse, neglect or misappropriation of resident property or witnesses suspected abuse, neglect...the staff member will immediately report this to a supervisor and ... 2.a. If this is an allegation of staff to resident abuse, the staff person will be removed from providing direct care to all residents. Additionally, the staff person will be placed on suspension pending the results of the internal investigation..5. Notification Procedures: a. Notify the center administrator immediately of any incidents of resident abuse..Notify the designated agencies in accordance with state law, including the state survey and certification agency. You may need to notify more than one state agency in order to fulfill federal and state regulations..." 1. Record review revealed a pamphlet located in the lobby of the facility dated 3/07 and titled, "We Don't Tolerate Abuse" In the Abuse Definitions on the back side of the pamphlet was written, "Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability." B. Record review of the facility's 10/24/11 State Agency (SA) incident report revealed, "Date Completed 10/24/11, Time Completed 5:00 pm." The Incident Report was signed by the Director of Nurses (DON) as the person completing the report. The Incident Report was stamped by the SA Intake personnel on 10/24/11. The section titled, "After the Incident" revealed, "On 10-14-11, I was approached by (Name of FM #1)...at approximately 5 to 5:30 pm.... (Name of FM #1) went on to tell me that two of the other nurse's aides on the hall told (FM #1) that (CNA #1) like to inappropriately touch (Resident #1) when is changing (Resident #1) and also likes to give (Resident #1) showers with cold water in an attempt to 'excite' his penis. (FM #1) also told me that (FM #2)...was in the room when (CNA #1) had inappropriately touched (Resident #1)." 1. Record review of facility statements taken on 10/19/11 and 10/20/11 during the facility internal investigation revealed a written statement from the DON dated 10/14/11. This statement revealed, "At approximately 5 to 5:30 pm, on Friday (10/14/11) I was leaving work when I was approached by (FM #1)...began to inform me that two other Nurses Aides on the hall told (FM #1) that (CNA #1) likes to inappropriately touch (Resident #1) when she is changing (the Resident) and also likes to give (the Resident) showers in an attempt to 'excite' (Resident #1)...We discussed other things, not necessarily in relation to these allegations." a. The statement continued with a date of 10/19/11 that revealed, "At approximately 11:00 am, I received a visit from Ombudsman (Name), who received reports from (FM #1) with allegations that (Resident #1) had been inappropriately touched by (CNA #1), along with multiple other complaints. 11:15 (am)...I also called APS to report sexual inappropriate allegations towards (CNA #1)..." b. The written statement from the DON continued with a date of 10/24/11 that revealed, "I received a letter from APS...stating the case had been referred to (Local Police Department) and Licensing and Certification DOH (Department of Health)...(Name of APS Investigator) told me the case had been screened out to the (local police department) and licensing and certification. I then called DOH... and spoke to (Name of Intake Person)...(Intake Person) informed me that I should have reported to them on that day..." 2. Record review of witness statements taken by the facility on 10/19/11 and 10/20/11 revealed a statement from FM #2 dated 10/19/11, "(FM #2) stated that she was cleaning (Resident #1)'s room...when (CNA #1) and another CNA either (CNA #4) or (CNA #5) wheeled (Resident #1) back into the room after a shower. (FM #2) turned her head, cause (FM #2) does not like to see (Resident #1) like that. FM #2 stated that (CNA #1) told (FM #2) they were done, then when (FM #2) turned her head back, stated that (CNA #1) moved the diaper, showing (Resident #1)'s privates to (FM #2). (FM #2) said that (CNA #1) stated to (FM #2), 'Does it make you feel uncomfortable to see (Resident #1)'s 'junk'? (FM #2) stated that she heard (CNA #1) say 'Wake up nigger' to (Resident #1). (FM #2) stated she would protest to (CNA #1) and (CNA #1) would tell (FM #2) that maybe if we call him 'nigger' it will wake him up." C. On 11/09/11 at 11:50 am, an interview was conducted with FM #2. When FM #2 was asked about Resident #1's genitals being exposed to FM #2, FM #2 stated, "I worked in (Resident #1)'s room as the housekeeper and was cleaning the room, CNA #4 and CNA #5 had taken (Resident #1) to the shower and brought (Resident #1) back to the room. They were positioning (Resident #1) with the lift, (CNA #1) walked in the room after they had brought (Resident #1) back. FM #2 stated that she was at the foot of the bed. She stated that the CNAs' were bringing (Resident #1) down with the lift and the resident had a incontinent pad covering the genitals which came loose. FM #2 stated, "I saw his privates, ... turned away, and (Name of CNA #1) saw that I was embarrassed. FM #2 stated that when she looked back, (CNA #1) pulled his diaper back and exposed his genitals to FM #2 and said, "Does it make you uncomfortable to see your (Resident #1's relation) 'junk'. FM #2 stated, "I told (CNA #1), 'That's not right.' I was embarrassed." FM #2 stated that Resident #1 was very modest and FM #2 did not even see (Resident #1) without a shirt but once. FM #2 was asked if this was an intentional act by (CNA #1) to flash (Resident #1)'s privates, FM #2 stated, "Yes. It really upset me." FM #2 also stated that (CNA #1) would say to (Resident #1), "What's up 'nigger'." FM #2 stated that she told CNA #1 that (Resident #1) can hear you. FM #2 stated that CNA #1 continued saying it several times." FM #2 also stated that CNA #1 told Resident #1 that his grandchildren were black. FM #2 stated that this upset her because the resident had a car accident and was in a coma prior to the baby being born and that Resident #1 never got to see the grandchild. FM #2 stated that they were not prejudiced, but that it was wrong for CNA #1 to say that. FM #2 stated that she told CNA #1 that it was not right for her to do this. FM #2 was observed crying during the interview. 