Every finding on record at Nightingale at Stonegate

Based on observation, interview, record, and facility policy review, the facility failed to ensure housekeeping and maintenance provided a safe, sanitary, comfortable environment for the residents who reside in the facility. This failed practice has the potential to affect 38 of 59 residents living in the facility. The findings include: Halls 100 and 300 During an observation on 07/21/2025 at 2:17 PM, in the Shower Room on the 300 hall, it was observed to have dried, brown substance and a black ring around in the toilet bowl; the smaller shower chair had clusters of black spots on all four legs, the back of the chair, under the chair and on the back mesh of the seat. Orange, brown, and white residue noted on the mesh of the seat. A strap on the chair was observed to have black, orange, brown, grey and white residues on the clasp and along the length of the strap. The larger shower chair also had black spotted residue on the back of the chair and legs and orange, brown, grey and white residue on the seat back and piping. There was a purple loofah sponge hanging on the shower caddy with pink/orange colored residue on the cord of the loofah. Black spots were observed around the lower shower wall tile. During an observation on 07/21/2025 at 02:30 PM, a black, transferable substance was observed on multiple shower tiles and grout lines in the Shower Room on 100 Hall. The shower chair was observed to have an orange discoloration under the seat on the frame. During an observation on 07/22/2025 at 4:26 PM on the 300 Hall and 100 Halls, no changes were observed since the previous observation of the shower room on 300 Hall, including that of the chairs, toilet, tiles, and loofah, nor of the shower room on 100 Hall, including the tiles, grout, and chair. A loose body chair bucket was under the shower chair in the 100 Hall shower room with cloudy, dirty liquid full to the rim. During an observation on 07/23/2025 at 4:15 PM on the 300 Hall and 100 Hall no changes were observed since the previous observation. During an observation and interview on 07/24/2025 at 9:24 AM in the 300 Hall Shower Room, Housekeeper #2 described how housekeeping cleaned the shower room. Housekeeper #2 stated they wipe everything, for the big shower chair, wipe down the seat and, on the small shower chair, wipe down the seat. Housekeeper #2 stated they also scrub the floor. Housekeeper #2 was asked to raise the toilet and describe what was seen. The housekeeper stated, “Ew…that is poop in the toilet.” She described the smaller shower chair as, “the black stuff on the back of the chair looks like mold. It is black, gray, and brown stuff that looks like it is growing stuff.” Housekeeper #2 described the strap and chair legs as “mold and dirty with a little bit of everything” and stated it was the same for the big shower chair. “It has mold on it as well.” The Certified Nursing Assistants (CNA)s are supposed to come in to clean the shower room during the week, and housekeepers only clean on Sundays. During an interview and observation in the 300 Hall Shower Room on 07/24/2025 at 9:30 AM, CNA #3 stated housekeeping cleaned the shower rooms on Sundays. CNA #3 stated the shower was sprayed with multipurpose cleaner after every shower given. CNA #3 placed gloves on their hands and raised the toilet lid and stated it has “poop in there.” The CNA described the substance on the back of the small shower chair at “black mold with orange and brown color residue with black spots” CNA #3 stated the small chair belt and chair legs had “the same.” CNA #3 describe the larger shower chair as “the same stuff, black mold and brown residue.” CNA #3 stated the toilet was supposed to be cleaned daily by housekeeping. CNA #3 stated, “This room is not clean or sanitary for residents to use this shower and I just used it for a resident’s shower.” During an interview and observation in the 300 Hall Shower Room on 07/24/2025 at 10:09 AM, the Director of Nursing (DON) placed gloves on her hands and raised the toilet lid. She stated, I see feces residue. The DON described the small shower chair with “brown substance, and black grayish, frothy substance all over bottom, sides and back.” She described the strap as “the same substances.” The DON stated the loofah should not have been hanging in the shower. The DON described the larger shower chair to have, white, grayish, black, frothy substance.” She stated, “It is not sanitary for the resident to be in here.” The DON also stated the shower room was supposed to be sanitized after each shower by the CNAs, and it should be thoroughly cleaned by housekeeping staff daily. During an interview and observation in the 300 Hall Shower Room on 07/24/2025 at 10:19 AM, the Administrator stated housekeeping cleaned the showers daily and deep cleaned on Sundays. After placing gloves on and raising the toilet lid, the Administrator stated, “I see dried feces and stains” inside the toilet. The administrator stated the small shower chair had “white, tan, and black mildew, and the same on the legs.” The strap also had the same substances as legs and back of chair. The Administrator stated the loofah that was hanging should be taken out and not left hanging in the shower. The Administrator stated the larger shower chair had the same substances as the smaller chair, but “not as bad.” The Administrator stated the bathroom was “not sanitary for residents. The Administrated stated residents had mentioned previously there was “mold on the wall and the facility did get the “mold” off the shower wall on this hall. During an interview and observation of the 300 Hall on 07/24/2025 at 10:41 AM with the Housekeeping Supervisor, the Administrator, three housekeepers, and the Maintenance Director, the Housekeeping Supervisor placed gloves on their hands and raised the toilet lid. The Housekeeping Manager described the toilet to contain “feces and mold.” The Housekeeping Supervisor described the small shower chair back, legs, seat, and strap as having “black mold with orange and brown looking substance.” She stated the larger shower chair was not as bad, but it had “the same mold and colors on it.” The Housekeeping Supervisor stated it was “not clean and sanitary for the residents to shower in there. Resident Rooms On 07/21/2025 at 10:46 AM in room [ROOM NUMBER] B, this surveyor observed an electrical outlet missing half of the face plate. The inside of the outlet and wiring was exposed. The resident’s bed was observed to be covered with a fuzzy blanket, in the low position, and was pushed against the wall, next to the exposed outlet. On 07/21/2025 at 1:34 PM the Maintenance Supervisor accompanied this surveyor to room [ROOM NUMBER] B and confirmed the exposed outlet was a safety hazard. The Maintenance Supervisor went on to say he was responsible for maintaining outlet covers and that all outlet covers should be intact to prevent injury to residents from electrical shock or fire. Review of maintenance work requests dated 01/20/2025 to present revealed there was no request for repair for the broken outlet in room [ROOM NUMBER] B. Hall 400 On 07/21/2025 from 10:40 AM to 12:00 PM, during initial rounds on the 400 hall, dirt, dust, debris and food crumbs were observed inside the vents, that provided air flow into the rooms, of the heating/air-conditioning units installed on both A and B side of each resident room for rooms 401, 403, 404, 405, 407, 408, and 410. The dirt, dust, debris and food crumbs were again observed in the above listed rooms on 07/22/2025 at 9:52 AM and 07/23/2025 at 3:26 PM. On 07/21/2025 at 2:22 PM the following observations were made in the 400 Hall Shower Room and Whirlpool Room. The bath chair in the shower room had white, black, gray and pink substances on the mesh netting that formed the back of the chair, down the legs of the chair, under the seat and in the security belt attached to the chair. There was a dark substance along the tiles in the floor corners, going up the wall, and behind the toilet. The toilet in the shower room had a greenish brown ring in the toilet bowl. The whirlpool Room contained a shower gurney with a thick padded foam mattress. The mattress had cracks along the seams. Under the mattress was various debris, including an orange stick designed to be used to clean under fingernails and toenails. During an interview on 07/21/2025 at 1:16 PM, Resident #4 stated there was mold on the shower chairs, on the legs, and back of shower chair. It had been on the wall, but they tried covering it up. It is so nasty, and we don't want to take showers in there.” During an interview on 07/24/2025 at 8:58 AM, Housekeeper #2 stated the shift for the day was 7:00 AM to 3:00 PM. Housekeeper #2 stated cleaning staff switched halls all the time. “Today my assignment is to work 300 Hall and half of 100 Hall.” Housekeeper #2 stated in the residents’ room they gathered the trash, placed a new trash bag, swept the rooms, wiped down the tables, cleaned the bathroom, toilets, soap holder, paper towel holder, and straighten the floor if shoes were present. The rooms were mopped after all other cleaning tasks were completed. Housekeeper #2 state, on Sundays housekeepers clean up the soiled room and shower rooms and verified that Sunday was the only day the shower room was cleaned. Housekeeper #2 stated when they cleaned the shower room, they gathered the trash, cleaned the sink, toilets, and shower area, sanitized, and organized the shampoos. Housekeeper #2 stated they used a bottle of disinfecting acid bathroom cleaner spray and wipe it then spray with multi-surface disinfectant cleaner. Housekeeper #2 stated shower chairs were cleaned with acid cleaner, wiped and then sprayed with multi surface also. On 07/24/2025 at 9:48 AM, Housekeeper #4 stated they had worked at the facility for 4 or 5 years, reported she works four days a week, and usually cleaned the shower room and spa on the last two days of her work week. When asked who was responsible for cleaning the air conditioning units in resident rooms, Housekeeper #4 stated housekeeping was responsible for surface cleaning of the units, but maintenance was responsible for cleaning the vents. On 07/24/2025 at 9:58 AM, the Maintenance Supervisor stated they had worked in the position for almost a year. The Maintenance Supervisor stated he and the housekeeper were responsible for keeping the heating/air conditioning units clean, and the last time he had cleaned them was at the start of using the air conditioning for the year. The Maintenance Supervisor stated it was time to clean them again. He confirmed it was important to keep the heating/air conditioning vents clean to prevent any respiratory symptoms and to promote air flow. During an interview on 07/24/2025 at 10:31 AM, the Housekeeping Supervisor stated there were two housekeepers daily and a third housekeeper would come in to help make all halls clean. The Housekeeping Supervisor stated housekeepers would clean the lobby first thing in the morning and then start cleaning their assigned hall. The Housekeeping Supervisor stated the shower rooms get deep cleaned on Sundays since there are no baths given on Sundays. Review of the facility “Housekeeping and Maintenance” policy indicated “…housekeeping services with be provided daily, including weekends…every part of the building will be kept clean and orderly…toilet and bath and toilet facilities…will be clean and sanitary at all times.”

Based on record review and interview, the facility failed to post the resident census on a daily basis. A review of a Daily Staffing Log dated 07/23/2025 revealed the census was not provided or posted. A review of a Daily Staffing Log, dated June 2025, revealed the allotted area to display the census was not completed for the month of June. During an interview on 07/24/2025 at 12:28 PM, the Business Office Manager (BOM) stated she had been in the role for over a year and was responsible for maintaining the Daily Staffing Logs. She verified there was no place in the facility where the census was posted and available for viewing. The BOM also verified the respective information had not been completed on the Daily Staffing Logs since she began the role as the BOM. During an interview on 07/24/2025 at 1:43 PM, the Administrator stated she was responsible for ensuring the BOM completed the Daily Staffing logs. The Administrator also stated there was not another area where the census was posted.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator and freezer were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; 1 of 1 ice machine was maintained in clean and sanitary condition to prevent contamination of airborne particles; baseboard was secured, wall were free of chips, stains and rust and were maintained in clean sanitary conditions, and dietary staff. washed their hands before handling clean. equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; These failed practices had the potential to affect 55 residents who received. meals from the kitchen, (total census: 56). The findings are: 1. On 04/09/2024 at 09:59 AM, an opened box of biscuits was on a shelf in the freezer. The box was not covered, and was not completely sealed, exposing it to cross contamination. There was no date on the box to indicate when it was opened. 2. On 04/09/2024 at 10:09 AM, the following observations were made in the refrigerator. a. An open box of sausage was on a shelf in the refrigerator. The box was not covered or sealed. b. An opened box of bacon was on a shelf in the refrigerator. The box was not covered or sealed. 3. On 04/09/2024 at 10:21 AM, the top inside panel of the ice machine in the kitchen had wet black/gray residue on it. The Dietary Supervisor was asked how often they cleaned the ice machine and who used the ice from the machine. She stated, We clean it once a week. That's the ice the CNAs (Certified Nursing Assistants) use for the water pitchers in the residents' rooms, and we use it to fill beverages served to the residents at mealtimes. 4. On 04/09/2024 at 10:29 AM, the following observations were made in the dish washing machine room: a. The base board under the dish washing machine was loose, the area that was exposed had sage color. b. The corner of the wall in the dish washing machine had a sage color on it. c. There was a crack on the wall in the dish washing machine room. 5. On 04/09/2024 at 10:44 AM, the following observations were made in the kitchen: a. The floor between the deep fryer and oven, in front of the deep fryer, and behind the deep fryer, had thick buildup of grease on it. b. There was lint hanging from the edges of the deep fryer. 6. On 04/09/2024 at 10:46 AM, the shelf below the food preparation counter was a rack that contained cutting boards and containers of dried cereal with rust stains. 7. On 04/09/2024 at 11:00 AM, Dietary Employee (DE) #1 turned on the 2-compartment sink faucet and rinsed the glasses. After rinsing the glasses, she turned off the faucet with her hand contaminating them. Then picked up glasses by their rims and placed them on the trays to be used in serving beverages to the residents for a noon meal. At 02:22 PM, the Surveyor asked DE #1, What should you have done after touching dirty objects and before handling clean equipment? DE #1 stated, I should have washed my hands. 8. A facility policy titled, Hand Washing and Glove Usage in Food service provided by the Dietary Supervisor on 04/09/2024 at 3:34 PM documented, When Food Handlers must wash their hands: a. Before starting work b. After leaving and returning to the kitchen /prep area. c. After touching anything, work else such as dirty equipment, work surfaces or cloths .

Based on interview and record review, the facility failed to ensure care plans were reviewed and revised at least quarterly and/or when residents' care needs changed, as evidence by failure to revise the plan of care to address an indwelling urinary catheter and dementia care, to ensure staff were aware of the necessary care, assessments and services required for 1 (Resident #15) of 1 sampled resident who had an indwelling catheter and 1 (Resident #6) of 3 sampled residents whose care plans were reviewed for dementia care. The findings are: 1. Resident #6 had a diagnosis of dementia as documented in an Order Summary Report. a. An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/2024 documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 6 (00-07 indicates severe cognitive impairment) and an active diagnosis of non-Alzheimer ' s dementia. b. A Care Plan revised on 03/14/2024 had no documented interventions regarding Dementia Care. c. On 04/12/2024 at 02:31 PM, the MDS Coordinator was interviewed by telephone, and she confirmed that Dementia Care should have been added to Resident #6's care plan for staff to know how to care for Resident #6. 2. Resident #15 had a diagnosis of retention of urine as documented on the Order Summary Report. a. An Order Summary documented, .Change 16 Fr [French, which indicates the size of the device] [Brand Name] catheter Q [every] month . and PRN [as needed] using sterile technique . [Brand name] catheter care q [every] shift and prn with soap and water or wipes. Ensure privacy bag and leg band are in place . b. A Quarterly MDS with an ARD of 01/19/2024 documented Resident #15 had a BIMS score of 15 (13-15 indicates cognitively intact) and had an indwelling catheter. c. A Care Plan dated 01/26/2024 documented Resident #15 was readmitted on [DATE] with a catheter and there was no other documentation regarding catheter care. d. On 04/09/2024 at 02:05 PM, Resident #15 was lying in bed and a catheter bag in a privacy bag was hanging on the right side of the bed with cloudy sediment in the tubing. e. A Nursing Progress Note dated 04/11/2024 at 1:05 PM documented, .Resident back in facility from wound clinic. Assessed by this nurse with resident noted to be short of breath, pale in color, with temp of 101.3 pulse ox [oximeter] 90% [percent] RA [room air] . Call placed to APRN [Advanced Practice Registered Nurse] with update on condition provided with new orders to send to ER for evaluation and treatment . f. A Progress Note dated 04/11/2024 at 4:05 PM documented, .Spoke with [name] at [local hospital] .was informed resident was admitted with AKI [Acute Kidney Injury] and UTI [Urinary Tract Infection]. g. On 04/12/2024 at 02:29 PM the Director of Nursing (DON) was asked about the catheter being mentioned on the care plan but no interventions regarding catheter care. She telephoned the MDS Coordinator at 02:29 PM and confirmed there should have been interventions on Resident #15's care plan. h. On 04/12/2024 the Administrator provided a typed document with no title that documented, .Our facility follows the RAI [Resident Assessment Instrument] Manual for guidance on completion of care plans .

