Every finding on record at Meadowview Healthcare and Rehab

Number of residents sampled: Number of residents cited: Based on observations, interviews, record reviews and facility policy review, the facility failed to ensure oxygen tubing and humidifier bottle were changed as ordered by the Physician, and a resident who was not Care Planned for self-administration was not left unattended while receiving an inhaled medication for one (Resident #5) of two residents reviewed for respiratory therapy. The findings include: Review of an admission Record revealed the facility admitted Resident #5 on 03/16/2026 with diagnoses which included chronic obstructive pulmonary disease. Review of an admission Minimum Data Set with an Assessment Reference Date of 03/16/2026 revealed Resident #5 had a Brief Interview of Mental Status score of 10 which indicated the resident had moderate cognitive impairment. Review of Resident #5's Care Plan, initiated on 03/27/2026, revealed that Resident #5 had oxygen therapy related to ineffective gas change. Interventions included monitoring for signs and symptoms of respiratory distress, increased heart rate, lethargy, confusion, cough, and chest pain. The Care Plan review revealed Resident #5 was not Care Planned to self-administer medications. Review of an Order Summary Report revealed an order with a start date of 03/16/2026 to check water level in humidifier and clean filter every night shift, every 7 days. The Order Summary Report revealed an order with a start date of 03/16/2026 to change the oxygen tubing and the humidifier bottle every 14 days. The Order Summary Report also revealed an order with a start date of 04/27/2026 indicated to administer [bronchodilator] (breathing treatment) by nebulizer three times a day related to Chronic Obstructive Pulmonary Disease. During an observation and concurrent interview on 05/04/2026 at 1:38 PM, this surveyor observed Resident #5 in bed with a nebulizer mask on the resident's face. Resident #5 stated that they were receiving a bronchodilator breathing treatment. The medication was visible in the cup on the nebulizer. There was no water in the resident's oxygen humidification bottle and there was not a nurse in the room, nor was a nurse in the line of sight of Resident #5. Resident #5 stated that the nurse put the oxygen mask on the resident and left the room. Resident #5 stated they received a breathing treatment three times a day that was administered over the course of approximately 15 minutes, and that the nurses did not stay in the room while the resident received the breathing treatments. Review of Resident #5's medical records indicated that Resident #5 did not have a self-administration assessment. During an observation on 05/04/2026 at 2:03 PM, this surveyor observed that Resident #5's oxygen tubing and humidifier bottle was dated 04/13/2026. During an interview on 05/04/2026 at 2:27 PM, Registered Nurse (RN) #2 stated that she would set a timer for 15 minutes after Resident #5's breathing treatment was started then she would go back to the room and turn the nebulizer off. RN #2 stated that she was not sure if Resident #5 was Care Planned for self-administration of the breathing treatment. RN #2 stated that she did not check the water level in the humidifier bottle daily. RN #2 stated that she checked the humidifier bottle if one of the Certified Nursing Assistants (CNAs) informed her that the water bottle was empty and that oxygen tubing was changed once a month. During an interview on 05/06/2026 at 9:33 AM, Resident #5 indicated that the nurse changed the oxygen tubing and added water to the humidifier bottle today. During an interview on 05/06/2026 at 3:37 PM, the Director of Nursing (DON) stated that the nurse should remain in Resident #5's room while a breathing treatment was being administered. The DON stated that the humidifier water should be filled with water every 7 days and when empty. The DON indicated that the nurses should check the water bottle every time they were giving medications. The DON indicated that the oxygen tubing should be changed every 14 days on the 10 PM-6 AM shift. Review of a facility policy titled Oxygen Policy with a handwritten date of 05/04/2026, revealed that refillable humidifier bottles should be replaced every two weeks, refilled as needed with fresh distilled water, labeled with date, and initialed. The policy also revealed that the nasal cannula should be changed every two weeks, labeled with date and initials.

Based on record review, interview, facility policy review, and document review, the facility failed to ensure an allegation of abuse was reported to facility administration, and subsequently the State Agency, for 1 (Resident #2) of 3 residents reviewed for abuse. The findings include: A review of a Nursing Progress Note, created by Licensed Practical Nurse (LPN) #1 on 11/01/2024 at 11:21 AM, revealed nursing documentation of an allegation of abuse from Resident #2, which read in part, Resident #2 stated someone on night shift with dark hair had kicked the resident in the night, because the resident had made the person mad. During an interview on 06/12/2025 at 1:23 PM, the Director of Nursing (DON) indicated that on 01/24/2025, the Progress Note documentation dated 11/01/2024, was brought to the Administrator ' s attention by surveyors. At that time, the Administrator initiated an investigation into the allegation made by Resident #2 and reported the allegation to the state agency. A review of a Social Progress Note dated 01/24/2025 at 3:00 PM, after the Administrator had been informed of the allegation documented in the progress note dated 11/01/2024, indicated the Administrator spoke with Resident #2, related to the allegation. The resident reportedly stated that they did not recall such an incident. [Resident #2] reported that [Resident #2] felt safe, secure and loved this facility. A review of a Social Note, dated 01/24/2025 at 7:16 PM, revealed the Administrator had spoken with Resident #2 ' s responsible party about the incident. A review of Resident #2 ' s Care Plan Report revealed the resident had diagnoses which included hallucinations, anxiety, and depression. The Care Plan Report, with a closed date of 03/18/2025, indicated the resident planned to remain in the facility under the care of hospice. The resident had impaired cognitive function, dementia or impaired thought processes related to cancer. Resident #2 was on pain medication therapy, used antidepressant medication, antianxiety medications, and psychotropic medications related to hallucinations. A review of Resident #2's quarterly Minimum Data Set, with an Assessment Reference Date of 12/12/2024, revealed the resident had a Brief Interview for Mental Status score of 14, which indicated Resident #2 was cognitively intact. A review of am LPN job description with a copyright date of 2023 revealed, policies and procedures would be complied with, the nurse would observe the resident for changes and notify the physician and family of changes and document findings. The nurse would report incidents and/or allegations to the supervisor or administrator. The nurse would protect the residents from abuse. A review of LPN #1 ' s Employee Record revealed an unnamed document signed on 09/14/2024, with LPN #1's name, which indicated an employee should immediately report a suspected allegation of abuse to the Administrator or their designee. The Administrator would notify the State Agency. The Director of Nursing (DON) or designee would notify the resident ' s representative of the allegation of abuse. An acknowledgment page, signed on 09/14/2024 with LPN #1 ' s name, read in part that LPN #1 agreed to follow the policies included in the handbook. A review of an Orientation Document dated 02/06/2019, indicated through signature that LPN #1 implied understanding of the instructions of the Abuse/Neglect policy. A review of an In-service Education Report, dated 10/09/2024, revealed an all-staff in-service for abuse. The in-service specified how to report an allegation of abuse and to contact their supervisor immediately. The in-service was signed by LPN #1, next to her printed name. A review of an Employee Disciplinary Action dated 04/05/2025, revealed a verbal warning for failing to report a resident-to-resident incident signed at the bottom on 04/11/2025, with LPN #1's name. During an interview on 06/11/2025 at 3:44 PM, LPN #1 reported her employment period with the facility had been off and on for 10 years. LPN #1 confirmed the last abuse in-service was within the last month, and many times over the last 10 years. LPN #1 indicated, with suspected or alleged abuse, it was the expectation of nursing staff to notify the DON or the Administrator. LPN #1 confirmed the progress note that revealed Resident #2 reported being kicked by someone over the night, dated 11/01/2024, was her documentation. LPN #1 reported texting the DON and the Administrator about the incident. LPN #1 was unable to verify that any documentation was available to verify the notification, stating, I just messed up, I didn't document everything that I should have. LPN #1 confirmed that the expectation of direct contact for reporting allegations of abuse was not a new policy, it had always been the expectation. LPN #1 reported the DON had provided retraining and a disciplinary warning had been given. During an interview 06/12/2025 at 1:23 PM, the DON confirmed all staff were expected to report allegations of abuse immediately in person or via phone to their direct supervisor, the DON or the Administrator. The nursing staff had not been trained to notify the DON or Administrator, via text notification, of abuse allegations. During orientation and at least quarterly, all staff were trained to report an allegation of abuse or neglect immediately to their supervisor. The DON confirmed that the physician and the resident ' s responsible party were expected to be notified of an allegation of abuse. The state agency was expected to be notified within two hours, after the notification of an allegation of abuse. The DON confirmed that LPN #1 had not reported the allegation of abuse to any administrative staff. The DON reported that LPN #1 had been retrained and disciplinary action had been taken due to the failure to report the allegation of abuse at the time it was reported to LPN #1 by the resident. During an interview on 06/12/2025 at 1:45 PM, the Administrator indicated when an allegation of abuse was reported, an investigation was immediately initiated and reported to the state agency within two hours. The Administrator confirmed the expectation of staff was to report the allegation immediately to their supervisor, the DON, or the Administrator, either in person or via phone conversation. The Administrator indicated all staff were trained on abuse reporting during orientation, at least quarterly, and through in-service training. The Administrator confirmed, with any allegation of abuse, it was the facility ' s policy to notify the physician and the resident ' s responsible party. The Administrator confirmed that LPN #1 had not reported Resident #2's allegation of abuse on 11/01/2024, to either the Administrator or the DON. The Administrator confirmed that staff were expected to follow the facility ' s policies, and the charge nurse was expected to notify the physician and responsible party when a resident had a change of condition. A review of a facility policy titled Abuse, Neglect and Maltreatment revealed that an alleged violation is an allegation reported by staff or others but has not been investigated, physical abuse included kicking, and employee training indicated that existing staff would receive retraining annually, and as needed. Employees were expected to report allegations of abuse immediately to the Administrator. The abuse allegation investigation was expected to be initiated immediately, investigated thoroughly, and reported to the appropriate state agency within two hours.

Based on observations, interviews, record review, it was determined that the facility failed to monitor and maintain safe hot water temperatures, which were found to be up to 151 degrees Fahrenheit (F), on all residential wings/units of the facility, including the shower rooms. Further, staff failed to implement the system for reporting and acting upon ongoing concerns related to excessively hot water in resident care areas. Specifically, direct care staff with knowledge of excessively hot water temperatures did not record this information on the facility's Maintenance Log sheets as the concerns were identified. In addition, maintenance staff did not implement any additional checks of facility water temperatures to ensure they were within safe ranges after adjusting the mixing valve; and the facility failed to ensure an emergency call system was accessible to residents who used a common bathroom on the entry hall. This had the potential to affect all 48 residents in the facility; and the facility also failed to ensure a safe and secure environment by not having a monitoring system in place for residents who wandered and/or had exit seeking behaviors. This deficient practice affected one (Resident #49) of 18 sampled residents. The facility identified one current resident who was at risk for elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, S483.25 (Quality of Care) at a scope and severity of L. The IJ began on 10/04/2024, when the Environmental Director adjusted the mixing valves to change the hot water temperature. The Administrator, Director of Nursing (DON), and Business Office Manager were notified of the IJ on 10/08/2024 at 10:23 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 10/09/2024 at 1:29 PM related to hot water temperatures. The IJ was removed, for the water temperatures, prior to the exit from the facility on 10/16/2024 at 6:00 PM, however the IJ an acceptable plan of removal was not received prior to exiting the facility related to elopement. In addition to the IJ above, the facility also failed to adequately assess, establish interventions, and provide supervision to prevent falls for 2 (Resident #21 and #25) of 18 sampled residents; failed to maintain safe and secure practices during medication preparation, which allowed Resident #49 to drink a medication left on the medication cart while the nurse was preparing medications. Findings include: Findings include: 1. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/13/2024, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated resident was cognitively intact. Resident #18 used a manual wheelchair for ambulation, required substantial to maximal assistance with toileting, had active neurological diagnoses with deficit to left side. During an interview on 10/07/2024 at 11:27 AM, Resident #18 stated the facility had issues with the hot water temperature, and during a shower, the knob was set on cold and only hot water was coming of the faucet and burned the top of Resident #18's thigh. Resident #18 could not remember the staff member assisting with the shower. During an observation and interview on 10/07/2024 at 12:08 PM, the surveyor, with permission, entered Resident #21's bathroom and turned on the sink's hot water faucet, and placed their right hand under running water. The surveyor pulled their right hand out of the water stream due to the hot temperature, causing a red area on the back of the surveyor's hand. Resident #21 stated the water was hot and had received a burn while they were washing their hands, but did not report it to anyone. Resident #21 denied blistering and had only reddened hands. During an observation on 10/07/2024 at 1:24 PM revealed a white paper with all capital, black letters, hanging in the shower room, that indicated, Caution: do not turn on straight hot water. you must adjust the temperature with cold water to prevent burns. The quarterly MDS, with an ARD of 07/18/2024, revealed Resident #20 had a BIMS score of 15 which indicated the resident was cognitively intact. Resident #20 required partial to moderate assistance with toileting, bathing, and ambulation, and had a diagnosis of hand numbness and tingling caused by a pinched nerve. During an interview on 10/07/2024 at 3:20 PM, Resident #20 reported the water in the restroom sink had been scalding since Friday 10/4/2024 and had not washed their hands in their room since that time. Resident #20 stated the issue had been reported to the nurse and had not been fixed. During observations on 10/07/2024, a surveyor obtained hot water temperatures in shower rooms and resident rooms. Any common bathroom accessible to residents and staff. Temperatures were as follows: - At 2:30 PM Hot water coming from faucets in the bathroom in resident room # 310 was 139 F, Assistant Administrator used facility thermometer. The Assistant Administrator was unable to continue testing and Medical Records assisted the surveyor with the remaining water temperatures. Two rooms on each hall were checked. Hot water temperatures ranged from 139 F to 145 F. The Environmental Director was not at the facility. - At 2:33 PM Hot water coming from faucet in bathroom in resident room # 301 was 143 F, Medical Records used facility thermometer. - At 2:38 PM Hot water coming from faucet in bathroom in resident room # 201 was 145 F, Medical Records used facility thermometer. - At 2:40 PM Hot water coming from faucet in bathroom in resident room # 404 was 141 F, Medical Records used facility thermometer. - At 2:42 PM Hot water coming from the faucet in bathroom in resident room # 501 was 135 F, Medical Records used facility thermometer. - At 2:52 PM Hot water coming from faucet in bathroom in resident room [ROOM NUMBER] was 141 F, Medical Records used facility thermometer. - At 3:52 PM hot water coming out of shower head faucet in double shower room was 135 F, taken by surveyor. - At 4:00 PM hot water coming out of the faucet in Resident #20 - room [ROOM NUMBER] bathroom was 148 F, taken by surveyor. - At 5:04 PM hot water coming out of faucet in Resident #18 - room [ROOM NUMBER] bathroom was 145 F, Administrator used facility provided thermometer. - At 5:09 PM hot water coming out of the faucet in Resident #21 - room [ROOM NUMBER] bathroom was 148 F, Administrator used facility provided thermometer. - At 5:14 PM hot water coming out of the faucet in Resident #30 - room [ROOM NUMBER]A bathroom was 143 F, Administrator used facility provided thermometer. - At 5:23 PM hot water coming out of faucet in room [ROOM NUMBER] was 145 F, and Rooms #103, 105 and 107 were 151 F. No residents are housed on 100-hall, however, Resident #49 was observed wandering into rooms on 100-hall by surveyor. - At 5:34 PM hot water coming out of faucet in room [ROOM NUMBER] was 148 F, taken by Environmental Director, using a meat thermometer and confirmed by surveyor using non touch infrared thermometer. The Environmental Director stated hot water heaters were installed by (Company Name), a local plumbing company and the mixing valve could not be bypassed. During an observation on 10/07/2024 at 3:38 PM Administrator escorted surveyor to boiler room where three on-demand hot water heaters installed. The temperature on all three hot water heaters was set to 170 F. During interviews on 10/07/2024 at 3:55 PM, Certified Nursing Assistant (CNA) #4 stated they were unaware of any maintenance to the hot water being done recently, had noticed very hot water in all rooms, and was only aware of one resident who complained of hot water being especially hot and that was Resident #20, on 200-hall. CNA #4 stated to ensure water temperatures are comfortable for residents, staff test the water on their own arm without gloves. CNA #4 stated no residents have been burned yet. CNA #4 stated room [ROOM NUMBER] is too hot, and Resident #20 will not use the sink, and staff will not wash their hands in resident rooms, they use hand sanitizer after leaving rooms due to the temperature of the hot water. During interviews on 10/07/2024 at 3:57 PM, CNA #5 stated they were unaware of any maintenance on the hot water being done recently, had not noticed the water temperature being too hot and has not had a resident complain about the water temperature, and was not aware of anyone being burned by hot water. To ensure resident comfort when bathing, CNA #5 tested the temperature of the water on their wrist. The quarterly MDS, with an ARD of 08/15/2024, revealed Resident #30 had a BIMS score of 15 which indicated the resident was cognitively intact. Resident #30 required partial to moderate assistance with toileting and ambulation, used a manual wheelchair, required substantial to maximal assistance bathing, and had a neurological brain disorder. During an interview on 10/07/2024 at 3:57 PM, Resident #30 stated the water, in a shared restroom, was really hot since admission to the facility in February and was scared to use the water in the room. Resident #30 stated an aide was notified but could not recall the name of the aide. During an interview on 10/07/2024 at 3:57 PM, CNA #17 described the process used when providing resident showers by turning the water faucet half-way between hot and cold, and spraying it on the residents' leg and adjusting it per resident preference. During interviews on 10/07/2024 at 4:00 PM, Licensed Practical Nurse (LPN) #6 stated she had been employed at the facility for one week, was not aware of any service done on hot water heaters, and had noticed the water got hot and had to turn on a lot of cold water to try to adjust the temperature. LPN #6 stated no one had complained about the water temperature or of being burned by the hot water. During an interview on 10/07/2024 at 5:15 PM , the Environmental Director (ED) stated water temperatures were checked weekly. The ED stated water coming out of a resident's bathroom faucet was 148 degrees F, it would be a concern. The Environmental Director further stated anything over 120 degrees was of concern as it was a scald issue for residents and would expect staff to remove residents from the water. The Environmental Director stated the facility installed on-demand hot water heaters (HWH) that were set at 170 F, and there was a brass 2.5-inch mixing valve, a 1.5-inch pipe that sent water to the kitchen and laundry, and 2.5- inch pipe that carried water to other areas. The Environmental Director explained the mixing valve mixed in the cold water to keep the temperature at a goal, When I can get the mixing valve to work, the goal of the resident rooms was 115 degrees F to 120 degrees F. The Environmental Director stated the last time the mixing valve was adjusted was on Tuesday (10/01/2024) due to a CNA reporting there was no hot water to provide a shower, so the mixing valve was adjusted. The Environmental Director stated changes were not documented and was not aware changes needed to be documented. A review of a facility logs titled, Weekly Water Temperatures, dated 10/09/2023 to 10/01/2024, revealed water temperature readings were 115 degrees in all tested areas. Logs were not provided for the first week in October 2023, the fourth week in September 2024. The last documented entry was on 10/01/2024. A review of an untitled document identified as Maint. Log, revealed an entry on 10/05/2024 that indicated the bathroom water in room [ROOM NUMBER] gets too hot. During a phone interview on 10/07/2024, at 5:56 PM the plumbing company representative stated three on-demand hot water heaters were installed by the company and the hot water temperature can be adjusted all the way down to 120 degrees F at the hot water heaters and could be set up to bypass the mixing valve completely. The company representative stated the 2.5-inch mixing value was hard to come by and the last one was ordered from New Jersey. The representative further stated that at the time of installation the temperature was turned up to 170 F for the dishwasher in the kitchen. On 10/07/2024 at 6:01 PM, surveyors notified the Administrator and DON of unsafe water temperatures in resident bathrooms, common areas, and bath/shower rooms and no further showers/baths for residents should be done in the shower rooms until water temperatures are in the safe zone. During an interview on 10/07/2024, at 6:14 PM the Dietary Manager stated the dishwasher was a low temperature dishwasher and reaches a temperature of 125 degrees Fahrenheit and nothing in the kitchen required water temperatures to reach 170 degrees Fahrenheit. When the sink water was turned on it was very hot and steamy. The dietary manager stated it is very hot, be careful. The water temperature in the sink was 145 F. During an interview on 10/07/2024 at 6:20 PM, the Administrator stated signs were posted on shower doors that instructed that residents were not to receive showers or baths. During an interview on 10/07/2024 at 6:20 PM, the Administrator stated signs were [NAME] d 10/07/2024 after 6:01 PM on shower room doors that residents are not to receive showers/baths. Photos taken by surveyor. Signs were posted at 6:23PM. DON stated signs were posted because the facility was told they could not give showers until further notice. DON is unsure of why but thinks the temps were too high. No in-services were conducted. During an observation on 10/07/2024, the main hall bathroom was accessible to residents, staff, and visitors. The bathroom door opened to the left, pushing inward. An emergency pull cord was located on the back of the door, over 5 feet from the floor, centered from left to right, would not be accessible to a resident, staff or visitor who was on the floor, or on the toilet, requiring assistance. The emergency pull device was just above surveyor's head, while standing, surveyor's height is 5' 4. The lock on the bathroom door was a slide lock and located above and to the right of the emergency light, requiring the surveyor to fully extend their arm to activate lock. During an interview on 10/08/2024 at 09:52 AM, CNA #2 stated Resident #18 did not notify the CNA of any burn. Showers did have to be stopped on 10/07/2024 due to cold water being too hot and the issues with the hot water were going on for about 2 weeks. CNA #2 stated Resident #18 received a shower on 10/107/2024 before lunch and was not documented until later in the afternoon. Resident #18 did complain about the temperature, the water was tested on CNA #2's arm and Resident #20 told CNA #2 it was still too warm, and CNA #2 turned the water down again. CNA #2 did not notify the nurse to assess Resident #20 for burns because the water was adjusted. During an interview on 10/11/2024 at 11:48 AM, CNA #8 stated staff were made aware of hot water temperatures on Monday and were told to stop doing showers and whirlpool baths and began doing bed baths, after checking water temperatures with a thermometer. CNA #8 stated reporting of repairs was done by writing on a clipboard in the charting room and needed to include the problem, room or location and the Environmental Director would take it from there, and the Environmental Director or a nurse would notify staff of any issues, problems or needed repairs that would affect the residents. During an interview on 10/11/2024 at12:03 PM, LPN #11 stated staff were made aware of hot water temperatures on Monday or Tuesday, and bed baths were begun with temperatures being checked with a thermometer. LPN #11 stated anything that involved residents, or the facility would be on the nurse's 24-hour report sheet and the nurse would call or text the information to the Administrator, DON and the Medical Director, and LPN #11 stated the CNAs do not receive the 24-hour report and are notified verbally by the nurse. LPN #11 stated residents are notified if they can understand, if not, families are notified. During an interview on 10/11/2024 at 2:13 PM, the DON stated she was not notified of the hot water temperatures until Monday, she contacted the Environmental Director and educated staff to begin checking water temperatures before providing bed baths. The DON stated residents were notified of the hot water temperatures, families were not notified and could not provide a reason. During an interview on 10/14/2024 at 11:51 AM, RN #12 stated the bathroom is used by residents, staff, and visitors and an ambulatory resident may be able to engage the lock. RN #12 stated if a resident fell in the bathroom, hopefully someone would hear them fall and check on them because there is no call light in the bathroom. RN #12 clarified there is no call light next to the toilet in the bathroom and the one on the door would be out of reach if a resident was on the floor near the door. During an interview on 10/16/2024 at 12:45 PM, CNA #1 stated the problem of hot water was identified when providing a shower to a resident and the water was not turning colder. CNA #1 stated the nurse was notified. CNA #1 could not recall a specific date but was prior to surveyors' arrival. During an interview on 10/16/2024 at 2:51 PM, the Administrator did not recall being notified of the hot water issues, had a phone tree to notify staff of hazards and risks, but the document was not up to date and was not used for notification of hot water issues. The Administrator then stated on Saturday evening something was said about adjusting water temperatures and was notified on Monday of a maintenance log entry made on Saturday about hot water. During an observation on 10/16/2024 at 12:34 PM, the surveyor obtained follow-up hot water temperatures in room [ROOM NUMBER] bathroom sink 77 degrees F; room [ROOM NUMBER] bathroom sink 75 degrees F. During an observation on 10/16/2024 at 12:28 PM, hot water heaters number 1 and 2 were set to 110 F, and number 3 was at 140 F. During an interview on 10/16/2024 at 3:00 PM, the Administrator stated residents did not normally use the bathroom on the main hall and if they did fall someone would either hear them or would find them if they were missing by calling an elopement. The Administrator stated there was a cord on the back of the main door, up high and it is not low enough for someone to reach if they were on the floor and there was not an emergency call light in the toilet area. 2. A review of the facility's undated new hire paperwork, facility policy titled, Elopement Policy and Procedure, indicated, if the resident is not found after an organized search of the facility the Administrator and Director of Nursing (DON) should be notified and the staff would be directed to notify the authorities/law enforcement to assist. A review of the Admission Record, indicated the facility admitted Resident #49 on 07/25/2024 with diagnoses that included dementia, generalized anxiety disorder, and delusional disorders. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/06/2024, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident was had severe cognitive impairment. A review of Resident #49's care plan initiated on 07/30/2024 and revised on 08/31/2024, revealed the resident was disoriented to place, had impaired safety awareness, wandering behaviors, a history of elopement from home, and an elopement from the facility on 08/30/2024. Interventions included distraction with structured activities, food, conversation, television, and books. Encourage placement of air tag watch per family. Identify patterns of wandering; purposeful, aimless, or escapist and intervene as appropriate. A review of Progress Note dated 07/25/2024 at 8:15 PM revealed, Medical Director was contacted when Resident #49 became agitated with exit seeking behaviors and stated they were getting out of here one way or another and that somebody better let them out so they could go home. A review of Elopement Risk Evaluation dated 07/25/2024 at 8:04 PM revealed, Resident #49 was At Risk of elopement with a score of 4. A review of Progress Note dated 07/28/2024 at 9:18 PM revealed, Resident #49 opened the emergency door at the 500-Hall, Resident #49 was taken back to her room and administered as needed order of an antipsychotic medication. A review of Elopement Risk Evaluation dated 08/04/2024 at 9:23 PM revealed Resident #49 was At Risk of elopement with a score of 4. The resident had a history of attempting to leave the facility, verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door, wandered aimlessly or non-goal-directed, and the wandering behavior was like to affect the safety or well-being of the resident or others. A review of Progress Note dated 08/07/2024 at 7:35 PM revealed Resident #49 was agitated and exhibiting exit seeking behaviors. Resident #49 stated they had to get out, Resident was pushing on exit doors and setting off the alarms as they opened. A review of Progress Note dated 08/14/2024 at 5:24 PM revealed, Resident #49 was exhibiting exit seeking behaviors. It was stated Resident #49 wouldn't stop pushing on the doors and trying to get outside, the door alarms kept going off. During an interview on 10/11/2024 at 11:00 AM Licensed Practical Nurse (LPN) # 11 was asked about Resident #49's elopement. LPN # 11 responded which one? LPN # 11 stated there was an elopement on 08/30/2024 where the resident was found in the parking lot, again on 09/19/2024 when Resident #49 went through the first set of doors and was going out the second set on 500-Hall when LPN #11 reached the resident, and an unknown Sunday when Resident #49 walked out the front doors with visitors. During an interview on 10/11/2024 at 2:10 PM, the Administrator stated he was only aware of one elopement Resident #49 had on 500-Hall and was not aware of Resident #49 walking out the front door with visitors. The Administrator stated the resident was never out of sight of staff. The Administrator stated it was possible the facility staff had failed to report other occurrences. The Administrator stated the cameras were not regularly monitored and the front hallway was unoccupied on the weekends and was not in the line of sight of staff, making a more difficult area to monitor for elopement. The Administrator stated this was not an appropriate facility for Resident #49 and family had been approached about it in care plan meetings. The Administrator stated Resident #49's family was made aware the facility's interventions may not work and Resident #49 may have to be relocated to a facility with a memory care/dementia unit which was more secure. During an interview on 10/11/2024 at 2:54 PM Certified Nursing Assistant (CNA) #20 stated they had seen Resident #49 go out the 500-Hall doors twice. CNA #20 stated she yelled Resident #49's name, the resident turned and looked, then kept going. CNA #20 stated Resident #49 walked out the front doors on a Sunday and stated it was harder on the weekends to monitor the resident. The front doors were out of sight. During an interview on 10/15/2024 at 1:30 PM, a facility visitor stated about two months ago when entering the facility, Resident #49 walked out the front doors. In a follow-up interview on 10/16/2024 at 12:58 PM, the visitor stated the resident went to the left when exiting the facility. During an interview on 10/16/2024 at 12:41 PM, CNA # 1 stated Resident #49 exited the front door of the facility when no one was at the front. CNA #1 exited the facility through the front doors, when the shift ended at approximately 2:30 PM. CNA #1 stated the Administrator was at the door when CNA #1 opened the door and asked if the person outside was Resident #49. CNA #1 stated yes, and the Administrator, and an unknown staff member exited the doors and ran after Resident #49. The unknown staff member reached Resident #49 who was in front of the building, in the grass up by the road. CNA #1 stated the elopement was before public school started, either at the end of July or the beginning of August. During an interview on 10/15/2024 at 2:17 PM, Resident #49's family member stated they did not want to move Resident #49, but wanted to know why the facility accepted the resident if they could not handle the situation. 3. Review of an untitled, confidential document, located in the risk management history (Incident and Accident [I&A]) of the electronic health record revealed Resident #21 experienced 63 falls from 10/2023 to 10/2024. A review of the Admission Record, indicated the facility admitted Resident #21 with diagnoses that included a decreased blood flow to the brain, convulsions, mental illness, and nerve damage of the extremities. A review of a revised care plan, dated 01/09/2024, revealed Resident # 21 had unavoidable falls r/t [related to] noncompliance with interventions. Interventions with an initiation date of 01/09/2024 were to continue fall precautions, educate resident on fall precautions, and follow facility protocol for fall precautions. 10/17/2023 non-skid strips were placed in front of toilet; 10/19/2023 signs placed; 10/19/23 non slip pad to w/c; 11/13/23 non-skid strips to bedside 11/21/23 toilet riser removed; 6/21/23 verbal education to staff; 6/5/24 encourage activities in common areas in evenings; 9/11/23 refer to FMP program; 9/11/24 Part B reveal; 9/11/2023 continue interventions on the at-risk plan, 06/21/2023 follow facility PP pertaining to falls; 10/01/24 staff will encourage resident to change into bed clothes after evening meal. A review of the quarterly MDS with ARD 08/09/2024 revealed Resident #21 had a BIMS of 12, which indicated the resident was moderately cognitively impaired, was independent standing from a seated position, required supervision with toilet transfer and was independent walking 10 feet; and had two or more falls since prior assessment with no injury, and two or more falls with injury. During an interview on10/07/2024 at 12:09 PM, Resident #21 stated they fell in the bathroom while toileting. Review of progress note dated 08/28/2024 at 11:47 AM, revealed Resident #21 was found on floor again, with no injury. Review of progress note dated 09/02/2024 at 2:19 PM, revealed Resident #21 was found on floor in room at 1:45 PM. Review of progress note dated 09/10/2024 at 1:18 PM, revealed Resident #21 was found on floor at 1:00 PM in front of their recliner, stood up to go to bathroom and fell , there was no injury. A review of skin evaluation dated 09/10/2024 at 1:32 PM, revealed Resident #21 did not have any skin issues. A review of progress note dated 09/11/2024 at 2:31 PM, revealed Resident #21 had a bruise to right buttocks related to fall. A review of Fall Risk Evaluation, dated 09/11/2024 at 7:37 AM, revealed Resident #21 was alert and oriented times 3, ambulatory, incontinent, had adequate vision, balance problems with standing and walking, required assistive device for ambulation, and had 3 or more falls in 3 months. During an interview on 10/11/2024 at 12:29 PM, LPN #11 stated Resident #21 was a fall risk and had 8 falls in the last year. LPN #11 stated the care plan should reflect the interventions for falls and the Assistant Director of Nursing (ADON) was responsible for updating the care plan and changes were made based on what was triggered in risk management and fall risk assessments. Current interventions included reminding the resident to use the call light, assist every 2 hours to toilet, observe when up and about, encourage participation in activities, monitor for mood, notify of activities, follow facility protocol - which was will have decreased falls, encourage participation in activities, and do frequent checks on the resident. LPN #11 stated it was important to have an accurate care plan and reflect a resident's needs in order to give them the best care and giving them what they need. LPN #11 stated specific interventions implemented included ensuring resident was coming out of their room and sitting and visiting or doing activities. During an interview on 10/14/2024 at 10:50 AM, the DON stated Resident #21 had greater than 25 falls since November 2023. Care plans were established by the MDS coordinator (ADON) and interventions were added when the facility reviewed falls in the morning meetings. Risk evaluations were completed after each fall on how likely the resident was to fall, medications currently being taken and what interventions the facility could change. The DON stated, We have done everything we can with Resident #21. The DON stated there was no root cause analysis done for why the resident had so many falls and that Resident #21 would get up, made their bed, and went to the bathroom without calling for assistance. The DON revealed that Resident #21 liked attention and would get on the floor and most of the incidents did not result in any injury and she was unaware if the Medical Director had evaluated Resident #21 regarding the falls. The DON stated interventions currently in place were non-skid strips in front of the toilet, non-slip pad in the wheelchair, non-skid strips at bedside, remove the toilet riser, verbal education, encouraged activities in evening, therapy and restorative therapy, and to have staff to assist with bedtime routine after the evening meal. The DON stated it was important for the care plan to be accurate and reflect the residents' needs So that everyone can take the best care of that resident and know to take care of them. During an interview on 10/14/2024 at 12:14 PM, the ADON stated Resident #21 had 59 falls since November of 2023 and fall risk assessments were done after each one and one was done quarterly and should be accurate to ensure interventions were in place on the care plan, which gives us a chance to better help our residents and staff knows what to do. The ADON stated Resident # 21 was non-compliant with interventions and the Medical Director had said to encourage activities and place resident in common areas to help prevent falls. Interventions that have been effective was a karaoke machine and resident coming out of the room into the common area during shift change. 4. A review of the Admission Record, indicated the facility admitted Resident #25 with diagnoses that included a brain disorder causing forgetfulness, limited social skills, impaired thinking abilities; low blood pressure that causes lightheadedness, dizziness, fainting; anxiety disorder; weakness and cataracts. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/25/2024, revealed Resident #25 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #25 required partial to moderate assistance with oral hygiene, shower/bathing, dressing, personal hygiene, sitting to standing, transfer from bed to chair and walking; substantial to maximal assistance with toileting; and supervision or touch assistance with eating. A review of Resident #25's care plan, with an initiated date of 08/15/2023, revealed Resident #25 had an actual/potential risk for falls related to decreased mobility, impaired vision and decreased safety awareness. Resident #25 experienced falls on 07/08/2023, 06/19/2024, and 09/02/2024 with no injuries reported. Interventions included, educated staff, anticipate and meet needs, follow facility fall protocol and PT (physical therapy) to evaluate and treat as ordered or PRN (as needed) on 08/07/2023, educated staff to assist resident with changing positions and toileting every 2 hours, on 06/19/2024, concave mattress on 09/03/2024. Interventions for antidepressant use included monitoring for gait changes, balance problems, movement problems, falls, and dizziness/vertigo. A review of the Order Summary Report, revealed Resident #25 had medications that included two medications