1. On 11/09/11 at 5:30 pm, FM #2 was interviewed. When given the (Corporate Organization) pamphlet "We Don't Tolerate Abuse", FM #2 was asked if Resident #1 had been subjected to verbal abuse, FM #2 stated, "After reading this, I understand better what it is. The part about oral language and derogatory terms to residents or their families, or within their hearing distance is really what happened and so that would be verbal abuse." 2. On 11/10/11 at 1:35 pm, CNA #4 was interviewed. When asked if she heard CNA #1 use derogatory or abusive language to residents, CNA # stated, "No but I did hear her use the slang term "niggah" but she did not call (Resident #1) that. (CNA #1) did ask (FM #2) if her (name of relation) was told she was going to marry a 'niggah' if he would wake up (from the coma). (CNA #1) used that just like a quirky teenager would." 3. On 11/10/11 at 1:55 pm, CNA # 5 was interviewed. When asked if she was present when the exposure incident occurred with Resident #1 to FM #2. She stated that she was in the room at that time and CNA #1 asked FM #2 if it embarrassed her to see her (name of relation's) privates. She stated that CNA #1 also asked FM #2 in front of Resident #1 that if CNA #1 told Resident #1 that FM #2 was married to a black man, would he wake up because Resident #1 did not like blacks. CNA # 5 was asked if this was verbal abuse to the resident, CNA #5 stated, "Yes, it was abuse for Resident #1 to have to hear that. I did not report it, but I think it would be abuse, and I would report it because I think he can hear. " D. Record review revealed a State Agency (SA) intake dated 10/24/11 alleged that CNA #1 was verbally abusive to Resident #2 by pushing him down a hallway and loudly stating, "That is the last time I'm toileting him-he can[***]on himself." Visitor #1 (V#1) alleged that this happened in front of her and Licensed Practical Nurse (LPN) #1. 1. Review of the facility's witness statements dated 10/19/11 at 1:45 pm obtained from the Business Office Manager (BOM) revealed, "I stated that this was an official investigation of allegations of inappropriate behavior against C.N.A #1. I stated that V #1 made a statement of an incident where C.N.A #1 was pushing Resident #2 down the hall after toileting him saying in a loud voice that she was not going to toilet Resident #2 again. ...LPN #1 said, 'I can't remember. I slept since then' ...Q: (Question) Has any inappropriate behavior been reported to you? LPN #1 stated no. LPN #1 stated that V #1 had come to her and said--I want to apologize to you if you have any trouble. I went to Administrator about CNA#1 and Resident #2 the other day. LPN #1 stated that she told V#1 that she did not have a memory of this." 2. Review of the facility's witness statements dated 10/25/11 obtained from the BOM revealed, "Present: CNA #3, 0-25-11 at 10:35 am ...I stated that I have a question about the incident you told us about in your interview, in the bathroom with Resident #2 when you were toileting him. Q: Do you feel like CNA #1 sexually abused Resident #2? CNA #3 stated, Physically, no. Verbally, it was between us. Q: When you say us, who do you mean? You and CNA #1? CNA #3 stated, yes me and CNA #1. Q: Was Resident #2 present? CNA #3 stated yes." E. On 11/04/11 at 1:15 pm, V#1 was interviewed. V#1 was asked if V #1 was witness to anything inappropriate being said to Resident #2. V #1 stated that, unknown date, CNA #1 came out of a bathroom pushing Resident #2 in the wheelchair and stated in a loud voice, "That's the last time I will toilet him. He can[***]himself as far as I'm concerned." V#1 stated that LPN #1 was witness to the verbal abuse. 1. LPN #1 was on medical leave and was not available for interview. 2. On 11/09/11 at 3:10 pm, CNA #3 was interviewed. CNA #3 was asked if she was witness to any inappropriate behaviors by CNA #1 during resident care. CNA #3 stated, "When (CNA #1) and I were assisting (Resident #2) after he went to the toilet, CNA #1 would pull on his penis to clean it, which is not the right thing to do. While (CNA #1) cleaned (Resident #2), (CNA #1) would say things like, 'You sure do have a big penis, I bet you really did made your wife happy,' and things like that. I told her not to say things like that in front of him." When given the definition of verbal abuse as defined on the pamphlet by the (Corporate Organization), "We Don't Tolerate Abuse, "Abuse Definitions...," CNA #3 stated, "By that definition, then that was definitely verbal abuse." F. On 11/09/11 at 10:05 am, an interview was conducted with the Administrator (ADM). When asked when he was notified of the allegation, he stated, "I was notified on 10/18/11. When I was notified I assigned the Business Office Manager (BOM) to conduct interviews related to this allegation. I assigned the BOM because the Social Worker (SW) was on vacation." When asked if an internal Incident Report was generated, he stated, "No, it was not done." When asked if the facility's policy was to begin an internal Incident Report immediately, he stated, "I know, but it wasn't done. When asked if a SA Incident was generated when he was notified of the allegation or when the investigation began, he stated, "No, we didn't at the time. We felt reporting