Every finding on record at Milton Home, The

Based on observation, record review and interview, the facility failed to provide ongoing Pre and Post Dialysis Evaluations for 1 of 1 residents reviewed for Dialysis management. (Resident 1) Findings include: Resident 1's record was reviewed on 01/05/2026 10:16 AM. Diagnoses on Resident 1's profile included, but were not limited to, end stage renal disease on dialysis, implants and grafts, lower left leg amputation, gastrostomy status, and type II diabetes mellitus. Physician's orders, dated 09/11/2025, included, but were not limited to: a. Check permacath (A permanent catheter, often called a permacath, is a long-term, tunneled tube used for dialysis or urinary drainage, placed under the skin into a large vein or directly into the bladder) site daily upon return from dialysis: Check right chest every evening shift includes caps in place and tight, dressing dry and intact.b. 09/08/2025-No blood pressure or lab draw from either arm with dialysis site, blood pressure to be taken per thigh every shift.c. 12/11/2025- Dialysis: Check access site for bruit and thrill, record/report abnormalities. A care plan, dated 11/11/2025, indicated the resident required hemodialysis related to end stage renal disease. Interventions included but were not limited to: check for thrill and bruit 2 times per shift on day resident returns from dialysis, then daily. Resident to receive dialysis Tuesday, Thursday, Saturday, vital signs checked every shift for 24 hours post-dialysis, or per physician's order. Dialysis Communication Record is sent to the dialysis center with each appointment and return of form is ensured after appointment is completed, encourage resident to go for the scheduled dialysis appointments.There were no post dialysis communication record forms completed and available for review for the month of December 2025.On 12/20/2025 at 1:19 P.M., the Minimum Data Set Coordinator, provided a Hemodialysis policy, dated 1/20/2020, and indicated the policy was the one currently being used by the facility. The policy indicated Purpose: The facility will ensure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Compliance Guidelines: 14. The nurse will ensure that the dialysis access site is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent the nurse will immediately notify the attending position dialysis facility and or nephrologist. 15. The resident will not receive blood pressures or laboratory sticks on the arm where the dialysis access device is located. During an interview, on 01/05/2026 at 11:39 A.M., the Float Director of Nursing- Corporate Regional Nurse Consultant -Director of Nursing, indicated Resident 1's blood pressures should have been taken in their thigh, as the order indicated, and the resident should have had a post dialysis assessment on the following dates: 12/2, 12/4, 12/6, 12/9, 12/11, 12/13, 12/16, 12/18, 12/20, 12/22, 12/24, 12/27, 12/31, 2025. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure resident medications were secured for 1 of 1 resident room reviewed for unsecured medications. Finding included:During an interview, on 12/30/2025 at 11:32 A.M., Resident 21 indicated she had been administered some Tylenol and some Tramadol several days ago, during the evening shift, by a Qualified Medical Assistant (QMA). Resident 21 indicated the QMA had not witnessed her swallowing these pills, so the resident had put them away in case I needed to show someone. Resident 21 was observed to remove 2 round, white pills within a plastic medicine cup from her closet. One pill had an imprint of AN 627 and the other pill had PH 020 imprinted on it.During an interview on 12/30/2025 at 11:38 A.M. the Regional Corporate Nurse Consultant indicated the pills should not have been unsecured in a resident's room.The clinical record of Resident 21 was reviewed on 12/31/2025 at 11:13 A.M. The resident's diagnoses included, but were not limited to: metabolic encephalopathy, acute and chronic respiratory failure, hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage, hypertension, muscle wasting and atrophy, personal history of pulmonary embolism, obesity, cardiomegaly, depression and anxiety.An admission Minimum Data Set (MDS) assessment, dated 11/19/2025, indicated Resident 21 was cognitively intact and had been receiving as needed pain medication.Current physicians' orders included, but were not limited to:-Acetaminophen Tablet 325 mg (milligrams); give 2 tablets every 4 hours as needed for pain, not to exceed 3 grams per day.-Tramadol Hydrochloride Oral Tablet 50 mg; give 1 tablet by mouth every 6 hours as needed for pain or discomfort.Resident 21's December 2025 Medication Administration Record (MAR) indicated the resident had received Tramadol Hydrochloride on the following dates: 12/2, 12/3, 12/4, 12/8, 12/17, and 12/24.The December 2025 MAR indicated Resident 21 had received Acetaminophen on the following dates:12/4, 12/18 and 12/22.On 1/5/2025 at 11:35 A.M., the Regional Corporate Nurse Consultant provided a policy titled, Storage of Medications, dated 4/2019 and indicated the policy was the one currently used by the facility. The policy indicated .facility stores all drugs and biologicals in a safe, secure, and orderly manner.the nursing staff is responsible for maintaining medication storage.3.1 - 25(j)3.1 - 25(m)3.1 - 25(n)

Based on observation, record review and interviews, the facility failed to ensure a resident's wheelchair was correctly secured in the facility van during transportation for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in the resident's wheelchair tipping during transportation requiring an evaluation by an acute care center emergency room and treatment for a skin tear to the elbow and an abrasion to the head.Finding includes:Review of a Nursing Progress Note, dated 10/27/2025 at 5:05 P.M., indicated Resident B had fallen over in his wheelchair while being transported from a medical appointment on the facility bus. The note indicated the Emergency Medical Staff had transported Resident B to a local emergency room where he had treated for minor injuries incurred during the accident and was admitted for an unrelated medical condition.Review of a Narrative Nursing Note from the local emergency department indicated the resident had an abrasion to the right side of his head and a skin tear to his right elbow related to his wheelchair falling over while on the facility bus. The two wounds did not have any drainage, were cleaned with soap and water and were bandaged.Resident B's record was reviewed on 11/6/2025 at 9:30 A.M. Diagnosis included, but was not limited to, Pressure Ulcer of the Sacrum, stage 4, chronic respiratory failure, chronic pain, atherosclerotic heart disease. coronary artery disease, post coronary artery bypass graft, gonococcal infection of the lower genitourinary tract and anxiety.The facility's investigative report related to the bus accident involving Resident B, which had occurred on 10/27/2025 , was reviewed on 11/5/2025 at 1:30 P.M. Review of the report included statements from Employee 2, the National Project Manager, who had confirmed the four point floor securement system and the seat belt had worked properly on 10/27/2025. There was also a statement from Employee 3, the Activity Director, who had been driving the bus when the accident had occurred. The statement from Employee 3 indicated all of the restraints had been secured prior to the transportation of Resident B, but the statements did not include if all of the safety restraints had still been in place after the resident's wheelchair had tipped over. The facility's investigation had not been able to determine any factor that had contributed to Resident B's wheelchair tipping during transportation.During an interview, on 11/5/2025 at 2:30 P.M., with the Regional Nurse Consultant (RNC), she indicated the facility had not identified a reason Resident B's wheelchair had been able to fall over while the facility bus had been in motion and all equipment related to securing the resident on the bus had been checked and was found to be in working condition.During an interview, on 11/6/2025 at 8:57 A.M. with Employee 3, she indicated she had been transporting Resident B back to the facility from a medical appointment (on 10/27/2025) and his wheelchair had fallen over while she was driving the facility vehicle. She indicated prior to transporting Resident B, she had secured his wheelchair with all 4 floor securement belts that had locked and a seatbelt. Employee 3 indicated when she had turned a corner, off of an access street, she had heard a noise from the back and when she lookedl in the rearview mirror, she saw Resident b and his wheelchair laying on their right sides, on the floor of the bus. She indicated Resident B's seatbelt and 3 of the 4 floor safety restraints were still properly secured, but the left front floor restraint was loosened. Employee 3 indicated Resident B had not complained of pain, but due to the scrapes on his head and right arm, she had called for EMS services.During an observation with Employee 3, of the process to secure a wheelchair in the facility bus, on 11/6/2025 at 10:00 A.M., a red level was noted under the front left footrest of the wheelchair and able to be accessed by the feet of resident's in the wheelchair. Employee 3 pushed the red lever and the floor security restraint strap loosened when the wheelchair was purposely tipped to the right side for demonstration. Once the wheelchair was completely placed on it's right side, on the floor of the bus, the security strap on the left front was still attached to the floor of the bus, but was extremely loose. The other 3 security restraint straps remained locked in place and had not loosened when the wheelchair was tipped to the side.During an interview, on 11/6/2025 with a Customer Service Representative (CSR) 4, for the wheelchair floor securement device manufacturer, they indicated the red lever on the floor securement was an emergency release level. CSR 4 indicated the floor securment device was designed so the passengers using the floor securement device were not to have access to the red release lever on the device. CSR 4 indicated if the wheelchair had been properly secured, the straps on the floor securement system would have been at a 45 degree angle, leaving too much room between the resident's foot and the emergency release lever, to prevent accidental engagement. CSR 4 indicated the emergency release lever was to be on the outside of the safety straps not on the inside of the safety straps. The CSR 4 representative indicated the whelechair had been improperly installed by Employee 3, which had allowed the emergency release device to have been activated, which had led to the loosening of the restraint safety strap and the tipping of Resident B's wheelchair.During an interview with the RNC, on 11/6/2025 at 2:00 P.M., she indicated the facility had spoken with the manufacturer of the floor securement devices and had found that Resident B's wheelchair had likely fell over, on 10/27/2025, because Employee 3 had incorrectly secured the wheelchair in the facility bus.Review of Employee 3's skill valadation check off sheet, provided by the RNC on 11/6/2025 at 2:00 P.M. indicated she had been found competent regarding securing a wheelchair correctly in the facility bus, on 1/25/2025.This citation relates to Intake 2654973 and 2658962.3.1-45(a)

Based on observation, interview and record review, the facility failed to prepare food under sanitary conditions related to a dirty range and oven in 1 of 1 kitchen reviewed. This had the potential to affect 24 of the 24 residents who received their meals from the kitchen. Findings include: 1. During the initial kitchen tour on 10/10/2024 at 11:00 A.M. with the Dietary Director (DD), the gas range had four burners with a black substance on all of the grates. The single door oven had a build up of grease and a black substance on the inside. 2. During the final kitchen tour on 10/15/2024 at 9:30 A.M., the range had four burners with a black substance on all the grates and below the grates. The single door oven had a build up of grease and a black substance on the inside. During an interview on 10/15/2024 at 9:31 A.M., the DD indicated the range and the oven were dirty and should be cleaned. The facility used a daily cleaning schedule to complete the kitchen cleaning tasks. On 10/15/2024 at 11:00 A.M., the DD provided a cleaning schedule titled, [Facility Name] Daily Cleaning Schedule and indicated it was the cleaning schedule currently used by the facility. The daily cleaning schedule included the task, Cleaning the range top/ovens/flat top. On 10/15/2024 at 11:00 A.M., the DD provided an undated policy titled, Food Safety and Sanitation, and identified it as the policy currently used by the facility. The policy indicated, .Sanitation .Follow a regular written cleaning schedule and document cleaning 3.1-21(i)(3)

Based on interview and record review, the facility failed to develop a person-centered care plan regarding refusal of showers for 1 of 16 residents whose care plans were reviewed. (Resident 16) Finding includes: A record review was completed on 10/10/2024 at 1:45 P.M. for Resident 16. Diagnoses included, but were not limited to: type 2 diabetes mellitus, vascular dementia, and adjustment disorder with depressed mood. A Quarterly Minimum Data Set (MDS) assessment, dated 8/23/2024, indicated Resident 16's cognition was intact. During an interview on 10/11/2024 at 10:06 A.M., CNA 6 indicated showers were charted in the Point of Care (POC) under the showering task. She indicated when a resident refused a shower, it was charted in the POC as refused. She indicated they notified the nurse about the resident's refusal and they also filled out a shower sheet and marked refused. A review of Resident 16's shower sheets was completed on 10/11/2024 at 11:03 A.M. The shower sheets indicated the resident refused showers on 9/16/2024, 9/19/2024, 9/23/2024, 9/26/2024, 10/3/2024, 10/7/2024 and 10/11/2024. The showering task in the POC lacked any documentation to indicate Resident 16 refused any showers within the last 30 days. Instead, not applicable was documented under the resident's POC showering task for the last 30 days. A current Care Plan, initiated on 12/3/2024, indicated Resident 16 had a self-care performance deficit related to a diagnosis of type 2 diabetes, neuropathy, and adjustment disorder. Interventions included, but were not limited to: the resident preferred showers and required extensive assistance by staff with bathing and showering. Resident 16's Care Plan lacked documentation indicating he refused showers. On 10/11/2024 at 11:17 A.M., a policy regarding refusal of showers was requested but one was not provided prior to the survey exit. 3.1-35(b)(2)

