Every finding on record at Mid-Del Skilled Nursing and Therapy

Based on observation and interview, the facility failed to ensure: a. food products were stored below 41 degrees F for 1 (milk cooler) of 2 coolers observed, and b. the low temperature dish machine was dispensing the correct concentration of sanitizer for 1 of 1 kitchen observation. [NAME] #1 identified 45 residents received services from the kitchen.Findings: On 08/11/26 at 10:18 a.m., during an initial tour of the kitchen, the thermometer in the two-door milk cooler read 60 degrees F. The internal temperature of a gallon of 2% milk was 50 degrees F, a plastic bag of ready to eat hot dogs was 50 degrees F, and a plastic bag of ready to eat ground sausage was 49 degrees F. On 08/11/26 at 10:33 a.m., during an initial tour of the kitchen, [NAME] #2 was observed operating the low temperature dish machine and the chemical sanitizer when tested read 0 parts per million. On 08/11/26 at 10:26 a.m., the director of culinary stated food products stored in the cooler were to be held below 41 degrees F. On 08/11/26/26 at 10:36 a.m., [NAME] #2 stated they could not remember what the range was for the chemical sanitizer on the low temperature dish machine. They stated they thought 100 to 150 if they remembered correctly. On 08/11/26 at 10:39 a.m., the director of culinary stated the sanitizer should be between 50 to 100 parts per million, and the dish machine should be checked at least three times a day.

Based on observation, record review, and interview, the facility failed to ensure showers were provided to 1 (#41) of 2 sampled residents reviewed for activities of daily living. The administrator identified 45 residents resided in the facility.Findings: A policy titled Nursing Skills Guideline, revised 03/2025, read in part, Final Steps .Document the procedure per facility standards .Shower, 7. Complete Final Steps.An undated shower schedule for Resident #41 showed showers were to be given three times a week and as needed (Monday, Wednesday, and Friday).Documentation Survey Report sheets for Resident #41, dated 07/2026 and 08/2026, showed showers were not given on the following dates:a. 07/10/26 (Friday),b. 07/17/26 (Friday),c. 07/20/26 (Monday),d. 07/22/26 (Wednesday),e. 07/31/26 (Friday),f. 08/07/26 (Friday), andg. 08/10/26 (Monday).On 08/11/26 at 10:20 a.m., Resident #41 stated they were having a hard time getting a shower. Resident #41 stated their shower days were Monday, Wednesday, and Friday, but they hadn't received a shower on Monday. Resident #41 stated they had requested a shower this morning, but no one had responded to them.On 08/12/26 at 12:06 p.m., Resident #41 stated they had never received a shower on Tuesday or today. On 08/12/26 at 2:44 p.m., Certified Nursing Assistant #1 stated they had not documented showers. CNA #1 stated they gave their shower sheets to the nurse and the nurse documented them.On 08/12/26 at 2:52 p.m., the assistant director of nursing acknowledged there was no documentation of a shower having been completed for Resident #41 on 07/10/26, 07/17/26, 07/20/26, 07/22/26, 07/31/26, 08/07/27 and 08/10/26. On 08/12/26 at 4:29 p.m., the director of nursing stated staff were expected to document showers.

Based on record review and interview, the facility failed to notify a resident's family member listed as the emergency contact, of a change in condition for 1 (#2) of 3 sampled residents reviewed for notification of change related to assess, monitor, and intervene. The ADON identified 38 residents resided in the facility. Findings: A policy titled Resident's Family or Physician Notification of Change Guideline, dated 12/01/09, read in part, The facility will inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or interested family member of the following events: .A significant change in the resident's physical, mental, or psychosocial status. (i.e. [that is/or in other words] a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. A quarterly resident assessment, dated 02/25/25, showed Resident #2 had a BIMS of 03 meaning severely impaired cognition. Resident #2's face sheet, dated 09/04/24, showed the resident had diagnoses which included dysarthria and anarthria, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and unspecified dementia without behavior disturbance. A Nurses Progress Note, dated 04/27/25 at 8:24 p.m., read in part, Resident was acting lethargic and not talkative as normal. Resident only ate 20% at dinner and drank 30% of juice. Nurse called on call provider. [provider name withheld] stated since there was no abnormal finding to vitals and resident was alert and coherent, [they] answered by continuing to monitor resident. [Provider name withheld] will be rounding tomorrow, and was advise for resident to be seen by PCP [primary care physician]. Nurse continued to monitor through out shift and night shift. Resident was placed in bed, with call light in reach. v/s [vital signs] bp [blood pressure] 123/71, p [pulse]69, 95% ra [room air]. No pain stated. There was no documentation the emergency contact was notified of Resident #2's change in condition. On 05/15/25 at 1:54 p.m., LPN #1 read the nurse progress note dated 04/27/25 at 8:20 p.m. LPN #1 stated they did not see documentation the family was notified. LPN #1 stated the family should have been notified of any change of condition.

Based on record review and interview, the facility failed to ensure a care plan was fully developed for 1 (#2) of 7 sampled residents whose care plans were reviewed. The ADON identified 38 residents resided in the facility. Findings: An undated paper copy labeled patient identification card showed Resident #2 had an insertable cardiac monitor (loop monitor). The document showed the monitor was implanted 08/21/23. Resident #2's face sheet, dated 09/04/24, showed the resident had diagnoses which included dysarthria and anarthria, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and unspecified dementia without behavior disturbance. A history and physical, dated 09/05/24, showed Resident #2 had a loop monitor recorder insertion. A progress note, dated 10/28/24, showed Resident #2 had no a-fibrillation on the implantable loop monitor. A quarterly resident assessment, dated 02/25/25, showed Resident #2 was admitted to the facility on [DATE] and had a BIMS of 03 meaning severely impaired cognition. Resident #2's care plan, dated 03/18/25, did not show the resident had a loop monitor. A physician order, dated 05/02/25, showed to ensure monitor for loop was plugged in and functioning every shift at bedside. The facility was aware the resident had an implanted loop monitor and did not care plan it until after the resident returned from a hospital stay on 05/02/25. On 05/14/25 at 2:36 p.m., certified nurse aide #1 stated they were not aware of a medical device for Resident #2. On 05/15/25 at 1:51 p.m., LPN #1 stated Resident #2 did not have an order for the loop monitor prior to a recent hospital stay on 04/28/25. They stated the nurses knew about the monitor through report. They stated the loop monitor looked like a cell phone and the order was recently placed to make sure everyone knew about it. LPN #1 stated Resident #2 always had it. On 05/16/25 at 11:13 a.m., MDS coordinator #1 stated a care plan gave a summary of the residents' diagnoses, medications, and everything pertinent in their care. They stated the loop monitor was placed on Resident #2's care plan on 05/05/25. On 05/16/25 at 11:15 a.m., MDS coordinator #1 stated Resident #2 had the loop monitor prior to their recent hospital stay of 04/28/25. They stated they cared for the resident prior to becoming the MDS coordinator and could not speak on why the loop monitor was not present on the care plan then. They stated Resident #2's guardian took care of the monitor and just asked the staff to make sure it was on the resident. MDS Coordinator #1 stated outside of seeing the monitor, and knowing the resident and the family, staff would not have known.

Based on observation, record review, and interview, the facility failed to follow hospital transfer orders for 1 (#5) of 1 sampled resident reviewed for respiratory care . The ADON reported 38 residents resided in the facility. Findings: On 05/02/25 at 5:24 a.m., Resident #5 was observed laying in bed with eyes closed. Resident #5 was not observed to wear oxygen, CPAP or BIPAP. An undated medical diagnoses list for Resident #5 showed diagnosis of unspecified asthma. Resident #5's transfer orders from the hospital, dated 04/11/25, showed General Instructions for oxygen at 4 liters/minute by nasal cannula continuously. The orders showed a diagnoses of obesity hypoventilation syndrome and chronic respiratory failure, and CPAP/BIPAP instructions. Resident #5's care plan, initiated on 03/11/25, showed oxygen 1-4 liters as needed. The April and May 2025 treatment record for Resident #5 did not show continuous oxygen at 4 liters. The facility did not follow/implement the hospital orders for oxygen and CPAP/BIPAP. On 05/16/25 at 1:51 p.m., LPN #1 stated the process for new orders upon readmission was to check the orders and compare them to the profile and make changes as needed. LPN #1 stated if there were questions they would call the provider. On 05/16/25 at 1:54 p.m., LPN #1 stated after review of Resident #5's orders and the hospital transfer order general instructions from the 05/02/25 hospital discharge, they did not see a facility order for the CPAP/BIPAP. LPN #1 stated they could not locate the hospital diagnoses of obesity hypoventilation syndrome and chronic respiratory failure, and CPAP/BIPAP instructions in the facility's electronic medication record. They stated the general instructions/orders for oxygen were not implemented.

Based on record review and interview, the facility failed to ensure residents were instructed arbitration agreements were voluntary for 3 (# 5, 34, and #43) of 5 sampled residents reviewed for arbitration agreements The administrator identified 40 residents who had entered into a binding arbitration agreement. Findings: An undated document titled An Explanation to the Resident/Family, read in part, By signing our admission contract your electronic signature will be placed on the following forms, which you will receive copies of after signing. Admission Agreement/Arbitration/Medical Records Release Form: This agreement allows for admission into the facility, gives the facility consent to provide medical care/treatment, consent to have your medical records, and bill for your medical care. An admission packet, revised 11/29/22, showed DocuSign (signature) was set up in which the resident/resident's legal representative agreed to everything inside of the admission packet with just one signature. The arbitration agreement was part of the admission packet and was agreed to upon admission for everyone admitted to the facility. 1. Resident #5 was admitted on [DATE] and signed the arbitration agreement, but there was no date on the agreement. 2. Resident #34 was admitted on [DATE] and signed the arbitration agreement on 9/03/24. 3. Resident #43 was admitted on [DATE] and signed the arbitration agreement on 2/13/25. On 3/17/25 at 2:01 p.m., the administrator stated everyone signed the arbitration agreement. On 3/18/25 at 12:48 p.m., the admissions coordinator stated, I was told in training that if the resident or representative didn't sign the admission agreement including the arbitration agreement then there was nothing we could do for them. The admissions coordinator stated if the resident did not sign then they could not be admitted to the facility. On 3/18/25 at 2:27 p.m., the administrator stated they did not realize they were out of compliance.

Based on record review and interview, the facility failed to ensure a resident was not involuntarily discharged for one (#149) of one sampled residents reviewed for involuntary discharge. The administrator identified 45 residents resided in the facility. Findings: Resident #149 had diagnoses which included Alzheimer's disease and dementia. Resident #149's quarterly resident assessment, dated 05/16/23, documented the resident had severe cognitive impairment. A Social Service Note, dated 06/21/23, documented Resident #149 had memory issues and wandered a lot throughout the day and night. Resident #149's discharge return not anticipated resident assessment, dated 07/29/23, documented Resident #149 was discharged on [DATE]. It documented Resident #149's decision making skills were moderately impaired. A Nurses Note, dated 07/29/23 at 3:15 a.m., documented Resident #149 was observed in another Resident's room exposed. It documented Resident #149 was discharged to the hospital and an emergency order of discharge sent with law enforcement. Resident #149's care plan, revised 08/07/23, documented Resident #149 wandered. It documented behavior monitoring three times a day was initiated on 12/09/21. On 11/22/23 at 9:01 a.m., the administrator stated Resident #149 was discharged to the hospital on 07/29/23. On 11/22/23 at 9:02 a.m., the administrator stated EMSA brought Resident #149 back to the facility in the morning but the facility denied re-entry. On 11/22/23 at 9:03 a.m., the administrator stated Resident #149 was discharged to the hospital with an emergency order of discharge so the facility could not allow the resident's entry back to the facility. On 11/22/23 at 9:04 a.m., the administrator and DON stated EMSA took Resident #149 back to the hospital. On 11/22/23 at 9:09 a.m., the DON stated Resident #149 had never exhibited sexual behaviors in the facility prior to the documented incident on 07/29/23. On 11/22/23 at 12:04 p.m., the DON stated they could not locate any behavior monitoring as documented on the care plan for Resident #149.

Based on observation, record review and interview, the facility failed to ensure expired medications were removed from circulation for one (#42) of three sampled residents observed during medication pass and storage. The administrator identified 45 residents resided in the facility. Findings: The MEDICATION STORAGE IN THE FACILITY policy, dated 01/22, read in part, .Outdated .medications .are immediately removed from inventory, disposed of according to procedures for medication disposal . Resident #9 had diagnoses which included arthropathy and depression. A physician's order, dated 11/16/23, documented boswellia [NAME] 150 mg give two capsules one time a day. On 11/21/23 at 7:59 a.m., CMA #1 handed the surveyor a bottle of boswellia [NAME] 150 mg with Resident #42's name written on the bottle. The manufacturer's expiration date documented 05/23. There was no open date on the bottle. On 11/21/23 at 8:00 a.m., CMA #1 stated the manufacturer's expiration date documented on the bottle was 05/23. They stated the medication was expired and should be discarded. On 11/21/23 at 8:02 a.m., the DON stated the manufacturer's expiration date documented on the bottle was 05/23. They stated the medication was expired and should be discarded.