to APS was enough." When the key elements of the SA Incident Management System Guide were reviewed with the ADM that stated, "...Abuse, neglect, misappropriation of property (i.e., exploitation), and injuries of unknown origin shall be reported to (The State Agency) within 24 hours", the ADM stated, "If the Social Worker had been here, it would have been done." When asked if he was aware that all facility staff should be trained in Abuse reporting procedures, he stated, "Yes, I am but, it wasn't done." G. On 11/10/11 at 3:00 pm, the Director of Nurses (DON) was interviewed. The DON stated that on 10/14/11 she was leaving the building, was on her way home, when FM #1 came to her. She stated that FM#1 was screaming, alleging that Resident #1 had been inappropriately touched by CNA #1 along with other complaints. The DON stated that she thought FM #1 was "wishy washy and venting." 1. When asked if she thought to protect Resident #1, the DON stated that she thought it was something she needed to look into. 2. When asked what protections were done for Resident #1 such as suspending CNA #1, the DON stated that she did not suspend CNA #1 for that day because she was already gone for the day and CNA #1 was off for the weekend. The DON stated, "On Monday morning, (CNA #1) came into work at 6:30 am, and I came in about 6:45 am. When I asked her if she had any inappropriate contact with (Resident #1) or any other resident or had given (Resident #1) a cold shower to get a reaction from him, (CNA #1) said 'why do you ask, who said I did that.' (CNA #1) denied everything." The DON stated that CNA #1 was upset and got up and left the building. 3. When asked if the DON had suspended CNA #1, the DON stated, "No, she was upset and left." The DON stated that CNA #1 was off work on 10/18/11 and came back to work on 10/19/11 at 6:30 am. When asked what happened on the morning of 10/19/11, the DON stated that she (the DON) was in Care Plan meetings and she was called out of the meetings when the Ombudsman came in to talk to the Administrator and her (about the allegations of abuse.) When they completed talking to the Ombudsman, the DON called CNA #1 into her office at 11:15 am, and did suspend her pending an investigation. 4. When the DON was asked if she had ever heard CNA #1 call anyone "Nigger" or that CNA #1 had been inappropriate to a resident or to staff, the DON stated she had never heard a staff complaint related to any sexual touching. 5. The DON stated that she did not think CNA #1 was guilty of any resident abuse but she did have inappropriate behavior with some staff. 6. When the DON was asked what the facility policy was when there is an allegation of abuse, the DON stated, "If anyone is accused, they should be suspended immediately. I did not do that." 7. When asked if CNA #1 should have been sent home immediately on 10/17/11, the DON stated, "Yes, I should have sent her home on suspension then, but I did not, she just left because she was upset." 8. The DON was asked if (CNA #1) worked with the residents on 10/19/11 from 6:30 am to 11:15 am, the DON stated, "Yes, she did."

Based on record review and interview the facility failed to follow their policies on abuse reporting and protection for 2 (Resident #1, 2) of 4 sampled residents (#1, 2, 3, 4). The facility also failed to follow their policies to prevent further potential abuse while the investigation was in progress by not suspending the alleged perpetrator and allowing the alleged perpetrator to work with residents. These failures were evidenced by: 1. A sexual abuse allegation was made on 10/14/11 and the facility did not file a notice with the State Agency until 10/24/11. 2. The Alleged perpetrator was not suspended until 10/19/11 and worked with residents from 6:30 am until 11:15 am on 10/19/11. 3. Staff members did not report the abuse to protect residents. This is a repeat deficiency from 04/01/11. The findings are: A. Record review of the Facility's policy's and procedures "Procedure Abuse and Neglect' issued May 2003 and revised 01/11 revealed, "Procedure 1. If a staff member receives an allegation of abuse, neglect or misappropriation of resident property or witnesses suspected abuse, neglect...the staff member will immediately report this to a supervisor and ... 2. a. If this is an allegation of staff to resident abuse, the staff person will be removed from providing direct care to all residents. Additionally, the staff person will be placed on suspension pending the results of the internal investigation..5. Notification Procedures: a. Notify the center administrator immediately of any incidents of resident abuse..Notify the designated agencies in accordance with state law, including the state survey and certification agency. You may need to notify more than one state agency in order to fulfill federal and state regulations..." 1. Record review revealed a pamphlet located in the lobby of the facility dated 3/07 and titled, "We Don't Tolerate Abuse" In the Abuse Definitions on the back side of the pamphlet was written, "Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability." B. Record review of the facility's 10/24/11 State Agency (SA) incident report revealed, "Date Completed 10/24/11, Time Completed 5:00 pm." The Incident Report was signed by the Director of Nurses (DON) as the person completing the report. The Incident Report was stamped by the SA Intake personnel on 10/24/11. The section titled, "After the Incident" revealed, "On 10-14-11, I was approached by (Name of FM #1)...at approximately 5 to 5:30 pm.... (Name of FM #1) went on to tell me that two of the other nurse's aides on the hall told (FM #1) that (CNA #1) like to inappropriately touch (Resident #1) when is changing (Resident #1) and also likes to give (Resident #1) showers with cold water in an attempt to 'excite' his penis. (FM #1) also told me that (FM #2)...was in the room when (CNA #1) had inappropriately touched (Resident #1)." 