Every finding on record at Noble Health Care Center

Based on record review and interview, the facility failed to follow physician's orders for monitoring for weight loss by documenting weekly weights for 1 (#7) of 3 sampled residents reviewed for nutrition.The administrator identified 84 residents resided in the facility. Findings: A care plan for Resident #7, dated 07/02/26, showed they were at risk for weight changes and the facility's goal was to improve or maintain the current weight. The care plan showed to weigh the resident per physician orders and as needed.A physician's order for Resident #7, dated 06/05/26 to 06/26/26, showed the resident was ordered weekly weight checks on Wednesdays for four weeks on the 7:00 a.m. to 7 p.m. shift, by the nurse.A review of Resident #7's history of vitals showed only three recorded weights on the following dates: 06/05/26 (215 pounds), 06/10/26 (215 pounds), and 06/24/26 (222 pounds). Resident #7 was missing a recorded weight for the date 06/17/26.On 07/01/26 at 4:18 p.m., the corporate nurse stated ordered weekly weights were done on Wednesdays. They stated some weights had been missed for some residents and they had just been made aware of this and were working on it. The corporate nurse stated there needed to be a process change.

Based on observation, record review, and interview, the facility failed to maintain infection control practice during incontinent care for 1 (#1) of 3 sampled residents observed for incontinent care.The ADON identified 74 residents resided in the facility.Findings:On 11/19/25 at 10:32 a.m., CNA #1 and CNA #2 entered Resident #1's room to perform incontinent care. They both wore gloves.On 11/19/25 at 10:33 a.m., CNA #1 wiped the resident's abdominal folds and peri area. Resident #1 was turned to their right side. Resident #1 had a bowel movement. CNA #1 wiped the resident's fecal matter, removed the dirty brief, and discarded in a trash bag. With the same gloves, CNA #1 put a new pad under the resident. Resident #1 was turned to their left side and CNA #2 removed the soiled pad and adjusted the new pad. CNA #2 put a new brief on the Resident. Resident #2 was then turned to their right side and CNA #1 adjusted the brief. The brief tab tore.On 11/19/25 at 10:37 a.m., CNA #1 removed their gloves and exited the room to get a new brief.On 11/19/25 at 10:38 a.m., CNA #1 came back with a new brief and put on the resident with CNA #2's assistance.A bowel and bladder care plan, initiated 05/07/25, showed the resident was incontinent of bowel and bladder and needed assistance with toileting. The care plan showed the resident had diagnoses which included frontal lobe and executive function deficit following cerebral infarction.On 11/19/25 at 10:43 a.m., CNA #1 stated the process for glove use during incontinent care was put on gloves prior to providing incontinent care and discard them once procedure was complete.On 11/19/25 at 10:44 a.m., CNA #1 stated they did not change their gloves after cleaning the resident's bowel movement. CNA #1 stated they should have changed them.On 11/19/25 at 3:40 p.m., the DON stated gloves should be changed between dirty and clean.

Based on observation, record review, and interview, the facility failed to ensure a resident's call light was in reach for 1 (#1) of 7 sampled residents whose call lights were observed.The ADON identified 74 residents resided in the facility.Findings:On 11/19/25 at 1:21 p.m., Resident #1 was observed in their chair. Their call light was on the floor by the head of the bed.The call light was out of reach of the resident.On 11/19/25 at 1:30 p.m., CNA #1 handed Resident #1 their call light. The resident demonstrated how to use the call light by pressing the button on the end.The CALL LIGHTS ANSWERING policy, revised 02/12/20, read in part, When leaving the room, be sure the call light is placed within the resident's reach.A fall care plan, initiated 04/25/25, showed to keep the call light within the resident's reach. The care plan showed the resident had diagnoses which included frontal lobe and executive function deficit following cerebral infarction.A BIMS, dated 10/30/25, showed the Resident #1 had moderate cognitive impairment with a BIMS of 9.On 11/19/25 at 1:22 p.m., Resident #1 stated they could not see their call light. They instructed the surveyor to give it to them.On 11/19/25 at 1:27 p.m., CNA #1 stated they believe the resident could use their call light. They stated the call light process was to make sure it was within reach of the resident.On 11/19/25 at 1:31 p.m., CNA #1 stated the resident's call light was not in reach.On 11/19/25 at 3:42 p.m., the DON stated call lights should be placed in reach of the residents.

Based on observation, record review, and interview, the facility failed to ensure residents were free from abuse for 4 (#1, #2, #3, and #4) of 4 sampled residents reviewed for abuse. The DON identified 81 residents resided in the facility. Findings: A policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, reviewed 02/12/20, read in part, Residents must not be subjected to abuse. neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident,family members, legal guardians, resident representative, friends or other individuals. 1. Resident #1's Quarterly MDS assessment, dated 06/20/25, showed they had a BIMS score of 13 indicating they were cognitively intact. On 06/24/25 at 9:43 a.m., Resident #1 stated, I just witnessed [Resident #5] hit other people. They took [Resident #5] somewhere else, [Resident #5] does not live here anymore. 2. On 06/23/25 at 1:17 p.m., Resident #2's left ear was observed with dried blood on it. There was an approximately 1 cm scratch on the top of the [NAME] (ear). Resident #2 stated all staff did was put Betadine (antiseptic) on it. Resident #2 takes Eliquis (an anticoagulant) 5 milligrams every 12 hours. Resident #2's Quarterly MDS assessment, dated 06/13/25, showed they had a BIMS score of 12 indicating they were moderately cognitively impaired. On 06/23/25 at 1:17 p.m., Resident #2 stated Resident #5 came up to me twice and started hitting me as hard as [they] could in the head. Resident #2 stated Resident #5 beats on anybody that [they] can get away with it. Resident #2 stated staff told Resident #5 to go to their room. Resident #2 stated, Don't want to kill anybody, but [Resident #5] makes me want to kill [them]. 3. Resident #3's Quarterly MDS assessment, dated 06/07/25, showed they had a BIMS score of 8 indicating they were moderately cognitively impaired. On 06/23/25 at 2:27 p.m., Resident #3 stated, When [Resident #5] was yelling at me, [they] spit in my face. I told the officer that was assault. The officer said eventually I would get a summons in the mail and would have to go to court regarding trying to press charges. Unfortunately I couldn't walk or I would have hit [Resident #5]. Staff split us up. Nothing else happened. [Resident #5] still looks at me like [they] wants some trouble. [Resident #5] goes around behind me when I am sitting down and bumps into my chair on purpose. [Resident #5] is just a bully. If it comes down to it, I will cripple [Resident #5]. 4. Resident #4's Quarterly MDS assessment, dated 05/04/25, showed they had a BIMS score of 12 indicating they were moderately cognitively impaired. On 06/23/25 at 2:22 p.m., Resident #4 stated they were scared to death of [Resident #5] and [Resident #5] needs to be somewhere else. I hate [Resident #5]. 5. On 06/23/25 at 3:34 p.m., during the interview of Resident #5 outside in the smoking area, with their 1:1 staff present, other residents started coming out for their timed cigarette break. Resident #5 started pointing out people saying that piece of [expletive] right there in the red hat. Resident #5 proceeded to call another resident a fat [expletive], fat piece of [expletive], faggot amongst other derogatory terms. Resident #5 then yelled Shut up when residents started telling Resident #5 to stop talking to them like that. Resident #5 stood up, shaking with rage so badly that they spilled coffee on surveyor. Resident #5 then started slamming their walker onto the ground repeatedly while continuing to yell expletive words at staff and other residents. Resident #5 came towards male staff who was attempting to get Resident #5 to calm down. Resident #5 had their hands balled up in fists yelling right into male staff members face. No staff touched Resident #5 at all, they simply stood between Resident #5 and the other residents trying to get Resident #5 to calm down. Seven staff members came outside to try to de-escalate the situation . The staff had to send in the residents that were coming out to smoke. On 06/23/25 at 3:39 p.m., once the other residents had went back inside, Resident #5 started yelling at the only other resident that remained outside, and banging their walker around. The DON and administrator arrived to the scene and at 3:40 p.m., the administrator called the police and asked them to get there as soon as possible. Multiple staff members created a barricade with their bodies around the other resident while one staff walked with Resident #5 to their room. Resident #5 was yelling and cussing the entire way to their room. On 06/23/25 at 3:44 p.m., two police officers arrived to speak with staff and Resident #5. Resident #5's admission MDS assessment, dated 04/23/25, showed they had a BIMS score of 15 indicating they were cognitively intact. An Incident Report, dated 06/09/25, showed Resident #1 accidentally ran into Resident #5's walker, causing Resident #5 to grab Resident #1's arm. Resident #2 then stated come and get some to Resident #5. Resident #5 then proceeded to hit Resident #2 in the head. Staff split the residents up. Medications were changed for Resident #1 and #5, Resident #2 was sent out to ER with no injury found. On 06/16/25, an Abuse policies and procedures staff in-service was completed. An Incident Report, dated 06/19/25, showed Resident #5 closed the blinds in the dining room due to the glare, and Resident #3 yelled at Resident #5 to open the blinds back up. Both residents started yelling at each other and then Resident #5 spit in Resident #3's face. Resident #3 then wanted to press charges. Police were called. Residents were separated. A mental health physician was contacted. A mental health agency scheduled de-escalation in-service with staff. On 06/20/25, a QAPI (Quality Assurance and Performance Improvement) behavior sheet was initiated, and it has continued to be updated with each behavior and the interventions. An Incident Report, dated 06/22/25, showed Resident #5 started yelling and hitting Resident #2 in their left ear. Resident #5 also pushed their walker against Resident #4's wheelchair causing it to roll backwards. Staff split up the residents. Resident #2's ear was treated, Resident #4 had no injury, and Resident #5 was put on 1:1. On 06/23/25 at 3:12 p.m., Resident #5 stated, I am an easygoing person to get along with. I am not going to be a captive audience to these idiots. [Resident #2] threatened me four times and came at me and I hit [Resident #2] upside the head. [Resident #2] could have easily went around. Satan [referring to Resident #1] started coming in to bingo when it was almost over staff put [Resident #1] out and when [Resident #1] came back in, I wanted [Resident #1] to leave. [Resident #1] came over and rammed their wheelchair into me again. Later when I was coming back in from smoking [Resident #2] said something like 'what makes you special.' I followed [Resident #2] and asked what is your problem? They said 'you are.' I started wailing on [Resident #2] again. The sun was shining on me and I went to shut the blinds and [Resident #3] started screaming at me. I went and asked why are you yelling at me? [Resident #3] also screams at staff. [Resident #3] told me they were going to take care of the problem. That is when I spit on [Resident #3] and started screaming to call the police. A police officer did come. I have been on 1:1 before it might have been the other time. Today I am sitting with the person doing the 1:1, and a dietary person said 'what floor are you on' and [the 1:1 staff] said I'm right here, and the dietary person said 'exactly.' I asked the [1:1 staff] if it was directed at me and they said they didn't know what it was about. I said [to the dietary person] 'do you have something to say because I don't want to think you are a sissy' and if I see [dietary staff] looking at me I am going to go after them. On 06/23/25 at 3:29 p.m., Resident #5 stated [the DON] told me I could either go to jail or the hospital, so I packed and got ready to go to jail. The officer told me, I wasn't going to jail. [The DON] said 'I'm not sending you to jail, if is your behavior that is sending you to jail.' I packed again today for wherever they want to send me. They have my finances tied up so when I do leave I wont have my social security. On 06/24/25 at 11:42 a.m., licensed practical nurse #1 stated, [Resident #5] refused care a lot. [Resident #5] had an altercation with a resident and spit on them. We separated them and tried to take [Resident #5] to their room to calm down. Sunday [Resident #5] had an altercation with other residents and when I tried to get [Resident #5] to go to their room, they rammed into a different resident unprovoked. [Resident #5] got in my face and told me 'I was going to my room already.' When I was here, I did not feel [Resident #5] was provoked in any way, but [Resident #5] told me if they felt threatened they would fight. That day we also initiated the 1:1 and [Resident #5] would be mad that someone had to sit with them. On 06/24/25 at 10:30 a.m., the administrator stated they have been in contact with the physician, the psychiatric physician, a mental health agency, the police, and tried multiple interventions. The administrator stated Resident #5 signed against medical advice papers and left with the cops on 06/23/25 at 4:15 p.m., after telling staff it was none of their business where they (Resident #5) went. On 06/24/25 at 12:15 p.m., the DON stated, Law enforcement was called and they said they cant take [Resident #5] to jail unless they are actively abusing someone when the cops arrive, and to press charges, it has to go to the DA [district attorney] first. I don't know what else we can do.

Based on record review and interview, the facility failed to perform weekly skin assessments for one (#4) of three sampled residents reviewed for skin assessment and monitoring. The BOM identified 78 residents who resided in the facility. Findings: A Skin Data Collection: Licensed Nurses policy, revised July 2018, read in parts, Weekly, the Licensed Nurse performs a head to toe check of the resident's skin, pay attention to: the surfaces of the skin that come in contact with the bed and chair, bony prominences, and the surfaces of the skin that come in contact with any orthotic device, tube, brace or positioning device, breast and gluteal folds .The licensed nurse should pay attention to: redness, rashes, discolorations, open areas, blisters, dry/flaking skin, and edema .Any significant abnormal findings are reported to the resident's physician and resident or responsible party .Documentation that the check was performed is denoted on the EMR/medical record. Res #4 had diagnoses which included type II diabetes mellitus, rash, and irritant contact dermatitis due to fecal, urinary or dual incontinence. A care plan, dated 09/28/24, documented the resident was at risk for skin breakdown with an intervention to inspect the skin on the body, head to toe every week and document results. A physician order, dated 10/16/24, documented Triad wound dressing paste topically twice daily to MASD on lower bilateral buttocks until resolved. A quarterly assessment, dated 10/20/24, documented the resident was cognitively intact, required substantial to maximum assistance with toileting and transfer, was always incontinent of bowel, and had moisture associated skin damage which required application of ointments/medications. A skin assessment, dated 10/28/24, documented Res #4 had MASD on the buttocks and peri-area. A skin assessment, dated 11/04/24, documented Res #4 had MASD on the buttocks, right leg, and left leg. There were no weekly skin assessments documented for 11/11/24 and 11/18/24. A nurse's note, dated 11/20/24, documented the resident was transported out of the facility to the hospital. The resident did not return to the facility. On 01/23/25 at 9:30 a.m., the wound care nurse stated Res #4 had MASD to buttocks that was being treated with ointment twice daily. They stated the weekly skin assessments on 11/11/24 and 11/18/24 were not completed. On 01/23/25 at 10:30 a.m., the DON stated skin assessments should be completed weekly on all residents. They stated Res #4's skin assessment for the week of 11/11/24 and 11/18/24 were not completed, but should have been.

Based on observation and interview, the facility failed to ensure housekeeping services maintained a clean environment. The DON reported 74 residents resided in the facility. Findings: On 12/23/24 at 10:45 a.m., Resident #2 reported their restroom was dirty. The resident reported housekeeping did not clean the restrooms. On 12/23/24 at 10:46 a.m., Resident #2's restroom sink was observed to be brown with grime and there were brown rings on the countertop. Black debris was observed randomly on the restroom floor and around the toilet. On 12/23/24 at 12:22 p.m., housekeeper #1 was observed entering Resident #6's room. The housekeeper was not observed to sweep the floor. The housekeeper was observed dragging a mop through the room and chatting with Resident #6. The housekeeper was observed to exit the room and went down the hall to another resident's room. On 12/23/24 at 12:31 p.m., CNA #1 informed housekeeper #1 resident room [ROOM NUMBER] needed to be cleaned. The CNA reported it was badly stained and state surveyors were in the building. On 12/23/24 at 12:34 p.m., Resident #6 reported housekeeping swept and mopped their rooms and restrooms every other day. The resident reported the sink and toilet were only cleaned if housekeeping was asked to do so. The resident reported the housekeeper had just cleaned the room, but had not cleaned the restroom. On 12/23/24 at 12:40 p.m., the administrator reported housekeepers were in the building every day and all resident rooms, including resident restrooms, should be cleaned daily. On 12/23/24 at 12:41 p.m., the administrator was taken to Resident #5's restroom and shown the black ring in the toilet and the stained sink. The administrator reported the residents in that room did not use the restroom and the stains were from hard water. The administrator reported housekeeping would be notified. On 12/23/24 at 12:43 p.m., the administrator was taken to Resident #2's restroom and shown the brown grime in the sink and that it was not stained because it would wipe away. The administrator reported it would be cleaned. On 12/23/24 at 12:51 p.m., the toilet riser in Resident #6's room was observed soiled with a large area of dried stool. The sink was observed mostly covered with brown grime that wiped away with ease with the use of a paper towel. The floor in the resident's restroom was also observed to have black debris randomly on the floor and around the toilet and baseboards. On 12/23/24 at 1:05 p.m., housekeeper #1 reported resident rooms and bathrooms, including the sink and toilets, were to be cleaned every other day. On 12/23/24 at 2:40 p.m., the DON and RN #1 were taken to Resident #6's room to observe the restroom. The DON and RN #1 agreed the restroom had not been cleaned properly.

Based on observation and interview, the facility failed to ensure staff used infection control measures when getting ice for a resident (name unknown). The DON reported 74 residents resided in the facility. Findings: On 12/23/24 at 2:45 p.m., housekeeper #1 was observed carrying a resident's (name unknown) ice cup down the hallway to the ice machine without the lid on it to get the resident some ice. The housekeeper was observed to carry the cup and their thumb was inside the cup. The housekeeper was observed cleaning rooms before taking the cup to get ice for the resident. On 12/23/24 at 2:50 p.m., housekeeper #1 was observed pushing the housekeeping cart down the hall with the resident's (name unknown) ice cup set on top of wet floor signs on top of the cart. On 12/23/24 at 2:51 p.m., the DON was made aware of housekeeper #1's actions and the concerns related to infection control. The DON reported that was not proper infection control practices.