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 (Residents #7, #10, #50) sampled residents. The findings are: 1. Resident #7 had diagnoses of Intervertebral disc degeneration lumbar region and Gastro-esophageal reflux disease. According to a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/2024, Resident #7 scored 09 (8-12 indicates moderately impaired cognition) on a Brief Interview of Mental Status (BIMS). The care plan documented that Resident #7 needed assistance with spoon feeding for all meals. Resident is to be up for all meals. 2. Resident #50 had diagnoses of Dementia and muscle weakness. According to a Quarterly MDS with an ARD of 02/27/2024 Resident #50 scored 13 (13-15 indicates cognitively intact) on a BIMS. The care plan documented that Resident #50 required assistance with eating. 3. On 04/09/2024 at 12:19 PM, the Surveyor observed Licensed Practical Nurse (LPN) #3 standing over Resident #50 and #7 while providing feeding assistance. The Surveyor observed several chairs in the dining area unoccupied during the time LPN #3 was standing while aiding Resident #7 and #50. 4. On 04/09/2024 at 01:15 PM, the Surveyor asked LPN #3, What should you have done prior to assisting Residents #50 and #7 with meal service? LPN #3 stated, Ask if they needed something. The Surveyor asked LPN #3, How should staff be positioned when assisting Residents with meal service? LPN #3 stated, Prefer to sit but if we don't have enough chairs we usually stand. 5. On 04/11/2024 at 11:25 AM, the Surveyor asked the Director of Nursing (DON), How should staff be positioned when assisting Residents with eating? The DON stated, They should be seated. The Surveyor asked the DON, By staff not being seated what issue could this cause? The DON stated, dignity issue. 6. Resident #10 had diagnoses of Dementia and Weakness. According to a Quarterly MDS with an ARD of 03/08/2024, Resident #10 scored 06 (0-7 indicates severe cognitive impairment) on a BIMS. The care plan documented that Resident #10 required set-up assistance with meals/eating. 7. On 04/09/2024 at 01:30 PM, the Surveyor observed Resident #10 self-propelling in wheelchair around the day room. The Surveyor observed dried food on the Resident's shirt and mouth. 8. On 04/09/2024 at 03:00 PM, the Surveyor observed Resident #10 self-propelling in wheelchair on 100 hall. The Surveyor observed dried food on the Resident's shirt and mouth. 9. On 04/10/2024 at 02:22 PM, the Surveyor observed Resident #10 sitting in wheelchair in his/her room. Resident #10 was picking at the dried food on his/her shirt. The Surveyor also observed dried food on Resident 10's pants. 10. On 04/09/2024 at 03:05 PM, the Surveyor asked Nursing Assistant (NA) #3, Can you tell what you see on Resident #10's clothing? CNA #3 voiced that Resident had dried food from lunch or something that [Resident #10] had gotten into on his/her shirt. 11. On 04/10/2024 at 02:50 PM, the Surveyor asked Certified Nursing Assistant (CNA) #2, Can you describe for me what you see on [Resident #10's] clothing? CNA #2 stated, It look like food my partner had .I will get [Resident #10] cleaned up. 12. On 04/11/2024 at 11:25 AM, the Surveyor asked the Director of Nursing (DON), Should a Resident have dried food on their face and clothing after meal service? The DON stated, no. The Surveyor asked the DON, What do you think is a decent amount of time for staff to assist a Resident with the cleaning of the face and clothing? The DON stated, thirty minutes. The Surveyor asked the DON what issue could a dirty face and clothing cause the Resident? DON stated, dignity. 13. On 04/11/2024 at 02:05 PM, a policy titled Resident Rights and Responsibility was provided that documented the nursing facility protects and promotes the rights of each Resident/Elder admitted in order to provide a dignified existence, self-determination and communication with and access to persons and services inside and outside the nursing facility. The facility will protect and promote the rights of each Resident/Elder.

Based on interview and record review, the facility failed to ensure a resident and/or resident representative was provided a copy of a bed hold policy after a transfer to the hospital for 1 (Resident #21) of 1 sampled resident reviewed for bed-hold policy notification. The findings are: 1. Resident #21 was admitted to the facility on [DATE] as documented on a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/2024. Resident #21 had a Brief Interview for Mental Status (BIMS) score of 6 (00-07 indicates severe cognitive impairment). a. A Progress Note dated 01/13/2024 at 08:16 AM documented, .resident noted to be vomiting dark brown emesis with foul odor noted .received orders to send resident to [local hospital] ER [emergency room ] for further eval/tx [evaluation / treatment]. resident transferred via [by way of] [ambulance service] . b. On 04/11/2024 at 06:00 AM, Resident #21's electronic health record was reviewed and there was no documentation regarding a bed hold notification for the resident's transfer on 01/13/2024. c. On 04/11/2024, the Administrator was asked to provide documentation regarding a bed hold policy for Resident #21's transfer on January 13, 2024. At 4:50 PM, the Administrator stated they did not have a bed hold notification for Resident #21 for the January 13th hospital visit.

Based on observation, interview and record review, the facility failed to ensure nail care was consistently provided to promote good grooming and personal hygiene for 1 (Resident #54) of 1 sampled resident who required staff assistance with nail care. The findings are: 1. Resident #54 had diagnoses of reduced mobility and muscle wasting, as documented in an Order Summary Report. a. An Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/26/2024 documented Resident #54 had a Brief Interview for Mental Status (BIMS) score of 11 (08-12 indicates moderately cognitive impaired) and had an impairment in range of motion on one side in an upper extremity which included the shoulder, elbow, wrist, and hand. b. A Care Plan dated 03/06/2024 documented Resident #54 had a deficiency in performing Activities of Daily Living (ADL) due to a Cerebrovascular Accident (CVA), also known as a Stroke, required extensive care with personal hygiene and nail length was to be checked, trimmed, and cleaned on bath day and as necessary. c. On 04/09/2024 at 01:50 PM, Resident #54 said she had a stroke on January 25th, came to the facility in February of this year and had been doing therapy because the entire left side was affected. The fingernails on the Resident's right hand were greater than 0.25 inch in length. Resident #54 admitted she liked for the nails to be trimmed and admitted to the nails on the left hand being clipped independently but needed help with the right hand since unable to use the left hand and that staff had not offered. d. On 04/11/2024 at 08:44 AM, Resident #54 was in bed and Certified Nursing Assistance (CNA) #3 had the curtain pulled and stated Resident Care after the surveyor knocked and opened the door. CNA #3 stepped out to get more wash clothes. The fingernails on the right hand were greater than 0.25 inch in length. e. On 04/11/2024 at 08:49 AM, CNA #3 was asked if she was familiar with [Resident #54]'s care and she confirmed she was. The Surveyor asked to look at Resident #54's fingernails on the Resident's right hand and describe what she saw. She confirmed the fingernails were long and uneven. The Surveyor asked who does the nail care? CNA #3 said sometimes the Activity Director does them on Fridays, and sometimes the CNAs do them and some residents like to do it themselves. The Surveyor asked if [Resident #54] was care planned to do Resident #54's nail care. CNA #3 said she was not sure but, [Resident #54] could speak for herself, and she thought the nurses do nail care if a resident has an illness. She confirmed CNAs do nail care if the nails need to be cared for. f. On 04/11/2024, the Administrator provided a typed document with no title that documented, .The facility does not have an individual policy on fingernail care. Fingernail care is part of the ADL care provided to residents on an as needed basis .

Based on interview and record review, the facility failed to ensure a resident and or resident representative and the Office of the State Long-Term Care Ombudsman were provided written documentation regarding a transfer to the hospital for 1 (Resident #21) of 1 sampled resident reviewed for transfer / discharge to the hospital. The findings are: Resident #21 was admitted to the facility on [DATE] as documented on a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/2024. Resident #21 had a Brief Interview for Mental Status (BIMS) score of 6 (00-07 indicates severely impaired). a. A Progress Note dated 01/13/2024 at 8:16 AM documented, .resident noted to be vomiting dark brown emesis with foul odor noted .received orders to send resident to [local hospital] ER [emergency room ] for further eval/tx [evaluation / treatment]. resident transferred via [by way of] [ambulance service] . b. On 04/11/2024 at 06:00 AM, Resident #21's electronic health record was reviewed and there was no documentation regarding a notice of transfer and or discharge for the resident's transfer on 01/13/2024. c. On 4/11/24, the Surveyor ask the Administrator to provide documentation regarding a notice of transfer and bed hold policy for Resident #21's transfer on January 13, 2024. At 04:50 PM, the Administrator said they do not have a notice of transfer or bed hold notification for Resident #21 for the January 13th hospital visit.

Based on observation, interview and record review, the facility failed to ensure that staff used proper hand hygiene when assisting residents during meal service to prevent spread of bacteria, viruses, and/or infections. This failed practice had the potential to affect 2 (Residents #7, #50) sampled residents residing in the facility requiring assistance with meal service. The findings are: On 04/09/2024 at 12:11 PM, the Surveyor observed Certified Nursing Assistant (CNA) #1 positioning Resident #7 to an upright position in a Geri-chair (a type of chair that is useful for those with mobility issues and can also be used for bedridden patients who have difficulty sitting upright in a conventional wheelchair). CAN #1 did not sanitize/wash hands after contact with Resident #7. CNA #1 picked up silverware from the table and initiated meal assistance for Resident #50. CNA #1 placed a napkin over Resident #7 shirt, tucking the napkin in the Resident's shirt (encountering Resident's skin) and did not wash/sanitize hands. CNA #1 took silverware from Resident #50's hand, who was attempting to assist self, and gave the Resident a bite of food. CAN #1 brushed her left hand across her nose and without performing hand hygiene re-positioned Resident #7, placing a pillow to the side of the Resident. On 04/09/2024 at 01:01 PM, the Surveyor stated to CNA #1, I noticed during meal service that you did the following: positioned Resident #7, assisted Resident #50 with feeding, tucked a napkin into Resident #7's shirt encountering her skin, and grabbed silverware from Resident #50's hands, touched your face, and re-positioned Resident #7, and placed a pillow at her side. The Surveyor asked CNA #1, Does this sound accurate to you? CNA stated, Maybe so. The Surveyor asked CNA #1, What should you have done after positioning Resident #7? CNA #1 stated, Wash/sanitize my hands. The Surveyor asked CNA #1, What should you have done after placing a napkin over Resident #7's shirt, tucking it in and touching the skin? CNA #1 stated, Wash/sanitize my hands. The Surveyor asked, What should you have done after you took silverware from Resident 50's hand? CNA #1 stated, Wash/sanitize my hands. On 04/11/2024 at 11:25 AM, the Surveyor asked the Director of Nursing (DON), Between positioning a Resident (physically shifting in the wheelchair) and assisting a different Resident with meal service what should staff do? The DON stated, sanitize hands. The Surveyor asked the DON, What should staff do after making physical contact with their face (staff wiped hand across their nose), physical contact with a Resident, and/or touching an item previously touched by the Resident? The DON stated, They should sanitize their hands.The Surveyor asked the DON what could be a negative outcome of improper hand hygiene could be. The DON Passing on infection. On 04/11/2024 at 02:05 PM, the Surveyor was provided a policy titled Handwashing and Glove Usage in food Service that documented Introduction: According to the Centers for Disease Control and Prevention (CDC) hand washing is the single most important way to stop the spread of infection.

Based on observation, interview, and record review, the facility failed to ensure the Admission Evaluation accurately assessed 1 (Resident #100) of 1 sampled resident whose Admission Evaluation was reviewed for the use of psychotropic medications and smoking. The findings are: Resident #100 was admitted on [DATE] and had diagnoses of Atherosclerosis of Coronary Artery, Type 2 Diabetes Mellitus and Primary Hypertension. The Medicare 5 Day Minimum Data Set (MDS). was still in progress. As documented on a list provided by the Director of Nursing (DON) on 04/20/23 at 11:23 AM, Resident #100 smoked. a. The Physician orders dated 04/06/23 documented, .risperiDONE Oral Tablet 1 MG (Risperidone) Give 1 tablet by mouth one time a day for Delirium for 30 Days . b. The Admission Evaluation dated 04/06/23 documented, .2. Medications .D. Abnormal Involuntary Movement Scale (AIMS) 1. Does the resident/elder receive ANY psychotropic medications such as antipsychotics, antidepressants, antianxiety, sedatives or hypnotics? b. No . 13. Safety .C. Smoking Risk 1. Does the resident smoke? b. No . c. On 04/20/23 at 9:10 AM, the Surveyor asked the Assistant Director of Nursing (ADON) what information was required for the Admission Assessment. The ADON stated, Everything relevant to provide care for a resident. The Surveyor asked if the Admission Assessment should reflect if a resident uses any psychotropic medications. The ADON stated, Yes. That is a question on the assessment. The Surveyor asked if the Admission Assessment should reflect if a resident is a smoker. The ADON stated, Yes. That is also a question on the assessment. The Surveyor asked why the Admission Assessment was important. The ADON stated, It sets up how to take care of a resident and that information is pulled to formulate the Baseline Care Plan. d. On 04/20/23 at 9:25 AM, the Surveyor asked the Director of Nursing (DON) what information was required for the Admission Assessment. The DON stated, The diagnosis, how a resident transfer, medications a resident takes, and basically everything it takes to provide care for a resident. The Surveyor asked if the Admission Assessment should reflect if a resident uses any psychotropic medications. The DON stated, Yes. The Surveyor asked if the Admission Assessment should reflect if a resident is a smoker. The DON stated, Yes. The Surveyor asked why the Admission Assessment was important. The DON stated, So staff will know what type of medications and how to monitor for those medications, if monitoring is required. Also, if a resident is a smoker it will help to determine what safety interventions may need to be put in place.

Based on observation, and interview, the facility failed to ensure 300 Hall medication cart was locked when out of the nurse's line of vision to keep medications and biologicals securely stored and to prevent potential access by residents or visitors. This failed practice had the potential to affect 14 self-mobile residents who resided on the 300 Hall as documented on a list provided by the Director of Nursing (DON) on 04/20/23 at 11:20 AM. The findings are: 1. On 04/20/23 at 8:17 AM, Licensed Practical Nurse (LPN) #1 was on the 300 Hall preparing mediations outside of a resident's room. LPN #1 entered the resident's room leaving the medication cart facing the hall unlocked. No other facility staff was in sight. The Surveyor was standing beside the cart and observed 3 residents in manual wheelchairs come within reach of the medication cart. The medication cart was unlocked and not supervised, and accessible to residents on the 300 Hall for 7 minutes. 2. On 04/20/23 at 8:24 AM, when LPN #1 came out of the resident's room, the Surveyor asked, Should your medication cart be locked when it is not within sight or attended by staff? She stated, Yes ma'am. The Surveyor asked, What could happen if the medication cart is unlocked and accessible in the hall? She replied, Anybody could get in it and take the medications. 3. On 04/20/23 at 10:40 AM, the Surveyor asked the DON, Should the medication cart that is unattended by staff be locked? The DON stated, Yes. The Surveyor asked, What could happen if the medication cart is left unlocked and unattended by staff? The DON stated, Residents could get into the medications. 4. The facility policy titled, Pharmaceutical Services, provided by the DON on 04/20/23 at 11:20 AM states, .Storage of drugs. All drugs and biologicals are stored in locked compartments .