1. Record review of facility statements taken on 10/19/11 and 10/20/11 during the facility internal investigation revealed a written statement from the DON dated 10/14/11. This statement revealed, "At approximately 5 to 5:30 pm, on Friday (10/14/11) I was leaving work when I was approached by (FM #1)...began to inform me that two other Nurses Aides on the hall told (FM #1) that (CNA #1) likes to inappropriately touch (Resident #1) when she is changing (the Resident) and also likes to give (the Resident) showers in an attempt to 'excite' (Resident #1)...We discussed other things, not necessarily in relation to these allegations." a. The statement continued with a date of 10/19/11 that revealed, "At approximately 11:00 am, I received a visit from Ombudsman (Name), who received reports from (FM #1) with allegations that (Resident #1) had been inappropriately touched by (CNA #1), along with multiple other complaints. 11:15 (am)...I also called APS to report sexual inappropriate allegations towards (CNA #1)..." b. The written statement from the DON continued with a date of 10/24/11 that revealed, "I received a letter from APS...stating the case had been referred to (Local Police Department) and Licensing and Certification DOH (Department of Health)...(Name of APS Investigator) told me the case had been screened out to the (local police department) and licensing and certification. I then called DOH... and spoke to (Name of Intake Person)...(Intake Person) informed me that I should have reported to them on that day..." 2. Record review of witness statements taken by the facility on 10/19/11 and 10/20/11 revealed a statement from FM #2 dated 10/19/11, "(FM #2) stated that she was cleaning (Resident #1)'s room...when (CNA #1) and another CNA either (CNA #4) or (CNA #5) wheeled (Resident #1) back into the room after a shower. (FM #2) turned her head, cause (FM #2) does not like to see (Resident #1) like that. FM #2 stated that (CNA #1) told (FM #2) they were done, then when (FM #2) turned her head back, stated that (CNA #1) moved the diaper, showing (Resident #1)'s privates to (FM #2). (FM #2) said that (CNA #1) stated to (FM #2), 'Does it make you feel uncomfortable to see (Resident #1)'s 'junk'? (FM #2) stated that she heard (CNA #1) say 'Wake up nigger' to (Resident #1). (FM #2) stated she would protest to (CNA #1) and (CNA #1) would tell (FM #2) that maybe if we call him 'nigger' it will wake him up." C. On 11/09/11 at 11:50 am, an interview was conducted with FM #2. When FM #2 was asked about Resident #1's genitals being exposed to FM #2, FM #2 stated, "I worked in (Resident #1)'s room as the housekeeper and was cleaning the room, CNA #4 and CNA #5 had taken (Resident #1) to the shower and brought (Resident #1) back to the room. They were positioning (Resident #1) with the lift, (CNA #1) walked in the room after they had brought (Resident #1) back. FM #2 stated that she was at the foot of the bed. She stated that the CNAs' were bringing (Resident #1) down with the lift and the resident had a incontinent pad covering the genitals which came loose. FM #2 stated, "I saw his privates, ... turned away, and (Name of CNA #1) saw that I was embarrassed. FM #2 stated that when she looked back, (CNA #1) pulled his diaper back and exposed his genitals to FM #2 and said, "Does it make you uncomfortable to see your (Resident #1's relation) 'junk'. FM #2 stated, "I told (CNA #1), 'That's not right.' I was embarrassed." FM #2 stated that Resident #1 was very modest and FM #2 did not even see (Resident #1) without a shirt but once. FM #2 was asked if this was an intentional act by (CNA #1) to flash (Resident #1)'s privates, FM #2 stated, "Yes. It really upset me." FM #2 also stated that (CNA #1) would say to (Resident #1), "What's up 'nigger'." FM #2 stated that she told CNA #1 that (Resident #1) can hear you. FM #2 stated that CNA #1 continued saying it several times." FM #2 also stated that CNA #1 told Resident #1 that his grandchildren were black. FM #2 stated that this upset her because the resident had a car accident and was in a coma prior to the baby being born and that Resident #1 never got to see the grandchild. FM #2 stated that they were not prejudiced, but that it was wrong for CNA #1 to say that. FM #2 stated that she told CNA #1 that it was not right for her to do this. FM #2 was observed crying during the interview. 1. On 11/09/11 at 5:30 pm, FM #2 was interviewed. When given the (Corporate Organization) pamphlet "We Don't Tolerate Abuse", FM #2 was asked if Resident #1 had been subjected to verbal abuse, FM #2 stated, "After reading this, I understand better what it is. The part about oral language and derogatory terms to residents or their families, or within their hearing distance is really what happened and so that would be verbal abuse." 2. On 11/10/11 at 1:35 pm, CNA #4 was interviewed. When asked if she heard CNA #1 use derogatory or abusive language to residents, CNA # stated, "No but I did hear her use the slang term "niggah" but she did not call (Resident #1) that. (CNA #1) did ask (FM #2) if her (name of relation) was told she was going to marry a 'niggah' if he would wake up (from the coma). (CNA #1) used that just like a quirky teenager would." 