Based on observation and interview, the facility failed to ensure food was palatable and served at appetizing temperatures during meals. The Administrator identified 80 residents received services from the kitchen. Findings: 08/05/24 at 8:08 a.m., Resident #72 stated the food is not good. trays sit out too long in the hallway, and it is cold when we get it. On 08/05/24 at 8:45 a.m., Resident #37 stated it could be better, the taste is not good and we need variety. On 08/05/24 at 9:23 a.m., Resident #7 stated what is served is never what is on the menu. On 08/05/24 at 11:14 a.m., Resident # 41 stated I would rather have decent food, its atrocious. On 08/06/24 at 9:09 a.m., there were 2 uninsulated wire carts on hall 200 with trays waiting to be passed. At 9:13 a.m., a tray is taken into room [ROOM NUMBER]. On 08/06/24 at 9:23 a.m., Resident # 31's tray is observed sitting on the bedside table unopened and not within reach due to a fall mat against the bed. Resident # 31 is lying in bed and did not answer when asked if they were hungry. There were no staff in the room. Resident # 31's roommate stated Resident # 31 is unable to talk and is usually fed in the dining room. On 08/06/24 at 9:46 a.m., Resident # 31 is observed sitting up in wheelchair with tray on bedside table placed in front of them uneaten. There were no staff during this observation. On 08/06/24 at 9:50 a.m., Resident # 31 was observed with oatmeal for breakfast, a large cup of water, Resident # 31 was able to drink with assistance, but had no interest in meal, a CNA was in the room to assist and prompt resident to eat. On 08/06/24 food was temped before being placed on steam table and while on steam table for proper temperatures. The dining room trays were plated first with the first tray going out at 12:03 p.m. On 08/06/24 at 1:20 p.m., the last tray was taken as a test tray. The food was lukewarm. The sweet potato was 118 degrees, the zucchini was 126.7 degrees and very bland with no flavor, and the pork was 116 degrees with a large amount of fat and gristle. The orange juice, apple juice, and cranberry juice were diluted. On 08/06/24 at 1:35 p.m., dietary aide #1 stated usually one of the cooks taste the food, but was unaware if that was done today. Dietary aide #1 is who plated the food for the test tray, when they observed the pork on the test tray they stated that's just pure gristle, I hope one of our residents didn't get a piece like that. On 08/06/24 at 1:58 p.m., the LD stated the meat should have been trimmed before serving because gristle and fat shouldn't be served. They stated the juice machine doesn't mix properly and that the juice was diluted. They stated it was supposed to be calibrated and they did call the company today. They stated in the future the juice would be taste tested before being served. They stated the policy is for food to be served at a palatable temperature.

Based on observation, record review, and interview, the facility failed to assess, monitor, and intervene for: A. a resident who tested positive for COVID-19 for one (Res #6) of one sampled resident reviewed for COVID-19, and B. a resident with a PICC line for one (Res #31) of one sampled resident reviewed for IV therapy. The administrator identified 82 residents resided in the facility. Findings: A facility Vascular Access Devices and Infusion Therapy Procedures, dated 2011, documented a PICC line as a peripheral intravenous line that ends just above the atria of the heart. The external length of the PICC line should be measured with every dressing change. The procedure documented the extension kit should be changed every seven days. 1. Res #6 had diagnoses which included weakness and difficulty swallowing after a stroke. A quarterly MDS, dated [DATE], documented Res #6 was cognitively intact. A progress note, dated 08/02/24 at 1:30 a.m., documented Res #6 had complained of difficulty breathing and was assessed to have a fever and diminished lung sounds. The note documented the resident was sent to the hospital for evaluation at 10:00 p.m. the prior evening. A progress note, dated 08/02/24 at 1:36 a.m., documented Res #6 returned to the facility around 12:30 a.m. with a diagnosis of COVID-19. There are no progress notes documented on 08/03/24 through 08/05/24. A record review documented no order to monitor the resident's respiratory status. On 08/05/24 at 09:39 a.m., Res #6 was observed receiving their breakfast tray. A sign on the door documented the resident was on isolation due to COVID-19. A physician order, dated 08/08/24 at 12:50 p.m., documented to monitor the resident's respiratory status every 8 hours and report worsening symptoms to the physician. The order documented to monitor temperature, blood pressure, pulse, respirations, and oxygen saturation. On 08/08/24 at 1:34 p.m., the DON stated Res #6 was not being monitored for respiratory status secondary to COVID-19 prior to 08/08/24. 2. A discharge MDS, dated [DATE], documented Res #31 was severely cognitively impaired. Res #31 readmitted to the facility on [DATE] with diagnoses which included sepsis. A physician order, dated 07/11/24, documented to administer daptomycin (an antibiotic) intravenously one time per day for UTI. A progress note, dated 07/17/24, documented the resident was receiving antibiotics through a PICC line in the right arm. The note documented there was a clear dressing in place. A progress note, dated 07/18/24, documented the resident was receiving antibiotics through a PICC line in the right arm. The note documented there was a clear dressing in place. A care plan, reviewed 07/18/24, did not document the resident had a PICC line or interventions for the monitoring and management of a PICC line. A progress note, dated 07/20/24, documented the resident was receiving antibiotics through a PICC line. A progress note, dated 07/22/24, documented the resident's PICC dressing was saturated due to their shower and was changed. Skilled nurses notes from readmission to 07/23/24 were reviewed and did not document dressing changes, monitoring, or removal of the PICC line. Record review documented no order for the monitoring or management of the PICC line. There was no order to discontinue the PICC line or change the dressing. There was no further documentation regarding the PICC line in the progress notes. On 08/06/24 at 12:15 p.m., Res #31 was observed seated in their wheelchair in the dining room. When asked if the resident had an IV in their arm they shrugged and shook their head. They were wearing a long sleeve shirt and the upper arm could not be visualized. On 08/07/24 at 9:46 a.m., the DON stated the PICC was discontinued, but there was no documentation when the PICC line was discontinued or by whom. On 08/07/24 at 1:18 p.m., LPN #2 stated PICC care involved ensuring the dressing was clean, dry, and intact with no drainage. They stated the line must be checked for patency and the hubs covered with a green cap (antibacterial cap) when not in use. They stated the PICC should be flushed as ordered and the site should be assessed at least once per shift. On 08/07/24 at 1:21 p.m., the DON stated there should have been an order to monitor the resident's PICC site. They stated there should have been an order to change the dressing every 7 days.

Based on observation, record review, and interview, the facility failed to ensure food items were labeled, dated, and stored according to the facility policy. The administrator identified 80 residents received services from the kitchen. Findings: The facility's Food Storage policy, revised February 6, 2024, read in part, air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item and date opened. On 08/05/24 at 7:20 a.m., a container that read sugar was observed with the lid completely open. A large bag of flour was in the original bag, but was ripped open with more than half already absent from the container. On 08/05/24 at 7:24 a.m., the DM stated they believed that one of the unmarked containers in the refrigerator was jello, and the other contained cream corn. They stated there was no label or date. On 08/05/24 at 7:26 a.m., the DM stated they had premade ice cream snacks in cups in the freezer, but agreed they had no label or date. On 08/05/24 at 7:29 a.m., the DM stated they had no idea why the sugar was open and they stated I don't have an answer, we need a container in reference to the ripped open partially used flour in the original container. On 08/06/24 at 10:06 a.m., the LD stated everything needs to be dated, labeled, and securely closed.

Based on record review and interview, the facility failed to maintain an antibiotic stewardship program and infection surveillance to monitor antibiotic use for residents from April 2024 through June 2024. The MDS coordinator identified 6 residents who were prescribed antibiotics. Findings: The facility's Antibiotic Stewardship Program policy, dated January 2022, read in part, . stewardship actions .prescription record keeping, dose, duration, route, and indication of every prescription MUST be documented in the medical record of every resident, regardless of prior prescriptions or documentation elsewhere .records will be reviewed monthly to assess compliance with this requirement as well as prescription appropriateness .site and type of infection .utilize the McGreer's Criteria .data will be compiled monthly .interpret monthly data .compile monthly information for the Quality Committee . During antibiotic stewardship and infection surveillance review, there was missing documentation of the McGreers criteria, symptoms, organism from culture from April to June 2024. On 08/08/24 at 12:14 p.m., the DON stated there was no documented antibiotic stewardship/infection surveillance from April to June 2024.

Based on observations, record review, and interviews the facility failed to follow their enhanced barrier precautions while providing wound care for one (# 3) of 20 residents that required enhanced barrier precautions and failed to follow infection control practices during medication pass. The Administrator identified 81 residents resided in the facility. Findings: An Enhanced Barrier Precautions policy, dated April 1, 2024, read in part, this facility uses enhanced barrier precautions as a strategy to decrease transmission of CDC-targeted and epidemiologically important MDROs when contact precautions do not apply. Indications: Wounds and high contact resident care activities that include wound care. 1. Resident # 3 was readmitted on [DATE] and had diagnoses which included stage 4 pressure ulcer to right buttocks, congenital scoliosis, and contractures of right upper arm and bilateral lower legs. A physician order, dated 04/10/24, documented to conduct hand hygiene before entering and after leaving room, all healthcare personnel must wear gown and gloves for the following high-contact resident care activities: dressing, bathing, transfers, changing linens, providing hygiene, changing briefs/toileting, indwelling device care or use, and wound care on chronic wounds. On 08/07/24 at 2:30 p.m., no signage was posted for EBP precautions, no PPE was observed near resident's door. On 08/07/24 at 2:31 p.m., LPN #1 prepared supplies and walked into resident # 3's room to do wound care. LPN #1 donned gloves and positioned resident for wound care. LPN #1 removed old dressings and discarded used gloves. LPN #1 then donned clean gloves to clean wounds to right shoulder and right ischium. LPN #1 donned new gloves before applying santyl with a q-tip to both wounds, finished wound care, applied dressings, and repositioned resident #3. LPN #1 was not wearing a gown and did not wash or sanitize their hands at any point during the observation of wound care being provided. On 08/07/24 at 2:43 p.m., LPN #1 stated they wished they would have put on a gown and used sanitizer when changing gloves. On 08/07/24 at 2:50 p.m. the DON stated LPN #1 is the wound care nurse, and they must have been nervous being watched by a state surveyor. 46387 2. On 08/07/24 at 8:25 a.m., medication pass was observed performed by CMA #2. Upon arrival to the medication cart an open purple can of energy drink and an open package of wafer cookies on top of the medication cart on the towel placed under the resident water container was observed. On 08/07/24 at 8:34 a.m., CMA #2 entered a resident's room and obtained a blood pressure from the resident. They did not perform hand hygiene before returning to the medication cart and preparing the resident's medications. On 08/07/24 at 8:38 a.m., the CMA was observed touching three pills with their bare hands to place them into the medication cup. On 08/07/24 at 8:44 a.m., the CMA left a residents room after administering medications and did not perform hand hygiene before returning to the medication cart and preparing the next resident's medications. On 08/07/24 at 8:45 a.m., the CMA was observed touching one pill with their bare fingers to place it into the medication cup. On 08/07/24 at 8:51 a.m., the CMA was observed touching one pill with their bare fingers. On 08/07/24 at 8:55 a.m., CMA #2 stated hand hygiene should be performed before and after each resident. They stated medications should not be touched with bare hands. They further stated personal food and drink are not to be on the medication cart. They were observed removing the can and package of cookies and placing them into the bottom drawer of the medication cart. On 08/07/24 at 9:05 a.m., the ADON stated medication should not be touched with bare hands. They stated hand hygiene should be performed before and after each patient interaction and before touching the medications. They stated an open can and food should not be on the medication cart.

Based on record review and interview, the facility failed to ensure psychotropic medications were monitored for target behaviors and side effects for one (#28) of five sampled residents reviewed for unnecessary medications. The DON identified 50 residents received psychotropic medications. Findings: Res #28 had diagnoses which included anxiety disorder. A physician order, dated 06/19/24, documented to administer mirtazapine 7.5 mg at bedtime for anxiety disorder. A physician order, dated 04/24/22, documented to administer buspirone 5 mg twice per day for anxiety disorder. A physician order, dated 02/28/24, documented to administer fluoxetine 40 mg in the morning for anxiety disorder. Behavior and side effect monitoring for 06/01/24 through 06/30/24 documented missing documentation for 25 of 60 opportunities. Behavior and side effect monitoring for 07/01/24 to 07/31/24 documented missing documentation for 25 of 62 opportunities. Behavior and side effect monitoring for 08/01/24 to 08/07/24 documented missed documentation for 11 of 14 opportunities. On 08/08/24 at 11:18 a.m., the DON stated the facility did not do consistent monitoring of psychotropic medications for Res #28.

Based on observation, record review, and interview, the facility failed to supervise a resident while administering a breathing treatment for one (#49) of one sampled residents reviewed for respiratory treatments. The administrator identified 82 residents resided in the facility. Findings: Res #49 had diagnoses which included COPD. A physician order, dated 05/21/24, documented to administer budesonide 0.5 mg/2 mL suspension for nebulization twice per day for pneumonia. On 08/05/24 at 11:00 a.m., Res #49 was observed seated on the end of their bed holding a breathing treatment mask to their face. A nurse was not observed in the room or in the hall. The resident was observed turning off the treatment and setting the mask aside. On 08/05/24 at 11:06 a.m., Res #49 stated the nurse set up his breathing treatment and left. They stated the nurses never stay to monitor them during the treatment. On 08/05/24 at 11:08 a.m., LPN #2 stated the resident should be monitored during the breathing treatment unless they have been assessed to self administer medications. Res #49 did not have an assessment to self administer medications. On 08/08/24 at 11:13 a.m., the DON stated the nurse should stay with the resident during administration of a breathing treatment to monitor the resident.

Based on observation, record review, and interview, the facility failed to obtain a physician order for the placement of a foley catheter for one (#31) of three sampled residents reviewed for catheters. The administrator identified 82 residents resided in the facility. Findings: Res #31 readmitted to the facility on [DATE] with diagnoses which included sepsis. A progress note, dated 07/12/2024 at 6:24 p.m., documented a foley catheter was inserted per provider order. A review of physician orders from 07/11/24 to 08/06/24 did not document an order for placement of a foley catheter. On 08/06/24 at 12:15 p.m., Res #31 was observed seated in their wheelchair in the dining room. A foley catheter drainage bag was observed hanging from the wheelchair. On 08/07/24 at 9:46 a.m., the DON stated the nurse did not enter an order to place the foley before it was placed.

Based on record review, and interview, the facility failed to complete neurological checks per protocol after an unwitnessed fall for one (#71) of seven sampled residents reviewed for accidents. The administrator identified 82 residents resided in the facility. Findings: An INCIDENT/ACCIDENT REPORTING policy, reviewed 01/12/22, documented a neurological assessment flow sheet will be immediately initiated and maintained for each incident/accident involving an injury of any kind to the head or any unwitnessed fall. It documented monitoring is triggered to be completed for 72 hours. Res #71 admitted to the facility on [DATE] with diagnoses which included history of right femur fracture and spinal disc disorder. An incident report, dated 07/04/24, documented the resident had an unwitnessed fall resulting in a small bruise to the residents top right side of the head. The incident report documented neuro checks were started. A neuro check log for Res #71 dated 07/04/24 through 07/06/24, documented neuro checks were not completed 16 of 18 opportunities. On 08/08/24 at 11:13 a.m., the DON stated neuro checks were not completed per protocol for the 07/04/24 fall.

Based on record review and interview, the facility failed to ensure resident assessments were accurately coded on two of the MDS assessments completed for one (#7) of 19 sampled residents reviewed for accurate assessments. The Administrator identified 81 residents resided in the facility. Findings: Resident #7 had diagnoses which included traumatic brain injury, nephrolithiasis, and left upper extremity paralysis. A Resident Summary, dated 01/19/24, 01/20/24/01/21/24, and 01/22/24, all document resident #7 had an indwelling catheter. A Physician's order, dated 01/24/24, documented to change foley catheter as needed for clogged/dislodged/or clinically indicated. The quarterly MDS, dated [DATE], documented Resident #7 had no bowel or bladder appliances. The quarterly MDS, dated [DATE], documented Resident #7 had no bowel or bladder appliances. On 08/07/24 at 11:46 a.m. the MDS Coordinator stated the 01/23/24 and 04/24/24 quarterly MDS were both coded inaccurately because Resident #7 did have an indwelling catheter at the time of both assessments.

Based on record review and interview, the facility failed to ensure residents were offered the choice to formulate an advanced directive for two (#7 and #40) of 24 sampled residents whose advance directive acknowledgements were reviewed. The administrator identified 81 residents resided in the facility. Findings: An Advanced Directives policy, reviewed April 22, 2024, read in part, Upon admission, identify if the resident has an advance directive and if not, determine if the resident wishes to formulate an advance directive. 1. Resident #7 was readmitted on [DATE] with diagnoses which included traumatic brain injury. 2. Resident #40 was admitted on [DATE] with diagnoses which included hemiplegia of left side and acute kidney failure. On 08/05/24 at 11:57 a.m., the DON stated that they are to ask each resident at admission, and they did not see that an advance directive was uploaded for either resident. On 08/07/24 at 1:20 p.m., the DON stated they were unable to locate the advance directives for Resident #7 or #40, and that it may have been in Resident #7's old chart. They stated they have both been completed as of 08/06/24 and are uploaded into their charts.