Based on observations, document review, and interviews, the administration failed to provide training and oversight to ensure the facility was free from the potential for injury related to identified concerns regarding elevated hot water temperatures. During the survey, the survey team identified hot water temperatures throughout all residential units / wings of the facility. Temperatures were found to be as high as 151 degrees Fahrenheit (F) in resident bathroom sinks, as well as resident shower rooms. Furthermore, the facility failed to ensure call light system was effectively working for 200 and 300 halls; and failed to implement an emergency backup system. The facility also failed to ensure a resident was free from physical abuse for 1 resident, Resident #21, who was heard yelling out at the contract lab technician to not draw the resident's blood. CNA #1 physically restrained Resident #21 while the resident's blood was drawn. These failures all resulted in Immediate Jeopardy for F600, F689, and F919. This failed practice resulted in Resident #18 and #20 complaining of being burned by the hot water on 10/07/2024 and 10/04/2024. Resident #30 indicated they were scared to use the water in their bathroom since February 2024 due to the hot water temperature. Resident #21 complained of water in their bathroom being too hot to use. Lack of an effective call light system has resulted in residents having to call out for assistance and or have a delay in assistance resulting in care not being received. Resident #21 reported a fear of needles, feeling terrible after the incident, and due to psychosocial harm, refused to take a shower today. Resident #21 was visibly upset as evidence by writhing hands, rubbing legs, and wiping tears from his/her cheek. The Administrator was notified of the IJ on 10/11/2024 at 11:51 AM. Before ending the survey, the survey team offered the facility the opportunity to provide a plan to remove the Immediate Jeopardy and ensure serious harm would not occur or recur. An Immediate Jeopardy removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely. The State Agency accepted a plan of removal on 10/13/2024 at 1:07 PM. The IJ was not removed prior to the exit from the facility on 10/16/2024 at 6:00 PM The findings include: A review of Administrator's job description revealed that they were responsible for managing and directing day to day operations for the facility in an effective and efficient manner. On 10/06/2024 at 6:00 AM shift change, when night shift staff notified day shift staff that the call lights were not working. Administrator and was notified and Administrator reported that he did not have a backup plan and attempted to call other nursing homes and was unable to borrow any bells. A review of an online shopping platform invoice, dated 10/06/2024, indicated the facility ordered 3 Jingle Bells, 24 wrist band jingle bells, 12 musical instruments, and 50 hand bells. A review of an invoice from (Business Name), dated 10/08/2024 indicated an order for a Central Unit NC 110/150/200. A hand notation at the bottom of the invoice indicated Call light part. On 10/9/2024 hand and wrist bells came in and were distributed to the residents. On 10/15/2024 (Business Name) arrived at facility and call light system was repaired. On 10/6/2024 it was observed by surveyors that the water temperatures coming from residents' bathrooms and common areas were extremely hot. Temperatures were observed with a staff member obtaining temperatures as high as 151 F in resident bathroom faucet. Report of Resident #18 and Resident #20 sustaining burns from hot water. A review of maintenance log dated 10/5/2024 had revealed an entry that indicated the bathroom water in room [ROOM NUMBER] gets too hot. During an observation on 10/07/2024 at 1:24 PM, revealed a white paper with all capital, black letters, hanging in the shower room, that indicated, Caution: do not turn on straight hot water. you must adjust the temperature with cold water to prevent burns. On 10/07/2024 at 5:15 PM , the Environmental Director stated the last time the mixing valve was adjusted was on Tuesday (10/01/2024) due to a CNA reporting there was no hot water to provide a shower, so the mixing valve was adjusted. The Environmental Director stated changes were not documented and was not aware changes needed to be documented. Also reported that mixing valve for hot water heater has problems getting it to work. 10/07/2024 after 6:01 PM on shower room doors that residents are not to receive showers/baths. Photos taken by surveyor. Signs were posted at 6:23PM. DON stated signs were posted because the facility was told they could not give showers until further notice. DON is unsure of why but thinks the temps were too high. No in-services were conducted. On 10/07/2024 at 1:52 PM, when Resident #21 was heard by yelling, crying, and begging, from room [ROOM NUMBER], by surveyor and facility staff. A surveyor and a facility staff member entered room [ROOM NUMBER] and observed a contracted laboratory technician standing next to Resident #21 drawing blood despite Resident #21 stating no. DON/Administrator was notified. On 10/08/2024 the contracted laboratory technician returned and had contact with seven residents. During an interview with a surveyor on 10/14/2024 at 10:10 AM, the Administrator stated the first incident of abuse was reported to the State Agency on 10/08/2024 at 10:54 AM but should have been reported 2 hours after the notification to them was made. The Administrator stated a pre-investigation was being done to see if there was a miscommunication to do a soft file, but there was no miscommunication. On 10/14/2024 at 2:51 PM, an interview with Administrator was completed and it revealed that there was no sitting administrator upon hire of the current Administrator. So, the Administrator felt like they were self-trained. The Administrator revealed that they educate themselves by googling it, phoning a friend, consult with the Interdisciplinary team, and looking at regulations. The Administrator stated the facility did not have any consultants and felt like the administrator needed more training. The Administrator stated the facility had a person that comes in on weekends and assists the administrator in areas that they are lacking in knowledge about. The Administrator stated the person was not a consultant but was just a friend from the industry. The Administrator reported that he just found out about the State Operations Manual Appendix PP within the last week. The Administrator stated he reviewed PP over the weekend to update himself on the regulations and felt it would increase their knowledge. Removal Plan: On 10/11/2024, upon notification of deficient practice of administration failing to perform education and training to ensure the facility was free from the potential for injury the facility completed the following: On 10/11/2024 at approximately 2:00 PM, the Board President and Medical Director met with DON and administrator to complete the following: Full review of job descriptions and expectations Full review of expectations of administration as held by the board of directors Education on regulations regarding reporting abuse and neglect allegations Education on ensuring emergency backup planning in the event of system failures such as call light systems. Education on follow up regarding tasks performed by interdisciplinary teams. This review and education will be placed on and reviewed at next board meeting currently scheduled for 10/16/2024 at 7:00 AM. Administrator/Designee will monitor resident areas for potential for injury through rounding twice daily and documentation five times per week for 8 weeks or until compliance is confirmed and verified with OLTC. Any negative findings will be reported to Admin, DON and Board President. Onsite Verification: The IJ was removed on 11/07/2024 at 12:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 10/11/2024 when the Board of Directors President and the Medical Director met with the Director of Nursing and Administrator to review their job descriptions and expectations. The Board of Directors reviewed the DON and Administrators job descriptions and expectations, federal regulations were reviewed for reporting abuse and neglect allegations, education on the need for emergency backup systems in the event of failures, education on the follow-up regarding task assigned to the interdisciplinary team. A total of five staff interviews were conducted with staff to verify training had been completed. The staff interviewed included Head of Hospitality, Environmental Service Director, Assistant Director of Nursing, Director of Nurse and the Administrator. The staff interviewed verified they had been trained on follow-up of interdisciplinary task, emergency backup plans, reporting of abuse and neglect, job expectations. A review of in-service sheets provided indicated the Director of Nursing and the Administrator had received education on job duties and Board of Directors expectations.

Based on interviews, record review, and facility policy review, it was determined the facility's Governing Body failed to ensure facility policies were implemented regarding management and operation of the facility. The Governing Body failed to ensure compliance with Freedom from Abuse, Neglect, and Exploitation during Survey. Immediate Jeopardy and Substandard Quality of Care (SQC) was cited at F600 at a S/S of a J. Additionally, Administration, F835 was cited at a S/S of a J; Quality Assurance and Quality Improvement, F867 was cited at a S/S of a J. Resident Call Systems, F919 was cited at a S/S of K. Supervision to Prevent Accidents, F689 was cited at a S/S of K. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.70 - Administration at a scope and severity of L. The Administrator was notified of the IJ on 10/11/2024 11:51 AM. Before ending the survey, the survey team offered the facility the opportunity to provide a plan to remove the Immediate Jeopardy and ensure serious harm would not occur or recur. An Immediate Jeopardy removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely. The State Agency accepted a plan of removal on 10/14/2024 at 7:51 AM. The IJ was not removed prior to the exit from the facility on 10/16/2024 at 6:00 PM The findings include: On 10/11/2024 at 10:45 AM, the Administrator stated the facility did not have a governing body policy. A review of a document titled, Meadowview Healthcare and Rehab Board Members documented members as the Board President, Governing Body Member (GBM) #13, GBM #18 and GMB #19. On 10/12/2024 at 2:51 PM, an interview with the Administrator revealed that the facility was a non-profit facility and did not have a governing body, but they had a Board of Directors that met once a month. The Administrator and the Board of Directors go over the current census, bank account balances, and from May to August 2024 their Medicaid funds were cut off due to not receiving non-profit paperwork. The Administrator reported to Surveyor that they request from the Board of Directors things such as trainings, to have consultants come in and assist the Administrator, update policies/procedures and the requests are always denied. The Administrator reports that the Board of Directors reply with that there is no reason to change or update anything due to the way things are handled have been the same way for a long time. The Administrator reported that anytime he asks the Board of Directors for anything, the Administrator does not get it. The Board of Directors will be identified as the Governing Body. On 10/15/2024 at 3:07 PM, a telephone interview with survey team with Governing Body Member (GBM) #13 revealed that the governing board met monthly. But GBM #13 did not attend the meeting in September and then revealed that they have not been to a meeting in a couple of months. It was revealed that there were four board members. GMB #13 reported that there had been some financial problems, but they were addressed and fixed. No further financial problems that GBM #13 was aware of. GBM #13 revealed that resident funds had not been addressed with the governing body. GBM #13 was not aware of the call lights being out or that the hot water burnt a resident. GBM #13 reported that GBM #13 had not had a recent meeting with the governing board since state surveyors had been in the building. The GBM #13 disclosed that they had worked on roof damage and few other building issues. GBM #13 reported that they were not aware of a pest problem or trash problem. Also, as far as GBM #13 knowledge, the Administrator had not asked for any trainings, or any other items related to training assistance. During an interview on 10/15/2024 at 3:28 PM, he Board President stated the board met monthly at the nursing facility. There are four board members, and the administrator was present during the meetings, and sometimes the Director of Nursing (DON) is present. The Board President revealed that they are short a member at this time. They have tried finding another member but have not been successful. The Board President revealed that they did not receive Medicaid funds from March to August due being frozen because they had to get all the paperwork submitted proving they were non-profit. They were unable to do so themselves, so they hired some Certified Payroll Accountants to assist them with the process. Also, the Board President revealed that the facility had to terminate a staff member that worked for the facility for using the facility credit cards and checks. The staff member was let go in February. It was reported that the board was aware of the pest problem and the administrator was told to fix it and the board members were under the assumption that it was taken care of. They were not aware that there continued to be a problem. The Board President revealed that the board was aware of the trash problem, revealed that the company that they were using was not picking up the trash routinely and the Administrator had changed companies to resolve the problem. They were not aware that there was an ongoing problem. The Board President reported that the Administrator had not asked for any more training. The board had provided a consultant to help the Administrator, but unsure of when or what the consultant helped with. The board was not aware of the federal rules and regulations for the nursing home. The board also did not review the bank statements or any financial papers of the nursing facility. On 10/16/2024 at 2:38 PM, an interview with the Administrator revealed that the governing body met that morning at 7:00 AM. The Administrator revealed that the governing body and himself realized there was a systemic failure and criteria for the nursing facility had not changed in thirty years. The Administrator stated federal rules and regulations were reviewed at the meeting. Removal Plan: On 10/11/2024, upon notification of deficient practice of ensuring a governing bodies implementation of policy and procedure regarding management and operations of facility the facility completed the following: On 10/11/2024 at approximately 2:00 PM, immediate board members- Board President and Physician- met with Administrator and Director of Nursing (DON). Review of current facility bylaws- such as Interdisciplinary team job descriptions and general day to day policy and operations- occurred. Board president and Physician reviewed job descriptions and expectations with Administrator and DON at this time. Board of directors to review and implement policy and procedures regarding management, operations and implementation of further policies. Additional policies- such as assignment and allocation to additional over viewers, appointment of additional board members, and expectations of the sitting board- to be reviewed and further discussed at scheduled board meeting currently scheduled for 10/16/2024 at 7:00 AM. Review and further implementation to be documented in board meeting minutes. Administrator/Designee will monitor implementation of board policy and procedures 2 times weekly through review and documentation with report to be provided to board president weekly on Fridays before end of business day for 8 weeks or until compliance is confirmed and verified with OLTC. All corrections were completed on 10/11/2024. Onsite Verification: The IJ was removed on 11/07/2024 at 12:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 10/11/2024 at 2:00 PM when the Board of Directors President, Medical Director, Director of Nursing, and Administrator met to review the facility ' s current by-laws for interdisciplinary team job descriptions, and the facility ' s general day to day policy and operations. The Board of Directors President, Medical Director, Director of Nursing, and Administrator met to review the facility ' s current by-laws for interdisciplinary team job descriptions, and the facility ' s general day to day policy and operations, Director of Nursing and Administrator job descriptions and expectations were reviewed, new board members were appointed and assignments were allocated, by-laws were updated, and the Administrator monitored new implementations and reported to the Board of Directors President every Friday. A total of 2 staff interviews were conducted to verify training had been completed. The staff interviewed included the Director of Nursing and the Administrator. The staff interviewed verified they had been trained on new bylaws, job descriptions, and expectations of the board. A review of in-service sheets provided indicated both had been provided training.

The facility's Quality Assurance Performance Improvement Program (QAPI) failed to maintain a program that developed and implemented effective improvement plans to correct identified areas of concern. After identifying Immediate Jeopardy at F600, F689, F835, F837, and F919, the facility's QAPI plan was requested. The Administrator was unable to locate the facility QAPI plan. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.75 - Quality Assurance and Performance Improvement at a scope and severity of L. The Administrator was notified of the IJ on 10/11/2024 at 11:51 AM. Before ending the survey, the survey team offered the facility the opportunity to provide a plan to remove the Immediate Jeopardy and ensure serious harm would not occur or recur. An Immediate Jeopardy removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely. The State Agency accepted a plan of removal on 10/14/2024 at 7:51 AM. The IJ was not removed prior to the exit from the facility on 10/16/2024 at 6:00 PM. Findings include: A review of an undated policy titled Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Policy & Procedure revealed that the facility would develop a QAPI plan in accordance with federal guidelines. The facility would address clinical care, resident quality of life and residents' choice. During an interview on 10/11/2024 at 2:30 PM, the Administrator stated that the QAPI binder was unable to be located. The Administrator stated that the QAPI binder was not up to par and he would no longer look for the binder. The Administrator stated the QAPI team was going to meet the second Tuesday of the month. The Administrator also stated the facility would like to add a resident to the QAA/QAPI team because he felt it would help identify systemic issues. The Administrator stated the QAPI program would help with better documentation and current policies. The Administrator stated that some of the facilities' current policies were from 1991 and need to be updated to current standards. The Administrator reported that a new QAPI binder had been started. The Administrator reported that it was important to have a QAPI program to help find issues within the facility and be able to fix them quickly. The Administrator stated he felt like his employees came to him a lot with problems. He did not think the QAPI program would bring any more problems up that his staff did not already bring to him, however, the Administrator stated he realized during the survey, he had a lot more problems than he knew about. Removal Plan: On 10/11/2024, upon notification of deficient practice to ensure an effective QAPI is in place, the facility completed the following: On 10/11/2024, the Director of Nursing (DON) and Administrator reviewed current regulations revolving around a Quality Assurance Performance Initiative (QAPI) program ensuring further comprehension of program needs, placement, reasoning and requirements. Interdisciplinary team (IDT) met with DON & Administrator to review and increase knowledge and education on QAPI. On 10/11/2024, DON and Administrator reviewed, adjusted and updated facility QAPI Policy & Procedure to include the following: - Scheduled time of the month for QAPI to be held - Reassignment of information to be provided from different members of IDT. - Requesting for resident president to be a part of QAPI meetings and information gathering Requesting that a floor staff member be a part of QAPI meetings and information gathering - Review on providing in-service education to all staff pertaining to QAPI, it's reasoning and methodology. Administrator/designee will oversee the implementation of comprehensive QAPI program through documentation 1 time per week for 8 weeks or until compliance is verified by OLTC. All corrections were completed on 10/11/2024. Onsite Verification: The IJ was removed on 11/06/2024 at 2:49 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 10/11/2024 when the Director of Nursing (DON) and Administrator reviewed current regulations for Quality Assurance Performance Initiative (QAPI) program. The Interdisciplinary Team (IDT) met with the DON and Administrator reviewed and increased their knowledge on QAPI, monthly QAPI meetings were scheduled for the 2nd Tuesday of every month at 2:00 PM, QAPI responsibilities were assigned to each IDT member, the resident council present was asked to take part in the monthly meetings, the Activities Director met with residents from resident council for input on needed improvements, a Licensed Practical Nurse (LPN) who works the floor was asked and accepted to join QAPI committee, all staff were educated on QAPI, and the administrator provided his weekly documentation of QAPI oversite. A total of 9 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurse. The staff interviewed verified they had been trained on QAPI. A review of in-service sheets provided indicated 54 of 69 had been provided training. Those staff who were not physically present to receive the in-services were provided the power point on paper by the night shift charge nurse and signed the acknowledgement sheet which was returned to Human Resources.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure a resident was free from physical abuse for 1 (Resident #21) resident, who was heard yelling out at the contract lab technician to not draw the resident's blood. Specifically, Certified Nursing Assistant (CNA) #1 physically restrained Resident #21 while the resident's blood was drawn. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, S483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of K. The IJ began on 10/07/2024 at 1:52 PM, when Resident #21 was heard yelling, crying, and begging, from room [ROOM NUMBER], by the surveyor and facility staff. The surveyor and a facility staff member entered room [ROOM NUMBER] and observed a contracted laboratory technician standing next to Resident #21 with lab supplies to perform a blood draw. The Administrator, Director of Nursing, and Business Office Manager were notified of the IJ on 10/08/2024 at 5:31 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 10/13/2024 at 1:15 PM. The IJ was not removed prior to exit from the facility on 10/16/2024 at 6:00 PM. Findings include: A review of a facility policy titled, Patient Abuse/Neglect, dated 2017, outlined the policy and procedures for investigation and reporting of alleged violations that included abuse and neglect. The procedures included reporting alleged violations to the state agency, immediately performing an investigation, Protection: indicated the accused employee will be immediately sent home and immediately placed on suspension. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Training of employees includes appropriate interventions, examples of reportable incidents to assist staff in detection of such incidents, shall be done on admission and annually. A review of an undated facility policy titled, Your Rights and Protections as a Nursing Home Resident revealed, residents have a right to be free from verbal, sexual, physical, and mental abuse. A review of an undated facility document titled Resident Rights, revealed residents have rights that included being treated with dignity and to live in a safe, homelike environment. A review of an undated facility document titled N.A./C.N.A. [Nursing Assistant/Certified Nursing Assistant] Job Description revealed CNAs perform care and related duties for disabled, physically ill, and geriatric residents. Duties and responsibilities included communicating with residents and the nurse and assisting with safety measures. A review of the Employee Handbook, dated 2023, page 3 revealed Any allegation, suspicion or witnessed events of abused (sic), neglect, or theft must be reported immediately to: and listed individuals and agencies to be notified. Page 20 of the handbook indicated Grounds for Immediate Dismissal included verbal or physical abuse, speaking rude or disrespectful to anyone, disregard or violation of facility policies, or use of profanity. Page 21 of the handbook contained a Patient Abuse/Neglect policy, with a change effective date of 09/25/2017, number 15. S483.5 Definitions defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Page 24 included a signature line and date for the abuse and neglect policy. A document titled Inservice Instructor Video, Handout or Review on Page 56 included a list of in-services, including Adult and Long-Term Care Facility Resident Maltreatment, and a signature line for the employee attending the in-service. A review of in-services provided by the facility included Abuse, Neglect, & Misappropriation/Exploitation with signature pages. The In-service Education Report indicated it was an all-staff in-service, with dates of 12/06/23, 2/14, 6/12, and 8/9, and included the types of abuse with definitions and how to report abuse. A review of Certified Nursing Assistant (CNA) #1's personnel file revealed on 05/29/2024, CNA #1 received abuse training, and signed a reporting and corrective action document that revealed, any employee shall immediately notify the Administrator regarding abuse. CNA #1 signed an attendance document titled, Inservice Instructor Video, Handout or Review, that included training on identifying and reporting abuse and neglect, on 05/29/2024. A review of the [Contracted Lab Name] Services Agreement with an effective date of 10/04/2022, indicated the contracted laboratory company was the Provider, and shall comply with policies provided by the facility. A review of the [Contracted Lab Name] Handbook for Policies and Procedures dated 06/7/2022 did not address abuse of residents or patients. A review of the Admission Record, indicated the facility admitted Resident #21 with diagnoses that included depressive disorders and anxiety disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/2024, revealed Resident #21 had a Brief Interview for Mental Status score of 12 which indicated the resident had moderate cognitive impairment. No mood or behavior was indicated. Resident #21 required partial to moderate assistance with shower/bathing and toileting, required setup or clean-up assistance with eating and oral care and was independent with dressing and personal hygiene. Resident #21 used a manual wheelchair for ambulation. A review of Resident #21's care plan initiated, 06/21/2023 revealed no focus or intervention for anxiety or fear of needles. A review of Order Summary Report, revealed Resident #21 had laboratory orders for blood tests that included, Lipid panel every 6 months with an order date of 10/04/2024, CBC (complete blood count) every 91 days with an order date of 05/26/2023, CMP (comprehensive metabolic panel) every month with an order date of 10/04/2024, Dilantin every 91 days with an order date of 05/26/2023, Keppra, Lacosamide, Phenobarbital every 91 days with an order date of 05/26/2023, NH3 (Ammonia) level every 91 days with an order date of 05/26/2023, and a BMP (basic metabolic panel) on 10/10/2024. A review of October Medication Administration Record, did not reveal Resident #21 had any laboratory draws done. A review of the October Treatment Administration Record, did not reveal Resident #21 had any laboratory draws done. During an observation on 10/07/2024 at 1:52 PM, the surveyor heard yelling, crying, and begging from a room on 200-hall. Resident #21 was sitting in a recliner, their legs were elevated and covered with a blanket. Resident #21 was pleading Please no, don't, not today. I don't want to, not today. Resident #21 repeatedly stated no to the man standing next to the recliner, while shanking head side to side, with voice raised, tears in eyes and on cheeks, arms crossed over chest and pulled blanket upward to cover arms. Resident was looking at a man in in blue scrubs, who identified himself as Phlebotomist with the contracted lab company, to draw blood for an Ammonia test. At 2:03 PM, CNA #1 entered Resident #21's room and stated they heard yelling and came to see what was going on. Resident #21 grabbed CNA #1's left hand and tearfully said I just don't want this. Phlebotomist asked to look at Resident #21's arm and Resident #21 stated, I don't want this. Phlebotomist placed tourniquet on Resident #21's left arm, Resident #21 actively crying and looking at CNA repeating No. Resident #21's right arm remained under blanket. Phlebotomist removed the tourniquet from the left arm and moved to Resident #21's right side. CNA #21 moved to Resident #21's left side and held resident's left arm, while the Phlebotomist placed tourniquet on Resident #21's right arm. Resident #21 continued to cry stating they did not want the blood draw. CNA #1 let go of resident's left arm and moved to close door. The Phlebotomist stood up to gather supplies. The surveyor asked CNA #1 what Resident #21 was saying. CNA #1 stated, No, and did not want to have blood drawn. CNA #1 was asked if blood should be drawn if the resident says no. CNA #1 did not respond and left the room. Phlebotomist stated blood would not be drawn blood until the nurse returned. Resident #21 again stated they did not want to have blood drawn. CNA #1 reentered the room, moved to Resident #21's left side and held Resident #21's hand and arm. Phlebotomist placed tourniquet on Resident #21's right arm and began to move toward resident with the needle. Shaking their head side to side, Resident #21 repeated the word no. Surveyor asked Phlebotomist, If the resident is saying no, refusing, should you continue to draw the blood? Phlebotomist responded that is why the nurse is here because some people are apprehensive. The phlebotomist proceeded to insert the needle into Resident #21's right arm and obtain blood in vials. Resident #21 continued to cry looking at the CNA. During an interview on 10/07/2024 at 2:09 PM, CNA #1 stated they do have a duty to care for and protect residents. If a resident says no then we should not do something. [Pronoun] grabbed my hand, so I stayed. Residents should be allowed to say no, and I probably should have gone to get my nurse. CNA #1 stated the residents should not be forced to have a procedure that they do not want and that is abuse. CNA #1 walked away and was observed with tears in eyes. During an interview on 10/07/2024 at 2:12 PM, Resident #21 stated, If I say no, they do it anyway because the doctor needs it. I am scared of needles. I feel terrible and this was supposed to be my shower day and now I can't do it. I just can't. Resident observed writhing hands, rubbing legs, and wiping tears from right cheek. During an interview on 10/07/2024 at 2:19 PM, the Director of Nursing (DON) was notified of the abuse. The DON stated Resident #21's refusal should have been accepted, and staff should have notified the nurse of the refusal. I will speak with the lab tech and the aide. During an interview on 10/07/2024 at 4:10 PM, the DON stated the Administrator was notified of the situation with Resident #21 and Resident #21 was interviewed. CNA #1 and Phlebotomist were reeducated on what to do if a resident refuses blood work. The Phlebotomist finished blood draws and was not asked to leave the building. The DON stated she did not believe this was abuse, only a misunderstanding. A review of the [Contracted Lab Name] Patient Service Log dated 10/07/2024, revealed Resident #21 had routine blood drawn at 2:00 PM, by Phlebotomist. The Phlebotomist drew blood on two (2) additional residents after leaving Resident #21's room. A review of the [Contracted Lab Name] Patient Service Log dated 10/08/2024 revealed the Phlebotomist returned to the facility and had contact with 7 residents. On 10/09/2024 at 10:53 AM, a policy and procedure on specimen collection for the contracted lab and the facility was requested from the DON. The DON stated the contracted lab would be contacted to obtain that information and did not believe the facility had a policy and procedure. During an observation on 10/10/2024 at 11:45 AM, at the front entry, an employee of the (contract lab) was speaking with the DON and stated, They fired him referring to the Phlebotomist, and the DON replied, I heard. During an interview on 10/14/2024 at 10:10 AM, the Administrator stated the first incident of abuse was reported to the State Agency on 10/08/2024 at 10:54 AM but should have been reported 2 hours after the notification to them was made. The Administrator stated a pre-investigation was being done to see if there was a miscommunication to do a soft file, but there was no miscommunication. The second incident was sent to the State Agency at 4:30 PM on Friday (10/11/2024). A soft file was described as an incident needing education. The Administrator stated he was not aware of another incident and reported two. During an interview on 10/11/2024 at 11:49 AM, CNA #8 stated upon hire staff receive training on abuse and neglect and are paired with a skilled CNA for orientation on the hall. CNA #8 stated abuse and neglect are mentioned quite a bit, and are required to sign a form during the in-service, which includes the types of abuse and how to report it to the nurse, DON and the Administrator. CNA #8 stated after the in-service presentation, questions were answered if they have any, and forms are handed out on abuse. During an interview on 10/11/2024 at 12:21 PM, Licensed Practical Nurse (LPN) #11 stated upon hire, in-services on Dementia, peri-care and proper transfer was received and training on the floor with a nurse was done. LPN #11 stated a packet including Resident Rights, including abuse and neglect, and Dementia training was also provided. LPN #11 stated the last in-service on abuse and neglect was on Wednesday (10/09/2024) and included a print off of Resident Rights that included types of abuse, how and who to notify, the CNA is to notify the nurse, and the nurse is to notify the Administrator and DON. LPN #11 stated they had to report abuse in the past, could not recall when, stated before January, and notified the Registered Nurse (RN) on duty, sent the person home after they wrote a statement, and the Administrator, police and state were notified. LPN #11 stated the resident involved would be monitored and the physician would be notified of changes. When asked how LPN #11 ensured staff understand and are able to identify abuse, LPN #11 stated it was like mouth care and if someone didn't know how to perform it, they would ask for assistance. During an interview on 10/11/2024 at 2:22 PM, the DON stated initial training on abuse and neglect was done upon hire, by the Human Resource Director (HRD). The DON stated abuse and neglect training that includes the type of abuse, who and when to report to is done at least yearly by the DON or Administrator and is followed by a test to ensure staff understood the information. The DON stated CNA #1, CNA #2 and CNA#3 should have received training on abuse and neglect, in the hiring packet, in-services are done yearly, and follow-up should have been done. The DON stated the follow-up is asking questions and getting feedback. The DON stated that when made aware of the abuse involving Resident #21 and Resident #23, an investigation was done that included talking to all parties involved and reporting to the state agency, Medical Director, police, and families. Physician orders received for Resident #21 and Resident #23 were for vital signs every shift for 3 days. Resident #21 did not receive any medical evaluation or referral. During an interview on 10/15/2024 at 12:02 PM, the Human Resources Director (HRD) stated new Staff training/orientation begins with Long Term Care Training videos viewed by the employee on an online video sharing platform. HRD stated the facility did not have a DVD player to show DVDs, so the online video sharing platform video for Abuse, Neglect, Exploitation, and Misappropriation Property, by NORC Ombudding, along with the video titled, Resident Rights in Action, from the Pennsylvania State Ombudsman, were used by the facility. The HRD stated personal stories are also used. Orientees were expected to watch the videos and attest that they have watched them by signing the Inservice Instructor Video, Handout or Review in the employee handbook. The HRD stated follow-up with staff is done during the video training and staff are told to call if they have a question on the new hire training. CNA #1 received training on abuse and neglect. The HRD stated CNA #1 sat down with the HRD and went through the employee handbook page by page together. The HRD stated CNA #2 and CNA #3 were employed prior to HRD taking position and both received in-services and updates with other staff. After abuse and neglect in-services staff sign they attendance and interact with questions and answers, We keep an open dialogue. HRD stated the last in-service on abuse and neglect was done by the Administrator last week. During an interview on 10/16/2024 at 4:37 PM, CNA #1 stated new hire training included an assigned trainer watching tasks being performed and signing off on a competency list, and prior to hire did watch some videos but did not recall any training on abuse and neglect. CNA #1 stated no training, or in-service was received after Resident #21's abuse allegation, and stated they were not suspended because they were not scheduled to work the remainder of the week. During an interview on 10/14/2024 at 12:10 PM, the Assistant Director of Nursing (ADON) stated information was received regarding Resident #21 and Resident #23 abuse allegations during the daily debrief. Discussion included care planning fear of needles for Resident #21, and unless there was a total refusal during the lookback period it would not be placed on the MDS. The ADON was not aware of any referral treatment for Resident #21. During an interview on 10/16/2024 at 10:20 AM, CNA #9 stated training on abuse and neglect was received last week, and had not had anyone complain, and had not witnessed anyone being forced to do anything after saying no and had not witnessed abuse. A review of an Inservice Education Report, dated 12/06/2023, 02/14/2024, 06/12/2024, and 08/09/2024, revealed the topic was Abuse, Neglect & Misappropriation/Exploitation, and included signature pages of staff attendance. CNA #1 and CNA #9 attended the in-services on 06/12/2024 and 08/09/2024. During an interview on 10/16/2024 at 3:27 PM, the Administrator stated the abuse should have been immediately reported and was not as It did not register that it was abuse. The Administrator stated the CNA should have gotten a nurse, and the nurse should have intervened. The Phlebotomist should have been removed from the room, and the building. The Administrator stated it was not presented as abuse, it was presented in a calm way, by the DON, and that the CNA needed to be educated. Removal Plan: On 10/8/2024, upon notification of deficient practice to report abuse allegations, the facility took the following measures: At approximately 10:30 PM, the Administrator notified DHS via portal of abuse allegation pertaining to Resident #21. At approximately 12:15 PM, the Director of Nursing (DON) provided verbal education to Certified Nursing Assistant (CNA) #1 and contracted lab technician in question pertaining to resident's right to refusal, and types of abuse. CNA #1 out of facility on suspension at this time. Lab tech exited facility after verbal education with DON. DON contacted lab techs supervisor. Lab supervisor reported that lab company will provide education to employee, and are supposed to follow up with facility/DON the afternoon of 10/9/2024. On 10/11/2024 at 4:32 PM, Administrator completed and submitted 7734, notification of abuse allegation to DHS, via portal. The Administrator provided education at all staff in-service held 10/9/2024 at 2:00 PM about resident rights and types of abuse. Staff unable to attend scheduled in-service will be provided a handout by Human Resources then they come to facility to pick up checks. Any remaining staff will be contacted for one on one education prior to the start of their next shift. On 10/11/2024, the Administrator provided immediate verbal in-service to staff currently in the facility. Witness statements provided to staff. DON educated nurses. Witness statements provided to nurses with notification placed on 24-hour report sheet. The Social Services Director (SSD)/Designee to interview all residents with a Brief Interview for Mental Status (BIMS) of 13 or above pertaining to if they have ever felt or have any knowledge of abuse occurring within the facility. Second shift charge nurse to perform body audit on all non-cognitive residents and those scoring a 12 or below on BIMS quarterly assessment to check for discoloration or bruising. On 10/11/2024, DON interviewed all residents with a Brief Interview for Mental Status (BIMS) of 13 or above pertaining to if they have ever felt, or have any knowledge of abuse occurring within the facility. Second shift floor nurses- with the assistance of DON and additional nursing staff- to perform body audits on all residents-both cognizant and non-cognizant- as they will allow. DON/Designee to monitor resident areas for possible abuse occurrences twice a day for 8 weeks or until compliance is confirmed and verified by OLTC. Any negative findings will be reported immediately to Admin. All corrections were completed on 10/11/2024. Onsite Verification: The IJ was removed on 10/29/2024 after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 10/09/2024 at 2:00 PM when a mandatory meeting providing in-service on resident rights and abuse was completed. Staff in-serviced on resident rights and types of abuse, Social Services Director interviewed all residents with Brief Interview Mental Status (BIMS) of 13 or greater, second shift charge nurse conducted body audits on all non-cognitive residents and those with a BIMS of 12 or less, and Director or Nursing (DON) monitored resident areas for possible abuse occurrences twice a day. A total of 12 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Kitchen Aide, Hospitality Services, and Environmental Services. The staff interviewed verified they had been trained on resident rights an abuse. A review of in-service sheets provided indicated 65 of 71 had been provided training. 51064