3. On 11/10/11 at 1:55 pm, CNA # 5 was interviewed. When asked if she was present when the exposure incident occurred with Resident #1 to FM #2. She stated that she was in the room at that time and CNA #1 asked FM #2 if it embarrassed her to see her (name of relation's) privates. She stated that CNA #1 also asked FM #2 in front of Resident #1 that if CNA #1 told Resident #1 that FM #2 was married to a black man, would he wake up because Resident #1 did not like blacks. CNA # 5 was asked if this was verbal abuse to the resident, CNA #5 stated, "Yes, it was abuse for Resident #1 to have to hear that. I did not report it, but I think it would be abuse, and I would report it because I think he can hear. " D. Record review revealed a State Agency (SA) intake dated 10/24/11 alleged that CNA #1 was verbally abusive to Resident #2 by pushing him down a hallway and loudly stating, "That is the last time I'm toileting him-he can[***]on himself." Visitor #1 (V#1) alleged that this happened in front of her and Licensed Practical Nurse (LPN) #1. 1. Review of the facility's witness statements dated 10/19/11 at 1:45 pm obtained from the Business Office Manager (BOM) revealed, "I stated that this was an official investigation of allegations of inappropriate behavior against C.N.A #1. I stated that V #1 made a statement of an incident where C.N.A #1 was pushing Resident #2 down the hall after toileting him saying in a loud voice that she was not going to toilet Resident #2 again. ...LPN #1 said, 'I can't remember. I slept since then' ...Q: (Question) Has any inappropriate behavior been reported to you? LPN #1 stated no. LPN #1 stated that V #1 had come to her and said--I want to apologize to you if you have any trouble. I went to Administrator about CNA#1 and Resident #2 the other day. LPN #1 stated that she told V#1 that she did not have a memory of this." 2. Review of the facility's witness statements dated 10/25/11 obtained from the BOM revealed, "Present: CNA #3, 0-25-11 at 10:35 am ...I stated that I have a question about the incident you told us about in your interview, in the bathroom with Resident #2 when you were toileting him. Q: Do you feel like CNA #1 sexually abused Resident #2? CNA #3 stated, Physically, no. Verbally, it was between us. Q: When you say us, who do you mean? You and CNA #1? CNA #3 stated, yes me and CNA #1. Q: Was Resident #2 present? CNA #3 stated yes." E. On 11/04/11 at 1:15 pm, V#1 was interviewed. V#1 was asked if V #1 was witness to anything inappropriate being said to Resident #2. V #1 stated that, unknown date, CNA #1 came out of a bathroom pushing Resident #2 in the wheelchair and stated in a loud voice, "That's the last time I will toilet him. He can[***]himself as far as I'm concerned." V#1 stated that LPN #1 was witness to the verbal abuse. 1. LPN #1 was on medical leave and was not available for interview. 2. On 11/09/11 at 3:10 pm, CNA #3 was interviewed. CNA #3 was asked if she was witness to any inappropriate behaviors by CNA #1 during resident care. CNA #3 stated, "When (CNA #1) and I were assisting (Resident #2) after he went to the toilet, CNA #1 would pull on his penis to clean it, which is not the right thing to do. While (CNA #1) cleaned (Resident #2), (CNA #1) would say things like, 'You sure do have a big penis, I bet you really did made your wife happy,' and things like that. I told her not to say things like that in front of him." When given the definition of verbal abuse as defined on the pamphlet by the (Corporate Organization), "We Don't Tolerate Abuse, "Abuse Definitions...," CNA #3 stated, "By that definition, then that was definitely verbal abuse." F. On 11/09/11 at 10:05 am, an interview was conducted with the Administrator (ADM). When asked when he was notified of the allegation, he stated, "I was notified on 10/18/11. When I was notified I assigned the Business Office Manager (BOM) to conduct interviews related to this allegation. I assigned the BOM because the Social Worker (SW) was on vacation." When asked if an internal Incident Report was generated, he stated, "No, it was not done." When asked if the facility's policy was to begin an internal Incident Report immediately, he stated, "I know, but it wasn't done. When asked if a SA Incident was generated when he was notified of the allegation or when the investigation began, he stated, "No, we didn't at the time. We felt reporting to APS was enough." When the key elements of the SA Incident Management System Guide were reviewed with the ADM that stated, "...Abuse, neglect, misappropriation of property (i.e., exploitation), and injuries of unknown origin shall be reported to (The State Agency) within 24 hours", the ADM stated, "If the Social Worker had been here, it would have been done." When asked if he was aware that all facility staff should be trained in Abuse reporting procedures, he stated, "Yes, I am but, it wasn't done." G. On 11/10/11 at 3:00 pm, the Director of Nurses (DON) was interviewed. The DON stated that on 10/14/11 she was leaving the building, was on her way home, when FM #1 came to her. She stated that FM#1 was screaming, alleging that Resident #1 had been inappropriately touched by CNA #1 along with other complaints. The DON stated that she thought FM #1 was "wishy washy and venting." 1. When asked if she thought to protect Resident #1, the DON stated that she thought it was something she needed to look into. 2. When asked what protections were done for Resident #1 such as suspending CNA #1, the DON stated that she did not suspend CNA #1 for that day because she was already gone for the day and CNA #1 was off for the weekend. The DON stated, "On Monday morning, (CNA #1) came into work at 6:30 am, and I came in about 6:45 am. When I asked her if she had any inappropriate contact with (Resident #1) or any other resident or had given (Resident #1) a cold shower to get a reaction from him, (CNA #1) said 'why do you ask, who said I did that.' (CNA #1) denied everything." The DON stated that CNA #1 was upset and got up and left the building. 