Based on observation and interview, the facility failed to promote resident dignity by staff standing over residents while assisting them to eat. The administrator identified 81 residents resided in the building and 17 required assistance with eating. Findings: On 08/06/24 at 8:37 a.m., CMA #1 was observed standing while assisting two residents to eat at the dining table. CNA #1 was at the next table standing while assisting a resident to eat. There were eight empty dining chairs within a few feet of both staff that were standing. There was also another staff that was seated while feeding residents. On 08/06/24 at 9:26 a.m., CMA #1 stated they did not know about standing or sitting because they usually worked the night shift. On 08/06/24 at 9:29 a.m., CMA #1 stated they are supposed to sit down with the resident, but they were just trying to help the resident get the food on the spoon, so it wouldn't get scooped off the plate. They stated they did not mean any disrespect towards the resident. On 08/06/24 at 10:03 a.m., the DON stated the policy is to sit down eye level to feed residents and that staff were aware of the policy.

Based on observation and interview, the facility failed to ensure: a. the kitchen was kept clean and maintained in good repair, b. food products were properly thawed, c. soiled/damp cloths were properly stored, and d. staff changed their gloves and/or washed their hands after touching parts of their body before handling food. The DM identified 71 residents received services from the kitchen. Findings: On 07/05/23 at 8:46 a.m., a tour of the kitchen was conducted and breakfast meal service was observed. The following observations were made: a. there was an accumulation of lint on the return vents, b. there was food splatter on the ceiling in the cook area, c. there were five soiled/damp cloths laying in and/or on the two compartment sink, d. there was a metal container of multiple packages of pre-cooked sliced turkey stored in standing water in the two compartment sink. The water was not running in the sink. The temperature of the standing water in the metal container was 73 degrees F, e. base board tiles were missing near the hot water heater closet and in the dish wash area, f. there was an accumulation of grease, black residue, and food on the floor and the walls under and behind the equipment in the cook area, g. there was an accumulation of grease and food on the fryer, h. there was black duct tape on the bottom and sides of a plastic shaker of salt on the shelf above the food preparation table in the cook area, i. there was an accumulation of black residue on the feet/legs of food preparations tables, j. there was a spray bottle of detergent disinfectant stored on the shelf above the food preparation table in the cook area, k. there was water leaking from the hot water knob on the three compartment sink, l. there was brown residue and material was peeling off of the dish storage racks in the dish wash area, m. there was an accumulation of black and white residue on the floor, walls, three compartment sink, and dish machine in the dish wash area, n. there was brown residue and material was peeling off of the food storage racks in the walk-in cooler, o. a metal piece on the outside wall area of the walk-in cold hold units was not secure to the wall. The piece was protruding outward and not flush with the wall, p. lights in the dry food storage area were not properly shielded. On 07/05/23 at 9:00 a.m., CNA #1 was observed assisting with meal service in the kitchen. They were observed scratching their left ear with their left gloved hand. They were then observed separating biscuits in a metal pan on the steam table. They were not observed changing their gloves or washing their hands. On 07/05/23 at 9:11 a.m., dietary cook #1 was observed removing the metal container of pre-cooked sliced turkey from the two compartment sink and sat the container on the food preparation table in the cook area. Once one of the packages of turkey was opened an internal temperature of the turkey was obtained. The temperature of the turkey was 73 degrees F. Dietary cook #1 stated they had the turkey in the sink for about one hour. They stated the container of turkey had been under running water and had been placed in the sink frozen. They stated someone must have turned the hot water on in the sink. On 07/06/23 at 9:04 a.m., the RD and DM was asked how staff ensured equipment, food dispensing items, and the physical environment was kept clean and maintained in good repair. They stated staff cleaned daily and had a cleaning schedule. They stated there was a maintenance book at the nurses station to report repairs. They stated they would call the repair company when needed, but still let maintenance know. The RD and DM were asked what was the procedure for thawing foods. They stated food should be thawed under cold running water, the refrigerator, or defrosted in the microwave. They were asked how cleaning cloths were to be stored when not in use. They stated they threw the disposable ones away and the others in sanitizer. The RD and DM were asked what was the protocol for glove usage and hand washing. They stated hands were to be washed between tasks and gloves should be treated as if they were their hands. They were were asked what was the protocol for storage of toxic products. They stated toxic items should be stored in the chemical storage room. The above observations were discussed with the RD and DM.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 10/01/20 related to the facility's failure to ensure four residents were free from abuse. The facility failed to prevent a staff member from sexually, verbally, and mentally abusing residents. Resident #1 was sexually abused related to two nurse aides reporting hearing resident #1 scream out while certified nurse aide (CNA) #1 was in her room. Two nurse aides reported they went immediately to the resident's room and observed the resident lying on the bed with her brief off and CNA #1 by her bedside. Two nurse aides reported at that time they asked CNA #1 if everything was ok. The NAs reported CNA #1 told them he had performed a ''C clamp'' on the resident to help stimulate her to have a bowel movement. When they asked him what a ''C clamp was, he stated, It was when you put two fingers in the vagina and one finger in the butt and squeeze. Resident #2 was verbally and mentally abused by CNA #1 as reported by the resident #2, one CNA, and 2 nurse aides. Resident #3 was verbally abused by CNA #1 as reported by resident #2, two nurse aides and one agency CNA. Resident #4 was verbally and mentally abused as reported by resident #4, one nurse aide, and one CNA. On 11/20/20 at 1:55 PM, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to protect and prevent abuse; report abuse immediately; and thoroughly and timely investigate allegations of abuse. The past noncompliance IJ was removed, effective 11/13/20 at 3:00 PM, after the facility put measures in place to prevent recurrence. CNA #1, who was the alleged perpetrator, was suspended immediately, on 11/01/20, upon the nurse aide's reporting to a licensed practical nurse then the administrator. CNA #1 had not worked in the building since the time of suspension. The facility notified Oklahoma State Department of Health, nurse aide registry, physicians, families, Adult Protective Services, and Local Law Enforcement of the allegations against the CNA #1. A 'Quality Assurance Plan of Correction (QAPI) Plan of Correction', dated 11/02/20, documented the following: Individual inservices would be completed with staff 11/02/20 through 11/07/20 on abuse prevention policy and the responsibility of reporting abuse. A handout on abuse and documentation to be given to every employee and signature obtained on their understanding. Explained to each nurse regarding the completion of an incident report with reporting requirements within two hours. Director of nursing and nurse managers were to do daily monitoring of nurse notes, grievance reports, incident reports, wound reports, and hospital records upon returns daily in clinical meeting to ensure all reporting was completed as required. The facility conducted 'Safe Survey' interviews with residents on all halls related to respect and abuse. 'Ambassador Rounds' related to quality of care and staff treatment related to respect and dignity were assigned to staff to perform weekly. Results of theses rounds were to be given to the administrator. Code of Conduct service with all staff and signed for personnel file. A log to be maintained to ensure timeliness for reporting. QAPI committee will review audits and incident reports monthly and make any additional recommendations as needed. The facility conducted a mandatory in-service, which included all staff, on 11/13/20. The inservice was over the facility's abuse policy, investigation guidelines, and reporting suspected or witnessed abuse in a timely manner to their charge nurse or supervisor. Each staff member completed a post test over abuse prevention and reporting. Each staff member signed an acknowledgement of the abuse policy and reporting requirements which documented an employee may be criminally liable for failure to report abuse. Based on observation, interview, and record review, it was determined the facility failed to conduct and document a thorough investigation of allegations of abuse for four (#1, 2, 3, and #4) of four residents sampled for abuse. NA #3 reported an allegation of verbal abuse against resident #4. Resident #4 was not interviewed until five days later, at which time she alleged sexual abuse. Allegations of abuse were reported to LPN #1. The interview of LPN #1 was not documented by the administrator. LPN #2 was the nurse who was in charge of the perpetrator and the nurse aides who reported the alleged abuse. LPN #2 was not interviewed. An agency nurse who had also witnessed abuse was not interviewed. Allegations of verbal abuse were reported concerning resident #3. Resident #3 was not interviewed. The most recent assessment documented resident #3 was cognitively intact. The administrator (adm) identified 87 residents who resided at the facility. Findings: The facility's abuse policy, dated 06/23/17, documented.Each resident has the right to be free from abuse, neglect, exploitation, .Residents must not be subject to abuse, neglect, .by anyone .The facility must prohibit and prevent abuse, neglect, and exploitation of residents .All facility staff members have a duty to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the administrator of the facility, who serves as the abuse coordinator .Upon receiving an allegation of abuse .the abuse coordinator will notify the regional director and initiate an investigation into the allegation .if the allegation is reportable, report such allegation to the State Regulatory Agency, Adult Protective Services, and in certain cases, local law enforcement, within the following timeframes: a. not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or .The results of all investigations will be reported to the Abuse Coordinator or designated representative and other officials in accordance with state law (including the State Department of Health Regulatory Agency within five (5) working days of the incident .The Abuse Coordinator or designated representative will immediately begin an investigation and follow the State Guidelines for reporting incidents and accidents. Such investigation guidelines include: a. Resident(s) and responsible party interviews, as applicable; b. Physical examination of the resident, if applicable; c. Staff interviews and written statements, as applicable; .'' 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/21/20, documented the resident was severely cognitively impaired and required extensive assistance of one person with most activities of daily living. An initial 283 incident report, dated 11/01/20, documented it was reported by nurse aide (NA) #2 that she had worked with CNA #1 approximately 10/01/20. The report documented NA #2 heard the resident scream, then she, NA #3, and CNA #4 went into the room to check on the resident. The report documented the resident was lying on the bed and CNA #1 told them he had just performed a ''C clamp'' on the resident to help stimulate her to have a bowel movement. The report documented they did not know if this was acceptable and later started feel uncomfortable about it and told her charge nurse. The report documented the charge nurse notified the administrator and CNA #1 was suspended immediately with an investigation to follow. CNA #1's time records were reviewed. The records documented 10/30/20 as the last day the CNA worked. A facility investigation interview with NA #2, dated 11/02/20 at 9:00 AM, documented the following: NA#2 usually worked doubles on the weekend but started helping out during the week on Hall 200. One of the employees NA #2 started working with was CNA #1. NA #2 said at first she thought he was great but then things started happening which she didn't think were quite right. NA #2 stated she she was on the hall around 10/02/20 with CNA #1, NA #3, and CNA #4. NA #2 stated she, NA #3 and CNA #4 heard the resident scream out. They ran in the room and CNA #1 was standing by the resident's bed holding the resident's brief in his hand. When NA #1 asked if everything was ok, CNA #1 said, Yeah, sometimes you gotta give her a C clamp to help her go poop. NA #2 asked CNA #1 what a C clamp was and he said it was when you put two fingers in the vagina and one finger in her butt and squeeze. NA #2 said she did not think that sounded right but did not think she knew enough as a new nurse aide. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the following: NA #3 stated she was standing in the hall on or about 10/02/20 and she heard resident #1 scream. NA#3 said she went into the room to find out what was wrong. Resident #1 was in bed and CNA #1 was standing by her with her brief in his hand. CNA #1 said everything was ok and that he had to do a C clamp to assist resident #1 in having a BM. NA #2 asked him what a C clamp was and he stated it's when you put two fingers in the vaginal and one finger in the butt and squeeze. A signed hand-written statement by CNA #1, dated 11/02/20, documented, (Name deleted resident #1) has severe costipation (sic). Nurse has been notified of it. Sometimes its so large you have to push around her anus to release the bowel movement. Never have I ever put anything inside any of my residents .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A facility Safe Survey interview, dated 11/02/20 with resident #1 documented, the resident said she felt comfortable about talking to staff about any concerns or complaints. The interview documented the resident said the staff treat her with respect. The interview documented the resident felt comfortable and safe at the facility. A facility investigation interview with CNA #4, dated 11/03/20 at 11:00 AM, documented the following: CNA #4 stated she did not know anything about the incident with resident #1. CNA #1 said she had heard him make inappropriate comments to residents like telling them they had a nice butt and then he would pat them on it. A final 283 incident report, with a facsimile date of 11/12/20, documented the following: On 11/01/20 the director of nursing (DON) was informed by NA #2 that while working with CNA #1 on or about 10/01/20, she heard resident #1 cry out. NA #2 reported that she, NA #3, and CNA #4 went into resident's #1 room to check on her. According to NA #1, the resident was lying in bed and CNA #1 was in the room. CNA #1 told them he had just performed a C clamp procedure on the resident to help stimulate her to have a bowel movement. At the time they did not know whether the practice described by CNA #1 was acceptable nursing practice or not, but after considering the event further, decided to inform their charge nurse about the incident. The charge nurse notified the facility administrator, who initiated this investigation. CNA #1 was suspended immediately. CNA #1's schedule was reviewed and it was determined he had only worked with residents on Hall 200. An investigation was initiated which included assessing the resident, and interviewing the residents and staff involved. And conducted safe surveys on Hall 200 where CNA #1 worked and all residents on other halls were also included. Resident #1 was interviewed and she stated that everyone was very nice to her and she did not recall anyone mistreating her. She also did not recall any problems with having bowel movements. When examined by her physician, there was no harm noted. When CNA #1 was interviewed he denied knowing what a ''C clamp'' was or saying anything in that regard to NA #2, NA #3, or CNA #4. He did say that he sometimes ''pressed on the resident's bottom to assist her with having a bowel movement. He did not explicitly admit to any wrongdoing. The police station was notified and the matter was assigned a case umber. All staff have been inserviced on the facility's abuse policy and reporting protocols with returned competencies completed. The facility has updated the resident's care plan to include at least one female care giver at all times. The resident's family and physician were notified of the outcome of the investigation and the ongoing police investigation. A QAPI plan was completed for abuse reporting. Social Services will do well-being checks weekly times four and counseling referrals as indicated. On 11/19/20 at 11:38 am, the resident was observed sitting up in her bed. The resident was asked if she had been verbally abused, physically hurt, or touched inappropriately by any staff members. The