Based on observation, record review, and interview, the facility failed to ensure 1 (Resident #12) of 2 (Residents #12 and #100) sampled residents who smoked as documented on a list provided by the Director of Nursing (DON) on 04/20/23 at 11:23 AM, was supervised while smoking to prevent potential accidents. The findings are: 1. Resident #12 had diagnoses of Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease Affecting Unspecified Side and Muscle Weakness and Unspecified Lack of Coordination. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was independent with set up help only with locomotion on the unit. a. A Smoking - Safety Screen dated 12/05/22, provided by the Director of Nursing (DON) on 04/19/23 at 11:11 AM documented, .E. SAFETY 6. Can resident light own cigarette? No . 7. RESIDENT NEED FOR ADAPTIVE EQUIPMENT 7a. Smoking apron . 7c. Supervision . 8. Does resident need facility to store lighter and cigarettes? 1. Yes . 9. Plan of care is used to assure resident is safe while smoking? 1. YES F. IDTC [Interdisciplinary Team Committee] Decision 1. Notes on Safety from IDTC (i.e. [for example] resources required to support resident, other resident safety, potential capabilities): Resident is to be supervised and wear smoking apron while smoking 2. Team Decision: 2. Safe to smoke with supervision 3. Rationale/conditions: Resident can safely hold cigarette while smoking. b. The Care Plan with a revision date of 04/04/23 documented, Smoking Safety . Resident requires assistance and/or supervision with smoking . Smoking apron while smoking . c. On 04/17/23 at 10:10 AM, Resident #12 was outside at the smoking area. She was sitting in a wheelchair smoking. There was no staff in attendance. Resident #12 remained in the smoking area and continued to smoke without staff supervision until 10:59AM. d. On 04/18/23 at 11:11 AM, the Surveyor asked Resident #12 who she was smoking with on Monday (04/17/23). She stated, That was [Resident #100] and his [family member]. The Surveyor asked if she had permission to smoke without the supervision of the staff. She stated, I gave myself permission. The Surveyor asked who let her go out to smoke. She stated, [Resident #100's family member] opened the door. I smoke when I want. The Assistant Director of Nursing (ADON) and the Administrator both came outside at the smoking area while Resident #12 was outside smoking and went back inside. e. On 04/19/23 at 4:18 PM, the Surveyor asked the DON who she expected to take a resident who is assessed and care-planned to be supervised to smoke, out to smoke. She stated, A staff member or a family member. The Surveyor asked what could happen if a resident is not supervised as assessed. She stated, Burn themselves. f. On 04/19/23 at 4:25 PM, the Surveyor asked the Administrator who she expected to take a resident who was assessed, and care planned to be supervised, out to smoke. She stated, Their family or staff. The Surveyor asked if anybody's family member could take a resident out to smoke. She stated, No, just their own family. g. A facility policy titled, Smoking Policy and Procedure, provided by the Administrator on 04/19/23 at 4:31 PM documented, .4. Accommodation for residents at risk: The facility will accommodate residents with a desire to smoke who have been assessed as unable to safely smoke independently .

Based on record review and interview, the facility failed to ensure a lift was used during a transfer to prevent the potential for accidents for 1 (Resident #3) of 3 (Residents #1, #2, #3) sampled residents who required the use of a lift for transfers. The findings are: Resident #3 had diagnoses of Unspecified Lack of Coordination and Postpolio Syndrome. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/25/22 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview of Mental Status (BIMS), was totally dependent of two plus persons for transfers. a. A care plan with a completed date of 2/17/22 documented, .TRANSFER: The resident requires Hoyer lift with 2 staff assistance for transfers . b. On 3/15/22 at 10:59 AM, Resident #3 was sitting in her Geri chair. She was asked, Did staff use a lift to put you in your chair this morning? She stated, No, they just picked me up. She was asked, How did they transfer you this morning? She stated, They just picked me up. She was asked, How many people picked you up? She stated, Two. c. On 3/15/22 at 2:55 PM, Resident #3 was in bed. There was a lift pad in her Geri-chair. She was asked, Did the staff transfer you to your bed using a lift? She stated, No, it was 2 of them and they grabbed me under my arms. d. On 3/15/22 at 2:58 PM, Certified Nursing Assistant (CNA) #2 was asked, Can you tell me why you didn't use the lift to put [Resident #3] back in bed? She stated, No ma'am. She was asked, Should you have used a lift to put her back in bed? She stated, Yes ma'am. [CNA #1] and [CNA #3] helped me put her back in bed. e. On 3/16/22 at 9:37 AM, the Director of Nursing (DON) provided a form titled, Lifting/Transfer with Mechanical Lift that documented, .The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device . At least (2) nursing assistants/staff are needed to safely move a resident with a mechanical lift . f. On 3/16/22 at 9:39 AM, CNA #1 was asked, Did you assist in the transfer of [Res #3] yesterday evening? She stated, Yes ma'am. She was asked, How did you transfer her? She stated, We just transferred her because the lift pad wasn't even up under her. She was asked, According to her care plan how do she supposed to be transferred? She supposed to be a two- person with a Hoyer lift. She was asked, Can you tell me why it's important to follow the care plan when transferring a resident? She stated, For the safety of the resident. g. On 3/16/22 at 9:48 AM, CNA #3 was asked, Did you assist in the transfer of [Res #3] yesterday evening? She stated, Yes ma'am. She was asked, How did you transfer her? She stated, Me and one of the other girls picked her up and put her in the bed. She was asked, According to her care plan how do she supposed to be transferred? She stated, Hoyer lift 2 persons assist. She was asked, Can you tell why you didn't use the Hoyer lift? She stated, They didn't have a lift pad under her and she's always complaining about it hurting. She was asked, Can you tell me why it's important to follow the care plan when transferring a resident? She stated, It's very important because we could have dropped her, hit her head, dropped her. Yes, we should have used the lift. h. On 3/16/22 at 11:22 AM, the DON was asked, How is [Resident #3] care planned to be transferred? She stated, Mechanical lift, two-person assist. She was asked, Why is it important that staff follow the care plan when transferring a resident? She stated, The resident safety. So, they don't hurt the resident. i. On 3/16/22 at 11:30 AM, the Administrator was asked, How is [Resident #3] care planned to be transferred? She stated, With a Hoyer lift and two persons. She was asked, Why is it important that staff follow the care plan when transferring a resident? She stated, Safety of the resident and the staff.

Based on observation and interview, the facility failed to ensure dietary staff used clean dish-handling practices during meal service to prevent potential contamination that could result in food borne illness for residents who received meals from 1 of 1 kitchen. The findings are: On 11/29/21 at 12:15 PM, while on the serving line, with no gloves on, Dietary Employee #1 removed a clean plate from the cart, touching the interior surfaces of the clean plate with her fingers prior to placing a serving of chicken on the plate. She then passed the plate to the next person on the serving line. She proceeded to remove another plate from the cart, touching the interior surfaces of the plate with her fingers and she placed chicken on the plate. a. On 11/29/21 at 12:20 PM, the Dietary Manager accompanied the surveyor to the serving line to observe Dietary Employee #1 plate the food being served on the tray line. She witnessed Dietary Employee #1 removing clean plates from the cart, touching the interior surfaces of the plates with her fingers. b. On 12/2/21 at 9:43 AM, the Dietary Manager was asked if she witnessed Dietary Employee #1 touching the insides of the plates prior to plating food to be served to the residents. She stated, Yes, I saw her fingers touching the inside of the plate. Once I noticed it, I instructed her to handle the plate by the rim. c. On 12/2/21 at 10:57 AM, Dietary Employee #1 was asked if she was aware that on 11/29/21 her fingers were touching the insides of the clean plates prior to plating food to be served to the residents. She stated, Yes, I am so used to working fast that I didn't realize my fingers were touching the insides of the plates. d. The facility's policy titled, Kitchen Management, provided by the Dietary Manager on 12/02/21 at 10:51 AM, documented, The facility strives to promote a clean and safe environment . All employees shall: .Pick up dishes by their rims .

Based on observation, record review and interview, the facility failed to ensure fingernails were groomed and trimmed to promote good personal hygiene and grooming for 1 (Resident #11) of 16 (Residents #32, 13, 16, 33, 2, 17, 35, 23, 27, 44, 11, 30, 7, 1, 28, and 48) sampled residents who required assistance with nail care. The findings are: Resident #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 9/3/21 documented the resident scored 7 (0-7 indicates severe impairment) on a brief interview for mental status and required supervision with one person assistance for personal hygiene. a. On 11/29/21 at 2:45 PM, the resident was sitting in her room. The nail polish on her fingernails was chipped and had grown out, exposing approximately 1/4 to 1/2 of the unpolished section of the nails. The fingernails also had jagged edges. The resident stated, I've asked them to do my nails, and they haven't yet. b. On 11/30/21 at 1:25 PM, the resident's nails were jagged with chipped and grown-out nail polish. c. On 12/01/21 at 10:05 AM, the resident's nails remained in the same condition. The resident asked, Where do I go to get them done? d. On 12/02/21 at 11:27 AM, Certified Nursing Assistant (CNA) #1 was asked, How often is nail care done on the residents? She answered, On shower days and on Sundays, everyone gets nail care. She was asked, Who does the nail care? She answered, The CNAs do the cutting and trimming. Activities do the painting. Nurses do the diabetics. She was asked when Resident #11's nails were trimmed last. She responded, I don't know . e. On 12/02/21 at 1:58 PM, Registered Nurse (RN) #1was asked, How often should nail care be done? She answered, Once a week. She was asked, Who does it? She answered, I am responsible for the diabetics on the weekends. The treatment nurse does the other diabetics during the week. The CNAs do the rest during the week on bath days. f. On 12/02/21 at 1:48 PM, the Director of Nursing (DON) was asked, Who does the nail care on the residents? She answered, The CNAs do everybody but the diabetics. They are done by the nurses. She was asked, How often should it be done? She answered, Every week. g. The facility policy titled, Personal Needs, provided by the DON on 12/2/21 at 2:43 PM, documented, .The facility strives to promote a healthy environment by meeting the personal care needs of the residents, as indicated . Personal care and ADL [activities of daily living] support will be provided according to the resident's Plan of Care. Personal care and support include but is not limited to the following: .nail care .

Based on observation, record review, and interview, the facility failed to ensure oxygen therapy was administered only when ordered by a physician to prevent potential complications for 1 (Resident #21); failed to ensure oxygen was administered at the flow rate ordered by the physician to prevent potential complications for 2 (Residents #2 and #28 ); and failed to ensure an Oxygen in Use sign was posted to alert staff and visitors of the need for precautions for 1 (Resident #2) of 3 (Residents #2, #21, #28) sampled residents who received oxygen therapy. This failed practice had the potential to affect 4 residents who received oxygen therapy, as documented on a list provided by the Director of Nursing on 12/01/21 at 11:50 AM. The findings are: 1. Resident #2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/26/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and did not receive oxygen therapy while a resident. a. A Physician's Order dated 7/16/20 documented, .O2 [oxygen] at 2L [Liters] via nasal cannula prn [as needed] SOB [Shortness of Breath] . b. On 11/29/21 at 2:05 PM, Resident #2 was lying in bed with her eyes open. Oxygen was in use at 3 liters per nasal cannula. There was no Oxygen in Use sign on the door. c. On 11/30/21 at 10:02 AM and 12:25 PM, Resident #2 was lying in bed with her eyes closed. Oxygen was in use at 3 liters per minute via nasal cannula. There was no Oxygen in Use sign on the door. d. On 12/01/21 at 10:42 AM, Resident #2 was lying in bed. She had oxygen in use at 3 liters per nasal cannula. There was no Oxygen in Use sign on the door. e. On 12/01/21 at 11:11 AM, Licensed Practical Nurse (LPN) #1 was asked, What is [Resident #2's] oxygen flow rate? LPN #1 stated, It is set at 3. LPN #1 was asked, What should [Resident #2's] oxygen flow rate be? LPN #1 looked at the resident's electronic medical record and stated, It should be set at 2 liters . LPN #1 was asked, Who is responsible for making sure the oxygen flow rate is correct? LPN #1 stated, The nurses are. LPN #1 was asked, How often should the oxygen flow rate be checked? LPN #1 stated, Every shift. LPN #1 was asked, Does [Resident #2] have a sign on the door stating, Oxygen in Use? LPN #1 stated, She does not have one, but she should have one. 2. Resident #28 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/6/21 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received oxygen therapy. a. The Physician's Order dated 4/2/20 documented, .Oxygen 2 LPM [Liters Per Minute] VIA NC [nasal cannula] every shift . b. The Care Plan with a revision date of 4/10/20 documented, The resident has [CONDITION(S)] . OXYGEN SETTINGS: O2 at 2L per nasal cannula as needed . c. On 11/29/21 at 11:59 AM, Resident #28 was sitting in bed watching television. He had oxygen in use per nasal cannula at 3.5 liters per minute. d. On 11/29/21 at 02:28 PM, Resident #28 was lying in bed with his eyes closed. The resident had oxygen in use at 3.5 liters per minute via nasal cannula. e. On 11/30/21 at 9:28 AM and 12/01/21 at 10:48 AM, Resident #28 was lying in bed with his eyes closed. Oxygen was in use at 3.5 liters per minute via nasal cannula. f. On 12/01/21 at 11:20 AM, Registered Nurse (RN) #1 was asked, What is [Resident #28's] oxygen flow rate? RN #1 stated, Its set at 3.5 liters. RN #1 was asked, What should [Resident #28's] oxygen flow rate be? RN #1 looked at the electronic medical record and stated, The order states 2 liters by nasal cannula . RN #1 was asked, Who is responsible for making sure the oxygen flow rate is correct? RN #1 stated, The nurse is. RN #1 was asked, How often should the oxygen flow rate be checked? RN #1 stated, Every shift. RN #1 was asked, 3. Resident #21 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 9/30/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received oxygen therapy while a resident. a. The Care Plan dated 10/11/21 documented, The resident has Congestive Heart Failure . OXYGEN SETTINGS: O2 at 2L per nasal cannula as needed . b. On 11/29/21 at 11:11 AM, the resident was sitting in bed with O2 in use at 4L per NC. c. On 11/30/21 at 10:22 AM, the resident was sitting in a wheelchair in the hallway with portable O2 in use at 3.5 L per NC. d. The November and December 2021 Physician Orders did not document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] e. On 12/02/21 at 1:48 PM, the DON was asked if Resident #21 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked, Should he have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? She replied, Yes. f. On 12/02/21 at 1:58 PM, Registered Nurse #1 was asked if a resident using oxygen should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. On 12/01/21 at 11:29 AM, the Director of Nursing (DON) was asked, Who is responsible for making sure the oxygen flow rate is correct? The DON stated, The charge nurse. The DON was asked, How often should the oxygen flow rate be checked? The DON stated, Every shift. The DON was asked, Should a resident that is receiving oxygen therapy have a sign on the door stating, Oxygen in Use? The DON stated, Yes. 5. The facility policy titled, Oxygen Management, provided by the DON on 12/01/21 at 11:50 AM, documented, It is the policy of the facility to require a physician's order for administration of oxygen . Equipment: . 4. Oxygen Sign . Procedure/Protocol: 4. turn flow meter to the appropriate flow as ordered by the physician .

