Every finding on record at Majestic Care of Hopemont

Based on observation, record review and staff interview, the facility failed to ensure menus meet the nutritional needs of residents and menus were followed. This failed practice had the potential to affect more than a limited number of residents: Resident Identifiers:. #1, #4, #5, #11, #15 and #18. Facility Census: 47.e)Resident #4 On 02/16/2026 at approximately 12:00 PM a meal tray was delivered to Resident #4 room. It was placed down and when opened the tray was observed to contain the following: Tray contained Full chicken breast (not cut up and not diet appropriate) Polenta Summer squash was missing and was subbed w/ spinach (not diet appropriate) Roll (not diet appropriate) Malt vinegar - missing Margarine - missing Chocolate pudding was missing and subbed out w/ brownie (not diet appropriate) Coffee Soy milk The Residents diet is Minced and moist with nectar thick liquids. This is a requirement per Speech therapy #77, who confirmed Resident #4 is a high aspiration risk and pockets their food. There were four (4) items on the residents tray (marked above) as not diet appropriate. This tray was delivered by LPN #21 and when called back into the room to confirm the contents do not meet the prescribed dietary requirements she stated that the chicken should not have been a whole piece, should be shredded. She then took the chicken in the lid and said she will be back with it corrected. Went back to check if the tray was corrected and the family stated they never came back with anything and that all they fed Resident was the polenta since that is all he was able to eat off it. Resident #4 was full and didn't need the rest of the tray. Further interview with Speech Therapist #77 on 02/16/2026 at 02:17 PM she stated the following: When told about what appeared on his tray for lunch she said mmmhmm that sounds about right, this is the problem we have here. Im only in my first few weeks there and i have see this issues multiple times. Yes , if Ed was fed the diet you describe to me he would be at risk for aspiration. Diets are not consistent from the kitchen and it is very hit or miss. On 02/17/2026, the second day of the survey Resident #4 meal tray was incorrect again and this time contained: Minced and moist dietary items - Ham and gravy, squash and peppers, mashed potatoes, vanilla pudding. All of these items were prepared to the correct dietary requirements of Resident #4. Drinks Two (2) Fruit punch and soy milk, both of which were not thickened at all. According to Resident #4 orders all liquids shall be Nectar Thick. Interview conducted on [DATE] at 12:50 PM with CNA #46 when asked if those two (2) beverages are correct thicknesses. CNA #46 stated that she wasn't sure if they were right but didn't look like it. The CNA removed the fruit punch and said they would get a new one that was the correct thickness. Interview with ADMIN on [DATE] at 1:00 PM,, when shown the soy milk they stated that it definitely was not correct and went down with me to the kitchen to find out why. Admin also stated, only the kitchen can thicken any liquids, the floor staff is not trained/qualified. Interview with Kitchen manager #91 on [DATE] at 1:10 PM,, stated that the soy milk was not right and she will make a new one. Findings included: a) The facility's policy and procedure for Meal Service ( Tray Line) stated, Purpose: To ensure that all meals are served safely, accurately, and attractively to residents/patients . b) On 02/16/2026, during the Dining Observation, tray card discrepancies were as follows: Resident # 15 did not receive chocolate pudding or fruit as printed on his tray card, Resident #11 did not receive PU4 Marbled Brownies as printed on his tray card, and Resident #1 not receive chocolate pudding as printed on his tray card. At 12:41 PM, Nurse Aide #18 confirmed the try cards and food that was not received. On 02/16/2026 at 12:50 PM, Dietary Aide #18 confirmed Resident #5 did not receive chilled peaches, MT2 Punch, MT2 Cold Tea or MT2 lemonade as printed on his tray card. On 02/17/2026, the menu stated PU4 Snickerdoodle cookie and -vanilla ice cream were the desserts for mechanically altered diets. AT 12:17 PM, Corporate Health Care Services Dietary Manager #99 stated that pudding was the dessert for any remaining mechanically alternated diet. c) On 02/17/2026 at 12:45 PM, [NAME] #98 stated, Hey [NAME] .we don't have enough vegetables. Account Manager #91 confirmed there were not enough vegetables to complete lunch. The account manager replaced the southwest vegetables with a salad without approval of Registered Dietician #100. d) On 02/17/2026, the menu stated a coconut fruit bar was to be served for dessert. The residents were served cheesecake with fruit on top and pudding for dessert, not a coconut fruit bar. Corporate Health Care Services Dietary Manger 99# reported that the dessert was a coconut fruit bar. No coconut was tasted in the cheesecake with fruit on the top by two state surveyors. Account Manager #91 confirmed the coconut fruit bar was not served and stated, We ain't got coconut.

Based on observation, staff interview, and record review, the facility failed to prepare food in a form to meet individual needs. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #1, #8, #4 and #24. Facility Census: 47. Findings included: a) The facility's policy and procedure for Meal Supervision and Assistance stated, 5. Check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. On 02/16/26, when asked what diet levels are served at the facility, Dietary Aide #94 reported they serve puree, ground, minced and moist, and bite-sized -and stated, I just call them all ground. On 02/16/26 at 2:09 PM, the State Surveyor interviewed the Speech-Language Pathologist (SLP) regarding the diet consistencies served at the facility. The SLP reported the consistencies of the diets vary in what is served, but the diet levels she was told to use were: Puree, Minced and Moist, Soft and Bite-sized and Regular. On 02/17/26, Corporate Health Care Services Dietary Manager #99 stated that the only diet levels served are Regular, Puree, Easy to Chew and Minced and Moist (gravy on all food). On 02/17/26 at 2:55 PM, Registered Dietician (RD) #100 reported that the diet levels served in the facility included: Puree, Minced and Moist, Soft and Bite-sized, Easy to Chew and Regular. Descriptions of each diet level were given to the State Surveyor including thickened liquids by the RD. The RD reported they don't have anyone on a 'Ground' diet and said, We don't use it. On 02/17/2026, Corporate Health Care Services Dietary Manager #99 was asked by the state surveyor how do the cooks know what to serve when the tray cards vary with different diets. Resident #1's ordered diet was: Regular diet, Soft and Bite Sized texture, Thin consistency. Resident #8's ordered was: Regular diet, Minced and Moist texture, Thin consistency, Double protein. Account Manager #91 and Corporate Health Care Services Dietary Manager #99 were unable to state the difference and preparation and Corporate Health Care Services Dietary Manager #99 stated, I know what your asking. and reported the were consulting with corporate concerning diets and tray cards. On 02/17/26, the State Surveyor intervened because regular cheesecake with crust was brought out just as trays were ready to be served. The surveyor asked what was being served for residents' ordered puree and minced and moist. The menu production sheet stated that for pureed, the residents received a PU4 Snickerdoodle cookie and for Minced and Moist a vanilla ice cream. The residents were served pudding following surveyor intervention The following residents require a mechanically altered diet, according to the Diet Type Report: Easy to Chew - one (1) resident. Minced and Moist- five (5) residents. Soft and Bite Sized - nine (9) residents.

Based on observation, record review and staff interview, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 47.Findings included: a) The facility's policy for Labeling and Dating stated, A. All food items prepared, opened, or stored in the facility kitchen must be clearly labeled and dated., B.c.1.a) Label with the date the item is placed in storage and the date of discard - add 6 to today's date. and C.a. The Culinary Manager or designee will perform frequent checks of all food storage areas for proper labeling and dating. The Administrator reported items should be dated for seven (7) days. Dietary Aide #94 reported, [NAME] wants everything for three (3) days. b) On 02/16/2026 at 10:15 AM, the Kitchen Investigation was initiated with the Administrator. The following items were found and confirmed by the Administrator: Spaghetti uncooked noodles - not labeled.[NAME] Choice Gravy Mixes- no received or used by dates.Boxes of Gelatin - no use by date, one bag leaking, orange lime and lemon flavors.Pudding received 1/16/2026 with use by date 10/14/2025.Kellogg Corn Flakes dated 08/27/25 with use by date 10/23/25.Corn Flakes - dated 12/31/25 with no use by date and not labeled.Eggs - no used by date.Soup - no use by date. c) At 10:35 AM, the Kitchen Investigation was continued with Dietary Aide #94. The following items were found and confirmed by Dietary Aide #94: Juice glasses x10 - not labeled and not dated.Mixed glasses of juices - not labeled or used by dates.Whipped cream - opened, not sealed and no use by date.Cottage cheese - no use by date.Pre-thickened Liquids - opened and not dated.French Fries - not labeled and no use by date.Hashbrowns - not labeled , no open or use by date.Bag of Ice - opened and not sealed. d) At 10:50 AM, the panties on the halls were investigated with Dietary Aide #94. The following items were found and confirmed by Dietary Aide #94: B Hall Pantry at 10:50 AM:Lean Cuisine - not dated. Friendly's Celebration Cake - opened with no use by dateTai [NAME] egg rolls - opened and not dated.Package of Sauce - not labeled and not dated. A Hall Pantry - 11:00 AM:Ranch dressing - open and not datedNot labeled or use by dates on snacks for the following residents:1 Resident #47 - Peaches2. Resident #41 - pudding3. Resident #1 - cottage cheeses4. Resident #9 - pudding On 02/17/2026 at11:05 AM, the dishwashing process and temperatures were observed by the State Surveyor. o temperature for this date was logged. [NAME] #98 stated, No temps, yet. when asked if the dishwashing and rinse temperatures had been taken. [NAME] #96 confirmed that multiple loads of dishes had been completed and the dishwasher temperatures had not been checked or logged. The wash and rinse temperature were within normal limits when the dishwasher was run. [NAME] #96 confirmed the dishwasher temperature log had not been completed and stated, We haven't documented temps, yet. The facility's policy and procedure for Dish Machine Monitoring stated, A log will be utilized to document temperatures and or chemical sanitizer PPM to verify requirements are met and functioning.

Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to the resident's personal products and unsanitary practices. This failed practice was a random opportunity for discovery. Resident identifiers: 8, 34, 36, and 38 Facility Census: 47. a) On 02/17/26 at 1:48PM, during a facility walk through it was observed that resident #'s 8, 34, 36, and 38's wheel chairs or Geri chairs had holes, rips and tears with exposed inner padding On 02/18/26 at 2:08 PM, during a facility walk through and interview with Assistant Director of Nursing (ADON) #79, she acknowledged the wheel chairs and Geri chairs in the resident rooms and the chairs in the activities room with holes, rips and tears exposing the inner padding. She agreed this was an infection control issue.

Based on observation and staff interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible This failed practice was a random opportunity for discovery. Resident identifier: #8. Facility Census:47Findings included: a) During a facility tour on 02/17/26 at 2:40 PM, the following environmental accident hazards were observed: Solarium: A steady leak in the ceiling with a continuous drip was blocked off with a retractable post/belt barrier, The barrier did not encompass the entire restricted area leaving a 2(two) to 3(three) foot gap that anyone could freely walk through to the wet floor. Further observation found missing electrical conduit with jagged edges and exposed electrical wiring around the wall. 100 and 200 Hallways: -Plastic molded lower rub rails in both resident halls had separated with 1/4 inch to 1/2-inch finger sized gaps -Lower encased wall lighting boxes below handrails opened with glass bulb and electric wires exposed Shower Room: A half empty opened carton of Ensure plus drink with a straw was observed left sitting on the window shelf. room [ROOM NUMBER] -212 shared bathroom: -broken and loose drywall with 1/8 to1/4 inch sized pieces falling out of the wall onto the floor -2 (two) 1/4 inch bolts protruding from the wall in Residents shared bathroom Staff Interviews: During a facility walk through and interview with the maintenance supervisor, on 02/17/26 at 1:15PM, he acknowledged the areas in need of attention in resident rooms, bathrooms, halls and in the solarium and stated he would close off the gap to make sure no one would be able to get into that area. He also called on maintenance staff to repair the conduit with the exposed electrical wiring. During a facility walk through and interview with the maintenance supervisor, on 02/17/26 at 1:15PM, he acknowledged the areas in need of attention in resident rooms, bathrooms, halls and in the solarium and stated he would close off the gap to make sure no one would be able to get into that area. He also called on maintenance staff to repair the conduit with the exposed electrical wiring. During an interview with the executive director on 02/18/26 at 2:55PM, he acknowledged the needed repairs and accident hazards and stated the maintenance department will receive a list of needed repairs. Resident #8 On 02/16/26 at 11:40 AM observation in Resident #8's Bathroom cabinet revealed Clorox Wipes, [NAME] pack and three (3) skin prep wipe packs. There was also an out of order sign in the shower and rust around the bottom shower pan that was in very bad disrepair. Social Worker #47 confirmed that the cleaning and prep supplies were not supposed to be left in residents' rooms. Oh, shoot those don't belong in there.

Based on observation, staff interview and interview with Resident [NAME], the facility failed to ensure survey results were readily accessible in an area where individuals wishing to examine them did not have to ask to see them. Facility Census: 47 Findings included: During Resident Council on 02/17/26 at 11:00 AM, it was revealed the survey book in the lobby was empty with a sign informing the reader to ask the front desk to see the book. An interview with Social Worker #47 on 02/17/26 at approximately 5:00 PM, revealed the book was kept behind the front desk to keep resident's from tearing the pages. The SW said at no time was the book accessible to anyone without them having to ask. There was a sign stating this, but it is important to note that the desk is unmanned at the end of a specific shift, daily. On 02/18/726 5:20 PM the surveyor observed an empty binder and in the lobby with a note stating survey results were available upon request.

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents. This failed practice was observed to have affected a shared bathroom between room [ROOM NUMBER] and #215. Facility census: 47On 02/16/26 at 1:25PM, during a facility walk through it was observed that resident shared bathroom between room [ROOM NUMBER] and #215loose dark rusty pipes dirty buildup in the corners and around the base of the toiletcracked and loose drywall falling from the wall Dusty build up of hair and debris observed between the bathroom door and the [NAME] 02/18/26 at 12:40 PM, during a facility walk through and interview with the Assistant Director of Nursing (ADON) #79, she acknowledged the needed repairs in the resident rooms and hallways. she stated she would take note of it and make sure the issued would be added to the maintenance list.During a facility walk through and interview with the maintenance supervisor, on 02/17/26 at 1:15PM, he acknowledged the areas in need of attention in resident rooms, bathrooms, halls and in the solarium and stated he would close off the gap to make sure no one would be able to get into that area. He also called on maintenance staff to repair the conduit with the exposed electrical wiring. He reported that the facility did not have a plan of improvement. He has been in this position for approximately 6 weeks. The plan of improvement is high on his list and is planning to start it soon.During an interview with the executive director on 02/18/26 at 2:55 PM, he acknowledged the needed repairs and stated the a list of needed repairs would be sent to the maintenance department.

Based on Record review and staff interview, the facility failed to provide quality care by not following or updating physicians orders as needed. This was discovered during the normal Long Term Survey Process and has the ability to affect more than a limited number of residents. Resident Identifiers: #4 and #5. Census 47.Findings included: a) Resident #5 On 02/16/26 at 3:00 PM, review of resident's physician orders reviewed an order for Geri call cord in room due to Cerebrovascular Accident (CVA) with inability to use standard call bell system. Start date of 11/25/25 On 02/16/26 at 4:00 PM, I observed resident's call light in room to be a regular, thumb press button call system. On 02/16/26 at approximately 4:20 PM, Restorative Nurse Assistant #34 was walking by resident's room and was asked if Resident #5 is ordered to have a specific type of call button. She looked in his room and then walked to the room next door and replied, He changed rooms with the resident next door and they didn't move his call light. When asked how long ago the rooms were changed, she could not recall and stated several weeks. On 02/16/26 at 5:20, an interview was help with Regional [NAME] President of Operations who acknowledge and reported she would discuss with administrated to correct immediately. Review of facility call lights policy, procedure #4 states Special accommodations will be identified on the resident's person-centered plan of care , and provided accordingly. Examples include touch pads, larger buttons, bright colors, etc.) b) Resident #4 During a record review of Resident #4 chart on 02/16/2026 at 4:18 PM it showed that he had active orders for turn and reposition every two (2) hours (Q2) to prevent skin breakdown. Resident #4 is currently on hospice care and had a large decline in their self care and activities of daily living (ADL) capabilities. In order to prevent skin breakdown and wound formation R#4 needs to be moved into different positions every two (2) hours by staff and this task documented in the system. There is no documentation as to the order being followed, nor turn and reposition notes in chart or task marked off completed. On 02/16/2026 at 4:22 PM when interviewed CNA #46 where they document the turn and reposition of residents, they stated we dont have a specific place, we just kinda do it.

The facility failed to ensure the physician acknowledged Montly Medication Review's for residents. Resident identifiers: #2, #4, #31, and #36. Facility census: 47. Findings included: a) Resident #2 Physician Recommendation Forms were not reviewed by the physician for psychoactive medications for the following dates: 11/15/25, 12/17/25, 01/15/26 and 02/16/26. On 02/19/26 at 1:00 PM, the Regional Clinical Operations Manager of Acquisitions and the Administrator confirmed there were no medication forms reviewed and signed by the physician secondary to the physician refusing to sign and the previous Director of Nursing receiving the recommendations and not getting them signed by the physician. b) Resident #31 Physician Recommendation Forms were not reviewed by the physician for psychoactive medications for the following date: 12/17/25. On 02/19/26 at 1:00 PM, the Regional Clinical Operations Manager of Acquisitions and the Administrator confirmed there were no medication forms reviewed and signed by the physician secondary to the physician refusing to sign and the previous Director of Nursing receiving the recommendations and not getting them signed by the physician. c) Resident #4 Physician Recommendation Forms were not reviewed by the physician for psychoactive medications for the following dates: 11/15/2025, 12/17/2025, 01/17/2026 and 02/16/2026. On 02/19/2026 at 12:10 PM, Medical Records #32 stated they were all given to either the MD or DON to be looked at and signed off as needed. They were told to not handle them anymore since the sale. Secondary interviews on 02/19/2026 at 1:00 PM, with the Regional Clinical Operations Manager of Acquisitions and the Administrator confirmed there were no medication forms reviewed and signed by the physician secondary to the physician refusing to sign and the previous Director of Nursing receiving the recommendations and not getting them signed by the physician. d) Resident #36: On 02/19/26 12:11 PM, Record review and staff interviews found the Physician Recommendation Forms were not reviewed by the physician for psychoactive medications for the following dates: 11/15/25, 12/17/25, 01/15/26 and 02/16/26. On 02/19/26 at 1:00 PM, the Regional Clinical Operations Manager of Acquisitions (RCOMA) and the Administrator confirmed there were no medication forms reviewed and signed by the physician secondary to the physician refusing to sign and the previous Director of Nursing receiving the recommendations and not getting them signed by the physician.

Based on observation, record review and staff interview, the facility failed to ensure residents were receiving therapeutic diets as ordered by the physician. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #1 and #8. Facility Census: 47. Findings included: a) Different diet levels per staff interview:1. The facility's policy and procedure for Meal Supervision and Assistance stated, 5. Check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow.2. On 02/16/2026, Dietary Aide #94, when asked what diet levels are served at the facility, the dietary aide reported they have puree, ground, minced and moist, and bite-sized -and stated, I just call them all ground.3. On 02/16/2026 at 2:09 PM, the State Surveyor Interviewed the Speech-Language Pathologist (SLP) for diet consistencies served at the facility. The SLP reported the consistencies of the diets vary in what is served, but the diet levels she was told to use were: Puree, Minced and Moist, Soft and Bite-sized and Regular.4. On 02/17/2026, Corporate Health Care Services Dietary Manager #99 sated that the only diet levels served are Regular, Puree, Easy to Chew and Minced and Moist (gravy on all food).5. On 02/17/2026 at 2:55 PM, Registered Dietician (RD) #100 reported the diet levels served in the facility included: Puree, Minced and Moist, Soft and Bite-sized, Easy to Chew and Regular. Descriptions of each diet level were given to the State Surveyor including thickened liquids by the RD. The RD reported they don't have anyone on a 'Ground' diet and we don't us it. b) On 02/17/2026, Corporate Health Care Services Dietary Manager #99 was asked by the state surveyor how do the cooks know what to serve when the tray cards vary with different diets. Resident #1's ordered diet was: Regular diet, Soft and Bite Sized texture, Thin consistency. Resident #8's ordered was: Regular diet, Minced and Moist texture, Thin consistency, Double protein. Account Manager #91 and Corporate Health Care Services Dietary Manager #99 were unable to state the difference and preparation and Corporate Health Care Services Dietary Manager #99 stated, I know what your asking. and reported the were consulting with corporate concerning diets and tray cards. c) On 02/17/2026, the State Surveyor intervened, as trays were being ready to be served and regular cheesecake with crust was brought out, and asked what was being served for residents' ordered puree and minced and moist. The menu production sheet stated that for pureed, the residents received a PU4 Snickerdoodle cookie and for Minced and Moist a vanilla ice cream. The residents were served pudding following surveyor intervention d) The following residents are ordered a mechanically altered diet per the Diet Type Report:1) Easy to Chew - one (1) resident.2) Minced and Moist - five (5) residents.3) Soft and Bite Sized - nine (9) residents.

Based on record review and staff interview the Facility failed to provide accurate documentation by listing inaccurate diagnosis of Post Traumatic Stress Disorder for a resident. This was a random opportunity for discovery. Resident Identifier: #1. Facility census: 47. Findings included: a) Resident #1 On 02/16/26 during documentation review, it was observed that Resident #1 had a diagnosis of Post Traumatic Stress Disorder (PTSD) onset of 09/7/23 on his diagnosis list. Upon further review of his records, this diagnosis nor treatment for said diagnosis could be found. An interview with Social Services Director (SSD) on 02/17/26 at 4:11 PM revealed the diagnosis had been taken off the Matrix and Minimum Data Set (MDS) assessment per suggestion of their corporate MDS coordinator due to lack of proof resident had this diagnosis. SSD reported Resident #1's intake information nor in-house diagnostic information suggested Resident #1 had a diagnosis of PTSD. An interview with Administrator on 02/18/26 at approximately 2:00 PM, he relayed per the facility's Corporate MDS Coordinator, the facility has no record of origin of resident having PTSD diagnosis. No assessments, it was not on any History and Physical and they could not find where it was on any admissions or discharge paperwork. Administrator reported it is unclear how the diagnosis got added to resident's diagnosis list.

Based on staff interview and documentation review the Facility failed to complete [NAME] Virginia Pre-admission Screening with new diagnosis of Major Depressive Disorder. This is true for Resident #3. Facility Census 47. Findings Included:a) Resident #3 On 02/16/26, a review wascompleted of a document titled [NAME] Virginia Department of Health and Human Resources Pre-admission Screening (PAS) dated for 11/13/24. For Resident #3, on Question #30 the answer was marked a. None. Upon Review of Resident #3's diagnosis list, resident was diagnosed with Major Depressive Disorder, Recurrent, Moderate on 11/15/24. Interview with Administrator on 02/17/26 at 5:25 PM who acknowledged Resident #3 did not have a new PAS did not contain his new diagnosis of Major Depressive Disorder.

Based on observation, record review, staff interview and resident interview, the facilitate failed to ensure the resident received food that accommodated allergies, intolerances and preferences. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #30. Facility Census: 47. Findings included: a) Resident #30's diet order stated, Consistent Carbohydrate, Regular, Thin, and no added salt, no beef or pork ,yogurt at Breakfast and Lunch. On 02/17/26 at 12:31 PM, [NAME] #98 served the resident ham on her tray. Following state surveyor intervention, Dietary Aide #97 removed Resident #30's tray from delivery cart and confirmed the tray card stated food allergy for milk and no beef or pork. [NAME] #98 stated, I ain't got anything .only pork. and It depends on her mood. - referring to if the resident eats pork or not. The resident received a peanut butter and jelly sandwich. The facility does not provide an alternate menu, but resident's can choose something from the always available menu according to Account Manager #91. On 02/16/2026 at 12:50, Resident # 30 had milk on her tray. The resident was observed to drink some of the milk and stated, I don't like milk so they had to put allergic. Nurse Aide #60 confirmed the resident had milk with her lunch meal. Resident #30's Dietary Profile was reviewed. The following items were listed: Allergy to milk, No beef or pork. and yogurt at breakfast and lunch. Yogurt was not observed on the resident's tray on 02/16/26 and 02/17/26 at lunch by this state surveyor.

Based on observation and staff interview, the Facility failed to provide a resident with an assistive device during meals by not providing nosey cup. This was a random opportunity for discovery. Resident identifierz: #6. Facility Census: 47. Findings Included:a) Resident #6 On 02/17/26 at approximately 12:50 PM, Resident #6 was observed dining in the dining room with assistance from Nurse Aide #74. Observation of Resident #6's tray card revealed he was to have one nosey cup, not present on his tray. He did have cold tea, orange juice and and milk all served in regular clear plastic cups. An interview with Nurse Aide #74 was conducted 02/17/26 at 12:55 PM revealed they were not familiar with a nosey cup and these were the cups that resident normally used at meals. Review of Care Plan for Resident #6 stated the following: Focus: Resident presented with potential for nutritional risk related to diagnosis major depressive disorder, vitamin D deficiency. Receiving a mechanically altered diet with thickened liquids to ease chewing/swallowing concerns secondary to dx of Huntington's Disease, dementia, and History of Traumatic Brain Injury. Interventions included: Thickened liquids, double protein, no straws, nosey cup for all fluids. Review of Facility's Policy and Procedure tiled, Adaptive Feeding Equipment 3.Policy, Section C, d. Dietary must be notified of adaptive equipment needs and ensure equipment is placed on tray at each meal.

Based on observation and staff interviews, the facility failed to follow prescribed dietary order for liquid consistency for the residents. Resident identifier: #4. Facility census: 47. Findings Include: a) Resident #4 On 02/16/26 at approximately 12:00 PM a meal tray was delivered to Resident #4 room. It was placed down and when opened the tray was observed to contain the following:Tray contained Full chicken breast (not cut up and not diet appropriate)Polenta Summer squash was missing and was subbed w/ spinach (not diet appropriate)Roll (not diet appropriate)Malt vinegar - missingMargarine - missingChocolate pudding was missing and subbed out w/ brownie CoffeeSoy milk The Residents diet was Minced and moist with nectar thick liquids. This was a requirement per Speech therapy #77, who confirmed Resident #4 was a high aspiration risk and pocketed their food. This tray was delivered by LPN #21 and when called back into the room to confirm the contents did not meet the prescribed dietary requirements, she stated that The chicken should not have been a whole piece, should be shredded. She then took the chicken in the lid and said she would be back with it corrected. The surveyor back to check if the tray was corrected and the family stated they never came back with anything and that all they fed Resident was the polenta since that is all he was able to eat off it Further interview with Speech Therapist #77 on 02/16/26 at 02:17 PM when told about what appeared on his tray for lunch she said mmmhmm that sounds about right, this is the problem we have here. I'm only in my first few weeks there and I have seen these issues multiple times. Yes , if (resident #4's name) was fed the diet you describe to me he would be at risk for aspiration.Diets are not consistent from the kitchen, and it is very hit or miss. On 02/17/2026, the second day of the survey Resident #4 meal tray was incorrect again and this time contained: Drinks Two (2) Fruit punch and soy milk, both of which were not thickened at all. According to Resident #4 orders all liquids should be Nectar Thick. Interview conducted on 02/17/26, at 12:50 PM with NA #46 when asked if those two (2) beverages were correct thicknesses. NA #46 stated that she was not sure if they were right but did not look like it. The NA removed the fruit punch and said they would get a new one that was the correct thickness. During an interview with the administrator on 02/17/26 at 1:00 PM, when shown the soy milk they stated that it was not correct and went down to the kitchen to find out why. The Administrator also stated that only the kitchen can thicken any liquids, the floor staff is not trained/qualified.During an interview with Kitchen Manager (KM) #91 on 02/17/26 at 1:10 PM, KM #91 stated that the soy milk was not right and she would make a new one.

Based on record review and staff interviews, the facility failed to monitor, evaluate and document restraints for residents. This was discovered during the Long Term Survey Process and had the ability to effect more than a limited number of residents. Resident Identifier: #6. Facility census: 47. Findings Include: a) Resident #6 On 02/16/2026 at approximatley 4:00 PM a record review was done on Resident #6. The record review revealed it stated that Resident #6 had a diagnosis of Huntington's Disease. This disease can limit a person's functional status and control of limbs. For Resident #6 safety they had orders to have a wheel chair restraint belt on while in a wheel chair at all times. Resident #6 also had orders for limb restraint for Inter-Muscular (IM) Injections, due to the disease process making it hard to stay still during these procedures. The orders from the medical record were as follows: Broda Chair with quick release pelvic restraints while out of bed to maintain optimal upright position. Monitor Q 30 minutes and release Q 2 hours x 15 minutes for ROM, toileting and repositioning. Dx-huntingtons disease May restrain patient for IM injection as needed related to patient safety. Resident #6's care plan also showed the need for restraints, but to assess and document for skin breakdown and wounds. Care Plan Reivew revealed: Focus Resident #6 uses physical restraints cross leg seat belt in chair due to Huntington's Disease Date Initiated: 11/10/2025 Revision on: 11/10/2025 Goal Resident #6 will utilized the least restrictive device and remain free of complications related to restraint use, including contractures, skin breakdown, altered mental status, isolation or withdrawal Date Initiated: 11/10/2025Interventions Ensure The resident is positioned correctly with proper body alignment while restrained. Date Initiated: 11/10/25 IDT to review at least quarterly for least restrictive device Date Initiated: 11/10/25 observe for decline in mood, change in behavior, decrease in adl self performance, decline in cognitive ability or communication, contracture formation, skin breakdown, s/sx of delirium, falls/accidents/injuries, agitation, weakness. Date Initiated: 11/10/2025 Provide a meaningful program of activities that accommodates restraint use without drawing unwanted attention. Provide restraint-free time during activities when possible to supervise closely. Date Initiated: 11/10/2025 RESTRAINT USE: Restraint type: cross leg seat belt while up in chair Check hourly, release and reposition at least every 2 hours. Date Initiated: 11/10/2025 Revision on: 11/10/2025 The resident needs to be toileted every 2 hours and as needed During an interview with the Administrator and MD on 02/16/26 at approximately 4:20 PM about the restraints they said they would remove the IM one but the resident will still be in the wheel chair restraints as they are needed for his safety. Further record review was completed on 02/17/26 at 2:50 PM to look for any documentation for the restraints being used on Resident #6. No restraint documentation were located and/or provided to the Survey team prior to exit. A secondary interview with RN #79 and NA #46 on 02/17/26 at 3:15 PM was conducted and when asked where they document restraint checks every two hours and skin assessments, they stated We dont have anywhere to document restraint checks and never have.