Based on record review and interview, the facility failed to ensure care plan conferences were completed every quarter for 1 of 4 residents reviewed for care plan conferences. (Resident 16) Finding includes: During an interview on 10/9/2024 at 2:50 P.M., Resident 16 indicated he had never been to a care plan conference since being admitted to the facility on [DATE]. On 10/10/2024 at 1:44 P.M., a record review was completed for Resident 16. The record lacked documentation that a care plan conference had been completed for the [AGE] year. During an interview on 10/15/2024 at 9:34 A.M., the Social Services Director indicated Resident 16 attended a care plan conference on 12/19/2023, 6/6/2024 and 8/29/2024. She indicated the resident did not have a care plan conference in February or March of 2024 but should have had one completed. On 10/15/2024 at 10:40 A.M., a policy regarding care plan conferences was requested but one was not provided prior to the survey exit. 3.1-35(e)

Based on observation, interview and record review, the facility failed to ensure a resident was provided 1:1 activities per the plan of care for 1 of 1 resident reviewed for activities. (Resident 6) Finding includes: During an observation on 10/10/2024 at 9:56 A.M., Resident 6 was sitting on her sofa folding a small blanket. During an interview on 10/10/2024 at 2:47 P.M., Resident 6 was sitting on the sofa in her room and indicated she liked to color and did not know what kind of activities the facility offered. During an observation on 10/11/2024 at 10:30 A.M., Resident 6 was sitting on the sofa looking through a coloring book. During an observation on 10/11/2024 at 1:00 P.M., Resident 6 was sitting on her sofa folding a shirt. During an observation on 10/15/2024 at 9:31 A.M., Resident 6 was sitting on her sofa with her eyes closed. A record review was completed on 10/11/2024 at 10:03 A.M. Diagnoses included, but were not limited to: Parkinson's Disease with dyskinesia, with fluctuations, dysphagia, oropharyngeal phase and Alzheimer's Disease. A current Care Plan, initiated 4/29/2024, indicated Resident 6 liked to color in coloring books and did not like to attend group activities. It indicated she would receive 1:1 activities at least twice a week. Review of the electronic medical record the documentation of activity participation for 1:1; indicated no data found. During an interview on 10/15/2024 at 11:59 A.M., the Activity Director indicated when a resident did not like to attend group activities she did a 1:1 with them. She would ask the resident what they would like to do, such as, read them a book, play a game, put on music. She then documented in the electronic medical record point of care under activities 1:1. The Activity Director indicated she did not document in Resident 6's chart when she had visited with the resident and should have had. On 10/15/2024 at 1:30 P.M. the DON provided a policy titled, Activities,dated 5/25/2023, and indicated the policy was the one currently used by the facility. The policy indicated .4. Activities may be conducted in different ways: a. One-to-One Programs. b. Person Appropriate - activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for. 9. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. These include, but are not limited to, considerations for: e. Residents who have withdrawn from previous activity interest/customary routines, and isolates self in room/bed most of the day . 3.1-33(a)(8)

Based on observation, interview and record review, the facility failed to adequately label an over the counter medication stored in a medication cart for 1 of 1 medication cart reviewed. (First Floor Medication Cart) The facility also failed to monitor and maintain proper temperatures of a refrigerator where medications were stored for 1 of 2 medication refrigerators reviewed. (First Floor Medication Refrigerator) Findings include: 1. During an observation of the first floor medication cart on 10/9/2024 at 1:25 P.M. with LPN 8, an opened bottle of Women 50+ Complete Multivitamin with no resident identifying information was in a drawer. An interview with LPN 8 was completed on 10/9/2024 at 1:27 P.M. LPN 8 indicated she did not know whose medication the Women 50+ Complete Multivitamin was, but the medication should be labeled with the resident's name. An interview with the Unit Manager (UM) was completed on 10/9/2024 at 1:30 P.M. The UM indicated all medication should have a label with the resident's name, date of birth, Physician's name, and dosing information. 2. During an observation of the first floor medication refrigerator on 10/9/2024 at 1:35 P.M. with the UM, the medication refrigerator had two thermometers, one was 29 degrees Fahrenheit (F) and the other thermometer was 36 degrees F. The refrigerator had one bottle of Rezvoglar, three boxes of the facility's supply of influenza vaccinations, eight Bisacoydl suppositories and one bottle of Tuberculin. The temperature logs did not have a temperature logged for the following dates: - 9/21/2024 - 9/22/2024 - 9/26/2024 - 9/27/2024 - 9/30/2024 - 10/5/2024 - 10/6/2024 The temperature logs had out of range temperatures logged for the following dates: - 9/1/2024 11 degrees F - 9/2/2024 20 degrees F - 9/3/2024 21 degrees F - 9/4/2024 22 degrees F - 9/5/2024 20 degrees F - 9/6/2024 22 degrees F - 9/7/2024 22 degrees F - 9/8/2024 22 degrees F - 9/9/2024 24 degrees F - 9/10/2024 22 degrees F - 9/11/2024 26 degrees F - 9/12/2024 24 degrees F - 9/13/2024 22 degrees F - 9/14/2024 26 degrees F - 9/15/2024 28 degrees F - 9/16/2024 24 degrees F - 9/17/2024 22 degrees F - 9/18/2024 24 degrees F - 9/19/2024 22 degrees F - 9/20/2024 20 degrees F - 9/23/2024 29 degrees F - 9/24/2024 28 degrees F - 9/25/2024 26 degrees F - 9/28/2024 24 degrees F - 9/29/2024 26 degrees F - 10/1/2024 22 degrees F - 10/2/2024 24 degrees F - 10/3/2024 26 degrees F - 10/4/2024 22 degrees F - 10/7/2024 28 degrees F An interview with the Unit Manager (UM) was completed on 10/9/2024 at 1:37 P.M. The UM indicated the nurse was responsible for checking and logging the medication refrigerator temperatures on the daily log sheets. The UM indicated the temperatures logged on the September and October daily log sheets were within normal range. An interview with the Director of Nursing (DON) was completed on 10/9/2024 at 1:47 P.M. The DON indicated safe temperatures for the medication refrigerator were between 36 and 46 degrees F. On 10/9/2024 at 1:47 P.M. the DON provided a policy, dated 5/15/2023 and titled, Medication Storage and Medication Labeling and indicated it was the policy currently used by the facility. The policy indicated, .1. General Guidelines: . f. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 6. Refrigerated Products: . b. Temperatures are maintained within 36-46 degrees F. Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee . Medication Labeling . 2. The medication label includes, at a minimum: a. medication name, b. prescribed dose, c. strength, expiration date, resident's name, route of administration and appropriate instructions and precautions 3.1-25 (j) 3.1-25 (m)

Based on observation, interview and record review, the facility failed to distribute medication in a sanitary manner during 2 of 4 medication administration observations. (RN 2 & RN 3) Findings include: 1. During an observation on 10/10/2024 at 9:45 A.M., RN 2 dropped one tablet of Vitamin D onto the medication cart. RN 4 applied hand sanitizer and gloves and then picked up the tablet of Vitamin D and put it into the medication cup with other medications. The resident was given the medication cup and took all the medications. During an interview on 10/10/2024 at 9:47, RN 2 indicated the medication should have been discarded and replaced with a new tablet. 2. During an observation on 10/11/2024 at 8:49 A.M., RN 3 dropped one tablet of Lisinopril onto the medication cart and used a spoon to pick up the tablet and put it into the medication cup. The resident was given the medication cup and took all the medications. During an interview on 10/11/2024 at 8:53 A.M., RN 3 indicated she did not know if the tablet of Lisinopril should have been discarded after it fell on to the medication cart, but she would ask someone and follow-up later. RN 3 did not follow-up before the exit of the survey. During an interview on 10/11/2024 at 9:45 A.M., the Director of Nursing (DON) indicated the facility did not have a policy specific to what to do when a medication was dropped. 3.1-18(b)

Based on observation, interview and record review, the facility failed to ensure 1 of 6 residents reviewed were free from abuse. (Resident C) Finding includes: A self-report incident #196, dated 11/27/23 at 8:30 A.M., indicated Resident C had stated a CNA was rough with her care. The incident indicated CNA 3 was suspended pending the investigation. The resident had received no psychosocial distress. The follow-up, dated 11/30/23, indicated during the investigation it was discovered CNA 3 had a pattern of customer service concerns. The CNA was educated and disciplinary action was taken. A Grievance Form, dated 11/24/23 at 6:10 A.M., and completed by CNA 2 indicated .I walked in room with stuff getting my rooms ready and [name of Resident C] says Hey I said good morning how are you doing she better now you are hear I said whats the matter she said .girl almost toss me out of bed she is real mean. I said you want me to write a grivance she said yes This form did not indicate who the CNA had been, but indicated the CNA had been suspended, pending investigation, on 11/24/23. A typed statement from Resident C, dated 11/24/23 indicated .The CNA from night shift almost threw me out of the bed when she was changing me this morning. I had to grab the bar to keep from falling on the floor .She is always rude to me and always mean. I feel safe now but not when she is here A hand written statement, dated 11/28/23 at 11:00 A.M., written by the Director of Nursing (DON) regarding a phone conversation with CNA 3 indicated on her last rounds, around 4:30 A.M., CNA 3 said she tapped the resident and asked her if she needed changed and resident responded that she did. When I turned her back she acted like she didn't hear me.I might have had a tone with her. I told her I can't leave her. I pulled the sheet (draw) close to turn her. She said she didn't want to do it. I've got some stuff going on in my life-my dog is in the ER. I'm sure she didn't like my tone The statement concluded with the following .Reviewed her prior suspension & current grievance. Notified her we were going to terminate her employment r/t [related to] pattern of behavior that is perceived to be negative A Performance: Correction Notice, dated 7/26/23, indicated a resident stated on 7/21/23 .CNA was loud and cursed in resident's presence. This was corroborated by the CNA's statement. CNA stated to ED [Executive Director] that Its my mouth. I can do whatever I want with it The Notice indicated CNA 3 was suspended pending the investigation and had been reinstated to her position on 7/26/23. An Employee Coaching/Counseling Form, dated 11/24/23-early A.M., indicated CNA 3 had inappropriate conduct. Resident C .alleges rough treatment during care. Another resident alleges CNA is mean & nasty & cusses The form indicated in July of 2023, CNA 3 was educated on positive communication. The form indicated CNA was suspended on 11/24/23 and terminated on 11/28/23. During an interview/observation, on 12/13/23 at 10:28 A.M., Resident C was observed in her bed. She was alert and oriented to self, place and time. Resident C recalled the incident with CNA 3. The resident indicated CNA 3 was rough, pulled her sheet hard and she had talked down to her. The resident indicated she reported the incident to her nurse and the CNA was written up. The resident indicated CNA 3 had not been back in her room since then and she feels safe now that she's not around. During an interview, on 12/14/23 at 11:10 A.M., CNA 2 indicated she was coming onto day shift and was going to each resident to see how they were doing. She indicated when she checked on Resident C, she reported to her CNA 3 had pulled on her sheet to hard and was rude to her. CNA 2 indicated she had wrote the grievance regarding Resident C and how she was treated by CNA 3. She indicated she gave the grievance to the nurse on night shift, as the day shift nurse wasn't in the facility. She indicated she was instructed to call the Administrator, a previous one, which she did and reported to him what the resident had communicated to her. She verified this occurred on the morning of the 24th, the day she wrote the grievance. A typed page, included in the incident investigation, undated, with Definitions and Terms indicated verbal abuse was defined .as the use of oral, written, and/or gestured language that willfully includes disparaging and derogatory term to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability .Physical: Using bodily or mechanical force, inappropriately touching, pulling, shoving, pushing, hitting, shaking, whipping, slapping, pinching, or any form of corporal punishment and/or inflicting any degree of pain or discomfort. On 12/13/23 at 10:44 A.M., the DON provided a policy titled, Abuse Prevention Program, dated 2001 and revised December 2016, and indicated the policy was the one currently used by the facility. The policy indicated .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms This concern relates to complaint IN00422710. 3.1-27(a)(b)