3. When asked if the DON had suspended CNA #1, the DON stated, "No, she was upset and left." The DON stated that CNA #1 was off work on 10/18/11 and came back to work on 10/19/11 at 6:30 am. When asked what happened on the morning of 10/19/11, the DON stated that she (the DON) was in Care Plan meetings and she was called out of the meetings when the Ombudsman came in to talk to the Administrator and her (about the allegations of abuse.) When they completed talking to the Ombudsman, the DON called CNA #1 into her office at 11:15 am, and did suspend her pending an investigation. 4. When the DON was asked if she had ever heard CNA #1 call anyone "Nigger" or that CNA #1 had been inappropriate to a resident or to staff, the DON stated she had never heard a staff complaint related to any sexual touching. 5. The DON stated that she did not think CNA #1 was guilty of any resident abuse but she did have inappropriate behavior with some staff. 6. When the DON was asked what the facility policy was when there is an allegation of abuse, the DON stated, "If anyone is accused, they should be suspended immediately. I did not do that." 7. When asked if CNA #1 should have been sent home immediately on 10/17/11, the DON stated, "Yes, I should have sent her home on suspension then, but I did not, she just left because she was upset." 8. The DON was asked if (CNA #1) worked with the residents on 10/19/11 from 6:30 am to 11:15 am, the DON stated, "Yes, she did."

Based on record review and interview the facility's administrative staff failed to follow their policies on abuse reporting and protection for 2 (Resident #1, 2) of 4 sampled residents (#1, 2, 3, 4). The facility also failed to follow their policies to prevent further potential abuse while the investigation was in progress by not suspending the alleged perpetrator and allowing the alleged perpetrator to work with residents. These failures were evidenced by: 1. A sexual abuse allegation was made on 10/14/11 and the facility did not file a notice with the State Agency until 10/24/11. Administrative staff were aware of the allegation. 2. The Alleged perpetrator was not suspended until 10/19/11 and worked with residents from 6:30 am until 11:15 am on 10/19/11. 3. Staff members did not report the abuse of Resident #1 and Resident #2 to protect residents. This is a repeat deficiency from 04/01/11. The findings are: A. Record review of the Facility's policy's and procedures "Procedure Abuse and Neglect' issued May 2003 and revised 01/11 revealed, "Procedure 1. If a staff member receives an allegation of abuse, neglect or misappropriation of resident property or witnesses suspected abuse, neglect...the staff member will immediately report this to a supervisor and ... 2. a. If this is an allegation of staff to resident abuse, the staff person will be removed from providing direct care to all residents. Additionally, the staff person will be placed on suspension pending the results of the internal investigation..5. Notification Procedures: a. Notify the center administrator immediately of any incidents of resident abuse..Notify the designated agencies in accordance with state law, including the state survey and certification agency. You may need to notify more than one state agency in order to fulfill federal and state regulations..." 1. Record review revealed a pamphlet located in the lobby of the facility dated 3/07 and titled, "We Don't Tolerate Abuse" In the Abuse Definitions on the back side of the pamphlet was written, "Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability." B. Record review of the facility's 10/24/11 State Agency (SA) incident report revealed, "Date Completed 10/24/11, Time Completed 5:00 pm." The Incident Report was signed by the Director of Nurses (DON) as the person completing the report. The Incident Report was stamped by the SA Intake personnel on 10/24/11. The section titled, "After the Incident" revealed, "On 10-14-11, I was approached by (Name of FM #1)...at approximately 5 to 5:30 pm.... (Name of FM #1) went on to tell me that two of the other nurse's aides on the hall told (FM #1) that (CNA #1) like to inappropriately touch (Resident #1) when is changing (Resident #1) and also likes to give (Resident #1) showers with cold water in an attempt to 'excite' his penis. (FM #1) also told me that (FM #2)...was in the room when (CNA #1) had inappropriately touched (Resident #1)." 1. Record review of facility statements taken on 10/19/11 and 10/20/11 during the facility internal investigation revealed a written statement from the DON dated 10/14/11. This statement revealed, "At approximately 5 to 5:30 pm, on Friday (10/14/11) I was leaving work when I was approached by (FM #1)...began to inform me that two other Nurses Aides on the hall told (FM #1) that (CNA #1) likes to inappropriately touch (Resident #1) when she is changing (the Resident) and also likes to give (the Resident) showers in an attempt to 'excite' (Resident #1)...We discussed other things, not necessarily in relation to these allegations." a. The statement continued with a date of 10/19/11 that revealed, "At approximately 11:00 am, I received a visit from Ombudsman (Name), who received reports from (FM #1) with allegations that (Resident #1) had been inappropriately touched by (CNA #1), along with multiple other complaints. 11:15 (am)...I also called APS to report sexual inappropriate allegations towards (CNA #1)..." b. The written statement from the DON continued with a date of 10/24/11 that revealed, "I received a letter from APS...stating the case had been referred to (Local Police Department) and Licensing and Certification DOH (Department of Health)...