resident was pleasant and said no one had abused her and everyone was nice to her. The resident was asked if she had any problems with certified nurse aide (CNA) #1. She shook her head no. She was asked if she had any children and how many. The resident said she had children but did not know how many. On 11/19/20 at 12:47 PM, NA #2 was interviewed related to abuse and the alleged incident on 10/01/20 involving the resident. She stated she worked on weekends and only worked a few days with CNA #1 in October. She stated she, CNA #4, and NA #3 heard the resident scream from the other end of the hallway. She said she saw him crouched down near the resident who was lying on her bed. She stated CNA #1 had wipes in one hand and a brief in the other. She stated she asked CNA #1 if everything was ok. She stated CNA #1 said he had to do a C clamp on the resident to help her poop. She stated she asked CNA #1 what that was and he said it when you put two fingers in the vagina and one in the butt and squeeze. She stated since she was a new nurse aide, she thought it must be something she did not know about yet. She said she did not report it at that time. She said she reported it to licensed practical nurse (LPN) #1 on 11/01/20. On 11/19/20 at 2:25 PM, CNA #4 was interviewed and she denied knowing anything about CNA #1 saying he had performed a C clamp on the resident. She stated CNA #1 would make rude comments to the residents. On 11/19/20 at 3:12 PM, NA #3 was interviewed related to abuse and the alleged incident on 10/01/20 involving the resident. She stated she, NA #2, and CNA #4 were out in the hall when they heard the resident yelling. The CNA stated when the three of them entered the resident's room, CNA #1 was bent over her and it looked like he was changing her brief. CNA #1 said he performed a C clamp on the resident. NA #3 stated she was just getting out of school and was not aware it was not okay. She stated I trusted he was doing the right thing. She stated she did not report the incident until she was interviewed on the 11/02/20. On 11/19/20 at 4:28 PM, CNA #1 was interviewed related to the allegation of abuse concerning the resident. He stated there was never a time when other CNA's came in after the resident had screamed out. He stated the resident will yell out in pain when she transfers sometimes. When asked about if he had told anyone about performing C clamp, he said a hospice nurse once asked him about the resident's constipation and he said he told her the 'C clamp' was what she needed. He stated he told her that was out of his scope, a nurse would have to do that. When asked what a 'C clamp' was, he stated it was when you push around the anus like a C. He said he had never performed it on a resident. He stated it was something a nurse would do. He was asked what nurse had performed this on a resident but he did not answer the question. The CNA stated he had never put his fingers in the resident's vagina or anus. He was unable to name the hospice nurse. On 11/20/20 at 10:15 AM, during an interview with licensed practical nurse (LPN) #1, she stated NA #2 reported to her on Sunday 11/01/20 that she, NA #3, and CNA #4 had heard resident #1 scream out. LPN #1 reported NA #2 told her they went to the resident's room to find the resident lying in bed with brief off. LPN #1 stated NA #2 told her they ask CNA #1 if everything was ok and CNA #1 report he had performed a 'C clamp' on the resident to help her to poop. The LPN stated NA #2 told her CNA #1 said a 'C clamp' was when you put two fingers in the vaginal and one in the butt. The LPN stated the NA told her she was not sure if that was a procedure that should be done or not. The LPN stated she immediately told the NA she had to tell the administrator and did report it at that time. On 11/20/20 at 9:30 AM, during an interview with the administrator (adm), she stated she first heard of the allegation on 11/01/20. The adm stated LPN #1 reported the allegation to her after NA #2 reported it to the LPN. She stated no one had reported any allegations of abuse related to CNA #1 until that day. When asked about the investigation interviews she stated the DON conducted the interviews. On 11/20/20 at 11:27 AM, during an interview with the director of nurses (DON), she stated the first time she had heard of the allegation of abuse was on 11/01/20. The DON stated the administrator had called her that day on Sunday. The DON stated she started conducting interviews with the staff and the residents on the next day. The DON was asked about the interviews with LPN #1, LPN #2, and agency staff. She stated she did not conduct any interviews with nurses or agency. 2. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 10/07/20, documented the resident was moderately cognitively impaired and required extensive assistance of two people for activities of daily living. A facility investigation interview with NA #2, dated 11/02/20 at 9:00 AM, documented NA #2 stated a couple of days after the incident with resident #1, she heard CNA #1 screaming at resident #2. The interview documented NA #2 went into the room and the resident was suspended in the lift and was crying. The interview documented NA #2 asked what was going on and CNA #1 said, She[***]again and I just changed her. The interview documented NA #2 told CNA #1 to leave the room and she would take care of it. The interview documented the resident told NA #2 that CNA #1 was hateful to her and she did not like him. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the interviewer asked if NA #3 had witnessed anything else besides the incident with resident #1. The interview documented NA #3 stated CNA #1 had lost his temper with several residents and cussed at them. The interview documented NA #3 said CNA #1 was mean and cursed at resident #2, resident #3, and resident #4. A signed hand-written statement by CNA #1, dated 11/02/20, documented, .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A facility Safe Survey interview, dated 11/02/20 with resident #2 documented, the resident said she did not want to say anything about concerns or complaints. The interview documented the question, do you feel the staff treats you with respect. The interview documented the resident said one staff member is mean to her and hurts her feelings and makes her mad. The interview documented the resident felt comfortable and safe at the facility except for the one male aide who is mean to her and her roommate. A facility investigation interview with CNA #4, dated 11/03/20 at 11:00 AM, documented CNA #4 stated CNA #1 would tell residents to get their MF[***]together'' and that he cussed at the residents all the time. The interview documented a question to NA #4 if she knew that was considered verbal abuse and that she was required to report immediately. The interview documented CNA #4 did not have a reason to why she did not say anything. A final 283 incident report, with a facsimile date of 11/12/20, documented, during an investigation of allegations of abuse, Safe Survey interviews were conducted on Hall 200. The report documented resident #2 reported she had been cussed at and talked rudely to by a male aide she identified as CNA #1. The report documented the resident stated CNA #1 hurt her feelings when talking that way to her. The report documented the resident could not identify a specific date or time on which the alleged behavior occurred. The resident also said she did not like the way CNA #1 spoke to her roommate, resident #3. On 11/19/20 at 11:26 PM, the resident was observed lying on her bed in her room watching TV. She was questioned about any abuse or mistreatment happenings to her or any of the other residents. She said the staff are nice and no abuse had happened to her knowledge. On 11/19/20 at 12:47 PM, during an interview with NA #2 she stated she heard resident #2 crying. She stated she went in to check on her and she was in the lift. NA #2 stated CNA #1 was in the room and he said, She[***]again and I just changed her. NA #2 stated she told him to get out and she would take care of her. She stated the resident had told her she did not like CNA #1. On 11/19/20 at 2:25 PM, during an interview with CNA #4, she stated CNA #1 would make rude comments to the residents and Alma was one of them. CNA #4 stated she had not reported CNA #1 until the time she was interviewed by the DON on 11/03/20. On 11/19/20 at 3:12 PM, during an interview with NA #3, she stated CNA #1 would be really rude and yell at resident #2 and tell her, Yelling like a two year old will only piss me off! The NA could not pin point a time except sometime in October. She stated she did not report it until interviewed by the DON on 11/02/20. On 11/19/20 at 4:28 PM, CNA #1 was interviewed related to the allegations of mental and verbal abuse concerning the resident. The CNA denied any cursing or disrespect to the resident. On 11/20/20 at 9:30 AM, during an interview with the administrator (adm), she stated she first heard of the allegations of abuse on 11/01/20 while she was interviewing NA #2. She stated NA #2 reported allegations of abuse related to residents #1, #2, and #3. When asked about the investigation interviews she stated the DON conducted the interviews. On 11/20/20 at 11:27 AM, during an interview with the director of nurses (DON), she stated the first time she had heard of the allegation of abuse was on 11/01/20. The DON stated the administrator had called her that day on Sunday. The DON stated she started conducting interviews with the staff and the residents on the next day. The DON was asked about the interviews with LPN #1, LPN #2, and agency staff. She stated she did not conduct any interviews with nurses or agency. 3. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 09/06/20, documented the resident was cognitively intact and required limited assistance with activities of daily living. A facility investigation interview with NA #2, dated 11/02/20 at 9:00 AM, documented NA #2 stated resident #3 (date unknown) was being anxious and trying to get up and leave the dining room repeatedly. The interview documented NA #2 said CNA #1 walked over to resident #3 and got down in her face and said, quit your [***] ing[***](name deleted resident #3) you are not going anywhere set down. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the interviewer asked if NA #3 had witnessed anything else besides the incident with resident #1. The interview documented NA #3 stated CNA #1 had lost his temper with several residents and cussed at them. The interview documented NA #3 said CNA #1 was mean and cursed at resident #2, resident #3, and resident #4. A signed hand-written statement by CNA #1, dated 11/02/20, documented, .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A facility interview with resident #3 was not provided. A facility investigation interview with CNA #4, dated 11/03/20 at 11:00 AM, documented CNA #4 stated CNA #1 would tell residents to get their MF[***]together'' and that he cussed at the residents all the time. The interview documented a question to NA #4 if she knew that was considered verbal abuse and that she was required to report immediately. The interview documented CNA #4 did not have a reason to why she did not say anything. A final 283 incident report, with a facsimile date of 11/12/20, documented, during an investigation of allegations of abuse, Safe Survey interviews were conducted on Hall 200. The report documented resident #2 reported she had been cursed and talked rudely to by a male aide she identified as CNA #1. Resident #2 also said she did not like the way CNA #1 spoke to her roommate, resident #3. The report documented resident #3 was not interviewable and could not provide a statement. During the survey time, resident #3 was residing on the COVID-19 unit and was unable to be interviewed due to not feeling well. On 11/19/20 at 12:47 PM, during an interview with NA #2, she stated resident #3 was trying to leave the dining room a couple of weeks ago and CNA #1 got in her face and said, Quit your [***] ing[***]you are not going anywhere. She said she didn't think anyone else heard. She did not report it until 11/01/20. On 11/19/20 at 2:36 PM, during an interview with an agency CNA, she stated she never observed CNA #1 physically or sexually abuse a resident. She stated she did hear him yell at resident #3 over a month ago. She stated resident #3 would like to change her clothes a lot. She stated CNA #1 in an angry voice told the resident she was not going to change her clothes. The agency CNA stated he had made her feel uncomfortable at times with his sexual comments about her body. She stated she did not report him. On 11/19/20 at 4:28 PM, CNA #1 was interviewed related to the allegations of verbal abuse concerning the resident. The CNA denied any cursing or disrespect to the resident. On 11/20/20 at 9:30 AM, during an interview with the administrator (adm), she stated she first heard of the allegations of abuse on 11/01/20 while she was interviewing NA #2. She stated NA #2 reported allegations of abuse related to residents #1, #2, and #3. When asked about the investigation interviews she stated the DON conducted the interviews. On 11/20/20 at 11:27 AM, during an interview with the director of nurses (DON), she stated the first time she had heard of the allegation of abuse was on 11/01/20. The DON stated the administrator had called her that day on Sunday. The DON stated she started conducting interviews with the staff and the residents on the next day. The DON was asked about the interviews with LPN #1, LPN #2, and agency staff. She stated she did not conduct any interviews with nurses or agency. The DON was asked why resident #3 was not interviewed. She stated she did not know how she was missed. 4. Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/23/20, documented the resident was moderately cognitively impaired and required extensive to total assistance with activities of daily living. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the interviewer asked if NA #3 had witnessed anything else besides the incident with resident #1. The interview documented NA #3 stated CNA #1 had lost his temper with several residents and cussed at them. The interview documented NA #3 said CNA #1 was mean and cursed at resident #2, resident #3, and resident #4. The interview documented NA #3 was asked when CNA #1 cursed at resident #4 because she had camera in her room. The interview documented CNA #1 cursed her when they got out in the hall. A facility investigation interview with resident #4, dated 11/07/20 at 6:00 PM, documented the resident was asked if anyone had been mean to her. The report documented the resident immediately answered, CNA #1, and that she did not like him. The interview documented the resident was asked why she did not like him and the resident stated because he tortured her. The interview documented the resident was asked what she meant. The interview documented the resident stated he did what the Nazis did to the Jewish women. The interview documented the resident was asked what that meant. The interview documented the resident said CNA #1 put his hands up in me and and hurt me. The interview documented the resident was asked why he would do that and she stated he was pleasing himself. A signed hand-written statement by CNA #1, dated 11/02/20, documented, .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A final 283 incident report, with a facsimile date of 11/12/20, documented, during the Safe Survey interviews, resident #4 informed the DON that CNA #1 ''tortured'' her on several occasions while giving her a shower. The report documented the resident could not identify any special date or time of the alleged incidents, although she thought they had occurred over the last two months. The report documented the resident stated CNA #1 put his hands up inside of her and that she thought he was doing this to pleasure himself. The report documented the residents stated she had not told anyone about these alleged incidents, except for her spouse. The report documented the resident's physician and spouse were immediately notified. The report documented the resident's husband was interviewed and he said that the resident had told him of these incidents over the past couple months, but that he did not believe her and had not reported it to anyone because he found CNA #1 to be very nice and because the resident had been know to make up things in the past. The report documented the resident's room is equipped with a camera and the resident's husband denied seeing anything inappropriate being done to his wife on the video from the camera. The report documented the resident was examined by her physician and there was no physical harm to the resident. The report documented the police were notified and an officer interviewed the resident. The report documented the officer referred the matter to a detective and requested that the facility not have any more contact with CNA #1 until the police had a chance to interview him and conduct its investigation. The report stated the facility updated the resident's care plan to include at least one female care giver at all times. The report documented social services will do well checks weekly times four and make counseling referrals as indicated. The report stated the facility is awaiting the final police investigation and CNA #1 remains suspended indefinitely. On 11/19/20 at 2:25 PM, during an interview with CNA #4, she stated CNA #1 would make rude comments to the residents. CNA #4 stated he was rude to resident #4. She said CNA #1 would get angry with the resident, not in her room, but in the shower room. CNA #4 stated CNA #1 wou (TRUNCATED)