Based on interview and record review, the facility failed to ensure an incident of abuse, involving Resident C, was reported timely. Finding includes: A self-report incident #196, dated 11/27/23 at 8:30 A.M., indicated Resident C had stated a CNA was rough with her care. The incident indicated CNA 3 was suspended pending the investigation and the resident had received no psychosocial distress. A typed statement from Resident C, dated 11/24/23 indicated .The CNA from night shift almost threw me out of the bed when she was changing me this morning. I had to grab the bar to keep from falling on the floor .She is always rude to me and always mean. I feel safe now but not when she is here During an interview, on 12/14/23 at 11:10 A.M., CNA 2 indicated she had wrote out a grievance form regarding Resident C and how she was treated by CNA 3. She indicated she gave the completed form to the nurse on the night shift, as the day shift nurse wasn't in the facility yet. She indicated she was instructed to call the Administrator, who no longer worked at the facility, which she did and reported to him what the resident had communicated to her. She verified this occurred, on the morning of 11/24/23, the day she wrote the grievance. During an interview, on 12/14/23 at 11:22 A.M., the Director of Nursing (DON) indicated she did not do the incident report to the state, until 11/27/23, because she was unaware of the incident until she reviewed the grievance, on 11/27/23. She indicated she had a conversation, with the previous administrator and he had no explanation as to why he had not reported the incident immediately. On 12/13/23 at 10:44 A.M., the DON provided a policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 2001 and revised September 2022, and indicated the policy was the one currently used by the facility. The policy indicated .1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility .3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury This concern relates to complaint IN00422710. 3.1-28(c)

Based on observation and interview, the facility failed to store and dispose expired foods for 1 of 1 dietary area observed. This deficient practice had the potential to affect 30 residents of 30 residents who received their meals in the dietary area. Findings include: During an observation on [DATE] at 10:08 A.M., the upright refrigerator had 2 cartons of half and half with an expiration date of [DATE]. On [DATE] at 10:15 A.M., the dry storage areas had an opened bag of flour that was not secured with a covering and loose flour was exposed. During an interview on [DATE] at 10:15 A.M., the Dietary District Manager indicated the flour should have been taken to the kitchen and stored in a closed container. On [DATE] at 10:19 A.M., three bags of soft tortilla shells were observed in a cabinet with a best by date of [DATE]. During an interview on [DATE] at 10:19 A.M., the Dietary District Manager thought the tortillas may have been stored in the freezer, but was unsure when the tortillas had been pulled from the freezer. On [DATE] at 10:20 A.M., a two-pound three-ounce bag of frosted flakes had a use by date handwritten of [DATE]. During an interview on [DATE] at 10:20 A.M., the Dietary District Manager indicated the date on the frosted flakes package was [DATE]. The Dietary District Manager had Cook 3 observe the date written, and Cook 3 indicated the date on the packaging was [DATE]. During an observation of the used spices on [DATE] at 10:21 A.M., the following was observed: -16 oz. (ounces) black pepper with no open date or use by date. -thyme 12 oz. dated [DATE] as an open date. -onion powder 2.62 oz. no open date or use by date. -herb seasoning 13 oz. no open date or use by date. -pumpkin pie spice 16 oz. open date of [DATE] with a use by date [DATE]. -seasoning salt 5 pound no open date or use by date. -ground sage 1.25 oz. no open date or use by date. -ground mustard opened [DATE], use by date [DATE]. -corn starch open box and not sealed. -ground ginger 16 oz. open [DATE], and use by [DATE]. -ground thyme 12 oz. open [DATE], use by [DATE]. -ground nutmeg 16 oz. open [DATE], use by [DATE]. -Mrs. Dash seasoning 21 oz. no open date or use by date. -ground cinnamon 2.37 oz. no open or use by date. During an interview on [DATE] at 10:35 A.M., the Dietary District Manager indicated the best practice for spice storage was to discard after 6 months of opening. On [DATE] at 12:01 P.M., an observation of self-serve cereals was observed in the dining area. Raisin Bran, with a preparation date of ,d+[DATE], and a use by date of [DATE] was observed, with approximately 1 cup left in the canister. Foot Loops in the self-serve container was not dated, and had a half full container. During an interview with CNA 2 on [DATE] at 12:17 P.M., he indicated the cereal is served by the staff in the mornings. On [DATE] at 12:19 P.M., the Dietary District Manger indicated the raisin bran should have been disposed and indicated label on the fruit loops must have fallen off. During an observation on [DATE] at 2:13 P.M., the flour bag in dry storage had a white bag over it, and the bag twisted at the top. The bag did not have any secure closure. A current policy was provided on [DATE] at 10:11 A.M. by the Director of Nursing. The policy was titled, Quick Resource Tool: Safe Storage of Food. The policy indicated, .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination .9. All packaged and canned food items will be kept clean, dry, and date marked as appropriate 3XXX,d+[DATE](i)(2)

Based on observation, record review and interview, the facility failed to provide quarterly statements to 3 of 9 residents with resident trust funds. (Residents 10, 20 and 13) Finding includes: The clinical record for Resident 10 was reviewed on 10/23/2023 at 2:00 P.M. The most recent MDS (Minimum Data Set) assessment for Resident 10, conducted as a quarterly review on 9/20/2023 indicated she was alert and oriented and cognitively intact. The clinical record for Resident 20 was reviewed on 10/7/23 . The most recent MDS assessment for Resident 20, conducted for an admission assessment indicated he scored a 12 out of 15 possible points and was moderately cognitively impaired. The clinical record for Resident 13 was reviewed on 10/26/2023 at 3:00 P.M. The most recent MDS assessment, completed on 8/20/2023 due to a significant change in condition, indicated the resident was alert and oriented and cognitively intact. During a review of the resident trust fund accounting, on 10/26/23 at 1:54 P.M. with the business office manager BOM, he indicated if the facility was the representative payee for the resident with a resident trust fund, they did not provide the resident with a quarterly statement. On 10/27/2023 at 9:00 A.M., the facility provided quarterly Resident Fund Statements for July through September 2023 for Residents 10, 13 and 20. All of the statements were signed with the same initials. During an interview with the Business Office Manager, on 10/27/2023 at 2:46 P.M. he confirmed the signature was the Administrators' because the facility was the representative payee for all three residents. When questioned why the alert and oriented residents, who were their own responsible party, were not given a copy of the quarterly statements, he indicated he was new to the position and the Corporate staff member training him informed him they were not given to the residents because the facility was the representative payee for all three residents. The current facility policy and procedure, titled, Transactions Involving Resident Funds, provided by the Director of Nursing on 10/30/2023 at 1:29 P.M., included the following: .8. Quarterly statements will be provided in writing to the resident, or the resident's representative, within 30 days after the end of the quarter and upon request 3.1-6(g)

Based on interview and record review, the facility failed to ensure a SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) Form was provided following the end of Medicare skilled services for 1 of 1 resident who discharged from Medicare services and remained in the facility. (Resident 55) Finding includes: On 10/26/2023 at 1:37 P.M., the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review Forms were reviewed. The form indicated Resident 55 was not issued an SNF-ABN form. Resident 55's representative was provided a Notice of Medicare Non-Coverage (NOMNC) Form which indicated Resident 55's Medicare coverage would end on 4/23/2023. The form indicated that the representative was notified that their financial liability would begin on 4/24/2023. On 10/26/2023 at 2:16 P.M., the Social Service Director indicated that Resident 55 should have received an SNF-ABN form since she remained in the facility after discharge from Medicare services. On 10/27/2023 at 9:05A.M., the Director of Nursing provided the current policy titled, Advanced Beneficiary Notices. The policy indicated, but was not limited to: .It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage .5. The current CMS-approved [Center for Medicare and Medicaid Services] version of forms shall be used at the time of issuance to the beneficiary 9 resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form. a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055 3.1-4(f)(2)

Based on observation, record review and interview, the facility failed to ensure food was served at a palatable temperature for 3 of 15 residents reviewed. (Residents 10, 17 and 20) Findings include: During an interview with alert and oriented Resident 10, on 10/23/2023 at 3:10 P.M., she indicated her food was often served cold and did not taste good. During an interview with Resident 10, on 10/27/2023 at 2:12 P.M., she indicated her lunch food was bland and was barely warm. During an interview with alert and oriented Resident 17, on 10/23/2023 at 2:19 P.M., she indicated the food was not always served hot. She indicated she used to have the staff heat the food up in the microwave but they had removed the microwave from the second floor dining room due to safety concerns. Resident 17 was discharged from the facility on 10/27/2023. During an interview with Resident 20, on 10/24/2023 at 10:24 A.M., he indicated the food was sometimes served cold. During an interview with Resident 20, on 10/27/23 at 2:16 P.M., he indicated his lunch was not very good and was kind of cold. He indicated the macaroni and cheese got hard because it was too cold. During a dining observation, the meal trays were delivered to the second floor of the facility on 10/25/2023 at 1:02 P.M. The trays were transported in an unheated metal cart and the meal plates were covered with a plastic insulated plate cover. There were two meal plates on each tray and there were no insulated plate holders underneath the plates. During an observation of food temperatures of the last tray to be delivered, conducted with the FSS (Food Service Supervisor) on 10/25/2023 at 1:11 P.M., the following food temperatures were obtained: The mashed potatoes were 124 degrees Fahrenheit, the cornbread stuffing was 138 degrees Fahrenheit, the pureed peas were 112 degrees Fahrenheit, and the pureed ham was 110 degrees Fahrenheit. During a dining observation, the meal trays were delivered to the second floor of the facility on 10/27/23 at 12:53 P.M. The meals were delivered in an unheated metal cart and each plate of food was covered with an insulated plastic plate cover and an insulated plastic plate holder was underneath each tray. At 1:02 P.M., the food temperatures of the food tray was assessed with Dietary Aide, Employee 10. The baked fish was 104.5 degrees Fahrenheit, the cauliflower was 100 degrees Fahrenheit and the macaroni and cheese was 116 degrees Fahrenheit. During an interview with dietary aide, Employee 10, regarding the target temperatures for food at the point of service, she indicated she was new to the facility and was not sure how hot the food was supposed to be when served. During an interview with the Registered Dietician, on 10/27/2023 at 1:10 P.M., she indicated the holding temperature should be 140 degrees Fahrenheit or above. She indicated the facility had a plate warmer in the kitchen but did not have hot pallets or an warm/heated delivery cart. She indicated the insulated plate covers and holders should be utilized. During an interview, on 10/27/2023 at 3:30 P.M. with the FSS he indicated the food was at the correct holding temperature in the kitchen before it was served. He indicated he had not conducted any test tray assessments of food temperatures at the point of service. The facility policy, titled, Safe Food Handling, provided by the Administrator on 10/24/2023 at 11:30 A.M., included the following: .3. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit and/or less than 135 degrees Fahrenheit, or per state regulation 10. When hot pureed, ground, or diced food drop into the danger zone (below 135 degrees Fahrenheit) the mechanically altered food must be reheated to 165 degrees Fahrenheit for 15 seconds if holding for hot service There was no specific policy provided regarding transporting hot food and target temperatures of hot food to ensure resident palatability. 3.1-21(a)(2)

Based on observation, record review and interview, the facility failed to ensure hot water temperatures were maintained at a safe level for 1 of 2 nursing units. Finding includes: During an Environmental tour of the facility, conducted on 1/30/2023 between 10:30 A.M. and 11:30 A.M., accompanied by the Maintenance Supervisor, Employee 2, the following elevated hot water temperatures were noted: The unlocked bathroom on the 1st floor, available for use by residents, staff and the community was 130 degrees Fahrenheit room [ROOM NUMBER], an occupied comprehensive healthcare room was 127 degrees Fahrenheit room [ROOM NUMBER], an occupied comprehensive healthcare room was 124 degrees Fahrenheit The Women's shower room on the Second floor of the comprehensive healthcare side of the building was 126 degrees Fahrenheit. Observation of the Boiler room indicated there was one large hot water heater, three holding tanks and a mixing valve set up to supply the hot and cold water to the building. The thermostat on the mixing valve was noted to be set at 130 degrees. When the concern was voiced to Employee 2, he indicated the mixing valve needed to be set at 130 degrees so the water was hot enough when it was pumped to the second floor. Employee 2 indicated he checked the hot water temperatures daily and they were normally between 100- 120 degrees Fahrenheit. He indicated the water must be hot because it had been sitting in the pipes. Review of the facility reportable incidents since 11/1/2022 indicated there had been no residents burned from hot water. Review of the facility policy and procedure, provided by the Director of Nursing (DON) on 1/30/2023 at 1:40 P.M., titled Water Temperatures, Safety of included the following: .1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees F (Fahrenheit) (48-89 degrees C (Celsius), or the maximum allowable temperature per state regulation. 2 Maintenance staff is responsible for checking thermostats and temperature controls int he facility and recording these checks in a maintenance log The Director of Nursing provided an additional form, titled Tels Masters on 1/30/2023 at 1:40 P.M., .1. Ensure patient room water temperatures are between 105 degrees and 115 degrees Fahrenheit (or as specified by state requirements), .Indiana - 100 degrees to 120 degrees 3.1-45(a)