(Name of APS Investigator) told me the case had been screened out to the (local police department) and licensing and certification. I then called DOH... and spoke to (Name of Intake Person)...(Intake Person) informed me that I should have reported to them on that day..." 2. Record review of witness statements taken by the facility on 10/19/11 and 10/20/11 revealed a statement from FM #2 dated 10/19/11, "(FM #2) stated that she was cleaning (Resident #1)'s room...when (CNA #1) and another CNA either (CNA #4) or (CNA #5) wheeled (Resident #1) back into the room after a shower. (FM #2) turned her head, cause (FM #2) does not like to see (Resident #1) like that. FM #2 stated that (CNA #1) told (FM #2) they were done, then when (FM #2) turned her head back, stated that (CNA #1) moved the diaper, showing (Resident #1)'s privates to (FM #2). (FM #2) said that (CNA #1) stated to (FM #2), 'Does it make you feel uncomfortable to see (Resident #1)'s 'junk'? (FM #2) stated that she heard (CNA #1) say 'Wake up nigger' to (Resident #1). (FM #2) stated she would protest to (CNA #1) and (CNA #1) would tell (FM #2) that maybe if we call him 'nigger' it will wake him up." C. On 11/09/11 at 11:50 am, an interview was conducted with FM #2. When FM #2 was asked about Resident #1's genitals being exposed to FM #2, FM #2 stated, "I worked in (Resident #1)'s room as the housekeeper and was cleaning the room, CNA #4 and CNA #5 had taken (Resident #1) to the shower and brought (Resident #1) back to the room. They were positioning (Resident #1) with the lift, (CNA #1) walked in the room after they had brought (Resident #1) back. FM #2 stated that she was at the foot of the bed. She stated that the CNAs' were bringing (Resident #1) down with the lift and the resident had a incontinent pad covering the genitals which came loose. FM #2 stated, "I saw his privates, ... turned away, and (Name of CNA #1) saw that I was embarrassed. FM #2 stated that when she looked back, (CNA #1) pulled his diaper back and exposed his genitals to FM #2 and said, "Does it make you uncomfortable to see your (Resident #1's relation) 'junk'. FM #2 stated, "I told (CNA #1), 'That's not right.' I was embarrassed." FM #2 stated that Resident #1 was very modest and FM #2 did not even see (Resident #1) without a shirt but once. FM #2 was asked if this was an intentional act by (CNA #1) to flash (Resident #1)'s privates, FM #2 stated, "Yes. It really upset me." FM #2 also stated that (CNA #1) would say to (Resident #1), "What's up 'nigger'." FM #2 stated that she told CNA #1 that (Resident #1) can hear you. FM #2 stated that CNA #1 continued saying it several times." FM #2 also stated that CNA #1 told Resident #1 that his grandchildren were black. FM #2 stated that this upset her because the resident had a car accident and was in a coma prior to the baby being born and that Resident #1 never got to see the grandchild. FM #2 stated that they were not prejudiced, but that it was wrong for CNA #1 to say that. FM #2 stated that she told CNA #1 that it was not right for her to do this. FM #2 was observed crying during the interview. 1. On 11/09/11 at 5:30 pm, FM #2 was interviewed. When given the (Corporate Organization) pamphlet "We Don't Tolerate Abuse", FM #2 was asked if Resident #1 had been subjected to verbal abuse, FM #2 stated, "After reading this, I understand better what it is. The part about oral language and derogatory terms to residents or their families, or within their hearing distance is really what happened and so that would be verbal abuse." 2. On 11/10/11 at 1:35 pm, CNA #4 was interviewed. When asked if she heard CNA #1 use derogatory or abusive language to residents, CNA # stated, "No but I did hear her use the slang term "niggah" but she did not call (Resident #1) that. (CNA #1) did ask (FM #2) if her (name of relation) was told she was going to marry a 'niggah' if he would wake up (from the coma). (CNA #1) used that just like a quirky teenager would." 3. On 11/10/11 at 1:55 pm, CNA # 5 was interviewed. When asked if she was present when the exposure incident occurred with Resident #1 to FM #2. She stated that she was in the room at that time and CNA #1 asked FM #2 if it embarrassed her to see her (name of relation's) privates. She stated that CNA #1 also asked FM #2 in front of Resident #1 that if CNA #1 told Resident #1 that FM #2 was married to a black man, would he wake up because Resident #1 did not like blacks. CNA # 5 was asked if this was verbal abuse to the resident, CNA #5 stated, "Yes, it was abuse for Resident #1 to have to hear that. I did not report it, but I think it would be abuse, and I would report it because I think he can hear. " D. Record review revealed a State Agency (SA) intake dated 10/24/11 alleged that CNA #1 was verbally abusive to Resident #2 by pushing him down a hallway and loudly stating, "That is the last time I'm toileting him-he can[***]on himself." Visitor #1 (V#1) alleged that this happened in front of her and Licensed Practical Nurse (LPN) #1. 