Based on observation, record review and interview, the facility failed to ensure a resident's bedside table was maintained in clean condition to provide a clean and homelike environment for 1 (Resident #32) of 21 (Residents #32, 39, 13, 16, 33, 2, 17, 35, 23, 27, 44, 11, 30, 36, 15, 7, 21, 1, 34, 28 and 48) sampled residents whose rooms were observed. The findings are: Resident #32 had diagnoses of Stroke with [CONDITION(S)], [CONDITION(S)], and Malnutrition. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/21 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 11/29/21 at 11:19 AM, Resident #32 was sitting up in bed. The brown top of the bedside table had many areas of a dry, whitish, tannish substance on top of it. The resident was asked, What are the stains? He stated, I don't know. The metal section at the bottom and sides of the bedside table also had multiple white /tannish stains. The resident was asked, How often are staff cleaning your room? He stated, Every day. b. On 11/30/21 at 10:06 AM, Resident #32 was lying in bed. The metal section at the bottom and on the sides of the bedside table continued to have multiple white/tannish stains on the surface. c. On 12/02/21 at 03:21 PM, the Administrator was asked to accompany the surveyor to Resident #32's room. The Administrator was asked, Can you describe the resident's bedside table? The Administrator stated, It needs to be cleaned. There is stuff spilled and splattered on it.

Based on record review and interview, the facility failed to review and revise the care plan to include oxygen therapy to ensure continuity of care for 1 (Resident #2) of 3 (Residents #2, #21, and #28) sampled residents who received oxygen therapy. This failed practice had the potential to affect 4 residents who received oxygen therapy, according to a list provided by the Director of Nursing (DON) on 12/01/21 at 11:50 AM. The findings are: Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/26/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and did not receive oxygen therapy. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan with a revision date of 8/10/21 did not address the resident's use of oxygen therapy. c. On 12/02/21 at 2:57 PM, the Minimum Data Set (MDS) Coordinator was asked, Does [Resident #2] have a care plan that addresses her use of oxygen? The MDS Coordinator looked in the electronic medical record and stated, No ma'am, she does not. I would have put it under her [CONDITION(S)] care plan if I had included it. She came back from the hospital on it as needed, and I did not add it to the care plan . d. The facility policy titled, Comprehensive Care Plans, provided by the Director of Nursing on 12/2/21 at 4:40 PM, documented, . It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care . Updating Care Plan: . 3. The Care Plan will be updated and/or revised for the following reasons . b. A change in planned interventions .

Based on observation, record review and interview, the facility failed to ensure foot care was regularly provided to a diabetic resident, to include regular trimming of toenails to prevent potential complications for 1 (Resident #35) of 16 (Residents #32, 13, 16, 33, 2, 17, 35, 23, 27, 44, 11, 30, 7, 1, 28, and 48) sampled residents who required assistance with nail care. The findings are: Resident #35 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/20/21 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required supervision with setup help for personal hygiene. a. The Care Plan dated 10/11/21 documented, .The resident has an ADL [activity of daily living] self-care performance deficit r/t [related to] [CONDITION(S)] . Nail Care: Check nail length and trim and clean as necessary . The resident has Diabetes Mellitus . Diabetic toenail care to be provided by Licensed Staff . b. On 11/29/21 at 12:42 PM, the resident stated, My toenails need cut bad. I have asked them. c. On 12/01/21 at 10:49 AM, the resident was asked if her toenails had been trimmed yet. She responded, No. She was asked how long it had been and she stated, It's been a long time, I can't remember. The resident's toenails were long, extending 1/4 to 1/2 inch past the nail beds. d. On 12/02/21 at 11:27 AM, Certified Nursing Assistant (CNA) #1 was asked, How often is nail care done on the residents? She answered, On shower days and on Sundays, everyone gets nail care. She was asked, Who does the nail care? She answered, The CNAs do the cutting and trimming. Activities do the painting. Nurses do the diabetics. e. On 12/02/21 at 1:58 PM, Registered Nurse (RN) #1 was asked, How often should nail care be done? She answered, Once a week. She was asked, Who does it? She answered, I am responsible for the diabetics on the weekends. The treatment nurse does the other diabetics during the week. The CNAs do the rest during the week on bath days. f. On 12/02/21 at 1:48 PM, the Director of Nursing (DON) was asked, Who does the nail care on the residents? She answered, The CNAs do everybody but the diabetics. They are done by the nurses. She was asked, How often should it be done? She answered, Every week. She was asked when Resident #35's nails were last trimmed. She answered, I don't know. g. The facility policy titled, Personal Needs, provided by the DON on 12/2/21 at 2:43 PM, documented, .The facility strives to promote a healthy environment by meeting the personal care needs of the residents, as indicated . Personal care and ADL support will be provided according to the resident's Plan of Care. Personal care and support include but is not limited to the following: .nail care .

Based on observation and interview, the facility failed to ensure food items stored in the dry storage area and refrigerator were covered and sealed; and expired food items were used or promptly removed from stock and discarded on or before the expiration or use by dates to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 49 residents who received meals from the kitchen, according to the Resident Census and Condition form provided by the Administrator on [DATE] at 2:42 p.m. The findings are: 1. On [DATE] at 11:20 a.m., a 36-ounce container of food thickener with a best by date of ,[DATE] was stored on a shelf in the dry goods storage area of the kitchen. The Dietary Manager was asked, Should this be used? The Dietary Manager stated, No, it shouldn't. This is the only one. I'll make sure I get rid of it. 2. On [DATE] at 11:31 a.m., a sealable plastic bag containing cheese slices was stored on a shelf in the refrigerator. The bag was unsealed, exposing the cheese slices to air. The Dietary Manager was asked, Should the bag be sealed? The Dietary Manager stated, Yes, it should be. The Dietary Manager was asked, What can happen if the bag isn't sealed properly? The Dietary Manager stated, The cheese is exposed to the air. It could get contaminated. 3. On [DATE] at 11:33 a.m., a sealable plastic bag containing grated cheese was stored on a shelf in the refrigerator. The bag was unsealed, exposing the grated cheese to air. The Dietary Manager was asked, Should the bag be sealed? The Dietary Manager stated, Yes. It should be. The Dietary Manager was asked, What can happen if the bag isn't sealed properly? The Dietary Manager stated, It could get contaminated. 4. On [DATE] at 9:45 a.m., Dietary Aide #1 was asked, If food items are placed in the refrigerator in a sealable plastic bag, should the bag be sealed? Dietary Aide #1 stated, Yes, it should be sealed and dated. Dietary Aide #1 was asked, Why should the bag be sealed? Dietary Aide #1 stated, So the food doesn't get spoiled or contaminated. 5. On [DATE] at 9:50 a.m., Dietary Aide #2 was asked, If food items are placed in the refrigerator in a sealable plastic bag, should the bag be sealed? Dietary Aide #2 stated, Yes. Dietary Aide #2 was asked, Why should the bag be sealed? Dietary Aide #2 stated, To prevent germs and contamination. 6. A facility policy titled Food Storage provided by the Dietary Manager on [DATE] documented, .All stock must be rotated with each new order received . Rotating stock is essential to ensure the freshness and highest quality of all foods . Place new items behind supply in stock of the same item; in this way oldest stock is always used first . Leftover food is stored in covered containers or wrapped carefully and securely . Each item is labeled and dated before being refrigerated . Leftover food is used within 48 hours or discarded . 7. A facility in-service dated [DATE] provided by the Dietary Manager on [DATE] at 10:30 a.m. documented, .Ziploc bags are to be used instead of film wrap to store food items, no exceptions . Date, label, seal everything .

Based on observation, record review and interview, the facility failed to ensure dishware, utensils, and drinking glasses were properly cleaned and sanitized before reusing, failed to ensure sanitizer levels in the low-temperature dish machine were routinely monitored and documented, and failed to ensure the low temperature dish machine achieved the minimum wash temperature specified by the manufacturer's instructions to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. This failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury or death for 67 residents who received meals from the kitchen (total census: 67), according to a list provided by the Administrator on 9/11/18 at 9:48 a.m. The Director of Nursing was notified of the immediate jeopardy condition on 9/10/18 at 5:30 p.m. The findings are: a. The installation and operation manual for the facility's low temperature dish machine, provided by the Administrator on 9/11/18 documented, .Page 4 . Chemical Sanitizing Water Temperatures (Fahrenheit/Celsius): Minimum Wash temperature 120/49 Minimum Rinse temperature 120/49 Minimum Water temperature 120/49 . Page 7 .Priming Chemical Feeder pumps: Chemical feeder pumps need priming when the machine is first installed or if the chemical lines have been removed and air is allowed to enter . Page 8 .Use the toggle on the front of the control box to prime each pump. There are 3 switches mounted by the peristaltic pumps. One will prime the sanitizer pump only, the second will prime the detergent and the third the rinse aid pump . To prime the pumps, hold the switch in the momentary position until the chemical can be observed entering the sump . b. A Pro blend Commercial series safety data sheet, provided by the Dietary Manager on 9/11/18 documented, LT SAN .physical state Liquid, Appearance Pale yellow/green, Odor Chlorine . c. A Pro Blend Test for Chlorine Sanitizer sheet, provided by the Dietary Manager on 9/11/18, documented, .50 PPM (parts per million) . Color scale is an approximation. Follow the guidelines of the test paper manufacturer . Time of test 1 seconds. Results should read 50 PPM, Dish machine: after sanitizing cycle, (130 degrees F. (Fahrenheit) -160 degrees F . d. A micro essential laboratory sheet, provided by the Dietary Manager on 9/14/18 documented, .Hydrion .measure the concentration of Quaternary sanitizers, particularly multi-quat broad range quaternary ammonium sanitizer solutions . e. An equipment sanitation safety and sanitation sheet, provided by the Dietary Manager on 9/13/18 documented, .The proper direction for cleaning equipment will be demonstrated to employees by either the Food Services Supervisor or designee. f. On 9/10/18 at 1:37 p.m., during initial observation of the kitchen with the Dietary Manager, Dietary Employees #1 and #2 were in the dishwasher area removing dirty dishes (plates , cups, drinking glasses, utensils) from the window, spraying the excess food from the dishes, and loading and unloading the dishwashing machine. The Dietary Manager (DM) and the surveyor went into the dishwashing area of the kitchen to observe as a load of dishes processed through the dishwashing machine. The water temperature gauge on the dishwashing machine registered 100 degrees Fahrenheit (F.) for the wash cycle and 120 for the rinse cycle. The Dietary Manager stated, I'll try these strips. She removed a Hydrion strips from the container. The Hydrion strips were not the correct type of strips to test the chlorine sanitizer in the dishwasher machine. The Dietary Manager dipped the strip in the rinse water. The strip tested at 150 and the color was orange. At this time, the Dietary Manager stated, The water from the dish machine has backed up into the Ultra san (sanitizer); I told them to change it out this morning. That is water in the (sanitizer) bucket. The 5-gallon ultra san bucket was approximately 1/4 full with only a clear liquid. The DM stated to Dietary Employee #4, Wash your hands and move those racks of dishes from the dish machine. Dietary Employee #4 removed the clean dishes from the dishwasher and placed them on the cart with previously washed dishes. The Dietary Manager and Dietary Employee #4 connected a new bucket of ultra san to the machine and, without priming the sanitizer tubing, Dietary Employee #4 continued to wash and store dishes that had been washed in sub-temperature water and without appropriate sanitizer solution. The Dietary Manager exited the dish area and went to the back of the kitchen. When she returned to the dishwasher area she stated, I was using the wrong strips. She removed a strip from the Ecolab compartment and tested the rinse water in the dishwasher. The strip read 10. She stated, I've been having problems with the temperatures. I called Ecolab about 1 month ago; he said it's a low temperature machine and its okay for it to run on low temperatures. It usually runs at 120 degrees (F). In the morning, we have to run 2 cycles before it goes up to 120 degrees (F). She then asked the surveyor, Will you please tell the people in the front office about it? She then performed another Ecolab chlorine sanitizer test, and this time, the strip registered 50 PPM. The dishes that had previously been sent through the machine were not re- washed and sanitized. g. On 9/10/18 at 2:35 p.m., the DM was asked if they kept a record of the temperatures and sanitizer readings for the dishwasher. She stated, We don't record sanitizer readings, but we do record the temperatures at each meal. h. On 9/10/18 at 2:44 p.m., the DM was asked if dishes had been washed prior to performing the Ecolab testing today. She stated, Yes, some had already been run through the dishwasher; remember, I told (Dietary Employee #4) to wash her hands and move those clean dishes from the dishwasher. i. On 9/10/18 at 2:50 p.m., Dietary Employee #4 was placing dirty dishes into the dishwasher and removing the clean dishes. The wash cycle was 110 degrees (F) and the rinse cycle was 120 degrees (F). She continued to place dirty dishes into the dishwasher and store the ones removed from the dishwasher on the cart with the dishes that had been run through the machine when the sanitizer was not working. At this time, the Wareforce sheet posted on the side of the dishwasher was reviewed and documented, .(Fahrenheit/Celsius): Minimum Wash temperature 120/49 Minimum Rinse temperature 120/49 Minimum Water temperature 120/49 . j. The Temperature Log was reviewed at this time. It documented morning and evening temperature results for the dish machine, but no sanitizer levels were documented. The temperature ranges for the wash cycle ranged from 160 to 161 degrees (F) and rinse cycle temperatures ranged from 160 to 161 degrees (F) for (MONTH) 1-31, (YEAR) and (MONTH) 1-10, (YEAR). k. On 9/10/18 at 3:25 p.m., the Dietary Manager stated, I know I'm not crazy; she didn't prime the lines to the detergent, rinse, and sanitizer. That's why the eco strips didn't register correctly. The solutions will settle in the line. She was asked if the dishes were clean, since the lines were not primed. She stated, I can't say if they were or not, maybe a little bit. l. On 9/10/18 at 3:29 p.m., the DM accompanied the surveyor to the dishwasher and demonstrated how to prime the sanitizer lines for the dishwasher. She stated, You hit that button to the detergent prime, prime rinse, prime sanitizer and, for each, count to five. There was a load of dishes in the machine at this time. The wash cycle was 120 degrees (F) and the rinse cycle was 130 degrees (F) and the test strip reading was 200 ppm. The dishes and utensils that had been run through the machine when the wash temperature was below 120 degrees F. and the sanitizer was not dispensing remained on the cart and had not been re-washed. m. On 9/10/18 at 4:35 p.m., Dietary Employee #4 obtained silverware that had not been properly washed and sanitized from the clean dish cart and was rolling the silverware into white napkins in preparation for the evening meal service. n. On 9/10/18 at 4:55 p.m., Dietary Employee #5 was asked not to serve the evening meal until this surveyor returned to the kitchen. The dietary staff had still not re-washed the dishes that had been run through the dish machine when the temperature was below 120 degrees F. and the sanitizer was not dispensing. o. On 9/10/18 at 5:25 p.m., residents were in the main dining room eating and had glasses of tea and / or water that had been served in the glasses from the cart of dishes that had not been properly washed and sanitized. The DM was asked by the surveyor to stop serving immediately, since the dishes had not been properly cleaned and sanitized. She stated, I will use Styrofoam. p. On 9/10/18 at 5:29 p.m., the Director of Nursing was asked if it had been reported to her that the dishwasher machine temperatures were not hot enough. She stated, Today, I knew something was wrong when you were in the kitchen. I just haven't had time to go to the kitchen yet. q. On 9/11/18, the following staff were asked these questions: Have there been concerns with the dishwasher temperatures or the sanitizer testing? Who do you report to if there are concerns with the temperatures or sanitizer testing? What temperature should the dishwasher be at all times? After the Dietary Manager and I checked the dishwasher temperatures and sanitizer level on 9/10/18 and the results were negative, did you re-wash and sanitize the dishes that had previously been washed? How do you monitor the temperatures, sanitizer levels for the dish washer, and how often and where are the readings recorded? How often does the dish washer water back-up into the ultra san solution bucket and how often should it be changed? How often should you prime the detergent, sanitizer, and rinse lines connected to the dishwasher? Should all utensils/dishes be cleaned and sanitized to prevent food borne illnesses? Were you trained on how to check the temperatures of the dishwasher and how to monitor the sanitizer? Their responses were as follows: 1.) At 9:42 a.m., Dietary Employee #1 stated, I was over washing and cleaning the dishes in the 3-compartment sink. When you were in the kitchen, I was just helping them move the dirty dishes from the window after lunch. I didn't operate the dishwasher. About 2 or 3 days ago, I heard another employee in the kitchen tell the Dietary Manager the water in the dishwasher wasn't getting hot enough. I think she reported it to maintenance. Yes, all dishes should be cleaned and sanitized before serving them to the residents. I was trained by another employee a few years ago. She no longer works here. 2.) At 9:55 a.m., Dietary Employee #2 stated, I had problems with it heating up off and on. It wasn't getting hot like it should, and I reported to the DM yesterday. I could tell it wasn't hot enough, because when I opened the door to the dishwasher, there was no steam. I checked the temperature on the machine every day. They should be between 120 -130 degrees. I left work at 2 pm yesterday. I didn't re-wash any dishes before I left work. I don't record the temperature or the sanitizer readings; I think the DM does. I didn't prime it (sanitizer) today. I (change) the buckets when they get empty. All the dishes should be cleaned and sanitized before serving food on them. DM trained me. 3.) At 10:15 a.m., Dietary Employee #3 stated, I'm not aware of any problems with the dishwasher. I test the temperature of the dishwasher by using a test strip. I put one inside the dishwasher after each time I run it. I washed dishes yesterday morning; the water seemed hot enough to me, because steam came out when I opened the doors on the machine. I didn't do the dishes during lunch time. I didn't re-wash any dishes yesterday. I recorded the temperatures in the morning shift. I don't test the sanitizer. All dishes should be cleaned and sanitized before using the dishes. r. On 9/11/18 at 12:50 p.m., the Administrator was asked if anyone reported to her that the dishwasher was not hot enough or that the sanitizer was not functioning properly. She stated I've been here since (MONTH) (YEAR). We use (Chemical Company) to service the dishwasher machine. We have not had any services provided by them since I've been here. I wasn't aware of a problem with the dishwasher until yesterday. s. On 9/13/18 at 1:15 p.m., Dietary Employee #4 was asked the same interview questions that had been asked of other Dietary employees on 9/11/18 (refer to paragraph q. above). She stated, No, ma'am, I hadn't had any problems with the machine. I just started a few weeks ago, and I hadn't been trained how to monitor temperatures. I'm not sure what the sanitizer testing is. No ma'am, I don't record anything. Never primed the dishwasher, either. No ma'am, I just wash the dishes as they come into the window. I was not told to re-wash them. We should re-wash the dishes if the machine is not working properly. t. On 9/13/18 at 2:00 p.m., the Dietary Manager was asked if all utensils and dishes should be properly cleaned and sanitized in order to prevent food borne illnesses. She stated, Yes. She was asked if all dietary employees washed dishes using the dishwashing machine. She stated, Yes. u. On 9/13/13 at 2:50 p.m., the Maintenance Director was asked if, prior to the survey team entering on Monday, anyone had reported to him that the dishwasher water wasn't getting hot. He stated, No. v. The Immediate Jeopardy was removed, and the scope/severity reduced to F on 9/11/18 at 9:40 a.m., when the facility implemented the following plan of removal: (Chemical Company) has been called to make adjustments to dishwasher, if applicable. Company will be here in a.m. (morning) on 9/11/18. In-service with kitchen staff initiated at 5:40 PM per maintenance that sanitizer strips must be checked 3 times daily prior to washing dishes after each meal and a demonstration was completed showing staff how to properly perform test. Results of checks will be documented on log that will be kept on dish machine in kitchen. Staff has been instructed that if any abnormal temperature or chemical discrepancies noted report to the dietary manager immediately. Dietary manager or administrator will continue in-servicing dietary staff until all have been instructed. Dietary manager/designee will monitor log at least 5 times weekly to ensure checks are being done and are within normal range. CEO (Chief Executive Officer) will monitor that this is being done at least weekly. If sanitizer is not reading at an appropriate level, staff will notify maintenance supervisor and administrator immediately. (Chemical Company) or appropriate service company will be called for service if needed. Facility will use Styrofoam/paper/plastic plates, cups and utensils for next meal or until problem resolved. Nursing staff is checking residents for signs and symptoms of food-borne illnesses, with all residents to be assessed by the end of the day today. B. Based on observation and interview, the facility failed to ensure kitchen equipment was maintained in clean condition and dietary staff washed their hands before handling food or clean equipment to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practice had the potential to affect 67 residents who received meals from the kitchen (total census: 67), according to a list provided by the Administrator on 9/11/18 at 9:48 a.m. The findings are: 1. On 9/10/18 at 1:37 p.m., Refrigerator #1 (glass doors) had a coating of dust on its louvered grill. It also had stains and spills of several colors on the front, toward the bottom of the refrigerator. The louvered grill on Refrigerator #2 (white refrigerator) had brown and black particles on it. 2. On 9/10/18 at 4:12 p.m., Dietary Employee #5 was preparing pureed and mechanical soft food for the evening meal. She dropped a large silver oven mitten on the floor. She picked the oven mitten up from the floor and placed it on top of the disposable pan liners that were stored on the second self of the silver prep table. Without washing her hands or donning gloves, Dietary Employee #5 removed 2 slices of bread from a bread bag, placed them into the blender and pureed them. 3. On 9/13/18 at 2:00 p.m., the Dietary Manager was asked if staff should pick up a contaminated item from the floor and place it on top of clean items. She stated, No. She was asked if kitchen appliances should be clean and free of spills and debris. She stated, Yes. 4. On 9/13/18 at 3:54 p.m., the DM was asked if staff should wash their hands and don gloves before preparing food. She stated, Yes. 5. On 9/13/18 at 4:07 p.m., Dietary Employee #5 was interviewed via telephone and was asked if she should wash her hands and don gloved before touching residents' food. She stated, Yes. She was asked if she should remove a contaminated kitchen mitten from the floor and place it on top of clean items. She stated, No.