Based on interview and record review, the facility failed to provide services, such as assessments and wound dressing changes, to promote the healing of a unstageable/full thickness pressure ulcer and Moisture Associated Dermitis for 1 of 3 residents reviewed for pressure ulcers/altered skin conditions. (Resident B) Finding includes: On 9/12/22 at 10:45 A.M., a review of the clinical record for Resident B was conducted. The record indicated the resident was admitted on [DATE] and left the facility Against Medical Advice (AMA) on 6/14/22. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Date Set (MDS) Admission Assessment, dated 5/10/22, indicated the resident weighed 144 pounds, required limited assist of 1 person with bed mobility, was always incontinent of bowel/bladder, was admitted with an unstageable pressure ulcer (full thickness tissue loss), which was covered by slough (dead yellow tissue) and or eschar (necrotic brown/black devitalized tissue). A care plan, dated 5/5/22, indicated the resident had the potential and/or actual skin issues related to: resident was admitted with wound. The interventions include: .Notify MD [Medical Doctor] of changes in the wound or emerging wounds. Observe wound healing. Provide wound care/preventative skin care per order. Skin checks weekly per facility protocol, document findings. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A Nurse's Transfer/Discharge Condition Assessment Form, dated 5/5/22, from the hospital indicated .Peri area rash, coccyx unstageable There were no measurements of the wound documented on this form. An Extended Care Facility Patient/Resident Transfer Form-Physician Orders, dated 5/5/22, from the hospital indicated, in the treatment section, the following: .Coccyx: unstageable, cleanse with NS [Normal Saline]. Apply Medi-honey, then cover with alginate & foam dressing every other day Form indicated resident was to be seen by his primary care physician within 2-3 days. An Admission/Readmission Evaluation Form, dated 5/5/22 at 2:59 P.M., within the Special Instructions section, was the following information, .Resident admitted to the skill unit due to weakness and [CONDITION(S)] [Urinary Tract Infection]. Resident will need therapy to assist him with ambulation, transfer, and bed mobility so as to strengthen his muscles and resolve open area to the coccyx The Skin assessment indicated the resident had an unstageable wound on his coccyx. There were no markings on the diagram to specify location and no measurements of the impaired coccyx area. A Braden Scale for Predicting Pressure Sore Risk form, dated 5/5/22 at 2:59 P.M., indicated the residents Braden score was 13. The scale indicated a score of 13-14 revealed the resident was at moderate risk of obtaining a pressure ulcer. A Progress Note, dated 5/5/22 at 3:11 P.M., indicated the writer had received report from the hospital regarding Resident B. The Note indicated the resident had rash to his peri area (genital area) and a pressure ulcer to his coccyx, which was described as unstageable. A Progress Note, dated 5/5/22 at 4:26 P.M., indicated the resident had arrived from the hospital, was alert and oriented to person place and time, with some confusion, but cooperative with the assessment. The Note indicated the resident's skin was intact, except for open area on his coccyx which measured 2.0 x 2.0 cm (centimeters) and was cleansed and then dressed with a [MEDICATION(S)] (an absorbent foam dressing for draining wounds). A Physician Note/Exam form, dated 5/5/22, indicated the resident was seen at the facility due to being a new admission. The form's skin assessment indicated the resident had no [CONDITION(S)]. There was no mention of the pressure ulcer and/or treatment on this form. A Nutritional Assessment, completed by the Dietician, dated 5/6/22 at 4:39 P.M., indicated resident had open area on his coccyx. The Dietician's recommendations were to start Prostat (nutritional supplement) 30 ml (milliliters) twice a day, for wound healing. The Skilled Charting form, dated 5/7/22, indicated resident had a wound to the coccyx area and treatment per orders.Resident admitted to the facility from the hospital due to weakness and [CONDITION(S)] [Urinary Tract Infection] which is being treated with [MEDICATION(S)] 750 mg[milligrams]. He requires one person assist with bed mobility, transfer, toileting and set up with meal. Resident was assessed by therapist today and found to be unable to walk well due to Parkinson disease. He is to use wheelchair until he gets enough strength as he froze while walking. He can feed self with set up. Resident is able to express his need and was educated about his need to use the call light when he needs assistance A Weekly Wound Observation form, dated 5/16/22 at 7:49 P.M.,, indicated Stage III to coccyx, measured 2.5 x 2.0 cm, with slough present. The form indicated the wound was first observed on 5/16/22. There was no indication of a treatment and/or dressing change being completed as the the Current Treatment Plan stated N/A. There were no other Weekly Wound Observation forms completed on this resident for the duration of his stay. An Initial Wound Evaluation & Management Summary, dated 5/18/22, indicated the resident was seen by a wound physician. The form indicated the resident presented with a full thickness sacrum wound which measured 2.0 x 0.2 cm, with moderate serous exudate, with 100% of the dermis/subcutaneous tissue effected. The treatment orders were to apply calcium alginate and cover with island gauze, daily, for 30 days. In addition, the form indicated the resident had MAD-Moisture Associated [CONDITION(S)] (inflammation and erosion of the skin caused by prolonged exposure to moisture) and the ordered/treatment was to apply house barrier cream to the MAD area daily. The plan of care was wound healing evidenced by decrease surface area of the wound and/or decrease in the percentage of necrotic tissue. Recommendations were to off-load wound; reposition per facility protocol. A Progress Note dated 5/18/22 at 8:28 P.M. indicated .While doing rounds with the NP [Nurse Practitioner] resident bottom was noted to be excoriated as well as the groin area. This nurse cleaned the resident and cream was applied. Aide was educated about the importance of keeping the resident clean and dry A Progress Note, dated 5/19/22 at 4:50 P.M., indicated .Dr. prescribed [MEDICATION(S)] [skin barrier cream] three times a day and as needed due to resident having rash to groin area and buttock. Responsible parties notified A Progress Note, dated 5/19/22 at 8:42 P.M., indicated [MEDICATION(S)] was not available. A NAR (Nutrition At Risk) Note, dated 5/20/22 at 1:17 P.M., indicated Prostate 30 ml BID was added on 5/20/22. NAR Note indicated .Skin status: 5/16 wound observation notes stage III open area to coccyx A Wound Evaluation & Management Summary, dated 5/25/22, indicated the sacrum, full thickness, wound measured 1.5 x 0.7 x 0.2 cm, had moderate serous exudate and wound was improving. Continue treatments daily for 23 days. The MAD progress had deteriorated and increased in size and severity of effective area. Treatment was to use the house barrier cream. A Head to Toe Weekly Skin Assessment, dated 5/31/22 at 4:59 P.M., indicated admitted with wound, site: coccyx with skin breakage. There were no other descriptions or measurements of the wound. After 5/31/22 there were no other skin or wound assessments, by facility nursing staff, documented. The May Treatment Administration Record (TAR) indicated .Protective skin barrier ointment after each incontinent episode, prn [as needed] The start date was 5/5/22 and there were no nurse's initials indicating the treatment was completed. The May Medication Administration Record (Mar) indicated on 5/19/22 there was a new ordered added which stated [MEDICATION(S)] Ointment, apply to groin area/buttock three times a day (at 8:00 A.M., 12:00 P.M. and 8:00 P.M.), cleanse injured area, pat dry then apply cream. The treatment started on 5/19/22 at 8:00 P.M., on 5/21, 5/22 and 5/29 the MAR indicated the treatment was completed only twice on those days. Niether, the MAR or TAR for May had the order for Prostat nor documentation indicating the resident was receiving the supplement for wound healing. A Wound Evaluation & Management Summary, dated 6/1/22, indicated the full thickness sacrum wound measured 1.2 x 0.8 x 0.2 cm, had 20% slough and 80% dermis/subcutaneous tissue. The Summary indicated .This wound is in the [CONDITION(S)] stage and is unable to progress to a healing phase because of the presence of a biofilm. An excisional debridement was explained to the resident who agreed to the procedure. There was no change in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician Note/Exam form, dated 6/2/22, indicated the resident was seen at the facility as a 30 day follow-up. The form's skin assessment indicated the resident had no [CONDITION(S)]. There was no mention of the pressure ulcer and/or treatment on this form. A Wound Evaluation & Management Summary, dated 6/8/22, indicated the full thickness sacrum wound measured 2.0 x 2.0 x 0.2 cm, had 20% slough and 80% dermis/subcutaneous tissue, and had deteriorated. Again, an excision debridement procedure was explained to the resident, and he agreed to the procedure. A Group 2 mattress and gel cushion to chair were added to the recommendations. The treatment remained the same. The June TAR indicated .Protective skin barrier ointment after each incontinent episode, prn [as needed] The start date was 5/5/22 and there were no nurse's initials indicating the treatment was completed. The June MAR indicated the treatment was completed as ordered on 6/1/22, then only twice on 6/2/22 and after 6/2/22 there were no other documentation indicating the [MEDICATION(S)] ointment had been applied as ordered. A June Certified Medical Technician (CMT) form indicated .Prostat two times a day related to muscle weakness There was no documentation indicating the Prostat had been administered. On 9/14/22 at 11:18 A.M., an interview was conducted with the Regional Nurse and the Clinical Nurse Specialist. The Clinical Nurse Specialist indicated the CMT note, which had the order for Prostat, dated 5/20/22, should have been seen by the nurse and documented as administered twice a day. She confirmed there was no documentation of the Prostat being provided to the resident. The Regional Nurse indicated when the Dietician recommended the Prostat, for wound care, the order should have been added to the MAR and administered as ordered. Both agreed there was no documentation for wound treatments being completed, such as medi-honey/calcium alginate/dressing, nor just calcium alginate/dressing. Both indicated the wound barrier cream was also not provided as ordered consistently. During an interview, on 9/14/22 at 11:37 A.M., the Wound Physician indicated he was the one who had evaluated the wounds on Resident B. He indicated he documented the wound as being 1 day old, as he was relying on the nurse for date the wound was acquired. He indicated his notes were documented electronically, then uploaded into their system. Otherwise, after he leaves the facility, he documents the notes and the facility was given a password to access his notes regarding measurements treatment etc. The Physician indicated he also communicated with the facility wound nurse and/or DON (Director of Nursing) prior to leaving the facility, to ensure staff are aware of his treatments etc. The Wound Physician indicated there were no delays in staff knowing the wound treatments. The Wound Physician indicated the term full thickness indicated the dermis and epidermis were gone and could view the subcutaneous, fatty tissues and confirmed this is what Resident B's wound was diagnosed as a full thickness pressure wound with MAD surrounding the pressure area. On 9/12/22 at 1:05 P.M., the Director of Nursing (DON) provided a policy titled, Prevention of Pressure Ulcers/Injuries, dated July 2017, and indicated the policy was the one currently used by the facility. The policy indicated .Moisture 1. Keep the skin clean and free of exposure to urine and fecal matter .Nutrition .2. Include nutritional supplements in the resident's diet to increase calories and protein .Mobility/Repositioning 1. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences .Monitoring 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis On 9/12/22 at 1:07 P.M., the Director of Nursing (DON) provided a policy titled, Physician Orders, dated 6/22/22, and indicated the policy was the one currently used by the facility. The policy indicated .MAR/TAR: Medication Administration Record/Treatment Administration Record - the legal medical record for recording medications and treatments .Policy Interpretation and Implementation: . 3. Execution of Order and Notifications a. The nurse that takes the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] b. Contact laboratory services, radiology services, pharmacy services, therapy or other outside vendors as required to execute the medical order c. Update eMAR/eTAR with changes or new orders d. Notify internal staff of changes/updates as appropriate e. Notify resident/resident representative of changes or new orders as appropriate f. Notify attending or other providers as appropriate g. Document notifications and appropriate assessments in the medical record On 9/14/22 at 3:23 P.M., the Regional Nurse provided a policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated July 2017, and indicated the policy was the one currently used by the facility. The policy indicated .Documentation The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment (s) conducted. 2. The date and time and type of skin care provided, if appropriate 3. The name and title (or initials) of the individual who conducted the assessment 4. Any change in the resident's condition, if identified. 5. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified. 6. How the resident tolerated the procedure or his/her ability to participate in the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment, the reason for the refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal. 9. Observations of anything unusual exhibited by the resident 10. The signature and title (or initials) of the person recording the data. 11. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration. This Federal tag relates to complaint IN 408. 3.1-40(a)(2) 3.1-40(a)(3)