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 10/01/20 related to the facility's failure to ensure four residents were free from abuse. The facility failed to prevent a staff member from sexually, verbally, and mentally abusing residents. Resident #1 was sexually abused related to two nurse aides reporting hearing resident #1 scream out while certified nurse aide (CNA) #1 was in her room. Two nurse aides reported they went immediately to the resident's room and observed the resident lying on the bed with her brief off and CNA #1 by her bedside. Two nurse aides reported at that time they asked CNA #1 if everything was ok. The NAs reported CNA #1 told them he had performed a ''C clamp'' on the resident to help stimulate her to have a bowel movement. When they asked him what a ''C clamp was, he stated, It was when you put two fingers in the vagina and one finger in the butt and squeeze. Resident #2 was verbally and mentally abused by CNA #1 as reported by the resident #2, one CNA, and 2 nurse aides. Resident #3 was verbally abused by CNA #1 as reported by resident #2, two nurse aides and one agency CNA. Resident #4 was verbally and mentally abused as reported by resident #4, one nurse aide, and one CNA. On 11/20/20 at 1:55 PM, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to protect and prevent abuse; report abuse immediately; and thoroughly and timely investigate allegations of abuse. The past noncompliance IJ was removed, effective 11/13/20 at 3:00 PM, after the facility put measures in place to prevent recurrence. CNA #1, who was the alleged perpetrator, was suspended immediately, on 11/01/20, upon the nurse aide's reporting to a licensed practical nurse then the administrator. CNA #1 had not worked in the building since the time of suspension. The facility notified Oklahoma State Department of Health, nurse aide registry, physicians, families, Adult Protective Services, and Local Law Enforcement of the allegations against the CNA #1. A 'Quality Assurance Plan of Correction (QAPI) Plan of Correction', dated 11/02/20, documented the following: Individual inservices would be completed with staff 11/02/20 through 11/07/20 on abuse prevention policy and the responsibility of reporting abuse. A handout on abuse and documentation to be given to every employee and signature obtained on their understanding. Explained to each nurse regarding the completion of an incident report with reporting requirements within two hours. Director of nursing and nurse managers were to do daily monitoring of nurse notes, grievance reports, incident reports, wound reports, and hospital records upon returns daily in clinical meeting to ensure all reporting was completed as required. The facility conducted 'Safe Survey' interviews with residents on all halls related to respect and abuse. 'Ambassador Rounds' related to quality of care and staff treatment related to respect and dignity were assigned to staff to perform weekly. Results of theses rounds were to be given to the administrator. Code of Conduct service with all staff and signed for personnel file. A log to be maintained to ensure timeliness for reporting. QAPI committee will review audits and incident reports monthly and make any additional recommendations as needed. The facility conducted a mandatory in-service, which included all staff, on 11/13/20. The inservice was over the facility's abuse policy, investigation guidelines, and reporting suspected or witnessed abuse in a timely manner to their charge nurse or supervisor. Each staff member completed a post test over abuse prevention and reporting. Each staff member signed an acknowledgement of the abuse policy and reporting requirements which documented an employee may be criminally liable for failure to report abuse. Based on observation, interview, and record review, it was determined the facility failed to ensure staff reported allegations of abuse immediately, but not later than two hours, to the administrator, Oklahoma State Department of Health (OSDH), and other officials for four (#1, 2, 3, and #4) of four residents sampled for allegations of abuse. The facility failed to: a. report an allegation of sexual abuse of a resident by a staff member to the administrator (adm) and to Oklahoma State Department of Health (OSDH) within the required time frame for resident #1. The abuse was not reported to the administrator (adm) until a month later and was not reported to OSDH within the two hour time frame. Law enforcement was notified eight days after the allegation was reported to the administrator. b. report an allegation of sexual abuse to OSDH within the required time frame for resident #4. The initial report to OSDH was subitted 5 days after the resident reported the allegation. Law enforcement was notified 2 days after the allegation was reported to the director of nursing. c. report allegations of verbal and mental abuse of residents by a staff member to the administrator and OSDH within the required time frame for residents #2, 3, and #4. The intial notification of the allegations of abuse to OSDH was 12 days after the allegations were reported to the administrator. The administrator (adm) identified 87 residents who resided at the facility. Findings: The facility's abuse policy, dated 06/23/17, documented.Each resident has the right to be free from abuse, neglect, exploitation, .Residents must not be subject to abuse, neglect, .by anyone .The facility must prohibit and prevent abuse, neglect, and exploitation of residents .All facility staff members have a duty to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the administrator of the facility, who serves as the abuse coordinator .Upon receiving an allegation of abuse .the abuse coordinator will notify the regional director and initiate an investigation into the allegation .if the allegation is reportable, report such allegation to the State Regulatory Agency, Adult Protective Services, and in certain cases, local law enforcement, within the following timeframes: a. not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or .The results of all investigations will be reported to the Abuse Coordinator or designated representative and other officials in accordance with state law (including the State Department of Health Regulatory Agency within five (5) working days of the incident .The Abuse Coordinator or designated representative will immediately begin an investigation and follow the State Guidelines for reporting incidents and accidents. Such investigation guidelines include: a. Resident(s) and responsible party interviews, as applicable; b. Physical examination of the resident, if applicable; c. Staff interviews and written statements, as applicable; .'' 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/21/20, documented the resident was severely cognitively impaired and required extensive assistance of one person with most activities of daily living. An initial 283 incident report, dated 11/01/20, documented it was reported by nurse aide (NA) #2 that she had worked with CNA #1 approximately 10/01/20. The report documented NA #2 heard the resident scream, then she, NA #3, and CNA #4 went into the room to check on the resident. The report documented the resident was lying on the bed and CNA #1 told them he had just performed a ''C clamp'' on the resident to help stimulate her to have a bowel movement. The report documented they did not know if this was acceptable and later started feel uncomfortable about it and told her charge nurse. The report documented the charge nurse notified the administrator and CNA #1 was suspended immediately with an investigation to follow. CNA #1's time records were reviewed. The records documented 10/30/20 as the last day the CNA worked. A facility investigation interview with NA #2, dated 11/02/20 at 9:00 AM, documented the following: NA#2 usually worked doubles on the weekend but started helping out during the week on Hall 200. One of the employees NA #2 started working with was CNA #1. NA #2 said at first she thought he was great but then things started happening which she didn't think were quite right. NA #2 stated she she was on the hall around 10/02/20 with CNA #1, NA #3, and CNA #4. NA #2 stated she, NA #3 and CNA #4 heard the resident scream out. They ran in the room and CNA #1 was standing by the resident's bed holding the resident's brief in his hand. When NA #1 asked if everything was ok, CNA #1 said, Yeah, sometimes you gotta give her a C clamp to help her go poop. NA #2 asked CNA #1 what a C clamp was and he said it was when you put two fingers in the vagina and one finger in her butt and squeeze. NA #2 said she did not think that sounded right but did not think she knew enough as a new nurse aide. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the following: NA #3 stated she was standing in the hall on or about 10/02/20 and she heard resident #1 scream. NA#3 said she went into the room to find out what was wrong. Resident #1 was in bed and CNA #1 was standing by her with her brief in his hand. CNA #1 said everything was ok and that he had to do a C clamp to assist resident #1 in having a BM. NA #2 asked him what a C clamp was and he stated it's when you put two fingers in the vaginal and one finger in the butt and squeeze. A signed hand-written statement by CNA #1, dated 11/02/20, documented, (Name deleted resident #1) has severe costipation (sic). Nurse has been notified of it. Sometimes its so large you have to push around her anus to release the bowel movement. Never have I ever put anything inside any of my residents .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A facility Safe Survey interview, dated 11/02/20 with resident #1 documented, the resident said she felt comfortable about talking to staff about any concerns or complaints. The interview documented the resident said the staff treat her with respect. The interview documented the resident felt comfortable and safe at the facility. A facility investigation interview with CNA #4, dated 11/03/20 at 11:00 AM, documented the following: CNA #4 stated she did not know anything about the incident with resident #1. CNA #1 said she had heard him make inappropriate comments to residents like telling them they had a nice butt and then he would pat them on it. A final 283 incident report, with a facsimile date of 11/12/20, documented the following: On 11/01/20 the director of nursing (DON) was informed by NA #2 that while working with CNA #1 on or about 10/01/20, she heard resident #1 cry out. NA #2 reported that she, NA #3, and CNA #4 went into resident's #1 room to check on her. According to NA #1, the resident was lying in bed and CNA #1 was in the room. CNA #1 told them he had just performed a C clamp procedure on the resident to help stimulate her to have a bowel movement. At the time they did not know whether the practice described by CNA #1 was acceptable nursing practice or not, but after considering the event further, decided to inform their charge nurse about the incident. The charge nurse notified the facility administrator, who initiated this investigation. CNA #1 was suspended immediately. CNA #1's schedule was reviewed and it was determined he had only worked with residents on Hall 200. An investigation was initiated which included assessing the resident, and interviewing the residents and staff involved. And conducted safe surveys on Hall 200 where CNA #1 worked and all residents on other halls were also included. Resident #1 was interviewed and she stated that everyone was very nice to her and she did not recall anyone mistreating her. She also did not recall any problems with having bowel movements. When examined by her physician, there was no harm noted. When CNA #1 was interviewed he denied knowing what a ''C clamp'' was or saying anything in that regard to NA #2, NA #3, or CNA #4. He did say that he sometimes ''pressed on the resident's bottom to assist her with having a bowel movement. He did not explicitly admit to any wrongdoing. The police station was notified and the matter was assigned a case umber. All staff have been inserviced on the facility's abuse policy and reporting protocols with returned competencies completed. The facility has updated the resident's care plan to include at least one female care giver at all times. The resident's family and physician were notified of the outcome of the investigation and the ongoing police investigation. A QAPI plan was completed for abuse reporting. Social Services will do well-being checks weekly times four and counseling referrals as indicated. On 11/19/20 at 11:38 am, the resident was observed sitting up in her bed. The resident was asked if she had been verbally abused, physically hurt, or touched inappropriately by any staff members. The resident was pleasant and said no one had abused her and everyone was nice to her. The resident was asked if she had any problems with certified nurse aide (CNA) #1. She shook her head no. She was asked if she had any children and how many. The resident said she had children but did not know how many. On 11/19/20 at 12:47 PM, NA #2 was interviewed related to abuse and the alleged incident on 10/01/20 involving the resident. She stated she worked on weekends and only worked a few days with CNA #1 in October. She stated she, CNA #4, and NA #3 heard the resident scream from the other end of the hallway. She said she saw him crouched down near the resident who was lying on her bed. She stated CNA #1 had wipes in one hand and a brief in the other. She stated she asked CNA #1 if everything was ok. She stated CNA #1 said he had to do a C clamp on the resident to help her poop. She stated she asked CNA #1 what that was and he said it when you put two fingers in the vagina and one in the butt and squeeze. She stated since she was a new nurse aide, she thought it must be something she did not know about yet. She said she did not report it at that time. She said she reported it to licensed practical nurse (LPN) #1 on 11/01/20. On 11/19/20 at 2:25 PM, CNA #4 was interviewed and she denied knowing anything about CNA #1 saying he had performed a C clamp on the resident. She stated CNA #1 would make rude comments to the residents. On 11/19/20 at 3:12 PM, NA #3 was interviewed related to abuse and the alleged incident on 10/01/20 involving the resident. She stated she, NA #2, and CNA #4 were out in the hall when they heard the resident yelling. The CNA stated when the three of them entered the resident's room, CNA #1 was bent over her and it looked like he was changing her brief. CNA #1 said he performed a C clamp on the resident. NA #3 stated she was just getting out of school and was not aware it was not okay. She stated I trusted he was doing the right thing. She stated she did not report the incident until she was interviewed on the 11/02/20. On 11/19/20 at 4:28 PM, CNA #1 was interviewed related to the allegation of abuse concerning the resident. He stated there was never a time when other CNA's came in after the resident had screamed out. He stated the resident will yell out in pain when she transfers sometimes. When asked about if he had told anyone about performing C clamp, he said a hospice nurse once asked him about the resident's constipation and he said he told her the 'C clamp' was what she needed. He stated he told her that was out of his scope, a nurse would have to do that. When asked what a 'C clamp' was, he stated it was when you push around the anus like a C. He said he had never performed it on a resident. He stated it was something a nurse would do. He was asked what nurse had performed this on a resident but he did not answer the question. The CNA stated he had never put his fingers in the resident's vagina or anus. He was unable to name the hospice nurse. On 11/20/20 at 10:15 AM, during an interview with licensed practical nurse (LPN) #1, she stated NA #2 reported to her on Sunday 11/01/20 that she, NA #3, and CNA #4 had heard resident #1 scream out. LPN #1 reported NA #2 told her they went to the resident's room to find the resident lying in bed with brief off. LPN #1 stated NA #2 told her they ask CNA #1 if everything was ok and CNA #1 report he had performed a 'C clamp' on the resident to help her to poop. The LPN stated NA #2 told her CNA #1 said a 'C clamp' was when you put two fingers in the vaginal and one in the butt. The LPN stated the NA told her she was not sure if that was a procedure that should be done or not. The LPN stated she immediately told the NA she had to tell the administrator and did report it at that time. On 11/20/20 at 9:30 AM, during an interview with the administrator (adm), she stated she first heard of the allegation on 11/01/20. The adm stated LPN #1 reported the allegation to her after NA #2 reported it to the LPN. She stated no one had reported any allegations of abuse related to CNA #1 until that day. She stated the allegations should have been reported to her immediately. She stated she suspended CNA #1 on 11/01/20. She stated the initial report to OSDH was not sent in until the next day. The adm stated she did not notify law enforement until the investigation was completed. On 11/20/20 at 11:27 AM, during an interview with the director of nurses (DON), she stated the first time she had heard of the allegation of abuse was on 11/01/20. The DON stated the administrator had called her that day on Sunday. The DON stated she started conducting interviews with the staff and the residents on the next day. 2. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 10/07/20, documented the resident was moderately cognitively impaired and required extensive assistance of two people for activities of daily living. A facility investigation interview with NA #2, dated 11/02/20 at 9:00 AM, documented NA #2 stated a couple of days after the incident with resident #1, she heard CNA #1 screaming at resident #2. The interview documented NA #2 went into the room and the resident was suspended in the lift and was crying. The interview documented NA #2 asked what was going on and CNA #1 said, She[***]again and I just changed her. The interview documented NA #2 told CNA #1 to leave the room and she would take care of it. The interview documented the resident told NA #2 that CNA #1 was hateful to her and she did not like him. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the interviewer asked if NA #3 had witnessed anything else besides the incident with resident #1. The interview documented NA #3 stated CNA #1 had lost his temper with several residents and cussed at them. The interview documented NA #3 said CNA #1 was mean and cursed at resident #2, resident #3, and resident #4. A signed hand-written statement by CNA #1, dated 11/02/20, documented, .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A facility Safe Survey interview, dated 11/02/20 with resident #2 documented, the resident said she did not want to say anything about concerns or complaints. The interview documented the question, do you feel the staff treats you with respect. The interview documented the resident said one staff member is mean to her and hurts her feelings and makes her mad. The interview documented the resident felt comfortable and safe at the facility except for the one male aide who is mean to her and her roommate. A facility investigation interview with CNA #4, dated 11/03/20 at 11:00 AM, documented CNA #4 stated CNA #1 would tell residents to get their MF[***]together'' and that he cussed at the residents all the time. The interview documented a question to NA #4 if she knew that was considered verbal abuse and that she was required to report immediately. The interview documented CNA #4 did not have a reason to why she did not say anything. A final 283 incident report, with a facsimile date of 11/12/20, documented, during an investigation of allegations of abuse, Safe Survey interviews were conducted on Hall 200. The report documented resident #2 reported she had been cussed at and talked rudely to by a male aide she identified as CNA #1. The report documented the resident stated CNA #1 hurt her feelings when talking that way to her. The report documented the resident could not identify a specific date or time on which the alleged behavior occurred. The resident also said she did not like the way CNA #1 spoke to her roommate, resident #3. On 11/19/20 at 11:26 PM, the resident was observed lying on her bed in her room watching TV. She was questioned about any abuse or mistreatment happenings to her or any of the other residents. She said the staff are nice and no abuse had happened to her knowledge. On 11/19/20 at 12:47 PM, during an interview with NA #2 she stated she heard resident #2 crying. She stated she went in to check on her and she was in the lift. NA #2 stated CNA #1 was in the room and he said, She[***]again and I just changed her. NA #2 stated she told him to get out and she would take care of her. She stated the resident had told her she did not like CNA #1. On 11/19/20 at 2:25 PM, during an interview with CNA #4, she stated CNA #1 would make rude comments to the residents and Alma was one of them. CNA #4 stated she had not reported CNA #1 until the time she was interviewed by the DON on 11/03/20. On 11/19/20 at 3:12 PM, during an interview with NA #3, she stated CNA #1 would be really rude and yell at resident #2 and tell her, Yelling like a two year old will only piss me off! The NA could not pin point a time except sometime in October. She stated she did not report it until interviewed by the DON on 11/02/20. On 11/19/20 at 4:28 PM, CNA #1 was interviewed related to the allegations of mental and verbal abuse concerning the resident. The CNA denied any cursing or disrespect to the resident. On 11/20/20 at 9:30 AM, during an interview with the administrator (adm), she stated she first heard of the allegations of abuse on 11/01/20 while she was interviewing NA #2. She stated NA #2 reported allegations of abuse related to residents #1, #2, and #3. The adm stated the allegations should have been reported to her immediately. She stated she suspended CNA #1 on 11/01/20. She was asked why resident #2, 3, #4 were not reported to OSDH when the allegations were reported. She stated they were thinking it was all part of the investigation which started with resident #1. On 11/20/20 at 11:27 AM, during an interview with the director of nurses (DON), she stated the first time she had heard of the allegation of abuse was on 11/01/20. The DON stated the administrator had called her that day on Sunday. The DON stated she started conducting interviews with the staff and the residents on the next day. She was asked why resident #2, 3, #4 were not reported to OSDH when the allegations were reported. She stated she thought of it as one investigation, but could see now that each resident should have been reported at the time the allegations were reported. 3. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 09/06/20, documented the resident was cognitively intact and required limited assistance with activities of daily living. A facility investigation interview with NA #2, dated 11/02/20 at 9:00 AM, documented NA #2 stated resident #3 (date unknown) was being anxious and trying to get up and leave the dining room repeatedly. The interview documented NA #2 said CNA #1 walked over to resident #3 and got down in her face and said, quit your [***] ing[***](name deleted resident #3) you are not going anywhere set down. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the interviewer asked if NA #3 had witnessed anything else besides the incident with resident #1. The interview documented NA #3 stated CNA #1 had lost his temper with several residents and cussed at them. The interview documented NA #3 said CNA #1 was mean and cursed at resident #2, resident #3, and resident #4. A signed hand-written statement by CNA #1, dated 11/02/20, documented, .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A facility interview with resident #3 was not provided. A facility investigation interview with CNA #4, dated 11/03/20 at 11:00 AM, documented CNA #4 stated CNA #1 would tell residents to get their MF[***]together'' and that he cussed at the residents all the time. The interview documented a question to NA #4 if she knew that was considered verbal abuse and that she was required to report immediately. The interview documented CNA #4 did not have a reason to why she did not say anything. A final 283 incident report, with a facsimile date of 11/12/20, documented, during an investigation of allegations of abuse, Safe Survey interviews were conducted on Hall 200. The report documented resident #2 reported she had been cursed and talked rudely to by a male aide she identified as CNA #1. Resident #2 also said she did not like the way CNA #1 spoke to her roommate, resident #3. The report documented resident #3 was not interviewable and could not provide a statement. During the survey time, resident #3 was residing on the COVID-19 unit and was unable to be interviewed due to not feeling well. On 11/19/20 at 12:47 PM, during an interview with NA #2, she stated resident #3 was trying to leave the dining room a couple of weeks ago and CNA #1 got in her face and said, Quit your [***] ing[***]you are not going anywhere. She said she didn't think anyone else heard. She did not report it until 11/01/20. On 11/19/20 at 2:36 PM, during an interview with an agency CNA, she stated she never observed CNA #1 physically or sexually abuse a resident. She stated she did hear him yell at resident #3 over a month ago. She stated resident #3 would like to change her clothes a lot. She stated CNA #1 in an angry voice told the resident she was not going to change her clothes. The agency CNA stated he had made her feel uncomfortable at times with his sexual comments about her body. She stated she did not report him. On 11/19/20 at 4:28 PM, CNA #1 was interviewed related to the allegations of verbal abuse concerning the resident. The CNA denied any cursing or disrespect to the resident. On 11/20/20 at 9:30 AM, during an interview with the administrator (adm), she stated she first heard of the allegations of abuse on 11/01/20 while she was interviewing NA #2. She stated NA #2 reported allegations of abuse related to residents #1, #2, and #3. The adm stated the allegations should have been reported to her immediately. She stated she suspended CNA #1 on 11/01/20. She was asked why resident #2, 3, #4 were not reported to OSDH when the allegations were reported. She stated they were thinking it was all part of the investigation which started with resident #1. On 11/20/20 at 11:27 AM, during an interview with the director of nurses (DON), she stated the first time she had heard of the allegation of abuse was on 11/01/20. The DON stated the administrator had called her that day on Sunday. The DON stated she started conducting interviews with the staff and the residents on the next day. She was asked why resident #2, 3, #4 were not reported to OSDH when the allegations were reported. She stated she thought of it as one investigation, but could see now that each resident should have been reported at the time the allegation was reported. 4. Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/23/20, documented the resident was moderately cognitively impaired and required extensive to total assistance with activities of daily living. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the interviewer asked if NA #3 had witnessed anything else besides the incident with resident #1. The interview documented NA #3 stated CNA #1 had lost his temper with several residents and cussed at them. The interview documented NA #3 said CNA #1 was mean and cursed at resident #2, resident #3, and resident #4. The interview documented NA #3 was asked when CNA #1 cursed at resident #4 because she had camera in her room. The interview documented CNA #1 cursed her when they got out in the hall. A facility investigation interview with resident #4, dated 11/07/20 at 6:00 PM, documented the resident was asked if anyone had been mean to her. The report documented the resident immediately answered, CNA #1, and that she did not like him. The interview documented the resident was asked why she did not like him and the resident stated because he tortured her. The interview documented the resident was asked what she meant. The interview documented the resident stated he did what the Nazis did to the Jewish women. The interview documented the resident was asked what that meant. The interview documented the resident said CNA #1 put his hands up in me and and hurt me. The interview documented the resident was asked why he would do that and she stated he was pleasing himself. A signed hand-written statement by CNA #1, dated 11/02/20, documented, .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A final 283 incident report, with a facsimile date of 11/12/20, documented, during the Safe Survey interviews, resident #4 informed the DON that CNA #1 ''tortured'' her on several occasions while giving her a shower. The report documented the resident could not identify any special date or time of the alleged incidents, although she thought they had occurred over the last two months. The report documented the resident stated CNA #1 put his hands up inside of her and that she thought he was doing this to pleasure himself. The report documented the residents stated she had not told anyone about these alleged incidents, except for her spouse. The report documented the resident's physician and spouse were immediately notified. The report documented the resident's husband was interviewed and he said that the resident had told him of these incidents over the past couple months, but that he did not believe her and had not reported it to anyone because he found CNA #1 to be very nice and because the resident had been know to make up things in the past. The report documented the resident's room is equipped with a camera and the resident's husband denied seeing anythin (TRUNCATED)