Complaint # , (AR 593) was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure an incident of possible physical abuse was immediately and thoroughly investigated after a resident who was heard screaming during care accused a Certified Nurse Assistant (CNA) of physical abuse and was subsequently found with bruising to multiple areas; and failed to ensure protective measures were immediately implemented to prevent further potential abuse for 1 of 1 (Resident #1) case mix residents who was allegedly physically abused by staff. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who sustained bruising and reported complaints of increased pain levels and nightmares after the incident, and had the potential to affect 18 residents who resided on the 400 hall on 11/4/16 and 20 residents who resided on the 400 hall from 11/5/16 through 11/19/16 as documented on the Roster/Sample Matrix received from the Registered Nurse (RN) Consultant on 11/22/16 at 10:20 a.m. The Director of Nursing (DON) was notified of the Immediate Jeopardy on 11/22/16 at 5:20 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. An Annual Minimum Data Set with an Assessment Reference Date of 9/9/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS); required extensive assistance of one person for bed mobility, transfer, dressing, toilet use, personal hygiene; balance moving from seated to standing position, moving on and off toilet and surface to surface transfer not steady, only able to stabilize with staff assistance; was non-ambulatory, and had functional limitation in range of motion to the upper and lower extremities on one side; exhibited verbal behavioral symptoms directed toward others on 1 to 3 of the past 7 days that did not put the resident at significant risk for illness or injury and did not significantly interfere with care; had no physical behavioral symptoms; did not resist care; and experienced pain on an occasional basis that was rated at 5 on a 1 to 10 scale and did not affect resident's ability to sleep or limit her day-to-day activities. a. Nurses Notes dated 11/5/16 at 7:30 a.m. documented, 0700 (7:00 a.m.) CNA reported to this nurse, resident is hurting. Resident assessed and c/o (complained of) legs hurting when transferred. No open areas or ST (skin tears) to BLE (bilateral lower extremities) at this time. ROM (range of motion) of BLE, WNL (within normal limits) for this resident. Resident medicated with [MEDICATION NAME] 5/325 mg (milligrams) po (by mouth), tol (tolerated) well in applesauce. No other needs noted, will report resident status to oncoming nurse to reassess. C/L (call light) placed in reach. b. Nurse's Notes dated 11/6/16 at 1:51 p.m. documented, 0845 (8:45 a.m.) resident c/o BLE pain and pain all over 10/10 (10 being worst pain). Medicated with [MEDICATION NAME] 5/325 mg one po. c. An Office of Long Term Care (OLTC) Witness Statement Form signed by CNA #1 and dated 11/7/16 documented, On Saturday, November 5, 2016 around 0530 (5:30 a.m.) I was asked out of a patient's room to help another resident (Resident #1). I then went to room (Resident #1's room) to assist her to the restroom. When I proceeded to raise and sit her on the side of the bed she began to have an attitude. I apologized for the wait/delay and began to align the wheelchair with the bed. Her feet were in place with proper non-skid socks on, then I began to assist her to her chair. Once raised, her leg moved/kicked me but I still was able to place her in the chair. She then was mad and proclaimed I was going to drop her and that her leg hurt, that I had hurt it. I then had to get the pt (patient) and assisted her fully to the back of the chair. Once in the chair she was angered. I still proceeded to take her to the restroom where she was placed on the toilet. Once on the toilet she was still angered and told me to get out and to get someone else to help her. I told her I was going to get another person to help. Then as I left the room, I told my nurse what happened and asked her to check to see if anything was hurt. She did not go to her room but I proceeded to find another person to help. I went down 100 hall to ask the CNA and she agreed to do so if I would help finish up her patients. I then after finishing had to ask another nurse to examine (Resident #1) to see if anything was wrong/hurt. I was unable to ask the other CNAs for help due to they had previously been kicked out of her room. After she was on the toilet I do not know what happened due to I was not allowed in there. But I was told that the other CNA that helped her was also told to leave her in her wheelchair until morning was here for them to do it and that I was not allowed back in there. A statement dated 11/6/16 and written by CNA #3 documented, I came to work today 11/6/16. While getting (Resident #1) up for the day she was complaining of pains all over her body. She stated to me that an aid by the name of (CNA #1) had been very rough with her. She stated that she had threw her down on the arm of her wheelchair and was pulling and yanking her very hard. She stated that she (CNA #1) was putting her thumbs into her skin and was told and continued to (press her thumbs into the resident's skin). She also stated that (CNA #1) told the oncoming CNA that (Resident #1) was in one of her moods. (Resident #1) has cried and complained of pain since I came to work. There was no documentation to indicate CNA #3 reported the resident's allegation of abuse to facility administration. CNA #3 was unavailable for interview during the survey. d. Nurse's Notes dated 11/6/16 at 1:53 p.m. documented, At 0820 (8:20 a.m.) (Resident #1) stated that the CNA on 11/7 (11:00 p.m. - 7:00 a.m. shift) on 11/4/16 shift, (CNA #1) was very rough with her. She stated that CNA sat her in her wheelchair very hard and threw her on the arm rest on the wheelchair. She also stated that she heard (CNA #1) stating that '(Resident #1) was in one of her moods.' Resident stated that the CNA was pulling and jerking on her very hard, the CNA's thumbs were pushing very hard on both of her arms. Resident stated that she told the CNA that she was hurting her and the CNA continued to push into her arms. Right forearm has a reddish purple bruise measuring 3x (by) 4 cm (centimeters) on left forearm, 2x2 purple red bruise noted to the right forearm. Two dark discolorations noted to back of left lower leg one measuring 2x2 the other measuring 1x2 cm. Resident states that she is having pain right and left breast pain. Her pain is worse from the waist down. (Blood pressure (BP)) 159/87, (pulse (P)) 98, (respirations (R)) 18, (temperature (Temp)) 97.2 (degrees Fahrenheit (F)). Family notified at 0915 (9:15 a.m.). Daughter here at 0930 (9:30 a.m.). Director of Nursing (DON) and Administrator notified at 8:23 (a.m.). Police notified and here at 1004 (10:04 a.m.), visited with resident for 15 minutes. Officer (officer name and badge number). (Physician) was notified at 10:38 a.m. Resident was sent to ER (emergency room ) via facility van at 1105 (11:05 a.m.). Report called to (name) at (hospital) at 1043 (10:43 a.m.). Returned to facility at 2:15 (p.m.) with no new orders. Report from (hospital) resident has no broken bones. V/S (vital signs) upon return (BP) 154/64, (P) 80, (R) 18, (Temp) 98.1 (F). Staff assist to recliner in room. Call light in easy reach. Will cont (continue) to monitor and assist as needed. e. The Police Department Incident Report dated 11/6/16 at 10:04 a.m. documented, Narrative (officer's name)-11/6/16 (initials); A patient at (facility name), (Resident #1) filed a complaint on the suspect (CNA #1), who is an aide at the facility, for physical and verbal abuse. (Resident #1) stated she called for an aide for help to use the bathroom and during the aide helping her, she was very rough, repeatedly snatching and jerking on (Resident #1) to get her out of the bed; also she sat (Resident #1) on the arm of the wheelchair very aggressively. (Resident #1) suffered several large bruises to her legs and left forearm. (Resident #1) also stated that (CNA #1) was jabbing her in the breasts with her thumbs causing large amounts of pain. (Facility) will be taking (Resident #1) to (hospital) to receive a full evaluation on the injuries she received. (Resident #1) also stated this was not the first time (CNA #1) had treated her in this manner, it was just the worst. f. Clinical Report-Nurses, (Hospital) Emergency Department Notes dated 11/6/16 at 11:01 a.m., documented, TRIAGE; Acuity: LEVEL 4. Chief Complaint: STATED PHYSICAL ABUSE . patient reports 'I used my call light about 5:30 in the morning to get help getting up to go to the bathroom. (CNA #1) came in and grabbed my sore (left) leg and slung it out of bed, she then grabbed my arms and stood me up and slung me into my wheelchair. I told her to not be so rough. I told her I felt like I was falling out of the chair and she grabbed me under my breast and dug her thumb into my right breast. I told her she was hurting me, and told her to go get someone else that could help me without hurting me.' History; Stated assailant: caretaker. Location of injuries: right breast, lower back, right forearm, left forearm, left hip and left leg. This occurred yesterday (about 5:30 AM). Occurred at nursing home. Police department notified (notified by (facility) staff prior to patient's arrival) . ABUSE ASSESSMENT: Abuse history: patient reports physical abuse by caretaker against patient . PHYSICAL ASSESSMENT: 11:05 (a.m.). To room via stretcher. GENERAL/NEURO (neurological)/PSYCH (psychiatric): Alert. Oriented x (times) 4. Affect appears normal. Appears in pain . RESPIRATORY: Respirations not labored. Breath sounds within normal limits. (patient c/o (complains of)) tenderness to right breast, states 'that girl dug her thumb into it') . EXTREMITIES: Limited ROM (range of motion) present in the left shoulder, left upper arm, left elbow, left forearm, left wrist, left hand, left hip, left thigh, left knee, left lower leg, left ankle and left foot (patient has previous left [MEDICAL CONDITION]. Neuro-vascular status intact to the extremity. Right forearm: ecchymosis (1.5cm x 3cm). Left forearm: ecchymosis (1.5 cm x 3 cm). Left hip: tenderness. Left leg: tenderness . BACK: Vertebral point tenderness over the lumbar spine. Soft tissue tenderness in the right lower and left lower lumbar paraspinous region. g. Facility Nurse's Notes dated 11/7/16 at 3:19 a.m. documented, CHANGE IN CONDITION/PAIN: 0230 (2:30 a.m.) Resident complains of generalized pain. Rates as 7/10 (10 being the worst) on pain scale. Bruising noted to R (right) arm just above wrist. Dark purple in color. No new skin issues noted. Resident exhibits s/s (signs/symptoms) of severe anxiety about this nurse (name) (and) CNA leaving her in room alone. Reassured resident that we wouldn't let anything happen to her. Resident continues to repeat she is afraid. Resident asks 'Is (CNA #1) working? I'm scared she is going to come and do something to me.' This nurse spent several minutes reassuring resident. Resident denies any other pain or needs at present. Will continue to observe and assist as needed. Bed low. CLIR (call light in reach). 0300 (3:00 a.m.) Resident vomited x (times) 1 and states, 'it's just my nerves.' NFC (no further complaint) of nausea. No more vomiting reported. h. Nurse's Note dated 11/7/16 at 6:50 a.m. documented, Resident was on her call light, paranoid, crying, she had a bad dream stating that someone was trying to harm her. Social & (and) CNA (CNA #4) assured her that no one was going to harm her in any way. Her daughter is at her bedside. Social will follow up with this resident. i. On 11/22/14 at 1:14 p.m., Licensed Practical Nurse (LPN) #2 was asked, Did you work on the 5th (11/5/16) when the incident with (Resident #1) happened? The LPN stated, No. The LPN was asked, When did you find out about the incident? The LPN stated, She reported it to me Sunday (11/6/16). It actually happened Saturday morning (11/5/16) on graveyard shift when they were getting her up that morning. The LPN was asked, What did she tell you? The LPN stated, She told me that (CNA #1) was very, very rough with her when she got her up Saturday morning. She said when she got her up, she sat her back down real hard and she ended up on the arm of the wheelchair. She said that her thumbs were digging into her arms and that she was hurting her and being rough with her. She said, 'I heard her (CNA #1) tell another staff member that, 'well (Resident #1) is in another one of her moods today' when she walked out of the room. The LPN was asked, Did you examine her at that time? The LPN stated, Yes. The LPN was asked, What did you find? The LPN stated, She had bruises, one on her left forearm and 2 bruises on the back of her left lower leg, I didn't see anything on her butt. The LPN was asked, Did you do a full body assessment? The LPN stated, No, I just looked at her arm, leg, and bottom. I did look at her right breast area. The LPN was asked, Did you see anything on her breast? The LPN stated, No. The LPN was asked, After she told you that, did you report it to anybody? The LPN stated, I texted (Administrator) and (DON) and told them what she had said and they said to call the cops and do a reportable. I called her daughter too. Her daughter didn't have a way up here. (Resident #1) got really upset when she found that the cops were going to be called, so I went and got her daughter and brought her up here. The LPN was asked, Did you fill out an incident report? The LPN stated, Yes, she was sent to the ER too, just to make sure nothing was broken or anything like that. The LPN was asked, Did the Administrator or DON come in? The LPN stated, No. The LPN was asked, Was (CNA #1) in the building when (Resident #1) told you this? The LPN stated, No. The LPN was asked, Was an investigation started? The LPN stated, The cop came and questioned (Resident #1), but as far as other residents being questioned, no. They, the Administrator and DON, may have come in after three (3:00 p.m.) or whenever it was I left, but they didn't while I was here. The LPN was asked, What time was it that (Resident #1) told you about this? The LPN stated, It was while I was doing med pass she told me. I usually make it to her room about 8:15 to 8:30 (a.m.). The LPN was asked, About what time did you tell the Administrator and DON? The LPN stated, As soon as she told me, I sent a group text to both of them. The LPN was asked, Have you seen (CNA #1) working after this incident? The LPN stated, I'm pretty sure I've seen her, but I won't swear to it. j. On 11/22/16 at 1:44 p.m., CNA #2 was asked, Do you remember on 11/22/16 at 1:44 p.m. when (Resident #1) said one of the CNAs was rough with her? The CNA stated, Yes. The CNA was asked, What did (Resident #1) tell you? The CNA stated, When I went to the room, she was saying, 'Oh baby I'm hurting.' I asked her what was wrong and she said that (CNA #1) was rough with her. She said she didn't want her back in her room, and as soon as she told me that, I notified the nurse (LPN #2). The CNA was asked, Did she tell you what happened? The CNA stated, She just said how she picked her up from the bed and her butt hit the chair. The CNA was asked, Did she tell you anything else? The CNA stated, No ma'am. The CNA was asked, Did you see any bruises on her? The CNA stated, I didn't see any new bruises. The CNA was asked, Did you work all day? The CNA stated, Yes. The CNA was asked, (Did you work) the 7 (a.m.) to 3 (p.m.) shift? The CNA stated, Yes, I don't have anything else to say. I'm not saying anything else. k. On 11/22/16 at 1:58 p.m., Licensed Practical Nurse (LPN) #1 was asked, Were you