Based on observation, record review and staff interviews, the facility failed to ensure care was promoted in a manner that maintained or enhanced the resident's dignity and respect during the dining experience. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #18 and #24. Facility Census: 47.Findings included:a) Resident #18On 02/16/2026, Resident #18 was served by the staff,. The resident requested silverware from the State Surveyor as he was attempting to use his table mates dirty soiled napkin. The resident was served a piece of whole chicken breast and a salad. Nurse Aide #60 confirmed the resident did not receive silverware and got a black plastic spoon for the resident to use. Resident #24 was observed eating his lunch meal with plastic silverware.The resident's desserts were served in plastic bags and not on a regular dessert plate. On 02/16/2026 at 12:33 PM, the Administrator confirmed the desserts were served in a plastic bag.On 02/16/2026, during the initial dining room investigation, the State Surveyor observed all the residents eating lunch on their trays. At 12:33 PM, the Administrator confirmed the resident's food was not removed form their trays and their plates were not placed on the table for their meal.

Based on observation, record review and staff interview, the facility failed to provide a well -balanced diet taking into consideration preferences. The failed practice had the potential to affect a limited number of residents. Resident Identifier: #30. Facility Census: 47. Findings included: a) Resident #30 Resident #30's diet order stated, Consistent Carbohydrate, Regular, Thin, and no added salt, no beef or pork ,yogurt at Breakfast and Lunch.: On 02/17/2026 at 12:31 PM, [NAME] #98 served the resident ham on her tray. Following state surveyor intervention, Dietary Aide #97 removed Resident #30's tray from delivery cart and confirmed the tray card stated food allergy for milk and no beef or pork. [NAME] #98 stated, I ain't got anything .only pork. and It depends on her mood. - referring to if the resident eats pork or not. The resident received a peanut butter and jelly sandwich. The facility does not provide an alternate menu, but resident's can choose something from the always available menu according to Account Manager #91.

Based on observation, and staff interview, the facility failed to provide food at a palatable and appetizing temperature as determined by the type of food to ensure resident satisfaction. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 51. Findingd included: a) A tray on A-Hall was tested by DM #100 and temperatures were as follows: Pureed Pork - 122 degrees Mashed Potatoes - 126 degrees Pureed Peas - 102 degrees Pureed Bread - 100 degrees b) Temperatures were confirmed by DM #100. DM #100 reported pork should have been at 130 degrees and the vegetable's temperature was low. DM #100 stated the bread could be served hot or cold. The facility's Policy and Procedure stated, Hot foods will be served at a temperature 120 degrees F or higher. These findings confirmed by Dietary Manager (DM) #100 on 11/19/24 at 12:25 PM.

Based on observation, record review and staff interview, the facility failed to store and label food in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 51. Findings included: Findings confirmed by the Dietary Manager (DM) #100 and the Chief Operating Officer (COO) #35 on 11/18/24 during the investigation initiated at 11:42 AM included the following items in the pantry: a) An opened can of Shasta. b) Undated sandwiches in fold over bags. c) Unlabeled and undated drink in a cup -tea. d) Undated bowl of broth. e) Opened and used container of Boost in the freezer. f) Undated hamburger in the freezer. g) Undated package of lasagna in freezer. DM #100 asked, Is that me? and stated, I'm going to throw it away. COO #35 stated the refrigerators were the dietary department's responsibility. According to the 2013 US Publilc Health Service Food and Durg Administration Food Code: 3-202.15 Package Integrity: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Except when packagaing food using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in ¶¶ (E) and (F) of this section, refrigerated, Ready-to -eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on observation, staff interviews, medical record review, temperature log review, and facility reportable incident (FRI) review, and hospital record review the facility neglected to ensure one (1) of six (6) residents was not subjected to hot water temperatures of 134 degrees Fahrenheit (F). This failure resulted in physical harm to Resident #19. Resident #19 sustained second degree burns to left hand, bilateral lower extremities and feet, bilateral buttocks and scrotum. This created an immediate jeopardy situation that began on 01/04/24 at 7:12 PM when the resident was placed in the tub and ended on 01/07/24 at 6:54 PM when all hot water was shut off in the facility. All residents had the potential to be affected by the hot water temperatures. Resident identifier: #19. Facility census: 44. Findings included: a) Facility Reportable Incident (FRI) A facility reported incident was received at the state agency on 01/04/24. The report stated Nurse Aide (NA) #99 put Resident #19 into a whirlpool tub. She filled the tub to the knee level. The nurse aide realized the water was too warm. She had another aide try to adjust the water. The nurse aide admitted to not looking at the water temperature and this resulted in Resident #19 receiving severe burns to lower legs, feet, thighs, and left hand. The facility reported the immediate action taken was to suspend the nurse aide, take all tubs out of service and check for malfunction. Adult protective services were notified, as well as, the ombudsman, the local sheriff's department, and the nurse aide registry. A second facility reported incident dated 01/04/24 related to Resident #19 was also received by the state agency. This incident stated the registered nurse did not assess or treat a resident with severe burns timely. The immediate action taken was a suspension of the registered nurse in addition to the nurse aide and a shutdown of the bathtubs. A third facility reported incident dated 01/04/24 was sent to the state agency. This incident stated Maintenance Supervisor (MS) #76 had been monitoring water temperatures for over six (6) months which did not meet regulatory guidelines. MS #76 failed to report the temperatures or attempt to make any changes to meet regulatory compliance. The report revealed MS #76 said he was aware of the guidelines for water temperature and chose to keep it warmer per staff request. The five (5) day follow up report obtained on 01/09/24 revealed the following: After reviewing camera and interviewing staff (Registered Nurse #100) was asked by CNA (certified nurse assistant) that was giving (Resident #19) his bath to assess him. Another CNA asked nurse to assess him. Finally at 7:36 she went to shower room and left at 7:37. At 8:44 she got order to send to ER (emergency room ). No 1st aide administered by unit nurse until 9:05. Nurse (Registered Nurse #100) sent home until investigation over. (Registered Nurse #100) failed to assess (Resident #19) when asked 3 times by CNAs. Did not administer treatment in a timely manner. I find this report to be substantiated for neglect of resident. (Registered Nurse #100) will be removed from schedule and her agency will be notified of decision. Excessive delay in treatment. This report was completed by social service supervisor. A five day follow up to the immediate report for Certified Nurse Aide (NA) #41 revealed: After reviewing camera and interviewing NA #41 who was called to shower room and found the water too hot and adjusted water temperature. She was seen on camera leaving the shower room and going to nurses station but camera has no sound. I find this to be substantiated. NA #41 did adjust water but failed to assist in maintaining safety of resident. NA #41 sent home until investigation is done. I find this report to be substantiated for neglect of resident. NA #41 will be removed from schedule and her agency will be notified of decision. This report was completed by the social service supervisor. b) Facility Entrance During the entrance conference with the Assistant Nursing Home Administrator (ANHA) and the DON, on 01/09/24 at 12:25 PM, the DON stated Resident (#19) had received third degree burns to both lower extremities during a tub bath on the evening of 01/04/24. Resident #19 had been transferred to a local hospital and then transferred to an out of state burn unit. c) Resident #19 Resident #19 was admitted to the facility 10/12/17. Medical diagnoses included dementia with behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, peripheral vascular disease (PVD), alcohol dependence in remission, Fabry's disease, and high blood pressure. No Brief Interview for Mental Status (BIMS) was able to be obtained as the only verbal response was grunting. The resident was incontinent of bowel and bladder and required total care. The state of [NAME] Virginia served as health care surrogate for this resident. d) Timeline A timeline provided by the facility revealed Resident #19 was taken to the tub room on 01/04/24 at 7:12 PM by Nurse Aide (NA) #99. The following information is a review of the videotape of the hallway activity conducted by the Social Worker (SW) and the Minimum Data Set (MDS) Coordinator. This video was on 01/04/24 and reviewed on 01/05/24. 7:12 PM Resident #19 was taken to the tub room by Nurse Aide (NA) #99. 7:16 PM NA #99 out in the hall times two (2) and back to the tub room. 7:17 PM NA #99 out of the tub room-went to Resident #19's room and returned to the tub room. 7:20 PM NA #99 to Nurses Station (NS) then part way up hall got NA #41 and together they went to the tub room. 7:21 PM NA #41 leaves the tub room and goes to the NS back to the tub room and back to NS. 7:23 PM NA #41 in NS and leaves the NS at 7:24 PM. 7:26 PM NA #41 in the tub room then to NS at 7:27 PM. 7:29 PM NA #99 out in the hall to the linen cart and returns to the tub room. 7:33 PM NA #99 to NS and appears to be returning to the tub room. NA #99 gets NA #59 who is coming down the hall and they both go to the tub room together at 7:34. 7:35 PM NA #59 to NS. 7:36 PM NA #59 and RN #100 to tub room 7:36 PM NA #41 at NS 7:37 PM RN #100 returns to NS 7:52 PM NA #99 to NS and back to tub room 7:54 PM NA #99 to NS and back to tub room 8:00 PM RN #100 to tub room 8:02 PM RN #100 to NS 8:04 PM NA #63 arrives from Unit A1 to assist. 8:08 PM NA #41 leaves NS and goes to the tub room. 8:12 PM Resident #19 is taken back to his room. 8:15 PM NA #59 to NS and back to Resident #19's room 8:22 PM NA #41 to NS and then back to Resident #19's room 8:25 PM NA #63 leaves Resident #19's room, goes to the linen cart and returns to Resident #19's room. 8:28 PM NA #63 leaves Resident #19's room and returns with more linens. 8:33 PM NA #63 leaves Resident #19's room and returns with more linens. 8:38 PM NA #63 to NS and then to tub room 8:40 PM NA #59 to the tub room and then NS 8:41 PM NA #63 and #59 return to Resident #19's room. 8:42 PM NA #59 goes down B1 hall then returns to Resident #19's room. 8:43 PM NHA (nursing home administrator) on the unit and immediately goes to the tub room then NS and then to Resident #19's room. A review of a nursing progress note by RN #100 revealed the resident was transferred on 01/04/24 at 9:15 PM to the local hospital. Resident #19 was documented to have blistering and peeling skin to bilateral feet and calves. Vitals were documented from three (3) hours prior to transfer: Temperature: 97.7 (36.5 C) (01/04/2024 17:53 (5:53 PM) Pulse 55 (01/04/2024 17:53 (5:53 PM) Respiration: 18 (01/04/2024 17:53 (5:53 PM) Blood Pressure: 127/66 (01/04/2024 17:53 (5:53 PM) e) Investigation Statements -HSW (health service worker) #99 Statement dated 01/04/24 as follows: I was giving resident B110b (#19) a bath, as the last bit of water was draining out I noticed he had a blister on the back of his foot. I then went to the nurses station to tell the nurse (RN #100). she said she would come look at it shortly. I waited a few minutes and noticed more blisters were showing up so I went to get the other aide on the hall (name of aide) (HSW #59). She looked at it and also went to tell the nurse she needs to come look at it now. The nurse came to look at it and said she'd call the on call nurse to see what to do next. (see whether he'd need to be sent out or not.) HSW #99, #59 and #63 (identifiers used instead of names) transferred him to his wheelchair after letting some time go by to see what the nurse wanted us to do, then took him to his room, got him in bed, and laid cold compresses on his feet and legs to stop further blistering. Typed as written. -HSW #41 Statement dated 01/04/24 as follows: I am floating unit to unit. I came over to B. As I was walking down the unit HSW #99 waved me down and asked me to lower the water temp. I walked in and put my hand in the water and said that's hot. the [sic] looked at the temp gauge and it was 134. The water was past his knees but not running. I immediately turned the temp down and ran cold water in the bath. It cooled down and went out of the bath back to my task I was doing. Then when I walked back up the hall. I overheard he had blisters and recalled what happened. 1/4/24 9:01 pm I knew the bathtub would go to 140 but I didn't report it because the other staff told me it was normal and how to fix it. Typed as written. -HSW #59 Statement (first name of HSW #59) came to get me to see if I could get the nurse to look at Resident #19 because she thought his feet looked bad and the nurse to her she would look at them when he got back into bed. So I went to the tub room to look at them and seen they were badly blistered on the top and sides and a blister on his shin (left). After I seen them I went to the nurses station to tell the nurse she needed to come look at him. She said Why do they look bad? I told her no you want to come now. The nurse finally came into the tub room to see his feet when she saw the she asked if Resident #19 had edema? I told her yes, but that ' not the problem. The nurse then said she will go check the computer to see if day shift reported it. I told her it was from the water and those were burns because it looked like his skin was melting off. Resident #19 was left in the empty tub for awhile after and I decided he needed to be moved to his room via w/c (wheel chair) because he was ripping his skin off his legs by rubbing them together and ripping the skin off his feet by rubbing them on the drain. We put him to be and placed wet rags on his burns and stayed with him trying to keep him comfortable waiting to see what was going to happen. Stayed with him until EMS came. Signed by HSW #59 with date of 01/05/24. -Nursing Home Administrator (NHA) statement on 01/09/24 at 10:04 AM. I arrived at Hopemont once being made aware of this issue of the burn. I went to the resident floor. Nurse (last name) RN #100 was at the nurses station. She said to me (Resident first name) #19 is in his room. I went to his room and CNA staff advised they repeatedly told (RN first name) RN #100 that resident (resident first name) #19 was burned and she needed to look at him. They said she only momentarily observed him while in the tub and left the bathroom. They got him out of the tub and took him to his room. I observed Resident #19 and stated he is in obvious discomfort and pain that needs to be addressed. They stated the nurse never came to his room. My involvement and goal was to see that appropriate steps regarding addressing this issue were implemented to identify, correct, process, and investigate the matter fully and thoroughly. I went to the nurses station after watching the resident writhing in pain. I advised RN #100 he needs pain management now. I asked if she had been to his room. She said no and asked if she should call the doctor. I told her something needs to be done now. Further I learned that the doctor ordered the resident sent out and that it was almost 30 minutes before RN #100 even called 911. She in no way assessed the resident and his care needs. I helped interview her with the social worker. She excused her action on training and orientation. I explained as a long term RN and having worked here before she was well aware of the process, care responsibility, appropriate reaction to resident need and that emergency care is immediate paperwork second. She was removed from the schedule -RN #100 Statement This nurse was at nurses desk when first CNA came out to desk from shower room and asked if resident's (Resident #19) feet normally peel. Told CNA I would check on it. Other CNA approached several minutes later and asked nurse to come and assess residents feet. This nurse went to assess feet. Lower part of legs about 1 inch red and feet were red, blistering and starting to peel. Attempted to contact A! to get phone numbers to try and contact on call. There was no answer. Attempted to message on call but reply not immediate. Got on call number from another staff and (unable to determine this word). Informed of situation. On call supposed to re-contact. Contacted MD for order to send out after second assessment with blisters large and redness moving up his legs. Delay in call back from on call. MD gave permission to send out. Contacted back by phone and several minutes later contacted by ADON. Started process to send out. Called 911 and gave report. Contacted MD back as ADON arrived and went to see resident to get order for pain med. Paper work put together and EMS arrived after giving pain med. Signed by RN #100. There was no date nor times when this statement was to when it was written and no times when calls were made or resident assessments completed. A review of of nursing progress notes titled Nursing transfer/Discharge Note dated 01/04/24 at 20:27 (8:37 PM) found the following: The resident left the faciity on [DATE] at 9:00 PM. The transfer note described the resident as having blistering and peeling skin to bilateral feet and calves. The transfer note was electronically signed by Registered Nurse (RN) #100 on 01/04/24 at 8:49 PM. Vitals at Time of Transfer: Temperature: 97.7 (36.5 C) (01/04/2024 17:53 (5:53 PM) Pulse: 55 (01/04/2024 17:53 (5:53 PM) Respirations: 18 (01/04/2024 17:53 (5:53 PM) Blood Pressure: 127/66 (01/04/2024 17:53 (5:53 PM) These vitals were not taken at the time of transfer but approximately three (3) hours prior to transfer. At the time of transfer the resident was marked as confused. A nursing note dated 01/05/24 at 1:02 AM stated that Resident (#19) was sent to (initials of local hospital) by MD order for evaluation and treatment for burns to bilateral lower extremities (BLE). The note stated the resident was in the bath and when water was let out it was reported that he had red skin and blisters to BLE. The note stated that the on call nurse was notified at 7:59 PM and the Medical Director (MD) was contacted and an order to send the resident out was obtained at 8:44 PM. Morphine 10 milligram (mg) was given by mouth previous to EMT arriving at 9:05 pm. The Emergency Medical Technicians (EMTs) left with the resident at 9:15 PM by ambulance on a stretcher. Electronic signature by RN #100 on 01/05/24 at 1:07 AM. The resident's general condition was marked as confused, required total care and required total assistance for feeding. The resident moved all extremities. He had blisters on both lower extremities. He was incontinent of bowel and bladder with impairments of speech. RN #100 electronically signed the note on 01/04/24 at 8:40 PM. In an interview with the Nursing Home Administrator (NHA), on 01/12/24 at 3:40 PM by phone, the NHA stated when he arrived in Resident #19's room, the resident was moving all over the bed and flailing his arms and legs. When the NHA went to the NS he said he told RN #100 that Resident #19 needed something for pain immediately. A report from the local hospital where the resident was transferred revealed the resident had second degree burns to bilateral lower extremities and feet, left hand, bilateral buttocks and scrotum. The estimated surface area of the burns was 35%. At the local hospital the resident was given medications for pain including Morphine (injection 4 milligram) and Fentanyl (injection 100 microgram/2 milliliter). The resident was transported to a neighboring state burn center on 01/04/24 at 11:30 PM.

Based on observation, staff interviews, medical record review, temperature log review, facility reportable incident (FRI) review, and hospital record review, the facility failed to ensure one (1) of six (6) residents had an environment which was as free of accident hazards as was possible. Nurse Aide (NA) #99 failed to monitor the water temperature when filling the tub. In addition NA #99 failed to supervise this resident during the bathing process. After Resident #19 was placed in the tub, water at 134 degrees (F) was used to fill the tub. Resident #19 sustained second degree burns to the left hand, bilateral lower extremities and feet, bilateral buttocks and scrotum. This created an immediate jeopardy situation that began on 01/04/24 at 7:12 PM when the resident was placed in the water and it ended on 01/07/24 at 6:54 PM when the hot water in the facility was turned off. When the immediate jeopardy was removed the result was harm to Resident #19. Resident identifier: #19. Facility census: 44. Findings included: a) Facility Reportable Incident (FRI) A facility reported incident was received at the state agency on 01/04/24. The report stated Nurse Aide (NA) #99 put Resident #19 into a whirlpool tub. She filled the tub to the knee level. The nurse aide realized the water was too warm. She had another aide try to adjust the water. The nurse aide admitted to not looking at the water temperature and this resulted in Resident #19 receiving severe burns to lower legs, feet, thighs, and left hand. The facility reported the immediate action taken was to suspend the nurse aide, take all tubs out of service and check for malfunction. Adult protective services were notified, as well as, the ombudsman, the local sheriff's department, and the nurse aide registry. A second facility reported incident dated 01/04/24 related to Resident #19 was also received by the state agency. This incident stated the registered nurse did not assess or treat a resident with severe burns timely. The immediate action taken was a suspension of the registered nurse in addition to the nurse aide and a shutdown of the bathtubs. A third facility reported incident dated 01/04/24 was sent to the state agency. This incident stated MS #76 had been monitoring water temperatures for over six (6) months which did not meet regulatory guidelines. MS #76 failed to report the temperatures or attempt to make any changes to meet regulatory compliance. The report revealed MS #76 said he was aware of the guidelines for water temperature and chose to keep it warmer per staff request. The five (5) day follow up report obtained on 01/09/24 revealed the following: After reviewing camera and interviewing staff (Registered Nurse #100) was asked by CNA (ceritfied nurse assistant) that was giving (Resident #19) his bath to assess him. Another CNA asked nurse to assess him. Finally at 7:36 she went to shower room and left at 7:37. At 8:44 she got order to send to ER (emergency room ). No 1st aide administered by unit nurse until 9:05. Nurse (Registered Nurse #100) sent home until investigation over. (Registered Nurse #100) failed to assess (Resident #19) when asked 3 times by CNAs. Did not administer treatment in a timely manner. I find this report to be substantiated for neglect of resident. (Registered Nurse #100) will be removed from schedule and her agency will be notified of decision. Excessive delay in treatment. This report was completed by the social service supervisor. A five day follow up to the immediate report for Certified Nurse Aide (NA) #41 revealed: After reviewing camera and interviewing NA #41 who was called to shower room and found the water too hot and adjusted water temperature. She was seen on camera leaving the shower room and going to nurses station but camera has no sound. I find this to be substantiated. NA #41 did adjust water but failed to assist in maintaining safety of resident. NA #41 sent home until investigation is done. I find this report to be substantiated for neglect of resident. NA #41 will be removed from schedule and her agency will be notified of decision. This report was completed by the social service supervisor. b) Facility Entrance During the entrance conference with the Assistant Nursing Home Administrator (ANHA) and the DON, on 01/09/24 at 12:25 PM, the DON stated Resident (#19) had received third degree burns to both lower extremities during a tub bath on the evening of 01/04/24. Resident #19 had been transferred to a local hospital and then transferred to an out of state burn unit. c) Resident #19 Resident #19 was admitted to the facility 10/12/17. Medical diagnoses included dementia with behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, peripheral vascular disease (PVD), alcohol dependence in remission, Fabry's disease, and high blood pressure. No Brief Interview for Mental Status (BIMS) was able to be obtained as the only verbal response was grunting. The resident was incontinent of bowel and bladder and required total care. The state of [NAME] Virginia served as health care surrogate for this resident. d) Timeline A timeline provided by the facility revealed Resident #19 was taken to the tub room on 01/04/24 at 7:12 PM by Nurse Aide (NA) #99. The following information is a review of the videotape of the hallway activity conducted by the Social Worker (SW) and the Minimum Data Set (MDS) Coordinator. This video was on 01/04/24 and reviewed on 01/05/24. 7:12 PM Resident #19 was taken to the tub room by Nurse Aide (NA) #99. 7:16 PM NA #99 out in the hall times two (2) and back to the tub room. 7:17 PM NA #99 out of the tub room-went to Resident #19's room and returned to the tub room. 7:20 PM NA #99 to Nurses Station (NS) then part way up hall got NA #41 and together they went to the tub room. 7:21 PM NA #41 leaves the tub room and goes to the NS back to the tub room and back to NS. 7:23 PM NA #41 in NS and leaves the NS (nurses station) at 7:24 PM. 7:26 PM NA #41 in the tub room then to NS at 7:27 PM. 7:29 PM NA #99 out in the hall to the linen cart and returns to the tub room. 7:33 PM NA #99 to NS and appears to be returning to the tub room. NA #99 gets NA #59 who is coming down the hall and they both go to the tub room together at 7:34. 7:35 PM NA #59 to NS. 7:36 PM NA #59 and RN #100 to tub room 7:36 PM NA #41 at NS 7:37 PM RN #100 returns to NS 7:52 PM NA #99 to NS and back to tub room 7:54 PM NA #99 to NS and back to tub room 8:00 PM RN #100 to tub room 8:02 PM RN #100 to NS 8:04 PM NA #63 arrives from Unit A1 to assist. 8:08 PM NA #41 leaves NS and goes to the tub room. 8:12 PM Resident #19 is taken back to his room. 8:15 PM NA #59 to NS and back to Resident #19's room 8:22 PM NA #41 to NS and then back to Resident #19's room 8:25 PM NA #63 leaves Resident #19's room, goes to the linen cart and returns to Resident #19's room. 8:28 PM NA #63 leaves Resident #19's room and returns with more linens. 8:33 PM NA #63 leaves Resident #19's room and returns with more linens. 8:38 PM NA #63 to NS and then to tub room 8:40 PM NA #59 to the tub room and then NS 8:41 PM NA #63 and #59 return to Resident #19's room. 8:42 PM NA #59 goes down B1 hall then returns to Resident #19's room. 8:43 PM NHA (nursing home administrator) on the unit and immediately goes to the tub room then NS and then to Resident #19's room. A review of a nursing progress note by RN #100 revealed the resident was transferred on 01/04/24 at 9:15 PM to the local hospital. Resident #19 was documented to have blistering and peeling skin to bilateral feet and calves. Vitals were documented from three (3) hours prior to transfer: Temperature: 97.7 (36.5 C) (01/04/24 17:53 (5:53 PM) Pulse 55 (01/04/24 17:53 (5:53 PM) Respiration: 18 (01/04/24 17:53 (5:53 PM) Blood Pressure: 127/66 (01/04/24 17:53 (5:53 PM) e) Investigation Statements -HSW (health service worker) #99 Statement dated 01/04/24 as follows: I was giving resident B110b (#19) a bath, as the last bit of water was draining out I noticed he had a blister on the back of his foot. I then went to the nurses station to tell the nurse (RN #100). she said she would come look at it shortly. I waited a few minutes and noticed more blisters were showing up so I went to get the other aide on the hall (name of aide) (HSW #59). She looked at it and also went to tell the nurse she needs to come look at it now. The nurse came to look at it and said she'd call the on call nurse to see what to do next. (see whether he'd need to be sent out or not.) HSW #99, #59 and #63 (identifiers used instead of names) transferred him to his wheelchair after letting some time go by to see what the nurse wanted us to do, then took him to his room, got him in bed, and laid cold compresses on his feet and legs to stop further blistering. Typed as written. -HSW #41 Statement dated 01/04/24 as follows: I am floating unit to unit. I came over to B. As I was walking down the unit HSW #99 waved me down and asked me to lower the water temp. I walked in and put my hand in the water and said that's hot. the [sic] looked at the temp gauge and it was 134. The water was past his knees but not running. I immediately turned the temp down and ran cold water in the bath. It cooled down and went out of the bath back to my task I was doing. Then when I walked back up the hall. I overheard he had blisters and recalled what happened. 1/4/24 9:01 pm I knew the bathtub would go to 140 but I didn't report it because the other staff told me it was normal and how to fix it. Typed as written. -HSW #59 Statement (first name of HSW #59) came to get me to see if I could get the nurse to look at Resident #19 because she thought his feet looked bad and the nurse to her she would look at them when he got back into bed. So I went to the tub room to look at them and seen they were badly blistered on the top and sides and a blister on his shin (left). After I seen them I went to the nurses station to tell the nurse she needed to come look at him. She said Why do they look bad? I told her no you want to come now. The nurse finally came into the tub room to see his feet when she saw the she asked if Resident #19 had edema? I told her yes, but that ' not the problem. The nurse then said she will go check the computer to see if day shift reported it. I told her it was from the water and those were burns because it looked like his skin was melting off. Resident #19 was left in the empty tub for awhile after and I decided he needed to be moved to his room via w/c (wheel chair) because he was ripping his skin off his legs by rubbing them together and ripping the skin off his feet by rubbing them on the drain. We put him to be and placed wet rags on his burns and stayed with him trying to keep him comfortable waiting to see what was going to happen. Stayed with him until EMS came. Signed by HSW #59 with date of 01/05/24. -Nursing Home Administrator (NHA) statement on 01/09/24 at 10:04 AM. I arrived at Hopemont once being made aware of this issue of the burn. I went to the resident floor. Nurse (last name) RN #100 was at the nurses station. She said to me (Resident first name) #19 is in his room. I went to his room and CNA staff advised they repeatedly told (RN first name) RN #100 that resident (resident first name) #19 was burned and she needed to look at him. They said she only momentarily observed him while in the tub and left the bathroom. They got him out of the tub and took him to his room. I observed Resident #19 and stated he is in obvious discomfort and pain that needs to be addressed. They stated the nurse never came to his room. My involvement and goal was to see that appropriate steps regarding addressing this issue were implemented to identify, correct, process, and investigate the matter fully and thoroughly. I went to the nurses station after watching the resident writhing in pain. I advised RN #100 he needs pain management now. I asked if she had been to his room. She said no and asked if she should call the doctor. I told her something needs to be done now. Further I learned that the doctor ordered the resident sent out and that it was almost 30 minutes before RN #100 even called 911. She in no way assessed the resident and his care needs. I helped interview her with the social worker. She excused her action on training and orientation. I explained as a long term RN and having worked here before she was well aware of the process, care responsibility, appropriate reaction to resident need and that emergency care is immediate paperwork second. She was removed from the schedule -RN #100 Statement This nurse was at nurses desk when first CNA came out to desk from shower room and asked if resident's (Resident #19) feet normally peel. Told CNA I would check on it. Other CNA approached several minutes later and asked nurse to come and assess residents feet. This nurse went to assess feet. Lower part of legs about 1 inch red and feet were red, blistering and starting to peel. Attempted to contact A! to get phone numbers to try and contact on call. There was no answer. Attempted to message on call but reply not immediate. Got on call number from another staff and (unable to determine this word). Informed of situation. On call supposed to re-contact. Contacted MD for order to send out after second assessment with blisters large and redness moving up his legs. Delay in call back from on call. MD gave permission to send out. Contacted back by phone and several minutes later contacted by ADON. Started process to send out. Called 911 and gave report. Contacted MD back as ADON arrived and went to see resident to get order for pain med. Paper work put together and EMS arrived after giving pain med. Signed by RN #100. There was no date nor times when this statement was to when it was written and no times when calls were made or resident assessments completed. A review of of nursing progress notes titled Nursing transfer/Discharge Note dated 01/04/24 at 20:27 (8:37 PM) found the following: The resident left the faciity on [DATE] at 9:00 PM. The transfer note described the resident as having blistering and peeling skin to bilateral feet and calves. The transfer note was electronically signed by Registered Nurse (RN) #100 on 01/04/24 at 8:49 PM. The order from the physician to send the resident out of the facility was obtained by the RN at 8:44 PM. The reportable record showed the nurse aides (#41 and #99) first began asking RN #100 for assistance and to assess Resident #19 due to blisters from the hot water on 01/04/24 at 7:36 PM. f) A review of the water temperature logs revealed the following: Water Temperature Leaving Mixing Valve, located in the Potato Room i.e., boiler room, which supplies hot water to resident care areas as follows: Water Temperatures: January 2023 01/03/23 122 degrees (F), 01/04/23 120 degrees (F), 01/05/23 118 degrees (F), 01/06/23 124 degrees (F), 01/09/23 120 degrees (F), 01/10/23 126 degrees (F), 01/11/23 122 degrees (F), 01/12/23 120 degrees (F), 01/15/23 120 degrees 126 degrees (F), 01/18/23 124 degrees (F), 01/19/23 122 degrees (F), 01/20/23 120 degrees (F), , 01/24/23 126 degrees (F), 01/25/23 122 degrees (F), 01/26/23 126 degrees (F), 01/27/23 124 degrees (F), 01/30/23 126 degrees (F), 01/31/23 126 degrees (F), February 2023 02/02/23 124 degrees (F), 02/03/23 124 degrees (F), 02/06/23 126 degrees (F), 02/07/23 124 degrees (F), 02/08/23 130 degrees (F),02/13/23 126 degrees (F), 02/14/23 124 degrees (F), 02/15/23 128 degrees (F), 02/16/23 126 degrees (F), 02/17/23 128 degrees (F), 02/21/23 124 degrees (F), 02/22/23 128 degrees (F), 02/23/23 126 degrees (F), 02/24/23 128 degrees (F), 02/27/23 120 degrees (F) March 2023 03/01/23 126 degrees (F), 03/02/23 120 degrees (F), 03/03/23 124 degrees (F), 03/06/23 130 degrees (F), 03/07/23 124 degrees (F), 03/08/23 126 degrees (F), 03/09/23 126 degrees (F), 03/10/23 130 degrees (F), 03/16/23 120 degrees (F), 03/20/23 130 degrees (F), 03/21/23 130 degrees (F), 03/22/23 119 degrees (F), 03/23/23 124 degrees (F) 03/27/23 124 degrees (F), 03/28/23 128 degrees (F) April 2023 04/03/23 120 degrees (F), 04/04/23 126 degrees (F), 04/05/23 124 degrees (F), 04/06/23 119 degrees (F), 04/07/23 121 degrees (F), 04/10/23 120 degrees (F), 04/11/23 124 degrees (F), 04/12/23 123 degrees (F), 04/13/23 121 degrees (F), 04/14/23 115 degrees (F), 04/17/23 125 degrees (F), 04/18/23 120 degrees (F), 04/19/23 119 degrees (F), 04/20/23 121 degrees (F), 04/21/21 122 degrees (F), 04/24/23 130 degrees (F), 04/25/23 128 degrees (F), 04/26/23 115 degrees (F), 04/28/23 120 degrees (F) May 2023 05/01/23 120 degrees (F), 05/02/23 124 degrees (F), 05/03/23 122 degrees (F), 05/04/23 122 degrees (F), 05/05/23 118 degrees (F), 05/10/23 116 degrees (F), 05/11/23 124 degrees (F), 05/15/23 120 degrees (F), 05/16/23 126 degrees (F), 05/17/23 130 degrees (F), 05/18/23 120 degrees (F), 05/19/23 118 degrees (F), 05/22/23 122 degrees (F), 05/23/23 120 degrees (F), 05/24/23 116 degrees (F), 05/26/23 130 degrees (F), 05/29/23 130 degrees (F), 05/30/23 120 degrees (F), 05/31/23 124 degrees (F) June 2023 06/01/23 120 degrees (F), 06/02/23 112 degrees (F), 06/05/23 120 degrees (F), 06/06/23 116 degrees (F), 06/07/23 120 degrees (F), 06/08/23 130 degrees (F), 06/09/23 130 degrees (F), 06/12/23 118 degrees (F), 06/13/23 126 degrees (F), 06/14/23 122 degrees (F), 06/15/23 124 degrees (F), 06/16/23 118 degrees (F), 06/19/23 121 degrees (F), 06/20/23 114 degrees (F), 06/21/23 120 degrees (F), 06/22/23 122 degrees (F), 06/23/24 116 degrees (F), 06/26/23 131 degrees (F), 06/27/23 122 degrees (F), 06/28/23 124 degrees (F), 06/29/23 120 degrees (F), 06/30/23 124 degrees (F) July 2023 07/05/23 121 degrees (F), 07/06/23 120 degrees (F), 07/07/23 120 degrees (F), 07/10/23 121 degrees (F), 07/11/23 116 degrees (F), 07/14/23 120 degrees (F), 07/17/23 122 degrees (F), 07/18/23 132 degrees (F), 07/19/23 124 degrees (F), 07/20/23 114 degrees (F), 07/21/23 128 degrees (F),07/26/23 120 degrees (F), 07/27/23 118 degrees (F), 07/28/23 122 degrees (F), 07/31/23 120 degrees (F) August 2023 08/01/23 120 degrees (F), 08/02/23 118 degrees (F), 08/03/23 120 degrees (F), 08/04/23 124 degrees (F), 08/07/23 120 degrees (F), 08/08/23 121 degrees (F), 08/09/23 118 degrees (F), 08/10/23 122 degrees (F), 08/11/23 130 degrees (F), 08/14/23 121 degrees (F), 08/15/23 129 degrees (F), 08/16/23 118 degrees (F), 08/18/23 136 degrees (F), 08/21/23 120 degrees (F), 08/22/23 124 degrees (F), 08/23/23 133 degrees (F), 08/24/23 114 degrees (F), 08/25/23 126 degrees (F), 08/28/23 130 degrees (F), 08/29/23 140 degrees (F), 08/30/23 128 degrees (F), September 2023 09/01/23 125 degrees (F), 09/05/23 128 degrees (F), 09/06/23 130 degrees (F), 09/07/23 126 degrees (F), 09/08/23 130 degrees (F), 09/11/23 126 degrees (F), 09/12/23 124 degrees (F), 09/13/23 121 degrees (F) , 09/18/23 130 degrees (F), 09/19/23 126 degrees (F), 09/20/23 124 degrees (F), 09/21/23 120 degrees (F), 09/29/23 130 degrees (F) October 2023 10/02/23 125 degrees (F), 10/03/23 130 degrees (F), 10/04/23 132 degrees (F), 10/05/23 130 degrees (F) 10/09/23 140 degrees (F), 10/10/23 138 degrees (F), 10/11/23 10/13/23 130 degrees (F), 10/16/23 120 degrees (F), 10/17/23 130 degrees (F), 10/18/23 124 degrees (F), 10/19/23 124 degrees (F),10/20/23 128 degrees (F), 10/24/23 132 degrees (F), 10/25/23 128 degrees (F), 10/26/23 130 degrees (F), 10/27/23 142 degrees (F), 10/30/23 140 degrees (F), 10/31/23 132 degrees (F) November 2023 11/01/23 128 degrees (F), 11/02/23 132 degrees (F), 11/03/23 141 degrees (F), 11/06/23 140 degrees (F), 11/07/23 128 degrees (F), 11/08/23 130 degrees (F), 11/09/23 134 degrees (F), 11/13/23 130 degrees (F), 11/14/23 126 degrees (F), December 2023 12/01/23 130 degrees (F), 12/04/23 130 degrees (F), 12/05/23 132 degrees (F), 12/06/23 140 degrees (F), 12/07/23 128 degrees (F), 12/08/23 132 degrees (F), 12/11/23 130 degrees (F), 12/12/23 126 degrees (F), 12/13/23 140 degrees (F), 12/14/23 140 degrees (F), 12/15/23 138 degrees (F), 12/20/23 130 degrees (F), 12/21/23 126 degrees (F), 12/22/23 140 degrees (F), 12/26/23 128 degrees (F), 12/28/23 132 degrees (F), 12/29/23 130 degrees (F) January 2023 There were no temperatures avaialble prior to 01/04/24 when a temperature of 140 degrees (F) was recorded after the incident. Record review revealed water temperatures continued to be above 110 degrees (F) on 01/05/24, 01/06/24, and on 01/07/24. These temperatures logs revealed temperateurs were taken at four (4) sinks, and in the shower room. There were no temperatures recorded on weekends and holidays. Record review on 01/09/24 at 2:18 PM, revealed no evidence was provided during the survey to show the corrective action or adjustments to the resident hot water system when water temperatures were routinely recorded above 110 degrees Fahrenheit (F) monthly from January 2023 through December 2023. Approximately 121 days had temperatures logged above 110 degrees Fahrenheit. These temperatures were logged by the Maintenance Department Staff for resident corridors A1, B1, and resident areas ([NAME]) and Dining Room ([NAME]). An interview on 01/09/24 at 2:20 PM. with the Assistant Administrator verified this finding. Nurse Educator (NE) #78 An email from the nurse educator to administrative staff dated 01/07/24 at 9:54 AM revealed NE #78 was still concerned about the hot water in the sinks. In the email the nurse educator explained that the staff had been told not to use the hot water because it had been registering over 110 degrees (F). The nurse educator stated she was concerned that residents would use the sink and nursing could not monitor the situaiton. In her email the Nurse Educator said that Licensed Practical Nurse (LPN) #46 had asked about shutting the hot water off and was told it could not be done. On 01/11/24 the administrator gave a statement to the surveyor indicating he ordered access to all hot water be shut down in the resident care areas on 01/07/24 at 6:54 PM. g) The Quality Assurance and Performance Improvement Committee (QAPI) met on 01/09/24 at approximately 10:00 a.m. to discuss the current situation of water temps for resident care. Documentation revealed that water temps were being checked every hour since 01/05/24 at the four (4) main sinks on Resident corridors of A1 and B1 and the resident showers on the corridors of A1 and [NAME] 1, with this documentation forwarded to Administration for review. The showers had not been used since 01/04/24. Repairs were initiated on the hot water system on 01/08/24 to isolate the hot water distributed to the resident care areas and residents currently have no access to hot water until the final repairs are made. Prior to the time of survey, potential mechanical issues with an isolation valve, hot water tank thermostat, and a water system distribution mixing valve and gauge were discovered. The isolation valve, thermostat, and mixing valve gauge had been replaced prior to survey. The water system distribution mixing valve was being investigated further with parts being ordered for repair during survey. Nursing staff were notified that they would be using wipes and no rinse shampoo and body wash until further notice. Per the QAPI meeting minutes, reeducation was provided to staff reiterating appropriate hot water temperatures and completing maintenance work orders if issues are suspected with the temperature of the water system. Phone interview on 01/09/24 at approximately 11:36 AM., with the Director of Facilities and Plant Operations #97 revealed the perceived issue with the hot water system was a faulty thermostat on the hot water tank serving resident corridors A1 and B1 of the Nursing Building. The issue with the thermostat was believed to have failed in the close position and was discovered mid-morning on Friday, January 5th. The hot water system was drained and refilled with 55-degree city water. An isolation valve was added on Monday, January 8th. Interview also noted that hot water temperatures were not supposed to be above 110 degrees (F). Observation on 01/09/24 at approximately 12:14 PM. revealed the only hot water being provided was to the Dining Areas. The temperature of hot water at a hand sink in the Dining area was noted as 109.1 degrees (F). Hot water to the other resident areas such as Corridor A1, B1, and corridor [NAME] 1 was isolated off in the basement and handles removed form faucets and fixtures to prevent residents from accidentally turning on the hot water while repairs and adjustments were made to the system. Interview on 01/09/24 at approximately 1:03 PM., with Building Maintenance Mechanic #95 revealed that an issue with a thermostat on a hot water tank in the basement (Potato Room) was discovered and replaced. A ball valve was also replaced as a suspected back-feed elimination. A gauge for the mixing valve for the water leaving this area to the resident areas was also replaced. Interview noted that a daily log of the water temperatures was maintained in each mechanical room. Interview noted that he was not aware that temperatures above 110 degrees (F) needed to be reported and only recorded what the gauges read and was not previously aware of what the water temperatures were supposed to be maintained at. Phone interview on 01/10/24 at approximately 9:43 AM, with the Maintenance Supervisor #76 noted that he had been the Maintenance Supervisor for approximately 5 years. The interview revealed he recorded the temperatures of the hot water system as noted on the gauges and was aware that the temperatures were supposed to be maintained at 110 degrees (F). He also noted he tried to keep temperatures warm enough on the floors. He said nursing would let him know if the temperatures seemed too cold. Interview noted that he did not report the daily/monthly temperature logs to any committee or had not been asked for them. The Office of Health Facilities Policy (Policy OHF.LS.0002) for Preventive Maintenance and Casualty Prevention Plan was updated to include an effective date based upon the date of approval on the signature page. This policy outlined the testing and preventative maintenance procedures and documentation requirements for the Plant Operations, Maintenance, and Engineering Staff. Documentation from the Preventative Maintenance and Casualty Prevention Plan is monitored through safety surveillance, which is conducted hospital wide monthly by members of the Safety Committee. These inspection reports are to be given to the Safety Officer, who will then assign corrective action from the appropriate department. This policy outlines that all boiler room equipment gauges are to be visually monitored daily and that patient hot water is not to exceed 110 degrees Fahrenheit with any deviations reported the Maintenance Department immediately. In a conversation between the local plumber and NHA, on 01/11/24 at 3:45 PM, the plumber stated the mixing value was defective and would have to be replaced as well as relocating the mixing valve. There were no mixing valves available locally and would have to be ordered. The plumber also suggested that filters be built into the water system to collect dirt. The NHA comment was Whatever it takes.