Based on observations, interviews, record review, it was determined that the facility failed to ensure the call light system was effectively working for 200 and 300 halls; and failed to implement an emergency backup system for 2 of 4 halls. The facility census was 48. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manul, Appendix PP, S483.90 (Physical Environment) at a scope and severity of K. The IJ began on 10/06/2024 at 6:00 AM shift change, when night shift staff notified day shift staff that the call lights were not working. The Administrator, Director of Nursing (DON), and Assistant Administrator /Business Office Manager (BOM) were notified of the IJ on 10/08/2024 at 5:13 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Agency on 10/09/2024 at 1:19 PM. The IJ was removed on 10/16/2024 at 4:30 PM after the survey team performed onsite verification that the Removal Plan had been implemented. All call lights in the building functioned and bells were available for back-up system and plan for implementation. Findings include: A review of the Maintenance Log, revealed on 03/15/2024, call light outside room [ROOM NUMBER] was not working and initialed as completed; 04/08/2024, call light outside room [ROOM NUMBER] was not lighting up and initialed as working on 4/11/2024; 04/10/2024 call light room [ROOM NUMBER] not working and initialed as completed; on 04/15/2024 and 04/17/2024 call light outside room [ROOM NUMBER] not working and initialed as completed; 05/01/2024 call light room [ROOM NUMBER] not working, bed B and initialed as completed; 06/23/2024 emergency call light room [ROOM NUMBER] not working and initialed as completed; 06/27/2024 call light outside room [ROOM NUMBER] not working and initialed as completed; 10/06/2024 call light room [ROOM NUMBER] not working. During an interview on 10/08/2024 at 4:00 PM, the Environmental Director confirmed the initials under the completed column were his and that the work was completed. A review of a facility policy titled, Facility Assessment Tool, undated, did not address an emergency backup plan for the facility call system. A review of an online shopping platform invoice, dated 10/06/2024, indicated the facility ordered 3 Jingle Bells, 24 wrist band jingle bells, 12 musical instruments, and 50 hand bells. A review of an invoice from (Business Name), dated 10/08/2024 indicated an order for a Central Unit NC 110/150/200. A hand notation at the bottom of the invoice indicated Call light part. During an interview on 10/07/2024 at 11:27 AM, Resident # 18 requested assistant related to soiling of a brief. Resident #18 picked up the call button from the bed and pressed the button to activate the call light. Resident #18 stated they felt like the call light was not activating. The surveyor stepped into the hallway and the light above Resident #18's door was not lit, and no sound was coming from the nursing area where the call system makes an audible beeping sound. Resident #18 stated the call lights on 200 and 300 halls had not worked for at least one week and believed the facility ordered bells to go off. Resident #18 stated if staff take too long, Resident #18 would roll their wheelchair into hallway so they see me and if it took too long, I yell, and they come. During an interview and observation on 10/07/2024 at 11:52 AM, Resident #16's family member did not know if call lights were working. Resident #16 pushed the call button lying on the bed. The surveyor stepped into the hallway and the light above Resident #16's door was not lit, and no sound was coming from the nursing area where the call system makes an audible beeping sound. Resident #16 stated they would wait until an aide was in the hallway to tell them assistance was needed. During an interview on 10/07/2024 at 11:59 AM, Nursing Assistant (NA) #18 stated call lights had not been working for about 2 days and some residents holler for assistance, and other residents are checked every 2 hours. During an observation and interview on 10/07/2024 at 1:46 PM, Resident #20 pushed the call button, needing assistance. The surveyor knocked on door just as the resident pushed the call button to activate the call light. Resident #20 asked if call light was working because it was not and has not since at least Saturday. The light above Resident #20's door was not lit, and no sound was coming from the nursing area where the call system makes an audible beeping sound. During an interview on 10/07/2024 at 1:48 PM, Certified Nursing Assistant (CNA) #1 stated they work only Sunday and Monday, and was told on Sunday the call lights were not working. CNA #1 stated once residents were laid down, the aides walk the halls and see if anyone needed anything. During an interview on 10/07/2024 at 4:00 PM, Resident #46's family members stated Resident #46 had to lay in feces all evening due to call light not functioning and staff not rounding. During an interview on 10/08/2024 at 09:25 AM, the Environmental Director stated he was notified of the call light system on 200 and 300 halls not working on Sunday (10-06-2024) morning between 5 and 6 AM. Staff reported the call light stopped working at some point on Saturday night, unsure of the exact time. The Environmental Director stated he flipped the breaker on and off and the call light system still did not work. The Environmental Director telephoned a technician to have the call light system assessed and was told the transformer needed to be replaced, and was ordered from a company in North Carolina, however due to flooding on the east coast, the Environmental Director is unsure when the part will arrive. The Environmental Director stated a (Medical Business) from Louisiana will install the part once it is received, and the Administrator ordered bells, that are supposed to arrive today (10/08/2024), to be used until repairs are made. During an interview on 10/08/2024 at 4:00 PM, the Administrator reported that bells, (bells on a stick and bracelet bells), were ordered and would be delivered tomorrow (10/09/2024). The Administrator stated he called other facilities and tried to borrow bells from them, however they would not loan any as that was part of their back up plan. The Administrator stated he ordered bells online and provided a copy of the invoice. During an observation on 10/09/2024 at 9:29 AM, Resident #1 was yelling out from their room, asking for something to eat, and Resident #45 was yelling out for help. At 9:31 AM, an aide entered Resident #45's room and the resident stated they had been waiting to go the bathroom. During an observation on 10/09/2024 at 9:53 AM, there was no CNA visibly present on the 200-hall. During an interview on 10/09/2024 at 10:08 AM, CNA #8 stated rounds were normally made every 2 hours, however rounds were being done every 20 to 30 minutes because of call lights not working, and if the residents need the staff, they holler at us if we are not down there. During an interview on 10/10/2024 at 2:25 PM, the Environmental Director stated the call light part was received, and the company performing the repairs would be in the facility on Friday (10/11/2024). During an interview on 10/10/2024 at 2:59 PM, the Director of Nursing (DON) was notified that during resident council, several residents complained of the physical bells the facility ordered as a back-up system were not working because staff could not hear them, and staff were not coming to assist the residents. During an interview on 10/11/2024 on12:03 PM, LPN #11 stated staff were educated on reporting hazards and risks and implementing procedures for call lights not working. Staff were informed to do paper charting of rounds, like progress notes for residents. LPN #11 stated call lights were not working on Sunday, 10/06/2024, the Administrator, DON and Environmental Director were notified. LPN #11 notified CNAs to do rounds at least every 20 minutes until repairs were made and the LPN felt like CNAs did that. During an interview on 10/14/2024 at 11:51 AM, Registered Nurse (RN) #12 stated the bathroom on the main hall was usually used by staff and visitors. Residents did use it at times, and depending on the resident, they would be able to lock the door. RN #12 stated, if a resident fell in the main bathroom, hopefully someone would hear them fall and check on them because there is no call light in the bathroom. During an interview on 10/14/2024 at 12:35 PM, the Administrator reported the company scheduled to complete the call light repairs could not come out because all the technicians had COVID. The Administrator reported another company was supposed to be in to repair the call lights, but because of the federal holiday, they were off and would be at the facility tomorrow (10/15/2024) to put the part in. During an observation on 10/15/2024 at 1:45 PM, a bell was sounding down 200-hall, no staff were observed on 200-hall. The bell sounded again, and staff were at the nurse's station and no staff responded. At 1:50 PM, the bell sounded again as the Assistant Administrator walked onto 200-hall from the sub corridor and turned left toward nurse station. The Assistant Administrator asked if anyone heard ringing. Staff near the nurse's station denied hearing anything. The bell sounded again, and the Assistant Administrator responded to the bell on the 200 Hall and entered Resident #18's room. During an observation on 10/16/2024 at 12:05 PM, call lights on 200 and 300-halls were tested and call lights in rooms/beds 204-B, 208-B, 308-B, and 312-A were not working in the hallway, nurses' station, or in room. The Administrator was notified. During an interview on 10/16/2024 at 12:45 PM, CNA #1 stated if a hazard or risk was identified, CNA #1 would report it to the nurse, and the nurse would notify staff if there was a hazard and tell the staff what to do. CNA #1 gave the example of being notified of call lights and the use of bells. CNA #1 did not know if the bells were working due to not being on shift since implementation. During an interview on 10/16/2024 at 12:40 PM, the Administrator stated, of the 4 call lights reported not functioning, 2 were replaced and all 4 were now functioning. During an observation on 10/16/2024 at 1:00 PM, call lights in rooms/beds 204-B, 208-B, 308-B, and 312-A were rechecked and the call light in 308-B is not working. The Administrator accompanied the surveyor to 308-B to test the call light. The call light worked 2 out of 9 attempts. The Administrator stated the light would be replaced. During an interview on 10/16/2024 at 2:51 PM, the Administrator stated notification of call lights not working was made on Sunday, (10/06/2024) and staff were instructed to increase rounds on halls to every 15 minutes and contacted other facilities to borrow bells until the system could be repaired, and the request was denied as it was part of the facility emergency plan. Residents, families and staff are notified of any risks or hazards using an automated communication system that includes telephone calling, text, and email communication, through the electronic charting system. The Administrator stated no emergency plan was in place for the facility and the automated notifications to staff, residents and families was not used, I just didn't think about it. The Administrator stated an order for bells was placed with an online shopping platform. The Administrator stated once received, the bells were distributed, and nurses and CNAs were told to increase rounding, notification were made on the 24-hour report. During an interview on 10/11/2024 at 2:13 PM, the DON stated the process of implementing interventions once a hazard was identified, was checking in and following up to be sure it was working or if changes needed to be made. The DON used the example of the wrist bells not being heard by staff and residents were offered a bell with a handle. Removal Plan: On 10/8/2024, upon notification of deficient practice to report abuse allegations, the facility took the following measures: On Sunday October 6th at 2:10 PM, upon notification of failed call light system, the Director of Nursing (DON) directed direct care staff to increase rounding times to every 15 minutes in order to assist with call light failure on 200 and 300 Hall. Charge nurses were then asked to verbalize this change to oncoming shifts before the start of the staffs shift. Inservice education was created to be provided at all staff in-service held 10/9/2024 at 1400 [2:00 PM] pertaining to failure to document 15 minute checks. Any staff unable to attend all staff in-service will be provided 1 on 1 in-service by human resource director upon collection of their check. 15 minute check form created and placed at nurse's station. Confirmation of specialized repair parts provided via email and shown to be enroute and scheduled to be delivered 10/9/2024. Replacement parts ordered on 10/6/2024 after troubleshooting with the provider of our call system maintenance. Facility to utilize bells as a backup call system. Upon arrival, the Interdisciplinary Team (IDT) will converge and assist with dispersing back up call system. Confirmation via online tracking system shows that system will arrive at facility. Upon correction, DON/Designee to test 4 rooms per hall 5 times per week for 8 weeks or until compliance is verified by OLTC. Any negative findings will be corrected and reported immediately to Admin. All corrections were completed on 10/09/2024. Onsite Verification: The IJ was removed on 10/31/2024 at 12:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 10/06/2024 at 2:10 PM when rounding of resident halls was increased to every 15 minutes and a 15-minute check form was created. Repair company was contacted, replacement parts were ordered, an in-service was held on 10/09/2024 at 2:00 PM, bells were purchased for resident use and handed out on 10/10/2024. A total of 15 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Kitchen Aide, Hospitality Services, and Environmental Services. The staff interviewed verified they had been trained on bells as a back-up call system and 15-minute rounding. A review of in-service sheets provided indicated 67 of 71 had been provided training. Those staff who were not physically present to receive the in-services were given one on one education, with the in-service information provided and the employee completing and returning a post quiz.

Based on observations and interviews, it was determined that the facility failed to answer call bells/lights within a timely manner for 2 of 2 residents (Resident #36, and Resident #18), and the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain each resident's highest practicability. Findings Include: During the Resident Council Meeting on 10/10/2024 at 2:17 PM, Resident #18 and Resident #36 reported that it takes the Certified Nursing Assistants a long time to answer the call bells that were given to them. Resident #18 reported that especially right now the call bells were not being answered, the staff reports to them they can't hear them. Resident #18 stated they rang the bell for 45 minutes no one responded, so Resident #18 started yelling and was finally able to get help. Resident #36 said it takes a long time for the staff to answer the bells as well, unsure of exact time but it's a long time. On 10/15/2024 at 02:22 PM, during an interview with Resident #18 it was revealed that the Certified Nursing Assistants (CNA) were still not answering the ringing bells in a timely manner, it took them 30 minutes to answer the bell just prior to going to the dining room. The CNA responded then left and then didn't return to them for another 15 minutes. On 10/15/24 at 02:28 PM, during an interview Resident #36 revealed that it is taking about 20-30 minutes. Staff state they will come back, but they don't. On 10/16/24 at 12:05 PM, during an interview with CNA #15 was completed and CNA #15 reported that call lights are answered as soon as they are seen. CNA #15 reports that a call light should not go off more than 5 to 10 minutes. Reported that if CNA #15 cannot do what is being asked, they will tell them they are going to get help or tell the resident they will be right back and will go right back to the resident. An acceptable time to wait for a resident that needs to go to the bathroom is 10 minutes. On 10/16/24 at 12:16 PM, during an interview CNA #16 reported that call lights/bells should be answered immediately. Revealed that If CNA #16 hears the bell then it is answered. CNA #16 reports that if they are unable to address what the resident is needing at that moment, they tell them they will be back, but has never had to do so. There is always staff to answer the bells or call lights. 51064 Based on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain each resident's highest practicability. The findings include: During an interview on 10/10/2024 at 9:34 AM, Licensed Practical Nurse (LPN) #24 stated that due to insufficient staffing, particularly on the 2:00 PM to 10:00 PM shift, Resident #49 had eloped from the facility on numerous occasions. LPN #24 stated that certified nursing assistant competencies were not completed, and the certified nursing assistant staff did not have knowledge while working with dementia residents. Review of the facility provided, Nurse Aides Skills Yearly Reviews, revealed certified nursing assistants signed off on skills verifying they were competent in the skill set. Several forms were not completed in their entirety, several skills remained unverified including dementia care and activities of daily living such as brushing teeth. During an interview on 10/11/2024 at 9:00 AM, the Human Resource Director stated that competencies were reviewed upon hiring and that a skills carnival had been scheduled for the facility staff. The Human Resource Director denied knowing why the competency skill sets were not fully completed. During an interview on 10/16/2024 at 3:00 PM, Certified Nursing Assistant (CNA) #1 stated that she felt sort of competent when providing care to residents within the facility. CNA #1 denied knowing when her skill competency was evaluated or by whom. She stated that some residents had to wait for long periods of time for assistance when staff were assisting others as there is one certified nursing assistant per hall with a float certified nursing assistant that works between halls. During an interview on 10/14/2024 at 11:00 AM, the Director of Nursing (DON) stated the certified nursing staff and nursing staff demonstrated competency by completing the items on the skill competency list. The DON stated there was no way to verify if the certified nursing aids or nursing staff were competent in a skill if the skill was not verified and marked as completed. The DON stated she did not know what to say regarding staff competencies when the forms were not completed. During an interview on 10/14/2023 at 12:03 PM, the Administrator stated the certification of the nursing staff provides initial competency. The Administrator stated competencies should be maintained, reviewed, and renewed yearly. The Administrator denied having a system in place to verify staff competency. The Administrator stated that having one aid per hall with a float aid in-between halls is not ideal as some residents would have to wait long periods of time for care.

Based on observation, interview, and record review, the facility failed to have nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain each resident's highest practicability. The findings include: During an interview on 10/10/2024 at 9:34 AM, Licensed Practical Nurse (LPN) #24 stated that the certified nursing assistant competencies were not completed, and the certified nursing assistant staff did not have knowledge while working with dementia residents. Review of the facility provided, undated, Nurse Aides Skills Yearly Review, forms revealed that certified nursing assistants signed off on skills verifying they were competent in the skill set. Several forms were not completed in their entirety, several skills remained unverified, including dementia care and activities of daily living, such as brushing teeth. During an interview on 10/11/2024 at 9:00 AM, the Human Resource Director stated that competencies were reviewed upon hiring and that a skills carnival had been scheduled for the facility staff. The Human Resource Director denied knowing why the competency skill sets were not fully completed. During an interview on 10/16/2024 at 3:00 PM, Certified Nursing Assistant (CNA) #1 stated that she felt sort of competent when providing care to the residents within the facility. CNA #1 denied knowing when her skill competency was evaluated or by whom. During an interview on 10/14/2024 at 11:00 AM, the Director of Nursing (DON) stated the certified nursing staff and nursing staff demonstrated competency by completing the items on the skill competency list. The DON stated there was no way to verify if the certified nursing aids or nursing staff were competent in a skill if the skill was not verified and marked as completed. The DON stated she did not know what to say regarding staff competencies when the forms were not completed. During an interview on 10/14/2023 at 12:03 PM, the Administrator stated the certification of the nursing staff provides initial competency. The Administrator stated competencies should be maintained, reviewed, and renewed yearly. The Administrator denied having a system in place to verify staff competency.

Based on observation, interview, and record review, the facility did not dispose of garbage or refuse properly. The findings include: An observation on 10/7/2024 at 6:59 PM, showed garbage spilt around facility dumpster behind the facility. An observation on 10/8/2024 at 8:32 AM, showed garbage spilt around the facility dumpster behind the facility. During a telephone interview on 10/10/2024 at 9:34 AM, Licensed Practical Nurse (LPN) #24 stated that garbage often piles up in and around the facility dumpster as the facility often lacks the resources to pay the garbage company to empty the dumpster. During a telephone interview on 10/11/2024 at 1:16 PM, the waste disposable company stated the facilities account had been locked numerous times for failure to pay. The waste management company stated that if an account goes 30 days past due the account would be locked, and the facility dumpster would not be emptied. The waste disposable company stated that the facilities account had been locked approximately 4 times in the past 6 months due to failure to pay. During an interview on 10/14/2024 at 10:59 AM, the Environmental Director stated that the previous garage company had picked up the garbage around the facility dumpster. The Environmental Director stated that when the new company took over the facilities waste management, the Environmental Director assumed the new company would also pick up the garbage around the facility dumpster. The Environmental Director stated that the facility would be looking into changing the facilities waste management account to a different waste management company. The Environmental Director stated that the garbage that is not properly disposed of posed a risk of attracting pests and rodents to the facility. During an interview on 10/14/2024 at 11:27 AM, the Administrator stated that the facility was looking into changing waste management companies. The Administrator was unable to provide documentation of quotes or estimates from different waste management companies. The Administrator stated that the garbage that was not properly disposed of posed a risk of attracting pests and rodents to the facility. 50924

Based on document review and interviews, the facility failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents. This deficient practice had the potential to affect all residents of the facility. The total census was 48 residents. The findings are: Upon request for a Facility Assessment policy on 10/15/2024 at 10:55 AM, the surveyor was informed that the facility did not have a policy. A review of the facility's Facility Assessment Tool revealed a typed date at the bottom of the pages of 09/05/2024. The facility-wide assessment did not include the following: -Date of assessment or update -Date of assessment reviewed with QAA/QAPI committee - Name of the administrator - Accurate acuity levels to help the facility understand the potential implications regarding the intensity of care and services needed - Review of staff assignments for coordination and continuity of care - Staffing plan to evaluate the overall number of facility staff needed to ensure available and sufficient number of qualified staff are available to meet each resident's needs based on the facility census - Competency-based approach to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice - Assessment of resident's ethnic, cultural, or religious factors that may need to be considered to meet resident needs, such as activities, food preferences, and any other aspect of care identified - An evaluation of what policies and procedures may be required in the provision of care and how the facility would meet the current professional standards of practice. - Plan to recruit and retain enough medical personnel who are adequately trained and knowledgeable in the care of residents and/or how management expectations of medical personnel. - The facility's resources which included supplies, equipment, or other services necessary to provide for the needs of residents - An evaluation of any contracts, memorandums of understanding including third-party agreements for the provision of goods, services or equipment to the facility during both normal operations and emergencies - Heath information technology resources for managing resident records and sharing information with other organizations. - Description of how the facility would evaluate their infection prevention and control program that included systems for preventing, identifying, reporting, investigating, and controlling infections. - Evaluation of the physical environment necessary to meet the needs of the residents. -Description of other pertinent facts or descriptions of the resident population. -Identifying the type of staff members, other health care professionals, and medical practitioners that are needed to support and care for residents. -The building description and other structural buildings. On 10/15/2024 at 10:55 AM, during an interview the Administrator continued by saying that the facility assessment was started after the fall conference, but it was not completed. The Administrator reported that he gave the surveyor the guidelines that they found and filled it in with the numbers. The Administrator reported that the facility assessment would be brought to the Governing Body meeting set for 10/16/2024 at 7:00 AM. The facility assessment is important because it shows us how the facility is run.