working on 11/5 (16) when (Resident #1) said a CNA was rough with her? The LPN stated, Yes, I was working that night. But, she didn't refer to it as being rough with me. The LPN was asked, What did she say? She stated, She said '(CNA #1) hurt me when she transferred me'. The LPN was asked, Did she tell you what happened? The LPN stated, She didn't; she just said 'she hurt me when she transferred me' and 'I need a pain pill'. The LPN was asked, Did you ask her where she was hurting? The LPN stated, Yes. The LPN was asked, Where did she say? The LPN stated, She said 'my back'. The LPN was asked, Did you look at her back? The LPN stated, I didn't just physically look at her back; I assessed her legs and her arms. (Resident #1) has pain in her back all the time. She takes pain med (medication) for her back. The LPN was asked, What made you look at her arms and legs? The LPN stated, Because ever since I been working with her, she jumps when she is being moved, and they have a tendency to bump her legs. I saw nothing out of the ordinary on her arms or legs. She takes [MEDICATION NAME], so she tends to bruise easily. The LPN was asked, When (Resident #1) said (CNA #1) hurt her, was that the same morning? The LPN stated, It was the same morning during my med pass. The LPN was asked, Did (CNA #1) ask you to take a look at (Resident #1) after she transferred her? The LPN stated, No, I went to her. The LPN was asked, You went to (CNA #1)? She stated, Yes. The LPN was asked, What did you go to (CNA #1) about? She stated, I told her the resident complained about her hurting her during transfer and not to go back into the room because the resident said she didn't want her helping her. I told her to go to another CNA to transfer (Resident #1) once she is finished using the bathroom. The LPN was asked, So (Resident #1) was on the toilet when you saw her? She stated, No, initially she wasn't. The LPN was asked, Where was she? The LPN stated, When I went into the room to medicate (Resident #1) she was sitting in the wheelchair. That's when she complained and told me that girl hurt her. Let me start over. When I came around to Hall 2 (Resident #1) was yelling, so I pushed my cart to the middle of the hall. I went to see what was wrong. She said she needed to use the bathroom. (CNA #1) was busy with another resident and she is still in bed. So I left (Resident #1) and went and found (CNA #1) and told her she needs to work on (Resident #1) first; she hadn't started working on who she was with and she said yes. (Resident #1) was screaming 'I don't want to use the bathroom on myself'. So (CNA #1) did what I asked. I went on and started passing meds. During med pass, I could hear (Resident #1) yelling. That's not untypical of (Resident #1) during movement. You know, you have to know (Resident #1). She plays with me, she plays with CNAs, she teases with CNAs and me; that's what she does, so that's what I thought. I continued my med pass. I went back in there. She was on the commode. She told me she didn't want (CNA #1) back in here, she hurt me when she transferred her. I gave her pain med. She told me then, 'I don't want (CNA #1) helping me'. What she meant was getting off the toilet. Then I came out of the room and found (CNA #1) and let her know about the complaint, 'you hurt her and she don't want you back in the room.' I told her to go get (CNA #5), so they did that; I saw (CNA #5) go into her room. I didn't see her move her, I went on with med pass. I was pushing my cart and she said 'come here (LPN #1)' and she was sitting in the wheelchair in her bedroom and her complaint then was she was left in the wheelchair and 'I need a pain pill'. It was about (CNA #1) not (CNA #5). I asked her 'do you want to go back to bed or to the recliner?' She asked 'what time is it?' It was 5:30-6:00 a.m. She said 'go back to bed' so I transferred her to bed. Because by this time they were working on a 2 person transfer. That's when I assessed her arms and legs. The LPN was asked, Why did you assess her arms and legs? She stated, Because she said she was hurting. Her back hurts all the time. When she said she got hurt, I thought it was her arms or legs, because she jumps, she can jump into bed not meaning to. You have to know how to move (Resident #1). The LPN was asked, Has (CNA #1) worked with her before? She stated, Yeah, she should. The LPN was asked, Did you ask how (CNA #1) hurt her? She stated, No. The LPN was asked, Did you report it to anyone? She stated, I can't say I did. I reported to the on-coming nurse about the pain pill and that she was hurt during transport and I wrote it on the 24-hour report. I was thinking she was just hurting. The LPN stated she did not respond to hearing the resident screaming / yelling during care. The LPN did not report to the facility administration the allegation made by the resident that CNA #1 hurt her, did not want CNA #1 back in her room, and made no attempt to investigate or ask how the resident was hurt by the CNA. l. On 11/22/16 at 3:02 p.m., Resident #1 was asked, Do you remember when a CNA was rough with you? The resident stated, Yes. The resident was asked, Can you tell me what happened? The resident stated, I buzzed my light about 5:30 in the morning, she (CNA #1) came in and I said I needed to go to the bathroom. So she jerked my bad leg around out of the bed. She jerked it around, that's my bad leg, and it doesn't move good, and that really hurt me. She was jerking on my arms and legs. She grabbed my arms and jerked me up. I've had a stroke and if you grab this arm it hurts me. I said, now (CNA #1) if you can't help me would you get some help because I need to use the bathroom. The resident was asked, What did she say? The resident stated, She didn't say nothing. She just jerked me up and sat me in my chair hard, I hit the arm. She was trying to get me up in the chair and she was pulling on my arm and I had a thumb print where she pulled on my arm. I was yelling. She got behind me and reached around me and was digging her thumb into my breast under my right breast, trying to straighten me up in the chair, I was thinking I was going to fall out of the chair. The resident was asked, Have you had trouble with this CNA before? The resident stated, Yes, she has and she's always been a smart aleck to me, and she is still working here, but not down here because I told them not to let her back in here again and my legs hurt me for several days after pulling on them like she did. The resident was asked, Did you tell anyone? The resident stated, The nurse and I told (Administrator) and (DON) the next day. The resident's son, who was in the room for this interview, stated, You got hurt one morning, and they waited till the next day to send her over there (hospital), and that's a long time to wait with her saying they hurt her. The resident stated, This arm (indicating left arm which was observed to be contracted at the elbow and wrist) is very weak and her pulling on it didn't help much either. I had a stroke on that side. She always acted like she has an attitude with me. The resident was asked, Is there anything else you want to tell me? The resident stated, The police came and interviewed me, I told them what happened. They asked me if I was yelling and I told them, yes I was yelling my head off for help because what was I supposed to do wait and let it go until she really hurt me. m. (Corporate) Rapid Response Report (Name ) documented, Date of Call:11/14/16; Facility Name: (Name); Resident Name: (Resident #1) on 11/22/16 at 3:02 p.m.; Category of Call: Resident-Related: Allegation of Abuse/Neglect; Employee-Related: Guidance on Suspension/Termination; *acts of Event: Resident complained of pain following a transfer. Nurse aide transferred resident without a gait belt. Resident was kicking and attempting to strike the nurse aide. *Events Leading Up to Incident: The resident's daughter had previously been a nurse at the facility and was terminated. The resident is angry about this action. The resident displays aggressive behavior to staff with frequent complaints. *Status of the Resident After the Initial Intervention: The resident had slight bruising on her arm and calf. She does receive [MEDICATION NAME] which would increase bruising potential. *Did an Employee Receive Related Training in the Past? The nurse aide had been trained in transfer techniques. *Is Training to be provided? Safe transfer techniques and the use of gait belt will be reviewed. *Immediate Actions Taken: (ex. Employee placed on leave, resident transferred to ER, MD/family notified, etc.): The aide was immediately suspended. Witness statements were obtained from residents with a BIM (score) of 10 or above, witness statements were also obtained from staff, no issues were discovered. The roommate, who is alert and oriented, was interviewed and she stated that the resident was being aggressive and kicking out at the aide. She also stated that during the incident, the aide did not respond angrily or verbally abusive even though the resident was treating her badly. A body audit of all residents in the aide's assignment completed with no issues noted. The family, the physician and OLTC notified. The aide's HR (Human Resources) file was reviewed and no other disciplines or counseling were noted. * Plan of Action: The aide will be re-instated, intensive education will be provided, and the incident will by written up as discipline. Education for transfer techniques and gait belt use was provided to all staff. Staff transfer techniques will be monitored as a quality improvement step. Additional Notes: The CNA (CNA #1) that was involved in the incident with (Resident #1) was not following company protocol and safe practice standards. She was transferring the resident without a gait belt. The resident has physical injuries, bruising on right forearm and back of left calf, r/t (related to) the way she was handled. She did go to the ER and had no injuries. A large factor in the case is (CNA #1's) failure to follow policy. (Resident #1) has been a resident for a while, her daughter was one of the nurses that was terminated (daughter's name). (CNA #1) is an aide that works part time and is attending nursing school. (CNA #1) did not have any write ups in her file. She has been reinstated with education regarding use of gait belt and told that she would be terminated if there were any other write ups about use of gait belt or abuse/neglect. It was reported to the state found that the nurse aide used poor technique and did not follow policy. But it was not substantiated as abuse. Chart audit for care planning related to resident resisting care and kicking out at staff. Resident receives [MEDICATION NAME]. Roommate said she didn't hear (CNA #1) talk back, but that (Resident #1) was being verbally abusive to the aide. The staff have been trained on appropriate transfer techniques and gait belt use. n. On 11/22/16 at 4:15 p.m., Resident #1's roommate, who was assessed as being moderately impaired in cognitive skills for daily decision making on the MDS with an assessment reference date of 8/15/16, was asked, Did you hear the exchange between (Resident #1) and the aide (CNA #1)? The roommate stated, I didn't hear the exchange, but (Resident #1) told me her leg was hurting real bad because she (CNA #1) was rough with her when they transferred her. You know she is really weak on that one side because she had a stroke. She said she was hurting all over because she was just jerking her around. And she had bruises on her arms. o. On 11/22/16 at 2:23 p.m., the DON was asked for the CNA Hall Assignment sheets from November 4th to 11/22/16 and stated, I know why you are looking at these. You are wanting to see if (CNA #1) worked on (Resident #1's) hall. She has not worked on (Resident #1's) hall since the incident. The DON was asked, Was (CNA #1) suspended during the investigation? The DON stated, She only works 2 days a week, Friday and Saturdays. She was suspended the next week, but then she does not work from Sunday thru Thursday. She was off during that time. She was counseled when she came back to work that Friday, November 11th. She does not work on (Resident #1's) hall anymore. At 3:45 p.m. the DON was asked, When were you first notified of the allegation with (CNA #1) and (Resident #1)? The DON stated, I spoke to (CNA #1) Sunday (11/6/16) on the phone. I was told Sunday. She came up Monday morning. The DON was asked, When did you suspend her and do you have that form showing you suspended her? The DON stated, I did her write-up form. I don't know that we do a formal write-up. The DON was asked, Did you start an investigation on Sunday? The DON stated, The on-call nurse came up here on Sunday, (LPN #3), and started it. We have an outline of what to do, keep resident safe, call family, call police. At that time (CNA #1) was not here she was gone. The DON was asked, When was the next day (CNA #1) worked? The DON stated, The following Friday, which was the 11th. The DON was asked, Did you talk with any of the other residents? The DON stated, (Resident #7), in the same room with (Resident #1), said she had not had any problem. (Administrator) talked with other residents with a BIMS of 10 or greater on that hall and they had no problems. The DON was asked, Did you talk with (Resident #1)? The DON stated, Yes, first thing Monday (11/7/16) morning. The DON was asked, Why didn't (administration) come in and start the investigation. Is that your policy? The DON stated, Yes, something that will probably change. The DON was asked, You unsubstantiated the allegation? The DON stated, I wasn't there. I can't say what did or didn't happen. I spoke with (Resident #1) and (CNA #1). I know since (Resident #1's daughter) was terminated, things are escalated with (Resident #1). (CNA #1) has not had any other complaints, no write-ups, we felt she was trainable to use a gait belt. The DON was asked, Has (Resident #1) had any other complaints of other CNAs and not wanting them back in her room? The DON stated, Not that I recall. The DON was asked, How did (CNA #1) say she transferred her, grabbed her arm or what? The DON stated, I don't remember what she said, I know she did not use a gait belt. The DON was asked, Didn't you think it was strange that (Resident #1) said she grabbed her, hurt her and didn't want her back in her room when she had never said that before? The DON stated, You have to grab a person's legs to turn and set them up in bed. The DON was asked, Did (Resident #1's) roommate hear anything? The DON stated, She did not; she said she was asleep. The DON was asked, Where's your documentation of interviews with other residents, other staff? The DON stated, It is not abnormal for (Resident #1) to complain of pain after transferring, I mean that's not abnormal. At 5:10 p.m., the DON was asked for documentation of any monitoring/enhanced supervision of CNA #1 after she returned to work on 11/11/16. The DON stated, We did not do any monitoring. To be honest, we did not feel that there was any abuse, because we could not prove (CNA #1) did anything willfully. p. On 11/23/16 at 11:30 a.m., the DON was asked, After this incident with (Resident #1) on the morning of the 5th (November), did (CNA #1) work again on the 11 to 7 shift that evening? The DON stated, Yes. The DON was asked, What hall did she work on? The DON stated, The 100 hall. (Resident #1 resided on the 400 hall). The DON was asked, Was the CNA immediately suspended? The CNA stated, No, because we were not aware of what happened; it was not reported until the 6th. If I had known about it, she would not have been here; we would have proceeded with the susp