Based on a review of the orientation records, and staff interviews, the facility failed to ensure licensed staff and nurse aides were able to demonstrate competency skills and techniques necessary to care for resident needs. Registered Nurse #100 (RN) failed to render aid timely to Resident #19 who sustained third degree burns. A nurse aide (NA) failed to ensure one (1) of six (6) resident's safety during a bath. The nurse aide exposed the resident to water at 134 degrees Fahrenheit (F). This caused third degree burns to the resident. Resident identifier: #19. Staff identifiers: Registered Nurse (RN) #100, Nurse Aide #99. This failed practice created an immediate jeopardy situation that began on 01/04/24 when the resident was place in the bath and ended on 01/22/24 when all staff completed competencies on safe bathing. Water temperatures more than 110 degrees (F) were recorded from January 3, 2024, until the hot water access to resident care areas was shut down on 01/07/24 at 6:54 PM. This had the potential to affect all residents residing in the facility. Facility census: 44. Findings included: a) Facility Reportable Incident (FRI) A facility reported incident was received at the state agency on 01/05/24. The report stated Nurse Aide #99 put Resident #19 into a whirlpool tub. She filled the tub to the knee level. The nurse aide realized the water was too warm. She had another aide try to adjust the water. The nurse aide admitted to not looking at the water temperature and this resulted in Resident #19 receiving severe burns to lower legs, feet, thighs, and left hand. The facility reported the immediate action taken was to suspend the nurse aide, take all tubs out of service and check for malfunction. Adult protective services were notified, the ombudsman, the local sheriff's department, and the nurse aide registry. A second facility reported incident dated 01/04/24 related to Resident #19 was also received by the state agency. This incident stated the registered nurse did not assess or treat a resident with severe burns timely. The immediate action taken was a suspension of the registered nurse in addition to the nurse aide and a shutdown of the bathtubs. A third facility reported incident dated 01/05/24 was sent to the state agency. This incident stated MS #76 had been monitoring water temperatures for over six (6) months that did not meet regulatory guidelines. MS #76 failed to report the temperatures or attempt to make any changes to meet regulatory compliance. The report revealed MS #76 said he was aware of the guidelines for water temperature and chose to keep it warmer per staff request. The five (5) day follow up report obtained on 01/09/24 revealed the following: After reviewing camera and interviewing staff (Registered Nurse #100) was asked by CNA (ceritfied nurse assistant) that was giving (Resident #19) his bath to assess him. Another CNA asked nurse to assess him. Finally at 7:36 she went to shower room and left at 7:37. At 8:44 she got order to send to ER (emergency room ). No 1st aide administered by unit nurse until 9:05. Nurse (Registered Nurse #100) sent home until investigation over. (Registered Nurse #100) failed to assess (Resident #19) when asked 3 times by CNAs. Did not administer treatment in a timely manner. I find this report to be substantiated for neglect of resident. (Registered Nurse #100) will be removed from schedule and her agency will be notified of decision. Excessive delay in treatment. This report was completed by the social service supervisor. A five day follow up to the immediate report for Certified Nurse Aide (NA) #41 revealed: After reviewing camera and interviewing NA #41 who was called to shower room and found the water too hot and adjusted water temperature. She was seen on camera leaving the shower room and going to nurses station but camera has no sound. I find this to be substantiated. NA #41 did adjust water but failed to assist in maintaining safety of resident. NA #41 sent home until investigation is done. I find this report to be substantiated for neglect of resident. NA #41 will be removed from schedule and her agency will be notified of decision. This report was completed by the social service supervisor. Resident #19 was admitted to the facility 10/12/2017. Medical diagnoses included dementia with behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, peripheral vascular disease (PVD), alcohol dependence in remission, Fabry's disease, and high blood pressure. No Brief Interview for Mental Status (BIMS) was able to be obtained as the only verbal response was grunting. A review of nursing progress note revealed the resident was transferred on 01/04/24 at 9:00 PM. Resident #19 was documented to have blistering and peeling skin to bilateral feet and calves. Medical Record Review revealed the resident's general condition was marked as confused, required total care, and required total assistance for feeding. The resident moved all extremities. He had blistering to both lower extremities. He was incontinent of bowel and bladder with impairments of speech. RN #100 electronically signed her note on 01/04/24 at 8:40 PM. A nursing note dated 01/05/24 at 1:02 AM stated that Resident (#19) sent to (initials of local hospital) by MD order for eval and treat for burns to BLE (both lower extremities). The resident was in bath and when water was let out it was reported that he had red skin and blisters BLE. The note stated Contacted on call at 7:59 pm. MD notified and order for send out obtained and put in 9:10pm. Morphine 10 mg given P.O. before EMT arriving at 9:05pm. EMT left with resident at 9:15PM by ambulance on a stretcher. RN #100 electronically signed this note on 01/05/24 at 1:07 AM. b) A video review with statements was provided to the surveyor by the facility The following was a review of the video tape of the hallway activity conducted by the Social Worker (SW) and the Minimum Data Set (MDS) Coordinator. This video was on 01/04/24 and reviewed on 01/05/24. 7:12 PM Resident #19 was taken to the tub room by Nurse Aide (NA) #99. 7:16 PM NA #99 out in the hall times two (2) and back to tub room. 7:17 PM NA #99 out of tub room-went to Resident #19's room and returned to tub room. 7:20 PM NA #99 to Nurses Station (NS) then part way up hall got CNA #41 and together they went to tub room. 7:21 PM NA #41 leaves the tub room and goes to the NS back to tub room and back to NS. 7:23 PM NA #41 in NS and leaves the NS at 7:24 PM. 7:26 PM NA #41 in tub room then to NS at 7:27 PM. 7:29 PM NA #99 out in hall to linen cart and returns to tub room. 7:33 PM NA #99 to NS and appears to be returning to the tub room. CNA #99 gets CNA #59 who is coming down the hall and they both go to the tub room together at 7:34. 7:35 PM NA #59 to NS. 7:36 PM NA #59 and RN #100 to tub room 7:36 PM NA #41 at NS 7:37 PM RN #100 returns to NS 7:52 PM NA #99 to NS and back to tub room 7:54 PM NA #99 to NS and back to tub room 8:00 PM RN #100 to tub room 8:02 PM RN #100 to NS 8:04 PM NA #63 arrives from Unit A1 to assist. 8:08 PM NA #41 leaves NS and goes to tub room. 8:12 PM Resident #19 is taken back to his room. 8:15 PM NA #59 to NS and back to Resident #19's room 8:22 PM NA #41 to NS and then back to Resident #19's room 8:25 PM NA #63 leaves Resident #19's room, goes to linen cart and returns to Resident #19's room. 8:28 PM NA #63 leaves Resident #19's room and returns with more linens. 8:33 PM NA #63 leaves Resident #19's room and returns with more linens. 8:38 PM NA #63 to NS and then to tub room 8:40 PM NA #59 to tub room and then NS 8:41 PM NA #63 and #59 return to Resident #19's room. 8:42 PM NA #59 goes down B1 hall then returns to Resident #19's room. 8:43 PM NHA (nursing home administrator) on unit and immediately goes to tub room then NS and then to Resident #19's room. 8:44 PM ADON (assistant director of nursing) was on the unit and immediately went to Resident #19's room. 8:45 PM ADON running from unit to get supplies. 8:45 PM Building and Grounds Manager (BGM) #76 on unit and goes to tub room. 8:47 PM NHA and BGM #76 in tub room 8:49 PM BGM #76 checking water in hall 8:50 PM CNA #63 to NS and returns to Resident #19's room. 8:56 PM NHA goes to the Nursing Station. 8:57 PM Social Service Supervisor (SSS) #70-Advocate arrives on the unit. 8:57 PM CNA #63 running down hall for more supplies. 9:00 PM CNA #63 returning with supplies. 9:03 PM SSS #70 leaves unit 9:04 PM NHA goes to tub room. 9:05 PM CNA #63 rushing off unit. 9:05 PM RN (registered nurse) #100 leaves NS and goes to Resident #19's room. 9:06 PM RN #100 returns to NS 9:17 PM EMS leaves unit with Resident #19 9:18 PM NHA and ADON on unit at NS 9:19 PM NHA and ADON along with NA #99 walking off unit 9:21 PM RN #100 pushes med cart into hall 1:20 AM RN #100 clocked out and was escorted out of building by ADON. c) Assistant Director of Nursing (ADON) In a statement by the Assistant Director of Nursing (ADON) stated (first name of RN #100) was called to the bathroom for reported blisters of Resident #19 more than once. Eventually RN #100 went to observe, then left the room after 1.5 minutes at 7:36 pm. RN #100 did not render first aid or pain management. RN #100 went back to desk at 7:36 pm and did not call appropriate help (Doctor, On call nurse, 911, EMS, other unit nurse) until 8:25 pm when she contacted the RN on call. Between 8pm and 8:25 pm she did get the doctor's order to send out. 8:26 pm doctors order to send out written. EMS records show she did not call them until 8:54 pm. d) The Nursing Home Administrator's (NHA) statement dated 01/09/24 at 10:04 AM The NHA said he arrived at the facility once he was made aware of this issue of the burn. NHA said he went to the resident floor. RN #100 was at the nurse's station. She said to me (Resident first name) #19 was in his room. NHA said he went to Resident #19's room and nurse aide staff advised they repeatedly told RN #100 that Resident #19 was burned and she needed to look at him. They said she only momentarily observed him while in the tub and left the bathroom. They got him out of the tub and took him to his room. NHA said he observed Resident #19 and stated he was in obvious discomfort and pain that needed addressed. The nurse aides stated the nurse never came to his room. The NHA said his involvement and goal was to see that appropriate steps regarding addressing this issue were implemented to identify, correct, process, and investigate the matter fully and thoroughly. NHA said he went to the nurses' station after watching the resident writhing in pain. He advised RN #100 that he needed pain management now. He asked if she had been to his room. She said no and asked if she should call the doctor. NHA said he told her something needed done now. Further he said he learned the doctor ordered the resident sent out and that after receiving the order 30 minutes passed before RN #100 called 911. NHA said in no way did RN #100 assess the resident and his care needs. The NHA said RN #100 excused her action on training and orientation. NHA said he explained as a long-term RN and having worked here before she was well aware of the process, care responsibility, appropriate reaction to resident need and that emergency care was immediate and paperwork was second. NHA said he told RN #100 in his opinion her actions clearly were a delay in treatment and neglect. NHA said he told RN #100 until the investigation was completed; she was removed from the schedule. On 01/10/24 at 10:24 AM a review of employee records for skills competencies was conducted for Registered Nurse (RN) #100. No evidence was found of a skills competency being completed during orientation dated 11/14/23. RN #100 scored on a scenario-based testing 86% on pain evaluation and management, and 67% on resident evaluation. No evidence was provided regarding skills demonstration or evaluation of returned demonstrations. e) Nurse Aide #99 On 01/10/24 at 10:24 AM a review of employee records for skills competencies was conducted for HSW #99. No evidence was found of a skills competency being completed during orientation dated 11/13/23. The New Staff Orientation Competency with a start date of 11/13/23 and a completion date of 11/14/23 found in the area titled Legend (How Met) under Section F. Other (Specify: Return Demonstration) handwritten Discussion, Verbalized Understanding. The areas found on the New Staff Orientation Competency included major topics of Initial Employee Orientation, Tour of Department and Facility, HIPPA Officer, Safety, Social Services, Ethics and Compliance, Quality Assurance, Infection Control, and Departmental Expectations/Tasks and Responsibilities. The Safety section included the following: Emergency Codes Emergency Preparedness Shelter in Place Water Management Plan Active Shooter Training Interim Life Safety Infection Control Fire Watch Plan Resident Safety Fire Safety Fire Drills Fire Watch Fire Extinguisher Pull Stations Emergency Exits Workplace Security Preventative Maintenance Requirements Maintenance Work Orders Resident Environment Resident Equipment General Environment Location of MSDS Manuals Labeling and Storing of Chemicals and other hazardous materials. Elopement Procedure f) On 01/11/24 at 10:40 AM in the presence of the Director of Nursing (DON), CNA #66 was interviewed. NA #66 stated that she showed new employees how to operate the tub and then has the new employee complete a return demonstration. When asked how this was documented, CNA #66 stated We used to have one (skills competency check off sheet) but I don't have one now. During the night of 01/04/24 into 01/05/24 the ADON educated the night shift staff that temperatures that exceed 110 degrees were not within regulation and should not be used on any resident. The staff included RN #100, HSW's (health service worker) #99, # 41, #59, #63, #60 and #85. g) Nurse Educator (NE) #78 An email from the nurse educator to administrative staff dated 01/07/24 at 9:54 AM revealed NE #78 was still concerned about the hot water in the sinks. In the email the nurse educator explains that the staff had been told not to use the hot water because it had been registering over 110 degrees (F). The nurse educator stated she was concerned that residents would use the sink and nursing could not monitor the situaiton. In her email the Nurse Educator said that Licensed Practical Nurse (LPN) #46 had asked about shutting the hot water off and was told it could not be done. NE #78 had a written statement dated 1/11/24. NE #78 statement reflected she worked on 01/05/24 on B -1 from 6:30 PM - 10:30 PM. She worked with Nurse Aide #63, #59, #87 on safe bathing, burns and maintenance orders. She also spoke with RN #62, and #22 on the subject as well. An in-service was held on bathing, burns and safe temperatures. This in-service had a post test. On 01/07/24 10 staff members attended; on 01/08/24 13 attended on 01/09/24 one (1) attended and on 01/10/24 one (1) attended. Other discussions were held by the Staff Development Educator which included Bathing and burns with handouts that included a copy of the chain of command, flow chart for reporting process, assisting with a tub bath or shower, various bathing techniques, CMS chart Time and Temperature Relationship to Serious Burns, and a copy of the Maintenance Work Order. 11 staff attended on 01/07/24, 10 staff attended on 01/08/24, 1 attended on 01/09/24 and 01/10/24 respectively and 8 attended on 01/11/24. h) Maintenance Director and Maintenance Staff On 01/06/24 at 12:20 PM the Maintenance Director and maintenance staff was in -serviced. The in-services included the following information: Anytime the water Temp is Above 110 you must notify the charge nurse that the hot water is not to be used in that specific area and make corrections. You must document when notification was made and to whom. Typed as written.