Based on interviews, and record review, it was determined that the facility failed to submit required Centers for Medicare & Medicaid Services (CMS) quarterly staffing information for the third quarter of 2024. Findings include: A review of the CMS Payroll Based Journal (PBJ) Staffing Data Report for the third quarter of 2024, defined as April 1 to June 30, 2024, revealed the facility failed to submit data for the quarter. A review of CMS's Center for Clinical Standards and Quality/Survey & Certification Group Memorandum S&C: 17-45-NH revealed the requirements for participation in Medicare and Medicaid Services were amended to include submission of data related to staffing as staffing significantly affects the care delivered to residents. The memorandum further provides email contact information for questions and provides a link to the policy manual. During an interview on 10/16/2024 at 5:05 PM, the Administrator stated the previous Business Office Manager did the PBJ reporting, has not been employed since February, and does not know when the last reporting was done. The Administrator stated, I don't know how to do it, and I went to a conference and met someone that will be able to assist me. The Administrator stated the training assistance has not been scheduled and has not reached out to CMS or the state agency for assistance. 50924 51064

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure staff performed hand hygiene; after touching clothing and meal tray paper and providing food for 2 (Resident #8 and Resident #25) residents during dining observation of 1 dining room reviewed for infection control; when going from dirty to clean task during wound care for 1 Resident (Resident #29) for 1 resident reviewed for infection control during wound care; during blood draws for 1 laboratory technician review for infection control; failed to develop a Legionella Water Management Program/Plan; failed to have an effective Antibiotic Stewardship program; and failed to implement infection control practices for 1 of 1 facility reviewed for infection control. Findings include: 1. A review of the facility's undated policy titled; Hand Washing Policy & Procedure indicated the facility policy was to ensure all staff are educated/trained on hand washing and hand hygiene upon hire and as needed to industry standards. Staff are educated to industry standards upon hire and included the procedure steps 1-6 on washing with soap and water. Step 2 indicated, Apply soap or alternate cleaning compound. 2. A review of the facility's Infection Control Policy and Procedure dated 04/21/2021 stated, infection control coordinator/designee will in-service each new employee on infection control and provide periodic in-services. 3. A review of the facility's Infection Control Inservice dated both 05/22/2024 and 07/24/2024 stated, pathogens can be transmitted from person to person via hands. Hand hygiene is to be done before and after resident contact including contact with residents' intact skin, before and after dressing changes, before and after an invasive procedure, and after removing gloves. Inservice was signed by LPN #11. 4. A review of the Admission Record indicated the facility admitted Resident #29 with diagnoses that included diabetes mellitus type 2, pressure-induced deep tissue damage of the left heel, and severe sepsis with septic shock. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2024, revealed Resident #29 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #29 had added diagnoses of peripheral vascular disease and malnutrition and received wound care treatments of ointments and dressings changed to feet. A review of Resident #29's care plan, revised on 09/20/2024, revealed an ulcer to the left heal with a goal to show signs of healing and remain infection free. Interventions included monitor and report signs of infection. A review of Order Summary Report revealed Resident #29 had an order for daily wound changes to the left heal including application of an antibiotic ointment and rolled gauze. During an observation and interview on 10/07/2024 at 9:40 AM, LPN #11 removed Resident #29's dirty dressing and removed dirty gloves then immediately put on clean gloves without performing hand hygiene. LPN #11 reported no awareness about hand hygiene between removing dirty gloves and [NAME] clean gloves. During a concurrent interview observation on 10/09/2024 at 10:00 AM, a phlebotomist was in room [ROOM NUMBER] attempting to perform a lab draw for blood. Phlebotomist put on gloves with no hand hygiene, walking in and out of the resident's room looking for assistance, reaching in and out of the supply backpack, touching resident's light cord, recliner, bed, table, then sticking the resident twice first in the right forearm and then in the left forearm. Phlebotomist then filled the lab tube with the resident's blood, labeled it, and filled out paperwork. The phlebotomist repacked supplies in the supply backpack, then removed gloves at 10:23 AM. No hand hygiene was performed as the phlebotomist left room [ROOM NUMBER]. Phlebotomist then went into room [ROOM NUMBER] without performing hand hygiene where the resident arms were looked inspected, the nurses' station between 100-200 Halls, and then returned to room [ROOM NUMBER] with the Director of Nursing (DON). Phlebotomist and DON shared a pen and signed a paper. The phlebotomist stated lab draws were an aseptic technique. Phlebotomist stated their hand sanitizer was in their car, and they usually did not perform hand hygiene between resident interaction just changed gloves. Phlebotomist stated that would not be following aseptic technique. A review of the facility's contract with the laboratory services company dated 10/04/2022 and signed by the facility's representative stated it the responsibility of the laboratory service provide to comply with all policy and procedures provided by the facility. During an interview on 10/15/2024 at 3:12 PM the Administrator stated no policies or procedures were provided to the laboratory services company. 5. A review of the Employee Handbook, contained a document titled, Inservice Instructor Video, Handout or Review, that included a list of in-services that included, Hand Hygiene competence Assessment and Monitoring Tool, and a signature line for the employee attending the in-service. 42016 6. A review of a facility policy titled, Hand Washing Policy & Procedure undated indicated, staff are educated to industry standards upon hire and included the procedure steps 1-6 on washing with soap and water. Step 2 indicated, Apply soap or alternate cleaning compound. 7. A review of the Employee Handbook, contained a document titled, Inservice Instructor Video, Handout or Review, that included a list of in-services that included, Hand Hygiene competence Assessment and Monitoring Tool, and a signature line for the employee attending the in-service. 8. A review of the Admission Record, indicated the facility admitted Resident #8 with diagnoses that included hydrocephalus and seizures. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/2024, revealed Resident #8 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #8 was dependent on staff for all activities of daily living (ADL), including eating; had a swallowing disorder that included loss of food and liquids from mouth, coughing or choking during meals; and required a mechanically altered diet. A review of Resident #8's care plan, with a revised date of 08/14/2023, revealed the resident had an ADL self-care performance deficit related to organic brain syndrome and seizure disorder. Interventions included pudding thick liquids and puree textured food and dependent on assistance of 1 staff for eating. A review of Order Summary Report, revealed Resident #8 had a regular diet, pudding consistency, and fortified foods. 9. A review of the Admission Record, indicated the facility admitted Resident #25 with diagnoses that included dementia, anxiety disorder, and cataracts. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/25/2024, revealed Resident #25 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #25 required supervision and touch assistance with eating. A review of Resident #25's care plan, with an initiated date of 08/15/2023, revealed Resident #25 had an ADL self-care performance deficit related to dementia and mobility limitations. Interventions included limited assistance and placing food in bowls to maximize independence with eating. A review of Order Summary Report, revealed Resident #25 had a regular diet, mechanical soft texture, and thin consistency of fluids. During an observation on 10/07/2024 at 12:54 PM, Certified Nursing Assistant (CNA) #1 was seated at the half round assist table to the left of Resident #8. CNA #1 placed their hands, palm sides down, in their lap, brought both hands back to the top of the table, picked up a spoon and placed food in Resident #8's mouth. CNA #1 repeated this action twice with no hand hygiene being performed. During an observation on 10/07/2024 at 12:55 PM, CNA #9 touched the meal tray paper of Resident #8 when CNA #1 asked CNA #9 to identify the beverages in Resident #8's clear plastic cups. CNA #9 assisted Resident #25 by picking up a fork and placing food in Resident 25's mouth. CNA #9, using their index and middle finger to stabilize a straw, with palm facing downward over the top of the container of a (Brand Name) vanilla shake, provided Resident #25 a drink. No hand hygiene was performed. During an interview on 10/16/2024 at 10:23 AM, CNA #9 stated hand sanitation should have been done after touching the meal tray paper and when touching Resident #25's fork and straw because of the spreading of one resident's germs to another by placing hands close to another resident's mouth by touching another resident's straw and fork. During an interview on 10/14/2024 at 10:43 AM, the Director of Nursing (DON) stated hands should be sanitized between each resident, and after placing hands in lap or any other area because of transmission of diseases and any bodily fluids or bacteria that may be on their hands can be spread to the residents. During an interview on 10/15/2024 at 1:17 PM, the Infection Preventionist (IP) stated hand hygiene should be performed every time the CNAs get a meal tray, and use hand sanitizer between meal tray set up, and after touching their hair or their face. If CNAs are feeding residents and touch their hands, clothes, or a resident's hands or clothes, CNAs should use the sanitizer because they are spreading germs to residents and other employees, each time they touch something. During an interview on 10/16/2024 at 12:38 PM, CNA #1 stated hand hygiene should have been performed due to germs and bacteria from their clothing could have touched Resident #8's food and been ingested causing Resident #8 to become ill. During an interview on 10/16/2024 at 2:45 PM, the Administrator stated hand sanitation should have been performed by CNAs in between trays, after touching their face, hands, or other objects, before feeding a resident, touching the resident's cups, or utensils. The Administrator stated germs would be spread and cross contamination could occur causing a resident to be ill if hand sanitation was not performed. 49866 10. On 10/10/2024 at 12:32 PM, the Surveyor observed the documents, Legionella Water Management Program brought in by the Director of Nursing (DON). The documents were an instructional guide on how to set up a Legionella Water Management Program. The documents that were supposed to be filled in were blank. Also received informational handouts on Legionnaires Disease. On 10/10/2024 at 11:00 AM, the Surveyor interviewed the Environmental Director who reported that he flushed one room on each side of the hallway on the 100 Hall weekly, because the 100 Hall is not occupied. The Environmental Director reported that on the occupied halls he flushes at least one room on each hall weekly. He also revealed that it is not documented anywhere. The Environmental Director revealed that he does the flushing when he checks the water temperatures on the hallways. When asked about the Legionella plan, he did not know anything about it. The Environmental Director reported that he does not do any testing and that the local water department does not either. Asked if there had been any outbreaks of Legionella in the building that he knew of and he did not know. On 10/10/24 at 01:23 PM, during an interview the Surveyor asked the DON about the blank Legionella Water Management Plan and the DON revealed that what was given to me is all she has. There is no specific Legionella Water Management Plan. On 10/14/24 at 01:13 PM, during an interview the Infection Preventionist (IP) revealed that all the facility had on legionella was what the Surveyor had already received. When asked what the facility plan was if there was legionella in the building, the IP replied that that is a good question. The IP reported maintenance flushes the water but did not know how often or if it was documented. A review of the Antibiotic Stewardship Policy and Procedure revealed that the facility would utilize Suspected Urinary Tract Infection (UTI) Situation, Background, Assessment, and Recommendation (SBAR) tool when communicating with the physician and using the Medical Care Referral Form for other infections. A review of Resident #49's Progress Notes dated 8/1/2024 at 4:31 PM revealed that Resident #49 had complained of pain upon urination and an urin alysis was performed and the nurse documented that the results was positive for Urinary Tract Infection (UTI). The Physician was notified and Bactrim double strength was ordered at 7:21 PM. No UTI SBAR was observed to be filled out in electronic medical record. On 10/16/2024 at 1:25 PM, during an interview with Licensed Practical Nurse (LPN) #25 who had notified the physician about Resident #49's UTI symptoms and received the antibiotic order, revealed that she does not know anything about the guidelines used to identify infections in long-term care facilities, or what an Infection Preventative form is. Also reported there is no forms or anything she reviews prior to calling the physician. LPN #25 also stated that she knows what Antibiotic Stewardship is, indicated they use it at hospitals and clinics, but does not use it at this facility. On 10/16/24 at 01:47 PM, an interview with LPN #11 is not aware of what guidelines are used to identify infections in long-term care facilities or when an infection prevention evaluation is to be completed. Also reported that she was unaware of what an antibiotic stewardship program is. A review of the Infection Control Policy/Procedure did not address wearing Personal Protective Equipment. On 10/10/2024 at 10:30 AM, the surveyor observed the Environmental Director walking down the hall pushing a laundry bucket with an apron and gloves on. During an interview the Environmental Director was asked if he should be walking down the hall with an apron and gloves on. He replied with that he was not going to pick up dirty laundry without them on. The surveyor then asked if it was an infection control problem walking down the hall with the PPE on. The Environmental Director did not respond, just stared at the surveyor and then walked off. Observed the Environmental Director emptying the laundry bucket with PPE on and then walk back up the hall. On 10/14/2024 at 01:10 PM, during an interview with the Infection Preventionist (IP) she reported that there were concerns with the Environmental Director wearing gloves and going down the hall. The IP reported that the Environmental Director should not be doing that, because he is spreading germs by doing so. The laundry personnel should be putting their gloves on prior to picking up the laundry and then taking the gloves off after picking up the laundry. On 10/16/2024 at 10:26 AM, during an interview with the Director of Nursing (DON) she revealed that it was ok for the laundry employees to wear their Personal Protective Equipment (PPE) down the hall if they are not touching anything dirty. Then reported that it's ok if the laundry employees wear gloves going down hall to empty but should not be wearing gloves down hall back to laundry. The DON reported that it is an infection control issue wearing gloves and touching doorknobs and anything afterwards.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility is free of pests and rodents. The findings include: Review of the facility provided Maintenance Log, dated 05/2/2024, reported a resident in room [ROOM NUMBER] had a rat in their room per resident, rat trap in need. Review of facility provided Maintenance Log, dated 05/5/2024, reported a resident in room [ROOM NUMBER] had a mouse in their room. During initial rounds on 10/7/2024 at 12:01 PM, Resident #43 stated that the facility had mice. Resident #23 confirmed that mice had been seen on multiple occasions. During an interview on 10/7/2024 at 5:14 PM, Certified Nursing Assistant (CNA) #4 stated that mice are seen daily, and the last time she had seen a mouse was on 10/6/2024. During an interview on 10/7/2024 at 5:34 PM, the Environmental Director stated that there was a mouse problem. The Environmental Director stated that live traps and sticky traps had been deployed around the facility. The Environmental Director stated that the Pest Control company could not spray for rodents inside of the facility due to risk to the residents health. The Environmental Director stated the Administrator was aware of the rodent issue. An observation on 10/7/2024 at 6:59 PM, showed garbage and food spilt around the facility dumpster behind the facility. An observation on 10/8/2024 at 8:32 AM, showed garbage and food spilt around the facility dumpster behind the facility. During a telephone interview on 10/8/2024 at 2:30 PM, the facilities pest control company stated that they were responsible for maintaining the perimeter of the facility. The pest control company stated that they were never allowed inside of the facility. The pest control company stated that the Environmental Director reached out in November of 2023 for a quote on rodent control services. The pest control company stated that a quote was provided to the facility, but the facility did not move forward with the rodent control services. During a telephone interview on 10/10/2024 at 9:34 AM, the Licensed Practical Nurse (LPN) #24 stated that there were mice in the facility, and that the mice were seen multiple times on a daily basis by staff, residents, and visitors. LPN #24 stated that the mice have been seen in common areas and in the resident rooms. LPN #24 stated that Administration was aware of the mice issue. During a concurrent observation and interview on 10/10/2024 at 10:33 AM, the Kitchen Manager confirmed that the brown specks on the floor of the storage room in the kitchen area appeared to be mouse droppings. The Kitchen Manager stated that mice were an issue months ago in the kitchen area but had not been an issue recently. The Kitchen Manager stated that several bags of dried foods and bread had been wasted due to rodent infestation. During an interview on 10/11/2024 at 8:00 AM, the Head of Hospitality stated that mice were common around the facility. She stated that what appeared to be mice droppings were often found in the resident closets. and that the droppings were removed, and the floors were cleaned with soap and water. During an interview on 10/11/2024 at 1:00 PM, the Environmental Director stated that he had reached out to the pest control company for a quote on the rodent issue within the facility, and that the information was left with the Administrator for review and approval. The Environmental Director denied knowledge of any further action for pest or rodent control. During an interview on 10/11/2024 at 1:17 PM, the pest control company stated that no facility representative had contacted the pest control company to move forward with rodent/pest control measures related to the mice issue within the facility. The pest control company stated that the company used chemicals that were state and federally approved for use within a long-term care facility. During an interview on 10/11/2024 at 2:00 PM, the Administrator stated that he told the Environmental Director to move forward with the pest/rodent control quote from the pest control company. The Administrator denied any documentation of acceptance of the pest control company's quote or any other pest removal interventions for the mice. During an interview on 10/14/2024 at 10:59 AM, the Environmental Director stated that garbage and food waste should be properly disposed of so as to not attract rodent and/or pests. The Environmental Director stated that the mouse issue was out of control and the pest control company should be contacted to handle rodent issues. The following observations were made during onsite monitoring visit: During observation in the Conference Room on 10/29/24 at 5:12 AM near the entrance of the building, the surveyor observed a live grey rodent underneath a chair in the room. When the surveyor moved, the rodent scurried outside of the room and was unable to be found. During an interview on 10/30/2024 at 9:30 AM, the Low Voltage Technician (LVT) stated a live mouse was in the ceiling area while wiring was installed to correct the Immediate Jeopardy concern related to the call light system. The mouse was contained in a trash can and released outside the 200 Hall door by LVT.

Based on interviews and record review, the facility failed to establish a smoking policy in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also takes into account nonsmoking residents. The findings include: Per facility provided list of residents who smoke, undated, two residents within the facility smoke. During an interview on 10/10/2024 at 11:00 AM, the Director of Nursing (DON) denied there was a facility smoking policy. During an interview on 10/10/2024 at 11:30 AM, the Administrator denied there was a smoking policy.

Based on document review and interviews, the facility failed to provide required training to staff members for 1 of 1 facility. The findings are: Upon request of mandatory in-services, the surveyor received an Infection Control in-service and Resident Rights in-service. Upon reviewing the facility assessment there were no required trainings and/or in-services addressed. A review of an undated document titled, Required Annual State Inservices received by the Director of Nursing (DON), revealed that the in-services that the facility was going to provide were the following: Civil Rights, Disaster Preparedness, Fire Safety, Accident Prevention, Reporting Disaster/Outages, Utility Shut Off Demonstration, Oral and Dental Care, Restorative Nursing, Dignity, Death and Dying, Advanced Directives, Behavior Management, Assessments, Interventions, Medications, Documentation, Infection Control/Wound Management, Universal Precautions, Center of Disease Control, Tuberculosis Prevention, Nosocomial Infections, Treatments, Documentation, Abuse and Neglect, Types of Abuse and Neglect, Incident Reporting, Medication Administration and Resident Rights. On 10/11/24 at 10:44 AM, during an interview with the Human Resource Director (HRD) it was revealed that the Administrator does all the administrative training, and it depends on what the in-service is about, on who does the in-services. On 10/11/ 2024 at 2:30 PM, during an interview, the Administrator reported that they do not have all of the required training. And it was 100% his fault. He reported that the trainings were done, but the Administrator failed to document them. On 10/16/24 at 11:04 AM, during an interview with the HRD it was revealed that the Administrator had the spreadsheet/calendar that keeps up with the in-services and when they were due. The HRD does not keep up with the in-services, the Administrator does. The HRD reported that just recently the in-services were given back to Administrator and there probably in the Administrator's new office. The HRD reported that they would go and look and see what could be found. On 10/16/2024 at 2:00 PM, the HRD brought in two in-services that only had a cover sheet on them and pages of signatures with no information on what actually was covered in the in-services.

Based on document review, and in-service reviews, the facility failed to provide communication training for staff members. Findings include: Upon review the surveyor did not observe a communication training/in-service to staff members. On 10/16/24 at 11:18 AM, during an interview with the Human Resource Director (HRD) she stated she was unsure what communications in-services would be, but she would look for that as well. On 10/16/2024 at 2:00 PM, the HRD brought in in-services, but there were no communication in-services and the HRD revealed that's all she could find. On 10/16/24 at 11:48 AM, during an interview with the Assistant Administrator she reported that there was no communication in-services performed for new hires or existing employees. On 10/16/24 at 11:49 AM, during an interview, the Administrator revealed that a communication in-service would be important to have one so that it would increase communication with staff. On 10/11/2024 at 2:30 PM, during an interview the Administrator reported that the they do not have all the required trainings, and it was 100% his fault.

Based on document review, and interviews, the facility failed to provide Quality Assurance and Performance Improvement (QAPI ) training upon hire and in services to direct staff for 1 of 1 facility. Findings include: A review of the undated policy titled, Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Policy, revealed that all staff would be educated on the QAPI plan and the role in development and implementation of interventions. Upon record review there was no QAPI trainings or in services for new hire employees or current staff. On 10/11/2024 at 2:30 PM, during an interview with the Administrator, he reported that there was no QAPI training or in-services, for newly hired staff or current staff. The Administrator reported that they did not know that it had to be done. He stated it would be important to do so, because they want the employees to know when and how to report problems and so that the QAPI team could address issues within the facility. The Administrator also reported that they do not have all the required trainings. And it was 100% their fault.

Based on document review, and interviews, the facility failed to conduct a compliance/ethics training for staff members. The finds are: Upon observation no compliance/ethics training was observed. Om 10/11/24 at 10:44 AM, during an interview with the Human Resource Director (HRD) it was revealed that the Administrator does all the administrative training, and depending on what the in-service is about depends on who does the in-services. On 10/11/ 2024 at 2:30 PM, during an interview the Administrator reported that they do not have all the required training. And it was 100% his fault. He reported that the training was done, but the Administrator failed to document them. On 10/16/24 at 11:04 AM, during an interview with the HRD it was revealed that the Administrator has the spreadsheet/calendar that keeps up with the in-services and when they are due. The HRD does not keep up with the in-services, the Administrator does. The HRD reported that just recently the in-services were given back to the Administrator and there probably in the Administrator's new office. The HRD reported that she would go and look and see what could be found. On 10/16/2024 at 2:00 PM, the HRD brought in two in-services that only had a cover sheet on them and pages of signatures with no information on what actually was covered in the in-services.

Based on observation, interview, and record review, the facility failed to ensure a cognitively impaired resident did not exit the facility without staff knowledge for 1 (Resident #1) of 3 (Residents #1, #2, #3) sampled residents who were at risk for elopement, as evidenced by failure to ensure the locking mechanism on a door was in proper working order allowing Resident #1 to exit the facility. Resident #1 was missing for approximately 30 minutes and was found lying on the ground adjacent to a facility parking lot. The resident sustained a hematoma. The facility failed to ensure all residents were accounted for; no residents were reassessed for risk of elopement; no education was provided to staff; no assessment or monitoring of the remaining facility door locking mechanisms were put in place to prevent lock failures; facility elopement policy lacked clearly defined mechanisms and procedures for assessing or identifying, monitoring, and managing residents at risk for elopement. The failed practice resulted in non-compliance at the level of Immediate Jeopardy and placed a risk to the resident's health and safety, and placed the resident at risk of weather exposure, other medical complications, and being struck by a motor vehicle. The failed practice had the potential to cause serious injury, serious harm, serious impairment, or death to 5 residents who were at risk for elopement, as documented on a list provided by the Administrator on 12/12/23. The Administrator was informed of the Immediate Jeopardy situation on 12/13/23 at 11:47 AM. The findings are: Resident #1 had diagnoses of Depression, Alzheimer's disease, Dementia, Psychotic disturbance, Mood disorder and Anxiety. The Annual Minimum Data Set with an Assessment Reference Date of 9/28/23 documented the resident scored 4 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status; wandering occurred 1 to 3 days; ambulates independently with a walker. An Elopement Risk assessment dated [DATE] noted a score of 3, indicating at risk for elopement. The assessment answered 'yes' to the following questions: Does the resident have a history of attempting to leave the facility without informing staff? Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door? Does the resident wander? Is the wandering behavior a [NAME], goal-directed (i.e., specific destination in mind, going home, etc.)? Does the resident wander aimlessly or non-goal-directed (i.e., confused, moves without purpose, may enter other's rooms, and explore other's belongings)? Documented in the Comprehensive Plan of Care with the date initiated on 9/28/23 and a revision date of 10/20/23 a focus problem of an elopement risk/wanderer related to Impaired safety awareness, Resident wanders aimlessly. The goal: the residents ' safety will be maintained through the review date. The following interventions were documented: Assess for fall risk. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor for fatigue and weight loss. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. The resident's triggers for wandering/eloping are time of day, usually around 3-4. The resident's behaviors is de-escalated by reorienting resident to her room, talking on the phone with family. Additional problem initiated on 9/28/23 with a revision date of 10/20/23: the resident has impaired cognitive function/dementia or impaired thought process3es related to Alzheimer's; the resident will develop skills to cope with cognitive decline and maintain safety by the review date; with an intervention of cue, reorient and supervise as needed. Progress notes reviewed for the past 120 days revealed Resident #1 was experiencing increased anxiety and exit seeking behaviors on 8/30/23, 9/25/23, 10/7/23, 10/20/23 and 10/21/23. A Progress Note dated 12/8/23 documented, Resident noted to be missing from building at 1730 [5:30 P.M.]. All staff pulled to search for resident. Laundry room door open with resident's walker in doorway. Resident found lying in grass on right side outside laundry room door with feet towards curb. Large knot noted to right temple. MD [Medical Doctor] notified with new order received and noted may send to ER [emergency room ] if shows signs of ICP [increased intracranial pressure]. Administrator notified. Family notified. [Local Police Department] notified. On 12/12/23 at 1:44 PM, during an interview, the Administrator reported on 12/8/23 Resident #1 exited the building through service corridor that goes to dietary and laundry. The Administrator stated, The lock on it [the door going from 500 hall into the corridor/hall to the kitchen and laundry area] failed. [Resident #1] got through it and then to the laundry area, got to one of the doors and wedged her walker and that is when she got out. That is how they found her after they found her walker. Every door going out has a lock. So, I came up that night and replaced it with a keypad lock. We made sure the door pulls were adjusted appropriately. The Administrator confirmed Resident #1 had a history of wandering and exit seeking. He was asked to provide the facility elopement policy and procedure. On 12/12/23 at 1:53 PM, the Administrator provided a copy of a completed facility reported incident of Resident #1's elopement that was submitted to the state agency on 12/12/23. The incident report contained the following information: Notifications: Administrator, Doctor, Family, Law Enforcement. Description of Incident: Resident opened service hall door and proceeded to laundry area. Resident was able to open laundry room door and exit out the rear of the building. All staff pulled to search for resident. Resident found lying in grass outside of laundry area, with a large knot noted to right temple. Resident's current medical condition: Bruising to resident face with knot noted. No noted changes in cognition. Nursing staff continue to monitor resident for any notable changes. Resident currently at baseline. Findings and Actions Taken: Resident ambulated to service hall door, lock had not engaged properly, and resident able to open door and exit towards laundry room. Admin [Administrator] immediately replace door mechanism with electronic keypad at 2000 [8:00 PM] on 12/8/2023 to ensure this did not recur. Maintenance then adjusted all doors in service hallway to ensure self-closing mechanism was effective. On 12/12/23 at 3:14 PM, the Administrator provided a document titled, 'Elopement of Resident Policy. The policy outlined the search procedure when it became known a resident was missing. Preventive measures will be the responsibility of the Administrator and Director of Nursing. What we do to try to prevent an elopement: On admission and Elopement Risk Assessment will be completed. Talk to family about their usual routines. Report all elopement attempts immediately to supervisor. Involve them in activities that satisfy their needs. There were no other instructions. On 12/12/23 at 3:33 PM, during an interview with Registered Nurse (RN) #1, the nurse caring for Resident #1 at the time of elopement. The Surveyor asked if she could describe the incident of Resident #1's elopement from the facility. She reported that the resident was up at the nursing station at approximately 5:30 PM and was crying. RN #1 stated, I was going to give her prn [as needed] pain meds, I thought she might be hurting. She paces a lot, frequently in the evenings. After I pulled her meds [medications], she was not there. I thought she had walked down the hall to her room. I asked the CNAs [Certified Nursing Assistant] if they had seen her. The CNAs searched up the halls and rooms, couldn't find her. I pulled everybody to look for her. I called the DON [Director of Nursing]. [Environmental Technician] went down toward laundry and saw her walker was in the door. He went out the back door. I called the cops when we couldn't find her. When they found her, we got her in the building. She had a hematoma on the right side of her head. Called the doctor, he said we needed to make sure we had some kind of security system on the door. He said to do neuro checks and 15 minute checks and if she had any problems to send her to the ER [emergency room ]. [Environmental Technician] said she was laying by the vehicle out the back door. The Administrator came in and put a lock on the door. There was a locking mechanism, but it wasn't working. RN #1 denied knowing how long the lock on the door did not work. RN #1 confirmed Resident #1 had a history of exit seeking; confirms resident was missing approximately 30 minutes. When asked if she had resident elopement training, she stated, Yes, find the resident, if you can't find them, call the police, call the DON, Administrator, Physician. RN #1 was asked if she had checked on the other residents to confirm everyone was accounted for once Resident #1 was located. RN #1 said that the staff went in everybody's room to look for Resident #1 and her concern was with that patient. When asked again if she confirmed all other residents were accounted for, she stated, No. On 12/12/23 at 3:48 PM, during an interview with the Environmental Technician, he was asked to describe what happened when Resident #1 was missing on 12/8/23. He stated, She came up missing, we all looked around here. I went down through the hall, both doors to laundry was locked. I seen her walker in the door, ran up the front to tell them she was probably outside. The CNA went and found her in the parking lot. It is scary, we are right by the road. When asked if he was aware if the resident had a history of exit seeking or trying the doors. He stated, She is always crying out, wanting to go home. When asked if she tries the doors. He stated, Oh, yes. The Environmental Technician confirmed the door locking mechanism did not work. On 2/12/23 at 4:45 PM, the Administrator was asked if the staff are trained on elopement. He said it was in the hire packet, so they are trained on hire and quarterly. He was asked if the locks on the doors were checked for proper functioning. He said he was not sure. He was asked if the facility conducted emergency drills, and if they had an elopement drill. He said they had no elopement drills and stated, But we will now. On 12/12/23 at 4:54 PM, the Administrator was asked to show the Surveyor the door that the lock failed on; the door the resident exited the building, and where the resident was found. The Administrator pointed out the door at the beginning of the 500 Hall with a keypad lock that went down a hall or corridor that led to the kitchen entrance and then 2 doors that lead into the laundry area. The resident's walker was found wedged at one door that led to the back of the building. Outside this door was a truck loading dock and an incline from the building. Another door exited to the side and is where the resident was found lying in the grass at the edge of a parking lot on the side of the building. On 12/12/23 at 5:00 PM, the Surveyor asked the Environment Director if he was maintenance. He confirmed he did maintenance. He was asked if he checked the facility door locks functioning to make sure they were working. He said, Every time you go in and out. He was asked if he monitored the functioning of the doors on a regular basis. He stated, Just when someone says something is wrong. On 12/13/23 at 8:58 AM, during an interview with the DON, she was asked to describe the process if a resident is missing in the facility. She said the nurse looks for the resident, then staff help look, then they call the DON, the Administrator and then they call the police and continue looking. She was then asked to explain what happened on 12/8/23 when Resident #1 eloped from the facility. She said the nurse called and said they could not find her. They looked for 15 minutes and called the police. They continued looking. The DON stated, I called them when I was on the way. By the time I got here they had found her. The DON confirmed Resident #1 had been missing approximately 30 minutes. The resident was found outside the laundry hall. Her walker was by the door by the dock, she was found outside the other door. She had an abrasion and bruise to the right side of her face. When asked what was done for the resident she said, Neuro checks and 15 minute checks. The DON said she did not think Resident #1 had ever gotten out and confirmed she is a wanderer and would exit seek. When asked if staff received training on resident elopement, she said she was not sure probably yearly. She was asked if she was aware of any other elopements. She said years ago. She was asked if the doors were monitored for functioning. She stated I don't know. If I notice it not locking, I notify someone. She was asked if risk assessments were completed on residents to include elopement risk. She said they are done quarterly. She was asked if a resident was at risk, what was done. She said they care plan it and educate the staff. She was asked if all residents were accounted for after Resident #1 had eloped on 12/8/23. She stated, I think that is part of looking for someone, but I don't think we did a check. She was asked if any resident was reassessed for risk of elopement. She stated, No. On 12/13/23 at 11:47 AM, the Administrator was provided an IJ template and was notified the facility was in noncompliance and in Immediate Jeopardy for not providing adequate supervision to prevent a cognitively impaired resident who had a history of exit seeking from exiting the facility unknown to staff through a door with a failed locking mechanism. The resident was missing for approximately 30 minutes and was found lying on the ground adjacent to a facility parking lot. No residents were reassessed for risk of elopement, no education was provided to staff, no assessment of exits to ensure all exit locks were functioning properly, and no monitoring of exit locking devices were put in place to prevent future lock failures. On 12/13/23 at 1:20 PM, the Administrator provided a Plan of Removal with the following measures: On 12/11/2023, upon notification of deficient practice to provide adequate supervision to prevent a cognitively impaired resident from exiting the facility without their knowledge, facility took the following measures. Immediate reassessment of elopement assessment on each individual. MDSC [Minimum Data Set Coordinator], IP [Infection Preventionist], and DON to review and complete new assessments on all 52 residents currently within the facility to ensure all assessments are correct, and any new resident at risk of elopement is identified. Inservice education to staff. Inservice education to be presented to staff at all staff inserviced currently scheduled for 12/13/23 at 1400 [2:00 PM]. Inservice will review actions to be taken in the event a resident is missing or elopes from the facility. Evaluation and review of all external door locks, and assistant shutting devices. Environmental department to complete and check off review of all locks withing the facility to ensure that they are working correctly. Environmental department to assess and ensure all external doors with an assistant shutting device is in proper working order, and seats door firmly in place. On 12/13/23 at 1:15 PM, the DON provided a document that confirmed all 52 residents in the facility had an updated elopement risk assessment completed on 12/13/23. On 12/13/23 at 1:20 PM, the Administrator provided a document that confirmed all external doors were checked to ensure the locking mechanism and assistive shutting devices were working correctly. On 12/13/23 at 3:34 PM, the Administrator provided a document of inservice that was provided to staff related to resident elopement that included staff signatures of attendance.