1. Review of the facility's witness statements dated 10/19/11 at 1:45 pm obtained from the Business Office Manager (BOM) revealed, "I stated that this was an official investigation of allegations of inappropriate behavior against C.N.A #1. I stated that V #1 made a statement of an incident where C.N.A #1 was pushing Resident #2 down the hall after toileting him saying in a loud voice that she was not going to toilet Resident #2 again. ...LPN #1 said, 'I can't remember. I slept since then' ...Q: (Question) Has any inappropriate behavior been reported to you? LPN #1 stated no. LPN #1 stated that V #1 had come to her and said--I want to apologize to you if you have any trouble. I went to Administrator about CNA#1 and Resident #2 the other day. LPN #1 stated that she told V#1 that she did not have a memory of this." 2. Review of the facility's witness statements dated 10/25/11 obtained from the BOM revealed, "Present: CNA #3, 0-25-11 at 10:35 am ...I stated that I have a question about the incident you told us about in your interview, in the bathroom with Resident #2 when you were toileting him. Q: Do you feel like CNA #1 sexually abused Resident #2? CNA #3 stated, Physically, no. Verbally, it was between us. Q: When you say us, who do you mean? You and CNA #1? CNA #3 stated, yes me and CNA #1. Q: Was Resident #2 present? CNA #3 stated yes." E. On 11/04/11 at 1:15 pm, V#1 was interviewed. V#1 was asked if V #1 was witness to anything inappropriate being said to Resident #2. V #1 stated that, unknown date, CNA #1 came out of a bathroom pushing Resident #2 in the wheelchair and stated in a loud voice, "That's the last time I will toilet him. He can[***]himself as far as I'm concerned." V#1 stated that LPN #1 was witness to the verbal abuse. 1. LPN #1 was on medical leave and was not available for interview. 2. On 11/09/11 at 3:10 pm, CNA #3 was interviewed. CNA #3 was asked if she was witness to any inappropriate behaviors by CNA #1 during resident care. CNA #3 stated, "When (CNA #1) and I were assisting (Resident #2) after he went to the toilet, CNA #1 would pull on his penis to clean it, which is not the right thing to do. While (CNA #1) cleaned (Resident #2), (CNA #1) would say things like, 'You sure do have a big penis, I bet you really did made your wife happy,' and things like that. I told her not to say things like that in front of him." When given the definition of verbal abuse as defined on the pamphlet by the (Corporate Organization), "We Don't Tolerate Abuse, "Abuse Definitions...," CNA #3 stated, "By that definition, then that was definitely verbal abuse." F. On 11/09/11 at 10:05 am, an interview was conducted with the Administrator (ADM). When asked when he was notified of the allegation, he stated, "I was notified on 10/18/11. When I was notified I assigned the Business Office Manager (BOM) to conduct interviews related to this allegation. I assigned the BOM because the Social Worker (SW) was on vacation." When asked if an internal Incident Report was generated, he stated, "No, it was not done." When asked if the facility's policy was to begin an internal Incident Report immediately, he stated, "I know, but it wasn't done. When asked if a SA Incident was generated when he was notified of the allegation or when the investigation began, he stated, "No, we didn't at the time. We felt reporting to APS was enough." When the key elements of the SA Incident Management System Guide were reviewed with the ADM that stated, "...Abuse, neglect, misappropriation of property (i.e., exploitation), and injuries of unknown origin shall be reported to (The State Agency) within 24 hours", the ADM stated, "If the Social Worker had been here, it would have been done." When asked if he was aware that all facility staff should be trained in Abuse reporting procedures, he stated, "Yes, I am but, it wasn't done." G. On 11/10/11 at 3:00 pm, the Director of Nurses (DON) was interviewed. The DON stated that on 10/14/11 she was leaving the building, was on her way home, when FM #1 came to her. She stated that FM#1 was screaming, alleging that Resident #1 had been inappropriately touched by CNA #1 along with other complaints. The DON stated that she thought FM #1 was "wishy washy and venting." 1. When asked if she thought to protect Resident #1, the DON stated that she thought it was something she needed to look into. 2. When asked what protections were done for Resident #1 such as suspending CNA #1, the DON stated that she did not suspend CNA #1 for that day because she was already gone for the day and CNA #1 was off for the weekend. The DON stated, "On Monday morning, (CNA #1) came into work at 6:30 am, and I came in about 6:45 am. When I asked her if she had any inappropriate contact with (Resident #1) or any other resident or had given (Resident #1) a cold shower to get a reaction from him, (CNA #1) said 'why do you ask, who said I did that.' (CNA #1) denied everything." The DON stated that CNA #1 was upset and got up and left the building. 3. When asked if the DON had suspended CNA #1, the DON stated, "No, she was upset and left." The DON stated that CNA #1 was off work on 10/18/11 and came back to work on 10/19/11 at 6:30 am. When asked what happened on the morning of 10/19/11, the DON stated that she (the DON) was in Care Plan meetings and she was called out of the meetings when the Ombudsman came in to talk to the Administrator and her (about the allegations of abuse.) When they completed talking to the Ombudsman, the DON called CNA #1 into her office at 11:15 am, and did suspend her pending an investigation. 4. When the DON was asked if she had ever heard CNA #1 call anyone "Nigger" or that CNA #1 had been inappropriate to a resident or to staff, the DON stated she had never heard a staff complaint related to any sexual touching. 5. The DON stated that she did not think CNA #1 was guilty of any resident abuse but she did have inappropriate behavior with some staff. 6. When the DON was asked what the facility policy was when there is an allegation of abuse, the DON stated, "If anyone is accused, they should be suspended immediately. I did not do that." 7. When asked if CNA #1 should have been sent home immediately on 10/17/11, the DON stated, "Yes, I should have sent her home on suspension then, but I did not, she just left because she was upset." 8. The DON was asked if (CNA #1) worked with the residents on 10/19/11 from 6:30 am to 11:15 am, the DON stated, "Yes, she did."