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 10/01/20 related to the facility's failure to ensure four residents were free from abuse. The facility failed to prevent a staff member from sexually, verbally, and mentally abusing residents. Resident #1 was sexually abused related to two nurse aides reporting hearing resident #1 scream out while certified nurse aide (CNA) #1 was in her room. Two nurse aides reported they went immediately to the resident's room and observed the resident lying on the bed with her brief off and CNA #1 by her bedside. Two nurse aides reported at that time they asked CNA #1 if everything was ok. The NAs reported CNA #1 told them he had performed a ''C clamp'' on the resident to help stimulate her to have a bowel movement. When they asked him what a ''C clamp was, he stated, It was when you put two fingers in the vagina and one finger in the butt and squeeze. Resident #2 was verbally and mentally abused by CNA #1 as reported by the resident #2, one CNA, and 2 nurse aides. Resident #3 was verbally abused by CNA #1 as reported by resident #2, two nurse aides and one agency CNA. Resident #4 was verbally and mentally abused as reported by resident #4, one nurse aide, and one CNA. On 11/20/20 at 1:55 PM, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to protect and prevent abuse; report abuse immediately; and thoroughly and timely investigate allegations of abuse. The past noncompliance IJ was removed, effective 11/13/20 at 3:00 PM, after the facility put measures in place to prevent recurrence. CNA #1, who was the alleged perpetrator, was suspended immediately, on 11/01/20, upon the nurse aide's reporting to a licensed practical nurse then the administrator. CNA #1 had not worked in the building since the time of suspension. The facility notified Oklahoma State Department of Health, nurse aide registry, physicians, families, Adult Protective Services, and Local Law Enforcement of the allegations against the CNA #1. A 'Quality Assurance Plan of Correction (QAPI) Plan of Correction', dated 11/02/20, documented the following: Individual inservices would be completed with staff 11/02/20 through 11/07/20 on abuse prevention policy and the responsibility of reporting abuse. A handout on abuse and documentation to be given to every employee and signature obtained on their understanding. Explained to each nurse regarding the completion of an incident report with reporting requirements within two hours. Director of nursing and nurse managers were to do daily monitoring of nurse notes, grievance reports, incident reports, wound reports, and hospital records upon returns daily in clinical meeting to ensure all reporting was completed as required. The facility conducted 'Safe Survey' interviews with residents on all halls related to respect and abuse. 'Ambassador Rounds' related to quality of care and staff treatment related to respect and dignity were assigned to staff to perform weekly. Results of theses rounds were to be given to the administrator. Code of Conduct service with all staff and signed for personnel file. A log to be maintained to ensure timeliness for reporting. QAPI committee will review audits and incident reports monthly and make any additional recommendations as needed. The facility conducted a mandatory in-service, which included all staff, on 11/13/20. The inservice was over the facility's abuse policy, investigation guidelines, and reporting suspected or witnessed abuse in a timely manner to their charge nurse or supervisor. Each staff member completed a post test over abuse prevention and reporting. Each staff member signed an acknowledgement of the abuse policy and reporting requirements which documented an employee may be criminally liable for failure to report abuse. Based on observation, interview, and record review, it was determined the facility failed to implement their abuse prohibition policy for four (#1, 2, 3, and #4) of four residents sampled for abuse. The facility failed to: a. protect and prevent residents #1, 2, 3, and #4 from being abused by a staff member. The alleged abuser continued to work from the first alllegation event date of 10/01/20 until 10/30/20. Allegations of abuse were reported to the administrator on 11/01/20. b. report an allegation of sexual abuse of a resident by a staff member to the administrator (adm) and to Oklahoma State Department of Health (OSDH) within the required time frame for resident #1. The abuse was not reported to the administrator (adm) until a month later and was not reported to OSDH within the two hour time frame. Law enforcement was notified eight days after the allegation was reported to the administrator. c. report an allegation of sexual abuse to OSDH within the required time frame for resident #4. The initial report to OSDH was subitted 5 days after the resident reported the allegation. Law enforcement was notified 2 days after the allegation was reported to the director of nursing. d. report allegations of verbal abuse of residents by a staff member to the administrator and OSDH within the required time frame for residents #2, 3, and #4. The intial notification of the allegations of abuse to OSDH was 12 days after the allegations were reported to the administrator. e. conduct and document a thorough investigation of allegations of abuse for residents #1, 2, 3, and #4. NA #3 reported an allegation of verbal abuse against resident #4. Resident #4 was not interviewed until five days later, at which time she alleged sexual abuse. The interview with resident #4's family member was not documented. Allegations of abuse were reported to LPN #1. The interview of LPN #1 was not documented by the administrator. LPN #2 was the nurse who was in charge of the perpetrator and the nurse aides who reported the alleged abuse. LPN #2 was not interviewed. An agency nurse who had also witnessed abuse was not interviewed. Allegations of verbal abuse were reported concerning resident #3. Resident #3 was not interviewed. The most recent assessment documented resident #3 was cognitively intact. The administrator (adm) identified 87 residents who resided at the facility. Findings: The facility's abuse policy, dated 06/23/17, documented.Each resident has the right to be free from abuse, neglect, exploitation, .Residents must not be subject to abuse, neglect, .by anyone .The facility must prohibit and prevent abuse, neglect, and exploitation of residents .All facility staff members have a duty to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to the administrator of the facility, who serves as the abuse coordinator .Upon receiving an allegation of abuse .the abuse coordinator will notify the regional director and initiate an investigation into the allegation .if the allegation is reportable, report such allegation to the State Regulatory Agency, Adult Protective Services, and in certain cases, local law enforcement, within the following timeframes: a. not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or .The results of all investigations will be reported to the Abuse Coordinator or designated representative and other officials in accordance with state law (including the State Department of Health Regulatory Agency within five (5) working days of the incident .The Abuse Coordinator or designated representative will immediately begin an investigation and follow the State Guidelines for reporting incidents and accidents. Such investigation guidelines include: a. Resident(s) and responsible party interviews, as applicable; b. Physical examination of the resident, if applicable; c. Staff interviews and written statements, as applicable; .'' 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/21/20, documented the resident was severely cognitively impaired and required extensive assistance of one person with most activities of daily living. An initial 283 incident report, dated 11/01/20, documented it was reported by nurse aide (NA) #2 that she had worked with CNA #1 approximately 10/01/20. The report documented NA #2 heard the resident scream, then she, NA #3, and CNA #4 went into the room to check on the resident. The report documented the resident was lying on the bed and CNA #1 told them he had just performed a ''C clamp'' on the resident to help stimulate her to have a bowel movement. The report documented they did not know if this was acceptable and later started feel uncomfortable about it and told her charge nurse. The report documented the charge nurse notified the administrator and CNA #1 was suspended immediately with an investigation to follow. CNA #1's time records were reviewed. The records documented 10/30/20 as the last day the CNA worked. A facility investigation interview with NA #2, dated 11/02/20 at 9:00 AM, documented the following: NA#2 usually worked doubles on the weekend but started helping out during the week on Hall 200. One of the employees NA #2 started working with was CNA #1. NA #2 said at first she thought he was great but then things started happening which she didn't think were quite right. NA #2 stated she she was on the hall around 10/02/20 with CNA #1, NA #3, and CNA #4. NA #2 stated she, NA #3 and CNA #4 heard the resident scream out. They ran in the room and CNA #1 was standing by the resident's bed holding the resident's brief in his hand. When NA #1 asked if everything was ok, CNA #1 said, Yeah, sometimes you gotta give her a C clamp to help her go poop. NA #2 asked CNA #1 what a C clamp was and he said it was when you put two fingers in the vagina and one finger in her butt and squeeze. NA #2 said she did not think that sounded right but did not think she knew enough as a new nurse aide. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the following: NA #3 stated she was standing in the hall on or about 10/02/20 and she heard resident #1 scream. NA#3 said she went into the room to find out what was wrong. Resident #1 was in bed and CNA #1 was standing by her with her brief in his hand. CNA #1 said everything was ok and that he had to do a C clamp to assist resident #1 in having a BM. NA #2 asked him what a C clamp was and he stated it's when you put two fingers in the vaginal and one finger in the butt and squeeze. A signed hand-written statement by CNA #1, dated 11/02/20, documented, (Name deleted resident #1) has severe costipation (sic). Nurse has been notified of it. Sometimes its so large you have to push around her anus to release the bowel movement. Never have I ever put anything inside any of my residents .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A facility Safe Survey interview, dated 11/02/20 with resident #1 documented, the resident said she felt comfortable about talking to staff about any concerns or complaints. The interview documented the resident said the staff treat her with respect. The interview documented the resident felt comfortable and safe at the facility. A facility investigation interview with CNA #4, dated 11/03/20 at 11:00 AM, documented the following: CNA #4 stated she did not know anything about the incident with resident #1. CNA #1 said she had heard him make inappropriate comments to residents like telling them they had a nice butt and then he would pat them on it. A final 283 incident report, with a facsimile date of 11/12/20, documented the following: On 11/01/20 the director of nursing (DON) was informed by NA #2 that while working with CNA #1 on or about 10/01/20, she heard resident #1 cry out. NA #2 reported that she, NA #3, and CNA #4 went into resident's #1 room to check on her. According to NA #1, the resident was lying in bed and CNA #1 was in the room. CNA #1 told them he had just performed a C clamp procedure on the resident to help stimulate her to have a bowel movement. At the time they did not know whether the practice described by CNA #1 was acceptable nursing practice or not, but after considering the event further, decided to inform their charge nurse about the incident. The charge nurse notified the facility administrator, who initiated this investigation. CNA #1 was suspended immediately. CNA #1's schedule was reviewed and it was determined he had only worked with residents on Hall 200. An investigation was initiated which included assessing the resident, and interviewing the residents and staff involved. And conducted safe surveys on Hall 200 where CNA #1 worked and all residents on other halls were also included. Resident #1 was interviewed and she stated that everyone was very nice to her and she did not recall anyone mistreating her. She also did not recall any problems with having bowel movements. When examined by her physician, there was no harm noted. When CNA #1 was interviewed he denied knowing what a ''C clamp'' was or saying anything in that regard to NA #2, NA #3, or CNA #4. He did say that he sometimes ''pressed on the resident's bottom to assist her with having a bowel movement. He did not explicitly admit to any wrongdoing. The police station was notified and the matter was assigned a case umber. All staff have been inserviced on the facility's abuse policy and reporting protocols with returned competencies completed. The facility has updated the resident's care plan to include at least one female care giver at all times. The resident's family and physician were notified of the outcome of the investigation and the ongoing police investigation. A QAPI plan was completed for abuse reporting. Social Services will do well-being checks weekly times four and counseling referrals as indicated. On 11/19/20 at 11:38 am, the resident was observed sitting up in her bed. The resident was asked if she had been verbally abused, physically hurt, or touched inappropriately by any staff members. The resident was pleasant and said no one had abused her and everyone was nice to her. The resident was asked if she had any problems with certified nurse aide (CNA) #1. She shook her head no. She was asked if she had any children and how many. The resident said she had children but did not know how many. On 11/19/20 at 12:47 PM, NA #2 was interviewed related to abuse and the alleged incident on 10/01/20 involving the resident. She stated she worked on weekends and only worked a few days with CNA #1 in October. She stated she, CNA #4, and NA #3 heard the resident scream from the other end of the hallway. She said she saw him crouched down near the resident who was lying on her bed. She stated CNA #1 had wipes in one hand and a brief in the other. She stated she asked CNA #1 if everything was ok. She stated CNA #1 said he had to do a C clamp on the resident to help her poop. She stated she asked CNA #1 what that was and he said it when you put two fingers in the vagina and one in the butt and squeeze. She stated since she was a new nurse aide, she thought it must be something she did not know about yet. She said she did not report it at that time. She said she reported it to licensed practical nurse (LPN) #1 on 11/01/20. On 11/19/20 at 2:25 PM, CNA #4 was interviewed and she denied knowing anything about CNA #1 saying he had performed a C clamp on the resident. She stated CNA #1 would make rude comments to the residents. On 11/19/20 at 3:12 PM, NA #3 was interviewed related to abuse and the alleged incident on 10/01/20 involving the resident. She stated she, NA #2, and CNA #4 were out in the hall when they heard the resident yelling. The CNA stated when the three of them entered the resident's room, CNA #1 was bent over her and it looked like he was changing her brief. CNA #1 said he performed a C clamp on the resident. NA #3 stated she was just getting out of school and was not aware it was not okay. She stated I trusted he was doing the right thing. She stated she did not report the incident until she was interviewed on the 11/02/20. On 11/19/20 at 4:28 PM, CNA #1 was interviewed related to the allegation of abuse concerning the resident. He stated there was never a time when other CNA's came in after the resident had screamed out. He stated the resident will yell out in pain when she transfers sometimes. When asked about if he had told anyone about performing C clamp, he said a hospice nurse once asked him about the resident's constipation and he said he told her the 'C clamp' was what she needed. He stated he told her that was out of his scope, a nurse would have to do that. When asked what a 'C clamp' was, he stated it was when you push around the anus like a C. He said he had never performed it on a resident. He stated it was something a nurse would do. He was asked what nurse had performed this on a resident but he did not answer the question. The CNA stated he had never put his fingers in the resident's vagina or anus. He was unable to name the hospice nurse. On 11/20/20 at 10:15 AM, during an interview with licensed practical nurse (LPN) #1, she stated NA #2 reported to her on Sunday 11/01/20 that she, NA #3, and CNA #4 had heard resident #1 scream out. LPN #1 reported NA #2 told her they went to the resident's room to find the resident lying in bed with brief off. LPN #1 stated NA #2 told her they ask CNA #1 if everything was ok and CNA #1 report he had performed a 'C clamp' on the resident to help her to poop. The LPN stated NA #2 told her CNA #1 said a 'C clamp' was when you put two fingers in the vaginal and one in the butt. The LPN stated the NA told her she was not sure if that was a procedure that should be done or not. The LPN stated she immediately told the NA she had to tell the administrator and did report it at that time. On 11/20/20 at 9:30 AM, during an interview with the administrator (adm), she stated she first heard of the allegation on 11/01/20. The adm stated LPN #1 reported the allegation to her after NA #2 reported it to the LPN. She stated no one had reported any allegations of abuse related to CNA #1 until that day. She stated the allegations should have been reported to her immediately. She stated she suspended CNA #1 on 11/01/20. She stated the initial report to OSDH was not sent in until the next day. The adm stated she did not notify law enforement until the investigation was completed. When asked about the investigation interviews she stated the DON conducted the interviews. On 11/20/20 at 11:27 AM, during an interview with the director of nurses (DON), she stated the first time she had heard of the allegation of abuse was on 11/01/20. The DON stated the administrator had called her that day on Sunday. The DON stated she started conducting interviews with the staff and the residents on the next day. The DON was asked about the interviews with LPN #1, LPN #2, and agency staff. She stated she did not conduct any interviews with nurses or agency. 2. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 10/07/20, documented the resident was moderately cognitively impaired and required extensive assistance of two people for activities of daily living. A facility investigation interview with NA #2, dated 11/02/20 at 9:00 AM, documented NA #2 stated a couple of days after the incident with resident #1, she heard CNA #1 screaming at resident #2. The interview documented NA #2 went into the room and the resident was suspended in the lift and was crying. The interview documented NA #2 asked what was going on and CNA #1 said, She[***]again and I just changed her. The interview documented NA #2 told CNA #1 to leave the room and she would take care of it. The interview documented the resident told NA #2 that CNA #1 was hateful to her and she did not like him. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the interviewer asked if NA #3 had witnessed anything else besides the incident with resident #1. The interview documented NA #3 stated CNA #1 had lost his temper with several residents and cussed at them. The interview documented NA #3 said CNA #1 was mean and cursed at resident #2, resident #3, and resident #4. A signed hand-written statement by CNA #1, dated 11/02/20, documented, .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A facility Safe Survey interview, dated 11/02/20 with resident #2 documented, the resident said she did not want to say anything about concerns or complaints. The interview documented the question, do you feel the staff treats you with respect. The interview documented the resident said one staff member is mean to her and hurts her feelings and makes her mad. The interview documented the resident felt comfortable and safe at the facility except for the one male aide who is mean to her and her roommate (resident #3). A facility investigation interview with CNA #4, dated 11/03/20 at 11:00 AM, documented CNA #4 stated CNA #1 would tell residents to get their MF[***]together'' and that he cussed at the residents all the time. The interview documented a question to NA #4 if she knew that was considered verbal abuse and that she was required to report immediately. The interview documented CNA #4 did not have a reason to why she did not say anything. A final 283 incident report, with a facsimile date of 11/12/20, documented, during an investigation of allegations of abuse, Safe Survey interviews were conducted on Hall 200. The report documented resident #2 reported she had been cussed at and talked rudely to by a male aide she identified as CNA #1. The report documented the resident stated CNA #1 hurt her feelings when talking that way to her. The report documented the resident could not identify a specific date or time on which the alleged behavior occurred. The resident also said she did not like the way CNA #1 spoke to her roommate, resident #3. On 11/19/20 at 11:26 PM, the resident was observed lying on her bed in her room watching TV. She was questioned about any abuse or mistreatment happenings to her or any of the other residents. She said the staff are nice and no abuse had happened to her knowledge. On 11/19/20 at 12:47 PM, during an interview with NA #2 she stated she heard resident #2 crying. She stated she went in to check on her and she was in the lift. NA #2 stated CNA #1 was in the room and he said, She[***]again and I just changed her. NA #2 stated she told him to get out and she would take care of her. She stated the resident had told her she did not like CNA #1. On 11/19/20 at 2:25 PM, during an interview with CNA #4, she stated CNA #1 would make rude comments to the residents and Alma was one of them. CNA #4 stated she had not reported CNA #1 until the time she was interviewed by the DON on 11/03/20. On 11/19/20 at 3:12 PM, during an interview with NA #3, she stated CNA #1 would be really rude and yell at resident #2 and tell her, Yelling like a two year old will only piss me off! The NA could not pin point a time except sometime in October. She stated she did not report it until interviewed by the DON on 11/02/20. On 11/19/20 at 4:28 PM, CNA #1 was interviewed related to the allegations of mental and verbal abuse concerning the resident. The CNA denied any cursing or disrespect to the resident. On 11/20/20 at 9:30 AM, during an interview with the administrator (adm), she stated she first heard of the allegations of abuse on 11/01/20 while she was interviewing NA #2. She stated NA #2 reported allegations of abuse related to residents #1, #2, and #3. The adm stated the allegations should have been reported to her immediately. She stated she suspended CNA #1 on 11/01/20. She was asked why resident #2, 3, #4 were not reported to OSDH when the allegations were reported. She stated they were thinking it was all part of the investigation which started with resident #1. When asked about the investigation interviews she stated the DON conducted the interviews. On 11/20/20 at 11:27 AM, during an interview with the director of nurses (DON), she stated the first time she had heard of the allegation of abuse was on 11/01/20. The DON stated the administrator had called her that day on Sunday. The DON stated she started conducting interviews with the staff and the residents on the next day. She was asked why resident #2, 3, #4 were not reported to OSDH when the allegations were reported. She stated she thought of it as one investigation, but could see now that each resident should have been reported at the time the allegations were reported. The DON was asked about the interviews with LPN #1, LPN #2, and agency staff. She stated she did not conduct any interviews with nurses or agency. 3. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 09/06/20, documented the resident was cognitively intact and required limited assistance with activities of daily living. A facility investigation interview with NA #2, dated 11/02/20 at 9:00 AM, documented NA #2 stated resident #3 (date unknown) was being anxious and trying to get up and leave the dining room repeatedly. The interview documented NA #2 said CNA #1 walked over to resident #3 and got down in her face and said, quit your [***] ing[***](name deleted resident #3) you are not going anywhere set down. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the interviewer asked if NA #3 had witnessed anything else besides the incident with resident #1. The interview documented NA #3 stated CNA #1 had lost his temper with several residents and cussed at them. The interview documented NA #3 said CNA #1 was mean and cursed at resident #2, resident #3, and resident #4. A signed hand-written statement by CNA #1, dated 11/02/20, documented, .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A facility interview with resident #3 was not provided. A facility investigation interview with CNA #4, dated 11/03/20 at 11:00 AM, documented CNA #4 stated CNA #1 would tell residents to get their MF[***]together'' and that he cussed at the residents all the time. The interview documented a question to NA #4 if she knew that was considered verbal abuse and that she was required to report immediately. The interview documented CNA #4 did not have a reason to why she did not say anything. A final 283 incident report, with a facsimile date of 11/12/20, documented, during an investigation of allegations of abuse, Safe Survey interviews were conducted on Hall 200. The report documented resident #2 reported she had been cursed and talked rudely to by a male aide she identified as CNA #1. Resident #2 also said she did not like the way CNA #1 spoke to her roommate, resident #3. The report documented resident #3 was not interviewable and could not provide a statement. During the survey time, resident #3 was residing on the COVID-19 unit and was unable to be interviewed due to not feeling well. On 11/19/20 at 12:47 PM, during an interview with NA #2, she stated resident #3 was trying to leave the dining room a couple of weeks ago and CNA #1 got in her face and said, Quit your [***] ing[***]you are not going anywhere. She said she didn't think anyone else heard. She did not report it until 11/01/20. On 11/19/20 at 2:36 PM, during an interview with an agency CNA, she stated she never observed CNA #1 physically or sexually abuse a resident. She stated she did hear him yell at resident #3 over a month ago. She stated resident #3 would like to change her clothes a lot. She stated CNA #1 in an angry voice told the resident she was not going to change her clothes. The agency CNA stated he had made her feel uncomfortable at times with his sexual comments about her body. She stated she did not report him. On 11/19/20 at 4:28 PM, CNA #1 was interviewed related to the allegations of verbal abuse concerning the resident. The CNA denied any cursing or disrespect to the resident. On 11/20/20 at 9:30 AM, during an interview with the administrator (adm), she stated she first heard of the allegations of abuse on 11/01/20 while she was interviewing NA #2. She stated NA #2 reported allegations of abuse related to residents #1, #2, and #3. The adm stated the allegations should have been reported to her immediately. She stated she suspended CNA #1 on 11/01/20. She was asked why resident #2, 3, #4 were not reported to OSDH when the allegations were reported. She stated they were thinking it was all part of the investigation which started with resident #1. When asked about the investigation interviews she stated the DON conducted the interviews. On 11/20/20 at 11:27 AM, during an interview with the director of nurses (DON), she stated the first time she had heard of the allegation of abuse was on 11/01/20. The DON stated the administrator had called her that day on Sunday. The DON stated she started conducting interviews with the staff and the residents on the next day. She was asked why resident #2, 3, #4 were not reported to OSDH when the allegations were reported. She stated she thought of it as one investigation, but could see now that each resident should have been reported at the time the allegation was reported. The DON was asked about the interviews with LPN #1, LPN #2, and agency staff. She stated she did not conduct any interviews with nurses or agency. The DON was asked why resident #3 was not interviewed. She stated she did not know how she was missed. 4. Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/23/20, documented the resident was moderately cognitively impaired and required extensive to total assistance with activities of daily living. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the interviewer asked if NA #3 had witnessed anything else besides the incident with resident #1. The interview documented NA #3 stated CNA #1 had lost his temper with several residents and cussed at them. The interview documented NA #3 said CNA #1 was mean and cursed at resident #2, resident #3, and resident #4. The interview documented NA #3 was asked when CNA #1 cursed at resident #4 because she had camera in her room. The interview documented CNA #1 cursed her when they got out in the hall. A facility investigation interview with resident #4, dated 11/07/20 at 6:00 PM, documented the resident was asked if anyone had been mean to her. The report documented the resident immediately answered, CNA #1, and that she did not like him. The interview documented the resident was asked why she did not like him and the resident stated because he tortured her. The interview documented the resident was asked what she meant. The interview documented the resident stated he did what the Nazis (TRUNCATED)