Complaint # (AR 915) was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure residents were protected from the potential of further abuse following allegations of abuse; failed to ensure all allegations of abuse were thoroughly investigated; and failed to ensure all allegations of abuse were reported in a timely manner to law enforcement officials and the Office of Long Term Care as required by law for 3 of 3 (Residents #1, #2 and #6) cognitively impaired case mix residents who were allegedly the subjects of staff to resident abuse. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 and #6 for whom allegations of physical abuse had been received by the facility and had the potential to affect 41 residents who were cognitively impaired according to the list provided by the Director of Nursing on 1/11/16. The facility was notified of the Immediate Jeopardy (IJ) condition on 1/9/16 at 3:15 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/8/15 documented the resident scored a 3 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), is usually understood and usually understands. a. A handwritten statement dated 11/16/15 and signed by the Director of Nursing (DON) documented, (Certified Nursing Assistant (CNA) #2) (complains of) (CNA #1) not treating (residents) right, rough with them - some seem to be scared of her by the look on their face. No specific incident, just general (complaint of) not always using draw sheet to move (residents) in bed, pulling (residents) over quickly (not gently enough for her liking) using foul language in (resident) room. I spoke with (residents) on 500 hall, no one (complained of) anyone being rough or not treating them right. No visible signs of not being treated (with) care or anyone using foul language in front of them . b. A handwritten statement dated 1/6/16 and signed by CNA #2 documented, I witnessed (CNA #1) smack (Resident #1) on the back of the head with a hair brush when (Resident #1) was yelling . (CNA #1) kicked (Resident #1's) chair and her chair went back with her in it. (Resident #1) hit the night table . c.On 1/8/16 at 1:58 p.m., CNA #2 was asked, Have you ever seen any staff hit, slap, pinch, etc. residents? CNA #2 stated, A slap with a hair brush, yes. CNA #2 was asked, Who was that resident? CNA #2 stated, (Resident #1) on the back of her head. CNA #2 was asked, Who slapped her (with) the hair brush? CNA #2 stated, (CNA #1). CNA #2 was asked, You were where when this happened? CNA #2 stated, I was at her dresser looking for hose and she was in a wheelchair between the closet and the bathroom door facing towards her bed and (CNA #2) was behind the resident. Our brushes are gray and she turned the brush around and hit her with the back of the hair brush just once when she wouldn't shut up. CNA #2 was asked, Was there any one else in the room when this happened? CNA #2 stated, No. CNA #2 was asked, When did this happen? CNA #2 stated, The end of November. CNA #2 was asked, What did you do? CNA #2 stated, I went to (the) (DON). CNA #2 was asked, Did (the) (DON) ask you for a statement? CNA #2 stated, No, I didn't fill out a statement until the other day and she said I didn't tell her any of that. CNA #2 was asked, Have you ever seen staff kick a resident or kick a resident's wheel chair? CNA #2 stated, Yes. CNA #2 was asked, Who was the resident? CNA #2 stated, (Resident #1). CNA #2 was asked, When did this happen? CNA #2 stated, End of November or beginning of December (2015). I know it's happened twice but I've only witnessed it once. CNA #2 was asked, When did the second one, that one you saw, happen? CNA #2 stated, About 1 week later . she (CNA #1) kicked the resident's wheel chair because she wouldn't shut up. CNA #2 was asked, When you saw her kick the resident's wheel chair, where was the resident? CNA #2 stated, In her room by the night stand and bed facing toward the TV. (Resident #1) was wanting to go to bed and (CNA #1) had just given (Resident #1) her call light and she wanted to go to break. She kicked the metal bar on the side of the chair because she wanted to go on break and (Resident #1) kept saying I want to go to bed. CNA #2 was asked, Were there any witnesses other than you? CNA #2 stated, No. CNA #2 was asked, Did you tell anyone? CNA #2 stated, I told (the) (DON). CNA #2 was asked, Did (the) (DON) ask you for a witness statement? CNA #2 stated, No, she said she'd take care of it. CNA #2 was asked, Any resident injury? CNA #2 stated, No, it startled her and I think she was frightened . d. A handwritten statement dated 1/6/16 at 8:30 a.m. and signed by the DON documented, Had meeting in Administrator's (office) with (CNA #2) and (CNA #1) (regarding) conflict between them . (CNA #2) wrote down her concerns of resident care - had already addressed kicking of the wheel chair of (Resident #1). (Resident #1) had denied (at) that time anyone being rough or mean to her or kicking her chair. (CNA #2) denied hitting (Resident #1) on the head with a brush . I had already spoken to residents on that hall and did body audits and found no resident with a complaint on any staff of anyone being mean or mistreating them in any way. No concerns were found with body audits . We feel this is a personal conflict between these two staff members. e. On 1/9/16 at 1:12 p.m., the DON was asked, Have any staff reported that a resident had been kicked or the resident's wheel chair kicked? The DON stated, Yes. There again (CNA #2) reported that (CNA #1) did that. The DON was asked, When was this? The DON stated, Along about the same time in November. She reported (CNA #1) kicking the wheel chair . and she didn't like the way (CNA #1) turned the residents. She thought she (CNA #1) should have been easier when she turned them over. The DON was asked, Why isn't that on your statement? The DON stated, I wrote that up later and there was so much I forgot to write down some of it. The DON was asked, What did you do? The DON stated, I talked to (CNA #1) who said she never intentionally kicked any resident's wheel chair because she was mad or otherwise. I went down the hall and I talked to residents and I asked if anyone had been mean to them or didn't treat them right and no one did. The DON was asked, When you were told that (CNA #1) had kicked the resident's wheel chair, was it said that this had caused a skin tear? The DON stated, No, I was told the wheel chair rolled back some, nothing about any injury what so ever. The DON was asked, This resident was (Resident #1)? The DON stated, Yes. The DON was asked, On 1/6/16 you and (Administrator) got the statement dated 1/6/16 from (CNA #2)? The DON stated, Yes and I read it and I said what is this about hitting the resident on the head with a hair brush and (CNA #2) said I told you that and I said no you didn't, your never told me . and I said, yes you told me about her kicking the chair. The DON was asked, Is hitting a resident with a hair brush abuse? The DON stated, Yes. The DON was asked, Did you report this to OLTC, did you protect the resident, did you send the CNA (CNA #1) home on 1/6/16? The DON stated, No. (In response to all three questions) The DON was asked, Why not? The DON stated, I guess because we really didn't think it happened, that they were just fighting. The DON was asked, If this had been any other CNA with an allegation that a resident had been hit what would you do? The DON stated, Go down immediately and do an assessment and send the CNA home and investigate. The DON was asked, What have you done since Wednesday, 1/6/16, about this statement? The DON stated, They are both still working. The DON was asked, What does your statement dated 1/6/16 mean about the wheel chair? The DON stated, I knew about (CNA #1) kicking the resident's wheel chair - that was in November (2015). The DON looked at her written statement and stated, No, that wasn't then but it must (have) been in this same time frame. I had already talked to the resident in November so I didn't do anything else. f. On 1/9/16 at 2:40 p.m. the Administrator was asked, On 1/6/16 did you get a statement of concerns from (CNA #1)? The Administrator stated, Yes. The Administrator was asked, What is (CNA #1) smacked (Resident #1) on the back of the head with a hair brush? What is that an allegation of? The Administrator stated, Abuse. The Administrator was asked, What did you do? The Administrator stated, We did nothing. The Administrator was asked, What should you have done? The Administrator stated, Send her to the house, go check the resident and start an investigation and report it. The Administrator was asked, What are you going to do now? The Administrator stated, I'm going to go put her off. g. On 1/11/16 at 9:15 a.m., the Administrator stated, (OLTC Staff #1's) done called and asked, why the police weren't notified on all those reports I sent in on Saturday (1/9/16). h. The Division of Medical Service (DMS)-7734 OLTC Incident and Accident Report (I & A) form documented, Date & Time Submitted (if known): 1/9/16. Date & Time of Discovery: 1/6/16 . Staff reporting I & A: (Administrator) . Date of I & A: 1/6/16 Time: (Blank) Name of Injured Resident: (Resident #1) . Type of Incident: Abuse: Physical . Notifications: . Law Enforcement: Yes 7:30 a.m. 1/11/16 .Summary of Incident: A employee, (CNA #2) stated, she witnessed another employee (CNA #1) smack (Resident #1) on the back of the head with a hair brush . 2. Resident #6 had a [DIAGNOSES REDACTED]. The Resident Plan of Care reviewed on 1/7/16 documented, Communication: Resident has impaired communication as evidence by speech problem: absent . a. A handwritten statement dated 11/16/15 and signed by the DON documented (CNA #2) . said (CNA #1), not treating resident right, rough with them . b. A handwritten statement dated 1/6/16 and signed by CNA #2 documented, (CNA #1) was changing (Resident #6) and covered (Resident #6's) mouth with her gloved hand . c. On 1/8/16 at 1:58 p.m., CNA #2 was asked, Do you have concerns that abuse or neglect is occurring in the facility? CNA #2 stated, Yes with (CNA #1) about . (Resident #6). CNA #2 was asked, What happened with (Resident #6)? CNA #2 stated, We, (CNA #1) and I were changing her and were on opposite side of the bed. The resident was chanting and (CNA #1) put her hand over the resident's mouth. CNA #2 was asked, What did (Resident #6) do? CNA #2 stated, Started screaming louder, she was scared. CNA #2 was asked, What did you do in the resident's room when this happened? CNA #2 stated, I told (CNA #1) it was enough. CNA #2 was asked, If you witness a staff member being abusive toward a resident, what are you to do to protect the resident? CNA #2 stated, Tell them to stop. CNA #2 was asked, What about remove the resident or the CNA from the room? CNA #2 stated, I tell them to stop. d. A handwritten statement dated 1/6/16 at 8:30 a.m. and signed by the DON documented, Had meeting in Administrators (office) with (CNA #2) and (CNA #1) (regarding) conflict between them . (CNA #2) wrote down her concerns of resident care . I had already spoken to resident's on that hall . and found no resident with a complaint on any staff, of any one being mean or mistreating then in any way. No concerns were found with body audits . We feel this is a personal conflict between these two staff members. e.On 1/9/16 at 1:12 p.m., the DON was asked, On 1/6/16 you and (Administrator) got the statement dated 1/6/16 from (CNA #2)? The DON stated, Yes, and I read it . and I asked, about (Resident #6's) mouth being covered with a gloved hand and (CNA #2) said yea I told you and I said no you didn't . The DON was asked, Did you report this to OLTC, did you protect the resident, did you send the CNA (CNA #1) home on 1/6/16? The DON stated, No. (In response to all three questions) The DON was asked, Why not? The DON stated, I guess because we really didn't think it happened, that they were just fighting . f. On 1/9/16 at 2:40 p.m., the Administrator was asked, On 1/6/16 did you get a statement of concerns from (CNA #1)? The Administrator stated, Yes. The Administrator was asked, What is a CNA covering a resident's mouth with their hand? The Administrator stated, You're going to tell me its abuse aren't you? The Administrator was asked, What did you do? The Administrator stated, We did nothing. The Administrator was asked, What should you have done? The Administrator stated, Send her to the house, go check the resident and start an investigation and report it. The Administrator was asked, What are you going to do now? The Administrator stated, I'm going to go put her off. g. On 1/11/16 at 9:15 a.m., the Administrator stated, (OLTC Staff #1's) done called and asked, why the police weren't notified on all those reports I sent in on Saturday (1/9/16). h. The DMS-7734 OLTC Incident and Accident Report (I & A) form documented, Revised . Date & Time Submitted (if known): 1/9/16. Date & Time of Discovery: 1/6/16 . Staff reporting I & A: (Administrator) . Date of I & A: 1/6/16 Time: (Blank) Name of Injured Resident: (Resident #6) . Type of Incident: Abuse: Physical . Notifications: . Law Enforcement: Yes 7:30 a.m., 1/11/16 . 3. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/15 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS), had no speech, was rarely/never understood, sometimes understands - responds adequately to simple, direct communication only, and weighed 216 pounds. The Resident Plan of Care dated 10/7/15 documented, Communication: Resident has impaired communication as evidence by speech problem: absent. Notation dated, 7/2/15 (Resident) sometimes will nod head yes or no but, infrequent . a. A handwritten statement dated 11/16/15 and signed by the DON documented, (CNA #2) . said (CNA #1), not treating resident right, rough with them . b. A handwritten statement dated 1/6/16 documented, I witnessed (CNA #1) called (Resident #2) fat, stated, she needed to eat small portions. This statement was signed by CNA #2. 1) On 1/8/16 at 1:58 p.m., CNA #2 was asked, Have you ever heard a staff member tell a resident they are fat, chubby and needed to eat smaller portions? CNA #2 stated, Yes. CNA #2 was asked, Which resident? CNA #2 stated, (Resident #2). CNA #2 was asked, When was this? CNA #2 stated, The first part of December 2015. CNA #2 was asked, What did you do? CNA #2 stated, I went to (the) (DON) and she said she'd handle it and she'd take care of it. CNA #2 was asked, What exactly did you tell her (DON)? CNA #2 stated, I told her (CNA #1), that (CNA #1) was rough and calling (Resident #2) Chunky Monkey and she had made (Resident #2) cry several times . CNA #2 was asked, Was there anyone else on the hall who saw or heard (CNA #1) do this? CNA #2 stated, No, it was only me and (CNA #1) on the hall. CNA #2 was asked, Where was the resident when this happened? CNA #2 stated, In a lift. She kept telling her that the entire time during the transfer . I had to go talk with (Administrator) and (CNA #1) in (Administrator's) office and they had me tell (CNA #1) what all I said in front of her. CNA #2 was asked, Did you write out a statement? CNA #2 stated, Yes, they made me. CNA #2 was asked, When did you write out the statement? CNA #2 stated, Wednesday, 1/6/16. 2) On 1/9/16 at 10:30 a.m., CNA #1 was asked, Have you ever heard a staff member tell a resident they are fat, chubby and needed to eat smaller portions? CNA #1 stated, No. CNA #1 was asked, Have you ever told anyone that? CNA #1 stated, No. I have discussed with the nurse about getting smaller portions about one of the residents - (Resident #2) but never in front of the resident. CNA #1 was asked, Did you ever call her a Chunky Monkey? CNA #1 stated, Yes I have. It was Chunk Monk. It was just a nick name I use for (Resident #2). I would say are you ready to get up Chunk Monk. It wasn't used in a mean way towards her. I call her that all the time. CNA #1 was asked, Is it okay for someone to give you a nick name that you didn't ask for and call you that? CNA #1 stated, No. CNA #1 was asked, So why is it okay for you to call the resident Chunk Monk? CNA #1 stated, It's not. c. A handwritten statement dated 1/6/16 at 8:30 a.m. and signed by the DON documented, Had meeting in Administrators (office) with (CNA #2) and (CNA #1) (regarding) conflict between them . (CNA #2) wrote down her concerns of resident care . I had already spoken to (the) resident's on that hall . and found no resident with a complaint on any staff, of any one being mean or mistreating then in any way . We feel this is a personal conflict between these two staff members. d. On 1/9/16 at 1:12 p.m., the DON was asked, Have you ever heard a staff member tell a resident they are fat, chubby and needed to eat smaller portions? The DON stated, I heard that from a CNA. The DON was asked, When did you hear this? The DON stated, Sometime in November 2015. The DON was asked, Who was the resident? The DON stated, (Resident #2). I had 2 aides that started fighting and they both worked 500 hall and they started arguing a lot. (CNA #2) said (CNA #1) called (Resident #2) fat. I talked with (CNA #1) and she said it was an outright lie . The DON was asked, What did you do? The DON stated, I tried to spend more time on the halls to listen and no one else reported it. The DON was asked, If a CNA were to call (Resident #2) a Chunk Monk would that have been okay? The DON stated, No, that's not appropriate. The DON was asked, Were you ever told (Resident #2) had been called Chunky Monkey or Chunk Monk? The DON stated, No this is the first time I've heard of it. The DON was asked, On 1/6/16 you and the Administrator got the statement dated 1/6/16 from (CNA #2)? The DON stated, Yes and I read it . e. On 1/9/16 at 5:00 p.m., this surveyor informed the Administrator that (CNA #1) had stated, she called (Resident #2) Chuck Monk as a nick name. The Administrator stated, I'm not as large as (Resident #2) but if someone called me that it would make me madder than hell. I wasn't aware that was happening. f. On 1/11/16 at 9:15 a.m., the Administrator stated, (OLTC Staff # 1's) done called and asked, why the police weren't notified on all those reports I sent in on Saturday (1/9/16). g. The DMS-7734 OLTC Incident and Accident Report (I & A) form documented, Date & Time Submitted (if known): 1/9/16. Date & Time of Discovery: 1/6/16 . Staff reporting I & A: (Administrator) . Date of I & A: 1/6/16 Time: (Blank) Name of Injured Resident: (Resident #2) . Type of Incident: Abuse: Verbal . Notifications: . Law Enforcement: Yes 7:30 a.m. 1/11/16 . 4. On 1/11/16 at 3:10 p.m., the facility presented the following plan of removal: a. Currently, there are 41 cognitively impaired residents in the facility who are at risk for abuse, as identified by their MDS 3.0 BIMS scores. b. On 1/9/16 at 3:00 p.m., the accused staff was notified by phone by the DON that she was removed from the work schedule until the completion of the investigations of the allegations of abuse. c. On 1/9/16 starting at 4:10 p.m., body audits were done on all residents to assess (for) evidence of suspicious bruising or skin tears. d. Beginning on 1/9/16 at 4:00 p.m., the DON or designee will in-service all staff on recognizing and reporting abuse. In-service will be done for all employees before they are allowed to work, beginning with the evening shift 1/9/16 and will continue until all shifts have been in-serviced on: recognizing and reporting abuse; their legal obligation to immediately report all allegations to ensure all have knowledge of abuse reporting. In-services will be on going to include new hires and staff returning from leave. Staff will be in-serviced on the requirement of reporting all allegations immediately to administrator or designee. Charge nurses will begin filling out the paper work after allegations of abuse and will obtain witness statements. The Administrator or designee will report allegations to OLTC before 11:00 a.m. the following day. The Administrator or designee will ensure the police are notified immediately of all allegations of abuse. e. The following training will be conducted by OLTC and Arkansas Innovative Performance Program (AIPP) staff and Program Specialists: 1) On Wednesday, January 13, 2016 - Abuse Neglect Reporting and Investigation Training for Administrative staff. The Administrator and 1st Administrative Group to include department managers, consultants, licensed nurses, supervisors, activity director and social service designee: 8:30 a.m. to 11:30 am. (11: 30 -12:30 - Lunch) 2nd Administrative group to include department managers, consultants, licensed nurses, supervisors, activity director and social service designee: 1:00 p.m. to 4:00 p.m., (4:00 p.m. -5:00 p.m., for any questions and answers). 2) Thursday, January 14, 2016 - Abuse Neglect Reporting and Investigation Training for CNA, Dietary, Housekeeping, Maintenance & other non-supervisory staff 6:30 a.m. to 7:30 a.m. for the 11-7 shift that is going off. 1:00 p.m., to 2:00 p.m., for the evening shift prior to going on duty. 2:30 p.m., to 3:30 p.m., for Day shift getting off and off duty personnel. The Plan of Removal submitted today will allow removal of the IJ and reduction of scope/severity to H effective January 13, 2016. B. Based on record review, and interview, the facility failed to ensure allegations of misappropriation of property were reported in a timely manner to law enforcement officials and the OLTC; failed to protect the resident from possible further misappropriation of property, and failed to investigate the allegations of misappropriation of property for 1 (Residents #3) of 2 (Residents #3 and #8) case mix residents for whom the facility had been informed of allegations of misappropriation of property. The facility failed to report the allegations of misappropriation of property in a timely manner to law enforcement officials and the OLTC for 1 (Residents #8) of 2 (Residents #3 and #8) case mix residents for whom the facility had been informed of allegations of misappropriation of property. These failed practices had the potential to affect 3 residents in the facility who had missing property since 11/1/15 according to the provided by the Administrator on 1/11/16. The findings are: 1. Resident #3 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/16 documented the resident scored a 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. A handwritten statement dated 11/16/15 and signed by the DON documented, (CNA #2) . said (CNA #1) used (Resident #3's) perfume . I spoke with (residents) on 500 hall . (Resident #3) denied having any perfume missing . b. On 1/8/16 at 9:30 a.m., the resident was asked, Have you ever had any missing property? The resident stated, Cologne a few weeks ago. The resident was asked, Did you tell anyone? The resident stated, I told a CNA (Certified Nursing Assistant) and they helped me look for it. The resident was asked, Which CNA did you tell? The resident stated, I don't recall. c. On 1/8/16 at 1:02 p.m., CNA #3 was asked, Have any residents complained of missing items? CNA #3 stated, . (Resident #3) complained of missing stuff that she wanted to send home (with) her daughter. I don't remember when . CNA #3 was asked, What did you do (when) the resident told you this? CNA #3 stated, I thought her (family member) took it home or something. CNA #3 was asked, When residents report things are missing and you aren't able to find it then, what do you do? CNA #3 stated, Tell the nurse. I don't think I said anything about (Resident #3's) stuff. d. On 1/8/16 at 1:58 p.m., CNA #2 was asked, Have any residents complained of missing items? CNA #2 stated, (Resident #3) - she didn't tell me, I witnessed it being taken. (CNA #1) sprayed the perfume in the air. She talked about how good it smelled. She said 'Oh, this is called Pretty.' (There is a perfume by Elizabeth Arden by the name of Pretty). She put it in her scrub jacket, walked out (and) said 'I'm jacking this[***]' . CNA #2 was asked, Where was the resident? CNA #2 stated, She was out of the room. CNA #2 was asked, Did you tell anyone? CNA #2 stated, (the) (DON). CNA #2 was asked, When was this? CNA #2 stated, The middle of November. CNA #2 was asked, Did (the) (DON) ask you for a written statement? CNA #2 stated, No. e. On 1/8/16 at 12:35 p.m., the Social Service Director (SSD) was asked to review the Grievance Log with this surveyor. There was no documented grievance related to Resident #3. The Social Service Director was asked, How does the grievance process work? The Social Service Director stated, It depends on the department. If it's belongings it's me and anything else they tell (Administrator) or (DON) and they assign it to a department. The Social Service Director was asked, Have you had any grievances related to (Resident #3) missing perfume? The Social Service Director stated, No, today is the first day I've heard of it. f. On 1/9/16 at 1:12 p.m., the DON was asked, Have any residents complained of missing items? The DON stated, A resident did not . the perfume thing . let's see. (CNA #2) stated, (CNA #1) jacked (Resident #3's) perfume and sprayed it on her to cover up a urine smell. The DON was asked, When was this? The DON stated, In November all about the same time with the other stuff. The DON was asked, What did you do? The DON stated, I asked, the residents if they were missing anything and (Resident #3) said no. The DON was asked, Did you ask (Resident #3) if the CNA had used her perfume? The DON stated, No. I did hear later that (Resident #3's) perfume was missing as they were coming out of a care plan meeting and (the) (Administrator) told (the) (Social Service Director) to follow up. The DON was asked, Are staff supposed to be taking resident items to use, spray, eat, etc.? The DON stated, No they are not. I never thought about them using the resident's perfume before. The DON was asked, Did you start any misappropriation of property investigation? The DON stated, No, there again I talked with (CNA #1) and she denied it. g. The form titled Grievance Log documented, Date: 1/8/16. Resident Name: (Resident #3) . Describe the complaint: Bottle of perfume missing back before Christmas . Name of Person Investigating Complaint: (Social Service Director) . This form was received from the Administrator on 1/9/16 at 10:00 a.m. 1) The Social/Activity Investigation form documented, Date: 1/8/16. Note: SSD went and spoke to elder letting her know this was the first time I had heard of it . Elder stated, the aides would put some on her and sometimes on their selves . When exiting room aid stated, that she watched another aid place it in her pocket and reported it that same day to the DON. SSD called (family member) and she stated, it was back in November (and) she had only had it a (week), reported it to a nurse, unsure of her name, as well as a care plan (CP) meeting . This form was received from the Administrator on 1/9/16 at 10:00 a.m. 2) On 1/11/16 at 10:55 a.m. the Social Service Director was asked, Did you fill out the Social/Activity Investigation form stated, 1/8/16? The Social Service Director stated, Yes. The Social Service Director was asked, Are aides supposed to be putting the resident's perfume on themselves? The Social Service Director stated, No. The Social Service Director was asked, When the CNA stated she watched another aide place the resident's perfume in her pocket, what is that an allegation of? The Social Service Director stated, Theft. The Social Service Director was asked, Is theft abuse? The Social Service Director stated, Yes. The Social Service Director was asked, When someone makes an allegation of abuse, what are you to do? The Social Service Director stated, Report it immediately. The Social Service Director was asked, Did you? The Social Service Director stated, Yes I called (the) (DON) on Friday 1/8/16 after (CNA #2) told me that. The Social Service Director was asked, Do you normally notify the DON and not the Administrator with concerns of or allegations of abuse? The Social Service Director stated, Since it was nursing I called (the) (DON). The Social Service Director was asked, Where do you document whose at the care plan meetings? The Social Service Director stated, The families sign the care plan itself and so do we. I wasn't at the care plan meeting. The Resident Plan of Care dated 11/23/15 documented the Social Service Director was present at this care plan meeting. 3) On 1/11/16 at 4:50 p.m. the DON and Administrator were asked, Did either of you get a call about stolen or missing perfume on 1/8/16? The DON stated, I didn't talk with anyone about perfume. The Administrator stated, I don't remember it. h. On 1/11/16 at 10:45 a.m., the Administrator was asked, Did you have a stand up meeting this a.m.? The Administrator stated, Yes. The Administrator was asked, Did (the) Social Services (Director) tell you about any grievances this a.m.? The Administrator stated, No. The Administrator was asked, Did you know about this grievance regarding (Resident #3)? The Administrator stated, No. This surveyor asked the Administrator to review the grievance and Social/Activity Investigation form that she (Administrator) had given to this surveyor on 1/9/16 at 10:00 a.m. The Administrator stated, This was not brought up in stand up. I read this Saturday 1/9/16 before I brought it in here to you. The Administrator was asked, Did Social Services call you to report an aide said the resident's perfume was stolen on 1/8/16? The Administrator stated, No. The Administrator was asked, Where it says that CNA stole from a resident what does that make it? The Administrator stated, Misappropriation of property. The Administrator was asked, Have you reported this? The Administrator stated, No, Are you saying I need to? i. The DMS-7734 OLTC Incident and Accident Report (I & A) form documented, Date & Time Submitted (if known): 1/9/16 Date and Time of Discovery: 1/6/16 . Staff reporting I & A: Administrator . Date of I & A: 1/6/16 . Name of Injured Resident: (Resident #3) . Summary of Incident: A employee, (CNA #2) reported another employee put (Resident #3's) perfume in her pocket and left the room . The fax cover sheet documented a 5 page fax was sent to OLTC on 1/11/16 at 10:42 a.m. 2. Resident # 8 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Refe