Based on record review, observation, and interview, the facility failed to ensure a physician's order had been obtained for oxygen for one (#43) of one sampled resident reviewed for oxygen services. The administrator identified six residents with orders for oxygen. Findings: A Respiratory Therapy policy, dated 08/10/04, documented oxygen therapy would be administered as needed and directed by the ordering physician. It documented to obtain an order from a physician. Resident #43 readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Baseline care plan, dated 10/21/22, documented the resident used oxygen at four LPM. On 10/23/22 at 1:58 p.m., Resident #43 was observed in his room lying in bed. The resident had a nasal cannula in place and was receiving oxygen at 6 LPM from an oxygen concentrator. Resident #43's physician's orders did not document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/23/22 2:07 p.m., LPN #2 was asked what Resident #43's order was for oxygen. The LPN was observed to look in the EMR to find the order. LPN #2 stated they didn't see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/23/22 at 2:15 p.m., LPN #2 was shown Resident #43 in the resident's room. LPN #2 stated the resident was getting six liters of oxygen.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5 percent. The medication error rate was 19.23 percent. The Resident Census and Conditions of Residents report, dated 10/24/22, documented 47 residents resided in the facility. Findings: A Preparation for Medication Administration policy, revised on 08/14/07, documented medications were administered as prescribed, and the medication and dosage on the residents' MAR was compared with the medication label. 1. Resident #18 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/23/22 at 11:12 a.m., ACMA #1 was observed to administer five mls of [MEDICATION(S)] to Resident #18. 2. Resident #10 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/23/22 at 11:31 a.m., CMA #2 was observed to administer one tablet of [MEDICATION(S)] 200 mg, one tablet of [MEDICATION(S)] 2.5 mgs, and two drops of artificial tears to both eyes to Resident #10. 3. Resident #43 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/23/22 at 11:48 a.m., CMA #2 was observed to administer one [MEDICATION(S)] 25mcg tablet to Resident #43. On 10/23/22 at 1:48 p.m., CMA #2 was asked how they were made aware of what medications to administer. CMA #2 stated the MAR gave them the name, medication, and dose. They stated they would match the card and the dose to the order on the screen. CMA #2 stated If the medications were in a card,the dose would be on the label. They stated if the medications was a liquid, they matched it up to the MAR and poured the amount stated. CMA #2 was what the facility' s policy was for administering medications. They stated to administer in a timely manner, and to double check and make sure the resident is getting the medication on the MAR. On 10/24/22 at 8:13 a.m., the interim DON was made aware of the medication error rate of 19.23 percent.

Based on record review and interview, the facility failed to ensure a [CONDITION(S)] resident was assessed before and after [CONDITION(S)] for one (#43) of one sampled resident reviewed for [CONDITION(S)]. The Resident Census and Conditions of Residents report, dated 10/24/22, documented four residents received [CONDITION(S)] services. Findings: Resident #43 readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility calendar documented the resident received [CONDITION(S)] services three times weekly on Mondays, Wednesdays, and Fridays. April 2022 [CONDITION(S)] assessments had been conducted three out of 11 opportunities. May 2022 [CONDITION(S)] assessments had been conducted one out of 13 opportunities. June 2022 [CONDITION(S)] assessments had been conducted zero out of 13 opportunities. July 2022 [CONDITION(S)] assessments had been conducted one out of 13 opportunities. A care plan, dated 07/21/22, documented the resident received [CONDITION(S)] three times weekly, to check the [CONDITION(S)] port for patency and signs and symptoms of infection, and to send the communication form to [CONDITION(S)] with the resident. August 2022 [CONDITION(S)] assessments had been conducted three out of 14 opportunities. September 2022 [CONDITION(S)] assessments had been conducted two out of 13 opportunities. October 2022 [CONDITION(S)] assessments had been conducted five out of 12 opportunities. A Resident Assessment, dated 10/07/22, documented the resident had been receiving [CONDITION(S)] services. On 10/23/22 at 1:56 p.m., Resident #43 was asked if they received [CONDITION(S)] services. They stated they did. The Resident was asked if the facility did vital signs and an assessment prior to and after [CONDITION(S)]. They stated yes. On 10/25/22 at 11:24 a.m., LPN #2 was asked what days Resident #43 went to [CONDITION(S)]. They stated Mondays, Wednesdays, and Fridays at 11:45 a.m. LPN #2 was asked when they assessed [CONDITION(S)] residents. They stated they did a full set of vital signs prior to the resident leaving for [CONDITION(S)]. They stated the [CONDITION(S)] communication form was in computer. LPN #2 stated they would print out the form and send it with the resident to [CONDITION(S)] and that the [CONDITION(S)] center would sometimes send it back. LPN #2 was observed looking in the EMR and stated the last [CONDITION(S)] communication form completed was on 10/14/22. They stated the resident had readmitted on [DATE] and there were none since admission. On 10/25/22 at 3:44 p.m., the interim DON was asked what the policy was for assessing a [CONDITION(S)] resident. She stated the facility used a [CONDITION(S)] communication assessment form. She stated staff assessed the resident prior to going to [CONDITION(S)], filled out the assessment and sent it with the resident to [CONDITION(S)]. The interim DON was informed the assessments/communications had not been conducted per their policy.

Based on record review, observation, and interview, the facility failed to ensure medications were secured for one of two treatment carts observed for medication storage. The facility identified two treatment carts. Findings: A Medication Storage in the Facility policy, documented medications and biologicals are stored safely, securely and carts are locked when not attended by persons with authorized access On 10/23/22 at 11:25 a.m., a treatment cart for hall 200 was observed with keys in the lock, and unsecured without staff present. LPN #1 was observed to exit a room at the end of the hall. On 10/23/22 at 11:30 a.m., LPN #1 was asked how they ensured medications were secured. LPN #1 stated by locking the cart. LPN #1 was made aware of the keys observed in the treatment cart lock. They were asked the policy for securing medications. LPN #1 stated to keep the cart locked and to always have keys with them.

Based on record review, observation, and interview, the facility failed to ensure a catheter bag drainage bag was properly placed to avoid cross contamination for one (#38) of one sampled resident reviewed for urinary catheters. The Resident Census and Conditions of Residents report, dated 10/24/22, documented four residents with catheters. Findings: A Catheter Care policy, revised 04/05/13, documented to never allow any part of the drainage bag or tubing to touch the floor. Resident #38 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/23/22 at 12:16 p.m., Resident #38 was observed in bed supine. A catheter drainage bag was observed secured to the lower bed frame. The drainage was observed to be open. On 10/23/22 at 12:44 p.m., CNA #2 was observed to lower Resident #38's bed. When the bed was lowered, the catheter drainage bag with the open drain was observed laying on the floor. On 10/23/22 at 1:40 p.m., LPN #2 was asked what the policy was for positioning a catheter drainage bag to prevent cross contamination. They stated to keep the drainage bag should be stored below the level of the bladder and secured to the bed frame or hooked underneath their wheelchair. LPN #2 was shown Resident 38's catheter drainage bag on the floor with the drain open. They stated, it shouldn't be touching floor.

Based on observation, record review, and interview, the facility failed to ensure quarantine precautions were initiated in an effort to prevent the spread of COVID-19 for two residents (#2 and #5) of four sampled residents reviewed for infection control. The administrator identified 38 residents resided in the facility. Findings: A policy and procedure guide titled, Handling Admissions or Readmissions to the Facility and Following Quarantine requirements during COVID-19 Pandemic, read in part, .(Unvaccinated) New admissions and readmissions whose COVID-19 status is unknown should be placed on quarantine for 14 days in a single room in a separate observation area so the resident can be monitored for evidence of COVID-19 . On 10/18/21 at 3:30 p.m., the administrator was asked if the facility had any residents with COVID-19 or any residents who were on quarantine. He stated, No. At 3:40 p.m., an observation of the nursing home was conducted and no rooms were noted to have signage for TBP. No rooms were observed with PPE stations outside the rooms. 1. Resident #2 was admitted on [DATE]. A COVID-19 vaccination questionnaire, dated 10/01/21, documented Resident (Res) #2 had not received the COVID-19 vaccine. Res #2 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/18/21 at 3:50 p.m., the resident was observed in the commons area without a mask with five other residents. At 5:15 p.m., the resident's room was observed. There was not any signage on the door to signify the resident was on quarantine. There was not PPE located outside the door. 2. Resident (Res) #5 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A COVID-19 vaccination questionnaire, dated 10/07/21, documented the resident had not received the COVID-19 vaccine. On 10/18/21 at 5:20 p.m., CNA #1 was observed exiting the resident's room. The CNA was asked what PPE was worn while obtaining vital signs and providing direct care to the resident. He stated he wore gloves and a surgical mask. He was observed to doff his gloves outside the room and place the gloves in a trash can. The vital signs machine was not observed to be sanitized. It was placed in the hall. At 5:30 p.m., the DON was asked if Res #2 and #5 should have been on quarantine. She stated, Yes. She was asked if there should be signage on the door to indicate quarantine. She stated, Yes. She was asked if Res #2 should be in the commons area. She stated, No. At 6:00 p.m., the administrator was observed pushing resident #5 outside to smoke. The resident was observed without a mask.

Based on observation, record review and interview, it was determined the facility failed to ensure physician's orders were implemented for the routine administration of a pain medication for one (#3) of three sampled residents who were reviewed for implementing physicians orders. The facility identified 41 residents who resided in the facility. Findings: Resident #3 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The five day assessment, dated 08/01/21, documented the resident's cognition was intact, and received scheduled, as needed and non pharmacological pain therapies. The treatment administration record, dated 09/08/21 at 10:47 p.m., documented the resident was to receive [MEDICATION(S)] (a narcotic pain medication) every two hours as needed for air hunger. The treatment administration record, dated 09/12/21 at 2:31 p.m., documented the resident was to receive [MEDICATION(S)] every two hours related to [CONDITION(S)]. Documentation indicated the resident received the medication as ordered. The 'INDIVIDUAL PATIENT'S NARCOTICS RECORD' documented on 09/12/21, the resident received a dose of [MEDICATION(S)] at 9:00 p.m. There was no documentation to indicate the medication was administered at 11:00 p.m. On 12/13/21, the record documented the received the medication at 5:00 a.m., and did not receive another dose until 11:00 a.m. There was no documentation to indicate the medication was administered at 7:00 a.m. or 9:00 a.m. The record documented there was 9 milliliters (mls) remaining in the bottle. On 09/13/21 at 12:11 p.m., the resident was observed in bed and did not respond to verbal questions. Family members were seated at the residents bedside. They were asked if the resident was kept comfortable. They stated, no. She was not receiving her pain medication as ordered. The last time the resident was observed to receive pain medication was at 9:37 a.m. At 3:10 p.m., family members were at the bedside. They were asked about the residents pain. They stated she was just administered some medication. They did not understand why the resident could not have her pain medication every two hours as ordered. At 3:38 p.m., the corporate nurse and area administrator were shown the treatment record and the sign out sheet. The corporate nurse stated the new order for every two hours started on 09/12/21 at 3:00 p.m. Licensed practical nurse (LPN) #1 was asked to verify the amount of [MEDICATION(S)] [MEDICATION(S)] was in the bottle. He and certified medication aide (CMA) #1 were asked how many mls were observed in the medication bottle. The LPN stated approximately 9.5 mls and CMA #1 was in agreement. The administrator was informed of the observations and interviews. She stated she would start in-servicing staff. On 09/15/21 at 9:00 a.m., the corporate nurse provided another 'INDIVIDUAL PATIENT'S NARCOTICS RECORD' which documented the resident received the medication on 009/13/21 at 9:00 a.m. The record documented there were 29 mls left in the medication bottle.

Based on observation, interview, and record review, it was determined the facility failed to provide assistance with activities of daily living for one (#4) of three residents observed for assistance with activities of daily living. Findings: Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment, dated 08/22/21, documented the resident's cognition was moderately impaired, required extensive assistance of one staff for be mobility and personal hygiene. The assessment documented the required limited assistance on one staff member for toilet use. On 09/13/21 at 12:20 p.m., resident #4 was heard yelling for someone to please come take her to the bathroom. Outside the resident's door was a table with a computer. A staff member was observed sitting there looking at the screen. At 12:21 p.m., the resident yelled out three more times for someone to come and assist her to the bathroom. The staff member continued to sit at the computer. At 12:22 p.m., the resident yelled out, I can't make it to the bathroom, I'll fall. You are going to have to come help me. The staff member continued to sit at the computer. At 12:23 p.m., the resident yelled out, Do you hear me? There were no other staff member observed on the hall. At 12:24 p.m., the social services staff came down to the room to see what she needed. The resident stated she needed to go to the bathroom. The social service staff informed her she would get a certified nurse aide (CNA) to come and help her. The resident contained to yell out she needed help. At 12:26 p.m. CNA #1 entered the room to assist the resident. On 09/14/21 at 3:38 p.m., one of the administrators and the area administrator were asked who was responsible to answer call lights. The administrator stated anyone can answer the call light. They were informed of the above observation. The administrator stated she was a new staff completing training, but could have answered the light to see what was needed.