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 10/01/20 related to the facility's failure to ensure four residents were free from abuse. The facility failed to prevent a staff member from sexually, verbally, and mentally abusing residents. Resident #1 was sexually abused related to two nurse aides reporting hearing resident #1 scream out while certified nurse aide (CNA) #1 was in her room. Two nurse aides reported they went immediately to the resident's room and observed the resident lying on the bed with her brief off and CNA #1 by her bedside. Two nurse aides reported at that time they asked CNA #1 if everything was ok. The NAs reported CNA #1 told them he had performed a ''C clamp'' on the resident to help stimulate her to have a bowel movement. When they asked him what a ''C clamp was, he stated, It was when you put two fingers in the vagina and one finger in the butt and squeeze. Resident #2 was verbally and mentally abused by CNA #1 as reported by the resident #2, one CNA, and 2 nurse aides. Resident #3 was verbally abused by CNA #1 as reported by resident #2, two nurse aides and one agency CNA. Resident #4 was verbally and mentally abused as reported by resident #4, one nurse aide, and one CNA. On 11/20/20 at 1:55 PM, the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to protect and prevent abuse; report abuse immediately; and thoroughly and timely investigate allegations of abuse. The past noncompliance IJ was removed, effective 11/13/20 at 3:00 PM, after the facility put measures in place to prevent recurrence. CNA #1, who was the alleged perpetrator, was suspended immediately, on 11/01/20, upon the nurse aide's reporting to a licensed practical nurse then the administrator. CNA #1 had not worked in the building since the time of suspension. The facility notified Oklahoma State Department of Health, nurse aide registry, physicians, families, Adult Protective Services, and Local Law Enforcement of the allegations against the CNA #1. A 'Quality Assurance Plan of Correction (QAPI) Plan of Correction', dated 11/02/20, documented the following: Individual inservices would be completed with staff 11/02/20 through 11/07/20 on abuse prevention policy and the responsibility of reporting abuse. A handout on abuse and documentation to be given to every employee and signature obtained on their understanding. Explained to each nurse regarding the completion of an incident report with reporting requirements within two hours. Director of nursing and nurse managers were to do daily monitoring of nurse notes, grievance reports, incident reports, wound reports, and hospital records upon returns daily in clinical meeting to ensure all reporting was completed as required. The facility conducted 'Safe Survey' interviews with residents on all halls related to respect and abuse. 'Ambassador Rounds' related to quality of care and staff treatment related to respect and dignity were assigned to staff to perform weekly. Results of theses rounds were to be given to the administrator. Code of Conduct service with all staff and signed for personnel file. A log to be maintained to ensure timeliness for reporting. QAPI committee will review audits and incident reports monthly and make any additional recommendations as needed. The facility conducted a mandatory in-service, which included all staff, on 11/13/20. The inservice was over the facility's abuse policy, investigation guidelines, and reporting suspected or witnessed abuse in a timely manner to their charge nurse or supervisor. Each staff member completed a post test over abuse prevention and reporting. Each staff member signed an acknowledgement of the abuse policy and reporting requirements which documented an employee may be criminally liable for failure to report abuse. Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from abuse, report and protect residents from abuse for four (#1, 2, 3, and #4) of four sampled residents sampled for abuse. a) Resident #1 was sexually abused related to two nurse aides reporting hearing resident #1 scream out while (CNA) #1 was in her room. The two nurse aides reported they went immediately to the resident's room and observed the resident lying on the bed with her brief off and CNA #1 by her bedside. Two NAs reported at that time they asked CNA #1 if everything was ok. The NAs reported CNA #1 told them he had performed a ''C clamp'' on the resident to help stimulate her to have a bowel movement. When they asked him what a ''C clamp was, he stated, It was when you put two fingers in the vagina and one finger in the butt and squeeze. The abuse was not reported to the administrator (adm) until approximately a month later. b) Resident #2 was verbally and mentally abused by CNA #1 as reported by the resident #2, one CNA, and 2 nurse aides. The abuse was not reported to the adm immediately after the occurrence. c) Resident #3 was verbally abused by CNA #1 as reported by resident #2, two nurse aides and one agency CNA. The abuse was not reported to the adm immediately after the occurrence. d) Resident #4 was verbally and mentally abused as reported by resident #4, one nurse aide and one CNA. The abuse was not reported to the adm immediately after the occurrence. The administrator (adm) identified 87 residents who resided at the facility. Findings: 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/21/20, documented the resident was severely cognitively impaired and required extensive assistance of one person with most activities of daily living. An initial 283 incident report, dated 11/01/20, documented it was reported by nurse aide (NA) #2 that she had worked with CNA #1 approximately 10/01/20. The report documented NA #2 heard the resident scream, then she, NA #3, and CNA #4 went into the room to check on the resident. The report documented the resident was lying on the bed and CNA #1 told them he had just performed a ''C clamp'' on the resident to help stimulate her to have a bowel movement. The report documented they did not know if this was acceptable and later started feel uncomfortable about it and told her charge nurse. The report documented the charge nurse notified the administrator and CNA #1 was suspended immediately with an investigation to follow. CNA #1's time records were reviewed. The records documented 10/30/20 as the last day the CNA worked. A facility investigation interview with NA #2, dated 11/02/20 at 9:00 AM, documented the following: NA#2 usually worked doubles on the weekend but started helping out during the week on Hall 200. One of the employees NA #2 started working with was CNA #1. NA #2 said at first she thought he was great but then things started happening which she didn't think were quite right. NA #2 stated she she was on the hall around 10/02/20 with CNA #1, NA #3, and CNA #4. NA #2 stated she, NA #3 and CNA #4 heard the resident scream out. They ran in the room and CNA #1 was standing by the resident's bed holding the resident's brief in his hand. When NA #1 asked if everything was ok, CNA #1 said, Yeah, sometimes you gotta give her a C clamp to help her go poop. NA #2 asked CNA #1 what a C clamp was and he said it was when you put two fingers in the vagina and one finger in her butt and squeeze. NA #2 said she did not think that sounded right but did not think she knew enough as a new nurse aide. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the following: NA #3 stated she was standing in the hall on or about 10/02/20 and she heard resident #1 scream. NA#3 said she went into the room to find out what was wrong. Resident #1 was in bed and CNA #1 was standing by her with her brief in his hand. CNA #1 said everything was ok and that he had to do a C clamp to assist resident #1 in having a BM. NA #2 asked him what a C clamp was and he stated it's when you put two fingers in the vaginal and one finger in the butt and squeeze. A signed hand-written statement by CNA #1, dated 11/02/20, documented, (Name deleted resident #1) has severe costipation (sic). Nurse has been notified of it. Sometimes its so large you have to push around her anus to release the bowel movement. Never have I ever put anything inside any of my residents .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A facility Safe Survey interview, dated 11/02/20 with resident #1 documented, the resident said she felt comfortable about talking to staff about any concerns or complaints. The interview documented the resident said the staff treat her with respect. The interview documented the resident felt comfortable and safe at the facility. A facility investigation interview with CNA #4, dated 11/03/20 at 11:00 AM, documented the following: CNA #4 stated she did not know anything about the incident with resident #1. CNA #1 said she had heard him make inappropriate comments to residents like telling them they had a nice butt and then he would pat them on it. A final 283 incident report, with a facsimile date of 11/12/20, documented the following: On 11/01/20 the director of nursing (DON) was informed by NA #2 that while working with CNA #1 on or about 10/01/20, she heard resident #1 cry out. NA #2 reported that she, NA #3, and CNA #4 went into resident's #1 room to check on her. According to NA #1, the resident was lying in bed and CNA #1 was in the room. CNA #1 told them he had just performed a C clamp procedure on the resident to help stimulate her to have a bowel movement. At the time they did not know whether the practice described by CNA #1 was acceptable nursing practice or not, but after considering the event further, decided to inform their charge nurse about the incident. The charge nurse notified the facility administrator, who initiated this investigation. CNA #1 was suspended immediately. CNA #1's schedule was reviewed and it was determined he had only worked with residents on Hall 200. An investigation was initiated which included assessing the resident, and interviewing the residents and staff involved. And conducted safe surveys on Hall 200 where CNA #1 worked and all residents on other halls were also included. Resident #1 was interviewed and she stated that everyone was very nice to her and she did not recall anyone mistreating her. She also did not recall any problems with having bowel movements. When examined by her physician, there was no harm noted. When CNA #1 was interviewed he denied knowing what a ''C clamp'' was or saying anything in that regard to NA #2, NA #3, or CNA #4. He did say that he sometimes ''pressed on the resident's bottom to assist her with having a bowel movement. He did not explicitly admit to any wrongdoing. The police station was notified and the matter was assigned a case umber. All staff have been inserviced on the facility's abuse policy and reporting protocols with returned competencies completed. The facility has updated the resident's care plan to include at least one female care giver at all times. The resident's family and physician were notified of the outcome of the investigation and the ongoing police investigation. A QAPI plan was completed for abuse reporting. Social Services will do well-being checks weekly times four and counseling referrals as indicated. On 11/19/20 at 11:38 am, the resident was observed sitting up in her bed. The resident was asked if she had been verbally abused, physically hurt, or touched inappropriately by any staff members. The resident was pleasant and said no one had abused her and everyone was nice to her. The resident was asked if she had any problems with certified nurse aide (CNA) #1. She shook her head no. She was asked if she had any children and how many. The resident said she had children but did not know how many. On 11/19/20 at 12:47 PM, NA #2 was interviewed related to abuse and the alleged incident on 10/01/20 involving the resident. She stated she worked on weekends and only worked a few days with CNA #1 in October. She stated she, CNA #4, and NA #3 heard the resident scream from the other end of the hallway. She said she saw him crouched down near the resident who was lying on her bed. She stated CNA #1 had wipes in one hand and a brief in the other. She stated she asked CNA #1 if everything was ok. She stated CNA #1 said he had to do a C clamp on the resident to help her poop. She stated she asked CNA #1 what that was and he said it when you put two fingers in the vagina and one in the butt and squeeze. She stated since she was a new nurse aide, she thought it must be something she did not know about yet. She said she did not report it at that time. She said she reported it to licensed practical nurse (LPN) #1 on 11/01/20. On 11/19/20 at 2:25 PM, CNA #4 was interviewed and she denied knowing anything about CNA #1 saying he had performed a C clamp on the resident. She stated CNA #1 would make rude comments to the residents. On 11/19/20 at 3:12 PM, NA #3 was interviewed related to abuse and the alleged incident on 10/01/20 involving the resident. She stated she, NA #2, and CNA #4 were out in the hall when they heard the resident yelling. The CNA stated when the three of them entered the resident's room, CNA #1 was bent over her and it looked like he was changing her brief. CNA #1 said he performed a C clamp on the resident. NA #3 stated she was just getting out of school and was not aware it was not okay. She stated I trusted he was doing the right thing. She stated she did not report the incident until she was interviewed on the 11/02/20. On 11/19/20 at 4:28 PM, CNA #1 was interviewed related to the allegation of abuse concerning the resident. He stated there was never a time when other CNA's came in after the resident had screamed out. He stated the resident will yell out in pain when she transfers sometimes. When asked about if he had told anyone about performing C clamp, he said a hospice nurse once asked him about the resident's constipation and he said he told her the 'C clamp' was what she needed. He stated he told her that was out of his scope, a nurse would have to do that. When asked what a 'C clamp' was, he stated it was when you push around the anus like a C. He said he had never performed it on a resident. He stated it was something a nurse would do. He was asked what nurse had performed this on a resident but he did not answer the question. The CNA stated he had never put his fingers in the resident's vagina or anus. He was unable to name the hospice nurse. On 11/20/20 at 10:15 AM, during an interview with licensed practical nurse (LPN) #1, she stated NA #2 reported to her on Sunday 11/01/20 that she, NA #3, and CNA #4 had heard resident #1 scream out. LPN #1 reported NA #2 told her they went to the resident's room to find the resident lying in bed with brief off. LPN #1 stated NA #2 told her they ask CNA #1 if everything was ok and CNA #1 report he had performed a 'C clamp' on the resident to help her to poop. The LPN stated NA #2 told her CNA #1 said a 'C clamp' was when you put two fingers in the vaginal and one in the butt. The LPN stated the NA told her she was not sure if that was a procedure that should be done or not. The LPN stated she immediately told the NA she had to tell the administrator and did report it at that time. On 11/20/20 at 9:30 AM, during an interview with the administrator (adm), she stated she first heard of the allegation on 11/01/20. The adm stated LPN #1 reported the allegation to her after NA #2 reported it to the LPN. She stated no one had reported any allegations of abuse related to CNA #1 until that day. She stated the allegations should have been reported to her immediately. She stated she suspended CNA #1 on 11/01/20. She stated the initial report to OSDH was not sent in until the next day. On 11/20/20 at 11:27 AM, during an interview with the director of nurses (DON), she stated the first time she had heard of the allegation of abuse was on 11/01/20. The DON stated the administrator had called her that day on Sunday. The DON stated she started conducting interviews with the staff and the residents on the next day. 2. Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 10/07/20, documented the resident was moderately cognitively impaired and required extensive assistance of two people for activities of daily living. A facility investigation interview with NA #2, dated 11/02/20 at 9:00 AM, documented NA #2 stated a couple of days after the incident with resident #1, she heard CNA #1 screaming at resident #2. The interview documented NA #2 went into the room and the resident was suspended in the lift and was crying. The interview documented NA #2 asked what was going on and CNA #1 said, She[***]again and I just changed her. The interview documented NA #2 told CNA #1 to leave the room and she would take care of it. The interview documented the resident told NA #2 that CNA #1 was hateful to her and she did not like him. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the interviewer asked if NA #3 had witnessed anything else besides the incident with resident #1. The interview documented NA #3 stated CNA #1 had lost his temper with several residents and cussed at them. The interview documented NA #3 said CNA #1 was mean and cursed at resident #2, resident #3, and resident #4. A signed hand-written statement by CNA #1, dated 11/02/20, documented, .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A facility Safe Survey interview, dated 11/02/20 with resident #2 documented, the resident said she did not want to say anything about concerns or complaints. The interview documented the question, do you feel the staff treats you with respect. The interview documented the resident said one staff member is mean to her and hurts her feelings and makes her mad. The interview documented the resident felt comfortable and safe at the facility except for the one male aide who is mean to her and her roommate. A facility investigation interview with CNA #4, dated 11/03/20 at 11:00 AM, documented CNA #4 stated CNA #1 would tell residents to get their MF[***]together'' and that he cussed at the residents all the time. The interview documented a question to NA #4 if she knew that was considered verbal abuse and that she was required to report immediately. The interview documented CNA #4 did not have a reason to why she did not say anything. A final 283 incident report, with a facsimile date of 11/12/20, documented, during an investigation of allegations of abuse, Safe Survey interviews were conducted on Hall 200. The report documented resident #2 reported she had been cussed at and talked rudely to by a male aide she identified as CNA #1. The report documented the resident stated CNA #1 hurt her feelings when talking that way to her. The report documented the resident could not identify a specific date or time on which the alleged behavior occurred. The resident also said she did not like the way CNA #1 spoke to her roommate, resident #3. On 11/19/20 at 11:26 PM, the resident was observed lying on her bed in her room watching TV. She was questioned about any abuse or mistreatment happenings to her or any of the other residents. She said the staff are nice and no abuse had happened to her knowledge. On 11/19/20 at 12:47 PM, during an interview with NA #2 she stated she heard resident #2 crying. She stated she went in to check on her and she was in the lift. NA #2 stated CNA #1 was in the room and he said, She[***]again and I just changed her. NA #2 stated she told him to get out and she would take care of her. She stated the resident had told her she did not like CNA #1. On 11/19/20 at 2:25 PM, during an interview with CNA #4, she stated CNA #1 would make rude comments to the residents and Alma was one of them. CNA #4 stated she had not reported CNA #1 until the time she was interviewed by the DON on 11/03/20. On 11/19/20 at 3:12 PM, during an interview with NA #3, she stated CNA #1 would be really rude and yell at resident #2 and tell her, Yelling like a two year old will only piss me off! The NA could not pin point a time except sometime in October. She stated she did not report it until interviewed by the DON on 11/02/20. On 11/19/20 at 4:28 PM, CNA #1 was interviewed related to the allegations of mental and verbal abuse concerning the resident. The CNA denied any cursing or disrespect to the resident. On 11/20/20 at 9:30 AM, during an interview with the administrator (adm), she stated she first heard of the allegations of abuse on 11/01/20 while she was interviewing NA #2. She stated NA #2 reported allegations of abuse related to residents #1, #2, and #3. The adm stated the allegations should have been reported to her immediately. She stated she suspended CNA #1 on 11/01/20. On 11/20/20 at 11:27 AM, during an interview with the director of nurses (DON), she stated the first time she had heard of the allegation of abuse was on 11/01/20. The DON stated the administrator had called her that day on Sunday. The DON stated she started conducting interviews with the staff and the residents on the next day. 3. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 09/06/20, documented the resident was cognitively intact and required limited assistance with activities of daily living. A facility investigation interview with NA #2, dated 11/02/20 at 9:00 AM, documented NA #2 stated resident #3 (date unknown) was being anxious and trying to get up and leave the dining room repeatedly. The interview documented NA #2 said CNA #1 walked over to resident #3 and got down in her face and said, quit your [***] ing[***](name deleted resident #3) you are not going anywhere set down. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the interviewer asked if NA #3 had witnessed anything else besides the incident with resident #1. The interview documented NA #3 stated CNA #1 had lost his temper with several residents and cussed at them. The interview documented NA #3 said CNA #1 was mean and cursed at resident #2, resident #3, and resident #4. A signed hand-written statement by CNA #1, dated 11/02/20, documented, .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A facility interview with resident #3 was not provided. A facility investigation interview with CNA #4, dated 11/03/20 at 11:00 AM, documented CNA #4 stated CNA #1 would tell residents to get their MF[***]together'' and that he cussed at the residents all the time. The interview documented a question to NA #4 if she knew that was considered verbal abuse and that she was required to report immediately. The interview documented CNA #4 did not have a reason to why she did not say anything. A final 283 incident report, with a facsimile date of 11/12/20, documented, during an investigation of allegations of abuse, Safe Survey interviews were conducted on Hall 200. The report documented resident #2 reported she had been cursed and talked rudely to by a male aide she identified as CNA #1. Resident #2 also said she did not like the way CNA #1 spoke to her roommate, resident #3. The report documented resident #3 was not interviewable and could not provide a statement. During the survey time, resident #3 was residing on the COVID-19 unit and was unable to be interviewed due to not feeling well. On 11/19/20 at 12:47 PM, during an interview with NA #2, she stated resident #3 was trying to leave the dining room a couple of weeks ago and CNA #1 got in her face and said, Quit your [***] ing[***]you are not going anywhere. She said she didn't think anyone else heard. She did not report it until 11/01/20. On 11/19/20 at 2:36 PM, during an interview with an agency CNA, she stated she never observed CNA #1 physically or sexually abuse a resident. She stated she did hear him yell at resident #3 over a month ago. She stated resident #3 would like to change her clothes a lot. She stated CNA #1 in an angry voice told the resident she was not going to change her clothes. The agency CNA stated he had made her feel uncomfortable at times with his sexual comments about her body. She stated she did not report him. On 11/19/20 at 4:28 PM, CNA #1 was interviewed related to the allegations of verbal abuse concerning the resident. The CNA denied any cursing or disrespect to the resident. On 11/20/20 at 9:30 AM, during an interview with the administrator (adm), she stated she first heard of the allegations of abuse on 11/01/20 while she was interviewing NA #2. She stated NA #2 reported allegations of abuse related to residents #1, #2, and #3. The adm stated the allegations should have been reported to her immediately. She stated she suspended CNA #1 on 11/01/20. On 11/20/20 at 11:27 AM, during an interview with the director of nurses (DON), she stated the first time she had heard of the allegation of abuse was on 11/01/20. The DON stated the administrator had called her that day on Sunday. The DON stated she started conducting interviews with the staff and the residents on the next day. 4. Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10/23/20, documented the resident was moderately cognitively impaired and required extensive to total assistance with activities of daily living. A facility investigation interview with NA #3, dated 11/02/20 at 9:54 AM, documented the interviewer asked if NA #3 had witnessed anything else besides the incident with resident #1. The interview documented NA #3 stated CNA #1 had lost his temper with several residents and cussed at them. The interview documented NA #3 said CNA #1 was mean and cursed at resident #2, resident #3, and resident #4. The interview documented NA #3 was asked when CNA #1 cursed at resident #4 because she had camera in her room. The interview documented CNA #1 cursed her when they got out in the hall. A facility investigation interview with resident #4, dated 11/07/20 at 6:00 PM, documented the resident was asked if anyone had been mean to her. The report documented the resident immediately answered, CNA #1, and that she did not like him. The interview documented the resident was asked why she did not like him and the resident stated because he tortured her. The interview documented the resident was asked what she meant. The interview documented the resident stated he did what the Nazis did to the Jewish women. The interview documented the resident was asked what that meant. The interview documented the resident said CNA #1 put his hands up in me and and hurt me. The interview documented the resident was asked why he would do that and she stated he was pleasing himself. A signed hand-written statement by CNA #1, dated 11/02/20, documented, .I can admit when I'm wrong or have done something wrong, but I'm only guilty of being tired, frustrated and very overwhelmed with the workload on 200 hall. I will be putting in for my vacation time very soon because I need a break. A final 283 incident report, with a facsimile date of 11/12/20, documented, during the Safe Survey interviews, resident #4 informed the DON that CNA #1 ''tortured'' her on several occasions while giving her a shower. The report documented the resident could not identify any special date or time of the alleged incidents, although she thought they had occurred over the last two months. The report documented the resident stated CNA #1 put his hands up inside of her and that she thought he was doing this to pleasure himself. The report documented the residents stated she had not told anyone about these alleged incidents, except for her spouse. The report documented the resident's physician and spouse were immediately notified. The report documented the resident's husband was interviewed and he said that the resident had told him of these incidents over the past couple months, but that he did not believe her and had not reported it to anyone because he found CNA #1 to be very nice and because the resident had been know to make up things in the past. The report documented the resident's room is equipped with a camera and the resident's husband denied seeing anything inappropriate being done to his wife on the video from the camera. The report documented the resident was examined by her physician and there was no physical harm to the resident. The report documented the police were notified and an officer interviewed the resident. The report documented the officer referred the matter to a detective and requested that the facility not have any more contact with CNA #1 until the police had a chance to interview him and conduct its investigation. The report stated the facility updated the resident's care plan to include at least one female care giver at all times. The report documented social services will do well checks weekly times four and make counseling referrals as indicated. The report stated the facility is awaiting the final police investigation and CNA #1 remains suspended indefinitely. On 11/19/20 at 2:25 PM, during an interview with CNA #4, she stated CNA #1 would make rude comments to the residents. CNA #4 stated he was rude to resident #4. She said CNA #1 would get angry with the resident, not in her room, but in the shower room. CNA #4 stated CNA #1 would use curse words. CNA #3 stated she had not reported CNA #1 until she was interviewed by the DON on 11/03/20. CNA #4 said she was not aware of any sexual or physical abuse towards the resident. NA #2 was interviewed and was not aware of any abuse against resident #4. On 11/19/20 at 3:12 PM, during an interview with NA #3, she stated CNA #1 was verbally aggressive and hateful toward resident #4. The NA was not aware of any sexual or physical abuse towards the resident. On 11/19/20 at 11:00 AM, during an interview with resident #4, she was asked if she felt safe at the facility. The resident stated she did not feel safe. She said a guy tortured me, (name deleted CNA #1). She said CNA #1 and one of my bosses took me to the police department. She stated she did not feel safe at the police department because they are all his (CNA #1's) friends. The resident said she was in the hospital on Post Road and Air Depot. She said she was in a facility which could operate on my brain. The resident said CNA #1 burned her head with a hairdryer. She said I screamed and cried and begged him to stop and he said that don't hurt, I just drying your hair. The resident said CNA #1 put both hands up my vagina at the same time. She said I didn't tell on him. She stated I was afraid of him; he was really mean. The resident said CNA #1 burned her with hot water in the shower. She said he stuck the hose down my throat a (TRUNCATED)