Complaint # , (AR 915), was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to implement their Abuse Prohibition policy and procedures as evidenced by the facility ' s failures to ensure residents were protected from the potential of further abuse following allegations of abuse; all allegations of abuse were thoroughly investigated; and all allegations of abuse were reported in a timely manner to law enforcement officials and the Office of Long Term Care as required by law for 3 of 3 (Residents #1, #2 and #6) cognitively impaired case mix residents who were allegedly the subjects of staff to resident abuse. These failed practices resulted in Immediate Jeopardy (IJ) which caused or could have caused serious harm, injury or death to Resident #1 and #6 for whom allegations of physical abuse had been received by the facility and had the potential to affect 41 residents who were cognitively impaired according to the list provided by the Director of Nursing on 1/11/16. The facility was notified of the Immediate Jeopardy condition on 1/9/16 at 3:15 p.m. The facility also failed to implement written policies and procedures that prohibit the misappropriation of resident property to ensure all allegations of misappropriation of property were reported in a timely manner to law enforcement officials and the Office of Long Term Care as required by law; and failed to investigate all allegations of misappropriation of property for 1 (Residents #3) of 2 (Residents #3 and #8) case mix residents for whom the facility had been informed of allegations of misappropriation of property. The facility failed to report the allegations of misappropriation of property in a timely manner to law enforcement officials and the Office of Long Term Care as required by law for 1 (Residents #8) of 2 (Residents #3 and #8) case mix residents for whom the facility had been informed of allegations of misappropriation of property. These failed practices had the potential to affect 3 residents in the facility who had missing property since 11/1/15 according to the list provided by the Administrator on 1/11/16. The findings are: 1. The facility's policy titled Patient Abuse/Neglect documented, It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of patient property and to ensure that all alleged violations of federal or states laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriations of patient property (*alleged violations*) are reported immediately to the Administrator of the facility. Such violations will also be reported to state agencies in accordance with existing state law. The facility will investigate each such alleged violation (thoroughly) and report results of all investigations to the Administrator or his/her designee, as well as to stated, agencies as required by state and federal law .PREVENTIONS: A. Staff, families, and patients shall be encouraged to report incidents of suspected abuse, neglect, or misappropriation of resident property without fear of reprisal . INVESTIGATION: A. The Administrator or Director of Nursing shall conduct all investigations. In the event an alleged violation occurs when neither of these people are in the facility, the charge nurse is responsible for initiating the investigation procedures. B. The investigation shall include interviews of employees, visitors, or patients who may have knowledge of the alleged incident . Written statements from involved parties should be requested . PROTECTION: A. If the circumstances require(s) it, the Director of Nursing or his/her designee shall remove a patient suspected of being the subject of an alleged violation to an environment where the patient's safety can be protected . 2. If the suspected perpetrator is an employee, the Administrator shall place the employee on immediate investigation suspension while completing the investigations . REPORTING: A. Any employee who suspects an alleged violation shall immediately notify the Administrator or his/her designee. The Administrator or his/her designee shall also notify the appropriate state agency in accordance with state law (Next day reporting via fax.) B. The results of all investigations must be reported to the Administrator or his/her designee and to the appropriate state agency as required by state law with five (5) working days of the alleged violations . 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/8/15 documented the resident scored a 3 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), is usually understood and usually understands. a. A handwritten statement dated 11/16/15 and signed by the Director of Nursing (DON) documented, (Certified Nursing Assistant (CNA) #2) (complains of) (CNA #1) not treating (residents) right, rough with them - some seem to be scared of her by the look on their face. No specific incident, just general (complaint of) not always using draw sheet to move (residents) in bed, pulling (residents) over quickly (not gently enough for her liking) using foul language in (resident) room. I spoke with (residents) on 500 hall, no one (complained of) anyone being rough or not treating them right. No visible signs of not being treated (with) care or anyone using foul language in front of them . b. A handwritten statement dated 1/6/16 and signed by CNA #2 documented, I witnessed (CNA #1) smack (Resident #1) on the back of the head with a hair brush when (Resident #1) was yelling . (CNA #1) kicked (Resident #1's) chair and her chair went back with her in it. (Resident #1) hit the night table . c.On 1/8/16 at 1:58 p.m., CNA #2 was asked, Have you ever seen any staff hit, slap, pinch, etc. residents? CNA #2 stated, A slap with a hair brush, yes. CNA #2 was asked, Who was that resident? CNA #2 stated, (Resident #1) on the back of her head. CNA #2 was asked, Who slapped her (with) the hair brush? CNA #2 stated, (CNA #1). CNA #2 was asked, You were where when this happened? CNA #2 stated, I was at her dresser looking for hose and she was in a wheelchair between the closet and the bathroom door facing towards her bed and (CNA #2) was behind the resident. Our brushes are gray and she turned the brush around and hit her with the back of the hair brush just once when she wouldn't shut up. CNA #2 was asked, Was there any one else in the room when this happened? CNA #2 stated, No. CNA #2 was asked, When did this happen? CNA #2 stated, The end of November. CNA #2 was asked, What did you do? CNA #2 stated, I went to (the) (DON). CNA #2 was asked, Did (the) (DON) ask you for a statement? CNA #2 stated, No, I didn't fill out a statement until the other day and she said I didn't tell her any of that. CNA #2 was asked, Have you ever seen staff kick a resident or kick a resident's wheel chair? CNA #2 stated, Yes. CNA #2 was asked, Who was the resident? CNA #2 stated, (Resident #1). CNA #2 was asked, When did this happen? CNA #2 stated, End of November or beginning of December (2015). I know it's happened twice but I've only witnessed it once. CNA #2 was asked, When did the second one, that one you saw, happen? CNA #2 stated, About 1 week later . she (CNA #1) kicked the resident's wheel chair because she wouldn't shut up. CNA #2 was asked, When you saw her kick the resident's wheel chair, where was the resident? CNA #2 stated, In her room by the night stand and bed facing toward the TV. (Resident #1) was wanting to go to bed and (CNA #1) had just given (Resident #1) her call light and she wanted to go to break. She kicked the metal bar on the side of the chair because she wanted to go on break and (Resident #1) kept saying I want to go to bed. CNA #2 was asked, Were there any witnesses other than you? CNA #2 stated, No. CNA #2 was asked, Did you tell anyone? CNA #2 stated, I told (the) (DON). CNA #2 was asked, Did (the) (DON) ask you for a witness statement? CNA #2 stated, No, she said she'd take care of it. CNA #2 was asked, Any resident injury? CNA #2 stated, No, it startled her and I think she was frightened . d. A handwritten statement dated 1/6/16 at 8:30 a.m. and signed by the DON documented, Had meeting in Administrator's (office) with (CNA #2) and (CNA #1) (regarding) conflict between them . (CNA #2) wrote down her concerns of resident care - had already addressed kicking of the wheel chair of (Resident #1). (Resident #1) had denied (at) that time anyone being rough or mean to her or kicking her chair. (CNA #2) denied hitting (Resident #1) on the head with a brush . I had already spoken to residents on that hall and did body audits and found no resident with a complaint on any staff of anyone being mean or mistreating them in any way. No concerns were found with body audits . We feel this is a personal conflict between these two staff members. e. On 1/9/16 at 1:12 p.m., the DON was asked, Have any staff reported that a resident had been kicked or the resident's wheel chair kicked? The DON stated, Yes. There again (CNA #2) reported that (CNA #1) did that. The DON was asked, When was this? The DON stated, Along about the same time in November. She reported (CNA #1) kicking the wheel chair . and she didn't like the way (CNA #1) turned the residents. She thought she (CNA #1) should have been easier when she turned them over. The DON was asked, Why isn't that on your statement? The DON stated, I wrote that up later and there was so much I forgot to write down some of it. The DON was asked, What did you do? The DON stated, I talked to (CNA #1) who said she never intentionally kicked any resident's wheel chair because she was mad or otherwise. I went down the hall and I talked to residents and I asked if anyone had been mean to them or didn't treat them right and no one did. The DON was asked, When you were told that (CNA #1) had kicked the resident's wheel chair, was it said that this had caused a skin tear? The DON stated, No, I was told the wheel chair rolled back some, nothing about any injury what so ever. The DON was asked, This resident was (Resident #1)? The DON stated, Yes. The DON was asked, On 1/6/16 you and (Administrator) got the statement dated 1/6/16 from (CNA #2)? The DON stated, Yes and I read it and I said what is this about hitting the resident on the head with a hair brush and (CNA #2) said I told you that and I said no you didn't, your never told me . and I said, yes you told me about her kicking the chair. The DON was asked, Is hitting a resident with a hair brush abuse? The DON stated, Yes. The DON was asked, Did you report this to OLTC, did you protect the resident, did you send the CNA (CNA #1) home on 1/6/16? The DON stated, No. (In response to all three questions) The DON was asked, Why not? The DON stated, I guess because we really didn't think it happened, that they were just fighting. The DON was asked, If this had been any other CNA with an allegation that a resident had been hit what would you do? The DON stated, Go down immediately and do an assessment and send the CNA home and investigate. The DON was asked, What have you done since Wednesday, 1/6/16, about this statement? The DON stated, They are both still working. The DON was asked, What does your statement dated 1/6/16 mean about the wheel chair? The DON stated, I knew about (CNA #1) kicking the resident's wheel chair - that was in November (2015). The DON looked at her written statement and stated, No, that wasn't then but it must (have) been in this same time frame. I had already talked to the resident in November so I didn't do anything else. f. On 1/9/16 at 2:40 p.m. the Administrator was asked, On 1/6/16 did you get a statement of concerns from (CNA #1)? The Administrator stated, Yes. The Administrator was asked, What is (CNA #1) smacked (Resident #1) on the back of the head with a hair brush? What is that an allegation of? The Administrator stated, Abuse. The Administrator was asked, What did you do? The Administrator stated, We did nothing. The Administrator was asked, What should you have done? The Administrator stated, Send her to the house, go check the resident and start an investigation and report it. The Administrator was asked, What are you going to do now? The Administrator stated, I'm going to go put her off. g. On 1/11/16 at 9:15 a.m., the Administrator stated, (OLTC Staff #1's) done called and asked, why the police weren't notified on all those reports I sent in on Saturday (1/9/16). h. The Division of Medical Service (DMS)-7734 OLTC Incident and Accident Report (I & A) form documented, Date & Time Submitted (if known): 1/9/16. Date & Time of Discovery: 1/6/16 . Staff reporting I & A: (Administrator) . Date of I & A: 1/6/16 Time: (Blank) Name of Injured Resident: (Resident #1) . Type of Incident: Abuse: Physical . Notifications: . Law Enforcement: Yes 7:30 a.m. 1/11/16 .Summary of Incident: A employee, (CNA #2) stated, she witnessed another employee (CNA #1) smack (Resident #1) on the back of the head with a hair brush . 3. Resident #6 had a [DIAGNOSES REDACTED]. The Resident Plan of Care reviewed on 1/7/16 documented, Communication: Resident has impaired communication as evidence by speech problem: absent . a. A handwritten statement dated 11/16/15 and signed by the DON documented (CNA #2) . said (CNA #1), not treating resident right, rough with them . b. A handwritten statement dated 1/6/16 and signed by CNA #2 documented, (CNA #1) was changing (Resident #6) and covered (Resident #6's) mouth with her gloved hand . b. On 1/8/16 at 1:58 p.m., CNA #2 was asked, Do you have concerns that abuse or neglect is occurring in the facility? CNA #2 stated, Yes with (CNA #1) about . (Resident #6). CNA #2 was asked, What happened with (Resident #6)? CNA #2 stated, We, (CNA #1) and I were changing her and were on opposite side of the bed. The resident was chanting and (CNA #1) put her hand over the resident's mouth. CNA #2 was asked, What did (Resident #6) do? CNA #2 stated, Started screaming louder, she was scared. CNA #2 was asked, What did you do in the resident's room when this happened? CNA #2 stated, I told (CNA #1) it was enough. CNA #2 was asked, If you witness a staff member being abusive toward a resident, what are you to do to protect the resident? CNA #2 stated, Tell them to stop. CNA #2 was asked, What about remove the resident or the CNA from the room? CNA #2 stated, I tell them to stop. c. A handwritten statement dated 1/6/16 at 8:30 a.m. and signed by the DON documented, Had meeting in Administrators (office) with (CNA #2) and (CNA #1) (regarding) conflict between them . (CNA #2) wrote down her concerns of resident care . I had already spoken to resident's on that hall . and found no resident with a complaint on any staff, of any one being mean or mistreating then in any way. No concerns were found with body audits . We feel this is a personal conflict between these two staff members. d. On 1/9/16 at 1:12 p.m., the DON was asked, On 1/6/16 you and (Administrator) got the statement dated 1/6/16 from (CNA #2)? The DON stated, Yes, and I read it . and I asked, about (Resident #6's) mouth being covered with a gloved hand and (CNA #2) said yea I told you and I said no you didn't . The DON was asked, Did you report this to OLTC, did you protect the resident, did you send the CNA (CNA #1) home on 1/6/16? The DON stated, No. (In response to all three questions) The DON was asked, Why not? The DON stated, I guess because we really didn't think it happened, that they were just fighting . e. On 1/9/16 at 2:40 p.m., the Administrator was asked, On 1/6/16 did you get a statement of concerns from (CNA #1)? The Administrator stated, Yes. The Administrator was asked, What is a CNA covering a resident's mouth with their hand? The Administrator stated, You're going to tell me its abuse aren't you? The Administrator was asked, What did you do? The Administrator stated, We did nothing. The Administrator was asked, What should you have done? The Administrator stated, Send her to the house, go check the resident and start an investigation and report it. The Administrator was asked, What are you going to do now? The Administrator stated, I'm going to go put her off. f. On 1/11/16 at 9:15 a.m., the Administrator stated, (OLTC Staff #1's) done called and asked, why the police weren't notified on all those reports I sent in on Saturday (1/9/16). g. The DMS-7734 OLTC Incident and Accident Report (I & A) form documented, Revised . Date & Time Submitted (if known): 1/9/16. Date & Time of Discovery: 1/6/16 . Staff reporting I & A: (Administrator) . Date of I & A: 1/6/16 Time: (Blank) Name of Injured Resident: (Resident #6) . Type of Incident: Abuse: Physical . Notifications: . Law Enforcement: Yes 7:30 a.m., 1/11/16 . 4. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/15 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS), had no speech, was rarely/never understood, sometimes understands - responds adequately to simple, direct communication only, and weighed 216 pounds. The Resident Plan of Care dated 10/7/15 documented, Communication: Resident has impaired communication as evidence by speech problem: absent. Notation dated, 7/2/15 (Resident) sometimes will nod head yes or no but, infrequent . a. A handwritten statement dated 11/16/15 and signed by the DON documented, (CNA #2) . said (CNA #1), not treating resident right, rough with them . b. A handwritten statement dated 1/6/16 and signed by CNA #2 documented, I witnessed (CNA #1) called (Resident #2) fat, stated she needed to eat small portions. 1) On 1/8/16 at 1:58 p.m., CNA #2 was asked, Have you ever heard a staff member tell a resident they are fat, chubby and needed to eat smaller portions? CNA #2 stated, Yes. CNA #2 was asked, Which resident? CNA #2 stated, (Resident #2). CNA #2 was asked, When was this? CNA #2 stated, The first part of December 2015. CNA #2 was asked, What did you do? CNA #2 stated, I went to (the) (DON) and she said she'd handle it and she'd take care of it. CNA #2 was asked, What exactly did you tell her (DON)? CNA #2 stated, I told her (CNA #1), that (CNA #1) was rough and calling (Resident #2) Chunky Monkey and she had made (Resident #2) cry several times . CNA #2 was asked, Was there anyone else on the hall who saw or heard (CNA #1) do this? CNA #2 stated, No, it was only me and (CNA #1) on the hall. CNA #2 was asked, Where was the resident when this happened? CNA #2 stated, In a lift. She kept telling her that the entire time during the transfer . I had to go talk with (Administrator) and (CNA #1) in (Administrator's) office and they had me tell (CNA #1) what all I said in front of her. CNA #2 was asked, Did you write out a statement? CNA #2 stated, Yes, they made me. CNA #2 was asked, When did you write out the statement? CNA #2 stated, Wednesday, 1/6/16. 2) On 1/9/16 at 10:30 a.m., CNA #1 was asked, Have you ever heard a staff member tell a resident they are fat, chubby and needed to eat smaller portions? CNA #1 stated, No. CNA #1 was asked, Have you ever told anyone that? CNA #1 stated, No. I have discussed with the nurse about getting smaller portions about one of the residents - (Resident #2) but never in front of the resident. CNA #1 was asked, Did you ever call her a Chunky Monkey? CNA #1 stated, Yes I have. It was Chunk Monk. It was just a nick name I use for (Resident #2). I would say are you ready to get up Chunk Monk. It wasn't used in a mean way towards her. I call her that all the time. CNA #1 was asked, Is it okay for someone to give you a nick name that you didn't ask for and call you that? CNA #1 stated, No. CNA #1 was asked, So why is it okay for you to call the resident Chunk Monk? CNA #1 stated, It's not. c. A handwritten statement dated 1/6/16 at 8:30 a.m. and signed by the DON documented, Had meeting in Administrators (office) with (CNA #2) and (CNA #1) (regarding) conflict between them . (CNA #2) wrote down her concerns of resident care . I had already spoken to (the) resident's on that hall . and found no resident with a complaint on any staff, of any one being mean or mistreating then in any way . We feel this is a personal conflict between these two staff members. d. On 1/9/16 at 1:12 p.m., the DON was asked, Have you ever heard a staff member tell a resident they are fat, chubby and needed to eat smaller portions? The DON stated, I heard that from a CNA. The DON was asked, When did you hear this? The DON stated, Sometime in November 2015. The DON was asked, Who was the resident? The DON stated, (Resident #2). I had 2 aides that started fighting and they both worked 500 hall and they started arguing a lot. (CNA #2) said (CNA #1) called (Resident #2) fat. I talked with (CNA #1) and she said it was an outright lie . The DON was asked, What did you do? The DON stated, I tried to spend more time on the halls to listen and no one else reported it. The DON was asked, If a CNA were to call (Resident #2) a Chunk Monk would that have been okay? The DON stated, No, that's not appropriate. The DON was asked, Were you ever told (Resident #2) had been called Chunky Monkey or Chunk Monk? The DON stated, No this is the first time I've heard of it. The DON was asked, On 1/6/16 you and the Administrator got the statement dated 1/6/16 from (CNA #2)? The DON stated, Yes and I read it . e. On 1/9/16 at 5:00 p.m., this surveyor informed the Administrator that (CNA #1) had stated, she called (Resident #2) Chuck Monk as a nick name. The Administrator stated, I'm not as large as (Resident #2) but if someone called me that it would make me madder than hell. I wasn't aware that was happening. f. On 1/11/16 at 9:15 a.m., the Administrator stated, (OLTC Staff # 1's) done called and asked, why the police weren't notified on all those reports I sent in on Saturday (1/9/16). g. The DMS-7734 OLTC Incident and Accident Report (I & A) form documented, Date & Time Submitted (if known): 1/9/16. Date & Time of Discovery: 1/6/16 . Staff reporting I & A: (Administrator) . Date of I & A: 1/6/16 Time: (Blank) Name of Injured Resident: (Resident #2) . Type of Incident: Abuse: Verbal . Notifications: . Law Enforcement: Yes 7:30 a.m. 1/11/16 . 5. Resident #3 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/16 documented the resident scored a 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. A handwritten statement dated 11/16/15 and signed by the DON documented, (CNA #2) . said (CNA #1) used (Resident #3's) perfume . I spoke with (residents) on 500 hall . (Resident #3) denied having any perfume missing . b. On 1/8/16 at 9:30 a.m., the resident was asked, Have you ever had any missing property? The resident stated, Cologne a few weeks ago. The resident was asked, Did you tell anyone? The resident stated, I told a CNA (Certified Nursing Assistant) and they helped me look for it. The resident was asked, Which CNA did you tell? The resident stated, I don't recall. c. On 1/8/16 at 1:02 p.m., CNA #3 was asked, Have any residents complained of missing items? CNA #3 stated, . (Resident #3) complained of missing stuff that she wanted to send home (with) her daughter. I don't remember when . CNA #3 was asked, What did you do (when) the resident told you this? CNA #3 stated, I thought her (family member) took it home or something. CNA #3 was asked, When residents report things are missing and you aren't able to find it then, what do you do? CNA #3 stated, Tell the nurse. I don't think I said anything about (Resident #3's) stuff. d. On 1/8/16 at 1:58 p.m., CNA #2 was asked, Have any residents complained of missing items? CNA #2 stated, (Resident #3) - she didn't tell me, I witnessed it being taken. (CNA #1) sprayed the perfume in the air. She talked about how good it smelled. She said 'Oh, this is called Pretty.' (There is a perfume by Elizabeth Arden by the name of Pretty). She put it in her scrub jacket, walked out (and) said 'I'm jacking this[***]' . CNA #2 was asked, Where was the resident? CNA #2 stated, She was out of the room. CNA #2 was asked, Did you tell anyone? CNA #2 stated, (the) (DON). CNA #2 was asked, When was this? CNA #2 stated, The middle of November. CNA #2 was asked, Did (the) (DON) ask you for a written statement? CNA #2 stated, No. e. On 1/8/16 at 12:35 p.m., the Social Service Director (SSD) was asked to review the Grievance Log with this surveyor. There was no documented grievance related to Resident #3. The Social Service Director was asked, How does the grievance process work? The Social Service Director stated, It depends on the department. If it's belongings it's me and anything else they tell (Administrator) or (DON) and they assign it to a department. The Social Service Director was asked, Have you had any grievances related to (Resident #3) missing perfume? The Social Service Director stated, No, today is the first day I've heard of it. f.On 1/9/16 at 1:12 p.m., the DON was asked, Have any residents complained of missing items? The DON stated, A resident did not . the perfume thing . let's see. (CNA #2) stated, (CNA #1) jacked (Resident #3's) perfume and sprayed it on her to cover up a urine smell. The DON was asked, When was this? The DON stated, In November all about the same time with the other stuff. The DON was asked, What did you do? The DON stated, I asked, the residents if they were missing anything and (Resident #3) said no. The DON was asked, Did you ask (Resident #3) if the CNA had used her perfume? The DON stated, No. I did hear later that (Resident #3's) perfume was missing as they were coming out of a care plan meeting and (the) (Administrator) told (the) (Social Service Director) to follow up. The DON was asked, Are staff supposed to be taking resident items to use, spray, eat, etc.? The DON stated, No they are not. I never thought about them using the resident's perfume before. The DON was asked, Did you start any misappropriation of property investigation? The DON stated, No, there again I talked with (CNA #1) and she denied it. g. The form titled Grievance Log documented, Date: 1/8/16. Resident Name: (Resident #3) . Describe the complaint: Bottle of perfume missing back before Christmas . Name of Person Investigating Complaint: (Social Service Director) . This form was received from the Administrator on 1/9/16 at 10:00 a.m. 1) The Social/Activity Investigation form documented, Date: 1/8/16. Note: SSD went and spoke to elder letting her know this was the first time I had heard of it . Elder stated, the aides would put some on her and sometimes on their selves . When exiting room aid stated, that she watched another aid place it in her pocket and reported it that same day to the DON. SSD called (family member) and she stated, it was back in November (and) she had only had it a (week), reported it to a nurse, unsure of her name, as well as a care plan (CP) meeting . This form was received from the Administrator on 1/9/16 at 10:00 a.m. 2) On 1/11/16 at 10:55 a.m. the Social Service Director was asked, Did you fill out the Social/Activity Investigation form stated, 1/8/16? The Social Service Director stated, Yes. The Social Service Director was asked, Are aides supposed to be putting the resident's perfume on themselves? The Social Service Director stated, No. The Social Service Director was asked, When the CNA stated she watched another aide place the resident's perfume in her pocket, what is that an allegation of? The Social Service Director stated, Theft. The Social Service Director was asked, Is theft abuse? The Social Service Director stated, Yes. The Social Service Director was asked, When someone makes an allegation of abuse, what are you to do? The Social Service Director stated, Report it immediately. The Social Service Director was asked, Did you? The Social Service Director stated, Yes I called (the) (DON) on Friday 1/8/16 after (CNA #2) told me that. The Social Service Director was asked, Do you normally notify the DON and not the Administrator with concerns of or allegations of abuse? The Social Service Director stated, Since it was nursing I called (the) (DON). The Social Service Director was asked, Where do you document whose at the care plan meetings? The Social Service Director stated, The families sign the care plan itself and so do we. I wasn't at the care plan meeting. The Resident Plan of Care dated 11/23/15 documented the Social Service Director was present at this care plan meeting. 3) On 1/11/16 at 4:50 p.m. the DON and Administrator were asked, Did either of you get a call about stolen or missing perfume on 1/8/16? The DON stated, I didn't talk with anyone about perfume. The Administrator stated, I don't remember it. h. On 1/11/16 at 10:45 a.m., the Administrator was asked, Did you have a stand up meeting this a.m.? The Administrator stated, Yes. The Administrator was asked, Did (the) Social Services (Director) tell you about any grievances this a.m.? The Administrator stated, No. The Administrator was asked, Did you know about this grievance regarding (Resident #3)? The Administrator stated, No. This surveyor asked the Administrator to review the grievance and Social/Activity Investigation form that she (Administrator) had given to this surveyor on 1/9/16 at 10:00 a.m. The Administrator stated, This was not brought up in stand up. I read this Saturday 1/9/16 before I brought it in here to you. The Administrator was asked, Did Social Services call you to report an aide said the resident's perfume was stolen on 1/8/16? The Administrator stated, No. The Administrator was asked, Where it says that CNA stole from a resident what does that make it? The Administrator stated, Misappropriation of property. The Administrator was asked, Have you reported this? The Administrator stated, No, Are you saying I need to? i. The DMS-7734 OLTC Incident and Accident Report (I & A) form documented, Date & Time Submitted (if known): 1/9/16 Date and Time of Discovery: 1/6/16 . Staff reporting I & A: Administrator . Date of I & A: 1/6/16 . Name of Injured Resident: (Resident #3) . Summary of Incident: A employee, (CNA #2) reported another employee put (Resident #3's) perfume in her pocket and left the room . The fax cover sheet documented a 5 page fax was sent to OLTC on 1/11/16 at 10:42 a.m. 6. Resident # 8 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/15 documented the resident scored a 5 (0-7 indicates severe impairment) on the Brief Interview for Mental Status, (BIMS). a. A physician's orders [REDACTED]. b. The narcotic count page 54 documented