37324 Based on observation, record review, and staff interview the licensee failed to maintain hot water mechanical equipment in safe operating condition. According to CMS guidelines exposure at water temperature of 133 degrees Fahrenheit can lead to third degree burns in 15 seconds. Resident #19 was bathed in 134 degrees Fahrenheit water. Resident #19 sustained second degree burns to his feet, legs, thigh, and hand. The staff responsible for monitoring water temperatures and maintaining equipment knew the hot water had measured more than 110 degrees Fahrenheit (F) since January 2023. This caused an immediate jeopardy situation that began on 01/03/23 and ended on 01/07/24. This practice had the potential to affect all facility residents. Resident identifier: #19. Facility census 44. Findings included: a) Facility Reported Incident A facility reported incident was received at the state agency on 01/05/24. The report stated Nurse Aide #99 put Resident #19 into a whirlpool tub. She filled the tub to the knee level. The nurse aide realized the water was too warm. She had another aide try to adjust the water. The nurse aide admitted to not looking at the water temperature and this resulted in Resident #19 receiving severe burns to lower legs, feet, thighs, and left hand. The facility reported the immediate action taken was to suspend the nurse aide, take all tubs out of service and check for malfunction. Adult protective services were notified, the ombudsman, the local sheriff's department, and the nurse aide registry. A second facility reported incident dated 01/04/24 related to Resident #19 was also received by the state agency. This incident stated the registered nurse did not assess or treat a resident with severe burns timely. The immediate action taken was a suspension of the registered nurse in addition to the nurse aide and a shutdown of the bathtubs. A third facility reported incident dated 01/05/24 was sent to the state agency. This incident stated Maintenance Supervisor (MS) #76 had been monitoring water temperatures for over six (6) months that did not meet regulatory guidelines. MS #76 failed to report the temperatures or attempt to make any changes to meet regulatory compliance. The report revealed MS #76 said he was aware of the guidelines for water temperature and chose to keep it warmer per staff request. The five (5) day follow up report obtained on 01/09/24 revealed the following: After reviewing camera and interviewing staff (Registered Nurse #100) was asked by CNA (ceritfied nurse assistant) that was giving (Resident #19) his bath to assess him. Another CNA asked nurse to assess him. Finally at 7:36 she went to shower room and left at 7:37. At 8:44 she got order to send to ER (emergency room ). No 1st aide administered by unit nurse until 9:05. Nurse (Registered Nurse #100) sent home until investigation over. (Registered Nurse #100) failed to assess (Resident #19) when asked 3 times by CNAs. Did not administer treatment in a timely manner. I find this report to be substantiated for neglect of resident. (Registered Nurse #100) will be removed from schedule and her agency will be notified of decision. Excessive delay in treatment. This report was completed by the social service supervisor. A five day follow up to the immediate report for Certified Nurse Aide (NA) #41 revealed: After reviewing camera and interviewing NA #41 who was called to shower room and found the water too hot and adjusted water temperature. She was seen on camera leaving the shower room and going to nurses station but camera has no sound. I find this to be substantiated. NA #41 did adjust water but failed to assist in maintaining safety of resident. NA #41 sent home until investigation is done. I find this report to be substantiated for neglect of resident. NA #41 will be removed from schedule and her agency will be notified of decision. This report was completed by the social service supervisor. b) Facility Entrance During the entrance conference with the Assistant Nursing Home Administrator (ANHA) and the DON, on 01/09/24 at 12:25 PM, the DON stated Resident (#19) had received third degree burns to both lower extremities during a tub bath on the evening of 01/04/24. They said had been transferred to a local hospital and then transferred to an out of state burn unit. b) Record Review Record review on 01/09/24 2:18 PM, revealed no documentation was provided during the survey to show the corrective action or adjustments to the resident hot water system when water temperatures were routinely recorded above 110 degrees (F) monthly from August 2023 through December 2023 by the Maintenance Department Staff for resident corridors A1, B1, and resident areas Shower Room ([NAME]) and Dining Room ([NAME]). Interview on 01/09/24 at approximately 2:20 p.m. with the Assistant Administrator verified this finding. c) Maintenance Supervisor (MS) #76 A phone interview on 01/10/24 at approximately 9:43 a.m., with MS #76 noted he had been the Maintenance Supervisor for approximately 5 years. Interview revealed he recorded the temperatures of the hot water system as noted on the gauges and seemed to be aware that the temperatures were supposed to be maintained at 110 degrees Fahrenheit. He also noted that he tried to keep temperatures warm enough on the floors as Nursing would let him know if the temperatures seemed too cold. Interview noted that he did not report the daily/monthly temperature logs to any committee or had not been asked for them by any of the reporting committees, such as the Safety Committee or the Quality and Performance Improvement (QAPI) Committee. d) Preventative Maintenance and Casualty Prevention Plan Notes Record review on 01/10/24 at 12:37 p.m., revealed Preventative Maintenance and Casualty Prevention Plan notes state that Safety Surveillance is conducted hospital wide monthly by members of the Safety Committee. Reports of inspection are given to the Safety Officer who will then assign the deficiency correction to the proper department for action. Per the Preventative Maintenance and Casualty Prevention Plan these reports and corrective action documents are then also attached to the master copy of the Quality Committee minutes. Record review revealed no documentation provided during the survey to show that Safety Surveillance was reported to the Quality and Performance Improvement (QAPI) Committee from July 2023 through December 2023, as outlined in the Preventative Maintenance and Casualty Prevention Plan. e) Administrator and Assistant Administrator Interview On 01/10/24 at 1:10 PM during an interview the assistant administrator and the administrator agreed they had not looked at the hot water temperatures being recorded by the maintenance employee, nor had they checked to see if any preventative maintenance was being done to the hot water equipment. f) Resident #19 Record review revealed Resident #19 was admitted to the facility 10/12/17. Medical diagnoses included dementia with behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, peripheral vascular disease (PVD), alcohol dependence in remission, Fabry's disease, and high blood pressure. No Brief Interview for Mental Status (BIMS) was able to be obtained as the only verbal response was grunting. g) Water Temperature Log Review of temperatures taken at the mixing valve are as follows: January 2023 01/03/23 122 degrees (F), 01/04/23 120 degrees (F), 01/05/23 118 degrees (F), 01/06/23 124 degrees (F), 01/09/23 120 degrees (F), 01/10/23 126 degrees (F), 01/11/23 122 degrees (F), 01/12/23 120 degrees (F), 01/15/23 120 degrees 126 degrees (F), 01/18/23 124 degrees (F), 01/19/23 122 degrees (F), 01/20/23 120 degrees (F), , 01/24/23 126 degrees (F), 01/25/23 122 degrees (F), 01/26/23 126 degrees (F), 01/27/23 124 degrees (F), 01/30/23 126 degrees (F), 01/31/23 126 degrees (F), February 2023 02/02/23 124 degrees (F), 02/03/23 124 degrees (F), 02/06/23 126 degrees (F), 02/07/23 124 degrees (F), 02/08/23 130 degrees (F),02/13/23 126 degrees (F), 02/14/23 124 degrees (F), 02/15/23 128 degrees (F), 02/16/23 126 degrees (F), 02/17/23 128 degrees (F), 02/21/23 124 degrees (F), 02/22/23 128 degrees (F), 02/23/23 126 degrees (F), 02/24/23 128 degrees (F), 02/27/23 120 degrees (F) March 2023 03/01/23 126 degrees (F), 03/02/23 120 degrees (F), 03/03/23 124 degrees (F), 03/06/23 130 degrees (F), 03/07/23 124 degrees (F), 03/08/23 126 degrees (F), 03/09/23 126 degrees (F), 03/10/23 130 degrees (F), 03/16/23 120 degrees (F), 03/20/23 130 degrees (F), 03/21/23 130 degrees (F), 03/22/23 119 degrees (F), 03/23/23 124 degrees (F) 03/27/23 124 degrees (F), 03/28/23 128 degrees (F) April 2023 04/03/23 120 degrees (F), 04/04/23 126 degrees (F), 04/05/23 124 degrees (F), 04/06/23 119 degrees (F), 04/07/23 121 degrees (F), 04/10/23 120 degrees (F), 04/11/23 124 degrees (F), 04/12/23 123 degrees (F), 04/13/23 121 degrees (F), 04/14/23 115 degrees (F), 04/17/23 125 degrees (F), 04/18/23 120 degrees (F), 04/19/23 119 degrees (F), 04/20/23 121 degrees (F), 04/21/21 122 degrees (F), 04/24/23 130 degrees (F), 04/25/23 128 degrees (F), 04/26/23 115 degrees (F), 04/28/23 120 degrees (F) May 2023 05/01/23 120 degrees (F), 05/02/23 124 degrees (F), 05/03/23 122 degrees (F), 05/04/23 122 degrees (F), 05/05/23 118 degrees (F), 05/10/23 116 degrees (F), 05/11/23 124 degrees (F), 05/15/23 120 degrees (F), 05/16/23 126 degrees (F), 05/17/23 130 degrees (F), 05/18/23 120 degrees (F), 05/19/23 118 degrees (F), 05/22/23 122 degrees (F), 05/23/23 120 degrees (F), 05/24/23 116 degrees (F)< 05/26/23 130 degrees (F), 05/29/23 130 degrees (F), 05/30/23 120 degrees (F), 05/31/23 124 degrees (F) June 2023 06/01/23 120 degrees (F), 06/02/23 112 degrees (F), 06/05/23 120 degrees (F), 06/06/23 116 degrees (F), 06/07/23 120 degrees (F), 06/08/23 130 degrees (F), 06/09/23 130 degrees (F), 06/12/23 118 degrees (F), 06/13/23 126 degrees (F), 06/14/23 122 degrees (F), 06/15/23 124 degrees (F), 06/16/23 118 degrees (F), 06/19/23 121 degrees (F), 06/20/23 114 degrees (F), 06/21/23 120 degrees (F), 06/22/23 122 degrees (F), 06/23/24 116 degrees (F), 06/26/23 131 degrees (F), 06/27/23 122 degrees (F), 06/28/23 124 degrees (F), 06/29/23 120 degrees (F), 06/30/23 124 degrees (F) July 2023 07/05/23 121 degrees (F), 07/06/23 120 degrees (F), 07/07/23 120 degrees (F), 07/10/23 121 degrees (F), 07/11/23 116 degrees (F), 07/14/23 120 degrees (F), 07/17/23 122 degrees (F), 07/18/23 132 degrees (F), 07/19/23 124 degrees (F), 07/20/23 114 degrees (F), 07/21/23 128 degrees (F),07/26/23 120 degrees (F), 07/27/23 118 degrees (F), 07/28/23 122 degrees (F), 07/31/23 120 degrees (F) August 2023 08/01/23 120 degrees (F), 08/02/23 118 degrees (F), 08/03/23 120 degrees (F), 08/04/23 124 degrees (F), 08/07/23 120 degrees (F), 08/08/23 121 degrees (F), 08/09/23 118 degrees (F), 08/10/23 122 degrees (F), 08/11/23 130 degrees (F), 08/14/23 121 degrees (F), 08/15/23 129 degrees (F), 08/16/23 118 degrees (F), 08/18/23 136 degrees (F), 08/21/23 120 degrees (F), 08/22/23 124 degrees (F), 08/23/23 133 degrees (F), 08/24/23 114 degrees (F), 08/25/23 126 degrees (F), 08/28/23 130 degrees (F), 08/29/23 140 degrees (F), 08/30/23 128 degrees (F), September 2023 09/01/23 125 degrees (F), 09/05/23 128 degrees (F), 09/06/23 130 degrees (F), 09/07/23 126 degrees (F), 09/08/23 130 degrees (F), 09/11/23 126 degrees (F), 09/12/23 124 degrees (F), 09/13/23 121 degrees (F) , 09/18/23 130 degrees (F), 09/19/23 126 degrees (F), 09/20/23 124 degrees (F), 09/21/23 120 degrees (F), 09/29/23 130 degrees (F) October 2023 10/02/23 125 degrees (F), 10/03/23 130 degrees (F), 10/04/23 132 degrees (F), 10/05/23 130 degrees (F) 10/09/23 140 degrees (F), 10/10/23 138 degrees (F), 10/11/23 10/13/23 130 degrees (F), 10/16/23 120 degrees (F), 10/17/23 130 degrees (F), 10/18/23 124 degrees (F), 10/19/23 124 degrees (F),10/20/23 128 degrees (F), 10/24/23 132 degrees (F), 10/25/23 128 degrees (F), 10/26/23 130 degrees (F), 10/27/23 142 degrees (F), 10/30/23 140 degrees (F), 10/31/23 132 degrees (F) November 2023 11/01/23 128 degrees (F), 11/02/23 132 degrees (F), 11/03/23 141 degrees (F), 11/06/23 140 degrees (F), 11/07/23 128 degrees (F), 11/08/23 130 degrees (F), 11/09/23 134 degrees (F), 11/13/23 130 degrees (F), 11/14/23 126 degrees (F), December 2023 12/01/23 130 degrees (F), 12/04/23 130 degrees (F), 12/05/23 132 degrees (F), 12/06/23 140 degrees (F), 12/07/23 128 degrees (F), 12/08/23 132 degrees (F), 12/11/23 130 degrees (F), 12/12/23 126 degrees (F), 12/13/23 140 degrees (F), 12/14/23 140 degrees (F), 12/15/23 138 degrees (F), 12/20/23 130 degrees (F), 12/21/23 126 degrees (F), 12/22/23 140 degrees (F), 12/26/23 128 degrees (F), 12/28/23 132 degrees (F), 12/29/23 130 degrees (F) January 2024 Record review revealed water temperatures continued to be above 110 degrees (F) on 01/05/24, 01/06/24, and on 01/07/24. These temperatures logs revealed temperateurs were taken at four (4) sinks, and in the shower room. h) Education of staff During the night of 01/04/24 into 01/05/24 the ADON educated the night shift staff that temperatures that exceed 110 degrees were not within regulation and should not be used on any resident. The staff included RN #100, Nurse Aid #99, # 41, #59, #63, #60 and #85. i) Maintenance Director Inservice On 01/06/24 at 12:20 PM the Maintenance Director and maintenance staff was in -serviced the Maintenance staff as follows: Anytime the water Temp is Above 110 you must notify the charge nurse that the hot water is not to be used in that specific area and make corrections. You must document when notification was made and to whom. Typed as written. j) Nurse Educator (NE) #78 An email from the nurse educator to administrative staff dated 01/07/24 at 9:54 AM revealed NE #78 was still concerned about the hot water in the sinks. In the email the nurse educator explains that the staff had been told not to use the hot water because it had been registering over 110 degrees (F). The nurse educator stated she was concerned that residents would use the sink and nursing could not monitor the situaiton. In her email the Nurse Educator said that Licensed Practical Nurse (LPN) #46 had asked about shutting the hot water off and was told it could not be done. Record review revealed the nursing home administartor gave an order and the hot water was shut off at 6:54 PM on 01/07/24. k) Quality Assurance and Performance Improvement (QAPI) Evidence provided by the QA-QAPI RN on 01/09/24 stated that this was the first rough draft of events involving hot water that resulted in third degree burns to Resident #19. Resident #19 was transferred to the emergency room and is currently not residing in (name of facility). All residents have the potential to be affected. On 01/05/24, DON conducted a skin assessment of all residents which revealed no other residents to have evidence of burns. On 01/04/24 the maintenance director placed the identified whirlpool (tub) out of service and investigated what may have caused the increased hot water temperature in the tub during the incident. The investigation revealed a malfunctioning hot water tank thermostat, which was immediately replaced by the maintenance director/maintenance staff on 01/04/24. On 01/05/24, the QAPI team instituted a more frequent monitoring of hot water temperatures, every hour and to prevent resident use of hot water above 110 degrees. Additionally, on 01/05/24, the QAPI stopped all showers and tub baths until hot water could be restored to no higher than 110 degrees. The administrator on 01/07/24 directed maintenance staff to physically shut off all hot water access by residents as an added precaution pending further maintenance evaluation/repairs to the hot water system. On 01/05/24, the QAPI team instituted temperature checks of hot water outlets on the resident units, to be completed each hour. Temperatures found to be greater than 110 degrees, were to be reported immediately to the administrator, residents were to be prevented from using the identified outlet(S), and mechanical adjustments made to the hot water system in order to bring temperatures below 110 Fahrenheit. On 01/08/24, due to residents no longer having access/exposure to hot water outlets, the QAPI team modified the monitoring of hot water temperatures to an as needed basis due to repairs actively being made to the hot water system, until further. The Quality Assurance and Performance Improvement Committee (QAPI) met on 01/09/24 at 10:00 AM to discuss the current situation of water temps for resident care. Documentation revealed that water temps were being checked every hour since 01/05/24 at the four (4) main sinks on Resident corridors of A1 and B1 and the resident showers on the corridors of A1 and [NAME] 1, with this documentation forwarded to Administration for review. The showers have not been used since 01/04/24. Repairs were initiated on the hot water system on 01/08/24 to isolate the hot water distributed to the resident care areas and residents currently have no access to hot water until the final repairs are made. Prior to the time of survey, potential mechanical issues with an isolation valve, hot water tank thermostat, and a water system distribution mixing valve and gauge were discovered. The isolation valve, thermostat, and mixing valve gauge had been replaced prior to the survey. The water system distribution mixing valve was being investigated further with parts being ordered for repair during the survey. Nursing staff were notified that they would be using wipes and no rinse shampoo and body wash until further notice. Per the QAPI meeting minutes, reeducation was provided to staff reiterating appropriate hot water temperatures and completing maintenance work orders if issues are suspected with the temperature of the water system. l) Phone interview on 01/09/24 at 11:36 AM., with the Director of Facilities and Plant Operations #97 revealed that the perceived issue with the hot water system was a faulty thermostat on the hot water tank serving resident corridors A1 and B1 of the Nursing Building. The issue with the thermostat was believed to have failed in the close position and was discovered mid-morning on Friday, January 5th. The hot water system was drained and refilled with 55-degree city water. An isolation valve was added on Monday, January 8th. Employee #97 also noted that hot water temperatures were not supposed to be above 110 degrees. m) An observation on 01/09/24 at 12:14 PM, revealed that the only hot water being provided to the resident areas was to the Dining Area. The temperature of the hot water as recorded at a hand sink in the Dining area was noted as 109.1. Hot water to the other resident areas such as Corridor A1, B1, and [NAME] 1 was isolated off in the basement and handles removed from faucets and fixtures to prevent residents from accidentally turning on the hot water while repairs and adjustments were made to the system. n) Building Maintenance Mechanic (BMM)#95 An interview on 01/09/24 at 1:03 PM, with BMM #95 revealed that an issue with a thermostat on a hot water tank in the basement (Potato Room) was discovered and replaced. A ball valve was also replaced as a suspected back-feed elimination. A gauge for the mixing valve for the water leaving this area to the resident areas was also replaced. Employee #95 noted that a daily log of the water temperatures was maintained in each mechanical room. In addition, Employee #95 stated that he was not aware that temperatures above 110 degrees needed to be reported and only recorded what the gauges read and was not previously aware of what the water temperatures were supposed to be maintained at. o) Building Maintenance Mechanic (BMM) #14An interview on 01/09/24 at 1:15 PM, with Building Maintenance Mechanic #14 revealed that he was off work during the time of noted issues with the water system and had just returned to work on the morning of Monday, January 8th. Employee #14 noted that he was not aware that any issues with the noted water temperatures needed to be reported to anyone. p) Maintenance Supervisor (MS) #76 During a phone interview on 01/10/24 at 9:43 AM, the Maintenance Supervisor (MA) #76 noted that he had been the Maintenance Supervisor for approximately five (5) years.MS #76 noted that he recorded the temperatures of the hot water system as noted on the gauges and seemed to be aware that the temperatures were supposed to be maintained at 110 degrees. He also noted that he tried to keep temperatures warm enough on the floors as Nursing would let him know if the temperatures s#76 noted that he did not report the daily/monthly temperature logs to any committee or had not been asked for them. q) Preventive Maintenance and Caualty Prevention Plan The Office of Health Facilities Policy (Policy OHF.LS.0002) for Preventive Maintenance and Casualty Prevention Plan has been updated to include an effective date based upon the date of approval on the signature page. This policy outlines the testing and preventative maintenance procedures and documentation requirements for the Plant Operations, Maintenance, and Engineering Staff. Documentation from the Preventative Maintenance and Casualty Prevention Plan is monitored through safety surveillance, which is conducted hospital wide monthly by members of the Safety Committee. These inspection reports are to be given to the Safety Officer, who will then assign corrective action from the appropriate department. This policy outlines that all boiler room equipment gauges are to be visually monitored daily and that patient hot water is not to exceed 110 degrees (F) with any deviations reported to the Maintenance Department immediately.

Based on observation, record review, and staff interview the licensee failed to maintain hot water mechanical equipment in safe operating condition. According to CMS guidelines exposure at water temperature of 133 degrees Fahrenheit (F) can lead to third degree burns in 15 seconds. Resident #19 was bathed in 134 degrees (F) water. Resident #19 sustained second degree burns to the left hand, bilateral lower extremeties, bilateral buttocks, and scrotum. The staff responsible for monitoring water temperatures and maintaining equipment knew the hot water had measured more than 110 degrees (F) since January 2023. This caused an immediate jeopardy situation that began on 01/03/23 and ended on 01/07/24. This practice had the potential to affect all facility residents. Resident identifier: #19. Facility census 44. Findings included: a) Facility Reported Incident A facility reported incident was received at the state agency on 01/05/24. The report stated Nurse Aide #99 put Resident #19 into a whirlpool tub. She filled the tub to the knee level. The nurse aide realized the water was too warm. She had another aide try to adjust the water. The nurse aide admitted to not looking at the water temperature and this resulted in Resident #19 receiving severe burns to lower legs, feet, thigh, and left hand. The facility reported the immediate action taken was to suspend the nurse aide, take all tubs out of service and check for malfunction. Adult protective services were notified, the ombudsman, the local sheriff's department, and the nurse aide registry. A second facility reported incident dated 01/04/24 related to Resident #19 was also received by the state agency. This incident stated the registered nurse (RN #100) did not assess or treat a resident with severe burns timely. The immediate action taken was a suspension of the registered nurse in addition to the nurse aide and a shutdown of the bathtubs. A third facility reported incident dated 01/05/24 was sent to the state agency. This incident stated Maintenance Supervisor (MS) #76 had been monitoring water temperatures for over six (6) months that did not meet regulatory guidelines. MS #76 failed to report the temperatures or attempt to make any changes to meet regulatory compliance. The report revealed MS #76 said he was aware of the guidelines for water temperature and chose to keep it warmer per staff request. The five (5) day follow up report obtained on 01/09/24 revealed the following: After reviewing camera and interviewing staff (Registered Nurse #100) was asked by CNA (ceritfied nurse assistant) that was giving (Resident #19) his bath to assess him. Another CNA asked nurse to assess him. Finally at 7:36 she went to shower room and left at 7:37. At 8:44 she got order to send to ER (emergency room ). No 1st aide administered by unit nurse until 9:05. Nurse (Registered Nurse #100) sent home until investigation over. (Registered Nurse #100) failed to assess (Resident #19) when asked 3 times by CNAs. Did not administer treatment in a timely manner. I find this report to be substantiated for neglect of resident. (Registered Nurse #100) will be removed from schedule and her agency will be notified of decision. Excessive delay in treatment. This report was completed by the social service supervisor. A five day follow up to the immediate report for Certified Nurse Aide (NA) #41 revealed: After reviewing camera and interviewing NA #41 who was called to shower room and found the water too hot and adjusted water temperature. She was seen on camera leaving the shower room and going to nurses station but camera has no sound. I find this to be substantiated. NA #41 did adjust water but failed to assist in maintaining safety of resident. NA #41 sent home until investigation is done. I find this report to be substantiated for neglect of resident. NA #41 will be removed from schedule and her agency will be notified of decision. This report was completed by the social service supervisor. b) Entrance by State Agency During the entrance conference with the Assistant Nursing Home Administrator (ANHA) and the DON, on 01/09/24 at 12:25 PM, the DON stated Resident (#19) had received third degree burns to both lower extremities during a tub bath on the evening of 01/04/24. They said the resident had been transferred to a local hospital and then transferred to an out of state burn unit. Hospital records revealed the resident had second degree burns to bilateral lower extremities, the left hand, bilateral buttocks, and scrotum. The hospital report reflected the resident was burned an estimated 35% of his body. c) Facility provided hot water temperature logs from the mixing valve January 2023 01/03/23 122 degrees (F), 01/04/23 120 degrees (F), 01/05/23 118 degrees (F), 01/06/23 124 degrees (F), 01/09/23 120 degrees (F), 01/10/23 126 degrees (F), 01/11/23 122 degrees (F), 01/12/23 120 degrees (F), 01/15/23 120 degrees 126 degrees (F), 01/18/23 124 degrees (F), 01/19/23 122 degrees (F), 01/20/23 120 degrees (F), , 01/24/23 126 degrees (F), 01/25/23 122 degrees (F), 01/26/23 126 degrees (F), 01/27/23 124 degrees (F), 01/30/23 126 degrees (F), 01/31/23 126 degrees (F), February 2023 02/02/23 124 degrees (F), 02/03/23 124 degrees (F), 02/06/23 126 degrees (F), 02/07/23 124 degrees (F), 02/08/23 130 degrees (F),02/13/23 126 degrees (F), 02/14/23 124 degrees (F), 02/15/23 128 degrees (F), 02/16/23 126 degrees (F), 02/17/23 128 degrees (F), 02/21/23 124 degrees (F), 02/22/23 128 degrees (F), 02/23/23 126 degrees (F), 02/24/23 128 degrees (F), 02/27/23 120 degrees (F) March 2023 03/01/23 126 degrees (F), 03/02/23 120 degrees (F), 03/03/23 124 degrees (F), 03/06/23 130 degrees (F), 03/07/23 124 degrees (F), 03/08/23 126 degrees (F), 03/09/23 126 degrees (F), 03/10/23 130 degrees (F), 03/16/23 120 degrees (F), 03/20/23 130 degrees (F), 03/21/23 130 degrees (F), 03/22/23 119 degrees (F), 03/23/23 124 degrees (F) 03/27/23 124 degrees (F), 03/28/23 128 degrees (F) April 2023 04/03/23 120 degrees (F), 04/04/23 126 degrees (F), 04/05/23 124 degrees (F), 04/06/23 119 degrees (F), 04/07/23 121 degrees (F), 04/10/23 120 degrees (F), 04/11/23 124 degrees (F), 04/12/23 123 degrees (F), 04/13/23 121 degrees (F), 04/14/23 115 degrees (F), 04/17/23 125 degrees (F), 04/18/23 120 degrees (F), 04/19/23 119 degrees (F), 04/20/23 121 degrees (F), 04/21/21 122 degrees (F), 04/24/23 130 degrees (F), 04/25/23 128 degrees (F), 04/26/23 115 degrees (F), 04/28/23 120 degrees (F) May 2023 05/01/23 120 degrees (F), 05/02/23 124 degrees (F), 05/03/23 122 degrees (F), 05/04/23 122 degrees (F), 05/05/23 118 degrees (F), 05/10/23 116 degrees (F), 05/11/23 124 degrees (F), 05/15/23 120 degrees (F), 05/16/23 126 degrees (F), 05/17/23 130 degrees (F), 05/18/23 120 degrees (F), 05/19/23 118 degrees (F), 05/22/23 122 degrees (F), 05/23/23 120 degrees (F), 05/24/23 116 degrees (F), 05/26/23 130 degrees (F), 05/29/23 130 degrees (F), 05/30/23 120 degrees (F), 05/31/23 124 degrees (F) June 2023 06/01/23 120 degrees (F), 06/02/23 112 degrees (F), 06/05/23 120 degrees (F), 06/06/23 116 degrees (F), 06/07/23 120 degrees (F), 06/08/23 130 degrees (F), 06/09/23 130 degrees (F), 06/12/23 118 degrees (F), 06/13/23 126 degrees (F), 06/14/23 122 degrees (F), 06/15/23 124 degrees (F), 06/16/23 118 degrees (F), 06/19/23 121 degrees (F), 06/20/23 114 degrees (F), 06/21/23 120 degrees (F), 06/22/23 122 degrees (F), 06/23/24 116 degrees (F), 06/26/23 131 degrees (F), 06/27/23 122 degrees (F), 06/28/23 124 degrees (F), 06/29/23 120 degrees (F), 06/30/23 124 degrees (F) July 2023 07/05/23 121 degrees (F), 07/06/23 120 degrees (F), 07/07/23 120 degrees (F), 07/10/23 121 degrees (F), 07/11/23 116 degrees (F), 07/14/23 120 degrees (F), 07/17/23 122 degrees (F), 07/18/23 132 degrees (F), 07/19/23 124 degrees (F), 07/20/23 114 degrees (F), 07/21/23 128 degrees (F),07/26/23 120 degrees (F), 07/27/23 118 degrees (F), 07/28/23 122 degrees (F), 07/31/23 120 degrees (F) August 2023 08/01/23 120 degrees (F), 08/02/23 118 degrees (F), 08/03/23 120 degrees (F), 08/04/23 124 degrees (F), 08/07/23 120 degrees (F), 08/08/23 121 degrees (F), 08/09/23 118 degrees (F), 08/10/23 122 degrees (F), 08/11/23 130 degrees (F), 08/14/23 121 degrees (F), 08/15/23 129 degrees (F), 08/16/23 118 degrees (F), 08/18/23 136 degrees (F), 08/21/23 120 degrees (F), 08/22/23 124 degrees (F), 08/23/23 133 degrees (F), 08/24/23 114 degrees (F), 08/25/23 126 degrees (F), 08/28/23 130 degrees (F), 08/29/23 140 degrees (F), 08/30/23 128 degrees (F), September 2023 09/01/23 125 degrees (F), 09/05/23 128 degrees (F), 09/06/23 130 degrees (F), 09/07/23 126 degrees (F), 09/08/23 130 degrees (F), 09/11/23 126 degrees (F), 09/12/23 124 degrees (F), 09/13/23 121 degrees (F) , 09/18/23 130 degrees (F), 09/19/23 126 degrees (F), 09/20/23 124 degrees (F), 09/21/23 120 degrees (F), 09/29/23 130 degrees (F) October 2023 10/02/23 125 degrees (F), 10/03/23 130 degrees (F), 10/04/23 132 degrees (F), 10/05/23 130 degrees (F) 10/09/23 140 degrees (F), 10/10/23 138 degrees (F), 10/11/23 10/13/23 130 degrees (F), 10/16/23 120 degrees (F), 10/17/23 130 degrees (F), 10/18/23 124 degrees (F), 10/19/23 124 degrees (F),10/20/23 128 degrees (F), 10/24/23 132 degrees (F), 10/25/23 128 degrees (F), 10/26/23 130 (F) degrees (F), 10/27/23 142 degrees (F), 10/30/23 140 degrees (F), 10/31/23 132 degrees (F) November 2023 11/01/23 128 degrees (F), 11/02/23 132 degrees (F), 11/03/23 141 degrees (F), 11/06/23 140 degrees (F), 11/07/23 128 degrees (F), 11/08/23 130 degrees (F), 11/09/23 134 degrees (F), 11/13/23 130 degrees (F), 11/14/23 126 degrees (F), December 2023 12/01/23 130 degrees (F), 12/04/23 130 degrees (F), 12/05/23 132 degrees (F), 12/06/23 140 degrees (F), 12/07/23 128 degrees (F), 12/08/23 132 degrees (F), 12/11/23 130 degrees (F), 12/12/23 126 degrees (F), 12/13/23 140 degrees (F), 12/14/23 140 degrees (F), 12/15/23 138 degrees (F), 12/20/23 130 degrees (F), 12/21/23 126 degrees (F), 12/22/23 140 degrees (F), 12/26/23 128 degrees (F), 12/28/23 132 degrees (F), 12/29/23 130 degrees (F) January 2024 Record review revealed water temperatures continued to be above 110 degrees (F) on 01/05/24, 01/06/24, and on 01/07/24. These temperatures logs revealed temperatures were taken at four (4) sinks, and in the shower room. Record review on 01/09/24 at approximately 2:18 PM, revealed no documentation to show the corrective action or adjustments to the resident hot water system when water temperatures were routinely recorded above 110 degrees Fahrenheit from January 2023 through December 2023 by the Maintenance Department Staff. The water supplied resident corridors A1, B1, and Shower Room ([NAME]) and Dining Room ([NAME]). An interview on 01/09/24 at approximately 2:20 p.m. with the Assistant Administrator verified this finding. d) Maintenance Supervisor (MS) #76 Phone interview on 01/10/24 at approximately 9:43 AM, with MS #76 noted he had been the MS for approximately five (5) years. Interview revealed he recorded the temperatures of the hot water system as noted on the gauges and seemed aware the temperatures were supposed to be maintained at 110 degrees (F). He also said he tried to keep temperatures warm enough on the floors. He said nursing would let him know if the temperatures seemed too cold. The interview with MS #76 noted that he did not report the daily/monthly temperature logs to any committee. Furthermore, he said he had not been asked for these records by any of the reporting committees, such as the Safety Committee or the Quality and Performance Improvement (QAPI) Committee. Record review, on 01/10/24 at 12:37 PM, of Preventative Maintenance and Casualty Prevention Plan revealed that Safety Surveillance was conducted hospital wide monthly by members of the Safety Committee. Reports of inspection are given to the Safety Officer who will then assign the deficiency correction to the proper department for action. Per the Preventative Maintenance and Casualty Prevention Plan these reports and corrective action documents are also attached to the master copy of the Quality Committee minutes. Record review revealed no documentation provided during the survey to show that Safety Surveillance was reported to the Quality and Performance Improvement (QAPI) Committee from July 2023 through December 2023, as outlined in the Preventative Maintenance and Casualty Prevention Plan. On 01/10/24 at 1:10 PM during an interview the assistant administrator and the administrator confirmed they had not looked at the hot water temperatures being recorded by the maintenance employee, nor had they checked to see if any preventative maintenance was being done to the hot water equipment. e) Resident #19 Record review revealed Resident #19 was admitted to the facility 10/12/17. Medical diagnoses included dementia with behavioral disturbances, unspecified psychosis not due to a substance or known physiological condition, peripheral vascular disease (PVD), alcohol dependence in remission, Fabry's disease, and high blood pressure. No Brief Interview for Mental Status (BIMS) was able to be obtained as the only verbal response was grunting. f) Nurse Educator (NE) #78 An email from the nurse educator to administrative staff dated 01/07/24 at 9:54 AM revealed NE #78 was still concerned about the hot water in the sinks. In the email the nurse educator explains that the staff had been told not to use the hot water because it had been registering over 110 degrees (F). The nurse educator stated she was concerned that residents would use the sink and nursing could not monitor the situation. In her email the Nurse Educator said that Licensed Practical Nurse (LPN) #46 had asked about shutting the hot water off and was told it could not be done. Rercord review revealed the Nursing Home Administrator gave an order for the hot water to be shut off at 6:54 PM on 01/07/24. g) Maintenance Director In service On 01/06/24 at 12:20 PM the Maintenance Director and maintenance staff was in -serviced. The in-service included: Anytime the water Temp is Above 110 you must notify the charge nurse that the hot water is not to be used in that specific area and make corrections. You must document when notification was made and to whom. Typed as written. On 01/11/24 at 10:40 AM, in the presence of the Director of Nursing (DON), NA #66 was interviewed. NA #66 stated she showed new employees how to operate the tub and then had the new employee complete a return demonstration. When asked how this was documented, CNA #66 stated, We used to have one (skills competency check off sheet) but I don't have one now. h) Quality Assurance and Performance Improvement (QAPI) Evidence provided by the QA-QAPI RN on 01/09/24 stated that this was the first rough draft of events involving hot water that resulted in third degree burns to Resident #19. Resident #19 was transferred to the emergency room and is currently not residing in (name of facility). All residents have the potential to be affected. On 01/05/24, DON conducted a skin assessment of all residents which revealed no other residents to have evidence of burns. On 01/04/24 the maintenance director placed the identified whirlpool (tub) out of service and investigated what may have caused the increased hot water temperature in the tub during the incident. The investigation revealed a malfunctioning hot water tank thermostat, which was immediately replaced by the maintenance director/maintenance staff on 01/04/24. On 01/05/24, the QAPI team instituted a more frequent monitoring of hot water temperatures, every hour and to prevent resident use of hot water above 110 degrees. Additionally, on 01/05/24, the QAPI stopped all showers and tub baths until hot water could be restored to no higher than 110 degrees. The administrator on 01/07/24 directed maintenance staff to physically shut off all hot water access by residents as an added precaution pending further maintenance evaluation/repairs to the hot water system. The plan of correction supported this. On 01/05/24, the QAPI team instituted temperature checks of hot water outlets on the resident units, to be completed each hour. Temperatures found to be greater than 110 degrees, were to be reported immediately to the administrator, residents were to be prevented from using the water. The facility's hot water temperatures were recorded above 110 degrees Fahrenheit monthly from January 2023 through December 2023. However, the facility had established procedures and monitoring processes to address the self-reported issues with the hot water system. i) The Quality Assurance and Performance Improvement Committee (QAPI) met on 01/09/24 at 10:00 AM to discuss the current situation of water temps for resident care. Documentation revealed that water temps were being checked every hour since 01/05/24 at the four (4) main sinks on Resident corridors of A1 and B1 and the resident showers on the corridors of A1 and [NAME] 1, with this documentation forwarded to Administration for review. The showers have not been used since 01/04/24. Repairs were initiated on the hot water system on 01/08/24 to isolate the hot water distributed to the resident care areas and residents currently have no access to hot water until the final repairs are made. Prior to the time of survey, potential mechanical issues with an isolation valve, hot water tank thermostat, and a water system distribution mixing valve and gauge were discovered. The isolation valve, thermostat, and mixing valve gauge had been replaced prior to the survey. The water system distribution mixing valve was being investigated further with parts being ordered for repair during the survey. Nursing staff were notified that they would be using wipes and no rinse shampoo and body wash until further notice. Per the QAPI meeting minutes, reeducation was provided to staff reiterating appropriate hot water temperatures and completing maintenance work orders if issues are suspected with the temperature of the water system. Phone interview on 01/09/24 at 11:36 AM., with the Director of Facilities and Plant Operations (Employee #97) revealed that the perceived issue with the hot water system was a faulty thermostat on the hot water tank serving resident corridors A1 and B1 of the Nursing Building. The issue with the thermostat was believed to have failed in the close position and was discovered mid-morning on Friday, January 5th. The hot water system was drained and refilled with 55-degree city water. An isolation valve was added on Monday, January 8th. Employee #97 also noted that hot water temperatures were not supposed to be above 110 degrees. An observation on 01/09/24 at 12:14 PM revealed that the only hot water being provided to the resident areas was to the Dining Area. The temperature of the hot water recorded at a hand sink in the Dining area was noted as 109.1. Hot water to the other resident areas such as Corridor A1, B1, and [NAME] 1 was isolated in the basement and handles removed from faucets and fixtures to prevent residents from accidentally turning on the hot water while repairs and adjustments were made to the system. An interview on 01/09/24 at 1:03 PM, with the Building Maintenance Mechanic (BMM) #95 revealed that an issue with a thermostat on a hot water tank in the basement (Potato Room) was discovered and replaced. A ball valve was also replaced as a suspected back-feed elimination. A gauge for the mixing valve for the water leaving this area to the resident areas was also replaced. BMM #95 noted that a daily log of the water temperatures was maintained in each mechanical room. In addition, BMM #95 stated he was not aware that temperatures above 110 degrees needed to be reported and only recorded what the gauges read and was not previously aware of what the water temperatures were supposed to be maintained at. An interview on 01/09/24 at 1:15 PM, with Building Maintenance Mechanic (BMM) #14 revealed that he was off from work during the time of noted issues with the water system and had just returned to work on the morning of Monday, January 8th. BMM#14 noted that he was not aware that any issues with the noted water temperatures needed to be reported to anyone. During a phone interview on 01/10/24 at 9:43 AM, the Maintenance Supervisor (MS) #76 said he had been the MS for approximately five (5) years. MS #76 noted that he recorded the temperatures of the hot water system as noted on the gauges and seemed to be aware that the temperatures were supposed to be maintained at 110 degrees. He also noted that he tried to keep temperatures warm enough on the floors as Nursing would let him know if the temperatures seemed too cold. Employee #76 noted that he did not report the daily/monthly temperature logs to any committee or had not been asked for them.