Based on observation, record review, and interview, the facility failed to develop a baseline care plan within 48 hours of admission related to oxygen use for 1 of 17 residents whose care plans were reviewed. (Resident 23) Finding includes: On 7/26/22 at 11:39 a.m., Resident 23 was observed with oxygen on via a nasal cannula with a flow rate of 4 liters. The resident indicated she always wore her oxygen. Record review for Resident 23 was completed on 7/26/22 at 1:42 p.m. The resident was admitted to the facility on [DATE]. A Care Plan indicated the resident had [CONDITION(S)] ([CONDITION(S)]) and [CONDITION(S)]. The care plan did not reflect oxygen use. The record lacked any documentation a base line care plan related to oxygen use was completed. Interview with Nurse Consultant on 7/29/22 at 11:11 a.m., indicated she could not provide any documentation to indicate a baseline care plan for oxygen had been completed. 3.1-30(a)

Based on record review and interview, the facility failed to ensure an individualized care plan was developed related to diabetes management for 1 of 17 resident care plans reviewed. (Resident 11) Finding includes: Record review for Resident 11 was completed on 7/27/22 at 3:31 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated 5/30/22, indicated the resident was cognitively intact. The resident had received insulin (diabetes medication). The record lacked any documentation a care plan had been completed related to diabetes management. Interview on 7/28/22 at 10:23 a.m. with Regional MDS indicated the resident should have had a care plan for the management of diabetes. 3.1-35(a)

Based on observation, record review and interview, the facility failed to ensure dependent residents received ADL (activities of daily living) assistance related to scheduled showers and shaving for 2 of 2 residents reviewed for ADL care. (Residents 15 and 19) Findings include: 1. On 7/26/22 at 10:16 a.m., Resident 15 was observed in bed. He was wearing tubigrips (elastic coverings) on both arms. Both were soiled with dried blood. He indicated he was only getting a shower or bath once every two weeks. The resident's record was reviewed on 7/27/22 at 1:39 p.m. The resident was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment, dated 5/3/22, indicated the resident was cognitively intact, and required one person assistance for transfers, bed mobility and toileting. The June and July 2022 shower sheets indicated the resident was showered on the following days: 6/16/22, 7/7/22 and 7/16/22. He was scheduled to receive showers every Monday and Thursday. There was no documentation he had refused any scheduled showers. 2. On 7/27/22 at 9:41 a.m., Resident 19 was observed in bed. He was unshaven. The resident's record was reviewed on 7/27/22 at 9:33 a.m. The resident was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS, dated [DATE], indicated the resident had severe cognitive deficits, and required limited assistance with bed mobility, transfers and toileting. The June and July 2022 shower sheets indicated the resident was showered and shaved on 7/6/22, showered on 6/8/22, and refused on 7/16/22. He was scheduled to receive showers every Wednesday and Saturday evening. A telephone interview with a family member on 7/26/22 at 1:32 p.m., indicated the resident had always been clean shaven, but had not been shaved in a while. Interview with CNA 2 on 7/27/22 at 1:57 p.m., indicated residents should get two showers a week and a shower sheet should be completed with each shower. If refused, that should be documented also. 3.1-38(a)(3)