Complaint # (AR 915) was substantiated (all or in part) with these findings. Based on record review and interview, the facility Administration and Nursing Administration failed to ensure residents were protected from the potential of further abuse following allegations of abuse; failed to ensure all allegations of abuse were thoroughly investigated; and failed to ensure all allegations of abuse were reported in a timely manner to law enforcement officials and the Office of Long Term Care as required by law for 3 of 3 (Residents #1, #2 and #6) cognitively impaired case mix residents who were allegedly the subjects of staff to resident abuse. These failed practices resulted in Immediate Jeopardy (IJ) which caused or could have caused serious harm, injury or death to Resident #1 and #6 for whom allegations of physical abuse had been received by the facility and had the potential to affect 41 residents who were cognitively impaired according to the list provided by the Director of Nursing on 1/11/16. The facility was notified of the Immediate Jeopardy condition on 1/9/16 at 3:15 p.m. The facility Administration and Nursing Administration also failed to ensure all allegations of misappropriation of property were reported in a timely manner to law enforcement officials and the Office of Long Term Care as required by law and failed to investigate the allegations of misappropriation of property for 1 (Residents #3) of 2 (Residents #3 and #8) case mix residents for whom the facility had been informed of allegations of misappropriation of property. The facility Administration and Nursing Administration failed to report the allegation of misappropriation of property in a timely manner to law enforcement officials and the Office of Long Term Care as required by law for 1 (Residents #8) of 2 (Residents #3 and #8) case mix residents for whom the facility had been informed of allegations of misappropriation of property. These failed practices had the potential to affect 3 residents in the facility that had missing property since 11/1/15 according to the list provided by the Administrator on 1/11/16. The findings are: 1. The Job Description - Administrator - Administrative Services documented, Job Summary: The Administrator directs and coordinates all activities of the nursing home to enable all departments to carry out the objectives as to the care of the residents . Responsibilities (and) Authorities: The Administrator is responsible for . interpreting and administering policies of the Board of Directors and insuring that the residents receive the highest level of professional medical care . The Job Description - Nursing Service Department - Director of Nursing documented, I. Job Summary: The Director of Nursing Service directs and supervises Professional Nursing and Auxiliary Personnel rendering patient care services . She analyses and evaluates nursing and related services to improve quality of patient care . III. Responsibilities and Authorities: . 3. Formulates departmental policies, defines and interprets policies established . 2. The facility's policy titled Patient Abuse/Neglect documented, It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of patient property and to ensure that all alleged violations of federal or states laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriations of patient property (*alleged violations*) are reported immediately to the Administrator of the facility. Such violations will also be reported to state agencies in accordance with existing state law. The facility will investigate each such alleged violation (thoroughly) and report results of all investigations to the Administrator or his/her designee, as well as to stated,, agencies as required by state and federal law .PREVENTIONS: A. Staff, families, and patients shall be encouraged to report incidents of suspected abuse, neglect, or misappropriation of resident property without fear of reprisal . INVESTIGATION: A. The Administrator or Director of Nursing (DON) shall conduct all investigations. In the event an alleged violation occurs when neither of these people are in the facility, the charge nurse is responsible for initiating the investigation procedures. B. The investigation shall include interviews of employees, visitors, or patients who may have knowledge of the alleged incident . Written statements from involved parties should be requested . PROTECTION: A. If the circumstances require(s) it, the Director of Nursing or his/her designee shall remove a patient suspected of being the subject of an alleged violation to an environment where the patient's safety can be protected . 2. If the suspected perpetrator is an employee, the Administrator shall place the employee on immediate investigation suspension while completing the investigations . REPORTING: A. Any employee who suspects an alleged violation shall immediately notify the Administrator or his/her designee. The Administrator or his/her designee shall also notify the appropriate state agency in accordance with state law (Next day reporting via fax.) B. The results of all investigations must be reported to the Administrator or his/her designee and to the appropriate state agency as required by state law with five (5) working days of the alleged violations . 3. On 1/11/16 at 4:50 p.m., the Director of Nursing (DON) and the Administrator were asked, What is the DON's job responsibility for allegations of abuse? The DON stated, I check on residents, watch for any signs of abuse and do an investigation. The DON and Administrator were asked, Are both the DON and Administrator responsible for ensuring staff are knowledgeable, residents are protected, abuse and neglect allegations are investigated and reported to OLTC and law enforcement? The DON and Administrator stated, Yes. (To all questions) 4. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/8/15 documented the resident scored a 3 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), is usually understood and usually understands. a. A handwritten statement dated 11/16/15 and signed by the Director of Nursing (DON) documented, (Certified Nursing Assistant (CNA) #2) (complains of) (CNA #1) not treating (residents) right, rough with them - some seem to be scared of her by the look on their face. No specific incident, just general (complaint of) not always using draw sheet to move (residents) in bed, pulling (residents) over quickly (not gently enough for her liking) using foul language in (resident) room. I spoke with (residents) on 500 hall, no one (complained of) anyone being rough or not treating them right. No visible signs of not being treated (with) care or anyone using foul language in front of them . b. A handwritten statement dated 1/6/16 and signed by CNA #2 documented, I witnessed (CNA #1) smack (Resident #1) on the back of the head with a hair brush when (Resident #1) was yelling . (CNA #1) kicked (Resident #1's) chair and her chair went back with her in it. (Resident #1) hit the night table . c. On 1/8/16 at 1:58 p.m., CNA #2 was asked, Have you ever seen any staff hit, slap, pinch, etc. residents? CNA #2 stated, A slap with a hair brush, yes. CNA #2 was asked, Who was that resident? CNA #2 stated, (Resident #1) on the back of her head. CNA #2 was asked, Who slapped her (with) the hair brush? CNA #2 stated, (CNA #1). CNA #2 was asked, You were where when this happened? CNA #2 stated, I was at her dresser looking for hose and she was in a wheelchair between the closet and the bathroom door facing towards her bed and (CNA #2) was behind the resident. Our brushes are gray and she turned the brush around and hit her with the back of the hair brush just once when she wouldn't shut up. CNA #2 was asked, Was there any one else in the room when this happened? CNA #2 stated, No. CNA #2 was asked, When did this happen? CNA #2 stated, The end of November. CNA #2 was asked, What did you do? CNA #2 stated, I went to (the) (DON). CNA #2 was asked, Did (the) (DON) ask you for a statement? CNA #2 stated, No, I didn't fill out a statement until the other day and she said I didn't tell her any of that. CNA #2 was asked, Have you ever seen staff kick a resident or kick a resident's wheel chair? CNA #2 stated, Yes. CNA #2 was asked, Who was the resident? CNA #2 stated, (Resident #1). CNA #2 was asked, When did this happen? CNA #2 stated, End of November or beginning of December (2015). I know it's happened twice but I've only witnessed it once. CNA #2 was asked, When did the second one, that one you saw, happen? CNA #2 stated, About 1 week later . she (CNA #1) kicked the resident's wheel chair because she wouldn't shut up. CNA #2 was asked, When you saw her kick the resident's wheel chair, where was the resident? CNA #2 stated, In her room by the night stand and bed facing toward the TV. (Resident #1) was wanting to go to bed and (CNA #1) had just given (Resident #1) her call light and she wanted to go to break. She kicked the metal bar on the side of the chair because she wanted to go on break and (Resident #1) kept saying I want to go to bed. CNA #2 was asked, Were there any witnesses other than you? CNA #2 stated, No. CNA #2 was asked, Did you tell anyone? CNA #2 stated, I told (the) (DON). CNA #2 was asked, Did (the) (DON) ask you for a witness statement? CNA #2 stated, No, she said she'd take care of it. CNA #2 was asked, Any resident injury? CNA #2 stated, No, it startled her and I think she was frightened . d. A handwritten statement dated 1/6/16 at 8:30 a.m. and signed by the DON documented, Had meeting in Administrator's (office) with (CNA #2) and (CNA #1) (regarding) conflict between them . (CNA #2) wrote down her concerns of resident care - had already addressed kicking of the wheel chair of (Resident #1). (Resident #1) had denied (at) that time anyone being rough or mean to her or kicking her chair. (CNA #2) denied hitting (Resident #1) on the head with a brush . I had already spoken to residents on that hall and did body audits and found no resident with a complaint on any staff of anyone being mean or mistreating them in any way. No concerns were found with body audits . We feel this is a personal conflict between these two staff members. e. On 1/9/16 at 1:12 p.m., the DON was asked, Have any staff reported that a resident had been kicked or the resident's wheel chair kicked? The DON stated, Yes. There again (CNA #2) reported that (CNA #1) did that. The DON was asked, When was this? The DON stated, Along about the same time in November. She reported (CNA #1) kicking the wheel chair . and she didn't like the way (CNA #1) turned the residents. She thought she (CNA #1) should have been easier when she turned them over. The DON was asked, Why isn't that on your statement? The DON stated, I wrote that up later and there was so much I forgot to write down some of it. The DON was asked, What did you do? The DON stated, I talked to (CNA #1) who said she never intentionally kicked any resident's wheel chair because she was mad or otherwise. I went down the hall and I talked to residents and I asked if anyone had been mean to them or didn't treat them right and no one did. The DON was asked, When you were told that (CNA #1) had kicked the resident's wheel chair, was it said that this had caused a skin tear? The DON stated, No, I was told the wheel chair rolled back some, nothing about any injury what so ever. The DON was asked, This resident was (Resident #1)? The DON stated, Yes. The DON was asked, On 1/6/16 you and (Administrator) got the statement dated 1/6/16 from (CNA #2)? The DON stated, Yes and I read it and I said what is this about hitting the resident on the head with a hair brush and (CNA #2) said I told you that and I said no you didn't, your never told me . and I said, yes you told me about her kicking the chair. The DON was asked, Is hitting a resident with a hair brush abuse? The DON stated, Yes. The DON was asked, Did you report this to OLTC, did you protect the resident, did you send the CNA (CNA #1) home on 1/6/16? The DON stated, No.(In response to all three questions) The DON was asked, Why not? The DON stated, I guess because we really didn't think it happened, that they were just fighting. The DON was asked, If this had been any other CNA with an allegation that a resident had been hit what would you do? The DON stated, Go down immediately and do an assessment and send the CNA home and investigate. The DON was asked, What have you done since Wednesday, 1/6/16, about this statement? The DON stated, They are both still working. The DON was asked, What does your statement dated 1/6/16 mean about the wheel chair? The DON stated, I knew about (CNA #1) kicking the resident's wheel chair - that was in November (2015). The DON looked at her written statement and stated, No, that wasn't then but it must (have) been in this same time frame. I had already talked to the resident in November so I didn't do anything else. f. On 1/9/16 at 2:40 p.m. the Administrator was asked, On 1/6/16 did you get a statement of concerns from (CNA #1)? The Administrator stated, Yes. The Administrator was asked, What is (CNA #1) smacked (Resident #1) on the back of the head with a hair brush? What is that an allegation of? The Administrator stated, Abuse. The Administrator was asked, What did you do? The Administrator stated, We did nothing. The Administrator was asked, What should you have done? The Administrator stated, Send her to the house, go check the resident and start an investigation and report it. The Administrator was asked, What are you going to do now? The Administrator stated, I'm going to go put her off. g. On 1/11/16 at 9:15 a.m., the Administrator stated, (OLTC Staff #1's) done called and asked, why the police weren't notified on all those reports I sent in on Saturday (1/9/16). h. The Division of Medical Service (DMS)-7734 OLTC Incident and Accident Report (I & A) form documented, Date & Time Submitted (if known): 1/9/16. Date & Time of Discovery: 1/6/16 . Staff reporting I & A: (Administrator) . Date of I & A: 1/6/16 Time: (Blank) Name of Injured Resident: (Resident #1) . Type of Incident: Abuse: Physical . Notifications: . Law Enforcement: Yes 7:30 a.m. 1/11/16 .Summary of Incident: A employee, (CNA #2) stated, she witnessed another employee (CNA #1) smack (Resident #1) on the back of the head with a hair brush . 5. Resident #6 had a [DIAGNOSES REDACTED]. The Resident Plan of Care reviewed on 1/7/16 documented, Communication: Resident has impaired communication as evidence by speech problem: absent . a. A handwritten statement dated 11/16/15 and signed by the DON documented (CNA #2) . said (CNA #1), not treating resident right, rough with them . b. A handwritten statement dated 1/6/16 and signed by CNA #2 documented, (CNA #1) was changing (Resident #6) and covered (Resident #6's) mouth with her gloved hand . c.On 1/8/16 at 1:58 p.m., CNA #2 was asked, Do you have concerns that abuse or neglect is occurring in the facility? CNA #2 stated, Yes with (CNA #1) about . (Resident #6). CNA #2 was asked, What happened with (Resident #6)? CNA #2 stated, We, (CNA #1) and I were changing her and were on opposite side of the bed. The resident was chanting and (CNA #1) put her hand over the resident's mouth. CNA #2 was asked, What did (Resident #6) do? CNA #2 stated, Started screaming louder, she was scared. CNA #2 was asked, What did you do in the resident's room when this happened? CNA #2 stated, I told (CNA #1) it was enough. CNA #2 was asked, If you witness a staff member being abusive toward a resident, what are you to do to protect the resident? CNA #2 stated, Tell them to stop. CNA #2 was asked, What about remove the resident or the CNA from the room? CNA #2 stated, I tell them to stop. d. A handwritten statement dated 1/6/16 at 8:30 a.m. and signed by the DON documented, Had meeting in Administrators (office) with (CNA #2) and (CNA #1) (regarding) conflict between them . (CNA #2) wrote down her concerns of resident care . I had already spoken to resident's on that hall . and found no resident with a complaint on any staff, of any one being mean or mistreating then in any way. No concerns were found with body audits . We feel this is a personal conflict between these two staff members. e.On 1/9/16 at 1:12 p.m., the DON was asked, On 1/6/16 you and (Administrator) got the statement dated 1/6/16 from (CNA #2)? The DON stated, Yes, and I read it . and I asked, about (Resident #6's) mouth being covered with a gloved hand and (CNA #2) said yea I told you and I said no you didn't . The DON was asked, Did you report this to OLTC, did you protect the resident, did you send the CNA (CNA #1) home on 1/6/16? The DON stated, No. (In response to all three questions) The DON was asked, Why not? The DON stated, I guess because we really didn't think it happened, that they were just fighting . f. On 1/9/16 at 2:40 p.m., the Administrator was asked, On 1/6/16 did you get a statement of concerns from (CNA #1)? The Administrator stated, Yes. The Administrator was asked, What is a CNA covering a resident's mouth with their hand? The Administrator stated, You're going to tell me its abuse aren't you? The Administrator was asked, What did you do? The Administrator stated, We did nothing. The Administrator was asked, What should you have done? The Administrator stated, Send her to the house, go check the resident and start an investigation and report it. The Administrator was asked, What are you going to do now? The Administrator stated, I'm going to go put her off. g. On 1/11/16 at 9:15 a.m., the Administrator stated, (OLTC Staff #1's) done called and asked, why the police weren't notified on all those reports I sent in on Saturday (1/9/16). h. The DMS-7734 OLTC Incident and Accident Report (I & A) form documented, Revised . Date & Time Submitted (if known): 1/9/16. Date & Time of Discovery: 1/6/16 . Staff reporting I & A: (Administrator) . Date of I & A: 1/6/16 Time: (Blank) Name of Injured Resident: (Resident #6) . Type of Incident: Abuse: Physical . Notifications: . Law Enforcement: Yes 7:30 a.m., 1/11/16 . 6. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/15 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS), had no speech, was rarely/never understood, sometimes understands - responds adequately to simple, direct communication only, and weighed 216 pounds. The Resident Plan of Care dated 10/7/15 documented, Communication: Resident has impaired communication as evidence by speech problem: absent. Notation dated, 7/2/15 (Resident) sometimes will nod head yes or no but, infrequent . a. A handwritten statement dated 11/16/15 and signed by the DON documented, (CNA #2) . said (CNA #1), not treating resident right, rough with them . b. A handwritten statement dated 1/6/16 and signed by CNA #2 documented, I witnessed (CNA #1) called (Resident #2) fat, stated, she needed to eat small portions. 1) On 1/8/16 at 1:58 p.m., CNA #2 was asked, Have you ever heard a staff member tell a resident they are fat, chubby and needed to eat smaller portions? CNA #2 stated, Yes. CNA #2 was asked, Which resident? CNA #2 stated, (Resident #2). CNA #2 was asked, When was this? CNA #2 stated, The first part of December 2015. CNA #2 was asked, What did you do? CNA #2 stated, I went to (the) (DON) and she said she'd handle it and she'd take care of it. CNA #2 was asked, What exactly did you tell her (DON)? CNA #2 stated, I told her (CNA #1), that (CNA #1) was rough and calling (Resident #2) Chunky Monkey and she had made (Resident #2) cry several times . CNA #2 was asked, Was there anyone else on the hall who saw or heard (CNA #1) do this? CNA #2 stated, No, it was only me and (CNA #1) on the hall. CNA #2 was asked, Where was the resident when this happened? CNA #2 stated, In a lift. She kept telling her that the entire time during the transfer . I had to go talk with (Administrator) and (CNA #1) in (Administrator's) office and they had me tell (CNA #1) what all I said in front of her. CNA #2 was asked, Did you write out a statement? CNA #2 stated, Yes, they made me. CNA #2 was asked, When did you write out the statement? CNA #2 stated, Wednesday, 1/6/16. 2) On 1/9/16 at 10:30 a.m., CNA #1 was asked, Have you ever heard a staff member tell a resident they are fat, chubby and needed to eat smaller portions? CNA #1 stated, No. CNA #1 was asked, Have you ever told anyone that? CNA #1 stated, No. I have discussed with the nurse about getting smaller portions about one of the residents - (Resident #2) but never in front of the resident. CNA #1 was asked, Did you ever call her a Chunky Monkey? CNA #1 stated, Yes I have. It was Chunk Monk. It was just a nick name I use for (Resident #2). I would say are you ready to get up Chunk Monk. It wasn't used in a mean way towards her. I call her that all the time. CNA #1 was asked, Is it okay for someone to give you a nick name that you didn't ask for and call you that? CNA #1 stated, No. CNA #1 was asked, So why is it okay for you to call the resident Chunk Monk? CNA #1 stated, It's not. c. A handwritten statement dated 1/6/16 at 8:30 a.m. and signed by the DON documented, Had meeting in Administrators (office) with (CNA #2) and (CNA #1) (regarding) conflict between them . (CNA #2) wrote down her concerns of resident care . I had already spoken to (the) resident's on that hall . and found no resident with a complaint on any staff, of any one being mean or mistreating then in any way . We feel this is a personal conflict between these two staff members. d. On 1/9/16 at 1:12 p.m., the DON was asked, Have you ever heard a staff member tell a resident they are fat, chubby and needed to eat smaller portions? The DON stated, I heard that from a CNA. The DON was asked, When did you hear this? The DON stated, Sometime in November 2015. The DON was asked, Who was the resident? The DON stated, (Resident #2). I had 2 aides that started fighting and they both worked 500 hall and they started arguing a lot. (CNA #2) said (CNA #1) called (Resident #2) fat. I talked with (CNA #1) and she said it was an outright lie . The DON was asked, What did you do? The DON stated, I tried to spend more time on the halls to listen and no one else reported it. The DON was asked, If a CNA were to call (Resident #2) a Chunk Monk would that have been okay? The DON stated, No, that's not appropriate. The DON was asked, Were you ever told (Resident #2) had been called Chunky Monkey or Chunk Monk? The DON stated, No this is the first time I've heard of it. The DON was asked, On 1/6/16 you and the Administrator got the statement dated 1/6/16 from (CNA #2)? The DON stated, Yes and I read it . e. On 1/9/16 at 5:00 p.m., this surveyor informed the Administrator that (CNA #1) had stated, she called (Resident #2) Chuck Monk as a nick name. The Administrator stated, I'm not as large as (Resident #2) but if someone called me that it would make me madder than hell. I wasn't aware that was happening. f. On 1/11/16 at 9:15 a.m., the Administrator stated, (OLTC Staff # 1's) done called and asked, why the police weren't notified on all those reports I sent in on Saturday (1/9/16). g. The DMS-7734 OLTC Incident and Accident Report (I & A) form documented, Date & Time Submitted (if known): 1/9/16. Date & Time of Discovery: 1/6/16 . Staff reporting I & A: (Administrator) . Date of I & A: 1/6/16 Time: (Blank) Name of Injured Resident: (Resident #2) . Type of Incident: Abuse: Verbal . Notifications: . Law Enforcement: Yes 7:30 a.m. 1/11/16 . 7. Resident #3 had a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/16 documented the resident scored a 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. A handwritten statement dated 11/16/15 and signed by the DON documented, (CNA #2) . said (CNA #1) used (Resident #3's) perfume . I spoke with (residents) on 500 hall . (Resident #3) denied having any perfume missing . b. On 1/8/16 at 9:30 a.m., the resident was asked, Have you ever had any missing property? The resident stated, Cologne a few weeks ago. The resident was asked, Did you tell anyone? The resident stated, I told a CNA (Certified Nursing Assistant) and they helped me look for it. The resident was asked, Which CNA did you tell? The resident stated, I don't recall. c. On 1/8/16 at 1:02 p.m., CNA #3 was asked, Have any residents complained of missing items? CNA #3 stated, . (Resident #3) complained of missing stuff that she wanted to send home (with) her daughter. I don't remember when . CNA #3 was asked, What did you do (when) the resident told you this? CNA #3 stated, I thought her (family member) took it home or something. CNA #3 was asked, When residents report things are missing and you aren't able to find it then, what do you do? CNA #3 stated, Tell the nurse. I don't think I said anything about (Resident #3's) stuff. d. On 1/8/16 at 1:58 p.m., CNA #2 was asked, Have any residents complained of missing items? CNA #2 stated, (Resident #3) - she didn't tell me, I witnessed it being taken. (CNA #1) sprayed the perfume in the air. She talked about how good it smelled. She said 'Oh, this is called Pretty.' (There is a perfume by Elizabeth Arden by the name of Pretty). She put it in her scrub jacket, walked out (and) said 'I'm jacking this[***]' . CNA #2 was asked, Where was the resident? CNA #2 stated, She was out of the room. CNA #2 was asked, Did you tell anyone? CNA #2 stated, (the) (DON). CNA #2 was asked, When was this? CNA #2 stated, The middle of November. CNA #2 was asked, Did (the) (DON) ask you for a written statement? CNA #2 stated, No. e. On 1/8/16 at 12:35 p.m., the Social Service Director (SSD) was asked to review the Grievance Log with this surveyor. There was no documented grievance related to Resident #3. The Social Service Director was asked, How does the grievance process work? The Social Service Director stated, It depends on the department. If it's belongings it's me and anything else they tell (Administrator) or (DON) and they assign it to a department. The Social Service Director was asked, Have you had any grievances related to (Resident #3) missing perfume? The Social Service Director stated, No, today is the first day I've heard of it. f. On 1/9/16 at 1:12 p.m., the DON was asked, Have any residents complained of missing items? The DON stated, A resident did not . the perfume thing . let's see. (CNA #2) stated, (CNA #1) jacked (Resident #3's) perfume and sprayed it on her to cover up a urine smell. The DON was asked, When was this? The DON stated, In November all about the same time with the other stuff. The DON was asked, What did you do? The DON stated, I asked, the residents if they were missing anything and (Resident #3) said no. The DON was asked, Did you ask (Resident #3) if the CNA had used her perfume? The DON stated, No. I did hear later that (Resident #3's) perfume was missing as they were coming out of a care plan meeting and (the) (Administrator) told (the) (Social Service Director) to follow up. The DON was asked, Are staff supposed to be taking resident items to use, spray, eat, etc.? The DON stated, No they are not. I never thought about them using the resident's perfume before. The DON was asked, Did you start any misappropriation of property investigation? The DON stated, No, there again I talked with (CNA #1) and she denied it. g. The form titled Grievance Log documented, Date: 1/8/16. Resident Name: (Resident #3) . Describe the complaint: Bottle of perfume missing back before Christmas . Name of Person Investigating Complaint: (Social Service Director) . This form was received from the Administrator on 1/9/16 at 10:00 a.m. 1) The Social/Activity Investigation form documented, Date: 1/8/16. Note: SSD went and spoke to elder letting her know this was the first time I had heard of it . Elder stated, the aides would put some on her and sometimes on their selves . When exiting room aid stated, that she watched another aid place it in her pocket and reported it that same day to the DON. SSD called (family member) and she stated, it was back in November (and) she had only had it a (week), reported it to a nurse, unsure of her name, as well as a care plan (CP) meeting . This form was received from the Administrator on 1/9/16 at 10:00 a.m. 2) On 1/11/16 at 10:55 a.m. the Social Service Director was asked, Did you fill out the Social/Activity Investigation form stated, 1/8/16? The Social Service Director stated, Yes. The Social Service Director was asked, Are aides supposed to be putting the resident's perfume on themselves? The Social Service Director stated, No. The Social Service Director was asked, When the CNA stated she watched another aide place the resident's perfume in her pocket, what is that an allegation of? The Social Service Director stated, Theft. The Social Service Director was asked, Is theft abuse? The Social Service Director stated, Yes. The Social Service Director was asked, When someone makes an allegation of abuse, what are you to do? The Social Service Director stated, Report it immediately. The Social Service Director was asked, Did you? The Social Service Director stated, Yes I called (the) (DON) on Friday 1/8/16 after (CNA #2) told me that. The Social Service Director was asked, Do you normally notify the DON and not the Administrator with concerns of or allegations of abuse? The Social Service Director stated, Since it was nursing I called (the) (DON). The Social Service Director was asked, Where do you document whose at the care plan meetings? The Social Service Director stated, The families sign the care plan itself and so do we. I wasn't at the care plan meeting. The Resident Plan of Care dated 11/23/15 documented the Social Service Director was present at this care plan meeting. 3) On 1/11/16 at 4:50 p.m. the DON and Administrator were asked, Did either of you get a call about stolen or missing perfume on 1/8/16? The DON stated, I didn't talk with anyone about perfume. The Administrator stated, I don't remember it. h. On 1/11/16 at 10:45 a.m., the Administrator was asked, Did you have a stand up meeting this a.m.? The Administrator stated, Yes. The Administrator was asked, Did (the) Social Services (Director) tell you about any grievances this a.m.? The Administrator stated, No. The Administrator was asked, Did you know about this grievance regarding (Resident #3)? The Administrator stated, No. This surveyor asked the Administrator to review the grievance and Social/Activity Investigation form that she (Administrator) had given to this surveyor on 1/9/16 at 10:00 a.m. The Administrator stated, This was not

A. Based on record review and interview, the facility failed to ensure an allegation of abuse was immediately reported to the Administrator/designee; an investigation was initiated promptly after receiving an allegation of abuse; and immediate actions were taken to protect from the potential of further abuse during the investigation for 1 (Resident #13) of 1 case mix residents that had voiced an allegation of physical abuse This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Resident #13 who alleged being beaten by persons unknown and had the potential to affect 4 residents who had an allegation of physical abuse in the past 30 days as identified by the Administrator on 8/8/13. The findings are: 1. Resident #13 had [DIAGNOSES REDACTED]. a. A Nurse Note dated 7/7/13 at 10:00 a.m. and signed by LPN (Licensed Practical Nurse) #2 documented, "Elder has [MEDICAL CONDITION] (non pitting) on (left) side of face and 2 sm (small) bruises, states she was beaten up @ (at) 0500 this am (morning) by 2 women. States she didn't actually see them as it was dark. Daughter in law (name) notified. Left note for MD (Medical Doctor)." 1) An Unusual Occurrence Report dated 7/7/13 documented, "Reported at 0600 time of occurrence unknown ...Reported by CNA #2 ...During report nurse stated there is some [MEDICAL CONDITION] on L (left) side of face, when I went into room she has 2 small bruises and some [MEDICAL CONDITION] (non pitting) on L (left) cheek. She states she was beaten up by 2 women, of unknown origin ...Completed by (LPN #2)" 2) On 7/26/12 at 9:00 a.m., LPN #2 was asked if she reported the allegation of abuse voiced by the resident on 7/7/13. She stated, "I just do not recall." b. A Nurses Note dated 7/7/13 at 2:00 p.m. and signed by LPN #1 documented, " ...3 bruises noted to (left) side of face (with) [MEDICAL CONDITION]. Elder stated to this nurse after dinner on 7/6/13 that 'a woman' pulled her hair and dragged her across the floor, hitting her in the face. Elder's (left) side of face appeared to have non-[MEDICAL CONDITION] (no) red areas noted CNA (certified nursing assistant) ...told me that she found elder laying in bed (with) glasses on the floor." A body audit report dated 7/7/13 at 1400 (2:00 p.m.) documented, "Resident has red marks/bruises on L (left) side of cheek. She said that someone came in her room between 0500-0600 (5:00 and 6:00 a.m.) and beat her up. Also said they pulled her hair and hurt her L (left) hip, no bruises to be found on hip. Reported all to nurse (named nurse)." On 7/25/13 at 9:30 a.m., the surveyor asked Licensed Practical Nurse (LPN) #1 if she had seen the resident prior to the resident making the allegation of abuse on 7/7/13. LPN #1 stated, "I talked to her at 2:00 p.m. (7/6/13), when I came on duty and she was fine. No different than usual. About 7:00 p.m. (7/6/13) I went in to give her medications and she told me a woman had come in and slapped her in the face and dragged her across her bed and beat her up. I assessed her and her cheek and face were clear. The surveyor asked LPN #1 if she reported the allegation to anyone. LPN #1 stated, "No." c. A handwritten statement dated 7/9/13 and signed by CNA #11 documented, "7/6/13 Saturday night (Resident #13) told someone dragged her across the bed and beat her up. I reported to Nurse (LPN #1) around 1:00, morning I was getting resident up. I and (LPN #2) walked in woke her (resident) up to look at her face it looked like fluid with red blemishes. 7/7/13 Sunday night (CNA ) on 2-10 shift passed on to me that two women last night beat her (resident) up, (Resident #13) told the same story to me." d. Nurses Notes dated 7/8/13 at 3:00 a.m. and signed by LPN #1 documented, " ...Elder cont (continues) to c/o (complain of) '2 women' coming to her room and 'beating' her up ..." e. Nurses Notes dated 7/9/13 at 4:05 a.m. and signed by LPN #5 documented, "Elder (with) c/o (left) hip pain ...asked elder what she thinks happened to make her hip hurt. Elder stated 'one person rolled her over and beat her while the other person was over there making sure no one coming in.' This nurse asked elder when this happened do you know? Elder stated 'It was 4 or 5 this morning.' Elders call light was on at 0400. 2 aides responded to light together. Aides came to this nurse within one minute after answering call light ...with message of elders c/o pain and elder voicing that 'people beat her up' ..." f. A Nurse Note dated 7/17/13 at 12:45 p.m. documented, "When speaking (with) (resident) she stated (2) women came into her room [ROOM NUMBER]-3 nights ago drug the cover off her and beat her up while the other put (roommate) w/c (wheelchair) against BR (bathroom) door to keep people from coming in. When asked if this was the only time this happened she said 'yes'. No marks noted to rt (right) hip or ribs where she said they beat her ..." g. On 7/24/13 at 11:45 a.m., the resident was asked by the surveyor how the staff treated her. She stated, "Here about a week ago someone came in here way in the night and pulled the cover over me and beat me up. It was dark and I could not see them." i. The Resident Plan of Care documented the last review as 6/6/13. The Plan of Care did not address any behavioral issues. As of 7/23/13, Nurses Notes from 9/10/12 thru 7/23/13 did not address any previous incidents of the resident alleging staff abuse prior to 7/7/13. 2. On 7/24/13 at 9:30 a.m., the surveyor asked the Director of Nurses (DON) if there had been an investigation for the allegation of abuse on 7/7/13 or 7/17/13. The DON stated, "Yes. We did an in house investigation on 7/9/13 when I was informed of the allegation that was made on 7/7/13. I immediately started interviewing staff after I assessed the resident and talked to the resident. We felt like there was no abuse. The resident does get confused and will tell the story over and over. On 7/17/13, I felt like she was still talking about what she thought had happened to her on the 7th. There was no immediate investigation on the 7th because I was not informed until the 9th. There was no protection for the resident. There should have been. The staff all know they should report allegations of abuse immediately." 3. The Immediate Jeopardy was removed on 7/24/13 at 4:18 p.m. and the scope and severity decreased to E with the implementation of the following plan of removal: 1) "On 7/24/13 at 1:53 p.m., the DON and Designee (DON) initiated assessment (of) all current 71 residents for sign(s) of physical and other abuse. 2) The named resident affected was immediately placed on one on one protection during this time of investigation. The facility will notify at 7/24/13 police. 3) The facility will report the allegation to OLTC (Office of Long Term Care). 4) The initial investigation will be completed by 7/25/13. 5) All staff will be inservice(d) in recognize (sic) and reporting abuse beginning 07/24/13 at 2:00 (p.m.) by the DON or Designee. All staff will be inserviced before they are allowed to work to ensure they all have knowledge of abuse report. Inservice will be on going to include new hires and staff returning from leave and will sign they have received the training on abuse reporting. 6) Charge nurse will report all allegations the same day of occurrence and Administrator or manager designee will report to OLTC before 11:00 (a.m.) the following day. 7) The police, family and physician will be notified as required. 8) The DON or Manager Designee will monitor the nurses note(s) daily." B. Based on observation, record review and interview, the facility failed to ensure an allegation of misappropriation of property was thoroughly investigated for 1 (Resident #12) of 3 (Residents #11, 12 and 13) case mixed residents who resided on the 500 hall. This failed practice had the potential to affect 18 residents who resided on the 500 hall according to the Roster Matrix provided by the Administrator on 7/22/13. The findings are: Resident #12 had [DIAGNOSES REDACTED]. a. On 7/22/13 at 4:30 p.m., during initial rounds of the facility, the resident stated, "I had a 20 dollar bill plus a little more and a set of rings stolen from my dresser drawer last week." The surveyor asked the resident if she had reported to anyone that her things were missing. The resident stated, "I told everyone that would listen." b. On 7/25/13 at 1:20 p.m., Licensed Practical Nurse (LPN) #2 was asked by the surveyor if she was aware the resident said she had some money and her rings were missing. LPN #2 stated, "When she came back from the hospital she said she had money missing. Her son was called and said he had her money. Have not heard of any rings missing." c. On 7/25/13 at 1:25 p.m., Certified Nursing Assistance #2 was asked by the surveyor if she was aware the resident said she had some money and rings missing. CNA #2 stated, "She did tell me last week that she had some rings missing. Her son said he had the money. I looked for her rings and did not find them. I reported it to LPN #2." d. On 7/23/13 at 3:35 p.m., the Administrator was asked by the surveyor if she had been informed the resident has said she had a set of rings and some money missing. The Administrator stated, "We had not heard of the rings until last week. I talked to the son and the son said he honestly did not know if the rings were here or at home. He stated she may have come in with the rings and when she goes home for visits she could have hidden it at home. She has gotten where she dose hide things. The Administrator was asked by the surveyor if there was a grievance or write up completed. The Administrator stated, "Did not do a grievance because of what the son said. We did not investigate it. No one has said anything at all about any missing money." e. The Resident's Personal Items Checklist form not dated provided by the facility on 7/26/13 at 9:20 a.m. documented, " 2 Rings."