Based on medical record review and staff interview, the facility failed to follow a resident's and/or responsible party's directive to provide cardiopulmonary resuscitation (CPR) to a resident when he ceased breathing and his heart stopped beating. This was evident for one (1) of three (3) deceased residents reviewed for advanced directives. A nurse aide found Resident #9 was not breathing as he lay in his bed. The exact time the resident ceased breathing and his heart ceased to beat was unknown as the event was not witnessed when it occurred. The nurse aid summoned a licensed nurse, #200 (LPN #200). LPN #200 erroneously assessed he was a DNR (Do Not Resuscitate) status. Another LPN #201 telephoned both the physician and the registered nurse on call and notified them of the resident's death. After those notifications were completed, LPN #201 then looked for the contact information of the medical power of attorney to also notify him/her of the death. At that time, LPN #201 and a registered nurse (RN #202) saw in the medical record that the resident was a full code status. LPN #201 took the crash cart to the resident's bed to begin CPR while a RN #202 called the physician back to relay that the resident was supposed to be a full code. The physician then gave telephone orders to stop CPR, and gave new orders for Do Not Resuscitate. As a note, CPR was about to begin, but had not yet begun. This situation was deemed to be an immediate jeopardy situation. On [DATE], the facility conducted its own internal investigation after first notifying the Office of Health Facility Licensure and Certification (OHFLAC), adult protective services, and the ombudsman. Based on the facility's internal investigation that substantiated neglect. In response to the facility's internal investigation, they implemented the following corrective action plan: --All facility staff (100%) participated in inservice education on advance directives for staff who may have contact with residents, including, nursing, office assistants, activity specialists, dietary, physical therapy, maintenance, medical records, and agency staff. --Surveyors reviewed the inservice records related inservice training conducted on [DATE], [DATE], [DATE] and [DATE]. A total of 77 employees participated in the inservice based on reviewed inservice log signature pages. This list was compared to the staff listing of those employed at the facility adn 100% of direct access personnel participated in the training. --The facility developed a tool they posted throughout the departmental units in multiple sites which lists the names of residents who are no codes. The facility began auditing, and continues ongoing monthly audits, for each resident in the facility related to their code status, advance directives, matching records with the emergency contact binder, and matching the Medication Administration Record [REDACTED] --Surveyors reviewed the tool developed and found they implemented the corrective action plan related to posting infomation. This information was posted at the time of the survey. In addition, record reviews found the code status for all resident records were accurate. In view of the plans of action the facility developed to correct its deficient practice of not following a resident's advanced directives for resuscitation, it was deemed that the event which occurred with Resident #9 was a past non-compliance immediate jeopardy issue. The corrective action plan implemented by the facility addressed the deficient practice identifed by the facility on [DATE]. Resident identifier: #9. Facility census: 46. Findings included: a) Resident #9 Medical record review which began on [DATE] and continued through [DATE] revealed that nurse aides found Resident #9 lying in his bed on [DATE] on the night shift. He was not breathing. It was unknown how long he had been without respirations prior to the nurse aides finding him in that condition during shift rounds. According to witness statements, former employee licensed nurse #200 (LPN #200) was the first nurse to enter the room following the nurse aides' discovery. LPN #200 allegedly stopped the aides from obtaining vital signs, and announced that he was a DNR (Do Not Resuscitate) status. Former employee registered nurse #202 (RN #202) was next to enter the room. Per her witness statement, she assessed him as having no pulse and not breathing. Former employee licensed nurse #201 (LPN #201) was next to enter the room. Per witness statements, LPN #201 called the physician and the registered nurse on call and reported the resident was deceased . While in the process of contacting the medical power of attorney, LPN #201 and RN #202 found in the medical record and in the code status sheet from the wall at the nurses station that he was a full code. This meant he was to have cardiopulmonary resuscitation in the event of the absence of heart beat and/or respirations. Also, they found physician's orders [REDACTED]. LPN #201 then prepared to initiate CPR (cardiopulmonary resuscitation). At the same time, RN #202 contacted the physician who then gave a new order to do not resuscitate. No CPR was begun. A nurse progress note dated [DATE] at 3:14 AM stated that a health service worker informed the nurse that the resident ceased to breathe. RN #202 pronounced him deceased at 1:30 AM. Dr. (name of doctor) was called at 1:40 AM, the medical power of attorney was called at 1:46 AM, the on-call nurse was called at 1:50 AM, and the funeral home was called at 2:08 AM. The assistant director of nursing (ADON) completed an incident/accident report which stated that on [DATE] in the AM (the time was not included in the report), the Resident ceased to breathe. Resident was a full code. CPR not started at time resident found. This document was also signed by the facility's administrator. The assistant administrator completed an immediate fax reporting of allegation to the nursing home program on [DATE]. It stated Administration just learned nurses possible failed to render aid per proper nursing practice ie CPR. B wing resident was no code based on thought, later learned was a full code. A five (5) day follow-up report to the nursing home program was completed by licensed social worker #6 (LSW #6) on [DATE] after having requested an extension for the investigation. LSW #6 assessed that after reviewing camera and interviewing all staff, it was determined that Resident #9's advance directives was not followed. It was determined by the facility that neglect was substantiated. An interview was conducted with the assistant administrator on [DATE] at 2:30 PM. He said the incident occurred on [DATE]. He said nursing staff did not perceive that they did anything wrong, as the physician gave telephone orders to not do CPR when told by RN #202 that he was a full code status and that the length of time he was deceased before discovery was unknown. The assistant administrator said he first learned of the details on [DATE] and deemed it was a reportable situation. Review on [DATE] of the code status list for facility residents found that twenty-three (23) residents are full code status and twenty-three (23) residents are no code status in the event of a cardiopulmonary arrest. On [DATE] at 1:00 PM it was discussed with the assistant administrator that the OHFLAC staff believed that the incident on [DATE] constituted an immediate jeopardy situation. In view of the corrective actions the facility put in place on its own initiative during the month of (MONTH) 2019, it was felt that this immediate jeopardy issue was a past non-compliance deficiency.

Based on observation, staff interviews, testing of equipment, review of incident reports, and review of incidents reported to the State related to elopements, the facility failed to ensure an environment that was free from accident hazards over which the facility had control and failed to provide supervision to each resident to prevent accidents from wandering into unsafe places. This had the potential to affect the sixteen (16) residents (#42, #30, #38, #44, #50, #46, #37, #39, #45, #15, #12, #11, #26, #14, #10, and #6) identified by the facility as at risk of eloping who wore Secure Care tracking devices. The Secure Care system used by the facility was programmed to elicit an audible alarm whenever any of the 16 residents opened or went out an exit door. Simultaneously, the system was to send an alert identifying the resident and the location of the door the resident was opening to pagers worn by facility staff. In (MONTH) (YEAR), Resident #10, who was wearing a tracking device, had eloped. Staff were unaware of the resident's elopement until a nurse on the first floor heard him yelling outside and saw him sitting on the ground. The door alarm was not heard by staff and alerts were not sent to staffs' pagers. Testing of the system at the time of the survey found it was not functioning as intended. Alarms could not be heard by staff and alerts were not sent to staffs' pagers. Outside environmental safety issues included a busy main highway adjacent to the parking lot, outdoor temperatures that might adversely affect an individual, a nearby in-use railroad, and nearby wooded terrain. The facility's failure to identify and repair the non-working pager system upon which staff were dependent on for elopement prevention system, prior to surveyor intervention, created a situation in which immediate corrective action was necessary. The risk of elopement, along with environmental safety issues, was determined to pose a risk of serious injury, harm, impairment, or death to a resident receiving care in the facility. After consultation with program managers, the facility was informed these findings were determined to be an immediate jeopardy. On 08/06/18 at 1:45 p.m. the director of nursing (DON) was verbally notified of this situation which required immediate corrective action. The DON immediately assigned staff to be stationed at each of the exit doors. She in turn notified the administrator verbally of the situation at hand. On 08/06/18 at 4:08 p.m. a written immediate jeopardy statement was hand-delivered to the administrator. On 08/06/18 at 4:40 p.m., the DON provided a written plan of correction (P[NAME]) which was approved by an assistant program manager at the Office of Health Facility Licensure and Certification (OHFLAC). After verifying corrective actions were in place, the immediate jeopardy was abated on 08/06/18 at 5:10 p.m. No deficient practice remained for this requirement after removal of the immediate jeopardy. Findings included: a) On 08/06/18, review of the incident reports and occurrences reported to the required State agencies for (YEAR) found four (4) residents experienced elopements from the facility as follows: 1. Resident #45 On 03/26/18, this resident was observed by a nursing assistant at 6:29 p.m. exiting the back door off of downstairs unit A1. The alarm did not sound. A nurse and aide retrieved the resident from outside without issue. The 03/26/18 incident report stated (typed as written) Maintenance called & (symbol for and) informed that alarm did not sounds. RN & CNA (registered nurse and certified nursing assistant) reset back fire door to secure. According to the five (5) day follow-up note, the resident tried to open the door three (3) times. On the third time the door opened and the alarm did not sound. The facility's stated corrective action was, Staff education, trouble shot alarms system, redirect resident. During an interview with the licensed social worker (LSW) on 08/07/18 at 10:45 a.m., she said the former maintenance director or the assistant administrator took care of trouble shooting the alarm system and relayed that information to the LSW in the morning meeting. On 04/05/18 at 1:31 p.m. this resident was found lying on his back in the yard adjacent to the parking area. Review of the incident report and immediate fax report found that he was brought back into the facility safely at 1:31 p.m. in the afternoon. The five (5) day follow-up note said he left the facility by going out the front door. The five (5) day follow-up corrective action by the facility for this incident stated, We are hiring a night watchman to assist in elopement prevention. 2. Resident #11 On 03/06/18 this resident eloped out of the Solarium door (front door) which was unsecured, and went into the parking lot. According to the incident report dated 03/05/18 at 5:25 p.m., the front lobby Solarium sliding door was not locked, and did not alarm. The resident walked out the front door. The five (5) day follow-up report identified the facility's corrective action was, Staff person was re-educated as what to do in the event of an elopement and the proper procedure when securing the facility. On 08/07/18 at 10:45 a.m., during an interview, the LSW said at that time, one had to push a code to secure the door. She said an alarm would go off for a short time, perhaps fifteen (15) seconds, and then quit. The LSW said at that time they had no staff at the front desk. Instead, staff from either the downstairs A1 or B1 units would hear the alarm and would have to go see about it. She said now someone sits at the front desk 24/7, and pushes a button to open the door. She said no longer do they have to use any type of code. She said they also have camera now, but she was not certain if they were working. She said the facility also hired security guards as part of correction for elopements. On 04/13/18 at 7:25 a.m., this resident walked outside into the parking lot and sat in a staff member's parked car. According to the 04/13/18 incident report, a health service worker followed her out and redirected her back into the building. The five (5) day follow-up report identified this resident wore a tracking band which alerted staff when the doors opened. The corrective action by the facility stated, staff education by nurse management 3. Resident #50 Review of an incident report dated 04/13/18 at 7:20 p.m. found this resident exited the facility out of the front door, sounding the alarm. He was redirected back into the building with food and beverage. The 04/19/18 five (5) day follow-up report identified the corrective action by the facility was (typed as written) We were approved to hire a night watchman to assist. 4. Resident #10 On 07/11/18 at 7:30 p.m. this resident exited the building by going out of the upstairs B2 Unit fire escape. A nursing note dated 07/11/18 at 9:09 p.m. stated (typed as written), A nurse on the downstairs B2 unit heard resident yelling from outside and he had went out B2 fire escape and went down the stairs and was sitting on the ground . Resident was escorted back to unit A2 (upstairs) without incident The five (5) day follow-up report dated 07/13/18 included the corrective action taken by the facility was (typed as written), Resident wears a tracking bracelet. It is not known at this time if the alarm was faulty. However, maintenance has been testing the alarm system on a regular basis. Additionally, the facility has installed additional cameras and have placed monitors at the information desk to alert staff as well. The information desk is maintained 24/7. This facility has also just hired security guards to be implemented by the end of the month. Staff were re-educated on elopement. Resident was monitored closely and counseled. On 08/06/18 at 1:20 p.m. when tested by the acting maintenance director using a secure care tracker, and accompanied by a surveyor, the fire escape door alarm worked. It alarmed. It registered the number of the tracker that set off the alarm onto a small monitor device adjacent to the door. Several minutes passed, but no staff responded to the alarm. This door was in an isolated, unoccupied area of the building (Unit B2, upstairs) whereby the alarming door could not be heard by staff members on the other resident care areas upstairs (Unit A2). The facility's security/alarm system was set up to display a resident's tracker number and location of the breached door onto pagers which the employees carried on their persons. The acting maintenance director, accompanied by a surveyor, went to the nurses' desk on the upstairs Unit A2. Registered Nurse (RN) #90 sat at the nurse's station on the second floor resident unit (A2). She verified that the alarm from Unit B2 did not show up on her pager, nor did she hear the alarm. She said they were not able to hear an alarm from Unit B2 because of the distance. She said they relied on their pagers as part of their security system to alert staff of possible elopements in various parts of the building. Nursing Aide (NA) #67 was the only other staff person on duty on the unit on that shift. She verified the alarm did not sound or appear on her pager, either. Next, the acting maintenance supervisor, still accompanied by a surveyor, went downstairs to unit A1. Licensed Practical Nurse (LPN) #84 and one (1) aide verified that the alarm did not sound or light up on their pagers to give any indication a door alarm had sounded on Unit B2. They had only two (2) pagers on this unit. The acting maintenance supervisor tested a tracking device with A1's exit door which was located right beside the nurses' station. The acting maintenance supervisor also checked the exit door alarm by using the tracker/transmitter which another resident wore (Resident # 41). In both situations, the door alarmed, but did not sound or light up on either employees' pagers. The acting maintenance supervisor, accompanied by a surveyor, traveled to Unit B1 which was also downstairs. This unit had three (3) pagers. Upon inquiry, LPN #80 and NAs #137 and #68 verified that no alarms came through on their pagers for either the exit door on upstairs Unit B2, or for the exit door downstairs on Unit A1. Lastly, the maintenance supervisor and surveyor went to the front desk on 08/06/18 at 1:40 p.m., where Office Assistant #117 was stationed. When asked if her pager had signaled within the last fifteen (15) or twenty (20) minutes, she said the off-going night shift employee at the change of shift that morning told her the pager was not working. She said therefore, her pager was turned off. A television monitor with sixteen (16) screen shots sat on a desk to her left. These screen shots were of various places inside and outside the facility, and changed views every few seconds. She said the television was video only. She said she had no way to hear the door alarms going off via the television monitoring system. When asked if she observed the acting maintenance director and surveyor as they stood outside the upstairs unoccupied Unit B2's fire escape exit a short while ago, she replied in the negative. She said she had been quite busy at that time and had not really watched the monitor closely. On 08/06/18 at 1:45 the director of nursing (DON) was verbally notified of this situation which required immediate corrective action. The DON immediately assigned staff to be stationed at each of the exit doors. She in turn notified the administrator verbally of the situation at hand, and began a plan of correction to fix the problem. When interviewed on 08/06/18 at 3:10 p.m., LPN #8 said he was working unit A2 the evening Resident #10 eloped from the unoccupied B2 unit fire escape door. He said he was on break at the time the elopement occurred, and learned of it upon his return to the unit. He said the pagers should go off when an alarmed door opened, but upon his return from his break, he checked the alarm history of the pager, but it showed nothing. He said it was possible that someone deleted it before his return from break. He said there was one (1) aide working Unit A2 that evening. He said that aide only worked part-time because he is a college student, and was not scheduled to work this week. An interview was conducted with the DON on 08/08/18 at 10:00 a.m. She verified that each of the seventeen (17) residents who wore Secure care tracking devices were at risk of elopement. She also verified that each of those residents ambulated independently and could go onto other units and floors independently. She said one (1) resident was out of the facility on medical/hospital leave that week, but seven (7) of the remaining sixteen (16) residents ambulated on foot (R#50, R#12, R#11, R#26, R#14, R#10, and R#6), although one (1) of them (R#26) sometimes used a walker. She said five (5) residents ambulated with a wheelchair (R#42, R#30, R#38, R#39, R#15). She said four (4) residents ambulated with a walker (R#44, R#46, R#37, R#45). Testing of the system at the time of the survey found it was not functioning as intended. Alarms could not be heard by staff and alerts were not sent to staffs' pagers. Outside environmental safety issues included a busy main highway adjacent to the parking lot, outdoor temperatures that might adversely affect an individual, a nearby in-use railroad, and nearby wooded terrain. The facility's failure to identify and repair the non-working pager system upon which staff were dependent on for elopement prevention system, prior to surveyor intervention, created a situation in which immediate corrective action was necessary. The risk of elopement, along with environmental safety issues, was determined to pose a risk of serious injury, harm, impairment, or death to a resident receiving care in the facility. After consultation with program managers, the facility was informed these findings were determined to be an immediate jeopardy. On 08/06/18 at 1:45 p.m. the director of nursing (DON) was verbally notified of this situation which required immediate corrective action. The DON immediately assigned staff to be stationed at each of the exit doors. She in turn notified the administrator verbally of the situation at hand. On 08/06/18 at 4:08 p.m. a written immediate jeopardy statement was hand-delivered to the administrator. On 08/06/18 at 4:40 p.m., the DON provided a written plan of correction (P[NAME]) which was approved by an assistant program manager at the Office of Health Facility Licensure and Certification (OHFLAC). b) The facility's plan of correction Plan of Correction We immediately began placing staff at each exit door, to ensure resident safety and inability to leave. We used housekeeping and maintenance staff. Pager system panel was checked and reset at apprpox. 2:30 pm. Going forward On day shift, 6am-2pm, each door passed by maintenance will be checked and verified to ensure that door is secure, this will be done at least every 2 hours. Main panel will be checked as well. This will ensure that pagers are working as well. Maintenance will check pagers every morning to ensure that they are working properly. 4pm-8am security guard will make rounds every 2 hours to ensure that main panel and doors are working properly and secure. A sign off sheet will be kept ensuring compliance. After verifying corrective actions were in place, the immediate jeopardy was abated on 08/06/18 at 5:10 p.m. as no identified deficient practice remained for this requirement after removal of the immediate jeopardy. c) Based on a new complaint regarding a resident's elopement that occurred two (2) days after the exit for a complaint investigation ending on 08/08/18, that had identified an immediate jeopardy related to elopements. Although the extended survey for the 08/08/18 complaint investigation was completed on 08/21/18, the State survey agency was not made aware of an elopement occurring on 08/10/18 until anonymous complaints were received. According to the complaints, when the facility conducted a fire drill, a resident was locked in an unsafe area for an extended period. The facility was reentered on 09/19/18 to investigate this occurrence. Staff interviews, review of records of incidents reported to the State related to elopements, and review of facility records, the facility failed to ensure an environment that was free from accident hazards over which the facility had control and failed to provide supervision to residents to prevent them from wandering into unsafe places. The facility's failure to ensure the safety of wandering residents during fire drills created a situation for which immediate corrective action was necessary. The risk of elopement, along with environmental safety issues, was determined to pose a risk of serious injury, harm, impairment, or death to a resident receiving care in the facility. After consultation with program managers, the facility was informed these findings were determined to be an immediate jeopardy. On 09/19/18 at 5:42 PM, the Administrator, Assistant Administrator, and DON were provided a written statement of the immediate jeopardy. On 09/19/18 at 6:54 PM, the DON provided a written plan of correction (P[NAME]) which was approved by an assistant program manager at the Office of Health Facility Licensure and Certification (OHFLAC) contingent upon additional language being added when the administrator was available. At that time, the immediate jeopardy was removed as implementation of the P[NAME] had begun. On 9/21/18 at 10:58 AM, the Administrator provided an amended written P[NAME] which was approved by an assistant program manager at OHFLAC. Resident identifier: #12. Facility census 51. Findings included: 1. Resident #12 During an interview on 09/19/18 at 3:01 PM, the Activity Director stated when she was on the Gore 3 Hall, she had seen Resident #12 behind a locked fire door at lunch time. The resident was on the(NAME)D Good hall, an unmonitored, unsafe and unused portion of the building. The activity director stated she could not recall the exact date. During an interview on 09/19/at 3:43 PM, the Maintenance Director and Staff Development coordinator stated a fire drill inservice was conducted on 08/10/18 at 10:00 AM for 20 minutes. The Maintenance Director stated the fire door on Gore 3 hall opened to an unused portion of the building during that time and then locked at the end of the drill. The maintenance director stated at lunch time the PA (public address) system announced Resident #12 was missing. The Maintenance Director was able to unlock the fire door and bring Resident #12 back into the facility monitored area. Staff development coordinator could provide no evidence of resident head counts done during the inservice just sign-in sheets of who participated on 08/10/18. During the inservice a verbal head count was provided to the command center on the first floor. Resident #12 was not identified as being missing. During a telephone interview on 09/19/18 at 4:23 PM, Psychological Assistant #2 stated he had been asked to review video footage of the incident involving Resident #21 on 8/10/18. Psychological Assistant #2 stated he reviewed the video footage and provided an e-mail summary of his review of the footage to the management team. Psychological Assistant #2 stated the Maintenance Director got Resident #12 from behind the locked fire door at lunch time. Review of an e-mail from Psychological Assistant #2 addressed to the administrator, assistant administrator, social services director, director of nursing, and maintenance director dated 08/17/18 at 5:32 PM stated, I checked the cameras regarding (Resident #12's name) into the(NAME)D Good center during the fire alarm. The three key findings identified by Psychological Assistant #2 were (Resident #12 has been substituted for the resident's name): 1. As suspected, Resident #12 and other residents can open doors to(NAME)D Good on floor 3 during the fire drill. It's possible there is a window during which residents can leave after the alarm stops. I'll have to ask when exactly the alarm was shut off vs. (verses) when the systems may have been reset, because it appears that Resident #12 left GORE 3 the last time after the flashing lights stopped. 2. Unless I missed something reviewing Camera 27-31, Resident #12 was also on the 3rd floor during the entire fire drill (9:51-10:07 am). She was neither sought nor found on the third floor during the drill. 3. Because Resident #12 left our side of the building twice during the drill either 1) we missed more than one elopement alarm or 2) the elopement alarms did not trigger during the drill or 3) there is no working tracking sensor on the doors to(NAME)D. Good (I didn't spot any) Total time away from Hopemont: 2 hours 34 minutes Camera 31 9:51 am flashing alarms first seen 9:52 am Resident #12 checks the door to(NAME)D Good but returns toward G 3 dining hall 9:57 am Resident #12 wanders toward the doors and walks through to(NAME)D Good 9:59 am Resident #12 returns to Gore 3 (away for 2 minutes) 10:07 am flashing alarm lights appear to stop 10:07 am Resident #12 walks back to the doors but turns back toward G 3 dining hall 10:09 am Resident #12 returns to the hallway and exits to(NAME)D Good I did not spot Resident #12 re-entering the G 3 hallway until . 12:31 PM first employee seen looking for Resident #12 on G 3 hallway 12:34 PM second employee spots Resident #12 through the doors, additional employees come down the hallway and call for assistance 12:40/12:41 PM Maintenance personnel open the door, and Resident #12 returns to G 3 hallway/dining room (away for 2 hours 32 minutes) During an interview on 09/19/18 at 7:15 PM, the assistant Administrator stated no investigation of the incident involving Resident #12 was done other than the review of the video done by Psychological Assistant #2. The Assistant Administrator could provide no further evidence of any staff interviews or assessment of fire door alarm status during fire drills. The facility's failure to ensure the safety of wandering residents during fire drill inservices created a situation in which immediate corrective action was necessary. The risk of elopement, along with environmental safety issues, was determined to pose a risk of serious injury, harm, impairment, or death to a resident receiving care in the facility. After consultation with program managers, the facility was informed these findings were determined to be an immediate jeopardy. On 09/19/18 at 5:42 PM, The Administrator, Assistant Administrator, and DON were provided a written statement of the immediate jeopardy. The statement was hand delivered to the administrator. On 09/19/18 at 6:54 PM, the DON provided a written plan of correction (P[NAME]) which was approved by an assistant program manager at the Office of Health Facility Licensure and Certification (OHFLAC) contingent upon additional language being added when the administrator was available. At this time, the immediate jeopardy was removed as implementation of the P[NAME] had begun. On 9/21/18 at 10:58 AM, The Administrator provided an amended written P[NAME] which was approved by an assistant program manager at OHFLAC. After removal of the immediate jeopardy, no deficient practice remained for this requirement. d) The facility's plan of correction Hopemont wandering residents are unable to breech this exit into an unsafe area. All residents that breech the perimeters of Hopemont Nursing Home and wander into an unsafe area will be reported to OHFLAC per policy within 2 hours. During all fire drills, there will be a complete head count of all residents. Staff will perform a second head count at the end of the drill. Maintenance staff will monitor fire doors during drills. All staff will be in serviced on fire safety and procedure.