Based on observation, interview, and policy review, the facility failed to ensure two Certified Nursing Assistants (Certified Nurse Assistant (CNA)1 and CNA2), assigned to the COVID-19 recovering unit, and one Nurse Practitioner (NP), maintained infection control precautions for 16 residents This failed practice increased the possible spread of infection by allowing the staff to care for residents without following proper infection control procedures. Findings include: During tour of the facility on 12/02/20 at 9:00 AM, the Regional Nurse Consultant (RNC) stated the expectation on the COVID-19 recovering unit and the active COVID-19 unit, is that staff would wear masks and face shields throughout the units and put on gowns and gloves prior to entering the room and take off the gloves and gown prior to coming out of the room. During an observation on the COVID-19 recovering unit 12/02/20 at 9:25 AM, CNA1 was observed to be in full PPE which included gown, gloves, face mask and face shield as she left Resident (R)2's room. CNA1 went to the linen cart and took off some linen wearing the same gloves and proceeded to return to the room. During an observation on the COVID-19 recovering unit on 12/02/20 at 9:30 AM, CNA2 was observed to leave R6 while wearing full PPE and talking with other staff. CNA2 then returned to the room. During an observation on the COVID- 19 recovering unit 12/02/20 at 9:45 AM, the NP was observed leaving R6's room in full PPE and walked over to R5's and was observed in the room at R5's bedside touching her covers and asking questions. NP left the room in full PPE. NP was asked if she had walked from R6's room seeing one resident and then to another room where she was seen visiting R5 and touching her covers. NP was asked if she should have removed her gloves and gown before leaving the room, NP replied, that there was no trash can in the room for the gown and gloves. The NP also stated that she has asked about a place to throw way the gowns before but was not given an answer. It was observed there was a bin for gowns between the two resident areas in the room. The NP proceeded to walk down the hall and throw the gown and gloves in a trash can. The NP did not wash nor hand sanitizer her hands after doing so. The NP then donned a clean gown. The NP was asked if her hands should have been washed prior to placing on another gown. The NP stated, Where am I supposed to do that. I asked the staff where is a sink and hand sanitizer but I don't know where they are. During an interview on 12/02/20 at 10:00 AM, the Licensed Practical Nurse (LPN) was asked about CNAs and other staff or visitors wearing PPE in the hall. The LPN stated, No, it is not appropriate for staff to wear the gowns and gloves in the hall. Staff should also not wear them in the halls and then return to residents or to see other residents. During an interview on 12/02/20 at 10:03 AM, the Director of Nursing (DON) was asked what the expectations were for staff and visiting providers for PPE. The DON stated, Full PPE should be worn in the rooms only. If the staff need to leave the room then they should take off the gowns and gloves, get their supplies and then put on another gown and gloves. There are sinks in each room and wall units with hand sanitizer. During an interview on 12/02/20 at 12:00 PM, CNA1 was asked about wearing gown and gloves in the hall. CNA1 stated, It was not appropriate to wear the them in the hall. When asked about hand washing, CNA1 stated, There are sinks in each room. During an interview on 12/02/20 at 1:14 PM, CNA2 was ask about wearing gown and gloves in the hall. CNA2 stated, I came over to help and totally forgot about wearing the gown and gloves in the hall. It should not have happen. CNA2 was asked about hand washing and hand sanitizing, she stated, the sinks are in the rooms and hand sanitizer is everywhere. Review of the facility's policy titled, .Precautions to Prevent Transmission of Infectious Agents, revised 06/23/17 revealed, . Hand Hygiene . If hands are not visibly soiled, or after removing visible material with nonantimicrobial soap and water, the preferred method of hand decontamination is with an alcohol-based hand rub. Perform hand hygiene in the following clinical situations . Gowns . Remove gown and perform hand hygiene before leaving the patient's environment.

Based on interview, record review, and policy review, the facility failed to ensure nursing home staff were tested , twice a week for COVID-19, based on the county's positivity rate and guidance from Centers for Medicare Services (CMS). By the facility not following the positivity rate (red zone) to test staff for COVID-19 twice a week, this had the potential for spreading COVID-19 among the staff, the residents of the facility, and eventually into the community. Findings include: Review of the CMS Guidance, dated 08/26/20, Ref: QSO-20-38-NH, .§ 483.80 Infection control.§ 483.80(h) COVID-19 Testing. The LTC facility must test residents and facility staff, including individuals providing services under arrangement and volunteers, for COVID-19. At a minimum, for all residents and facility staff, including individuals providing services under arrangement and volunteers, the LTC facility must.Conduct testing based on parameters set forth by the Secretary, including but not limited to.The criteria for conducting testing of asymptomatic individuals specified in this paragraph, such as the positivity rate of COVID-19 in a county.Other factors specified by the Secretary that help identify and prevent the transmission of COVID-19. Routine testing should be based on the extent of [MEDICAL CONDITION] in the community, therefore facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. Per review of CMS COVID-19 Nursing Home Data, archived data, dated 10/28/20 the county positivity rate was 11.0 percent or red zone. The archived data dated 11/04/20 identified the county positivity rate was 13.3 percent or red zone. Both weeks nursing home staff were to be tested twice a week for COVID-19 based on the county positivity rate. During interviews conducted on the East Hall, on 11/13/20 at 9:33 AM, Certified Medication Assistant (CMA) 1 and Certified Nurse Aide (CNA) 1 both stated they are being tested by the facility once a week. During an interview on the North Hall on 11/13/20 at 9:47 AM , CMA 2 stated, she receives a COVID test weekly by the facility. During an interview conducted on 11/13/20 at 12:15 PM with the Infection Control Preventionist (ICP), the Regional Nurse Consultant (RNC), and the Administrator, the surveyor was informed the facility was currently conducting Outbreak testing of staff, which consists of testing the staff once weekly. The ICP was asked if the facility was aware of the current county positivity rate? The ICP stated yes, it's in the red. When questioned why the facility was testing only once weekly instead of twice weekly as per CMS guidance, the RNC responded, because we are in outbreak testing, which only requires testing once weekly. The facility Administrator, RNC, and ICP were asked if they had consulted with the Oklahoma Department of Health concerning the staff testing? The RNC responded, yes, and we were instructed we should only run one schedule of testing, if we are in an outbreak, we need to follow it and not the county positivity rate. Residents who are negative are tested every three to seven days and the staff are tested every seven days. During an interview in the dining area on 11/13/20 at 1:43 PM with Cook 1, she reported the staff are being tested on ce weekly. Cook 1 is not being tested due to testing positive for COVID. Record review revealed Cook 1 tested positive on 10/19/20 and was cleared to return to work no 11/03/20. Review of the facility's undated policy titled, COVID Testing Guidelines, revealed There are three triggers for testing: symptomatic, outbreak, and routine/surveillance. 1. Symptomatic testing: Test any staff or residents who have signs or symptoms of COVID-19. 2. Outbreak testing: Test all staff and residents in response to an outbreak (defined any single new infection in staff or any nursing home onset infection in a resident). Continue to test all staff and residents that tested negative every three days to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. (If Outbreak testing is occurring then Routine Testing will be stopped until Outbreak testing has resolved then routine testing will start again). 3. Routine testing: Test all staff based on CMS' published county positivity rate. Facility rates which will be reflected on the COVID Status Report. Red=county positivity rate of (>10%)- test all staff twice a week. Review of the facility's document titled, COVID-19 [MEDICATION NAME] Assay Using BD Veritor Testing Device revealed the facility's staff have been tested for COVID-19 on a weekly basis starting on 09/09/20 through 11/13/20.

Based on observations, record review and interviews, it was determined the facility failed to ensure the clinical records identified the correct code status for two residents (#37 and #40) of 24 residents who were reviewed for DNR (do not resuscitate) status. The administrator identified 12 residents who had a DNR status. The DON (director or nurses) identified 49 residents who resided in the facility. Findings: A facility policy titled, .DNR, Advanced Directives and End of Life Decisions, documented: .upon admission the facility will asked every new resident and\or the residents representative, if the resident has a written advance directive, durable power of attorney for health care, DNR consent, or related form .residents with DNR orders are identified by placing a red name plate on the door to the resident's room . Resident #37 had [DIAGNOSES REDACTED]. An electronic medical record documented the resident was a full code status. An advanced directive DNR consent admission acknowledgment form, dated [DATE], documented the resident currently had an advanced directive and a DNR consent. A care plan, dated [DATE], documented the resident was a full code status. A quarterly assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making. A doctor's order, dated [DATE], documented CPR (cardiopulmonary resuscitation) / full code. On [DATE] at 1:09 p.m., the resident's POA (power of attorney) was asked if the resident should be a full code or a DNR. She stated the resident was a DNR and it should be in his chart. At 3:08 p.m., the regional nurse consultant and RN (registered nurse) #1 was asked if the resident was a full code status on the electronic medical record. RN #1 said, Yes. She acknowledged the resident wanted to be a DNR and the medical records did not match the residents wishes. 2. Resident #40 had [DIAGNOSES REDACTED]. An electronic medical record documented resident was a full code status. An out of state do not resuscitate order, dated [DATE], was signed by resident #40 documenting her wishes. An advanced directive DNR consent admission acknowledgment form, dated [DATE], documented the resident currently had an advanced directive and a DNR consent. A care plan, dated [DATE], documented the resident was a full code status. A quarterly assessment, dated [DATE], documented the resident was severely impaired in cognitive skills for daily decision making. On [DATE] at 10:30 a.m., the physician was asked what was the code status of the resident if the electronic medical record noted full code, orders were a full code, but the resident's wishes were to be a DNR. The physician stated he would be confused and the facility would need to get the code status straightened out with the resident and resident's family. At 11:52 a.m., the resident's POA stated the resident should be a DNR. At 3:08 p.m., the regional nurse consultant and RN #1 was asked if the resident was a full code status on the electronic medical record. RN #1 stated yes. When asked what the red name plate on the resident's door signified. She stated the resident was a DNR. They were asked if the code status on the electronic medical record should match the red name plate on the door. She stated it should match. She acknowledged the resident wanted to be a DNR and the medical records did not match the resident's wishes.

Based on observations, record reviews and interviews, it was determined the facility failed to assess, monitor and intervene in a timely manner for one (#6) of two sampled residents who complained of bug bites. The DON (director of nurses) identified 49 residents who resided in the facility. Findings: Resident #6 had [DIAGNOSES REDACTED]. A facility weekly skin evaluation, dated 01/22/20, documented no new skin concerns. A treatment administration record, dated 01/25/20, documented the physician was called and order was received for triple antibiotic ointment for the resident's left cheek. A treatment administration record, dated (MONTH) 2020 documented the resident received one topical treatment of [REDACTED]. A facility weekly skin evaluation, dated 1/29/20, documented no new skin concerns. The resident record had no other documentation the facility assessed, intervened and monitored the resident who complained of bug bites while in bed. On 02/03/20 at 11:17 a.m., Resident #6 complained she was bitten by bed bugs. The resident was observed with small raised red bumps to her left posterior leg. The resident's left posterior arm was swollen and red, the center had three small raised bumps. The resident's right posterior arm was observed with raised red bumps extending from her elbow to her mid upper arm in a pattern of a line. The resident stated the areas itched and the only medication given was [MEDICATION NAME]. The resident said, I told the nurse this weekend and the RN (registered nurse) in charge. I'm still getting bitten by bed bugs. I was told the doctor was called and they were waiting for his return call. The resident stated they had given her cream one day and [MEDICATION NAME]. She said, Look at my face. They sprinkled white powder on my mattress and around the room. The right side of the resident's face was observed with three Band-Aides. The resident removed a Band-Aide from her face. There was a scaly dry discolored patch observed to her right cheek with redness surrounding the dry patch. The resident stated she was bitten on face first and received ointment one day more than a week ago, and the facility staff are not doing anything, I am miserable and I am afraid it is a staph infection.'' On 02/06/20 at 2:15 p.m., LPN #1 was asked if the resident had any skin concerns. LPN #1 stated the resident had no other skin issues only a rash to her face. She was asked if she had assessed the resident's skin. She said, No, the wound nurse did skin assessments weekly. At 2:18 p.m., LPN #1 was observed assessing the resident's skin. LPN #1 asked the resident what happened to her arms. Resident #6 said, The one bite on my left leg is gone now. LPN #1 confirmed the resident had skin concerns to her right elbow and left upper posterior arm. At 2:29 p.m., the wound nurse was asked how often she assessed the resident's skin. She stated she assessed the resident on each Wednesday. She said, I looked at her red skin Tuesday (02/04/20) and the doctor also looked at her and consulted with the DON and charge nurse. All I know is that she started two antibiotics and was not to have any topical, but she had no current topical ordered. The wound nurse was asked, when was the resident observed with red skin. She stated the resident had red patches that extended up her right arm, and the back of her left leg and areas to right side of her face. She said, (Named resident) stated to me Friday (01/31/19) it could be bed bug bites. I stripped bed and linen. The wound nurse was asked what was the facility protocol when a resident complained of bed bug bites. She said, Strip the bed and look for evidence, bag linen and treat room, tell the DON and Administrator and they handle it. She was asked if the protocol was followed. She stated she checked the bedding and the bed frameworks and mattress on Friday. She said, I notified the DON and the administrator. She was asked if she knew what day the DON and administrator were notified. She said,No. She was asked if the doctor was notified of resident's complaints and if treatment was put in place. She said, No, that was Friday and I was off Monday, I looked at her Tuesday and had the physician look at her since he was in the building. On 02/07/20 at 9:51 a.m., the DON was asked what did the facility do about the resident's complaints of bed bug bites. The DON stated the resident had been moved several times. She said, She states she has been bitten. She has moved halls. She picks at her skin. She has rash that does not heal. The DON was asked if there was documentation of the resident picking at her skin. At the end of the survey no documentation had been provided. On 02/10/20 at 9:46 a.m., the administrator stated if a resident complained of being bitten by bugs in bed they did a head to toe assessment, searched the room for pests, and if they determined it was a bug bite they would contact the physician and then contact pest control services.