Based on interview, observation and record review the facility failed to ensure to create/implement individualized interventions following falls and failed to complete risk cause analysis for 2 of 2 residents reviewed for falls, with 1 resident experiencing recurrent falls including one resulting in an a neck fracture of his 7th cervical vertebra. (Resident 16 and 23) Findings include: 1. A clinical record review was completed, on 8/13/2021 at 9:45 A.M., for resident 23's diagnoses included but were not limited to: displaced fracture of 7th cervical vertebra fracture, compression fracture of 1st lumbar, low vision and pacemaker. The significant change MDS (Minimum Data Set) assessment, dated 7/22/2021, indicated a brief interview for mental status score of 4, cognitive status severely impaired. During initial tour of the facility, on 8/11/2021 at 11:15 A.M., Resident 23 was observed sleeping in bed, he had dressings on the right elbow and the right forearm dated 8/10/2021, call light cord at the foot of the bed, fall mat next to the bed and water across the room. He aroused and could not remember what happened to his arm. On 8/13/21 at 10:28 A.M., observed Resident 23 sitting in his room in a reclining chair across the room. He was not wearing a pendent and no call light within reach. He had a C (cervical) collar on and had whiskers above the lip and chin. A Care Plan, dated 7/11/2021, indicated Resident 23 was to have a U/A C&S (urine analysis with a culture and sensitivity) A Nurses Note, dated 7/12/2021, indicated . writer heard someone yelling help, help rushed to go check and resident was lying on floor to his back in front of his bed A Nurses Note, dated 7/13/2021, indicated .At 05:30 resident found by CNA and writer on floor in front of his bed lying flat on his back. 2/3 of his head was under his bed. M.D. was updated and N.O. [new order] to send to ER Memorial for eval and treat A Nurses Note, dated 7/13/2021, indicated .called memorial hospital to check on pt [patient]. pt admitted to 11 south d/t [due to] C7 fracture A (IDT) Interdisciplinary Team note, dated 7/12/2021, indicated the .ROOT CAUSE: Resident was trying to ambulate without assistance. NEW INTERVENTIONS: U/A C&S to be obtained. A IDT note, dated 7/13/2021, indicated the ROOT CAUSE: Resident was trying to ambulate without assistance. NEW INTERVENTIONS: Resident sent to hospital for evaluation. A Care Plan intervention, indicated .date initiated: 7/13/2021 ER for evaluation A Nurses Note, dated 7/16/2021 at 3:45 P.M., indicated .Resident was found on the floor at bedside A Nurse Note, dated 7/16/2021 at 10:32 P.M., indicated .Resident found on the floor at the bedside. Hematoma to right eye A Care Plan intervention indicated, . date initiated 7/16/2021, Please remind me how to use call pendant and use hand over hand so I can feel the button to push. Please remind me to use call pendant when I need assist. Please provide frequent checks. Please place Cow Bell at foot of bed to alert staff I an moving my legs off the bed A Nurses Note, dated 7/19/2021 at 1 P.M., indicated .When staff entered [resident 23's name] room, he was laying on the floor next to his bathroom A Nurses Note, dated 7/19/2021 at 9:20 P.M., indicated . CNA went to check on this resident after heard him shouting for help. CNA found him laying on the floor A Care Plan intervention, indicated .date initiated 7/20/2021, revision 7/22/2021,Therapy to work on room placement of items due to poor vision. Room evaluation, set up and bed height A Nurses Note, dated 7/22/2021, indicated .Resident found on the floor by CNA A Care Plan intervention indicated, . date initiated 7/22/2021 Medication review for possible need for antianxiety and/or pain medication or adjustment in medication A Nurses Note, dated 7/27/2021, indicated .Resident was found on the floor while an aide was passing by the room and resident was yelling A Nurses Note, dated 7/28/2021, indicated .Slide from low bed to the floor mat. Found lying flat to his back A Nurses Note, dated 8/3/2021, indicated .When staff walked into to [resident's name] room, he was seen the floor next to his bed A Care Plan intervention indicated, . date initiated 8/4/2021 Please encourage me to stay up as much as I can tolerate after evening meal to assist in preventing getting my days and nights mixed up A Nurses Note, dated 8/5/2021, indicated .Lying on back on fall mat bedside his bed A Care Plan intervention indicated, .date initiated 8/6/2021 Move me to first floor net to nurse station A Nurses Note, dated 8/9/2021, indicated .Resident was floor in his room at the foot of his bed no apparent injury noted rom assessed full and active and weak, resident witnessed by another resident scooting out of the foot of the bed A Care Plan intervention, indicated, .date initiated 8/10/2021, I would like to be seen by [behavioral management company] and to manage [CONDITION(S)] medications During an interview, on 8/12/2021 at 2:40 P.M., the (DON) Director of Nursing indicated that a root cause analysis and new intervention should be completed after every fall that occurs. 2. On 8/11/21 at 3:04 P.M., Resident 16's record was reviewed. Diagnoses included, but were not limited to, [CONDITION(S)], [CONDITION(S)] with hallucinations, muscle weakness, and ataxic gait (unsteady and staggering). The resident had previously resided in the facility's residential wing and had a long history of falling. She admitted to the facility's skilled care unit following in-patient treatment at a behavioral care hospital. An admission MDS (Minimum Data Set) assessment, dated 6/24/21, indicated a BIMS (Brief Interview Mental Status) score of 11-moderately impaired cognition. She required extensive assistance of 1 staff member for bed mobility, transfers, ambulation, eating, dressing, personal hygiene, and toileting. She had many mood indicators which were severe in nature. Care Area Assessments (CAA) indicated she was at risk for falls and injury due to weakness, medication changes, recent fall at the hospital and routine use of [CONDITION(S)] medications. Resident 16 had difficulty maintaining sitting balance and had impaired balance during transitions She had symptoms of [CONDITION(S)] and had been exhibiting severe inattention, emotional disturbance, hallucinations and disturbances in her sleep cycle. A Care Plan, initiated on 6/18/21, indicated the resident was at risk for falls and injuries related falls due to weakness, medication changes, recent fall in hospital, and routine use of [CONDITION(S)] medications; resident was impulsive and believed she could do more, physically, than what was capable of. Interventions, initiated on 6/18/21, were to administer medications as ordered; encourage participation in therapy services; ensure proper footwear was on when out of bed; ensure walkways and pathways were clear and free from clutter; follow facility fall protocol; keep call light within easy reach; notify physician and Power of Attorney (POA) of adverse side effects to medications; provide assistance with toileting; remind and encourage to use call light; and therapy services per physician orders. Nurse Notes indicated the following: -6/17/21 at 3:50 p.m., an admission note indicated the resident had admitted to the facility and was assessed as being alert and oriented with confusion noted at times. She had difficulty making her needs known due to garbled speech. She had a laceration to her left scalp with stitches in place and fading bruises to her left arm and right side of her face which measured 10 cm (centimeters) by 12 cm. -6/21/21 at 9:20 a.m., an IDT (Interdisciplinary Team) note, indicated Resident 16 had a witnessed fall on 6/17/21. The resident had attempted to toilet herself after therapy returned her to her room. The IDT recommended the resident be toileted prior to her therapy sessions. -The fall intervention was initiated and placed on the care plan on 6/21/21. There was no further documentation or root cause analysis regarding the fall in the resident's record nor documentation of any injuries sustained. -6/29/21 at 6:30 a.m., Resident 16 was observed laying on the floor in her room. She had poor impulse control and was unsteady on her feet. She was assisted off the floor and into her wheel chair. Head to toe assessment showed no injuries. -11:37 a.m., the IDT met regarding the resident's fall that had occurred that morning. New interventions put into place were to remove the fall mat beside her bed due to an increased risk for tripping; give the resident table top activities such as flower arranging or folding clothes to do; and place anti-roll back devices on her wheelchair. There was no root cause analysis documentation in the resident's record. -At 2:51 p.m., Resident 16 had been sitting behind the nurse's station with the nurse. She had poor impulse control and jumped up from wheelchair which rolled from under her and she fell but did not hit her head. She was assisted back into the chair following a head to toe assessment which showed no injuries. -There were no immediate interventions documented in the record nor further information regarding the circumstances of the fall such as whether the anti-roll back devices had been in place on the wheelchair when the fall occurred. -6/30/21 at 2:52 p.m., the resident was observed on the floor in her room. Staff had left room seconds before a crash was heard. She continued to fall with interventions in place and had no impulse control. She was assisted from the floor and back to bed. She had a hematoma on her left forehead which measured 1.5 cm by 1.5 cm and on her right shoulder that measured 1 cm by 0.5 cm. She had multiple scratches on her right mid back. -The physician was notified and a new order was given for a STAT dose of an anti-psychotic medication to be given due to severe anxiety. There was no further documentation completed in the record following the fall nor fall root cause analysis completed. A fall intervention, initiated and placed on the care plan on 6/30/21, was for the resident to have a weighted lap blanket. -7/3/21 at 12:11 a.m., the resident was observed crawling on the floor and looked like she was picking up things. She was assisted to her wheelchair and then back into bed. -The record did not indicate if this had been a fall nor was there further information documented regarding the event. -7/4/21 at 12:41 p.m., staff heard a loud crash and upon entering the resident's room, found the resident lying on her back under the window near her bed. Her rolling walker sat next to the window by her feet. She was very confused with poor impulse control and poor safety awareness. She had no injuries noted at the time of the fall. She was assisted into her wheelchair and placed at the nurses station for supervision and safety. -There was no documentation in the record that a fall root cause analysis had been completed nor were there any new interventions placed on the care plan to prevent further falls from occurring. -8/6/21 at 4:42 a.m., Resident 16 was observed with an open area to her coccyx and a large skin discoloration to her right buttock. Staff attempted to turn and reposition her but she kept scooting until she could put her self onto her back. The progress note had not indicated if the resident was having pain due to the open area and if this was the cause of her scooting in the bed. -8/7/21 at 3:21 a.m., the resident lacked sleep on this night and was restless in bed. -At 10:00 a.m., Resident 16 was observed laying on the floor next to her bed. She had been alert but not oriented and wasn't able to explain what happened and why she was on the floor. -There was no further documentation regarding the fall nor root cause analysis completed. There were no new care plan interventions documented. On 8/16/21 at 2:31 P.M., the MDS (Minimum Data Set) Nurse provided a current copy of the facility's policy, titled Falls and Fall Risk, Managing which stated the following: Based on previous evaluations and current data, the staff will identify interventions related the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling .Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff .will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or risks of falling .3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions .4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall for one resident resulting in a hip fracture requiring a transfer to the hospital, and to implement interventions to prevent falls for 2 of 3 residents reviewed for falls. (Resident C and Resident B) Findings include: 1. A clinical record review was completed on 11/17/2016 at 9:45 A.M. and indicated Resident B was admitted on [DATE]. Her [DIAGNOSES REDACTED]. A behavior tracking form dated 10/17/2016 indicated Resident B experienced Attention Seeking Behaviors several times from 1:53 A.M. thru 4:48 A.M. A Nurses note dated 10/17/2016 indicated Social Services was notified of Resident B's behavior through the night. During an interview on 11/17/2016 at 10:53 A.M., Social Services indicated she was unaware of what Attention Seeking Behaviors indicated. During an interview on 11/17/2016 at 10:00 A.M., Nurse #46 indicated evening and night shift nursing staff would often move Resident B's wheelchair out of her room to keep her from getting out of bed. He further indicated Resident b often experienced voices in her head telling her to get up. A review of Resident B's care plans indicated no behavioral interventions were put into place. A nurses note, dated 10/24/2016 at 7:08 A.M., indicated .resident found on floor in her room. when asked what happened, she stated i thought i could walk resident refuses to be re-directed when told she can't walk, she becomes angry and curses @ (at) staff. no injuries noted. refuses to move BLE(bilateral lower extremities), states it hurts. confused about which extremity, she changes from one leg to the other. in bed @ present. MD and dtr (daughter) informed During an interview on 11/17/2016 at 10:25 A.M., DON (Director of Nursing) indicated Resident B had suddenly began pushing her call light button repeatedly on the night of 10/17/2016 and Nurse #45 notified Social Services of the behavior change during the night for follow up. Social Services indicated they discussed the behaviors in morning meeting. She indicated she had not followed up. The DON indicated that Social Services and Nursing should have assessed Resident B medically and mentally to figure out why Resident B was experiencing this new onset of behaviors. The DON indicated it was very possible that the lack of follow up on the new onset of behaviors may have allowed Resident B's fall to take place. A form titled, THE MILTON HOME - EVENT F/U (follow up) & INVESTIGATION, dated 10/24/2016, indicated .Resident found in her room after she was heard calling Help me, Help me. Resident was on floor by her night stand in the direction of going towards bathroom and .Resident confused upon waking, unit was noisy, R (Resident) had been tx (treatment) for UTI (urinary tract infection), R stated I thought I could walk R was dependant for transfers A review of Resident B's physician orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. An x-ray completed on 10/24/2016 indicated Resident d had a left hip femoral neck fracture. A nurses note dated 10/24/2016 at 12:31 P.M. indicated Resident B had a 2 cm(centimeter) x 3 cm area to her elbow that had skin removed and also noted a large amount of frequent incontinent voidings. A discharge summary dated 10/28/2016, from the local hospital indicated upon admission to the hospital she was diagnosed with [REDACTED]. The discharge summary further indicated Resident B had hypovolemic hypotension which was resolved with hydration. A policy was provided by the Administrator on 11/22/2016 at 12:08 P.M., titled Fall Risk Assessment, undated and indicated this was the policy currently used by the facility. The policy indicated .The nursing staff, Attending Physician, and Consultant Pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension .The Attending Physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as decreased vision and peripheral neuropathy) that may predispose to falls .The staff, with the support of the Attending Physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition .The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout .The staff and Attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable A policy was provided by the Administrator on 11/22/2016 at 12:08 P.M., titled Behavioral Assessment, Intervention and Monitoring dated March 2015 and indicated this was the policy currently used by the facility. The policy indicated .The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including: a. Physical or medical changes b. Emotional, psychiatric and/or psychological stressors c. Functional, social or environmental factors .The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm 2. On 11/14/16 at 1:28 P.M., Resident C was observed to have a forehead laceration, closed with approximately 4-5 sutures, and facial bruising. On 11/16/16 at 2:11 P.M., Resident C was observed walking in hallway with her walker. CNA (Certified Nursing Assistant) #5 was observed to give stand-by assist, while the resident was walking in hallway. During an interview, on 11/16/16 at 2:13 P.M., CNA #5 indicated the resident was a stand-by assist while walking with her walker in the hallway. On 11/18/16 at 11:32 A.M., a review of the clinical record for Resident C was conducted. The resident's [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) Assessment, dated 9/29/16, indicated the resident walked in room with no physical help from the staff, required two persons to assist her when transferring on the unit and her balance with walking was unsteady, but was able to steady herself without staff assistance. The assessment indicated the resident used a walker as a mobility device. The assessment also indicated the resident had a history of [REDACTED]. A care plan, dated 10/12/16, indicated the following: .The resident is (SPECIFY High, Moderate, Low) risk for falls r/t (related to) The rest of the care plan was blank. A Morse Fall Scale, dated 9/16/16, indicated the resident scored an 80, which determined the resident was high risk for a fall. An Incident Report, dated 11/2/16, indicated the resident had an unwitnessed fall in her son's room (son also lived at the facility). The report indicated the resident tripped on her walker and fell backwards. The resident had some swelling to back of her head, was ambulating without assistance, and had gait imbalance. Neurological checks were completed every 15 minutes, then every 30 minutes for 1.50 hours and then every hour for 3 hours, then daily for 72 hours. The physician and family member were notified of the fall. There were no interventions to prevent another fall documented on the Incident Report. An Incident Report, dated 11/7/16 at 12:30 P.M., indicated the resident had a witnessed fall in the dining room. The resident refused to be assessed. Later in the day, an Incident Report indicated the resident had another fall at 3:30 P.M. The report indicated the resident was found face down, with walker next to her and was bleeding from her forehead. The report indicated the resident had tried to take herself into the restroom and had not used her call light because she had just used it for another request. The physician and family member were notified of the fall. The physician ordered the resident to be taken to a local emergency room (ER). A progress note, dated 11/7/16 at 3:30 P.M., indicated the resident had used her call light to request pain medication and as the nurse approached the room she heard a loud bang and found resident on the floor. The resident was assessed and first aid treatment to forehead was given. A Nursing Note, dated 11/7/16 at 8:25 P.M., indicated the resident returned from the ER with four sutures in her forehead laceration. The note indicated she encouraged the resident not to get up without assistance and gave her the call light. During an interview, on 11/18/16 at 2:42 P.M., the Director of Nursing (DON) indicated there was no new interventions implemented after the residents falls to prevent falls. The DON indicated the staff would know how to assist the resident per the resident's care plan. During an interview, on 11/21/16 at 2:15 P.M., the DON indicated she had completed the 9/29/16 Admission MDS assessment and had incorrectly documented the resident to need two assists with locomotion on the unit, as the resident was fairly independent upon admission. The DON indicated she should have done a fall care plan. During an interview, on 11/22/16 at 9:25 A.M., the Occupational Therapist #6 indicated the resident had not been referred for any therapy. Therapist #6 reported she had spoken to the resident regarding safety in the dining room. The Therapist indicated she had talked to the resident about her new shoes, which had a rubber sole and gripped the floor. The Therapist thought the shoe's sole might have been the cause of her recent falls. On 11/18/16 at 12:30 P.M., the DON provided a policy titled Falls-Clinical Protocol dated September 2012, and indicated the policy was the one currently used in the facility. The policy indicated .Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling This Federal tag is related to Complaint IN 605. 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure that a resident was free from verbal, physical, and mental abuse when staff gave a shower against a resident's desire, sprayed the resident with cold and hot water, and spoke to the resident in a demeaning/intimidating manner causing the resident mental anguish for 1 of 1 residents reviewed for abuse. (Resident #22) This had the potential to affect 52 of 52 residents in the facility at risk for being verbally, physically, and mentally abused. This deficiency resulted in an Immediate Jeopardy. The immediate Jeopardy began on 8/12/14, when the staff gave the resident a shower against her desire. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy on 8/20/14 at 1:00 P.M. The Immediate Jeopardy was removed on 8/25/14, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: On 8-20-2014 at 9:22 A.M., an interview was conducted with Resident #22 in her room with the door closed, per her request. Resident #22 indicated, .on August 15th, I think it was (actual date 8/12/14), that girl nicknamed (name) (CNA - Certified Nursing Assistant #1) took me to take a shower.I don't like showers and I told her 'No'.she just kept on taking me and I kept telling her I don't want a shower, I don't like showers. Resident #22 indicated, I am always cold and I take bed baths, it is cold in the shower room. Resident #22 indicated, .she told me I had to take a shower and then she sprayed me with cold water.I told her that is too cold and she turned the water all the way to hot.I told her that is burning me. Resident #22 indicated, I felt like she was being mean to me and that she was upset with me because I had smart words with her the day before. Resident #22 indicated, .it burned me between my legs and I told her it hurts.I wanted CNA #2 to give me a shower cause he is nice and caring, CNA #1 has been mean to me in the past and I didn't want her to do it.CNA #2 came into the shower room and laughed at me.CNA #1 kept turning the water hotter and hotter when I was telling her I didn't want a shower and that it was hot, so I finally quit talking so she would not turn it up any more.I told her to take off my glasses so they wouldn't get broken and she said 'No, just hold your head the way I tell you and they won't get broken' and she wouldn't take them off.I told her I want someone else to take care of me.I told her that I am sick and CNA #1 said, 'That is not my fault (that you are sick)'.CNA #1 called the nurse (LPN - Licensed Practical Nurse #3) in to talk to me.the nurse told me to apologize to the CNA #1 for calling her names.she (LPN #3) never asked me why I was upset.I told another CNA later that day and I told my daughter about it.CNA #2 came in my room a few days later and said, 'I thought we were friends, are you trying to get me fired?.I have a wife and kids at home to take care of. On 8-20-2014 from 9:49 A.M. to 10:15 A.M., an interview was conducted with the Administrator, DON (Director of Nursing), Social Service Designee, CNA #2, and LPN #3 in the conference room. The Administrator indicated, .there are no [MEDICATION NAME] involving Resident #22.any abuse would be expected to be reported it to me immediately. The DON indicated, .I don't know anything about this (incident).I know that Resident #22 was covered in BM (bowel movement) and needed a shower.she was not happy with her shower, she doesn't like them but it was in her best interest to take a shower.I told LPN #3 to document the behaviors.I talked to Resident #22 right before I left for the day.she (Resident #22) stated she had had a good day.she was in Bingo at that time. CNA #2 indicated, .she (Resident #22) was calling her (CNA #1) names in the shower room, she (Resident #22) had a large bowel movement and she (Resident #22) needed a shower.I was in and out of the shower (room).there was no cussing going on. CNA #2 had no comment related to the statements made by Resident #22 regarding their conversation a few days after the incident. LPN #3 indicated, .I was called to come into the shower room.CNA #1 told me that Resident #22 was calling her names.I told her (Resident #22) to apologize to CNA #1.I did not ask Resident #22 what was wrong, I knew she (Resident #22) didn't like showers.I documented it in a nurses narrative that she was cussing at the staff.I told the DON about it.she (Resident #22) does this every day. The clinical record for Resident #22 was reviewed on 8-20-2014 at 12:24 P.M. The [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 6/7/14, indicated the resident was moderately cognitively impaired. The behavior sheets for Resident #22 for May, June, July and August 2014, indicated no documentation related to cussing/swearing at staff. The care plan, dated 8/7/14, indicated, Problem/Need.Resident exhibits inappropriate behavior of making rude comments towards other individuals.Approaches.*Do not argue with resident.*Talk with resident in a calm voice when behavior is disruptive.*Discuss resident's feelings of anger with resident. The nurses notes, dated 8/12/14 at 1:30 P.M., for Resident #22 indicated, .Pt. (patient) cussing at staff member D/T (due/to) getting shower.Had lg (large) loose BM (bowel movement) called her a 'B---- F---off' when approached resident calm-went to Bingo. (signed) LPN #3. The Shower Report, dated 8/12/14, for Resident #22 indicated Behavior Problem(s): Curses(is circled).Comments: Called me a B---- numerous times, told her I was going to get the nurse and she said f--- you and her. Signed by CNA #1 and Charge Nurse, LPN #3. The CNA assignment sheet, received from the DON, on 8/20/14 at 5:20 P.M., and last updated on 7/18/14, indicated BED BATH ONLY. During an interview on 8-20-2014 at 4:17 P.M., CNA #5 indicated, .she (Resident #22) told her on 8-12-2014 that CNA #1 gave her a shower and put cold water on her and then really hot water.I told her (Resident #22) that they can not do that and I was going to report it to the nurse.I did tell someone but I can't remember who but it was not LPN #3 because she doesn't do anything about things I tell her about the residents. During an interview on 8-20-2014 at 4:38 P.M., CNA #9 indicated, .when I got report from her (CNA #1) she told me she gave Resident #22 a shower that day, that she had a BM (bowel movement) and it was an easier clean up to put her in the shower. I usually give her (Resident #22) a bed bath Tuesday and Friday evenings because she is too cold to take a shower.she (Resident #22) asked me, 'where were you this morning when that girl threw me in the hot shower'.she (Resident #22) told me that CNA #1 put her in the shower and CNA #2 laughed at her because she didn't want to take a shower.I told LPN #3 and LPN #3 said, 'she always is saying stuff'.she (LPN #3) didn't do anything about it. During an interview on 8-20-2014 at 5:00 P.M., CNA #10 indicated, .she (Resident #22) said CNA #1 put cold water then hot water on her in the shower and it burned and CNA #2 laughed at her.I told LPN #3 and LPN #3 said to me that Resident #22 is always saying stuff like that.LPN #3 didn't do anything about it.I went to find the DON but couldn't connect with her. During an interview on 8-20-2014 at 5:38 P.M., CNA #1, by phone, indicated, .I did give her a shower on days on 8-12-2014.I did call LPN #3 in to the shower room because Resident #22 was cursing at me.LPN #3 asked Resident #22 to apologize to me and she did not.Resident #22 does not act this way on a daily basis. On 8-21-2014 at 9:34 A.M., the policy titled, Abuse Prevention and Reporting Policy, updated and revised on 7/12/14, was provided by the Human Resource staff and indicated the policy was the one currently used by the facility. The policy indicated, .Standards.10. Any staff member who has knowledge of or reasonable cause to believe a resident has been or is being abused, or has knowledge a resident has sustained a physical injury which is not reasonable explained by the history of injuries provided in the resident's medical record, is required to make an immediate oral report to the Administrator, Director of Nursing, their supervisor and Social Service Director, if appropriate.11. Any staff member who intentionally abuses or suspected of abusing a resident or permits to exist an abusive situation which results in the abuse of a resident, is subject to immediate dismissal.22. Written reports of alleged abusive incidents are to be initiated by a licensed nurse and the individual who observed or has first-hand knowledge of an abuse incident using either a Concern/Suggestion or Accident/Incident Report Form. The Administrator, Director of Nursing and Social Service Director are responsible for reviewing the report as well as other investigative reports, interviews, etc, and developing interventions to care for the resident's medical psychological needs. Review of written statement, signed by the Administrator on 8-22-2014, received on 8-22-2014 at 10:30 A.M., indicated, .during survey interviews res. (resident) report things that have not been previously reported and this doesn't result in an IJ (Immediate Jeopardy). This was especially true when there were no known injuries and with an individual with some history of making false (sic) statements. Review of Resident #22's care plans showed no indication of resident behavior of making false statements. The Immediate Jeopardy that began on 8/12/14 was removed 8/26/14, with an effective date of 8/25/14, when, through record review and interviews, staff had completed education regarding abuse and abuse prevention. This education included identification of abuse, how to report abuse, when to report abuse and to whom to report abuse. The administrators contact information was posted at various location for staff use. The staff were also given education related to bathing residents without a battle. Even though the facility ' s corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of widespread, no actual harm with potential for more than minimal harm that is no Immediate Jeopardy because of on-going monitoring to ensure residents were free of abuse. 3.1-27(a)(1) 3.1-27(b)