Based on observation of a facility video, clinical record review, review of facility staffing sheets, resident interview, staff interviews, and review of facility investigations, the facility failed to prevent resident abuse by a Health Service Worker (HSW). A staff member yelled at, cursed at, and slapped Resident #58's hand, then removed the resident from the dining room just as her meal arrived. Resident #6 was seated at the same table as Resident #58 and remained upset and distressed more than three (3) weeks after the occurrence. This occurrence resulted in actual harm to Resident #58 and Resident #6. Resident identifiers: #58 and #6. Facility census: 57. Findings include: a) Resident #58 Resident #58 had [DIAGNOSES REDACTED]. The 02/15/17 annual Minimum Data Set assessment indicated the resident had physical behaviors directed at others and rejected care 1-3 days and had severe cognitive impairment. She was non-ambulatory, used a wheelchair, and had limited range of motion on one side. She required setup assistance for eating. Her 02/20/17 care plan interventions included: - Due to limited verbal communication, staff are encouraged to ask simple questions which require yes/no answers. - observe facial expressions (smile or frown) - she has been known to become anxious in crowded and noisy areas, staff are recommended to ask if she would like to go to her room or a calmer location - Staff are recommended to avoid grabbing and holding down her left arm or hand when she is agitated. Review of the facility's investigation revealed on 03/02/17 at 5:20 p.m., Health Service Worker (HSW) #30 had physically, emotionally, and psychologically abused Resident #58. HSW #30 was initially suspended pending an investigation on 03/02/17 at 7:02 p.m. The investigation was completed, after requesting 2 extensions to complete the investigation, and submitted to the State agency on 03/15/17. The facility substantiated verbal, mental and physical abuse based on review of video footage of the incident, resident interviews, and staff interviews. Review of facility staffing assignments showed HSW #30 returned to work on 03/06/17 at 6:00 p.m. until 10:30 p.m. on the same hall that Resident #58 resided. HSW #30 again worked on Resident #58's hall on 03/07/17 from 2:00 p.m. until 5:45 p.m During an interview, on 03/21/17 at 3:06 p.m., Assistant Administrator (AA) #102 stated on 03/06/17 he and the administrator made the decision to bring HSW #30 back to work 03/06/17 since the investigation did not show the resident was physically harmed. AA #102 stated HSW #30 worked back on the floor for one and 1/2 shifts. AA #102 stated he had reviewed the video footage prior to making the decision to bring HSW #30 back to work. During an interview on 03/21/17 at 3:13 p.m., Recreation Specialist (RS) #52 stated she had witnessed HSW #30 abuse Resident #58 on 03/02/17 in the dining room during the evening meal. RS #52 stated HSW #30 yelled at Resident #58 telling her she was tired of her s---. Resident #58 kept saying, No, no, my god no. Resident #58 was frowning, shaking her head no, and trying to push herself away from the table. Resident #6, who was also sitting at the table, asked HSW #30 to leave Resident #58 alone. HSW #30 yelled at Resident #6 to mind her own business. Resident #6 stated, I am not going to stay in a place where they treat us like dogs. RS #52 stated when Resident #58's dinner tray arrived and HSW #30 stated, I guess you are out of here now and removed the resident from the dining room. I reported the incident to Social Work Supervisor (SWS) immediately. RS #52 stated she had never seen a resident abused like that before in 9 years. During an interview on 03/21/17 at 3:45 p.m., Administrator #90 and AA #102 stated after bringing HSW #30 back to work on 03/06/17, they determined they needed to further investigate the incident on 03/07/17 and sent HSW #30 home. We then brought her back to work in the dietary department on 03/08/17. During an interview on 03/21/17 at 4:33 p.m., HSW #30 stated she had received training regarding resident abuse and neglect. HSW #30 stated Resident #58 was agitated on 03/02/17 in the dining room and complained of the clothing protector being too tight around her neck. HSW #30 stated Resident #58 would not calm down so she took her back to her room. HSW #30 stated she returned to work on Resident #58's hall on 03/06/17 from 6:30 p.m. until 10:30 p.m. and on 03/07/17 from 2:30 p.m. until 3:30 p.m. when I was re-suspended. On 03/27/17 at 11:51 a.m., review of the facility's video with Administrator #90 and Psychological Assistant (PA) #7, noted HSW #30 took Resident #58 into the dining room on 03/02/17 at 5:21 p.m. The HSW double knotted a clothing protector around resident's neck. Resident #58 frowned, shook her head no, and pulled at clothing protector. HSW #30 pushed Resident #58 back to the table 4 times and locked her wheelchair. HSW #30 slapped Resident #58's left hand 5 times and held her hand down under the table. Resident #58 withdrew her hand and frowned and shook her head no when HSW #30 slapped her hand. When the meal arrived at the table, HSW #30 removed Resident from the dining room at 5:27 p.m. (30 seconds after the meal arrived). During the video review, the administrator stated, We should have not brought her back to work until we completed our investigation. He further stated HSW #30 was again suspended after an interview on 03/21/17. During an interview on 03/27/17 at 2:22 p.m., Social Work Supervisor (SWS) #32 stated she became aware of the abuse allegation on 03/02/17 from RS #52 and Resident #6. SWS #23 stated her investigation was not complete when HSW #30 was brought back to work on 03/06/17. SWS #32 stated she had only been able to work on the investigation for one day. During an interview on 03/29/17 at 10:50 am, Food Service Worker (FSW) #48 stated he had witnessed an incident between HSW #30 and Resident #58 in the dining room on 03/02/17. FSW #48 stated HSW #30 was aggressive, and yelled and cursed at Resident #58. HSW #30 slapped Resident #58's left hand and held it down. HSW #30 would not let Resident #58 move away from the table. Although the resident had severe cognitive impairment, a reasonable cognitively intact person would have been humiliated and demeaned by the treatment Resident #58 received. Therefore, this was determined to constitute actual harm for Resident #58. b) Resident #6 During an interview on 03/27/17 at 10:00 am, Resident #6 confirmed she was at the dining room table on 03/02/17 at 5:20 p.m. with Resident #58. Resident #6 stated that HSW #30 was mean to Resident #58. The resident continued, stating, I got very upset and wanted to cry . I got shaky and upset when (name of HSW #30) told me we could take it outside . No one should be treated like she did to (Resident #58's name). She (HSW #30) treated her worse than like a dog. I didn't want to stay in a place where people are yelled at and pushed around. (HSW #30) told, (Resident #58's name) 'Well I guess you are not going to get any dinner tonight.' She (HSW #30) took her out of the dining room. (Resident #58's name) was just trying to get her to fix her bread and setup her meal in the way she likes. (Resident #58's name) just can't talk for herself. During the interview, Resident #6 was visibly upset cried and her hands were shaky in describing the incident involving Resident #58 and HSW #30. Resident #6 continued to be upset and distressed by the occurrence on 03/02/17, which was more than three (3) weeks after the event. This was determined to constitute actual harm to Resident #6.

Based on record review, staff interview, and observations, the facility failed to ensure each resident was provided an environment as free of accident hazards as possible and failed to ensure each resident was provided with adequate supervision to prevent accidents. Resident #89 was placed in a reclining chair that in effect restrained the resident without first assessing whether this was safe for the resident. The resident subsequently flipped the chair over on 08/08/14 sustaining a small raised area on the posterior center of his head. He was placed back in the chair after the incident occurred. The facility continued to place the resident in the chair with leg straps applied. Prior to the resident flipping the chair over, on 07/22/14, the physician wrote an order for [REDACTED]. An order was written on 08/12/14 to keep the resident in sight at all times when he was up in his chair and to not lean the chair back. Observations on 09/22/14, 09/23/14, and 09/24/14, found the resident up in his chair with leg straps applied and with the chair leaned back, and no staff in sight. After reviewing the resident's medical record, conducting interviews with staff, and repeated observations of the resident, it was determined an immediate jeopardy existed for Resident #89. On 09/24/14 at 11:17 a.m., the Hospital Administrator #150, Acting Hospital Administrator #5, the Assistant Director of Nursing (ADON) #30, and the Director of Nursing (DON) #107 were notified an Immediate Jeopardy. Additionally, Resident #35 was noted to have experienced multiple falls. The injuries sustained from the falls ranged from no injury to injuries for which he was sent to the hospital. The facility had not assessed the resident for falls to determine what interventions should be attempted and the type and how much supervision needed to be employed to reduce the likelihood of falls. The resident was at times placed in a reclining geri-chair to prevent him from getting up. There was no assessment to determine whether this device was safe for Resident #35. Two (2) of five (5) residents investigated in Stage 2 for accidents were affected. The Stage 2 sample was 36. Resident identifiers: #89 and #35. Facility census: 87. Findings include: a) Resident #89 Review of the clinical record for Resident #89 revealed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] revealed Resident #89 was moderately cognitively impaired, unable to make himself understood and was rarely able to understand others. Resident #89 was documented as requiring the extensive assistance of two (2) staff for bed mobility and transfers and walking did not occur during this assessment period. The MDS documented the resident had experienced a fall with injury and a limb restraint was being utilized daily. This MDS also documented documented Resident #89 had exhibited behaviors such as hitting, kicking, pushing, or grabbing 1-3 days a week and rejected care 1-3 days a week. Review of the current fall care plan, dated 07/24/14, revealed Resident #89 was at risk for falls due to the inability to transfer without the assistance of staff. Interventions included for Resident #89 to be placed in a Broda chair (a type of reclining chair) with pelvic straps to be used while in this chair. The staff were to check on the resident every 30 minutes and the straps were to be released every 2 hours. The resident could also be placed in a reclining chair with his feet up for comfort and a alarming device to alert staff of unassisted attempts to rise from the chair. Review of the nurses' notes found the following: -- On 07/19/14 at 10:50 a.m., a nurse documented Resident #89 as being very restless and staff were unable to keep him in the reclining chair. The Broda chair they had been using was not available at that time, but when it became available they placed him into the Broda chair and applied the restraining straps around his legs. He continued to be very restless. -- On 07/23/14 the nurses' notes revealed Resident #89 was restless in the Broda chair and was repeatedly lifting his body up off on of the chair. -- On 08/08/14 at 2:48 p.m. - Resident #89 flipped the Broda chair over backwards. He received a 1/2 centimeter slightly raised area posterior center of his head. Neurological checks were implemented, but they were never completed. This was verified by the Director of Nursing Staff #107 on 09/25/14 at 11:10 a.m.. -- On 08/10/14 at 12:33 p.m. - Resident #89 frequently continued to try and stand up while he was seated in the Broda chair with the straps on and continues to be at risk for falls. -- On 08/10/14 at 9:44 p.m. - Resident #89 was anxious and attempting to stand up out of his Broda chair and Valium, an anti-anxiety medication was given. -- On 08/20/14 at 9:23 p.m. - Resident #89 was very anxious, agitated, combative with care and attempting to climb out of the Broda chair. -- On 08/31/14 at 4:12 a.m. - Resident #89 was fidgeting in his chair and pulling at the leg straps across his legs. -- On 08/31/14 at 2:58 a.m. - Resident #89 was in the Broda chair tugging at the leg straps saying "owl, owl'. -- On 09/15/14 at 4:27 a.m. and 09/20/14 at 3:31 a.m. - Resident #89 was seated in his Broda chair and was tugging at the leg straps that were secured around his legs. Review of the physician orders [REDACTED].#89 tipped his Broda chair over backwards, that the resident should be in sight of the staff at all times when he was up in the Broda chair. There was also an order [REDACTED]. These new fall prevention interventions were never added to the fall care plan. The following observations and interviews were conducted on 09/22/14, 09/23/14 and 09/24/14: -- On 09/22/14 at 3:48 p.m. - Resident #89 was observed in a Broda chair in the hall with his chair laid back and leg straps around both legs. -- On 09/23/14 at 1:20 p.m. - Resident #89 was again observed in a Broda chair in a semi-reclined position with straps secured around each of his legs. -- Observation on 09/23/14 at 3:40 p.m. revealed Resident #89 was still in his Broda chair and the nurse was at the desk at the nurses' station, but she was unable to see Resident #89 from the nurses' station. There were no other staff members noted to be on the unit from 3:40 p.m. until 3:42 p.m. when a HSW exited another resident room. Resident #89 was out of the view of staff for 2 minutes. -- On 09/23/14 at 3:55 p.m. - Resident #89 was observed attempting to turn side ways in his chair and was pulling on the handrail. He was leaning forward and attempting to pull his legs out of the leg straps, but he was unsuccessful in doing this. There were no staff in the area during this observation. -- In an interview on 09/23/14 at 3:50 p.m. with Health Service Worker (HSW) #4, she said she did not work on Unit A-1, so she was not familiar with Resident #89's day to day care. After the interview was complete HSW #4 went into a resident room and Resident #89 was observed to be seated in his Broda chair in a reclined position and there were no other staff in sight. -- On 09/24/14 at 8:30 a.m. - Resident #89 was again observed in the Broda chair in a semi-reclined position with the straps secured around each of his legs. He was attempting to pull his legs out of the leg straps and forcibly jerking himself around in the chair, pulling on the handrail and he was lifting one side of the chair up off of the floor. There was no staff observed to be in the area during this observation. This surveyor waited three (3) minutes until a staff member exited another resident's room and then conducted an interview with this staff member. Interview with Health Service Worker (HSW) #161 revealed Resident #89 would attempt to get out of the Broda chair all the time. She stated he had already flipped the chair over backwards a few weeks ago and bumped his head. She stated he got very agitated with the straps around his legs and tried to pull them off. When HSW #161 was asked if there had been any special precautions put in place for Resident #89 after the fall out of the Broda chair occurred, she stated not that she was aware of and indicated the resident would often sit in the chair all day long. She stated after he had fallen out of the chair she was in the dining room and Resident #89 was somehow able to get himself out of the Broda chair with the leg straps in place and he was noted to walking down the hall. HSW #161 was asked if Resident #89 was to be kept in the sight of staff at all times. She stated they tried to do that, but it was impossible. She stated they had three (3) HSWs on duty during the day and many of the residents required 2-3 staff members to assist with care. She stated when they were in other resident rooms or on a break, there was no possible way they could ensure Resident #89 was within the sight of a staff member at all times. She stated on the night shift they often worked with one (1) nurse that went between 2 units and and one (1) or two (2) HSWs, so it would be impossible to keep Resident #89 in sight at all times. Based on resident interviews, staff interviews, review of staffing schedules, and observations, the facility failed to ensure adequate staffing to provide care and supervision to residents and to ensure sufficient staff were available on a daily basis to meet residents' needs and in an environment which promoted each resident's physical, mental and psychosocial well-being, and safety, thus enhancing the individual resident's quality of care and quality of life. -- Interview with Physical Therapy (PT) #98 on 09/24/14 at 9:30 a.m. revealed Resident #89 was placed in the reclining Broda chair the day after he was admitted on [DATE]. She stated Resident #89 had not been assessed by the physical therapy department to determine if the resident was safe to be restrained in this device. PT #98 stated he was not assessed for safety for the use of the Broda chair until after he had fallen backwards while sitting in Broda reclining chair. She stated he fell out of the chair on 08/08/14, but he was not assessed for the use of the Broda chair by physical therapy until 08/17/14 when the licensed therapists returned to work. PT #98 stated Resident #89 was deemed to be in an appropriate positioning device at that time. Review of this physical therapy noted revealed Resident #89 should not be fully reclined in the reclining Broda chair due to increased instability of the chair in that position and it placed the resident at a higher risk for falls. During this interview the PT #98 was asked if they were aware of Resident #89's continued attempts to stand, pull his legs through the straps, and try to exit the Broda chair. She stated if they were aware of those actions by the resident they would not have deemed Resident #89 to be safe to be placed in the Broda chair. On 09/24/14 at 11:17 a.m., the Hospital Administrator #150, Acting Hospital Administrator #5, the Assistant Director of Nursing (ADON) #30, and the Director of Nursing (DON) #107 were notified an Immediate Jeopardy began on 07/17/12 when: -- Resident #89 was placed into a Broda chair (reclining chair that restrained the resident) without first assessing if it was safe for the resident to be in the reclining chair; and -- Resident #89 was placed back into this device in the reclining chair, and the resident tipped the chair over backwards onto the floor on 08/08/14. The Immediate Jeopardy was removed on 09/24/14 at 5:30 p.m. when Resident #89 was placed on 1:1 supervision. This reduced the potential for imminent danger as no other residents in the facility were observed to be at risk of injury while restrained in a reclining chair. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 3 (actual harm). The facility established a schedule to ensure 1:1 supervision for Resident #89 and physical therapy began an evaluation and assessment of Resident #89. -- Observation on 09/24/14 at 4:15 p.m., after the immediate jeopardy had been called, found Resident #89 in the Broda chair in the hall. PT #98, Director of Nursing (DON) #107, and Registered Nurse (RN) #103 were observed to assist Resident #89 up out of the Broda chair. The resident was observed to walk from Unit A-1 to the therapy room located approximately 100 feet down the hall. He was slightly unsteady and required the staff to steady him as he walked. The DON #107 spoke with this surveyor during this observation and stated they were not sure what they can do to keep Resident #89 safe. She stated if they put him the bed he will just crawl out and fall and they do not have the staff to do continual 1:1 with him. -- Interview with Licensed Practical Nurse (LPN) #147, on 09/24/14 at 5:10 p.m., revealed she was advised Resident #89 had been placed on 1:1 for the next 24 hours. She stated they had called in extra staff to ensure the 1:1. LPN #147 stated her HSWs had been educated on the evening shift regarding the need for Resident #89 to receive 1:1. Interview with Health Service Worker (HSW) #3 at this time revealed she was aware of the need for Resident #89 to be supervised at all times and indicated there was one staff currently assigned to sit with him at all times. Observation on 09/25/14 at 9:00 a.m. observed Resident #89 in bed and a HSW was sitting with him in his room providing supervision. b) Resident #35 Review of Resident #35's clinical record, on 09/24/14, revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set Assessment (MDS) 3.0, dated 06/10/13, noted the Brief Interview for Mental Status (BIMS) was scored 7m indicating the resident presented with severely impaired cognition. The resident was further assessed as independent with ambulation. The care plan, dated 05/28/13, included the problem: "Risk assessments (falls, elopement, bowel and bladder, skin, pain) as indicated," with the goal "Resident will remain free of harm throughout the review period," and included an intervention for a "Fall assessment." Review of "Hopemont Hospital Resident Incident/Accident reports revealed the following: On 07/18/13 at 3:00 a.m., the resident was found on the floor and referred the reader to "see attached nurses note. The nurse's note, dated 07/18/14 at 3:23 a.m., revealed "This nurse was paged to resident's room as resident had fallen backwards striking his head on dresser or possible bed frame." The clinical record was silent for a fall assessment and was silent for additional intervention to prevent another fall. On 07/21/13 at 2:00 a.m., the resident reported to HSW that he fell out of bed and was found to have a puncture wound to his left elbow and an abrasion with a small amount of bleeding to the back/top of his head. The clinical record was silent for a fall assessment and was silent for additional intervention to prevent another fall. On 07/22/13 at 6:15 a.m., the resident was walking in B hallway and fell "flat on his face." The nurses note dated 07/22/13 at 6:15 a.m. revealed the resident "was walking in hallway, lost his balance, and fell on floor, face first." The resident sustained [REDACTED]." The emergency squad was called and transported the resident to the emergency room where he received three sutures to his right eye. The clinical record was silent for a fall assessment and was silent for additional intervention to prevent another fall. On 07/24/13 at 2:15 a.m. the "Resident had just returned from hospital visit due to hitting head. Resident was in bed and staff heard him fall on floor." No injuries were noted at that time. The clinical record was silent for a fall assessment and was silent for additional intervention to prevent another fall. On 08/03/13 at 2:05 a.m., "heard noise and found resident lying on floor on back denies hitting head." The resident reopened wound to left elbow. The clinical record was silent for a fall assessment and for additional intervention to prevent another fall. On 08/06/13 at 12:00 a.m., "alarm sounding and heard a crash, resident found on floor on stomach with head under bed, TV on floor." The resident sustained [REDACTED]. The clinical record was silent for a fall assessment and the care plan was silent for use of an alarm and was silent for additional intervention to prevent another fall. On 08/11/13 at 2:30 a.m. "HSW found resident on floor beside bed no injuries/eversions/shortening of extremities. Neuro's started due to uncertainty of hitting his head." The clinical record was silent for a fall assessment and additional intervention to prevent another fall. On 08/22/13 at 5:30 a.m., "On floor B1 hallway lying on buttocks, denied hitting head." The clinical record was silent for fall assessment and additional intervention to prevent another fall. On 08/23/13 at 5:15 a.m., "staff went to do last set of vitals for neuro checks from previous fall and found resident lying on his right side in the bathroom." The resident sustained [REDACTED]. The clinical record was silent for a fall assessment and additional intervention to prevent another fall. Review of the clinical record revealed a care plan was developed on 09/04/13 for "Potential for falls due to unsteady gait" which included a goal of "No injuries" and interventions to "Provide assistance with transfers, ambulation and locomotion as needed. (hx when manic he will run in hallways and dance report this to the nurse), Provide recliner PRN (as needed), Check every 15 minutes due to increase fall risk and has a history of falls with injury. Resident to have a helmet during manic phases to protect from injuries due to risk for falls." On 09/28/13 at 12:00 a.m. "Resident stood up and stumbled and fell on to buttocks" the resident sustained [REDACTED]. The clinical record was silent for a fall assessment and intervention to prevent another fall. The corresponding nurses note dated 09/28/14 at 1:10 p.m. revealed the "Resident was in the B1 dining room at 12 noon awaiting his lunch. Resident stood up and stumbled sideways and fell on the floor landing on his buttocks. Resident received a 5cm x .5cm skin tear to his right forearm." The clinical record was silent for a fall assessment and intervention to prevent another fall. On 11/19/13 at 6:00 p.m., the resident was "Running down hallway and heard thud. The resident hit face first and rolled self to back." The resident sustained [REDACTED]. The corresponding nurse's note dated 11/19/13 at 6:23 p.m. revealed "Heard resident scream, found resident lying on floor. Resident was able to turn himself to a back position, which revealed a perfect 2 inch vertical laceration above the left brow. 911 called at this time." The resident received 4 sutures to his left brow. The clinical record was silent for a fall assessment and intervention to prevent another fall. On 11/22/13 at 9:30 a.m., "Resident found on left side on floor in front of nurse's station. Noted to have a 2cm laceration above the eyebrow with moderate amount of bleeding, stopped with applied pressure, edges well approximated. A 1cm abrasion to bridge of nose and slight swelling and discoloration at base of pinky finger." The clinical record was silent for a fall assessment and additional intervention to prevent another fall. Review of "Incident/Accident Report dated 01/13/14 at 11:00 a.m., revealed "Resident found on left side lying on left arm with right arm in front of resident no internal external rotation effect noted resident denies pain no noted injuries other than 2.5cm laceration to left brow." The steps taken to prevent recurrence were "resident has helmet for head protection and safety will have PT screen for needs." The clinical record was silent for a fall assessment. Review of a "Hopemont Physical Therapy Progress Note" dated 01/16/14 the resident was referred to physical therapy "due to a recent fall with ambulation. The resident will benefit from therapy intervention due to recent fall. Resident presents with intermittent unsteady gait patter, unsafe pace, and balance deficits placing at increased fall risk. Resident would benefit from short term rehab to address these deficits and reduce fall risk." Review of Incident/Accident Report dated 05/17/14 at 8:15 a.m., "Resident walking quickly tripped over feet and fell to floor landing in a prone position and hitting head/face on floor." The resident sustained [REDACTED]. The clinical record was silent for a fall assessment and intervention to prevent another fall. An Incident/Accident Report dated 05/17/14 at 8:30 a.m., revealed "Resident noted to have raw areas on pads of great toes-appears as busted blisters, shoes slightly big and flop on feet when walking." The steps taken to prevent reoccurrence of the blisters were for the social worker to look at the residents shoes to ensure they are the proper size. This was not added to the resident's potential for falls care plan as an intervention. Review of Resident #35's "Resident Daily Care Record" for September 2014 was silent for 15 minutes as indicated by the plan care for fall prevention. During Stage 1 of the survey on 09/22/14 and 09/23/14 the resident was observed ambulating independently in the hallway. During an interview conducted on 09/26/14 at 5:35 a.m. Health Service Worker (HSW) #120 stated they sometimes place resident #35 in a reclined chair to prevent falls. She further stated that when the chair is reclined the resident is unable to exit the chair and does at times try to climb out of the chair. HSW #120 stated the resident was not on 15 minute checks and denied knowledge of the resident requiring 15 minute checks. During an observation on 09/26/14 at 9:38 a.m., the resident was lying in bed on his left side. The resident's athletic shoes with Velcro straps were observed on the floor at bedside. During an interview on 09/26/14 at 9:40 a.m. with Licensed Practical Nurse (LPN) #65 when queried about the resident's risk for falls and current fall interventions stated "we just watch him and when he is unsteady we try to get him to sit down at the desk. When he becomes more manic we put him in the geri chair, when the chair is reclined he is unable to get out of the chair, he is pretty good about staying in the chair when we tell him to stay seated." LPN #65 denied knowledge of any other interventions to prevent falls. She further stated the resident did not use personal alarms. LPN #65 checked his treatment sheet and stated he uses a helmet when he is manic. She was unaware of the resident falling in the past, she stated she has been employed at Hopemont for about one year and was a float nurse. During an interview on 09/26/14 at 9:26 a.m., Health Service Worker (HSW) #106 when queried about the resident's fall history and interventions to prevent falls stated "the resident wears a helmet and we put him in the geri chair when he gets unsteady", she further stated the resident "tries to get out of the geri chair but he can't because the chair is leaned back." HSW #106 further stated that it had been "months and months" since the resident's last fall. During an interview on 09/26/14 at 10:15 a.m. with the Director of Nursing (DON) #107 verified the lack of assessment for fall risk after each fall and a lack of care plan interventions to prevent falls for Resident #35. She stated that they do not have a policy and procedure for fall prevention. During an interview conducted on 09/26/14 at 10:40 a.m., Care Plan Registered Nurse (RN) #89 who was responsible for completing Resident #35's Minimum Data Set 3.0 assessments and development of the resident's care plan, verified the lack of fall assessment and development of care plan interventions after each of the residents falls. In addition, review of nurse's note dated 11/23/13 at 12:15 a.m. "Resident was sitting in a reclining chair in the hallway; he was awake and alert", "Resident is not sitting calmly in his seat; he continually likes to get out of his seat; or try to get out of his seat and try to walk around." Further review of the clinical record was silent for an assessment for the use of the reclining chair (Geri chair) and its impact on the resident's functional ability making the use of the reclining (Geri-chair) an accident hazard for the resident. On 09/24/14 at 3:40 p.m. the resident was observed ambulating independently in the hallway. During an interview on 09/24/14 at 3:45 p.m., Nurse #65 stated "when the resident is in his manic phase we place him in a recliner to prevent him from ambulating due to his unsteady gait. We put him in the chair to keep him still." During an interview conducted on 09/26/14 at 5:35 a.m., Health Service Worker (HSW) #120 stated "we sometimes place the resident in a reclined chair to prevent him from falling." She further stated that "When the chair is reclined the resident is unable to exit the chair and does at times try to climb out of the chair." During an interview conducted on 09/26/14 at 8:10 a.m., Physical Therapy (PT) Supervisor #98 verified the resident has not been assessed by physical therapy for the use of a reclining (Geri) chair. During an interview conducted on 09/26/14 at 9:26 a.m., Health Service Worker (HSW) #106 stated "we put him in the Geri chair when he gets unsteady" she further stated "he tries to get out of the Geri chair but he can't because the chair is leaned back." c) The facility did not have adequate staffing to ensure residents were provided necessary supervision to prevent accidents: 1. An interview with Health Service Worker (HSW) #63 and Licensed Practical Nurse (LPN) #2 on 09/25/14 at 2:45 p.m. revealed Unit A-1 was unsafe to only have one or two HSWs working on the unit. They both stated there were several residents on the unit who had aggressive behaviors, fall risks, and potentially sexually abusive behavior. They stated if they were in a resident room providing care for a resident who required two (2) staff members to provide care and there was a resident to resident altercation or an alarm sounded to alert the staff of a resident attempting unassisted ambulation, then they would not be able to hear them and respond timely. They also stated most of the time the nurse who was working on the 11:00 p.m. to 7:00 a.m. shift was required to cover Unit 1-A and Unit 2-A, which was upstairs. They stated there were also times when there was only one (1) nurse for the two (2) units and there was also only one (1) HSW on the unit so when the nurse went upstairs, it would leave 1 HSW on the unit to provide supervision and care to 24 residents. 2. Interview with HSW #144 on Unit A-1 at 5:30 a.m. revealed there had been times when she had worked the unit with just herself and one nurse. She stated she could not remember the actual nights, but stated this could be verified by the schedule. HSW #144 stated they had so many HSWs that called off and the facility was not able to obtain coverage, so they were required to work short. She stated they would attempt to get the evening shift to stay over and at times the evening shift was actually mandated to stay over to cover the 11:00 p.m. to 7:00 a.m. shift, but other times they just worked short. HSW #144 stated most of the residents on the unit required at least two (2) staff to assist them to transfer them or to turn and position them. She stated the unit had several residents with aggressive behaviors and it was not safe to attempt to provide care to them with just one (1) HSW. 3. Interview with HSW #161 on 09/30/14 at 10:02 a.m. revealed she worked on Saturday 09/27/14 on the night shift and there were times when she was the only HSW on the unit because the other HSW was required to float between Unit A-1 and Unit A-2. She stated the nurse on the unit was also required to float between two (2) nursing units. This was verified by reviewing the working schedule provided by the DON #107. HSW Staff #161 stated with only one (1)HSW on the unit, it left the unit without adequate supervision for residents who have known aggressive behaviors and many who were at high risk for falls. 4. During an interview on 09/26/14 at 5:30 a.m., HSW #120 stated they, "Sometimes only have 1 or 2 HSWs working on a hallway. When they only have 1 HSW it is very hard to get all our work completed." 5. During an interview conducted on 09/26/14 at 6:05 a.m., HSW #49 stated they, "Sometimes only have 1 HSW working on the hallway and it is not safe for the staff and residents when they have to work short." 6. During an interview conducted on 09/26/14 at 6:15 a.m., Registered Nurse (RN) #37 stated she sometimes had to cover two hallways and when this happened she was unable to get all the resident's treatments completed. 7. Interview with DON #107 on 10/01/14 at 8:45 a.m., revealed she did the staffing based on the staffing requirements set forth by the State of West Virginia. She stated she did not base the scheduling on the nurses or the HSW according to the acuity of the residents. She stated her goal on the 7:00 a.m.-3:00 p.m. shift was to have have one (1) nurse on each floor and 3 HSWs. On 3:00 p.m.-11:00 p.m., her goal was the same as on the 7:00 a.m. to 3:00 p.m. shift. She stated on the 11:00 p.m. to 7:00 a.m. shift , she tried to always have two (2) nurses and three (3) if they could and at least two (2) HSWs per unit. The DON stated the facility struggled with staffing. She stated they were always trying to recruit, but just never had enough staff. She stated it was difficult to attract workers to the facility because of the rural location and it was a State facility that did not pay as much as other nursing homes. She verified that some of the staff had expressed discontent with having to work more than the amount of hours they want to work and there was staff burn out. She stated there were many times when the HSW staff had to stay over or come in early to cover a shift. She stated last week one (1) the HSWs worked 96 hours in one week to attempt to cover shifts for staff that called off. She stated they have staff burn out, but they were always having to mandate staff to work overtime to attempt to provide adequate coverage. The DON verified with the the acuity and behaviors of some of the residents on the units, that having two (2) HSWs and one (1) floating nurse between 2 units might not provide the supervision and provide the time needed to ensure all the residents' care was provided in a timely manner. She verified there were nights when HSWs would call off and they were not able to cover their shift so they would have to work with less than the desired 2 HSWs on each unit.