Based on observation, record review, and interview, it was determined the facility failed to; 1. Assess and intervene in a timely manner for an acute exacerbation of pain for one (#C) of one sampled resident whose records were reviewed for pain management. The resident's pain was not addressed in a consistent and timely manner. The resident remained in pain for long periods at a time. The facility identified no additional residents who had an exacerbation of pain. 2. Train and assess the nurses' competency in the care and maintenance of a peripherally inserted central catheter (PICC) line. The facility identified no additional residents who had PICC lines. The facility documented forty-nine residents resided in the facility. Findings: 1. Resident #C had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The resident's quarterly assessment, dated 10/02/15, documented the resident made herself understood, usually understood others, was severely impaired in cognition, required limited assistance with transfers and used a walker and/or wheelchair for ambulation. The assessment also documented the resident required only supervision while walking in her room and/or corridor. The range of motion portion of the assessment documented the resident had no functional impairment in her upper or lower extremities. The resident's care plan for pain, dated 10/07/15, documented: Focus The resident is on) Pain medication Therapy r/t (related to) disease process (specify) Date initiated: 08/05/15 Goal The resident will be free of any discomfort or adverse side effects from pain medication through the review date. Date initiated: 08/05/15 Revision on: 01/12/16 Target date: 01/13/16 Intervention Administer [MEDICATION NAME] (sic), [MEDICATION NAME] ([MEDICATION NAME]), and Tylenol per physicians orders Ask physician to review medication if side effects persist. For respiratory depression: Monitor respiratory rate, depth, and effort after administration of pain medications. Monitor for increased risk of falls. The resident had a physician's orders [REDACTED]. one tablet every 6 hours as needed for mild pain. The original order date was 06/19/15. The clinical record contained documentation the resident had complained of pain only one time in January prior to 01/15/16. The resident's Medication Administration Record [REDACTED]. The nurse's note at 1:12 p.m., contained no documentation of the location or type of pain the resident complained of. A nurse's note, at 7:10 p.m., documented the [MEDICATION NAME] 50 mg had been ineffective. The resident's MAR indicated [REDACTED]. The resident had gone nineteen hours and twenty-nine minutes without pain relief. The physician's orders [REDACTED]. The physician was not called. The clinical record contained no documentation of a pain assessment having been conducted due to the resident's complaint of severe pain. On 01/16/16 at 10:30 a.m. a nurse's note documented the [MEDICATION NAME] 50 mg was ineffective. The physician was not called. On 01/17/16 at 2:41 a.m., the MAR indicated [REDACTED]. The resident had gone without pain relief from 01/16/16 at 8:41 a.m. until 01/17/16 at 2:41 a.m., which was 18 hours. On 01/17/16 at 3:19 a.m., a nurse's note documented the pain medication had been effective. At 8:45 a.m., the MAR indicated [REDACTED]. The nurse's note, at 8:45 a.m., contained no documentation regarding the resident's pain. At 9:45 a.m., a nurse's note documented the pain medication had been effective. At 2:36 p.m., a nurse's note documented when the [MEDICATION NAME] wears off the resident would cry and become upset. At 2:46 p.m., the MAR indicated [REDACTED]. A nurse's note, at 2:46 p.m., contained no documentation about the location or type of pain the resident had experienced. A nurse's note, dated 3:46 p.m., documented the pain medication had been ineffective. The note documented the resident had facial grimacing and moaned when repositioned. A physician's orders [REDACTED]. which was administered at 7:41 p.m., for pain the resident rated at a 10. A hospice note, dated 01/17/16 at 8:43 p.m., documented the resident was crying and moaning in pain. The note further documented the resident stated her arm hurt, Real bad. The note documented the resident reported pain under her left armpit and the resident screamed in pain when the area was touched or moved. The note added the physician had been notified of the resident's pain. The physician had issued a new order for the resident to be administered [MEDICATION NAME] 0.25 millilters (mls) every 4 hours as needed for pain. A nurse's note, dated 01/18/16 at 12:00 p.m., documented, Focused charting r/t (related to) pain. Resident was given [MEDICATION NAME] 0.25ml SL (sublingual, under the tongue) d/t (due to) c/o (complaints of pain) in legs and back after repositioning several times, offering foods and fluids and resident refused all, became agitated and asked this nurse was she stupid, she was in pain and wanted pain med. Med has been effective thus far. The resident had not been medicated for her complaints of severe pain between 01/17/16 at 7:41 p.m., and 01/18/16 at 12:00 p.m., a time frame of 16 hours and nineteen minutes. At 2:13 p.m., a nurse's note documented the hospice nurse had been contacted to come assess the resident's minimal pain relief from [MEDICATION NAME], although the clinical record documented the [MEDICATION NAME] had not been administered per the physician's orders [REDACTED].>A hospice note, dated 01/18/16 at 3:20 p.m., documented, Pt. (patient) in bed, son at bedside, eyes closed. Son concerned about pain as pt has been complaining and crying out at night for 2 days. Son understands her pain is in the left shoulder and lower back. Pt grimaces when sits up in bed, and when left arm is moved across body. [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mL given earlier today but pt continues to c/o (complain of) pain. Discussed with (Charge nurse), called Dr. (Physician), orders received for [MEDICATION NAME] 0.5 mL BID (two times a day), 0.25 mL Q (every) 4 hours PRN (as necessary). BP (blood pressure) 154/114, HR (heart rate) 80, temp 97.9. A nurse's note, at 6:21 p.m., documented the resident had complained of pain. The note also documented the resident had been provided repositioning and back rubs, which had been ineffective. The resident kept asking for pain medication. At 6:21 p.m., the resident's TAR documented the resident had been administered 0.25 mls of [MEDICATION NAME]. The resident had rated her pain at a 9. It contained no documentation of [MEDICATION NAME] having been administered earlier at 12:00 p.m. There was no documentation the resident had been administered [MEDICATION NAME], for her severe pain, between 12:00 p.m., and 6:21 p.m., a time frame of six hours and 21 minutes. The resident could have been medicated with [MEDICATION NAME] 0.25 ml at 4:00 p.m. The facility had also received a new physician's orders [REDACTED]. A nurse's note at 8:11 p.m., documented the administration of [MEDICATION NAME] 0.25 ml had been ineffective. A nurse's note, at 8:42 p.m., documented the resident had been given [MEDICATION NAME] 0.5 ml for pain the resident had rated at a 9 to 10. The care plan for pain was revised on 01/18/16 and it documented: Interventions [MEDICATION NAME] per MD (medical doctor). A nurse's note, dated 01/19/16 at 4:56 a.m., documented the resident was complaining of left shoulder pain. The resident's TAR documented, at 4:56 a.m., the resident had been administered 0.25 ml of [MEDICATION NAME] for pain the resident had rated at an 8. At 6:43 a.m., a nurse's note documented the pain medication was ineffective and the resident rated her pain at a 6. At 6:45 a.m., a nurse's note documented the resident was yelling in pain and asking to be helped. She rated her pain at a 6. The note documented the resident had been medicated with 0.5 ml of [MEDICATION NAME]. At 7:00 p.m., the director of nurses (DON) was asked if an assessment had been conducted when the resident had an acute change in her range of motion and complained of severe pain in her back, left arm, and left shoulder. She stated she was unsure what had been done. The DON stated she would have to review her notes. She was asked if an X-ray had been obtained. She stated she didn't think so, but they could order one now. On 01/19/16 at 8:11 p.m., a hospice note documented the routine order of 0.5 ml [MEDICATION NAME] had been placed on hold (due to sedation) per the physician. The note documented the as necessary order for [MEDICATION NAME] 0.25 ml had remained in effect. A nurse's note, at 11:21 p.m., documented a mobile x-ray had been obtained of the resident's left shoulder. An x-ray result of the resident's left shoulder, dated 01/19/16, documented, loose bodies were seen in the axillary recess. The care plan for pain was revised on 01/20/16 and it documented: Focus (Named resident) has need for diagnostic testing Date initiated: 01/20/16 Goal Will be within normal limits and results called into physician Date initiated 01/20/16 . Target date 01/30/16 Interventions Re-Xay left shoulder and Left arm r/t (related to) pain. Date initiated:01/20/16 X-ray to left shoulder. Date initiated: 01/20/16 On 01/20/16 at 12:45 a.m., a nurse's note documented the resident was moaning and had facial grimacing. The resident's TAR documented, at 1:31 a.m., the resident had been administered 0.25 mls of [MEDICATION NAME] for pain she had rated at a 6. At 3:00 a.m., a nurse's note documented the resident was asking for help. The resident said, My arm hurts, make it stop. At 3:17 a.m., a nurse's note documented the resident complained of left shoulder pain. A pillow had been placed under the resident's shoulder and she had been repositioned. The note documented the resident continued to voice pain. At 3:17 a.m., the MAR indicated [REDACTED]. At 4:43 a nurse's note documented the pain medication had been effective. The TAR documented, at 5:40 a.m., the resident had been administered 0.25 mls of [MEDICATION NAME] for pain which the resident had rated at a 6. At 10:20 a.m., the director of nurses (DON) was asked when the resident's last pain assessment had been obtained. She reviewed the clinical record and stated the last pain assessment was on 12/24/15, when the resident had a fall. She added she could not locate a pain assessment dated later than 12/24/15. The DON was asked if the resident had received any type of assessment for the exacerbation of pain. The DON stated the resident was on hospice and the nurses' had been trying non-pharmaceutical interventions but nothing was helping. The DON stated she thought the resident probably had a low pain threshold. The DON added she thought [MEDICAL CONDITION] had spread and the [MEDICATION NAME] had confused the resident. At 2:04 p.m., LPN #2 was interviewed about the resident's sudden onset of pain. The LPN stated she had taken care of her on Friday 01/15/16, and the resident had been her usual self. The LPN stated the resident had been able to push herself out of her wheelchair with both arms, without complaints of pain. The resident was able to get out of bed and she had spent time in the lobby. The LPN stated she had not worked the weekend; when she returned to work on Monday 01/18/16, the resident was in pain and didn't want to get out of bed. The LPN was asked if the resident's exacerbation of pain had been assessed. She stated she had not done an assessment and she didn't know what had been done during the weekend. She was asked if, during report on Monday morning, the weekend nurse had told her an assessment had been conducted. The LPN stated she had been told the resident was in pain; no additional information had been provided to her. The clinical record contained no documentation of an assessment having been conducted to determine the cause of the resident's sudden onset of acute severe pain. 2. Resident #B had been admitted on [DATE], with [DIAGNOSES REDACTED]. No resident assessment had been completed. The resident had a PICC line in his right antecubital area. On 01/19/16 at 3:30 p.m., the DON was asked how she determined a nurse's competency to access and maintain PICC lines. The DON stated she had been certified and she had inserviced her nurses when they were hired. She was asked to provide documentation of the inservices. At 5:40 p.m., the corporate nurse stated there was no documentation of inservices provided to the nurses for PICC lines. At 6:00 p.m., LPN #1 was interviewed regarding the resident's PICC line. He stated he had just flushed the line with [MEDICATION NAME]. He was asked if the facility had educated him or assessed his competency to provide maintenance for the line. He stated he didn't remember. The clinical record documented one additional LPN had taken care of the PICC line.