Based on interview and record review, the facility failed to ensure a resident's allegation of verbal, physical, and mental abuse was reported immediately to the administrator after the resident had complained to other staff that she had received a shower against her desire, was sprayed with cold and hot water, and was spoken to in a demeaning/intimidating manner causing the resident to be upset for 1 of 1 residents reviewed for abuse. (Resident #22) This had the potential to affect 52 of 52 residents in the facility at risk for being verbally, physically, and mentally abused. This deficiency resulted in an Immediate Jeopardy. The immediate Jeopardy began on 8/12/14, when the staff gave the resident a shower against her desire. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy on 8/20/14 at 1:00 P.M. The Immediate Jeopardy was removed on 8/25/14, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: On 8-20-2014 at 9:22 A.M., an interview was conducted with Resident #22 in her room with the door closed, per her request. Resident #22 indicated, .on August 15th, I think it was (actual date 8/12/14), that girl nicknamed (name) (CNA - Certified Nursing Assistant #1) took me to take a shower.I don't like showers and I told her 'No'.she just kept on taking me and I kept telling her I don't want a shower, I don't like showers. Resident #22 indicated, I am always cold and I take bed baths, it is cold in the shower room. Resident #22 indicated, .she told me I had to take a shower and then she sprayed me with cold water.I told her that is too cold and she turned the water all the way to hot.I told her that is burning me. Resident #22 indicated, I felt like she was being mean to me and that she was upset with me because I had smart words with her the day before. Resident #22 indicated, .it burned me between my legs and I told her it hurts.I wanted CNA #2 to give me a shower cause he is nice and caring, CNA #1 has been mean to me in the past and I didn't want her to do it.CNA #2 came into the shower room and laughed at me.CNA #1 kept turning the water hotter and hotter when I was telling her I didn't want a shower and that it was hot, so I finally quit talking so she would not turn it up any more.I told her to take off my glasses so they wouldn't get broken and she said 'No, just hold your head the way I tell you and they won't get broken' and she wouldn't take them off.I told her I want someone else to take care of me.I told her that I am sick and CNA #1 said, 'That is not my fault (that you are sick)'.CNA #1 called the nurse (LPN - Licensed Practical Nurse #3) in to talk to me.the nurse told me to apologize to the CNA #1 for calling her names.she (LPN #3) never asked me why I was upset.I told another CNA later that day and I told my daughter about it.CNA #2 came in my room a few days later and said, 'I thought we were friends, are you trying to get me fired?.I have a wife and kids at home to take care of. On 8-20-2014 from 9:49 A.M. to 10:15 A.M., an interview was conducted with the Administrator, DON (Director of Nursing), Social Service Designee, CNA #2, and LPN #3 in the conference room. The Administrator indicated, .there are no [MEDICATION NAME] involving Resident #22.any abuse would be expected to be reported it to me immediately. The DON indicated, .I don't know anything about this (incident).I know that Resident #22 was covered in BM (bowel movement) and needed a shower.she was not happy with her shower, she doesn't like them but it was in her best interest to take a shower.I told LPN #3 to document the behaviors.I talked to Resident #22 right before I left for the day.she (Resident #22) stated she had had a good day.she was in Bingo at that time. CNA #2 indicated, .she (Resident #22) was calling her (CNA #1) names in the shower room, she (Resident #22) had a large bowel movement and she (Resident #22) needed a shower.I was in and out of the shower (room).there was no cussing going on. CNA #2 had no comment related to the statements made by Resident #22 regarding their conversation a few days after the incident. LPN #3 indicated, .I was called to come into the shower room.CNA #1 told me that Resident #22 was calling her names.I told her (Resident #22) to apologize to CNA #1.I did not ask Resident #22 what was wrong, I knew she (Resident #22) didn't like showers.I documented it in a nurses narrative that she was cussing at the staff.I told the DON about it.she (Resident #22) does this every day. The clinical record for Resident #22 was reviewed on 8-20-2014 at 12:24 P.M. The [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 6/7/14, indicated the resident was moderately cognitively impaired. The behavior sheets for Resident #22 for May, June, July and August 2014, indicated no documentation related to cussing/swearing at staff. The care plan, dated 8/7/14, indicated, Problem/Need.Resident exhibits inappropriate behavior of making rude comments towards other individuals.Approaches.*Do not argue with resident.*Talk with resident in a calm voice when behavior is disruptive.*Discuss resident's feelings of anger with resident. The nurses notes, dated 8/12/14 at 1:30 P.M., for Resident #22 indicated, .Pt. (patient) cussing at staff member D/T (due/to) getting shower.Had lg (large) loose BM (bowel movement) called her a 'B---- F---off' when approached resident calm-went to Bingo. (signed) LPN #3. The Shower Report, dated 8/12/14, for Resident #22 indicated Behavior Problem(s): Curses(is circled).Comments: Called me a B---- numerous times, told her I was going to get the nurse and she said f--- you and her. Signed by CNA #1 and Charge Nurse, LPN #3. The CNA assignment sheet, received from the DON, on 8/20/14 at 5:20 P.M., and last updated on 7/18/14, indicated BED BATH ONLY. During an interview on 8-20-2014 at 4:17 P.M., CNA #5 indicated, .she (Resident #22) told her on 8-12-2014 that CNA #1 gave her a shower and put cold water on her and then really hot water.I told her (Resident #22) that they can not do that and I was going to report it to the nurse.I did tell someone but I can't remember who but it was not LPN #3 because she doesn't do anything about things I tell her about the residents. During an interview on 8-20-2014 at 4:38 P.M., CNA #9 indicated, .when I got report from her (CNA #1) she told me she gave Resident #22 a shower that day, that she had a BM (bowel movement) and it was an easier clean up to put her in the shower. I usually give her (Resident #22) a bed bath Tuesday and Friday evenings because she is too cold to take a shower.she (Resident #22) asked me, 'where were you this morning when that girl threw me in the hot shower'.she (Resident #22) told me that CNA #1 put her in the shower and CNA #2 laughed at her because she didn't want to take a shower.I told LPN #3 and LPN #3 said, 'she always is saying stuff'.she (LPN #3) didn't do anything about it. During an interview on 8-20-2014 at 5:00 P.M., CNA #10 indicated, .she (Resident #22) said CNA #1 put cold water then hot water on her in the shower and it burned and CNA #2 laughed at her.I told LPN #3 and LPN #3 said to me that Resident #22 is always saying stuff like that.LPN #3 didn't do anything about it.I went to find the DON but couldn't connect with her. During an interview on 8-20-2014 at 5:38 P.M., CNA #1, by phone, indicated, .I did give her a shower on days on 8-12-2014.I did call LPN #3 in to the shower room because Resident #22 was cursing at me.LPN #3 asked Resident #22 to apologize to me and she did not.Resident #22 does not act this way on a daily basis. On 8-21-2014 at 9:34 A.M., the policy titled, Abuse Prevention and Reporting Policy, updated and revised on 7/12/14, was provided by the Human Resource staff and indicated the policy was the one currently used by the facility. The policy indicated, .Standards.10. Any staff member who has knowledge of or reasonable cause to believe a resident has been or is being abused, or has knowledge a resident has sustained a physical injury which is not reasonable explained by the history of injuries provided in the resident's medical record, is required to make an immediate oral report to the Administrator, Director of Nursing, their supervisor and Social Service Director, if appropriate.11. Any staff member who intentionally abuses or suspected of abusing a resident or permits to exist an abusive situation which results in the abuse of a resident, is subject to immediate dismissal.22. Written reports of alleged abusive incidents are to be initiated by a licensed nurse and the individual who observed or has first-hand knowledge of an abuse incident using either a Concern/Suggestion or Accident/Incident Report Form. The Administrator, Director of Nursing and Social Service Director are responsible for reviewing the report as well as other investigative reports, interviews, etc, and developing interventions to care for the resident's medical psychological needs. Review of written statement, signed by the Administrator on 8-22-2014, received on 8-22-2014 at 10:30 A.M., indicated, .during survey interviews res. (resident) report things that have not been previously reported and this doesn't result in an IJ (Immediate Jeopardy). This was especially true when there were no known injuries and with an individual with some history of making false (sic) statements. Review of Resident #22's care plans showed no indication of resident behavior of making false statements. The Immediate Jeopardy that began on 8/12/14 was removed 8/26/14, with an effective date of 8/25/14, when, through record review and interviews, staff had completed education regarding abuse and abuse prevention. This education included identification of abuse, how to report abuse, when to report abuse and to whom to report abuse. The administrators contact information was posted at various location for staff use. The staff were also given education related to bathing residents without a battle. Even though the facility ' s corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of widespread, no actual harm with potential for more than minimal harm that is no Immediate Jeopardy because of on-going monitoring to ensure residents were free of abuse. 3.1-28(c) 3.1-28(d) 3.1-28(e)