Complaint # (AR 593) was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure its abuse prohibition policies and procedures were implemented, by failing to ensure an incident of possible physical abuse was immediately and thoroughly investigated after a resident who was heard screaming during care accused a Certified Nurse Assistant (CNA) of physical abuse and was subsequently found with bruising to multiple areas; and failed to ensure protective measures were immediately implemented to prevent further potential abuse for 1 of 1 (Resident #1) case mix residents who was allegedly physically abused by staff. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who sustained bruising and reported complaints of increased pain levels and nightmares after the incident, and had the potential to affect 18 residents who resided on the 400 hall on 11/4/16 and 20 residents who resided on the 400 hall from 11/5/16 through 11/19/16 as documented on the Roster/Sample Matrix received from the Registered Nurse (RN) Consultant on 11/22/16 at 10:20 a.m. The Director of Nursing (DON) was notified of the Immediate Jeopardy on 11/22/16 at 5:20 p.m. The findings are: 1. The facility Abuse Prohibition Policy and Procedure, provided by DON on 11/23/16, documented, Identification: Immediate reporting of suspected violations is the responsibility of and shall be required by all staff. Incidents of alleged violations shall be reviewed by the facility's QA & A (Quality Assurance and Assessment) Committee for detection of patterns or trends. Protection: If the suspected perpetrator is an employee, the Administrator shall place the employee on immediate investigatory suspension while completing the investigation. It should be explained to the employee that if the investigation results do not require suspension or termination, the employee may be allowed to return to work. Any scheduled days missed during the suspension time may be paid if there is no disciplinary action issued. Where the circumstances of the alleged violation warrants, the DON (Director of Nursing) or his/her designee shall initiate a physical and mental assessment of the resident and document the findings. Factual information only shall be documented, not assumptions. The DON shall also notify the attending physician regarding the alleged violation and findings and document the contact. Reporting: Any employee who suspects an alleged violation shall immediately notify the Administrator or his/her designee. The Administrator shall also notify the appropriate state agency, in accordance with state law . Investigation: All investigations shall be conducted by the Administrator or DON. In the event an alleged violation occurs when neither of these people is in the facility, the charge nurse is responsible for initiating the investigation procedure. The investigation shall include interviews of employees, visitors or residents who may have knowledge of the alleged incident. Factual information only should be documented, not assumptions or speculation. Written statements from involved parties should be requested, utilizing the required State Witness Form . Corrective Action: the facility shall make reasonable efforts to determine the cause of the alleged violation and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. 2. Resident #1 had [DIAGNOSES REDACTED]. An Annual Minimum Data Set with an Assessment Reference Date of 9/9/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS); required extensive assistance of one person for bed mobility, transfer, dressing, toilet use, personal hygiene; balance moving from seated to standing position, moving on and off toilet and surface to surface transfer not steady, only able to stabilize with staff assistance; was non-ambulatory, and had functional limitation in range of motion to the upper and lower extremities on one side; exhibited verbal behavioral symptoms directed toward others on 1 to 3 of the past 7 days that did not put the resident at significant risk for illness or injury and did not significantly interfere with care; had no physical behavioral symptoms; did not resist care; and experienced pain on an occasional basis that was rated at 5 on a 1 to 10 scale and did not affect resident's ability to sleep or limit her day-to-day activities. a. Nurses Notes dated 11/5/16 at 7:30 a.m. documented, 0700 (7:00 a.m.) CNA reported to this nurse, resident is hurting. Resident assessed and c/o (complained of) legs hurting when transferred. No open areas or ST (skin tears) to BLE (bilateral lower extremities) at this time. ROM (range of motion) of BLE, WNL (within normal limits) for this resident. Resident medicated with [MEDICATION NAME] 5/325 mg (milligrams) po (by mouth), tol (tolerated) well in applesauce. No other needs noted, will report resident status to oncoming nurse to reassess. C/L (call light) placed in reach. b. Nurse's Notes dated 11/6/16 at 1:51 p.m. documented, 0845 (8:45 a.m.) resident c/o BLE pain and pain all over 10/10 (10 being worst pain). Medicated with [MEDICATION NAME] 5/325 mg one po. c. An Office of Long Term Care (OLTC) Witness Statement Form signed by CNA #1 and dated 11/7/16 documented, On Saturday, November 5, 2016 around 0530 (5:30 a.m.) I was asked out of a patient's room to help another resident (Resident #1). I then went to room (Resident #1's room) to assist her to the restroom. When I proceeded to raise and sit her on the side of the bed she began to have an attitude. I apologized for the wait/delay and began to align the wheelchair with the bed. Her feet were in place with proper non-skid socks on, then I began to assist her to her chair. Once raised, her leg moved/kicked me but I still was able to place her in the chair. She then was mad and proclaimed I was going to drop her and that her leg hurt, that I had hurt it. I then had to get the pt (patient) and assisted her fully to the back of the chair. Once in the chair she was angered. I still proceeded to take her to the restroom where she was placed on the toilet. Once on the toilet she was still angered and told me to get out and to get someone else to help her. I told her I was going to get another person to help. Then as I left the room, I told my nurse what happened and asked her to check to see if anything was hurt. She did not go to her room but I proceeded to find another person to help. I went down 100 hall to ask the CNA and she agreed to do so if I would help finish up her patients. I then after finishing had to ask another nurse to examine (Resident #1) to see if anything was wrong/hurt. I was unable to ask the other CNAs for help due to they had previously been kicked out of her room. After she was on the toilet I do not know what happened due to I was not allowed in there. But I was told that the other CNA that helped her was also told to leave her in her wheelchair until morning was here for them to do it and that I was not allowed back in there. A statement dated 11/6/16 and written by CNA #3 documented, I came to work today 11/6/16. While getting (Resident #1) up for the day she was complaining of pains all over her body. She stated to me that an aid by the name of (CNA #1) had been very rough with her. She stated that she had threw her down on the arm of her wheelchair and was pulling and yanking her very hard. She stated that she (CNA #1) was putting her thumbs into her skin and was told and continued to (press her thumbs into the resident's skin). She also stated that (CNA #1) told the oncoming CNA that (Resident #1) was in one of her moods. (Resident #1) has cried and complained of pain since I came to work. There was no documentation to indicate CNA #3 reported the resident's allegation of abuse to facility administration. CNA #3 was unavailable for interview during the survey. d. Nurse's Notes dated 11/6/16 at 1:53 p.m. documented, At 0820 (8:20 a.m.) (Resident #1) stated that the CNA on 11/7 (11:00 p.m. - 7:00 a.m. shift) on 11/4/16 shift, (CNA #1) was very rough with her. She stated that CNA sat her in her wheelchair very hard and threw her on the arm rest on the wheelchair. She also stated that she heard (CNA #1) stating that '(Resident #1) was in one of her moods.' Resident stated that the CNA was pulling and jerking on her very hard, the CNA's thumbs were pushing very hard on both of her arms. Resident stated that she told the CNA that she was hurting her and the CNA continued to push into her arms. Right forearm has a reddish purple bruise measuring 3x (by) 4 cm (centimeters) on left forearm, 2x2 purple red bruise noted to the right forearm. Two dark discolorations noted to back of left lower leg one measuring 2x2 the other measuring 1x2 cm. Resident states that she is having pain right and left breast pain. Her pain is worse from the waist down. (Blood pressure (BP)) 159/87, (pulse (P)) 98, (respirations (R)) 18, (temperature (Temp)) 97.2 (degrees Fahrenheit (F)). Family notified at 0915 (9:15 a.m.). Daughter here at 0930 (9:30 a.m.). Director of Nursing (DON) and Administrator notified at 8:23 (a.m.). Police notified and here at 1004 (10:04 a.m.), visited with resident for 15 minutes. Officer (officer name and badge number). (Physician) was notified at 10:38 a.m. Resident was sent to ER (emergency room ) via facility van at 1105 (11:05 a.m.). Report called to (name) at (hospital) at 1043 (10:43 a.m.). Returned to facility at 2:15 (p.m.) with no new orders. Report from (hospital) resident has no broken bones. V/S (vital signs) upon return (BP) 154/64, (P) 80, (R) 18, (Temp) 98.1 (F). Staff assist to recliner in room. Call light in easy reach. Will cont (continue) to monitor and assist as needed. e. The Police Department Incident Report dated 11/6/16 at 10:04 a.m. documented, Narrative (officer's name)-11/6/16 (initials); A patient at (facility name), (Resident #1) filed a complaint on the suspect (CNA #1), who is an aide at the facility, for physical and verbal abuse. (Resident #1) stated she called for an aide for help to use the bathroom and during the aide helping her, she was very rough, repeatedly snatching and jerking on (Resident #1) to get her out of the bed; also she sat (Resident #1) on the arm of the wheelchair very aggressively. (Resident #1) suffered several large bruises to her legs and left forearm. (Resident #1) also stated that (CNA #1) was jabbing her in the breasts with her thumbs causing large amounts of pain. (Facility) will be taking (Resident #1) to (hospital) to receive a full evaluation on the injuries she received. (Resident #1) also stated this was not the first time (CNA #1) had treated her in this manner, it was just the worst. f. Clinical Report-Nurses, (Hospital) Emergency Department Notes dated 11/6/16 at 11:01 a.m., documented, TRIAGE; Acuity: LEVEL 4. Chief Complaint: STATED PHYSICAL ABUSE . patient reports 'I used my call light about 5:30 in the morning to get help getting up to go to the bathroom. (CNA #1) came in and grabbed my sore (left) leg and slung it out of bed, she then grabbed my arms and stood me up and slung me into my wheelchair. I told her to not be so rough. I told her I felt like I was falling out of the chair and she grabbed me under my breast and dug her thumb into my right breast. I told her she was hurting me, and told her to go get someone else that could help me without hurting me.' History; Stated assailant: caretaker. Location of injuries: right breast, lower back, right forearm, left forearm, left hip and left leg. This occurred yesterday (about 5:30 AM). Occurred at nursing home. Police department notified (notified by (facility) staff prior to patient's arrival) . ABUSE ASSESSMENT: Abuse history: patient reports physical abuse by caretaker against patient . PHYSICAL ASSESSMENT: 11:05 (a.m.). To room via stretcher. GENERAL/NEURO (neurological)/PSYCH (psychiatric): Alert. Oriented x (times) 4. Affect appears normal. Appears in pain . RESPIRATORY: Respirations not labored. Breath sounds within normal limits. (patient c/o (complains of)) tenderness to right breast, states 'that girl dug her thumb into it') . EXTREMITIES: Limited ROM (range of motion) present in the left shoulder, left upper arm, left elbow, left forearm, left wrist, left hand, left hip, left thigh, left knee, left lower leg, left ankle and left foot (patient has previous left [MEDICAL CONDITION]. Neuro-vascular status intact to the extremity. Right forearm: ecchymosis (1.5cm x 3cm). Left forearm: ecchymosis (1.5 cm x 3 cm). Left hip: tenderness. Left leg: tenderness . BACK: Vertebral point tenderness over the lumbar spine. Soft tissue tenderness in the right lower and left lower lumbar paraspinous region. g. Facility Nurse's Notes dated 11/7/16 at 3:19 a.m. documented, CHANGE IN CONDITION/PAIN: 0230 (2:30 a.m.) Resident complains of generalized pain. Rates as 7/10 (10 being the worst) on pain scale. Bruising noted to R (right) arm just above wrist. Dark purple in color. No new skin issues noted. Resident exhibits s/s (signs/symptoms) of severe anxiety about this nurse (name) (and) CNA leaving her in room alone. Reassured resident that we wouldn't let anything happen to her. Resident continues to repeat she is afraid. Resident asks 'Is (CNA #1) working? I'm scared she is going to come and do something to me.' This nurse spent several minutes reassuring resident. Resident denies any other pain or needs at present. Will continue to observe and assist as needed. Bed low. CLIR (call light in reach). 