Based on observation, record review, and interview, it was determined the facility failed to; 1. Assess and intervene in a timely manner for an acute exacerbation of pain for one (#C) of one sampled resident whose records were reviewed for pain management. The resident's pain was not addressed in a consistent and timely manner. The resident remained in pain for long periods at a time. The facility identified no additional residents who had an exacerbation of pain. 2. Train and assess the nurses' competency in the care and maintenance of a peripherally inserted central catheter (PICC) line. The facility identified no additional residents who had PICC lines. The facility documented forty-nine residents resided in the facility. Findings: 1. Resident #C had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The resident's quarterly assessment, dated 10/02/15, documented the resident made herself understood, usually understood others, was severely impaired in cognition, required limited assistance with transfers and used a walker and/or wheelchair for ambulation. The assessment also documented the resident required only supervision while walking in her room and/or corridor. The range of motion portion of the assessment documented the resident had no functional impairment in her upper or lower extremities. The resident's care plan for pain, dated 10/07/15, documented: Focus The resident is on) Pain medication Therapy r/t (related to) disease process (specify) Date initiated: 08/05/15 Goal The resident will be free of any discomfort or adverse side effects from pain medication through the review date. Date initiated: 08/05/15 Revision on: 01/12/16 Target date: 01/13/16 Intervention Administer [MEDICATION NAME] (sic), [MEDICATION NAME] ([MEDICATION NAME]), and Tylenol per physicians orders Ask physician to review medication if side effects persist. For respiratory depression: Monitor respiratory rate, depth, and effort after administration of pain medications. Monitor for increased risk of falls. The resident had a physician's orders [REDACTED]. one tablet every 6 hours as needed for mild pain. The original order date was 06/19/15. The clinical record contained documentation the resident had complained of pain only one time in January prior to 01/15/16. The resident's Medication Administration Record [REDACTED]. The nurse's note at 1:12 p.m., contained no documentation of the location or type of pain the resident complained of. A nurse's note, at 7:10 p.m., documented the [MEDICATION NAME] 50 mg had been ineffective. The resident's MAR indicated [REDACTED]. The resident had gone nineteen hours and twenty-nine minutes without pain relief. The physician's orders [REDACTED]. The physician was not called. The clinical record contained no documentation of a pain assessment having been conducted due to the resident's complaint of severe pain. On 01/16/16 at 10:30 a.m. a nurse's note documented the [MEDICATION NAME] 50 mg was ineffective. The physician was not called. On 01/17/16 at 2:41 a.m., the MAR indicated [REDACTED]. The resident had gone without pain relief from 01/16/16 at 8:41 a.m. until 01/17/16 at 2:41 a.m., which was 18 hours. On 01/17/16 at 3:19 a.m., a nurse's note documented the pain medication had been effective. At 8:45 a.m., the MAR indicated [REDACTED]. The nurse's note, at 8:45 a.m., contained no documentation regarding the resident's pain. At 9:45 a.m., a nurse's note documented the pain medication had been effective. At 2:36 p.m., a nurse's note documented when the [MEDICATION NAME] wears off the resident would cry and become upset. At 2:46 p.m., the MAR indicated [REDACTED]. A nurse's note, at 2:46 p.m., contained no documentation about the location or type of pain the resident had experienced. A nurse's note, dated 3:46 p.m., documented the pain medication had been ineffective. The note documented the resident had facial grimacing and moaned when repositioned. A physician's orders [REDACTED]. which was administered at 7:41 p.m., for pain the resident rated at a 10. A hospice note, dated 01/17/16 at 8:43 p.m., documented the resident was crying and moaning in pain. The note further documented the resident stated her arm hurt, Real bad. The note documented the resident reported pain under her left armpit and the resident screamed in pain when the area was touched or moved. The note added the physician had been notified of the resident's pain. The physician had issued a new order for the resident to be administered [MEDICATION NAME] 0.25 millilters (mls) every 4 hours as needed for pain. A nurse's note, dated 01/18/16 at 12:00 p.m., documented, Focused charting r/t (related to) pain. Resident was given [MEDICATION NAME] 0.25ml SL (sublingual, under the tongue) d/t (due to) c/o (complaints of pain) in legs and back after repositioning several times, offering foods and fluids and resident refused all, became agitated and asked this nurse was she stupid, she was in pain and wanted pain med. Med has been effective thus far. The resident had not been medicated for her complaints of severe pain between 01/17/16 at 7:41 p.m., and 01/18/16 at 12:00 p.m., a time frame of 16 hours and nineteen minutes. At 2:13 p.m., a nurse's note documented the hospice nurse had been contacted to come assess the resident's minimal pain relief from [MEDICATION NAME], although the clinical record documented the [MEDICATION NAME] had not been administered per the physician's orders [REDACTED].>A hospice note, dated 01/18/16 at 3:20 p.m., documented, Pt. (patient) in bed, son at bedside, eyes closed. Son concerned about pain as pt has been complaining and crying out at night for 2 days. Son understands her pain is in the left shoulder and lower back. Pt grimaces when sits up in bed, and when left arm is moved across body. [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mL given earlier today but pt continues to c/o (complain of) pain. Discussed with (Charge nurse), called Dr. (Physician), orders received for [MEDICATION NAME] 0.5 mL BID (two times a day), 0.25 mL Q (every) 4 hours PRN (as necessary). BP (blood pressure) 154/114, HR (heart rate) 80, temp 97.9. A nurse's note, at 6:21 p.m., documented the resident had complained of pain. The note also documented the resident had been provided repositioning and back rubs, which had been ineffective. The resident kept asking for pain medication. At 6:21 p.m., the resident's TAR documented the resident had been administered 0.25 mls of [MEDICATION NAME]. The resident had rated her pain at a 9. It contained no documentation of [MEDICATION NAME] having been administered earlier at 12:00 p.m. There was no documentation the resident had been administered [MEDICATION NAME], for her severe pain, between 12:00 p.m., and 6:21 p.m., a time frame of six hours and 21 minutes. The resident could have been medicated with [MEDICATION NAME] 0.25 ml at 4:00 p.m. The facility had also received a new physician's orders [REDACTED]. A nurse's note at 8:11 p.m., documented the administration of [MEDICATION NAME] 0.25 ml had been ineffective. A nurse's note, at 8:42 p.m., documented the resident had been given [MEDICATION NAME] 0.5 ml for pain the resident had rated at a 9 to 10. The care plan for pain was revised on 01/18/16 and it documented: Interventions [MEDICATION NAME] per MD (medical doctor). A nurse's note, dated 01/19/16 at 4:56 a.m., documented the resident was complaining of left shoulder pain. The resident's TAR documented, at 4:56 a.m., the resident had been administered 0.25 ml of [MEDICATION NAME] for pain the resident had rated at an 8. At 6:43 a.m., a nurse's note documented the pain medication was ineffective and the resident rated her pain at a 6. At 6:45 a.m., a nurse's note documented the resident was yelling in pain and asking to be helped. She rated her pain at a 6. The note documented the resident had been medicated with 0.5 ml of [MEDICATION NAME]. At 7:00 p.m., the director of nurses (DON) was asked if an assessment had been conducted when the resident had an acute change in her range of motion and complained of severe pain in her back, left arm, and left shoulder. She stated she was unsure what had been done. The DON stated she would have to review her notes. She was asked if an X-ray had been obtained. She stated she didn't think so, but they could order one now. On 01/19/16 at 8:11 p.m., a hospice note documented the routine order of 0.5 ml [MEDICATION NAME] had been placed on hold (due to sedation) per the physician. The note documented the as necessary order for [MEDICATION NAME] 0.25 ml had remained in effect. A nurse's note, at 11:21 p.m., documented a mobile x-ray had been obtained of the resident's left shoulder. An x-ray result of the resident's left shoulder, dated 01/19/16, documented, loose bodies were seen in the axillary recess. The care plan for pain was revised on 01/20/16 and it documented: Focus (Named resident) has need for diagnostic testing Date initiated: 01/20/16 Goal Will be within normal limits and results called into physician Date initiated 01/20/16 . Target date 01/30/16 Interventions Re-Xay left shoulder and Left arm r/t (related to) pain. Date initiated:01/20/16 X-ray to left shoulder. Date initiated: 01/20/16 On 01/20/16 at 12:45 a.m., a nurse's note documented the resident was moaning and had facial grimacing. The resident's TAR documented, at 1:31 a.m., the resident had been administered 0.25 mls of [MEDICATION NAME] for pain she had rated at a 6. At 3:00 a.m., a nurse's note documented the resident was asking for help. The resident said, My arm hurts, make it stop. At 3:17 a.m., a nurse's note documented the resident complained of left shoulder pain. A pillow had been placed under the resident's shoulder and she had been repositioned. The note documented the resident continued to voice pain. At 3:17 a.m., the MAR indicated [REDACTED]. At 4:43 a nurse's note documented the pain medication had been effective. The TAR documented, at 5:40 a.m., the resident had been administered 0.25 mls of [MEDICATION NAME] for pain which the resident had rated at a 6. At 10:20 a.m., the director of nurses (DON) was asked when the resident's last pain assessment had been obtained. She reviewed the clinical record and stated the last pain assessment was on 12/24/15, when the resident had a fall. She added she could not locate a pain assessment dated later than 12/24/15. The DON was asked if the resident had received any type of assessment for the exacerbation of pain. The DON stated the resident was on hospice and the nurses' had been trying non-pharmaceutical interventions but nothing was helping. The DON stated she thought the resident probably had a low pain threshold. The DON added she thought [MEDICAL CONDITION] had spread and the [MEDICATION NAME] had confused the resident. At 2:04 p.m., LPN #2 was interviewed about the resident's sudden onset of pain. The LPN stated she had taken care of her on Friday 01/15/16, and the resident had been her usual self. The LPN stated the resident had been able to push herself out of her wheelchair with both arms, without complaints of pain. The resident was able to get out of bed and she had spent time in the lobby. The LPN stated she had not worked the weekend; when she returned to work on Monday 01/18/16, the resident was in pain and didn't want to get out of bed. The LPN was asked if the resident's exacerbation of pain had been assessed. She stated she had not done an assessment and she didn't know what had been done during the weekend. She was asked if, during report on Monday morning, the weekend nurse had told her an assessment had been conducted. The LPN stated she had been told the resident was in pain; no additional information had been provided to her. The clinical record contained no documentation of an assessment having been conducted to determine the cause of the resident's sudden onset of acute severe pain. 2. Resident #B had been admitted on [DATE], with [DIAGNOSES REDACTED]. No resident assessment had been completed. The resident had a PICC line in his right antecubital area. On 01/19/16 at 3:30 p.m., the DON was asked how she determined a nurse's competency to access and maintain PICC lines. The DON stated she had been certified and she had inserviced her nurses when they were hired. She was asked to provide documentation of the inservices. At 5:40 p.m., the corporate nurse stated there was no documentation of inservices provided to the nurses for PICC lines. At 6:00 p.m., LPN #1 was interviewed regarding the resident's PICC line. He stated he had just flushed the line with [MEDICATION NAME]. He was asked if the facility had educated him or assessed his competency to provide maintenance for the line. He stated he didn't remember. The clinical record documented one additional LPN had taken care of the PICC line.