Based on staff interview and record review, the facility failed to adequately assess and manage pain for one (1) of one (1) resident (Resident #89) reviewed for pain. This resulted in the resident experiencing pain which was avoidable, and therefore was actual harm. The facility also failed to monitor vital signs per physician's order for one (1) of five (5) residents (Resident #49) reviewed for unnecessary medications. Resident identifiers: #89 and #49. The Stage 2 sample was 36. Facility census: 87. Findings include: a) Resident #89 Review of the clinical record for Resident #89 revealed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE], revealed Resident #89 was moderately cognitively impaired, unable to make himself understood and was rarely able to understand others. Resident #89 was documented as requiring the extensive assistance of two (2) staff for bed mobility and transfers, and was incontinent of bowel and bladder. His pain assessment on this MDS revealed he was on a scheduled pain medication regimen. The MDS failed to reveal Resident required any of his ordered "as needed" pain medication. There was no pain care plan developed since Resident #89 was admitted on [DATE] and was identified as having daily pain. This was verified with the MDS/Care Plan Nurse #118 on 09/29/14 at 2:40 p.m. Nursing notes dated 07/21/14 at 12:38 a.m. revealed the nurse had spoken with Resident #89's medical power of attorney and she expressed concerns about him being in the Broda chair (reclining chair) all the time. She stated he had a history of [REDACTED]. admission orders [REDACTED] A review of the nursing notes revealed: -- On 08/13/14 Resident #89 was identified by the staff to have open areas to his buttocks. -- On 8/20/2014 at 6:20 a.m. the nursing notes documented while she was completing treatment on the buttocks for Resident #89, the resident was saying that it hurt when his buttocks were being cleaned and she administered pain medication after the treatment was completed. -- On 9/19/2014 at 2:12 a.m. the nursing notes documented Resident #89 was noted to be moaning saying "owwl" repeatedly while staff were changing his brief and cleansing his bottom. The open area to his buttocks was noted to remain open. -- On 09/26/14 at 2:00 a.m., the nursing notes documented the resident was becoming increasingly agitated and stated "his ass hurts" as they were providing incontinence care and washing his buttocks area. He continued to yell and moan and the nurse administered pain medication. -- On 09/28/14 at 1:44 a.m., the nursing notes documented Resident #89 was given pain medication after the completion of his treatment for [REDACTED]. There was no evidence the resident was assessed for pain prior to the treatment being completed. -- On 07/24/14, 07/25/14, 08/01/14, 08/20/14, and 09/15/14, the nursing notes documented the nurse was able to assess if Resident #89 was in pain by verbally asking him and he responded stating he was in pain and his "as needed" pain medication was administered. Interview with Licensed Practical Nurse (LPN) #2 on 09/29/14 at 9:20 a.m. revealed she did not do a routine pain assessment of any type for Resident #89. She stated she gave him pain medications per his current order in the morning and then she would observe for any non verbal signs of pain and provide the "as needed" pain medication. LPN #2 was not aware of any standard required pain assessment for residents at the facility. Interview with LPN #65 on 09/30/14 at 9:15 a.m., revealed Resident #89 did not always verbalize his pain. She verified the resident did have back pain and stated he sat in his chair a lot and he had open areas to his bottom that required a treatment. LPN #65 stated she did not do any type of routine pain assessment, she just looked for non-verbal signs of pain. When asked if she ever gave Resident #89 pain medications before his treatment was done to his buttocks, she stated she had to complete his treatment when she could because he was often in the chair. LPN #65 stated she would complete the treatment when the staff provide incontinence care, but she did not assess his pain level prior to the treatment. Resident #89 was noted to have a physician order for [REDACTED]. The nurses' notes revealed on numerous occasions (as noted previously) Resident #89 had experienced pain while the night nurse was performing his treatment to his buttocks. There was no evidence the resident was assessed for pain prior to the treatment being done to allow the nurse to identify the need for pain medication prior to completing the treatment. Review of the facility policy for pain management revealed the nurse would report persistent pain to the physician. This policy documented the nurses would perform pain assessments prior to a change of any dressing or treatment. Interventions should include nonpharmacological management of pain including the use of heat and re-positioning. The physician would review the resident's pain management on each visit. All pain management interventions would be documented and incorporated into the patient's treatment plan. During an interview on 09/25/14 at 2:55 p.m. with the Director of Nursing (DON) #107 and the Assistant Director of Nursing (ADON) #30, they both verified staff should be attempting to assess the resident's pain on a routine basis and should be assessed per facility policy which indicated residents would be assessed for the need for pain medication prior to performing a residents treatment. The facility failed to ensure the resident was as free of pain as possible, which constituted actual harm for the resident. . b) Resident #49 Review of the clinical record for Resident #49 on 09/25/14 revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's current physician orders included the antihypertensive medication [MEDICATION NAME] 80 mg daily and to monitor the resident's vital signs weekly. Review of the clinical record found no evidence of assessment of the resident's vital signs the week of 08/11/14 and 08/16/14. During an interview on 09/25/14 at 11:13 a.m., Recreation Specialist #25 verified the missing vital signs during the week of 08/11/14 and 08/16/14. .

Based on record review, family interview, and staff interview, the facility failed to notify the nurse in charge and/or nurse on call when Resident #4 sustained a change in condition and the physician could not be reached in a timely manner. Several hours later the facility reached the physician by telephone. The physician gave orders to maintain the resident's oxygen saturation level at 90%. The facility then failed to notify the physician in a timely manner when the resident's assessed condition failed to meet the parameter of 90% oxygen saturation that was set forth by the physician. The delays and/or omissions in notifying the physician and/or the registered nurse in charge resulted in delays in treatment and potentially avoidable stress to the resident mentally and physically which resulted in actual harm to Resident #4. The facility also failed to notify Resident #4's legal representative of the change in condition until the following day when the resident was transferred to the hospital emergency room . The resident was admitted to the hospital where he expired later that day. Additionally, the facility failed to inform the responsible party of a change in health status for Resident #1. Two (2) of five (5) sampled residents were affected. Resident identifiers: #4 and #1. Facility census: 83. Findings include: a) Resident #4 The resident's medical record was reviewed on [DATE] at 11:00 a.m. According to a nurse progress note, written at 2:30 p.m. on [DATE], Registered Nurse #70 assessed a change of condition in Resident #4. Health Service Workers reported the resident began to "go out." The nurse assessed that the resident was pale, had rapid respirations of thirty-two (32) breaths per minute, and was hypotensive at ,[DATE]. The resident normally kicked his legs and yelled aloud, but he was not moving his legs or yelling. Employee #70 paged Physician #1. Thirty (30) minutes later, at 3:00 p.m., Employee #70 assessed the resident as "very lethargic." His skin was pale and dry. The nurse checked his pulse oximetry and found his oxygen saturation level was quite low at 65%. The normal range is 90% to 100%. The nurse began oxygen at two (2) liters per minute per nasal cannula initially, then raised it to five (5) liters per minute. The resident's oxygen saturation level raised only into the low 80's. A second page was placed to Physician #1, and staff also called the physician's cell phone. There was no evidence the resident's legal representative was notified of these changes. (The legal representative was an employee of the local Department of Human Resources (DHHR), who had been assigned as the resident's legal representative.) At 4:45 p.m., Employee #70 assessed that although the resident was more alert, his oxygen saturation level was still only in the 80's. Also, the tips of his fingers were very pale with an occasional purple and bluish tint. Another cell phone call was placed to Physician #1. Physician #1 returned the call at 5:20 p.m. on [DATE]. He ordered oxygen via a nasal cannula to maintain oxygen saturation levels at 90%, and to continue to monitor. The next nurse's progress note occurred at 9:00 p.m. on [DATE]. Employee #70 assessed the resident's oxygen saturation level was 85% to 86% while on oxygen at five (5) liters. There was no evidence the nurse notified the physician the oxygen saturation level was below 90%. On [DATE] at 12:43 a.m., the night shift registered nurse, Employee #71, assessed that Resident #4's skin was cool and clammy. The lung sounds were diminished. Respirations were rapid at thirty-two (32) breaths per minute. The resident's oxygen saturation level was only 81% to 85% while on oxygen at five (5) liters per minute. It was not until 2:51 a.m. on [DATE] that Physician #1 was again notified of the resident's condition. The resident's oxygen saturation level was between 70% and 75% on oxygen at five (5) liters per minute. The resident was now mouth breathing, and the respiratory rate was rapid at thirty-two (32) breaths per minute. Physician #1 ordered to continue monitoring the resident, and he would see him in the morning. At 7:00 a.m. on [DATE], oncoming Registered Nurse (RN) #102 assessed that the resident appeared to be in respiratory distress and gasping for air. His respirations were shallow and rapid at forty-four (44) breaths per minute. The resident's nail beds were blue. His skin was yellow and diaphoretic (perspiring profusely) and cold to touch, especially the lower extremities. He had light mottling to the knees. His pulse was 122 beats per minute and bounding. Upon inquiry, the resident moaned in the affirmative that he was in pain. Employee #102 was unable to obtain the oxygen saturation level or blood pressure. Employee #102 placed an oxygen mask on his face, and increased the oxygen to eight (8) liters per minute. She notified the physician. The physician gave orders to send him to the emergency room for observation. The resident agreed he wanted to go to the hospital. Licensed practical nurse #120 notified the legal representative of the transport to Hospital #1 on [DATE] at 7:38 a.m. According to Employee #120's nurse progress note dated [DATE] at 11:51 a.m., the resident was admitted to Hospital #1 with comfort measures only. The resident reportedly had a [MEDICAL CONDITION] infarction,[MEDICAL CONDITION], and pneumonia. At that time, the charge nurse was notified. A message was left for the DHHR legal representative of the resident's admission to the hospital. At 2:36 p.m. on [DATE], the hospital notified registered nurse #102 that the resident had expired. An interview was conducted with the director of nursing (DON) and registered nurse #130 on [DATE] at 12:00 p.m. Upon inquiry, the DON said nurses have the authority to send a resident to the emergency room if a physician cannot be reached. Resident #4 had Physician order [REDACTED]. The POST directed no cardiopulmonary resuscitation (CPR). Medical interventions were comfort measures to treat with dignity and respect. It directed to transfer the resident to the hospital only if comfort needs could not be met in the current location. The DON said in her opinion, if a resident's respirations were thirty-two breaths (32) per minute, then that would be considered uncomfortable. The DON said the doctor always left pager and/or cell phone numbers where he can be reached on specific dates. She and registered nurse #130 said there was always a nursing supervisor available. The regular nursing supervisor was not working on Monday [DATE]. On her days off, and after 4:00 p.m. daily, administrative nurses rotated taking call. Employee #130 was on call [DATE]. She said she was not notified that a physician could not be located, or that the resident had sustained a change in condition. . . b) Resident #1 Review of the resident's medical record on [DATE], found a nursing entry, dated [DATE], noting Resident #1's foreskin was retracted and staff were unable to return the foreskin to its natural position. The head of the penis was noted to have swelling. The note also revealed the physician was notified and instruction were given to apply gentle pressure to the penis for several minutes and the foreskin would slip back into its natural position. On [DATE], a physician's note revealed Resident #1 had recently had some issues with his foreskin in which the foreskin was retracted and had not returned to its natural position. This same physician assessment revealed the physician applied gentle consistent pressure and to the penis but was unable to adequately return the foreskin. During an interview at 12:30 p.m. on [DATE] with Resident #1's wife, who was also his medical power of attorney (MPOA), she stated she was in the facility to visit her husband on [DATE] and found he was in a meeting with Adult Protective Services. She stated this was when she first was told by the facility her husband had a swollen glans penis and he might be sent out of the facility for an evaluation. She stated the facility staff had not reported to her that her husband had a problem with a swollen glans penis. She stated she had observed the swollen glans penis on [DATE] and called the physician to discuss the issue, but the facility had never informed her of the swollen glans penis. During an interview at 2:45 p.m. on [DATE], the facility's acting administrator, Employee #1 stated there was no evidence Resident #1's MPOA was notified concerning the swollen glans penis prior to [DATE]. .

Based on record review and staff interview, the facility failed to ensure two (2) of five (5) sample residents were provided care and services to reach or maintain their highest practicable well-being. 1) Neither the nurse in charge nor the nurse on call was contacted when Resident #4 experienced a change in condition and the physician could not be reached in a timely manner. After physician contact, the resident could not be maintained as directed by the physician; however, there was no evidence the physician was notified of this until approximately nine (9) hours later. The resident's condition had continued to decline, yet the physician was not notified to provide guidance and/or an opportunity to alter treatment to maintain the resident's optimal level of well-being. There was no evidence of on-going assessment of the resident's status and no evidence the resident was afforded comfort measures according to the resident's Physician order [REDACTED]. This resulted in a determination of actual harm for Resident #4. The resident was admitted to the hospital nearly 17 hours after the onset of symptoms, and expired 24 hours after the onset of the symptoms. 2) An appointment with a urologist was not scheduled in a timely manner for Resident #1. The employee who scheduled appointments was off, so the facility waited for the employee to return to work to schedule the appointment. Resident identifiers #4 and #1. Facility census: 83. Findings include: a) Resident #4 The resident's medical record was reviewed on [DATE] at 11:00 a.m. According to a nurse progress note, at 2:30 p.m. on [DATE], registered nurse #70 assessed a change of condition in Resident #4. Health Service Workers reported that the resident began to "go out." The nurse assessed that the resident was pale, had rapid respirations of thirty-two (32) breaths per minute, and was hypotensive at ,[DATE]. The resident normally kicked his legs and yelled aloud, but he was not moving his legs or yelling. Employee #70 paged Physician #1. Thirty (30) minutes later, at 3:00 p.m., Employee #70 assessed the resident as "very lethargic." His skin was pale and dry. The nurse checked his pulse oximetry and found his oxygen saturation level was quite low at 65%. The normal range is 90% to 100%. The nurse began oxygen at two (2) liters per minute per nasal cannula initially, then raised it to five (5) liters per minute. The resident's oxygen saturation level raised only into the low 80's. A second page was placed to Physician #1, and staff also called the physician's cell phone. At 4:45 p.m., Employee #70 assessed that although the resident was more alert, his oxygen saturation level was still only in the 80's. Also, the tips of his fingers were very pale with an occasional purple and bluish tint. Another cell phone call was placed to Physician #1. Physician #1 returned the call at 5:20 p.m. on [DATE]. He ordered oxygen via a nasal cannula to maintain oxygen saturation levels at 90%, and to continue to monitor. The next nurse's progress note occurred at 9:00 p.m. on [DATE]. Employee #70 assessed the resident's oxygen saturation level was 85% to 86% while on oxygen at five (5) liters. There was no evidence the nurse notified the physician the oxygen saturation level was below 90%. On [DATE] at 12:43 a.m., the night shift registered nurse, Employee #71, assessed that Resident #4's skin was cool and clammy. The lung sounds were diminished. Respirations were rapid at thirty-two (32) breaths per minute. The resident's oxygen saturation level was only 81% to 85% while on oxygen at five (5) liters per minute. There was no evidence the physician was notified of this assessment. It was not until 2:51 a.m. on [DATE] that Physician #1 was again notified of the resident's condition. The resident's oxygen saturation level was between 70% and 75% on oxygen at five (5) liters per minute. The resident was now mouth breathing, and the respiratory rate was rapid at thirty-two (32) breaths per minute. Physician #1 ordered to continue monitoring the resident, obtain vital signs at 4:00 a.m. and at 7:00 a.m., and he would see him in the morning when he made rounds. There was no evidence of a 4:00 a.m. nursing assessment and/or that vital signs were obtained. The next nurse progress note occurred At 7:00 a.m. on [DATE], when oncoming Registered Nurse (RN) #102 assessed that the resident appeared to be in respiratory distress and gasping for air. His respirations were shallow and rapid at forty-four (44) breaths per minute. The resident's nail beds were blue. His skin was yellow and diaphoretic (perspiring profusely) and cold to touch, especially the lower extremities. He had light mottling to the knees. His pulse was 122 beats per minute and bounding. Upon inquiry, the resident moaned in the affirmative that he was in pain. Employee #102 was unable to obtain the oxygen saturation level or blood pressure. Employee #102 placed an oxygen mask on his face, and increased the oxygen to eight (8) liters per minute. She notified the physician. The physician gave orders to send him to the emergency room for observation. The resident agreed he wanted to go to the hospital. Licensed practical nurse #120 notified the legal representative of the transport to Hospital #1 on [DATE] at 7:38 a.m. According to Employee #120's nurse progress note, dated [DATE] at 11:51 a.m., the resident was admitted to Hospital #1 with comfort measures only. The resident reportedly had a [MEDICAL CONDITION] infarction,[MEDICAL CONDITION], and pneumonia. At 2:36 p.m. on [DATE], the hospital notified registered nurse #102 that the resident had expired. An interview was conducted with the director of nursing (DON) and registered nurse #130 on [DATE] at 12:00 p.m. Upon inquiry, the DON said nurses have the authority to send a resident to the emergency room if a physician cannot be reached. Resident #4 had Physician order [REDACTED]. The POST directed no cardiopulmonary resuscitation (CPR). Medical interventions were comfort measures to treat with dignity and respect. It directed to transfer the resident to the hospital only if comfort needs could not be met in the current location. The DON said in her opinion, if a resident's respirations were thirty-two breaths (32) per minute, then that would be considered uncomfortable. . . b) Resident #1 The medical record was reviewed on [DATE] at 10:00 a.m. According to a nursing note dated [DATE], Resident #1's foreskin was retracted and the staff was unable to return the foreskin to the natural position. The head of the penis was noted to have swelling. The note also revealed the physician was notified and instruction were given to apply gentle pressure to the penis for several minutes and the foreskin would slip back into its natural position. On [DATE] a physician note revealed Resident #1 recently had some issues with his foreskin in which the foreskin was retracted and had not returned to its natural position. This same physician assessment revealed the physician applied gentle consistent pressure and to the penis, but was unable to adequately return the foreskin. On [DATE], Resident #1 was sent out of the facility to an acute care hospital for an assessment related to the swollen glans penis. Medical records from the hospital revealed discharge instructions that Resident #1 should receive follow-up care with urology as soon as possible for paraphimosis (inability to retract the distal foreskin over the glans penis). Review of medical records revealed a request for a consult was entered on Thursday [DATE] at 8:55 p.m. On [DATE] at 8:38 a.m. an entry was made by office assistant, Employee #143, revealing [DATE] was the first attempt to make an appointment for a urologist appointment for Resident #1. This was because the consult order was entered after she left the faciity on Thursday [DATE], and she was off work on Friday [DATE], Saturday [DATE], Sunday [DATE], and Monday [DATE]. There was no attempt to schedule an appointment for Resident #1 until Tuesday [DATE]. At that time, an appointment was scheduled for an assessment by a urologist on [DATE] at 12:45 p.m. The urologist saw the resident the same day the appointment was made. At 3:15 p.m., an interview was conducted with the acting administrator, Employee #1. She stated Employee #143 scheduled all appointments and explained an appointment was made as soon as Employee #143 returned to work. No attempt was made to obtain an appointment with a urologist between [DATE] and [DATE]. .

Based on resident interview, staff interview, a confidential interview, and medical record review, the facility failed to ensure care and services were provided to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (1) of thirteen (13) sampled residents. Resident #29's pain was not evaluated and addressed, resulting in harm to the resident. When finally evaluated, the resident was found to have [MEDICAL CONDITION] mass on the spleen, which had metastasized. Resident identifier #22. Facility census: 91. Findings included: a) Resident #29 During a resident interview on 08/20/13 at 1:00 p.m., Resident #29 said she had chronic pain down her left side and around her lower back. She said she did not leave her room much and did not attend activities because of the pain. The resident said she used to watch television in her room, but the pain interfered with that also. According to a confidential interview, this resident had been complaining of pain in her abdomen for the three (3) years the individual had known the resident. This individual also said the resident had a history of [REDACTED]. review of the resident's medical record revealed [REDACTED]. These included postherpetic [DIAGNOSES REDACTED], splenic mass, polymyalgia, rheumatic, and [MEDICAL CONDITION]. Employee #161, a social worker (SW) was interviewed on 08/22/13 at 12:30 p.m. She said Resident #29 had complained of pain, but the physician believed it was drug seeking behavior. The SW related she wanted further evaluation but the care plan team was not listening. She then talked to the guardian. Employee #161 said the guardian requested further intervention, so a CAT scan was completed. The scan showed [MEDICAL CONDITION] mass on the spleen, which had metastasized. The SW said a consult was made for hospice care to help manage the resident's pain. An interview with Employee #160, the social work supervisor, on 08/22/13 at 12:51 p.m., confirmed Resident #29 had chronic complaints of pain. She related the resident had "stock piled" her medications in July 2013. Employee#160 said the resident told her she did it so she would have medication when she needed it. The resident was placed on suicide precautions, and evaluated by the psychiatrist. It was determined she was not suicidal, and the precautions were lifted. .

Based on record review, staff interview, review of incident reports, resident interview, observation, and confidential staff interview, the facility failed to protect six (6) of ninety-six (96) residents from physical abuse by a resident known to have a history of aggressive behavior. The failure to prevent assaults and to effectively prevent further assaults resulted in a determination of an immediate jeopardy. Record review revealed Resident #45 struck elderly female residents a known total of ten (10) times since 12/16/11, sometimes causing injury such as bruising or skin tears. The most recent battery occurred on 05/28/12, during an unprovoked attack on Resident #60. This incident caused a skin tear above her eye, a bruise to her temple, and broke her eye glasses. Resident #45 was on a 15 minute watch to check his whereabouts, at the time of this attack. Facility staff did not make a decision to send the resident for inpatient evaluation and medication management, due to his aggressive behaviors, until 05/29/12, although the physical abuse happened frequently since 12/16/11. As of 06/01/12, he was still residing in the facility, and the only intervention related to his aggressive behavior was 15 minute watches to check his whereabouts. Confidential staff interviews with twelve (12) employees, who were familiar with Resident #45, revealed they believed he was a threat to others and could seriously harm someone. The employees described the resident had quick mood changes, making the planned 15 minute watches improbable of preventing physical assaults and battery on elderly female residents whom he targeted. A Resident identifiers: #45, #60, #81, #40, #82, #30, and #64. Facility census: 96. Findings include: a) Resident #60 1) Review of an incident/accident report on 06/01/12, with an incident date of 12/16/11, revealed Resident #60 cried, and reported that Resident #45 hit her across the face and eye glasses. The type of injury was redness and a laceration/skin tear. The discussion/plan, on 12/21/12, noted Resident #60 usually knew to avoid others that were aggressive. The report noted "QA" was done by the DON, a social worker, and the administrator. 2) Review of an incident/accident report on 06/01/12, with an incident date of 05/28/12, revealed Resident #45 wheeled up to Resident #60 and stopped. He then hit her in the face, punched her in the right eye breaking her glasses. He also punched her in the nose and twice on the right side of her head. Both residents were brought to the floor/unit. The type of injury was redness, bruise, and a small laceration/skin tear. Resident #60 was screaming and crying, very frightened, and stated she was very frightened of Resident #45 and of her face being bruised. The plan was the facility was working on placement at the hospital for Resident #45. The report noted "QA" was done by the DON, a social worker, and the administrator. 3) Observation of Resident #60, on 06/01/12, at approximately 12:00 p.m., revealed a fading bruise to her right temple approximately an inch and a half in length, and less than half an inch in width. When asked about her injury, she said she was hit by a male resident when they were outside. She said it hurt, and her glasses were broken from the hit. When asked, she said she was afraid of him, and she moves away from him when she sees him coming down the hall. She said she did not want to move to another room elsewhere. b) Resident #81 1) Review of an incident/accident report on 06/01/12, with an incident date of 12/28/11, revealed Resident #81 was hit by Resident #45 twice to the head, and once to the right upper cheek and glasses area. The resident stated, "He hit me I was just sitting in my W/C (wheelchair)." The type of injury was redness and an abrasion to the right cheekbone at the site of the glasses rim. The report noted "QA" was done by the DON, a social worker, and the administrator. 2) Review of an incident/accident report on 06/01/12, with an incident date of 01/30/12, revealed Resident #81 was hit by Resident #45 on the top left side of her head, and Tylenol was administered for a headache. The discussion/plan on 02/01/12 noted staff would prompt her due to getting too close to the aggressor. The report noted "QA" was done by the DON, a social worker, and the administrator. c) Resident #40 Review of an incident/accident report on 06/01/12, with an incident date of 03/03/12, revealed Resident #45 hit this resident, causing her to fall and hit the back of her head. The type of injury was redness "at base of head (back area)." The report noted "QA" was done by the DON, the social service supervisor, and the administrator. The discussion plan noted the unit social worker would provide counseling. d) Resident #82 1) Review of an incident/accident report on 06/01/12, with an incident date of 03/13/12, revealed Resident #82 reported Resident #45 hit her with a hairbrush. The type of injury was a 1/2 centimeter sized fresh bruise on the right occipital area of her head. The discussion plan noted the team would monitor. Also, the psychology assistant provided counseling, and Resident #45 was re-directed from the area. The report noted "QA" was done by the DON, a social worker, and the administrator. 2) Review of an incident/accident report on 06/01/12, with an incident date of 03/19/12, revealed Resident #45 was observed hitting Resident #82 on the head with his fist, and Resident #82 was yelling, crying, and cursing. The type of injury was redness. The report noted "QA" was done by the DON, a social worker, and the administrator. Resident #45 was counseled on not hitting residents. 3) Review of an incident/accident report on 06/01/12, with an incident date of 05/02/12, revealed Resident #45 punched Resident #82 on the nose, and hit her twice on the left forearm. Resident #82 was crying, and her eyes were red. The type of injury was a laceration/skin tear 0.5 centimeter on the bridge of her nose. e) Resident #30 Review of an incident/accident report on 06/01/12, with an incident date of 05/16/12, revealed Resident #30 became verbally aggressive with Resident #45. As Resident #45 was passing by, Resident #30 put out her arm as if to hit the other resident, but did not make contact. Resident #45 came in contact with her and repeatedly hit her on the top of her head and the right side of her head. She cried for hours. The type of injury was redness, but the report did not list the site. Resident #30 was moved to another unit at the time of the incident. A care plan meeting was held, and the team agreed to put the resident back in her former room and place her on 15 minutes checks for her safety. The report noted "QA" was done by the DON, a social worker, and the administrator. f) Resident #64 Review of an incident/accident report on 06/01/12, with an incident date of 05/22/12, revealed Resident #45 went up to Resident #64 and began hitting her on the left side of her face and the left upper arm. The report noted "QA" was done by the DON, a social worker, and the administrator. The discussion plan noted counseling was provided to Resident #45, they talked with this resident about the incident, and Resident #45 was to be seen by the psychiatrist. The report noted "QA" was done by the DON, a social worker, and the administrator. During an interview on 06/01/12, at approximately 12:30 p.m., Resident #64 pointed to Resident #45 when asked if anyone in the facility hit others. She stated Resident #45 pulled her out of her wheelchair and hit her in the head with his hand and it hurt. She said she was afraid of him. When asked what she does when she sees him, she said she moves far away from him and gets by the wall. g) Although not directed toward another resident, review of an incident/accident report on 06/01/12, with an incident date of 02/25/12, revealed Resident #45 chased a Health Service Worker (HSW) down the hall, rammed his wheelchair into the nurses' station door, then rammed his right knee into the sub wall of the nurses' station, before putting himself to bed. This was another indicator the resident had the potential to harm others. h) Resident #45 Confidential interviews with nursing employees, on 06/01/12, in the morning and afternoon, and on 06/11/12 through 06/13/12, found twelve (12) randomly chosen employees stated their belief Resident #45 was a threat to other residents, was physically strong and able to hurt someone if he wished, and was unpredictable. They stated he was habitually physically aggressive, and he targeted elderly females who could not fend for themselves. Those interviewed reported 15 minute watches did not deter him from hitting others, and staff were not always present in the hallways or in the solarium to observe him at all times. When asked about injuries, they reported he had caused bruising and skin tears to elderly females. They reported he sometimes showed warning signs of escalation, but not always. Record review revealed Resident #45 struck elderly female residents a known total of ten (10) times since 12/16/11, sometimes causing injury such as bruising and skin tears. The most recent physical assaults occurred in May 2012. He punched an elderly female resident (Resident #82) in the nose and forearm on 05/02/12. This was his third assault on Resident #82 since 03/13/12. Subsequently, she was moved to another floor and unit. On 05/16/12, a female resident (Resident #30) allegedly was verbally abusive to Resident #45, and raised her arm as if to hit him, but did not. Resident #45 hit her repeatedly about the top of her head and right side of her face. After first moving the resident (Resident #30) to another unit overnight, the care plan team agreed to put her back in her former room on 05/17/12, and placed her on 15 minutes checks for safety. Next, on 05/22/12, Resident #45 subjected a female resident (Resident #64) to an unprovoked physical assault. She was seated in her wheelchair in the hallway having a drink, when Resident #45 began hitting her on the left side of her face and upper arm. She was taken to the third floor dining area for separation, while Resident #45 was counseled, and he was placed on 15 minute checks due to aggression. She was offered a room change, but refused. Then, on 05/28/12 during an outside event, while still on 15 minute watches, Resident #45 wheeled up to an elderly resident (Resident #60), stopped, and hit her repeatedly in the face and head. According to the incident report dated 05/28/12, Resident #45 (sic) "hit her in the face, punched her in the R (symbol for right) eye breaking her glasses, in the nose & twice in the R side of the head." Resident #45 was (sic) "screaming and crying." The incident report described the resident was very frightened and stated she was very frightened of Resident (#45) and of her face being bruised. She was offered a room change, but refused. There was no evidence the facility sought professional assistance regarding Resident #45's aggressive behaviors until they contacted a hospital, on 05/29/12, concerning a transfer of the resident. At the time of the investigation, the facility had made no progress in transferring the resident. During interviews with a former social worker, Employee #169, and the social service director, Employee #106, on 06/01/12, at approximately 1:00 p.m., Employee #169 stated they could not come up with any way to transfer Resident #45 to the hospital, as the hospital required signed consent from the resident's health care surrogate (HCS), who lived in another town. Employee #169 said the required paperwork was mailed to the HCS on 05/30/12. However, the decision the resident needed to be transferred was made on 05/29/12, and contact was made with the hospital at that time. An interview was conducted, by telephone, with the hospital's intake worker, on 06/01/12 at 1:34 p.m. The intake worker stated the hospital typically faxed the consent information to the power of attorney at a convenient location, such as the local emergency room in the community, where it would be signed and faxed back to the hospital. On 06/01/12, at approximately 2:00 p.m., an interview with Employees #169 and #106 revealed Employee #169 had just spoken with the HCS, and was informed the papers had not yet arrived. At that time, the information provided by the hospital intake worker was shared with Employees #169 and #106. This was not something the facility had explored until surveyor intervention. At approximately 3:10 p.m., on 06/01/12, an interview was conducted with the director of nursing and the administrator. At that time, it was communicated that facility staff knew Resident #45 had aggressive behaviors, and had recently, on 05/22/12 and 05/28/12, physically assaulted residents without provocation. This was while he was on 15 minutes watches due to his aggressive behaviors. It was apparent the 15 minute watches did not prevent him from assaulting again. In view of these findings, and with consideration of multiple confidential staff interviews who reported their concerns that Resident #45 was a threat to others, and could potentially harm other residents, it was determined the resident's behaviors toward other residents was an immediate jeopardy to the other residents in the facility. During an interview with the administrator on 06/01/12, at approximately 4:15 p.m., and a confirmation from a nursing assistant, Employee #76, at approximately 4:30 p.m., the facility began, and will continue to provide, 1:1 monitoring with Resident #45 until he can be sent to the hospital for evaluation and medication adjustment. The immediate jeopardy was removed at 4:30 p.m. on 06/01/12. With the implementation of the 1:1 monitoring, no deficient practice in this area remained. Another interview was conducted with the administrator, on 06/01/12, at approximately 5:00 p.m. She stated she spoke with the HCS and found that she has a daughter close by, but because the daughter is working at present, is unable to take her to a community location today to receive and send faxes. When the HCS was asked, by the administrator, if she believed she was the best person to look after Resident #45's affairs, and the availability of the DHHR to do so if she desired, the HCS allegedly spoke positively about the DHHR being able to take over this duty for her. During this interview, the administrator stated she had authorized 1:1 staffing with Resident #45 all weekend, or until such time that he was placed at a hospital. A psychology assistant, Employee #164, was interviewed on 06/11/12 at 3:31 p.m. She said Resident #45 had busied residents "a couple of times." She stated that in the past few weeks, Resident #45 had not been sending warning signals he was becoming agitated before he struck. Employee #164 stated this was new for him. She stated he received 1:1 services on 06/01/12 in the evening. When asked, she did not recall him having 1:1 services in May. During an interview with the administrator on 06/11/12 at 4:45 p.m., she said Resident #45 had never hurt anyone. When asked about bruises, she stated there has been no bruising to others by Resident #45, to her knowledge, and if there were, " ...somebody had better be documenting them." Several incident/accident reports, reviewed on 06/01/12 described injuries, including bruising, as well as physical and emotional pain experienced by the residents who had been assaulted by Resident #45. All but one (1) of the incident/accident reports noted "QA" was done by the DON, a social worker, and the administrator. .