Based on interview and record review, the facility failed to implement policies and procedures which ensured the identification, investigation, and reporting verbal, physical, and mental abuse when a resident complained to other staff regarding a staff person giving her a shower against her desire, sprayed her with cold and hot water, and spoke to her in a demeaning/intimidating manner causing her to be upset for 1 of 1 residents reviewed for abuse. (Resident #22) This had the potential to affect 52 of 52 residents in the facility at risk for being verbally, physically, and mentally abused. This deficiency resulted in an Immediate Jeopardy. The immediate Jeopardy began on 8/12/14, when the staff gave the resident a shower against her desire. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy on 8/20/14 at 1:00 P.M. The Immediate Jeopardy was removed on 8/25/14, but noncompliance remained at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: On 8-20-2014 at 9:22 A.M., an interview was conducted with Resident #22 in her room with the door closed, per her request. Resident #22 indicated, .on August 15th, I think it was (actual date 8/12/14), that girl nicknamed (name) (CNA - Certified Nursing Assistant #1) took me to take a shower.I don't like showers and I told her 'No'.she just kept on taking me and I kept telling her I don't want a shower, I don't like showers. Resident #22 indicated, I am always cold and I take bed baths, it is cold in the shower room. Resident #22 indicated, .she told me I had to take a shower and then she sprayed me with cold water.I told her that is too cold and she turned the water all the way to hot.I told her that is burning me. Resident #22 indicated, I felt like she was being mean to me and that she was upset with me because I had smart words with her the day before. Resident #22 indicated, .it burned me between my legs and I told her it hurts.I wanted CNA #2 to give me a shower cause he is nice and caring, CNA #1 has been mean to me in the past and I didn't want her to do it.CNA #2 came into the shower room and laughed at me.CNA #1 kept turning the water hotter and hotter when I was telling her I didn't want a shower and that it was hot, so I finally quit talking so she would not turn it up any more.I told her to take off my glasses so they wouldn't get broken and she said 'No, just hold your head the way I tell you and they won't get broken' and she wouldn't take them off.I told her I want someone else to take care of me.I told her that I am sick and CNA #1 said, 'That is not my fault (that you are sick)'.CNA #1 called the nurse (LPN - Licensed Practical Nurse #3) in to talk to me.the nurse told me to apologize to the CNA #1 for calling her names.she (LPN #3) never asked me why I was upset.I told another CNA later that day and I told my daughter about it.CNA #2 came in my room a few days later and said, 'I thought we were friends, are you trying to get me fired?.I have a wife and kids at home to take care of. On 8-20-2014 from 9:49 A.M. to 10:15 A.M., an interview was conducted with the Administrator, DON (Director of Nursing), Social Service Designee, CNA #2, and LPN #3 in the conference room. The Administrator indicated, .there are no [MEDICATION NAME] involving Resident #22.any abuse would be expected to be reported it to me immediately. The DON indicated, .I don't know anything about this (incident).I know that Resident #22 was covered in BM (bowel movement) and needed a shower.she was not happy with her shower, she doesn't like them but it was in her best interest to take a shower.I told LPN #3 to document the behaviors.I talked to Resident #22 right before I left for the day.she (Resident #22) stated she had had a good day.she was in Bingo at that time. CNA #2 indicated, .she (Resident #22) was calling her (CNA #1) names in the shower room, she (Resident #22) had a large bowel movement and she (Resident #22) needed a shower.I was in and out of the shower (room).there was no cussing going on. CNA #2 had no comment related to the statements made by Resident #22 regarding their conversation a few days after the incident. LPN #3 indicated, .I was called to come into the shower room.CNA #1 told me that Resident #22 was calling her names.I told her (Resident #22) to apologize to CNA #1.I did not ask Resident #22 what was wrong, I knew she (Resident #22) didn't like showers.I documented it in a nurses narrative that she was cussing at the staff.I told the DON about it.she (Resident #22) does this every day. The clinical record for Resident #22 was reviewed on 8-20-2014 at 12:24 P.M. The [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 6/7/14, indicated the resident was moderately cognitively impaired. The behavior sheets for Resident #22 for May, June, July and August 2014, indicated no documentation related to cussing/swearing at staff. The care plan, dated 8/7/14, indicated, Problem/Need.Resident exhibits inappropriate behavior of making rude comments towards other individuals.Approaches.*Do not argue with resident.*Talk with resident in a calm voice when behavior is disruptive.*Discuss resident's feelings of anger with resident. The nurses notes, dated 8/12/14 at 1:30 P.M., for Resident #22 indicated, .Pt. (patient) cussing at staff member D/T (due/to) getting shower.Had lg (large) loose BM (bowel movement) called her a 'B---- F---off' when approached resident calm-went to Bingo. (signed) LPN #3. The Shower Report, dated 8/12/14, for Resident #22 indicated Behavior Problem(s): Curses(is circled).Comments: Called me a B---- numerous times, told her I was going to get the nurse and she said f--- you and her. Signed by CNA #1 and Charge Nurse, LPN #3. The CNA assignment sheet, received from the DON, on 8/20/14 at 5:20 P.M., and last updated on 7/18/14, indicated BED BATH ONLY. During an interview on 8-20-2014 at 4:17 P.M., CNA #5 indicated, .she (Resident #22) told her on 8-12-2014 that CNA #1 gave her a shower and put cold water on her and then really hot water.I told her (Resident #22) that they can not do that and I was going to report it to the nurse.I did tell someone but I can't remember who but it was not LPN #3 because she doesn't do anything about things I tell her about the residents. During an interview on 8-20-2014 at 4:38 P.M., CNA #9 indicated, .when I got report from her (CNA #1) she told me she gave Resident #22 a shower that day, that she had a BM (bowel movement) and it was an easier clean up to put her in the shower. I usually give her (Resident #22) a bed bath Tuesday and Friday evenings because she is too cold to take a shower.she (Resident #22) asked me, 'where were you this morning when that girl threw me in the hot shower'.she (Resident #22) told me that CNA #1 put her in the shower and CNA #2 laughed at her because she didn't want to take a shower.I told LPN #3 and LPN #3 said, 'she always is saying stuff'.she (LPN #3) didn't do anything about it. During an interview on 8-20-2014 at 5:00 P.M., CNA #10 indicated, .she (Resident #22) said CNA #1 put cold water then hot water on her in the shower and it burned and CNA #2 laughed at her.I told LPN #3 and LPN #3 said to me that Resident #22 is always saying stuff like that.LPN #3 didn't do anything about it.I went to find the DON but couldn't connect with her. During an interview on 8-20-2014 at 5:38 P.M., CNA #1, by phone, indicated, .I did give her a shower on days on 8-12-2014.I did call LPN #3 in to the shower room because Resident #22 was cursing at me.LPN #3 asked Resident #22 to apologize to me and she did not.Resident #22 does not act this way on a daily basis. On 8-21-2014 at 9:34 A.M., the policy titled, Abuse Prevention and Reporting Policy, updated and revised on 7/12/14, was provided by the Human Resource staff and indicated the policy was the one currently used by the facility. The policy indicated, .Standards.10. Any staff member who has knowledge of or reasonable cause to believe a resident has been or is being abused, or has knowledge a resident has sustained a physical injury which is not reasonable explained by the history of injuries provided in the resident's medical record, is required to make an immediate oral report to the Administrator, Director of Nursing, their supervisor and Social Service Director, if appropriate.11. Any staff member who intentionally abuses or suspected of abusing a resident or permits to exist an abusive situation which results in the abuse of a resident, is subject to immediate dismissal.22. Written reports of alleged abusive incidents are to be initiated by a licensed nurse and the individual who observed or has first-hand knowledge of an abuse incident using either a Concern/Suggestion or Accident/Incident Report Form. The Administrator, Director of Nursing and Social Service Director are responsible for reviewing the report as well as other investigative reports, interviews, etc, and developing interventions to care for the resident's medical psychological needs. Review of written statement, signed by the Administrator on 8-22-2014, received on 8-22-2014 at 10:30 A.M., indicated, .during survey interviews res. (resident) report things that have not been previously reported and this doesn't result in an IJ (Immediate Jeopardy). This was especially true when there were no known injuries and with an individual with some history of making false (sic) statements. Review of Resident #22's care plans showed no indication of resident behavior of making false statements. The Immediate Jeopardy that began on 8/12/14 was removed 8/26/14, with an effective date of 8/25/14, when, through record review and interviews, staff had completed education regarding abuse and abuse prevention. This education included identification of abuse, how to report abuse, when to report abuse and to whom to report abuse. The administrators contact information was posted at various location for staff use. The staff were also given education related to bathing residents without a battle. Even though the facility ' s corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of widespread, no actual harm with potential for more than minimal harm that is no Immediate Jeopardy because of on-going monitoring to ensure residents were free of abuse. 3.1-28(a)

Based on record review and interview, the facility failed to ensure a resident's medications were available related to a resident with a [DIAGNOSES REDACTED].# 22, for 2 of 10 residents reviewed for medications in a sample of 10. Residents # 9 and # 22. Findings include: 1. Resident # 9's record was reviewed on 5/31/12 at 11:00 a.m. The resident's record indicated [DIAGNOSES REDACTED]. Resident # 9's February 2012 MAR (Medication Administration Record) indicated a physician's orders [REDACTED]." The MAR indicated [REDACTED]. The back of the February MAR indicated The March 2012 MAR indicated [REDACTED]. The back of the MAR indicated The resident did not receive her [MEDICATION NAME] eye drops to treat her [MEDICAL CONDITION] for 11 days. During an interview with the DoN on 5/31/12 at 2:00 p.m. regarding the resident not receiving her prescription eye drops, she agreed the nurse should have contacted the physician/ family and the medication obtained for the resident. Nurses notes failed to indicate the physician or the family had been contacted. According to the 2010 Nursing Spectrum Drug Handbook regarding stopping [MEDICATION NAME] eye drops for 11 days, the drug book indicated "...Patient teaching...Caution patient not to stop taking drug abruptly. Dosage must be tapered...Instruct him to use drops only as prescribed, because they are absorbed systemically...." 2 .Resident # 22's record was reviewed on 5/31/12 at 9:00 a.m. The resident's record indicated [DIAGNOSES REDACTED]. The resident's February 2012 MAR indicated [REDACTED]." The MAR indicated [REDACTED]. The back of the February 2012 MAR indicated [MEDICATION NAME] Patches- none available." The nurse documenting the note was identified as LPN # 4. During an interview with LPN # 5 on 5/31/12 at 9:30 a.m. regarding the resident not receiving her pain patch for 19 days, she indicated the pharmacy did not authorize it, she further indicated the physician should have been notified sooner so an alternative medication could have been prescribed. The February 2012 MAR indicated [REDACTED]. The Tylenol was scheduled to be given at 12:00 a.m. 6:00 a.m., 12:00 p.m. and 6:00 p.m. The MAR indicated [REDACTED]. The back of the MAR indicated [REDACTED]. The nurse who documented the entries was identified as LPN # 4. Nurses note dated 2/18/12 at 7:30 a.m. indicated " Resident complaining she is having pain all over her body, very anxious, [MEDICATION NAME] (narcotic pain medication) and [MEDICATION NAME] (antianxiety medication) administered...resident in room at this time, states she is still having pain but seems less anxious with daughter here...." The resident's February 2012 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Nurse note dated 2/22/12 at 5:50 p.m. indicated "...prn (as needed) [MEDICATION NAME] and [MEDICATION NAME] effective in pain/anxiety...." Nurse note dated 2/25/12 at 2:00 a.m. indicated " Res (resident) requesting liquid [MEDICATION NAME] 0.5 ml (milliliter) for pain/discomfort at this time...." During an interview with the DoN on 5/31/12 at 11:30 a.m. regarding the resident not receiving her scheduled Tylenol for pain for all of those shifts, she indicated a nurse should have contacted the physician and let the family know, so the medication could have been obtained for the resident. 3.1-37(a)