Based on record review and interview, it was determined the facility failed to ensure three (#1, #13 and #9) of four sampled residents were free of verbal abuse from a family member of resident #3. This resulted in actual harm for resident #1. The facility identified 53 residents who resided in the facility. Findings: The facility's abuse policy documented: " Policy The resident has the right to be free form (sic) verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Abuse... Verbal Abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend or disability. Examples include, but are not limited to: threats of harm; saying things to frighten a resident..." Social service notes, dated 06/17/14 at 4:45 p.m., documented a resident council meeting was scheduled for 1:30 p.m. The notes documented the residents were to hold a vote regarding whether or not to allow a family member of resident #3 to attend the meeting. The social service notes documented the family member of resident #3 was advised she would not be able to attend the meeting until the vote had been completed. The social service director (SSD) documented the family member of resident #3 became very angry. She walked over to the resident council president (#13), raised her voice, started confronting him and pointing her finger at him. The episode occurred in a facility common area. The social service note also documented the episode was witnessed by the SSD and licensed practical nurse (LPN) #3. 1. Resident #1 had [DIAGNOSES REDACTED]. A significant change assessment, dated 04/22/14, documented the resident had the ability to understand others, make herself understood, was able to make her needs known and was cognitively intact. On 07/08/14 at 2:00 p.m., resident #1 was asked if she was a member of the resident council. She stated she was. She was asked if the council had ever voted to keep a family member out of the meetings. She said, "I remember the meeting and the vote because it almost cost me my friendship with (the family member of resident #3)." She was asked if she could explain what she meant. She said, "As I was leaving the meeting (the family member of resident #3) stopped me in the hallway. She started telling me I had betrayed her. She told me I was no longer her friend. I was never to speak to her or her mother again. She told me she would never help me with my problems again." The resident stated, "I was very upset. She (resident #3's mother) was very angry with me." On 07/09/12 at 10:30 a.m., the SSD was interviewed about the events prior to and after the resident council meeting on 06/17/14, in regard to resident #1. The SSD stated she knew the family member of resident #3 had verbally confronted resident #1 after the council meeting. She stated the resident was visibly upset and was crying. The resident's clinical record contained no documentation of a plan developed to prevent the family member of resident #3 from verbally confronting resident #1 again. 2. On 07/08/14 at 2:00 p.m., resident #13 was interviewed about the resident council meeting. He was asked if the council had ever voted to not allow a family member to attend the meeting. He stated the council had voted unanimously to prevent the family member of resident #3 from attending the meeting. The resident was asked about the reason why the residents didn't want the family member of resident #3 to attend. He said, "The family member has attended a previous council meeting and she has taken over the floor. She wanted the other members to discuss the topics she felt were important. She has shared all of the members statements and personal information she had obtained during the meeting with the rest of the facility. We have seen her be very explosive with the staff. She keeps the residents and staff very upset. She has always caused trouble. Then she will call all of the state agencies and the ombudsman about the facility. Pretty soon people show up and start asking us a lot of questions. The fact that you are here now interviewing me proves what I have said. I'm tired of it." The resident also stated, "She (the family member of resident # 3) has confronted me, yelled at me, and accused me of lying about her. She is such a trouble maker. She finds out personal information about us then she shares it with the facility. She keeps the facility in turmoil." On 07/09/14 at 9:30 a.m., the DON and the corporate nurse reported to the surveyors that the family member of resident #3 returned to the facility after the surveyors had left for the day. They stated the family member was yelling at staff, accusing them of hiding documents from the surveyors, and was very disruptive while in the facility. On 07/09/12 at 10:30 a.m., the SSD was interviewed about the events prior to and after the resident council meeting on 06/17/14, in regard to resident #13. She stated prior to the meeting the family member of resident #3 verbally confronted the resident council president (#13). The SSD stated that after the family member of resident #3 was redirected from vervbally confronting resident #13, the family member went to the DON's office. The door was closed. The family member started kicking the door, demanding to be allowed in. The SSD said the family member was allowed in the room. "She was ranting and very angry." When she left the meeting she kicked a medication cart that had been placed in the hallway. The SSD was asked if she was aware of any actions taken against the family member to prevent an episode like this from happening again. She said, "Nothing at this time." She was asked if the incidents involving the residents had been reported or investigated. She stated she didn't know. The SSD said, "I attended the council meeting on 06/17/14. The residents did not want her (the family member of resident #3) to attend the meetings because she had previously shared confidential information about residents with other residents and staff. The residents said she (the family member of resident #3) was a trouble maker." The SSD was asked if the resident's had given the family member of resident #3 permission to enter their rooms. She said, "The family member brings milk shakes and other treats to the residents. So the residents allow her in because she has treats in her hand for them." The SSD was asked if she was aware of any actions taken to prevent the family member from verbally confronting the residents again. She stated the DON requested a meeting with the family member, but she refused to attend. At 12:45 p.m., the family member of resident #3 entered the surveyor's room. She stated resident #8 wanted the surveyors to come to her room. The family member stated the resident wanted to speak with the surveyors. At 1:00 p.m., resident #8 was interviewed. She was asked if she wanted to speak with us. She said, "No, I don't have anything to discuss with you. I was told by (the family member of resident # 3) that I was to tell you the facility was telling lies about her (the family member). I didn't ask her to tell you to come talk with me. I don't know anything about this." On 07/09/14 at 3:15 p.m., LPN #2 was interviewed about the family members verbal confrontation with resident #13. She stated prior to the resident council meeting the family member of resident #3 was very angry about not being allowed to attend the meeting. She said, "She (the family member) went up to (resident #13) and began yelling and pointing her finger at him. The resident was backing up trying to get away from her, but she just kept coming at him." She stated staff broke up the confrontation and redirected the family member. LPN #2 stated the family member of resident #3 was able to find out information about the residents and shared the information with other residents. The LPN stated she wasn't sure how the family member found out information about the other residents. The LPN was asked if anyone had tried to find out how she (the family member) got the information. She stated she didn't know. At 3:30 p.m., the DON and the corporate nurse were interviewed. They were asked for investigation reports regarding investigations of abuse. The DON stated she was unaware of any abuse episodes and had not conducted any investigations of possible abuse. The DON was asked if she had been informed about the family member of resident #3 and verbal confrontations she had with residents #1, #9 and #13. She stated the staff had not reported the confrontation against resident #9. She stated she felt like the family member of resident #3, "manipulated the residents." She was asked if an investigation had been conducted about the possibility the family member was "manipulating" the residents. She stated she didn't think so. She said, "That is just what (the family member) does. She pushes the envelope. She pushes the line. When she gets close to the line she backs off." The DON said, "I did speak with (resident #1) after her confrontation with (the family member of resident # 3). She told me she was very sad. I did not know she had been crying. I really couldn't think of any interventions to put in place for (resident #1)." The DON stated the family member and resident #1 eventually became friends again. At 4:20 p.m., the assistant director of nursing (ADON) was interviewed. She was asked if she considered it verbal abuse when the family member verbally confronted resident #13 about the resident council meeting. She said, "That probably was abuse." The ADON was asked if she thought it was verbal abuse when the family member of resident #3 verbally confronted resident #1 about the resident council meeting. She said, "That probably was abuse." The ADON was asked if it was verbal abuse when the family member verbally confronted resident #9 about making resident #2 sick. She said, "That probably was abuse." She was asked if the staff should have reported it to her or the DON. She said, "Staff should have reported it to the charge nurse. The charge nurse should have reported it to me or the DON. The episodes should have been investigated." At 4:40 p.m. during the exit, the DON, administrator, and the corporate nurse were asked about why the family member of resident #3 had not been asked to leave the facility or why the police had not been called on the three occasions the family member verbally confronted other residents. They stated they did not know they could do that. They were asked if the public outbursts exhibited by the family member of resident #3 had disturbed the other residents. They stated they thought the family member of resident #3 would go just so far, then would back off. The DON said, "She (the family member of resident 3) really wouldn't cross a line and go too far." The DON stated a lot of the time the family member was not in the common areas, but she could see where some of the residents might have overheard her and been upset. 3. Resident #9's assessment (type unknown), dated 04/08/14, documented the resident understood others, was able to make herself understood, and was cognitively intact. The clinical record documented, prior to 06/05/14, resident # 9 and resident #3 shared a room. Both of the residents were waiting for the results of stool cultures which had been obtained to determine if one or both of the residents had [MEDICAL CONDITION], an infectious intestinal disease ([MEDICAL CONDITION] ). When the results of the stool cultures were received, on 06/05/14, the results indicated resident #3 was positive for [MEDICAL CONDITION] and resident #9 was free of [MEDICAL CONDITION]. The resident's were separated. Resident #3 was placed in isolation and resident #3 was moved to another room. On 07/09/14 at 1:15 p.m., CNA #1 was interviewed. She stated that prior to resident #3 having been placed in isolation and while resident #9 and resident # 3 were still roommates, she (the CNA) found resident #9 crying. The CNA stated the resident told her the family member of resident #3 had accused her of making her mother sick. At 1:30 p.m., CNA #3 was interviewed. She stated while the facility was awaiting the results of the cultures, she (the CNA) was in the residents' room providing care. The CNA stated she heard the family member of resident #3 accuse resident #9 of making her mother sick. The CNA stated resident #9 was very upset at the possibility she had made her roommate ill. On 07/09/14 at 2:20 p.m., resident #9 was interviewed. She was asked if a family member had made her cry. She said, "Yes, but I don't remember who." At 3:00 p.m., LPN #1 was asked if a family member had ever confronted any of the residents. She stated she had been told the family member of resident #3 had made resident #9 cry. She was asked why, after the verbal confrontation of resident #9 by the family member of resident #3, had resident #9 been moved back into the room of resident #3. She said she didn't know. The LPN was asked if anyone had asked resident #9 if she wanted to return to the same room. She said she didn't know. The LPN was asked if interventions to keep resident #9 from being verbally confronted again had been initiated. She stated if it happened again, we were to remove the resident from the family member. At 3:15 p.m., LPN #2 was interviewed. She was asked if she was aware of a family member verbally confronting a resident. She stated resident #9 had come to her crying. The resident was crying and reported the family member of resident #3 had accused her of making the resident (#3) ill. The LPN stated resident #9 was very upset because she felt guilty about making someone ill. The LPN stated she reassured the resident that she had not made anyone ill. The LPN was asked if the incident had been reported to anyone. She stated she thought a CNA had reported it. The LPN was asked why resident #9 was moved back into the room of resident #3 after resident #9 had been verbally confronted by the family member of resident #3. She stated because the family member of resident #3 told resident #9 that she was going to be returned to her (the family member) mother's room. The LPN was asked if anyone had spoken with resident #9 about her desire to return to the room she had shared with resident #3. She stated she didn't know. The LPN was asked if resident #9 would have spoken up if she had not wanted to return to the room with resident #3, due to the confrontation by the family member. She stated she didn't think so because resident #9 was very timid. The clinical record for resident #9 documented, when resident #3 was taken out of isolation, resident #9 was moved back into the room of resident #3. At 3:30 p.m., the DON was interviewed. She stated she had never been informed about the incident between the family member of resident #3 and resident #9. She stated an investigation had not been conducted, because she didn't know. The staff had not told her. At 4:20 p.m., the office manager was asked if she was responsible for arranging room changes for the residents. She stated she was. She was asked if she had been informed about problems between resident #9 and the family member of resident #3. She stated she had not been made aware of any problems. She was asked why resident #9 had a room change. She said, "(The family member of resident #3) came to me and said to me, you are moving (Resident #9) back into my mother's room, right?" The office manager stated resident #9 knew she was going to be moved back into the room of resident #3. She was asked how resident #9 found out she was going to have a room change. She stated she didn't know. The office manager said, "I thought the resident wanted to move back." The office manager added that when she spoke with resident #9 about the move, the resident was very quiet and not forthcoming with information. "She didn't complain." The clinical record contained no documentation of interventions put in place following the family member of resident #3 verbally confronting resident #9.

Based on observation, interview, and record review it was determined the facility failed to assess, monitor and intervene for one (#9) of one sampled resident who had abnormal laboratory values. On 07/05/12, the resident had a low hemoglobin level, hematocrit level and low red blood cell count. The resident was observed to be extremely pale with pale lips and gums. The resident required hospitalization for transfusion of three units of PRBC's, due to a critically low hemoglobin. This had the potential to affect 51 residents who resided in the facility and had laboratory testing performed. Findings: A facility policy titled Resident's Family or Physician Notification of Change Guideline documented the facility would consult with the resident's physician if a significant change occured in the resident's physical, mental, or psychosocial status. Resident #9 had [DIAGNOSES REDACTED]. A CBC performed on 04/11/12 documented a low hemoglobin level at 8.4 GM/DL (reference range of 11.5-16), low hematocrit of 32.7 (reference range of 34.5-46.5), and low red blood cell count of 3.74 (reference range of 3.9-5.2). A physicians progress note, dated 07/04/12, documented, "...4-12 hemaglobin appears to be down to 8.4...The patient does have some worsening [MEDICAL CONDITION]; we will check CBC next lab draw..." A physician's orders [REDACTED]. A CBC performed on 07/05/12 documented her hemoglobin level was low at 7.2, her hematocrit was low at 29.7, and her red blood cell count was low at 3.76. No further hemoglobin levels were documented after these dates. A nurse's note, dated 07/06/12, documented the physician was notified at 2:30 p.m. of lab results drawn 07/05/12, including a low hemoglobin of 7.2, low hemoglobin of 7.2, low RBC's of 3.76, and a low ferritin level of 3. No new orders were received. The most recent monthly physician's orders [REDACTED]. A quarterly assessment, dated 09/03/12, documented the resident had severely impaired cognitive skills for daily decision making. The assessment documented the resident was unable to make herself understood or to understand others, was always incontinent of bowel and bladder, and required total assistance with dressing, eating, and hygiene needs. A progress note by the nurse practitioner, dated 09/05/12, did not address the resident's abnormal lab values or worsening [MEDICAL CONDITION]. A care plan, dated 09/06/12, documented the resident had ineffective communication skills and was unable to make her needs known. The goals/objectives were to meet the residents needs daily. The care plan did not address the resident's low hemoglobin, hematocrit or red blood cell count, worsening [MEDICAL CONDITION], or a need to assess and monitor the resident's condition. On 10/16/12 at 5:00 p.m., the resident was observed during the evening meal. She appeared to be very pale, including her lips and gums. She was awake and alert. She was being fed her supper meal and was eating. On 10/17/12 at 10:05 a.m., the DON and the Administrator were asked if the resident had a Power of Attorney. They stated she did not have one. They further stated the resident's family was no longer involved with her care. They stated the phone numbers they have for the resident's brother and sister are not answered when they attempt to contact them for notification of changes in the resident's care or condition. At 3:15 p.m., the resident's physician was contacted regarding the resident's low hemoglobin level of 7.2 drawn on 07/05/12 and her pale appearance. He stated he did not have access to the resident's chart and asked the surveyor to have the facility staff to call him. The DON was informed of the request. At 3:30 p.m., CMA #1 was asked if she had noticed any change in the resident recently, such as lethargy or increased pallor. She stated she had not noticed any changes. At 4:00 p.m., the DON was asked what interventions were implemented after the resident's 07/05/12 abnormal hemoglobin values were reported to the physician. She stated, "I don't think they did anything". She stated she had not noted a change in resident's condition in recent weeks and stated the resident was normally pale. She further stated the facility had developed a new tracking system in September 2012 which includes lab results . The DON would be notified immediately of any falls, abnormal lab values or other changes in a resident's condition. The results would be put into the "24 hour book" and reviewed on a daily basis during daily staff meetings. She stated the change in process was not retroactive and the resident's lab values from 07/05/12 were not reviewed under the new system. She further stated the physician had given a new order for the resident to have a STAT (immediate) CBC drawn and arrangements had been made for the blood collection to be obtained that evening. On 10/18/12, at 8:30 a.m., it was noted the resident was not present at the facility. The DON stated the resident had been transferred last night to the hospital for treatment of [REDACTED]. Emerency room records obtained from the hospital documented the resident was admitted on [DATE] at 9:14 p.m. with the [DIAGNOSES REDACTED]. Laboratory tests obtained at the hospital on [DATE] at 9:40 p.m., documented the resident had a hemoglobin level of 5.2, red blood cells of 3.01 (reference range 3.9-5.8) and hematocrit of 22.6 (reference range of 35-46). The lab report documented the hemoglobin was at a panic low level. Laboratory tests obtained at the hospital on [DATE] at 11:50 p.m., documented the resident's serum iron level was 13 (reference range was 38-160), and her Ferritin level was 2.2 (reference range of 11-307). Treatment plans included transfusion of three units of PRBC's (packed red blood cells). At 10:45 a.m., LPN #1 was asked if she had noticed any change in the resident's condition recently, such as increased pallor. She stated the resident had been throwing up after meals and the nurse practitioner had seen her last week. She stated she was told to continue to watch her and feed the resident slowly. She stated the resident was eating 100% of her meals. She stated she had not received any reports of the resident passing dark, tarry stools. She further stated, "we didn't see anything" to indicate resident's hemoglobin levels were low. At 11:00 a.m., CNA #2 stated she hadn't noticed anything different, but stated the resident always had "heavy periods". Asked to elaborate, she stated resident's periods would last as long as two weeks. At 11:05 a.m., LPN #1 was asked about the resident's heavy periods. She stated this had never been reported to her. At 2:45 p.m., CNA #3 stated she had never observed the resident with any unusual sysmptoms. She had never observed the resident having dark, tarry stools. She stated the resident's menstrual period would last for a week or two, but were not heavy, more "spotting in nature." She stated that occassionally the resident would throw up, "but otherwise, everything was fine." At 3:20 p.m., LPN #3 was asked if she had seen any differences or changes in the resident . She stated the resident seemed more pale, but she didn't mention it to anyone because the doctor comes every Monday. She stated she had never had any reports from CNA's about dark, tarry stools or abnormal periods. At 3:30 p.m., CNA #4 and CNA #5 were asked if they had noticed any recent changes in the resident's condition. CNA #4 stated the resident had been vomiting, she did have heavy periods, and she did have dark stools. She stated she always told "the night nurse", but couldn't remember a specific nurse. CNA #5 stated she hadn't noticed the resident being more pale, but felt like resident had been "shakey" lately and that she had notified LPN # 2. She stated for the last month the resident had seemed "different", and was more easily agitated.