0300 (3:00 a.m.) Resident vomited x (times) 1 and states, 'it's just my nerves.' NFC (no further complaint) of nausea. No more vomiting reported. h. Nurse's Note dated 11/7/16 at 6:50 a.m. documented, Resident was on her call light, paranoid, crying, she had a bad dream stating that someone was trying to harm her. Social & (and) CNA (CNA #4) assured her that no one was going to harm her in any way. Her daughter is at her bedside. Social will follow up with this resident. i. On 11/22/14 at 1:14 p.m., Licensed Practical Nurse (LPN) #2 was asked, Did you work on the 5th (11/5/16) when the incident with (Resident #1) happened? The LPN stated, No. The LPN was asked, When did you find out about the incident? The LPN stated, She reported it to me Sunday (11/6/16). It actually happened Saturday morning (11/5/16) on graveyard shift when they were getting her up that morning. The LPN was asked, What did she tell you? The LPN stated, She told me that (CNA #1) was very, very rough with her when she got her up Saturday morning. She said when she got her up, she sat her back down real hard and she ended up on the arm of the wheelchair. She said that her thumbs were digging into her arms and that she was hurting her and being rough with her. She said, 'I heard her (CNA #1) tell another staff member that, 'well (Resident #1) is in another one of her moods today' when she walked out of the room. The LPN was asked, Did you examine her at that time? The LPN stated, Yes. The LPN was asked, What did you find? The LPN stated, She had bruises, one on her left forearm and 2 bruises on the back of her left lower leg, I didn't see anything on her butt. The LPN was asked, Did you do a full body assessment? The LPN stated, No, I just looked at her arm, leg, and bottom. I did look at her right breast area. The LPN was asked, Did you see anything on her breast? The LPN stated, No. The LPN was asked, After she told you that, did you report it to anybody? The LPN stated, I texted (Administrator) and (DON) and told them what she had said and they said to call the cops and do a reportable. I called her daughter too. Her daughter didn't have a way up here. (Resident #1) got really upset when she found that the cops were going to be called, so I went and got her daughter and brought her up here. The LPN was asked, Did you fill out an incident report? The LPN stated, Yes, she was sent to the ER too, just to make sure nothing was broken or anything like that. The LPN was asked, Did the Administrator or DON come in? The LPN stated, No. The LPN was asked, Was (CNA #1) in the building when (Resident #1) told you this? The LPN stated, No. The LPN was asked, Was an investigation started? The LPN stated, The cop came and questioned (Resident #1), but as far as other residents being questioned, no. They, the Administrator and DON, may have come in after three (3:00 p.m.) or whenever it was I left, but they didn't while I was here. The LPN was asked, What time was it that (Resident #1) told you about this? The LPN stated, It was while I was doing med pass she told me. I usually make it to her room about 8:15 to 8:30 (a.m.). The LPN was asked, About what time did you tell the Administrator and DON? The LPN stated, As soon as she told me, I sent a group text to both of them. The LPN was asked, Have you seen (CNA #1) working after this incident? The LPN stated, I'm pretty sure I've seen her, but I won't swear to it. j. On 11/22/16 at 1:44 p.m., CNA #2 was asked, Do you remember on 11/22/16 at 1:44 p.m. when (Resident #1) said one of the CNAs was rough with her? The CNA stated, Yes. The CNA was asked, What did (Resident #1) tell you? The CNA stated, When I went to the room, she was saying, 'Oh baby I'm hurting.' I asked her what was wrong and she said that (CNA #1) was rough with her. She said she didn't want her back in her room, and as soon as she told me that, I notified the nurse (LPN #2). The CNA was asked, Did she tell you what happened? The CNA stated, She just said how she picked her up from the bed and her butt hit the chair. The CNA was asked, Did she tell you anything else? The CNA stated, No ma'am. The CNA was asked, Did you see any bruises on her? The CNA stated, I didn't see any new bruises. The CNA was asked, Did you work all day? The CNA stated, Yes. The CNA was asked, (Did you work) the 7 (a.m.) to 3 (p.m.) shift? The CNA stated, Yes, I don't have anything else to say. I'm not saying anything else. k. On 11/22/16 at 1:58 p.m., Licensed Practical Nurse (LPN) #1 was asked, Were you working on 11/5 (16) when (Resident #1) said a CNA was rough with her? The LPN stated, Yes, I was working that night. But, she didn't refer to it as being rough with me. The LPN was asked, What did she say? She stated, She said '(CNA #1) hurt me when she transferred me'. The LPN was asked, Did she tell you what happened? The LPN stated, She didn't; she just said 'she hurt me when she transferred me' and 'I need a pain pill'. The LPN was asked, Did you ask her where she was hurting? The LPN stated, Yes. The LPN was asked, Where did she say? The LPN stated, She said 'my back'. The LPN was asked, Did you look at her back? The LPN stated, I didn't just physically look at her back; I assessed her legs and her arms. (Resident #1) has pain in her back all the time. She takes pain med (medication) for her back. The LPN was asked, What made you look at her arms and legs? The LPN stated, Because ever since I been working with her, she jumps when she is being moved, and they have a tendency to bump her legs. I saw nothing out of the ordinary on her arms or legs. She takes [MEDICATION NAME], so she tends to bruise easily. The LPN was asked, When (Resident #1) said (CNA #1) hurt her, was that the same morning? The LPN stated, It was the same morning during my med pass. The LPN was asked, Did (CNA #1) ask you to take a look at (Resident #1) after she transferred her? The LPN stated, No, I went to her. The LPN was asked, You went to (CNA #1)? She stated, Yes. The LPN was asked, What did you go to (CNA #1) about? She stated, I told her the resident complained about her hurting her during transfer and not to go back into the room because the resident said she didn't want her helping her. I told her to go to another CNA to transfer (Resident #1) once she is finished using the bathroom. The LPN was asked, So (Resident #1) was on the toilet when you saw her? She stated, No, initially she wasn't. The LPN was asked, Where was she? The LPN stated, When I went into the room to medicate (Resident #1) she was sitting in the wheelchair. That's when she complained and told me that girl hurt her. Let me start over. When I came around to Hall 2 (Resident #1) was yelling, so I pushed my cart to the middle of the hall. I went to see what was wrong. She said she needed to use the bathroom. (CNA #1) was busy with another resident and she is still in bed. So I left (Resident #1) and went and found (CNA #1) and told her she needs to work on (Resident #1) first; she hadn't started working on who she was with and she said yes. (Resident #1) was screaming 'I don't want to use the bathroom on myself'. So (CNA #1) did what I asked. I went on and started passing meds. During med pass, I could hear (Resident #1) yelling. That's not untypical of (Resident #1) during movement. You know, you have to know (Resident #1). She plays with me, she plays with CNAs, she teases with CNAs and me; that's what she does, so that's what I thought. I continued my med pass. I went back in there. She was on the commode. She told me she didn't want (CNA #1) back in here, she hurt me when she transferred her. I gave her pain med. She told me then, 'I don't want (CNA #1) helping me'. What she meant was getting off the toilet. Then I came out of the room and found (CNA #1) and let her know about the complaint, 'you hurt her and she don't want you back in the room.' I told her to go get (CNA #5), so they did that; I saw (CNA #5) go into her room. I didn't see her move her, I went on with med pass. I was pushing my cart and she said 'come here (LPN #1)' and she was sitting in the wheelchair in her bedroom and her complaint then was she was left in the wheelchair and 'I need a pain pill'. It was about (CNA #1) not (CNA #5). I asked her 'do you want to go back to bed or to the recliner?' She asked 'what time is it?' It was 5:30-6:00 a.m. She said 'go back to bed' so I transferred her to bed. Because by this time they were working on a 2 person transfer. That's when I assessed her arms and legs. The LPN was asked, Why did you assess her arms and legs? She stated, Because she said she was hurting. Her back hurts all the time. When she said she got hurt, I thought it was her arms or legs, because she jumps, she can jump into bed not meaning to. You have to know how to move (Resident #1). The LPN was asked, Has (CNA #1) worked with her before? She stated, Yeah, she should. The LPN was asked, Did you ask how (CNA #1) hurt her? She stated, No. The LPN was asked, Did you report it to anyone? She stated, I can't say I did. I reported to the on-coming nurse about the pain pill and that she was hurt during transport and I wrote it on the 24-hour report. I was thinking she was just hurting. The LPN stated she did not respond to hearing the resident screaming / yelling during care. The LPN did not report to the facility administration the allegation made by the resident that CNA #1 hurt her, did not want CNA #1 back in her room, and made no attempt to investigate or ask how the resident was hurt by the CNA. l. On 11/22/16 at 3:02 p.m., Resident #1 was asked, Do you remember when a CNA was rough with you? The resident stated, Yes. The resident was asked, Can you tell me what happened? The resident stated, I buzzed my light about 5:30 in the morning, she (CNA #1) came in and I said I needed to go to the bathroom. So she jerked my bad leg around out of the bed. She jerked it around, that's my bad leg, and it doesn't move good, and that really hurt me. She was jerking on my arms and legs. She grabbed my arms and jerked me up. I've had a stroke and if you grab this arm it hurts me. I said, now (CNA #1) if you can't help me would you get some help because I need to use the bathroom. The resident was asked, What did she say? The resident stated, She didn't say nothing. She just jerked me up and sat me in my chair hard, I hit the arm. She was trying to get me up in the chair and she was pulling on my arm and I had a thumb print where she pulled on my arm. I was yelling. She got behind me and reached around me and was digging her thumb into my breast under my right breast, trying to straighten me up in the chair, I was thinking I was going to fall out of the chair. The resident was asked, Have you had trouble with this CNA before? The resident stated, Yes, she has and she's always been a smart aleck to me, and she is still working here, but not down here because I told them not to let her back in here again and my legs hurt me for several days after pulling on them like she did. The resident was asked, Did you tell anyone? The resident stated, The nurse and I told (Administrator) and (DON) the next day. The resident's son, who was in the room for this interview, stated, You got hurt one morning, and they waited till the next day to send her over there (hospital), and that's a long time to wait with her saying they hurt her. The resident stated, This arm (indicating left arm which was observed to be contracted at the elbow and wrist) is very weak and her pulling on it didn't help much either. I had a stroke on that side. She always acted like she has an attitude with me. The resident was asked, Is there anything else you want to tell me? The resident stated, The police came and interviewed me, I told them what happened. They asked me if I was yelling and I told them, yes I was yelling my head off for help because what was I supposed to do wait and let it go until she really hurt me. m. (Corporate) Rapid Response Report (Name ) documented, Date of Call:11/14/16; Facility Name: (Name); Resident Name: (Resident #1) on 11/22/16 at 3:02 p.m.; Category of Call: Resident-Related: Allegation of Abuse/Neglect; Employee-Related: Guidance on Suspension/Termination; *acts of Event: Resident complained of pain following a transfer. Nurse aide transferred resident without a gait belt. Resident was kicking and attempting to strike the nurse aide. *Events Leading Up to Incident: The resident's daughter had previously been a nurse at the facility and was terminated. The resident is angry about this action. The resident displays aggressive behavior to staff with frequent complaints. *Status of the Resident After the Initial Intervention: The resident had slight bruising on her arm and calf. She does receive [MEDICATION NAME] which would increase bruising potential. *Did an Employee Receive Related Training in the Past? The nurse aide had been trained in transfer techniques. *Is Training to be provided? Safe transfer techniques and the use of gait belt will be reviewed. *Immediate Actions Taken: (ex. Employee placed on leave, resident transferred to ER, MD/family notified, etc.): The aide was immediately suspended. Witness statements were obtained from residents with a BIM (score) of 10 or above, witness statements were also obtained from staff, no issues were discovered. The roommate, who is alert and oriented, was interviewed and she stated that the resident was being aggressive and kicking out at the aide. She also stated that during the incident, the aide did not respond angrily or verbally abusive even though the resident was treating her badly. A body audit of all residents in the aide's assignment completed with no issues noted. The family, the physician and OLTC notified. The aide's HR (Human Resources) file was reviewed and no other disciplines or counseling were noted. * Plan of Action: The aide will be re-instated, intensive education will be provided, and the incident will by written up as discipline. Education for transfer techniques and gait belt use was provided to all staff. Staff transfer techniques will be monitored as a quality improvement step. Additional Notes: The CNA (CNA #1) that was involved in the incident with (Resident #1) was not following company protocol and safe practice standards. She was transferring the resident without a gait belt. The resident has physical injuries, bruising on right forearm and back of left calf, r/t (related to) the way she was handled. She did go to the ER and had no injuries. A large factor in the case is (CNA #1's) failure to follow policy. (Resident #1) has been a resident for a while, her daughter was one of the nurses that was terminated (daughter's name). (CNA #1) is an aide that works part time and is attending nursing school. (CNA #1) did not have any write ups in her file. She has been reinstated with education regarding use of gait belt and told that she would be terminated if there were any other write ups about use of gait belt or abuse/neglect. It was reported to the state found that the nurse aide used poor technique and did not follow policy. But it was not substantiated as abuse. Chart audit for care planning related to resident resisting care and kicking out at staff. Resident receives [MEDICATION NAME]. Roommate said she didn't hear (CNA #1) talk back, but that (Resident #1) was being verbally abusive to the aide. The staff have been trained on appropriate transfer techniques and gait belt use. n. On 11/22/16 at 4:15 p.m., Resident #1's roommate, who was assessed as being moderately impaired in cognitive skills for daily decision making on the MDS with an assessment reference date of 8/15/16, was asked, Did you hear the exchange between (Resident #1) and the aide (CNA #1)? The roommate stated, I didn't hear the exchange, but (Resident #1) told me her leg was hurting real bad because she (CNA #1) was rough with her when they transferred her. You know she is really weak on that one side because she had a stroke. She said she was hurting all over because she was just jerking her around. And she had bruises on her arms. o. On 11/22/16 at 2:23 p.m., the DON was asked for the CNA Hall Assignment sheets from November 4th to 11/22/16 and stated, I know why you are looking at these. You are wanting to see if (CNA #1) worked on (Resident #1's) hall. She has not worked on (Resident #1's) hall since the incident. The DON was asked, Was (CNA #1) suspended during the investigation? The DON stated, She only works 2 days a week, Friday and Saturdays. She was suspended the next week, but then she does not work from Sunday thru Thursday. She was off during that time. She was counseled when she came back to work that Friday, November 11th. She does not work on (Resident #1's) hall anymore. At 3:45 p.m. the DON was asked, When were you first notified of the allegation with (CNA #1) and (Resident #1)? The DON stated, I spoke to (CNA #1) Sunday (11/6/16) on the phone. I was told Sunday. She came up Monday morning. The DON was asked, When did you suspend her and do you have that form showing you suspended her? The DON stated, I did her write-up form. I don't know that we do a formal write-up. The DON was asked, Did you start an investigation on Sunday? The DON stated, The on-call nurse came up here on Sunday, (LPN #3), and started it. We have an outline of what to do, keep resident safe, call family, call police. At that time (CNA #1) was not here she was gone. The DON was asked, When was the next day (CNA #1) worked? The DON stated, The following Friday, which was the 11th. The DON was asked, Did you talk with any of the other residents? The DON stated, (Resident #7), in the same room with (Resident #1), said she had not had any problem. (Administrator) talked with other residents with a BIMS of 10 or greater on that hall and they had no problems. The DON was asked, Did you talk with (Resident #1)? The DON stated, Yes, first thing Monday (11/7/16) morning. The DON was asked, Why didn't (administration) come