Based on observation, record review and interview, the facility failed to ensure all allegations of abuse were immediately reported to the Administrator/Designee and a thorough investigation that included a documented physical assessment and staff/resident interviews was conducted for 2 of 2 (Resident #10 and #11) cognitively impaired case mix residents who voiced allegations of abuse. This failed practice had the potential to affect 59 residents who were cognitively impaired as identified by the Director of Nursing on 9/30/13. The findings are: 1. Resident #10 had [DIAGNOSES REDACTED]. The Admission 14 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/9/13 documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), required extensive assistance with Activities of Daily Living and exhibited physical and verbal behaviors. a. A Nurses Note dated 8/27/13 at 3:30 p.m. and signed by Registered Nurse (RN) #1 documented, "Spoke (with) (Resident #10) (reference to) allegation reported to (Administrator)." As of 9/19/13 at 2:45 p.m., there was no documented physical assessment for possible injury from sexual assault in the Nurses Notes. 1) On 9/19/13 at 10:10 a.m., CNA #1 was asked what day the resident voiced an allegation of rape and if she had reported it. She stated, "I reported it to (RN #1) the nurse that day on Friday (8/23/13) and told her again at the restorative meeting on Tuesday (8/27/13). I said remember about (Resident #10) saying he was raped ...I think maybe it was another nurse. Don ' t remember who. I thought I told (RN#1) but it may have been someone else ... " 2) On 9/19/13 at 10:20 a.m., RN #1 was asked when she was told of the allegation of rape voiced by the resident and how was the resident protected. She stated, "When it was told to me in the restorative meeting that (Resident #10) said he had been raped, I reported it to the Administrator and went down and talked to the resident immediately. I'm not sure what day it was on. When I went down to talk with (Resident #10) he was unable to answer my questions but (resident's wife) said she did not think he had been raped. We inserviced staff on not approaching the resident from his back side. She (CNA #1) did not tell me he told her last week that he had been raped. It would have been on Tuesday when she told me. I had not heard of it until the twenty seventh on that Tuesday (8/27/13)." b. The OLTC (Office of Long Term Care) Incident and Accident Report (I & A) DMS (Division of Medical Services) 7734 form dated 8/27/13 time 10:00 a.m. documented, "Type of Incident: Sexual. Summary of Incident: CNA (Certified Nursing Assistant) informed nurse that during incontinent care the resident stated he had been raped. ... Steps taken to prevent continued abuse or neglect during the investigation: Inservice staff on approaching resident from the front and explain what you are doing and why. There are two people doing resident care." c. The DMS-762 Facility Investigation Report documented, "Date and Time of Incident (if known): 8/27/13 Time: 10:00 a.m. (According to CNA #1, the resident alleged rape on 8/23/13), Date and Time of Discovery: 8/27/13 Time: 3:00 p.m., Date Incident Reported to OLTC: 8/28/13 Time: 9:45 a.m." The DMS-762 page 3 documented, "Complete Description of Incident, CNA told nurse that during incontinent care (Resident #10) told her and another CNA that he had been raped. Asked (Resident #10) what happened and when but (Resident #10) was unable to answer. RN went to talk to (Resident #10), spouse was present. Spouse (at) facility a minimum of 3-4 times daily. (Resident #10) was unable to answer appropriately. Spouse stated, "I don't believe he was raped. He had been at the VA (Veteran's Administration) right before coming here and had a bad impaction. They gave him a bunch of enemas and finally had to dig out the impaction with their fingers. His rectum was so big for a while after they did it. My daughter was changing him and saw it and brought it to my attention. I think that's what he is remembering. The VA staff would come up behind him and do the enemas and stuff. Just come up from the front and let him know what you got to do." 1) The OLTC Witness Statement Form dated 8/27/13 (no time) and signed by CNA #1 documented, "... Last week when attempting care (Resident #10) said that he had been raped. Elder did cry and get upset. Reported this to (RN #1)." 2) As of 9/19/13 at 2:30 p.m., there were no other documented Witness Statements attached to the investigation. " Section III - Findings and Actions Taken " documented the resident ' s medical condition, cognitive status, amount of assistance required for activities of daily living and " ...Will ramble with inappropriate answers when asked questions ... " There was no documentation to support the resident was assessed and that other staff/residents were interviewed to determine if allegation was substantiated. 2. Resident #11 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 7/25/13 documented the resident scored 12 (8-12 indicates moderately impaired cognitive skills) on the Brief Interview for Mental Status (BIMS), required extensive assistance of 1 person for toileting and exhibited no behaviors. a. A Nurses Notes dated 9/1/13 and signed by LPN (Licensed Practical Nurse) #2 documented, "R (resident) refused tx (treatment) from nurse on 2-10 and told nurse two teenage girls came in and roughed her up. ..." The Notes documented another staff member was asked to see if the resident would allow her to do the treatment and the resident again refused giving a " similar story. " The notes documented that later the resident refused the fingerstick blood sugar test and when 2nd nurse attempted later resident stated two girls had come in and hurt her. LPN #2 documented in the notes that took another CNA with her to witness further investigation, " R reported she didn ' t know what we were talking about when asked if R was hurt by anyone R stated ' No. ' When asked if anyone was mean to R. R stated no again I asked the question 3 times at different times each answer was no ... " On 9/19/13 at 5:40 p.m., LPN # 2 was asked what she did when the resident voiced the allegation of abuse. She stated, "I left her room and waited about five minutes and asked CNA (CNA #8) to go in and see if she would allow the CNA to apply lotion and A&D ointment. When CNA came back out of the room after about 8-10 minutes, CNA said she refused and told CNA that 2 girls had come in and pinched her bottom. About an hour later, I called DON (Director of Nurses) and she told me to do a follow up investigation and that I should have called immediately." LPN #2 was asked if there was anything she had done to investigate the allegation of abuse other than talk to the resident. She said, "You mean like a body audit? No. I would have done a body audit if the resident had said that yes she was hurt and because she said nothing had happened I did not do a body audit." b. The OLTC I & A DMS 7734 form dated 9/1/13 (no time) documented," Type of Incident: Physical. Summary of Incident: Resident states 2 teenagers come in her room and roughed her up. ... Steps taken to prevent continued abuse or neglect during the investigation: There was a CNA on the hall the rest of time observed no one on hall and no teenagers in building." c. The DMS-762 Facility Investigation Report documented, "Date and Time of Incident (if known): (blank), Date and Time of Discovery: 9/1/13 Time: 8:30 p.m., Date Incident Reported to OLTC: 9/3/13 Time: 10:00 a.m." The DMS-762 page 3 documented, "Complete Description of Incident ... She reported to both CNAs and nurse that 2 teenage girls came in and roughed her up and hurt her arm. ... When second nurse attempted to do blood sugar and treatment she was told she was hurt by 2 girls." The DMS-762 page 4 dated 9/1/13 documented, "Findings and Actions Taken. ... Hall was checked and found no one except staff present. Since resident started denying anyone hurt her findings show she was awakened to do treatment from a nap and was confused for a few minutes then could not remember any problems with the nurse. ..." d. The OLTC Witness Statement Form dated 9/1/13 at 8:30 p.m. and signed by LPN #1 documented, "... Told both CNAs and the nurse that 2 teenage girls had roughed her up and hurt her ..." e. The OLTC Witness Statement Form dated 9/1/13 at 8:30 p.m. and signed by CNA #2 documented, "... told me that two young girls came in and pinched her bottom ..." g. On 9/19/13 at 11:00 a.m., the DON was asked if there was any other investigation done. She stated, "Yes. The nurses checked the halls and did not see anyone in here that wasn't supposed to be. When they asked her about it again she did not remember saying it. So they thought they just had woke her up and she was confused." At 11:10 a.m., the Administrator was asked if there were other interviews conducted. She stated, "Yes. We asked staff." The Administrator was asked where staff interviews were documented. She stated, "I know if you don't document. It wasn't done." The facility was unable to show evidence of further interviews.

Based on observation, record review and interview, the facility failed to ensure the Abuse Prohibition policy and procedure was implemented as evidenced by: The facility's failures to ensure an allegation of abuse was immediately reported to the Administrator/designee; an investigation was initiated promptly after receiving an allegation of abuse; and immediate actions were taken to protect from the potential of further abuse during the investigation for 1 (Resident #13) of 1 case mix residents that had voiced an allegation of physical abuse This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Resident #13 who alleged being beaten by persons unknown and had the potential to affect 4 residents who had an allegation of physical abuse in the past 30 days as identified by the Administrator on 8/8/13. The findings are: 1. The facility's Abuse Policy provided by the Administrator on 7/23/13 documented " ...Policy; It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of patient property and to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriations of patient property (*alleged violations*) are reported immediately to the Administrator of the facility. Such violations will also be reported to state agencies in accordance with existing state law. The facility will investigate each such alleged violation thoroughly and report the results of all investigations to the Administration or his/her designee, as well as to state agencies as required by state and federal law. ... If the circumstance required it, the Director of Nursing or his/her designee shall remove a patient suspected of being the subject of an alleged violation to an environment where the patient's safety can be protected. ..." 2. Resident #13 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/16/13 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS), was independent with activities of daily living and exhibited no behaviors. a. A Nurse Note dated 7/7/13 at 10:00 a.m. and signed by LPN (Licensed Practical Nurse) #2 documented, "Elder has [MEDICAL CONDITION] (non pitting) on (left) side of face and 2 sm (small) bruises, states she was beaten up @ (at) 0500 this am (morning) by 2 women. States she didn't actually see them as it was dark. Daughter in law (name) notified. Left note for MD (Medical Doctor)." 1) An Unusual Occurrence Report dated 7/7/13 documented, "Reported at 0600 time of occurrence unknown ...Reported by CNA #2 ...During report nurse stated there is some [MEDICAL CONDITION] on L (left) side of face, when I went into room she has 2 small bruises and some [MEDICAL CONDITION] (non pitting) on L (left) cheek. She states she was beaten up by 2 women, of unknown origin ...Completed by (LPN #2)" 2) On 7/26/12 at 9:00 a.m., LPN #2 was asked if she reported the allegation of abuse voiced by the resident on 7/7/13. She stated, "I just do not recall." b. A Nurses Note dated 7/7/13 at 2:00 p.m. and signed by LPN #1 documented, " ...3 bruises noted to (left) side of face (with) [MEDICAL CONDITION]. Elder stated to this nurse after dinner on 7/6/13 that 'a woman' pulled her hair and dragged her across the floor, hitting her in the face. Elder's (left) side of face appeared to have non-[MEDICAL CONDITION] (no) red areas noted CNA (certified nursing assistant) ...told me that she found elder laying in bed (with) glasses on the floor." A body audit report dated 7/7/13 at 1400 (2:00 p.m.) documented, "Resident has red marks/bruises on L (left) side of cheek. She said that someone came in her room between 0500-0600 (5:00 and 6:00 a.m.) and beat her up. Also said they pulled her hair and hurt her L (left) hip, no bruises to be found on hip. Reported all to nurse (named nurse)." On 7/25/13 at 9:30 a.m., the surveyor asked Licensed Practical Nurse (LPN) #1 if she had seen the resident prior to the resident making the allegation of abuse on 7/7/13. LPN #1 stated, "I talked to her at 2:00 p.m. (7/6/13), when I came on duty and she was fine. No different than usual. About 7:00 p.m. (7/6/13) I went in to give her medications and she told me a woman had come in and slapped her in the face and dragged her across her bed and beat her up. I assessed her and her cheek and face were clear. The surveyor asked LPN #1 if she reported the allegation to anyone. LPN #1 stated, "No." c. A handwritten statement dated 7/9/13 and signed by CNA #11 documented, "7/6/13 Saturday night (Resident #13) told someone dragged her across the bed and beat her up. I reported to Nurse (LPN #1) around 1:00, morning I was getting resident up. I and (LPN #2) walked in woke her (resident) up to look at her face it looked like fluid with red blemishes. 7/7/13 Sunday night (CNA ) on 2-10 shift passed on to me that two women last night beat her (resident) up, (Resident #13) told the same story to me." d. Nurses Notes dated 7/8/13 at 3:00 a.m. and signed by LPN #1 documented, " ...Elder cont (continues) to c/o (complain of) '2 women' coming to her room and 'beating' her up ..." e. Nurses Notes dated 7/9/13 at 4:05 a.m. and signed by LPN #5 documented, "Elder (with) c/o (left) hip pain ...asked elder what she thinks happened to make her hip hurt. Elder stated 'one person rolled her over and beat her while the other person was over there making sure no one coming in.' This nurse asked elder when this happened do you know? Elder stated 'It was 4 or 5 this morning.' Elders call light was on at 0400. 2 aides responded to light together. Aides came to this nurse within one minute after answering call light ...with message of elders c/o pain and elder voicing that 'people beat her up' ..." f. A Nurse Note dated 7/17/13 at 12:45 p.m. documented, "When speaking (with) (resident) she stated (2) women came into her room [ROOM NUMBER]-3 nights ago drug the cover off her and beat her up while the other put (roommate) w/c (wheelchair) against BR (bathroom) door to keep people from coming in. When asked if this was the only time this happened she said 'yes'. No marks noted to rt (right) hip or ribs where she said they beat her ..." g. On 7/24/13 at 11:45 a.m., the resident was asked by the surveyor how the staff treated her. She stated, "Here about a week ago someone came in here way in the night and pulled the cover over me and beat me up. It was dark and I could not see them." i. The Resident Plan of Care documented the last review as 6/6/13. The Plan of Care did not address any behavioral issues. As of 7/23/13, Nurses Notes from 9/10/12 thru 7/23/13 did not address any previous incidents of the resident alleging staff abuse prior to 7/7/13. 3. On 7/24/13 at 9:30 a.m., the surveyor asked the Director of Nurses (DON) if there had been an investigation for the allegation of abuse on 7/7/13 or 7/17/13. The DON stated, "Yes. We did an in house investigation on 7/9/13 when I was informed of the allegation that was made on 7/7/13. I immediately started interviewing staff after I assessed the resident and talked to the resident. We felt like there was no abuse. The resident does get confused and will tell the story over and over. On 7/17/13, I felt like she was still talking about what she thought had happened to her on the 7th. There was no immediate investigation on the 7th because I was not informed until the 9th. There was no protection for the resident. There should have been. The staff all know they should report allegations of abuse immediately." 4. The Immediate Jeopardy was removed on 7/24/13 at 4:18 p.m. and the scope and severity decreased to E with the implementation of the following plan of removal: 1) "On 7/24/13 at 1:53 p.m., the DON and Designee (DON) initiated assessment (of) all current 71 residents for sign(s) of physical and other abuse. 2) The named resident affected was immediately placed on one on one protection during this time of investigation. The facility will notify at 7/24/13 police. 3) The facility will report the allegation to OLTC (Office of Long Term Care). 4) The initial investigation will be completed by 7/25/13. 5) All staff will be inservice(d) in recognize (sic) and reporting abuse beginning 07/24/13 at 2:00 (p.m.) by the DON or Designee. All staff will be inserviced before they are allowed to work to ensure they all have knowledge of abuse report. Inservice will be on going to include new hires and staff returning from leave and will sign they have received the training on abuse reporting. 6) Charge nurse will report all allegations the same day of occurrence and Administrator or manager designee will report to OLTC before 11:00 (a.m.) the following day. 7) The police, family and physician will be notified as required. 8) The DON or Manager Designee will monitor the nurses note(s) daily." B. Based on observation, record review and interview, the facility failed to ensure an allegation of misappropriation of property was thoroughly investigated for 1 (Resident #12) of 3 (Residents #11, 12 and 13) case mixed residents who resided on the 500 hall. This failed practice had the potential to affect 18 residents who resided on the 500 hall according to the Roster Matrix provided by the Administrator on 7/22/13. The findings are: Resident #12 had [DIAGNOSES REDACTED]. a. On 7/22/13 at 4:30 p.m., during initial rounds of the facility, the resident stated, "I had a 20 dollar bill plus a little more and a set of rings stolen from my dresser drawer last week." The surveyor asked the resident if she had reported to anyone that her things were missing. The resident stated, "I told everyone that would listen." b. On 7/25/13 at 1:20 p.m., Licensed Practical Nurse (LPN) #2 was asked by the surveyor if she was aware the resident said she had some money and her rings were missing. LPN #2 stated, "When she came back from the hospital she said she had money missing. Her son was called and said he had her money. Have not heard of any rings missing." c. On 7/25/13 at 1:25 p.m., Certified Nursing Assistance #2 was asked by the surveyor if she was aware the resident said she had some money and rings missing. CNA #2 stated, "She did tell me last week that she had some rings missing. Her son said he had the money. I looked for her rings and did not find them. I reported it to LPN #2." d. On 7/23/13 at 3:35 p.m., the Administrator was asked by the surveyor if she had been informed the resident has said she had a set of rings and some money missing. The Administrator stated, "We had not heard of the rings until last week. I talked to the son and the son said he honestly did not know if the rings were here or at home. He stated she may have come in with the rings and when she goes home for visits she could have hidden it at home. She has gotten where she dose hide things. The Administrator was asked by the surveyor if there was a grievance or write up completed. The Administrator stated, "Did not do a grievance because of what the son said. We did not investigate it. No one has said anything at all about any missing money." e. The Resident's Personal Items Checklist form not dated provided by the facility on 7/26/13 at 9:20 a.m. documented, " 2 Rings."

Based on observation, record review and interview, the facility failed to ensure the Abuse Prohibition policy and procedure was implemented as evidenced by the facility ' s failure to ensure all allegations of abuse were immediately reported to the Administrator/Designee and a thorough investigation that included a documented physical assessment and staff/resident interviews was conducted for 2 of 2 (Resident #10 and #11) cognitively impaired case mix residents who voiced allegations of abuse. This failed practice had the potential to affect 59 residents who were cognitively impaired as identified by the Director of Nursing on 9/30/13. The findings are: 1. The facility's Abuse Policy provided by the Administrator on 9/19/13 documented "...Policy; It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of patient property and to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriations of patient property (*alleged violations*)(sic) are reported immediately to the Administrator of the facility. Such violations will also be reported to state agencies in accordance with existing state law. The facility will investigate each such alleged violation thoroughly and report the results of all investigations to the Administration or his/her designee, as well as to state agencies as required by state and federal law. ... Investigation: A. The Administrator or Director of Nursing shall conduct all investigations. In the event an alleged violation occurs when neither of these people are in the facility, the charge nurse is responsible for initiating the investigation procedures. B. The investigation shall include interview of employees, visitors or patients who may have knowledge of the alleged incident. Factual information only should be documented, not assumptions or speculation. Written statements from involved parties should be requested. The documentation of the investigation shall be kept in the Administrator's office in an administrative file. ... Protection: A. If the circumstance required it, the Director of Nursing or his/her designee shall remove a patient suspected of being the subject of an alleged violation to an environment where the patient's safety can be protected. ... B. Where the circumstances of the alleged violation warrants, the DON or his/her designee shall initiate a physical and mental assessment of the patient and document the findings..." 2. Resident #10 had [DIAGNOSES REDACTED]. The Admission 14 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/9/13 documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), required extensive assistance with Activities of Daily Living and exhibited physical and verbal behaviors. a. A Nurses Note dated 8/27/13 at 3:30 p.m. and signed by Registered Nurse (RN) #1 documented, "Spoke (with) (Resident #10) (reference to) allegation reported to (Administrator)." As of 9/19/13 at 2:45 p.m., there was no documented physical assessment for possible injury from sexual assault in the Nurses Notes. 1) On 9/19/13 at 10:10 a.m., CNA #1 was asked what day the resident voiced an allegation of rape and if she had reported it. She stated, "I reported it to (RN #1) the nurse that day on Friday (8/23/13) and told her again at the restorative meeting on Tuesday (8/27/13). I said remember about (Resident #10) saying he was raped ...I think maybe it was another nurse. Don ' t remember who. I thought I told (RN#1) but it may have been someone else ... " 2) On 9/19/13 at 10:20 a.m., RN #1 was asked when she was told of the allegation of rape voiced by the resident and how was the resident protected. She stated, "When it was told to me in the restorative meeting that (Resident #10) said he had been raped, I reported it to the Administrator and went down and talked to the resident immediately. I'm not sure what day it was on. When I went down to talk with (Resident #10) he was unable to answer my questions but (resident's wife) said she did not think he had been raped. We inserviced staff on not approaching the resident from his back side. She (CNA #1) did not tell me he told her last week that he had been raped. It would have been on Tuesday when she told me. I had not heard of it until the twenty seventh on that Tuesday (8/27/13)." b. The OLTC (Office of Long Term Care) Incident and Accident Report (I & A) DMS (Division of Medical Services) 7734 form dated 8/27/13 time 10:00 a.m. documented, "Type of Incident: Sexual. Summary of Incident: CNA (Certified Nursing Assistant) informed nurse that during incontinent care the resident stated he had been raped. ... Steps taken to prevent continued abuse or neglect during the investigation: Inservice staff on approaching resident from the front and explain what you are doing and why. There are two people doing resident care." c. The DMS-762 Facility Investigation Report documented, "Date and Time of Incident (if known): 8/27/13 Time: 10:00 a.m. (According to CNA #1, the resident alleged rape on 8/23/13), Date and Time of Discovery: 8/27/13 Time: 3:00 p.m., Date Incident Reported to OLTC: 8/28/13 Time: 9:45 a.m." The DMS-762 page 3 documented, "Complete Description of Incident, CNA told nurse that during incontinent care (Resident #10) told her and another CNA that he had been raped. Asked (Resident #10) what happened and when but (Resident #10) was unable to answer. RN went to talk to (Resident #10), spouse was present. Spouse (at) facility a minimum of 3-4 times daily. (Resident #10) was unable to answer appropriately. Spouse stated, "I don't believe he was raped. He had been at the VA (Veteran's Administration) right before coming here and had a bad impaction. They gave him a bunch of enemas and finally had to dig out the impaction with their fingers. His rectum was so big for a while after they did it. My daughter was changing him and saw it and brought it to my attention. I think that's what he is remembering. The VA staff would come up behind him and do the enemas and stuff. Just come up from the front and let him know what you got to do." 1) The OLTC Witness Statement Form dated 8/27/13 (no time) and signed by CNA #1 documented, "... Last week when attempting care (Resident #10) said that he had been raped. Elder did cry and get upset. Reported this to (RN #1)." 2) As of 9/19/13 at 2:30 p.m., there were no other documented Witness Statements attached to the investigation. " Section III - Findings and Actions Taken " documented the resident ' s medical condition, cognitive status, amount of assistance required for activities of daily living and " ...Will ramble with inappropriate answers when asked questions ... " There was no documentation to support the resident was assessed and that other staff/residents were interviewed to determine if allegation was substantiated. 3. Resident #11 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 7/25/13 documented the resident scored 12 (8-12 indicates moderately impaired cognitive skills) on the Brief Interview for Mental Status (BIMS), required extensive assistance of 1 person for toileting and exhibited no behaviors. a. A Nurses Notes dated 9/1/13 and signed by LPN (Licensed Practical Nurse) #2 documented, "R (resident) refused tx (treatment) from nurse on 2-10 and told nurse two teenage girls came in and roughed her up. ..." The Notes documented another staff member was asked to see if the resident would allow her to do the treatment and the resident again refused giving a " similar story. " The notes documented that later the resident refused the fingerstick blood sugar test and when 2nd nurse attempted later resident stated two girls had come in and hurt her. LPN #2 documented in the notes that took another CNA with her to witness further investigation, " R reported she didn ' t know what we were talking about when asked if R was hurt by anyone R stated ' No. ' When asked if anyone was mean to R. R stated no again I asked the question 3 times at different times each answer was no ... " On 9/19/13 at 5:40 p.m., LPN # 2 was asked what she did when the resident voiced the allegation of abuse. She stated, "I left her room and waited about five minutes and asked CNA (CNA #8) to go in and see if she would allow the CNA to apply lotion and A&D ointment. When CNA came back out of the room after about 8-10 minutes, CNA said she refused and told CNA that 2 girls had come in and pinched her bottom. About an hour later, I called DON (Director of Nurses) and she told me to do a follow up investigation and that I should have called immediately." LPN #2 was asked if there was anything she had done to investigate the allegation of abuse other than talk to the resident. She said, "You mean like a body audit? No. I would have done a body audit if the resident had said that yes she was hurt and because she said nothing had happened I did not do a body audit." b. The OLTC I & A DMS 7734 form dated 9/1/13 (no time) documented," Type of Incident: Physical. Summary of Incident: Resident states 2 teenagers come in her room and roughed her up. ... Steps taken to prevent continued abuse or neglect during the investigation: There was a CNA on the hall the rest of time observed no one on hall and no teenagers in building." c. The DMS-762 Facility Investigation Report documented, "Date and Time of Incident (if known): (blank), Date and Time of Discovery: 9/1/13 Time: 8:30 p.m., Date Incident Reported to OLTC: 9/3/13 Time: 10:00 a.m." The DMS-762 page 3 documented, "Complete Description of Incident ... She reported to both CNAs and nurse that 2 teenage girls came in and roughed her up and hurt her arm. ... When second nurse attempted to do blood sugar and treatment she was told she was hurt by 2 girls." The DMS-762 page 4 dated 9/1/13 documented, "Findings and Actions Taken. ... Hall was checked and found no one except staff present. Since resident started denying anyone hurt her findings show she was awakened to do treatment from a nap and was confused for a few minutes then could not remember any problems with the nurse. ..." d. The OLTC Witness Statement Form dated 9/1/13 at 8:30 p.m. and signed by LPN #1 documented, "... Told both CNAs and the nurse that 2 teenage girls had roughed her up and hurt her ..." e. The OLTC Witness Statement Form dated 9/1/13 at 8:30 p.m. and signed by CNA #2 documented, "... told me that two young girls came in and pinched her bottom ..." g. On 9/19/13 at 11:00 a.m., the DON was asked if there was any other investigation done. She stated, "Yes. The nurses checked the halls and did not see anyone in here that wasn't supposed to be. When they asked her about it again she did not remember saying it. So they thought they just had woke her up and she was confused." At 11:10 a.m., the Administrator was asked if there were other interviews conducted. She stated, "Yes. We asked staff." The Administrator was asked where staff interviews were documented. She stated, "I know if you don't document. It wasn't done." The facility was unable to show evidence of further interviews. 4. On 9/20/13 at 10:55 a.m., the Administrator was asked, "What type of procedure is there to make sure the nursing needs of the residents are met?" The Administrator stated, "In regard to the Abuse investigation, I don't know how to answer that since it fell through." The Administrator was asked, "How do you monitor staff to ensure the systems they monitor are being done sufficiently?" The Administrator stated, "I don't know how to answer that." The Administrator was asked, "How do you think this incident came about?" The Administrator stated, "Because our investigation wasn't complete. We didn't monitor the halls and we didn't do body audits." The Administrator was asked, "What resources are available to you and your staff?" The Administrator stated, "We have the book and power point presentation (on Abuse Prohibition) from (The Office of Long Term Care)." The Administrator was asked, "Have you trained the nurses in Abuse investigation?" The Administrator stated, "No ...." 5. On 9/20/13 at 11:00 a.m., the Director of Nursing (DON) was asked, "What training did you ensure the nurse's had on how to investigate a resident with an allegation of abuse?" The DON stated, "We've inserviced several times on reporting immediately." The DON was asked, "Did you inservice on investigation?" The DON stated, "Probably not." Then the DON stated, "Not thoroughly enough." The DON was asked, "Did you inservice on how to protect?" The DON stated, "I tell them to check on them frequently." The DON was asked, "For allegations of physical abuse, did you include checks of the body for evidence of abuse?" The DON stated, "I don't think I did."