On 01/21/11 an immediate jeopardy (IJ) situation was determined to exist due to the facility's failure to identify possible abuse, investigate and report allegations of abuse and ensure the protection of residents during an investigation of abuse. At 12:45 p.m., the IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 12:50 p.m., the administrator, the DON and the corporate nurse were informed of the immediate jeopardy and were asked to provide a written plan of removal. At 4:10 p.m., the plan of removal was accepted. The plan of removal documented the following: "Plan of Removal Grace Living Centers - Del City 01-21-2011 3:59 p.m. 1. All staff will be in-serviced on the Policy and Procedure for Abuse Neglect and Misappropriation of Property. All staff will be in-serviced on the Policy and Procedure for Reports to the State Guidelines. The Administrator and the Director of Nurses will be in-serviced by the Regional Nurse over the above Policies. All staff working today has (sic) been in-serviced during their shift. All staff not working today will be called no later than midnight tonight and in-service will be conducted over the phone. 2. The D.O.N. and/or Administrator will be responsible for investigating and following up on all abuse allegations. 3. Residents (#1 and #7) will be interviewed/assessed for any signs of injury from abuse. All other residents will be interviewed and/or assessed by a nurse for any complaints of abuse/mistreatment or evidence of potential injury from abuse. If any further complaints of mistreatment are identified during the assessments it will be investigated and reported according to Policy and Procedure for Abuse Neglect and Misappropriation of Property. All residents will be reminded during interviews that any issues of mistreatment should be immediately reported to the administrator or D.O.N. 4. (CNA initials deleted) CNA in question will be terminated immediately. A State Report will be initiated to OSDH concerning the allegations against (CNA initials deleted) CNA. A Report 718 will be complete concerning (CNA initials deleted) CNA. Local Police Department will be notified of allegation against (CNA initials deleted) CNA." On 01/24/11 at 10:30 a.m., the IJ was removed effective 01/21/11 at 11:35 p.m., when the facility DON and the corporate nurse provided the survey team with evidence that all aspects of the plan of removal were completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on clinical record review, policy and procedure review and resident and staff interview, it was determined the facility failed to: a. thoroughly investigate allegations of abuse for four (#1, 4, 5 and #7) of five sampled residents for whom allegations of abuse were made; b. report allegations of abuse to facility administration and appropriate state agencies for four (#1, 4, 5 and #7) of five sampled residents for whom allegations of abuse were made; c. identify possible abuse by staff for one (#5) of five sampled residents, and d. ensure the protection of residents during the investigation of abuse for four (#1, 4, 5 and #7) of five sampled residents. This had the likelihood to affect all residents residing in the facility. Findings: A facility Policy and Procedure, titled Resident Abuse, Neglect and Misappropriation of Property, documented, "Policy The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Grace Living Centers will not tolerate mistreatment, neglect, or abuse of residents... Employee Responsibilities: Identification/Reporting: All employees of a nursing facility are mandated reporters of resident abuse, neglect or misappropriation of property and must report any and all incidents by following the procedure below: Identification/Reporting: Report the incident to the highest-ranking person working in the facility at the immediate time of the allegation... The licensed nurse in charge should then assess the resident for evidence of harm related to the allegation. The licensed nurse should report his/her findings to the administrator and/or physician as soon as possible after the assessment and receive instructions for notification of the resident's responsible party. The nurse should take immediate steps to protect the resident from further incident during this time... Investigation: A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH-283... Protection: If an employee is alleged to have abused a resident, the administrator shall then suspend the accused employee until the allegations are thoroughly investigated..." On 01/19/11 at 3:30 p.m., the DON and the administrator were asked to provide the surveyors with all abuse investigations for the past year. The facility provided four reports of resident to resident abuse for the previous 12 months. The facility had no other reports or investigations of any allegations of staff abuse, neglect, or misappropriation of property for the previous year. At 4:00 p.m., the ADON was asked if there had been any resident allegations against staff for verbal or physical abuse. She stated CNA #1 had been counseled and suspended for yelling at a resident. She stated LPN #1 had been counseled for yelling down the hall about a resident and LPN #2 had been counseled about refusing to provide an inhaler when a resident requested it. The ADON, DON and the administrator could not provide any documentation of investigations into the incidents of alleged abuse by staff. There were no investigative reports related to abuse or mistreatment reported to state agencies. On 01/21/11 at 8:10 a.m., resident # 6, who was cognitively aware, approached the surveyors to ask why we were in the facility. He was asked if he had witnessed or experienced mistreatment by staff. He stated he had heard staff yelling and cursing around the facility, especially while on break and when managers were not around. He stated, "This is our home and we shouldn't have to listen to that." He stated he reported the cursing and yelling to the administrator. He was asked what staff members were involved. He refused to disclose the staff names, stating, "I don't want to get anyone in trouble." He was asked if anyone had yelled or cursed at him. He stated, "No. But I know (resident #4) has been yelled at." At 8:45 a.m., the DON was asked if the facility had received any reports of staff cursing or yelling at residents. She stated she had a report of an LPN yelling to another LPN down the hall, saying "You better do something about (resident name deleted)!" The DON was asked what action was taken regarding this allegation. She stated she counseled the staff person and no other action was taken. The DON was asked if the facility investigated the incident to include talking to other residents and other staff. She stated, "No." She was asked if there was any documentation of the incident to include a report to OSDH. She stated, "No. The administrator just told me yesterday this is a report of abuse. I didn't know to report it." At 9:45 a.m., the administrator was asked if she had received any reports of staff yelling and cursing at residents. She stated CNA #1 had recently been suspended for one day for attitude problems and for talking loudly to residents. She stated the CNA was then placed with a mentor for one day. The administrator was asked if any resident had made a complaint about staff cursing and using bad language. She stated resident #6 had complained to her about some staff cursing, but she did not remember the persons involved. She stated she had gotten other reports but did not remember the details of who was involved. She stated she passed along the information to the DON. She was asked if the complaints had been documented, investigated and reported as abuse. She stated, "No." She was asked if she was familiar with the facility policy on abuse. She stated she was reviewing the policy that morning because she was not familiar with it. The administrator was asked if the facility had any documented reports of abuse allegations prior to her administration, or since she became the administrator. She stated there were no such reports. 1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 03/01/10, documented the resident was independent in cognitive skills for daily decision-making, and was totally dependent on staff for all activities of daily living. On 01/21/11 at 10:50 a.m., the resident was asked if he had any complaints about his treatment by staff, or if he had witnessed any incidents of mistreatment. He stated CNA #1 had yelled at him a couple of weeks ago. He stated this CNA often talked "roughly" to residents. He stated he felt CNA #1 was impatient with people and because of this, he did not want her help if he could avoid it. He stated he reported CNA #1 to the DON a few weeks ago. He said he was aware she had been suspended for a day, but since she returned to work, the behavior had started again. He stated CNA #1 recently yelled at him when he asked for assistance with a urinal. He said CNA #1 responded to his request by yelling loudly, "Gosh (resident's name deleted)!" He further stated CNA #1 often yelled at his roommate, who was currently admitted to the hospital. He stated he reported CNA #1's behavior to the social services director during the resident council meeting on 01/20/11. He stated the social services person told him she would tell the DON. At 11:40 a.m., the social services director was asked if there were any resident complaints about staff treatment in the resident council meeting. She stated, "No." The resident council meeting minutes were reviewed. There were no nursing issues identified on the report form. There was no documentation of any resident allegations or complaints about mistreatment by staff. The social services director was asked if any residents had complained in the resident council meeting about staff yelling, cursing, rough treatment, or other allegations of mistreatment. She stated she vaguely remembered something being said, but she thought the residents were talking about old issues. She was asked if she reported any resident allegations from the resident council meeting to anyone. She stated she mentioned the issues from the meeting to the ADON. The social services director was asked if she reported any of the allegations to the administrator or the DON. She stated she did not. She was asked if she had been trained by the facility on resident abuse and how to report allegations. She stated she had been trained a few months ago. She was asked what she should do if she learned about complaints from residents about abuse or neglect. She stated she was supposed to report it to the administrator. At 12:10 p.m., the ADON was asked if she was aware of residents' complaints about staff mistreatment from the resident council meeting. She stated she was not aware. She was informed the social services director stated she told her (the ADON) about the resident complaints from the meeting. The ADON stated, "Oh. I thought she was talking about old issues, not current ones." The ADON was asked if the facility investigated all allegations of abuse. She stated she thought only actual abuse, not allegations of abuse, should be investigated and reported. The ADON was asked if the facility should have investigated the allegations as abuse involving CNA #1. She stated, "Yes." The ADON was asked if CNA #1 worked on 01/20/11, the day the allegations of mistreatment were reported by the residents in the resident council meeting. She stated CNA #1 worked the 11-7 shift on that date. The ADON was asked how the facility could ensure the residents were protected while an abuse investigation was going on. She stated, "I guess we should suspend (the staff involved)." 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. An initial assessment, dated 11/10/10, documented the resident was independent in cognitive skills for daily decision-making. It also documented the resident had constant, severe pain. On 01/21/11 at 1:00 p.m., the resident was asked if she had experienced or witnessed any mistreatment by staff. The resident stated she was on a pain management program that had been ordered by a pain specialist. She stated an LPN on the night shift (LPN #2) either refused to give her pain medication, or forced her to wait long periods of time for pain medication. The resident stated LPN #2 would make remarks such as, "Do you think this (giving you pain medication) is the only thing I have to do?" and "You ask for pain medication too much." The resident stated she was aware of time limits for pain medication but stated she requested pain medication when it was an appropriate time. She stated the problems with LPN #2 and her pain medication had occurred on more than one occasion. She stated she had complained to the DON about it. At 3:50 p.m., the DON was asked if resident #5 had reported to her problems with LPN #2 withholding pain medications. She stated within the past few days, resident #5 had reported to her LPN #2 was not giving her pain medication as she requested. The DON stated, "I've talked to her (LPN#2) several times about giving prn pain medications." She was asked if talking to her was effective. She stated it was not. She was asked if other actions had been taken. She stated,"No." The DON was informed that withholding pain medication should be considered a form of abuse or neglect that required an investigation. She stated, "Oh. OK." At 4:00 p.m., the ADON was asked if LPN #2 had been counseled about refusing to give pain medications. She stated she was aware only that LPN #2 had been counseled about refusing to give another resident her inhaler as requested. There was no evidence to show investigations had been conducted regarding the allegations concerning pain medications. There was no evidence of reporting to state agencies and there was no evidence the residents had been protected against further neglect and abuse. 3. On 01/21/11 at 1:00 p.m., resident #5 stated she had witnessed CNA #1 "slam" a female resident (resident #7) into a wheelchair, bumping the resident's head on a part of the wheelchair back support. The resident stated she did not tell anyone about this until she mentioned it to the social services director in a resident council meeting the day before, on 01/20/11. Resident #7 was not cognitively aware and could not be interviewed about the incident. There was no documentation of the incident in the resident's clinical record. There was no documentation in the resident council meeting minutes that an allegation against CNA #1 had been made. The DON was asked if she had received any reports or complaints of staff mistreatment from the resident council meeting held the day before. She stated she had not. She was asked if she was aware resident #5 complained in the meeting about CNA #1 slamming resident #7 into a wheelchair. She stated she was not aware. There was no evidence to show the resident's complaint of resident #7 having been slammed into the wheelchair was reported to the Administrator or DON. There was no evidence of an investigation into this allegation or to show that residents were protected. 4. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 01/15/11, documented the resident had modified independence in cognitive skills for daily decision-making, had contractures to the lower extremities and had frequent, almost constant pain. On 01/19/11 at 4:00 p.m., the ADON was asked if there had been any resident allegations against staff for verbal or physical abuse. She stated approximately a week ago CNA #1 was reported for yelling at resident #1. She could not remember who reported this allegation. She was asked if an investigation had been conducted. The ADON stated CNA #1 had been counseled by the DON, suspended for one day, then returned to work assigned to a mentor for one day and was now working regular duty. There was no evidence in the personnel file for CNA #1 that any counseling or mentoring had been conducted. There was no evidence she had been suspended. There was no evidence to show a thorough investigation had been conducted. There was no evidence of reporting to state agencies. There was no evidence to show the residents had been protected from further abuse. On 01/21/11 at 9:30 a.m., resident #1 was observed lying in her bed. She stated she was in pain "all over". She was not able to answer any questions about mistreatment or abuse by staff. At 11:15 a.m., the DON was asked if she had received any complaints from residents about CNA #1. She stated resident #4 reported to her once he heard CNA #1 "speaking loudly" to an unknown resident on his hall. The DON was asked what action was taken in response to this allegation. She stated she could not recall any action taken. She was asked if there was any investigations into the allegations made against CNA #1. She stated there was not, but she had recently learned about a facility disciplinary form and would be completing the form that day.