Based on record review, staff interview, review of incident reports, resident interview, observation, and confidential staff interviews, the facility failed to protect six (6) of ninety-six (96) residents from physical abuse by a resident known to have a history of aggressive behavior. The facility failed to fully investigate and/or evaluate each incident of abuse by the same resident, and subsequently develop and implement interventions that would prevent further incidents of physical abuse from occurring. Record review revealed Resident #45 had struck elderly female residents a known total of ten (10) times since 12/16/11, sometimes causing injury such as bruising or skin tears. The most recent battery occurred on 05/28/12, during an unprovoked attack on Resident #60. This incident caused a skin tear above her eye, a bruise to her temple, and broke her eye glasses. Resident #45 was on a 15 minute watch to check his whereabouts, at the time of this attack. Facility staff did not make a decision to send the resident for inpatient evaluation and medication adjustment, due to his aggressive behaviors, until 05/29/12, although the physical abuse happened frequently since 12/16/11. As of 06/01/12, he was still residing in the facility, allowed to roam freely about the unit, solarium, and nearby long hallway with only 15 minute watches to check his whereabouts. Record reviewed revealed the facility failed to consider any of the ten (10) attacks to be physically or psychologically abusive from the perspective of the victims, as evidenced by none of the ten (10) attacks being reported to State agencies such as the State survey agency, the Ombudsman, or Adult Protective Services (APS). Confidential staff interviews with twelve (12) employees, who were familiar with Resident #45, revealed they believed he was a threat to others and could seriously harm someone. The employees described the resident had quick mood changes, making the planned 15 minute watches improbable of preventing physical assaults and battery on elderly female residents whom he targeted. Resident identifiers: #45, #60, #81, #40, #82, #30, and #64. Facility census: 96. Findings include: a) Resident #60 1) Review of an incident/accident report on 06/01/12, with an incident date of 12/16/11, revealed Resident #60 cried, and reported that Resident #45 had hit her across the face and eye glasses. The type of injury was redness and a laceration/skin tear. The discussion/plan on 12/21/12 noted Resident #60 usually knows to avoid others that are aggressive. The report noted "QA" was done by the DON, a social worker, and the administrator. 2) Review of an incident/accident report on 06/01/12, with an incident date of 05/28/12, revealed Resident #45 had wheeled up to Resident #60 and stopped. He then hit her in the face and punched her in the right eye, breaking her eye glasses. He also punched her in the nose and twice on the right side of her head. Both residents were brought to the floor/unit. The type of injury was redness, bruising, and a small laceration/skin tear. Resident #60 was screaming and crying, very frightened, and stated she was very frightened of Resident #45 and of her face being bruised. The plan was the facility was working on placement at the hospital for Resident #45. The report noted "QA" was done by the DON, a social worker, and the administrator. 3) Observation of Resident #60, on 06/01/12, at approximately 12:00 p.m., revealed a fading bruise to her right temple approximately an inch and a half in length, and less than half an inch in width. When asked about her injury, she said she was hit by a male resident when they were outside. She said it hurt, and her glasses were broken from the hit. When asked, she said she was afraid of him, and she moves away from him when she sees him coming down the hall. She said she did not want to move to another room elsewhere. b) Resident #81 1) Review of an incident/accident report on 06/01/12, with an incident date of 12/28/11, revealed Resident #81 was hit by Resident #45 twice to the head, and once to the right upper cheek, glasses area. The resident stated, "He hit me I was just sitting in my W/C (wheelchair)." The type of injury was redness and an abrasion to the right cheekbone at the site of the glasses rim. The report noted "QA" was done by the DON, a social worker, and the administrator. 2) Review of incident/accident report on 06/01/12, with an incident date of 01/30/12, revealed Resident #81 was hit by Resident #45 on the top left side of her head, and Tylenol was administered for a headache. The discussion/plan, on 02/01/12, noted staff will prompt Resident #81 due to getting too close to the aggressor. The report noted "QA" was done by the DON, a social worker, and the administrator. c) Resident #40 Review of an incident/accident report on 06/01/12, with an incident date of 03/03/12, revealed Resident #45 hit this resident, causing her to fall and hit the back of her head. The type of injury was redness "at base of head (back area)." The report noted "QA" was done by the DON, the social service supervisor, and the administrator. The discussion plan noted the unit social worker would provide counseling. d) Resident #82 1) Review of an incident/accident report on 06/01/12, with an incident date of 03/13/12, revealed Resident #82 reported Resident #45 hit her with a hairbrush. The type of injury was a 1/2 centimeter sized fresh bruise on the right occipital area of her head. The discussion plan noted the team will monitor. Also, the psychology assistant provided counseling, and Resident #45 was re-directed from the area. The report noted "QA" was done by the DON, a social worker, and the administrator. 2) Review of an incident/accident report on 06/01/12, with an incident date of 03/19/12, revealed Resident #45 was observed hitting Resident #82 on the head with his fist, and Resident #82 was yelling, crying, and cursing. The type of injury was redness. The report noted "QA" was done by the DON, a social worker, and the administrator. Resident #45 was counseled on not hitting residents. 3) Review of an incident/accident report on 06/01/12, with an incident date of 05/02/12, revealed Resident #45 punched Resident #82 on the nose, and hit her twice on the left forearm. Resident #82 was crying, and her eyes were red. They type of injury was a laceration/skin tear 0.5 centimeter on the bridge of her nose. e) Resident #30 Review of an incident/accident report on 06/01/12, with an incident date of 05/16/12, revealed Resident #30 became verbally aggressive with Resident #45. As Resident #45 was passing by, Resident #30 put out her arm as if to hit the other resident but did not make contact. Resident #45 came in contact with her and repeatedly hit her on the top of her head and the right side of her head. She cried for hours. The type of injury was redness, but it did not list the site. Resident #30 was moved to another unit at the time of the incident. A care plan meeting was held, and the team agreed to put the resident back in her former room and place her on 15 minutes checks for her safety. The report noted "QA" was done by the DON, a social worker, and the administrator. f) Resident #64 Review of an incident/accident report on 06/01/12, with an incident date of 05/22/12, revealed Resident #45 went up to Resident #64 and began hitting her on the left side of her face and the left upper arm. The report noted "QA" was done by the DON, a social worker, and the administrator. The discussion plan noted counseling was provided to Resident #45, they talked with this resident about the incident, and Resident #45 was to be seen by the psychiatrist. The report noted "QA" was done by the DON, a social worker, and the administrator. During an interview on 06/01/12, at approximately 12:30 p.m., Resident #64 pointed to Resident #45 when asked if anyone in the facility hit others. She stated Resident #45 pulled her out of her wheelchair and hit her in the head with his hand and it hurt. She said she is afraid of him. When asked what she does when she sees him, she said she moves far away from him and gets by the wall. g) Although not directed toward another resident, review of an incident/accident report on 06/01/12, with an incident date of 02/25/12, revealed Resident #45 chased a Health Service Worker (HSW) down the hall, rammed his wheelchair into the nurses' station door, then rammed his right knee into the sub wall of the nurses ' station, before putting himself to bed. This was another indicator the resident had the potential to harm others. h) Resident #45 Confidential interviews with nursing employees, on 06/01/12 in the morning and afternoon, and on 06/11/12 through 06/13/12, found twelve (12) randomly chosen employees stated their belief Resident #45 was a threat to other residents, was physically strong and able to hurt someone if he wished, and was unpredictable. They stated he was habitually physically aggressive, and he targeted elderly females who could not fend for themselves. Those interviewed reported 15 minute watches did not deter him from hitting others, and staff were not always present in the hallways or in the solarium to observe him at all times. When asked about injuries, they reported he had caused bruising and skin tears to elderly females. They reported he sometimes showed warning signs of escalation, but not always. Record review revealed Resident #45 struck elderly female residents a known total of ten (10) times since 12/16/11, sometimes causing injury such as bruising and skin tears. The most recent physical assaults occurred in May 2012. He punched an elderly female resident (Resident #82) in the nose and forearm on 05/02/12. This was his third assault on Resident #82 since 03/13/12. Subsequently, she was moved to another floor and unit. On 05/16/12, a female resident (Resident #30) allegedly was verbally abusive to Resident #45, and raised her arm as if to hit him, but did not. Resident #45 hit her repeatedly about the top of her head and right side of her face. After first moving the resident (Resident #30) to another unit overnight, the care plan team agreed to put her back in her former room on 05/17/12, and placed her on 15 minutes checks for safety. Next, on 05/22/12, Resident #45 subjected a female resident (Resident #64) to an unprovoked physical assault. She was seated in her wheelchair in the hallway having a drink, when Resident #45 began hitting her on the left side of her face and upper arm. She was taken to the third floor dining area for separation, while Resident #45 was counseled, and he was placed on 15 minute checks due to aggression. She was offered a room change, but refused. Then, on 05/28/12 during an outside event, while still on 15 minute watches, Resident #45 wheeled up to an elderly resident (Resident #60), stopped, and hit her repeatedly in the face and head. According to the incident report dated 05/28/12, Resident #45 {sic}"hit her in the face, punched her in the R (symbol for right) eye breaking her glasses, in the nose (symbol for and) twice in the R (symbol for right) side of the head." Resident #45 was {sic} "screaming and crying." The incident report described the resident was very frightened and stated she was very frightened of Resident (#45) and of her face being bruised. She was offered a room change, but refused. There was no evidence the facility sought professional in-patient assistance for assessment and medication adjustments related to the resident's aggressive behaviors, until they contacted a hospital, on 05/29/12, concerning a transfer of the resident. At the time of the investigation, the facility had made no progress in transferring the resident. During interviews with a former social worker, Employee #169, and the social service director, Employee #106, on 06/01/12, at approximately 1:00 p.m., Employee #169 stated they could not come up with any way to transfer Resident #45 to the hospital, as the hospital required signed consent from the resident's health care surrogate (HCS), who lived in another town. Employee #169 said the required paperwork was mailed to the HCS on 05/30/12. However, the decision the resident needed to be transferred was made on 05/29/12, and contact was made with the hospital at that time. An interview was conducted, by telephone, with the hospital's intake worker, on 06/01/12 at 1:34 p.m. The intake worker stated the hospital typically faxed the consent information to the power of attorney at a convenient location, such as the local emergency room in the community, where it would be signed and faxed back to the hospital. On 06/01/12, at approximately 2:00 p.m., an interview with Employees #169 and #106 revealed Employee #169 had just spoken with the HCS, and was informed the papers had not yet arrived. At that time, the information provided by the hospital intake worker was shared with Employees #169 and #106. This was not something the facility had explored until surveyor intervention. At approximately 3:10 p.m., on 06/01/12, an interview was conducted with the director of nursing and the administrator. At that time, it was communicated that facility staff knew Resident #45 had aggressive behaviors, and had recently, on 05/22/12 and 05/28/12, physically assaulted residents without provocation. This was while he was on 15 minutes watches due to his aggressive behaviors. It was apparent the 15 minute watches did not prevent him from assaulting again. In view of these findings, and with consideration of multiple confidential staff interviews who reported their concerns that Resident #45 was a threat to others, and could potentially harm other residents, it was determined the resident ' s behaviors toward other residents was an immediate jeopardy to the other residents in the facility. During an interview with the administrator on 06/01/12, at approximately 4:15 p.m., and a direct observation and a verbal confirmation from a nursing assistant, Employee #76, at approximately 4:30 p.m., the facility began, and will continue to provide, 1:1 monitoring with Resident #45 until he can be sent to the hospital for evaluation and medication adjustment. The immediate jeopardy was abated at 4:30 p.m. Another interview was conducted with the administrator on 06/01/12, at approximately 5:00 p.m. She stated she spoke with the HCS and found that she has a daughter close by, but because the daughter is working at present, is unable to take her to a community location today to receive and send faxes. When the HCS was asked, by the administrator, if she believed she was the best person to look after Resident #45's affairs, and the availability of the DHHR to do so if she desired, the HCS allegedly spoke positively about the DHHR being able to take over this duty for her. During this interview, the administrator stated she had authorized 1:1 staffing with Resident #45 all weekend, or until such time that he was placed at a hospital. A psychology assistant, Employee #164, was interviewed on 06/11/12 at 3:31 p.m. She said Resident #45 had bruised residents "a couple of times." She stated that in the past few weeks, Resident #45 had not been sending warning signals that he was becoming agitated before he struck. Employee #164 stated this was new for him. She stated he received 1:1 services on 06/01/12 in the evening. When asked, she did not recall him having 1:1 services in May. During an interview with the administrator, on 06/11/12 at 4:45 p.m., she said Resident #45 had never hurt anyone. When asked about bruises, she stated there has been no bruising to others by Resident #45, to her knowledge, and if there were, " ...somebody had better be documenting them. " Several incident/accident reports, reviewed on 06/01/12, described injuries, including bruising, as well as physical and emotional pain experienced by the residents who had been assaulted by Resident #45. All but one (1) of the incident/accident reports noted "QA" was done by the DON, a social worker, and the administrator.

Based on record review, staff interview, review of incident reports, resident interview, observation, and confidential staff interview, the facility failed to ensure the resident environment was as free of accident hazards as possible. The facility failed to provide adequate supervision to prevent resident-to-resident incidents when there was a known risk for resident-to-resident altercations by one (1) of eighteen (18) sampled residents. The resident had a history of [REDACTED]. The facility failed to provide adequate supervision to reduce the potential for physical and/or emotional harm to other residents. Record reviews revealed this resident struck elderly female residents a known total of ten (10) times since 12/16/11, sometimes causing injury such as bruising or skin tears. The most recent battery occurred on 05/28/12 during an unprovoked attack on Resident #60. This incident caused a skin tear above her eye, a bruise to her temple, and broke her eye glasses. Resident #45 was on a 15 minute watch to check his whereabouts, at the time of this attack. Confidential staff interviews with twelve (12) employees, who were familiar with Resident #45, revealed they believed he was a threat to others and could seriously harm someone. The employees described the resident had quick mood changes, making the planned every 15 minute watches improbable of preventing physical assaults and battery on elderly female residents whom he targeted. Resident identifiers: #45, #60, #81, #40, #82, #30, and #64. Facility census: 96. Findings include: a) Resident #60 1) Review of an incident/accident report on 06/01/12, with an incident date of 12/16/11, revealed Resident #60 cried, and reported that Resident #45 hit her across the face and eye glasses. The type of injury was redness and a laceration/skin tear. The discussion/plan on 12/21/12 noted Resident #60 usually knows to avoid others that are aggressive. The report noted "QA" was done by the DON, a social worker, and the administrator. 2) Review of an incident/accident report on 06/01/12, with an incident date of 05/28/12, revealed Resident #45 wheeled up to Resident #60 and stopped. He then hit her in the face, punched her in the right eye, breaking her glasses. He also punched her in the nose and twice on the right side of her head. Both residents were brought to the floor/unit. They type of injury was redness, bruise, and a small laceration/skin tear. Resident #60 was screaming and crying, very frightened, and stated she was very frightened of Resident #45 and of her face being bruised. The plan was the facility was working on placement at the hospital for Resident #45. The report noted "QA" was done by the DON, a social worker, and the administrator. 3) Observation of Resident #60, on 06/01/12 at approximately 12:00 p.m., revealed a fading bruise to her right temple approximately an inch and a half in length, and less than half an inch in width. When asked about her injury, she said she was hit by a male resident when they were outside. She said it hurt, and her glasses were broken from the hit. When asked, she said she was afraid of him, and she moves away from him when she sees him coming down the hall. She said she did not want to move to another room elsewhere. b) Resident #81 1) Review of an incident/accident report on 06/01/12, with an incident date of 12/28/11, revealed Resident #81 was hit by Resident #45 twice to the head, and once to the right upper cheek, glasses area. The resident stated, "He hit me I was just sitting in my W/C (wheel chair)." The type of injury was redness and an abrasion to the right cheekbone at the site of the glasses rim. The report noted "QA" was done by the DON, a social worker, and the administrator. 2) Review of incident/accident report on 06/01/12, with an incident date of 01/30/12, revealed Resident #81 was hit by Resident #45 on the top left side of her head, and Tylenol was administered for a headache. The discussion/plan on 02/01/12 noted staff will prompt her due to getting too close to the aggressor. The report noted "QA" was done by the DON, a social worker, and the administrator. c) Resident #40 Review of an incident/accident report on 06/01/12, with an incident date of 03/03/12, revealed Resident #45 hit this resident, causing her to fall and hit the back of her head. The type of injury was redness "at base of head (back area)." The report noted "QA" was done by the DON, the social service supervisor, and the administrator. The discussion plan noted the unit social worker would provide counseling. d) Resident #82 1) Review of an incident/accident report on 06/01/12, with an incident date of 03/13/12, revealed Resident #82 reported Resident #45 hit her with a hairbrush. The type of injury was a 1/2 centimeter sized fresh bruise on the right occipital area of her head. The discussion plan noted the team will monitor. Also, the psychology assistant provided counseling, and Resident #45 was re-directed from the area. The report noted "QA" was done by the DON, a social worker, and the administrator. 2) Review of an incident/accident report on 06/01/12, with an incident date of 03/19/12, revealed Resident #45 was observed hitting Resident #82 on the head with his fist, and Resident #82 was yelling, crying, and cursing. The type of injury was redness. The report noted "QA" was done by the DON, a social worker, and the administrator. Resident #45 was counseled on not hitting residents. 3) Review of an incident/accident report on 06/01/12, with an incident date of 05/02/12, revealed Resident #45 punched Resident #82 on the nose, and hit her twice on the left forearm. Resident #82 was crying, and her eyes were red. They type of injury was a laceration/skin tear 0.5 centimeter on the bridge of her nose. e) Resident #30 Review of an incident/accident report on 06/01/12, with an incident date of 05/16/12, revealed Resident #30 became verbally aggressive with Resident #45. As Resident #45 was passing by, Resident #30 put out her arm as if to hit the other resident but did not make contact. Resident #45 came in contact with her and repeatedly hit her on the top of her head and the right side of her head. She cried for hours. The type of injury was redness, but it did not list the site. Resident #30 was moved to another unit at the time of the incident. A care plan meeting was held, and the team agreed to put the resident back in her former room and place her on 15 minutes checks for her safety. The report noted "QA" was done by the DON, a social worker, and the administrator. f) Resident #64 Review of an incident/accident report on 06/01/12, with an incident date of 05/22/12, revealed Resident #45 went up to Resident #64 and began hitting her on the left side of her face and the left upper arm. The report noted "QA" was done by the DON, a social worker, and the administrator. The discussion plan noted counseling was provided to Resident #45, they talked with this resident about the incident, and Resident #45 was to be seen by the psychiatrist. The report noted "QA" was done by the DON, a social worker, and the administrator. During an interview on 06/01/12, at approximately 12:30 p.m., Resident #64 pointed to Resident #45 when asked if anyone in the facility hit others. She stated Resident #45 pulled her out of her wheelchair and hit her in the head with his hand and it hurt. She said she is afraid of him. When asked what she does when she sees him, she said she moves far away from him and gets by the wall. g) Resident #45 Confidential interviews with nursing employees, on 06/01/12 in the morning and afternoon, and on 06/11/12 through 06/13/12, found twelve (12) randomly chosen employees stated their belief Resident #45 was a threat to other residents,was physically strong and able to hurt someone if he wished, and was unpredictable. They stated he was habitually physically aggressive, and he targeted elderly females who could not fend for themselves. Those interviewed reported 15 minute watches did not deter him from hitting others, and staff were not always present in the hallways or in the solarium to observe him at all times. When asked about injuries, they reported he had caused bruising and skin tears to elderly females. They reported he sometimes showed warning signs of escalation, but not always. Record review revealed Resident #45 struck elderly female residents a known total of ten (10) times since 12/16/11, sometimes causing injury such as bruising and skin tears. The most recent physical assaults occurred in May 2012. He punched an elderly female resident (Resident #82) in the nose and forearm on 05/02/12. This was his third assault on Resident #82 since 03/13/12. Subsequently, she was moved to another floor and unit. On 05/16/12, a female resident (Resident #30) allegedly was verbally abusive to Resident #45, and raised her arm as if to hit him, but did not. Resident #45 hit her repeatedly about the top of her head and right side of her face. After first moving the resident (Resident #30) to another unit overnight, the care plan team agreed to put her back in her former room on 05/17/12, and placed her on 15 minutes checks for safety. Next, on 05/22/12, Resident #45 subjected a female resident (Resident #64) to an unprovoked physical assault. She was seated in her wheelchair in the hallway having a drink, when Resident #45 began hitting her on the left side of her face and upper arm. She was taken to the third floor dining area for separation, while Resident #45 was counseled, and he was placed on 15 minute checks due to aggression. She was offered a room change, but refused. Then, on 05/28/12 during an outside event, while still on 15 minute watches, Resident #45 wheeled up to an elderly resident (Resident #60), stopped, and hit her repeatedly in the face and head. According to the incident report dated 05/28/12, Resident #45 (sic)"hit her in the face, punched her in the R (symbol for right) eye breaking her glasses, in the nose & twice in the R side of the head." Resident #45 was (sic) "screaming and crying." The incident report described the resident was very frightened and stated she was very frightened of Resident (#45) and of her face being bruised. She was offered a room change, but refused. There was no evidence the facility sought professional assistance regarding the resident's aggressive behaviors until they contacted a hospital, on 05/29/12, concerning a transfer of the resident. At the time of the investigation, the facility had made no progress in transferring the resident. At approximately 3:10 p.m. on 06/01/12, an interview was conducted with the Director of Nursing and the Administrator. At that time, it was communicated that facility staff knew Resident #45 had aggressive behaviors, and had recently, on 05/22/12 and 05/28/12, physically assaulted residents without provocation. This was while he was on 15 minutes watches due to his aggressive behaviors. It was apparent the 15 minute watches did not prevent him from assaulting again. During an interview with a psychology assistant, Employee #164 on 06/11/12 at 3:31 p.m., she said Resident #45 has busied residents "a couple of times". She said the past few weeks Resident #45 had not been sending warning signals (two episodes) that he was becoming agitated before he struck, and this was new for him. .

Based on record review and staff interview, the facility failed to adequately assess one (1) of twenty-nine (29) Stage II sample residents for injuries immediately following a fall. Resident #63, who was totally dependent on staff for the performance of all activities of daily living (ADLs), fell from a reclined chair onto the floor and was not adequately assessed for injuries after the fall. The resident remained in the facility for two (2) days without physician intervention, receiving only Tylenol for pain. She was later assessed as having outward rotation of her right lower extremity and was subsequently transferred to the hospital, where she was diagnosed with [REDACTED]. Facility census: 94. Findings include: a) Resident #63 1. Record review revealed this [AGE] year old female was readmitted to the facility on [DATE], following a stay in the hospital for a [MEDICAL CONDITION]. The resident's [DIAGNOSES REDACTED]. The resident's care plan, dated 05/19/11, identified the following problem: " Potential for falls due to unsteady gait, recent right [MEDICAL CONDITION] (slid out of recliner), history of a left [MEDICAL CONDITION]. " The goal associated with this problem statement was: " No further injuries. " Interventions to achieve this goal included providing the resident with a recliner with a pad alarm to alert staff of needed assistance, chair and bed pad alarms to alert staff for assistance, mat at bedside, and Hipsters on at all times. In the previous MDS, a quarterly assessment with an ARD of 04/21/11, the assessor noted the resident was dependent on staff for all ADLs, and that she did not walk, had functional limitation to her lower extremities, and she utilized a wheelchair for locomotion. -- 2. Review of the resident ' s electronic medical record found the following progress note entries: - On 04/29/11 at 21:38 (9:38 p.m.), a licensed practical nurse (LPN - Employee #152) recorded (quoted as typed): "HSW (health service worker) heard (name of Resident #63) yelling and found her on floor in front of her recliner. Recliner had a sheet and pad and (name of Resident #63) slide onto the floor directly in front of chair. No injuries seen, no first aid needed. Charge nurse ADON (assistant director of nursing), Social worker notified." - On 04/30/11 at 05:59 (5:59 a.m.), a registered nurse (RN - Employee #81) recorded (quoted as typed): "Resting comfortably tonight. No s/s (signs / symptoms) or c/o (complaints of) pain or discomfort noted. No apparent injury from sliding out of recliner." - On 04/30/11 at 09:08 (9:13 a.m.), an LPN (Employee #125) recorded (quoted as typed): "Resident c/o (complained of ) right leg pain. Received Tylenol tabs 2 at 7:45am. Resident placed in bed, with no noted bruising or malformation noted at this time. Will cont (continue) to monitor. " - On 04/30/11 at 14:16 (2:16 p.m.), Employee #125 recorded (quoted as typed): " Resident up for lunch. Ate poor. Charge nurse checked resident at this time. Spoke with Dr. (name) ... wants resident observed for increase in pain, bruising. Will observe. " - On 04/30/11 at 14:27 (2:27 p.m.), an RN (Employee #145) recorded (quoted as typed): "Assessed res. (resident) while in bed; awake; positioned supine approx. 3cm dark purple flat area on right dorsal upper forearm; PROM (passive range of motion) of upper ext. (extremity) without complaint or evidence of discomfort; res. leans lower extremeties toward right when supine. sustains left foot briefly when supine then food moved medially toward right; right foot sustained briefly then moves laterall (however, not fully) toward right; res did not grimace on exam but moved my hand when right leg was examined. There is not redness, bruising or swelling of hips or legs1. Dr. (name) was notified. Monitoring. " - On 05/01/11 at 06:26 (6:26 a.m.), an LPN (Employee #72) recorded (quoted as typed): "Resident yelling during care this am care. Tylenol supp (suppository) 65 mg rectally given. Some eversion (meaning " turning outward " ) noted to RLL (right lower leg), 7-3 nurse aware and planning to notify Dr. (name). " - The next consecutive entry, recorded by Employee #125 on 05/01/11 at 08:12 (8:12 a.m.), was labeled a Resident Transfer Form. Under the heading " Reason for Transfer " , the nurse recorded (quoted as typed): " Fall on 4/29/11. No noted injury at the time. At present, resident screaming in pain on movement. Difficult to access d/t (due to) mental status. Resident will read notes written, stated her right leg hurts bad. " Resident #63 was subsequently picked up by the ambulance service at 9:15 a.m. and transferred to Hospital #1 ' s emergency room for evaluation. She was later transferred to Hospital #2. - On 05/01/11 at 19:27 (7:27 p.m.), Employee #152 recorded having received a call from staff at Hospital #2 stating they wanted to perform surgery on her hip. -- 3. An interview with Employee #72, on 05/23/11 at 1:15 p.m., revealed the resident was not adequately assessed for injuries after she fell on [DATE]. The RN did not check for any rotation to the legs. She further stated, "When I assessed the resident two (2) days later on 05/01/11, the resident had an eversion to the right leg. " -- 4. In an interview on 05/25/11 at 10:15 a.m., the director of nursing (DON) stated she felt the nurse should have documented a complete assessment of the resident on the day the resident fell . She further stated, "To only write that the resident was not injured and required no interventions was not suitable. The nurse should have documented all areas, if he assessed the resident appropriately." -- The facility failed to assess the resident for any abnormalities of her lower extremities immediately after she fell from the reclined chair. Two (2) days after the fall, an RN assessed the resident and found an eversion to the resident's right leg. The physician was notified, and the resident was transferred to the hospital and diagnosed with [REDACTED]. .

Based on medical record review and staff interview, the facility failed, for one (1) of thirty-two (32) Stage II sampled residents, to ensure nursing staff conducted a thorough assessment of a resident immediately following a fall. Staff then ambulated the resident, resulting in reports of pain. Staff reassessed her by doing "pelvic rocks", resulting in increased reports of pain (actual harm). Resident identifiers: #21. Facility census: 95. Findings include: a) Resident #21 Medical record review, on 02/09/10, disclosed a document titled Hopemont Hospital Resident Incident / Accident Report dated 01/21/10 at 2:25 a.m., which contained information related to a fall sustained by Resident #21. Entries on the report stated: - "Incident (describe what happened): Unknown cause of fall, health service worker (HSW) responded to resident yelling." - "Resident response / reactions and consequences (included protocol): Assessment of resident while on floor. Reassessed upon c/o (complaint) hurting to walk, then reassessed in bed. Resident was cooperative with each assessment." Review of the nursing progress notes, dated 01/21/10, revealed the following entry: "Did an assessment on resident at that times no apparent injuries. Resident was able to stand with 2 person assist. Began to ambulate, at that time resident began stating that it hurts and she could not do it (walk to chair). We stood her at nurses station and did a more thorough assessment. No bruises, redness or enema noted at that time. Resident continued to favor her left side. We placed her in chair and took her to room. At that time (staff member's name) began assessing her by doing pelvic rocks and check external rotation and length of loere (sic) limb. During assessment resident began to c/o (complaint) more pain and even upon subject change during communication once area was pressed the resident immediately responded by stating stop, that hurts..." During an interview on 02/11/10 at 2:45 p.m., the director of nursing (Employee #52) and the assessment coordinator (Employee #105) disclosed, "They should not have done that (ambulated her without assessment) and definitely should not have done pelvic rocks." Employee #52 disclosed this probably increased her pain following the fall, especially since the resident had a history of [REDACTED]. .