On 01/21/11 an immediate jeopardy (IJ) situation was determined to exist due to the facility's failure to implement it's policy for abuse prevention. At 12:45 p.m., the IJ situation was verified with the Oklahoma State Department of Health (OSDH). At 12:50 p.m., the administrator, the DON and the corporate nurse were informed of the immediate jeopardy and were asked to provide a written plan of removal. At 4:10 p.m., the plan of removal was accepted. The plan of removal documented the following: "Plan of Removal Grace Living Centers - Del City 01-21-2011 3:59 p.m. 1. All staff will be in-serviced on the Policy and Procedure for Abuse Neglect and Misappropriation of Property. All staff will be in-serviced on the Policy and Procedure for Reports to the State Guidelines. The Administrator and the Director of Nurses will be in-serviced by the Regional Nurse over the above Policies. All staff working today has (sic) been in-serviced during their shift. All staff not working today will be called no later than midnight tonight and in-service will be conducted over the phone. 2. The D.O.N. and/or Administrator will be responsible for investigating and following up on all abuse allegations. 3. Residents (#1 and #7) will be interviewed/assessed for any signs of injury from abuse. All other residents will be interviewed and/or assessed by a nurse for any complaints of abuse/mistreatment or evidence of potential injury from abuse. If any further complaints of mistreatment are identified during the assessments it will be investigated and reported according to Policy and Procedure for Abuse Neglect and Misappropriation of Property. All residents will be reminded during interviews that any issues of mistreatment should be immediately reported to the administrator or D.O.N. 4. (CNA initials deleted) CNA in question will be terminated immediately. A State Report will be initiated to OSDH concerning the allegations against (CNA initials deleted) CNA. A Report 718 will be complete concerning (CNA initials deleted) CNA. Local Police Department will be notified of allegation against (CNA initials deleted) CNA." On 01/24/11 at 10:30 a.m., the IJ was removed effective 01/21/11 at 11:35 p.m., when the facility DON and the corporate nurse provided the survey team with evidence that all aspects of the plan of removal was completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on clinical record review, policy and procedure review and resident and staff interview, it was determined the facility failed to implement it's abuse policy to ensure: a. thorough investigations of allegations of abuse for four (#1, 4, 5 and #7) of five sampled residents for whom allegations of abuse were made; b. reporting of all allegations of abuse to facility administration and appropriate state agencies for four (#1, 4, 5 and #7) of five sampled residents for whom allegations of abuse were made; c. identification of possible abuse by staff for one (#5) of five sampled residents; and d. the protection of residents during the investigation of abuse for four (#1, 4, 5 and #7) of five sampled residents. This had the likelihood to affect all residents residing in the facility. Findings: A facility Policy and Procedure, titled Resident Abuse, Neglect and Misappropriation of Property, documented, "Policy The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Grace Living Centers will not tolerate mistreatment, neglect, or abuse of residents... Employee Responsibilities: Identification/Reporting: All employees of a nursing facility are mandated reporters of resident abuse, neglect or misappropriation of property and must report any and all incidents by following the procedure below: Identification/Reporting: Report the incident to the highest-ranking person working in the facility at the immediate time of the allegation... The licensed nurse in charge should then assess the resident for evidence of harm related to the allegation. The licensed nurse should report his/her findings to the administrator and/or physician as soon as possible after the assessment and receive instructions for notification of the resident's responsible party. The nurse should take immediate steps to protect the resident from further incident during this time... Investigation: A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH-283... Protection: If an employee is alleged to have abused a resident, the administrator shall then suspend the accused employee until the allegations are thoroughly investigated..." On 01/19/11 at 3:30 p.m., the DON and the administrator were asked to provide the surveyors with all abuse investigations for the past year. The facility provided four reports of resident to resident abuse for the previous 12 months. The facility had no other reports or investigations of any allegations of staff abuse, neglect, or misappropriation of property for the previous year. At 4:00 p.m., the ADON was asked if there had been any resident allegations against staff for verbal or physical abuse. She stated CNA #1 had been counseled and suspended for yelling at a resident. She stated LPN #1 had been counseled for yelling down the hall about a resident and LPN #2 had been counseled about refusing to provide an inhaler when a resident requested it. The ADON, DON and the administrator could not provide any documentation of investigations into the incidents of alleged abuse by staff. There were no investigative reports related to abuse or mistreatment reported to state agencies. On 01/21/11 at 8:10 a.m., resident # 6, who was cognitively aware, approached the surveyors to ask why we were in the facility. He was asked if he had witnessed or experienced mistreatment by staff. He stated he had heard staff yelling and cursing around the facility, especially while on break and when managers were not around. He stated, "This is our home and we shouldn't have to listen to that." He stated he reported the cursing and yelling to the administrator. He was asked what staff members were involved. He refused to disclose the staff names, stating, "I don't want to get anyone in trouble." He was asked if anyone had yelled or cursed at him. He stated, "No. But I know (resident #4) has been yelled at." At 8:45 a.m., the DON was asked if the facility had received any reports of staff cursing or yelling at residents. She stated she had a report of an LPN yelling to another LPN down the hall, saying "You better do something about (resident name deleted)!" The DON was asked what action was taken regarding this allegation. She stated she counseled the staff person and no other action was taken. The DON was asked if the facility investigated the incident to include talking to other residents and other staff. She stated, "No." She was asked if there was any documentation of the incident to include a report to OSDH. She stated, "No. The administrator just told me yesterday this is a report of abuse. I didn't know to report it." At 9:45 a.m., the administrator was asked if she had received any reports of staff yelling and cursing at residents. She stated CNA #1 had recently been suspended for one day for attitude problems and for talking loudly to residents. She stated the CNA was then placed with a mentor for one day. The administrator was asked if any resident had made a complaint about staff cursing and using bad language. She stated resident #6 had complained to her about some staff cursing, but she did not remember the persons involved. She stated she had gotten other reports but did not remember the details of who was involved. She stated she passed along the information to the DON. She was asked if the complaints had been documented, investigated and reported as abuse. She stated, "No." She was asked if she was familiar with the facility policy on abuse. She stated she was reviewing the policy that morning because she was not familiar with it. The administrator was asked if the facility had any documented reports of abuse allegations prior to her administration, or since she became the administrator. She stated there were no such reports. 1. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 03/01/10, documented the resident was independent in cognitive skills for daily decision-making, and was totally dependent on staff for all activities of daily living. On 01/21/11 at 10:50 a.m., the resident was asked if he had any complaints about his treatment by staff, or if he had witnessed any incidents of mistreatment. He stated CNA #1 had yelled at him a couple of weeks ago. He stated this CNA often talked "roughly" to residents. He stated he felt CNA #1 was impatient with people and because of this, he did not want her help if he could avoid it. He stated he reported CNA #1 to the DON a few weeks ago. He said he was aware she had been suspended for a day, but since she returned to work, the behavior had started again. He stated CNA #1 recently yelled at him when he asked for assistance with a urinal. He said CNA #1 responded to his request by yelling loudly, "Gosh (resident's name deleted)!" He further stated CNA #1 often yelled at his roommate, who was currently admitted to the hospital. He stated he reported CNA #1's behavior to the social services director during the resident council meeting on 01/20/11. He stated the social services person told him she would tell the DON. At 11:40 a.m., the social services director was asked if there were any resident complaints about staff treatment in the resident council meeting. She stated, "No." The resident council meeting minutes were reviewed. There were no nursing issues identified on the report form. There was no documentation of any resident allegations or complaints about mistreatment by staff. The social services director was asked if any residents had complained in the resident council meeting about staff yelling, cursing, rough treatment, or other allegations of mistreatment. She stated she vaguely remembered something being said, but she thought the residents were talking about old issues. She was asked if she reported any resident allegations from the resident council meeting to anyone. She stated she mentioned the issues from the meeting to the ADON. The social services director was asked if she reported any of the allegations to the administrator or the DON. She stated she did not. She was asked if she had been trained by the facility on resident abuse and how to report allegations. She stated she had been trained a few months ago. She was asked what she should do if she learned about complaints from residents about abuse or neglect. She stated she was supposed to report it to the administrator. At 12:10 p.m., the ADON was asked if she was aware of residents' complaints about staff mistreatment from the resident council meeting. She stated she was not aware. She was informed the social services director stated she told her (the ADON) about the resident complaints from the meeting. The ADON stated, "Oh. I thought she was talking about old issues, not current ones." The ADON was asked if the facility investigated all allegations of abuse. She stated she thought only actual abuse, not allegations of abuse, should be investigated and reported. The ADON was asked if the facility should have investigated the allegations as abuse involving CNA #1. She stated, "Yes." The ADON was asked if CNA #1 worked on 01/20/11, the day the allegations of mistreatment were reported by the residents in the resident council meeting. She stated CNA #1 worked the 11-7 shift on that date. The ADON was asked how the facility could ensure the residents were protected while an abuse investigation was going on. She stated, "I guess we should suspend (the staff involved)." 2. Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. An initial assessment, dated 11/10/10, documented the resident was independent in cognitive skills for daily decision-making. It also documented the resident had constant, severe pain. On 01/21/11 at 1:00 p.m., the resident was asked if she had experienced or witnessed any mistreatment by staff. The resident stated she was on a pain management program that had been ordered by a pain specialist. She stated an LPN on the night shift (LPN #2) either refused to give her pain medication, or forced her to wait long periods of time for pain medication. The resident stated LPN #2 would make remarks such as, "Do you think this (giving you pain medication) is the only thing I have to do?" and "You ask for pain medication too much." The resident stated she was aware of time limits for pain medication but stated she requested pain medication when it was an appropriate time. She stated the problems with LPN #2 and her pain medication had occurred on more than one occasion. She stated she had complained to the DON about it. At 3:50 p.m., the DON was asked if resident #5 had reported to her problems with LPN #2 withholding pain medications. She stated within the past few days, resident #5 had reported to her LPN #2 was not giving her pain medication as she requested. The DON stated, "I've talked to her (LPN#2) several times about giving prn pain medications." She was asked if talking to her was effective. She stated it was not. She was asked if other actions had been taken. She stated,"No." The DON was informed that withholding pain medication should be considered a form of abuse or neglect that required an investigation. She stated, "Oh. OK." At 4:00 p.m., the ADON was asked if LPN #2 had been counseled about refusing to give pain medications. She stated she was aware only that LPN #2 had been counseled about refusing to give another resident her inhaler as requested. There was no evidence to show investigations had been conducted regarding the allegations concerning pain medications. There was no evidence of reporting to state agencies and there was no evidence the residents had been protected against further neglect and abuse. 3. On 01/21/11 at 1:00 p.m., resident #5 stated she had witnessed CNA #1 "slam" a female resident (resident #7) into a wheelchair, bumping the resident's head on a part of the wheelchair back support. The resident stated she did not tell anyone about this until she mentioned it to the social services director in a resident council meeting the day before, on 01/20/11. Resident #7 was not cognitively aware and could not be interviewed about the incident. There was no documentation of the incident in the resident's clinical record. There was no documentation in the resident council meeting minutes that an allegation against CNA #1 had been made. The DON was asked if she had received any reports or complaints of staff mistreatment from the resident council meeting held the day before. She stated she had not. She was asked if she was aware resident #5 complained in the meeting about CNA #1 slamming resident #7 into a wheelchair. She stated she was not aware. There was no evidence to show the resident's complaint of resident #7 having been slammed into the wheelchair was reported to the Administrator or DON. There was no evidence of an investigation into this allegation or to show that residents were protected. 4. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 01/15/11, documented the resident had modified independence in cognitive skills for daily decision-making, had contractures to the lower extremities and had frequent, almost constant pain. On 01/19/11 at 4:00 p.m., the ADON was asked if there had been any resident allegations against staff for verbal or physical abuse. She stated approximately a week ago CNA #1 was reported for yelling at resident #1. She could not remember who reported this allegation. She was asked if an investigation had been conducted. The ADON stated CNA #1 had been counseled by the DON, suspended for one day, then returned to work assigned to a mentor for one day and was now working regular duty. There was no evidence in the personnel file for CNA #1 that any counseling or mentoring had been conducted. There was no evidence she had been suspended. There was no evidence to show a thorough investigation had been conducted. There was no evidence of reporting to state agencies. There was no evidence to show the residents had been protected from further abuse. On 01/21/11 at 9:30 a.m., resident #1 was observed lying in her bed. She stated she was in pain "all over". She was not able to answer any questions about mistreatment or abuse by staff. At 11:15 a.m., the DON was asked if she had received any complaints from residents about CNA #1. She stated resident #4 reported to her once he heard CNA #1 "speaking loudly" to an unknown resident on his hall. The DON was asked what action was taken in response to this allegation. She stated she could not recall any action taken. She was asked if there was any investigations into the allegations made against CNA #1. She stated there was not, but she had recently learned about a facility disciplinary form and would be completing the form that day.