Based on observation, record review and interview, it was determined the facility failed to ensure interventions to aid in the prevention and healing of pressure ulcers were implemented for two (#77 and #20) of three sampled residents who were reviewed for facility acquired pressure ulcers. Resident's #77 and #20 developing both developed three unstageable pressure ulcers. The facility identified three residents with facility acquired pressure ulcers. Findings: 1. Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 11/05/18, documented the resident was at risk for the development of pressure ulcers. Interventions included to inspect skin (complete body head to toe) every week and document results. The admission assessment, dated 11/14/18, documented the resident's cognition was intact, he required extensive assistance with activities of daily living, he was at risk for pressure ulcers and had no unhealed pressure ulcers. The assessment documented a pressure reducing device for the bed was applied. A nurse's note, dated 11/23/18 and not timed, documented skin prep was applied to the left great toe. There was no documentation to indicate why the skin prep was applied. A nurse's note, dated 11/24/18 and not timed, documented skin prep was applied to the left great toe. There was no documentation to indicate why the skin prep was applied. A nurse's note, dated 11/25/18 at 3:00 a.m., documented a black spot on the left great toe without redness or warmth. There was no documentation to indicate the physician was notified or interventions put in place for treatment of [REDACTED]. A nurse's note, dated 11/26/18 at 3:05 a.m., documented a black spot was observed on the left great toe without redness or warmth. There was no documentation to indicate the physician was notified or interventions put in place for treatment of [REDACTED]. A nurse's note, dated 11/26/18, documented skin prep was applied to the left great toe. There was no documentation to indicate why the skin prep was applied. A nurse's note, dated 11/27/18 at 4:00 a.m., documented a black spot on the left great toe and second toe received skin prep every shift. Another skilled note, dated 11/27/18, documented a physician was in the facility and provided orders for an orthopedic consult due to the two black spots on the left great toe. A nurse's note, dated 11/28/18, documented, . skin prep on left great toe and second toe A nurse's note, dated 11/28/18, documented, .Daughter (name-deleted) took resident to VA ER ( Veterans Affairs emergency room ) to have Ortho look at residents L (left) great toe per (Name-deleted physician) recommendation. Left facility at 1000. A nurse's note, dated 11/29/18 not timed, documented skin prep applied to left great toe and second toe. A physician's telephone order, dated 11/30/18 at 11:30 a.m., documented treatment to left posterior medial heel apply [MEDICATION NAME] once daily, cover with gauze island dressing with border as needed if drainage. The [DIAGNOSES REDACTED]. Also monitor the heel and first toe of the left foot every shift for signs/symptoms of infection or drainage. The physicians order documented to please initial the documentation record as performed on the treatment sheet and the nurses notes. A physician's telephone order, dated 11/30/18 at 11;30 a.m., documented treatment to left dorsal first toe, apply [MEDICATION NAME] once a day, apply gauze island border as needed if drainage. [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. A wound evaluation management summary sheet, dated 12/06/18, documented the resident had an unstageable deep tissue injury (DTI) of the left dorsal first toe which measured 1.2 x 1.0 x not measurable. This was at least 13 days duration. The sheet also documented an unstageable DTI of the left distal first toe which measured 2.1 x 1.8 x not measurable. This was at least 13 days duration. The sheet also documented an unstageable, due to necrosis, of the left posterior medial heel which measured 0.5 x 0.3 x not measurable. Recommendations were for staff to offload the heels. This was at least 13 days duration. There was no documentation the facility had addressed the recommendation to offload the wounds. There was no documentation in the clinical record to indicate preventive measures were in place to prevent the development of the three unstageable pressure ulcers. The care plan, updated 12/09/18, documented the resident had an unstageable DTI to the left dorsal first toe, unstageable DTI to the left distal toe, and an unstageable DTI to the left posterior medial heel. The care plan documented the staff were to: ~ inspect the skin (compete body head to toe) every week and document results, ~ treatments and dressings as ordered per physician, ~ wound management to consult, and ~ weekly treatment documentation to include measurement of each area of skin breakdown. The resident was observed throughout the survey, There were no observations the lower extremity was floated or offloaded while in bed. The resident was asked if anyone had instructed/educated him about elevating his left foot to prevent pressure on the left heel. He stated, No. On 12/12/18 at 4:15 p.m., the wound care nurse was asked to review the recommendations from the wound doctor. After review, she was asked if the recommendation to offload the wound should be part of the order. She stated, Yes. She was asked to review the orders/documentation. After review, she was asked if the recommendation to offload the wound had been written. She stated, No. She was asked if there was documentation to indicate the wound had been offloaded. She stated she had instructed the resident and staff to float/offload the left foot numerous times but it was not documented. On 12/12/18 between 4:35 p.m., and 4:55 p.m., two of three certified nurse aides (CNA) stated they had been instructed to place a pillow under the resident's left foot. They stated they did not know why it was not being done. One CNA stated she had never been given any instructions regarding positioning for the left foot. A physician's telephone order, dated 12/12/18 at 5:35 p.m., documented to offload wound and float heels while in bed for a [DIAGNOSES REDACTED]. On 12/13/18 at 9:45 a.m., licensed practical nurse #1 was asked to review the nurse's notes and physician's orders [REDACTED]. He stated, Yes, he remembered calling the physician on Thanksgiving. He was asked if he had documented the physician notification. He stated, No. 2. Resident #20 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/22/18, documented the resident's cognition was intact, was at risk for the development of pressure ulcers and did not have any healed or unhealed pressure ulcers. The assessment documented the resident had not had any episodes of rejecting care. A pressure reducing device on the bed was to be applied. A care plan, documented the resident was at risk and/or had actual skin breakdown. The care plan documented interventions which included to off-load the resident's heels, initiated on 04/04/18 and to float the heels while in the bed to off-load pressure, initiated on 11/30/18. The monthly physician orders, dated 10/28/18, documented to off-load the heel every shift. An onset date of 05/08/18. A treatment administration record (TAR), dated 11/01/18 through 11/30/18, documented to off-load the heel every shift. There was no documentation to indicate the resident refused the treatment to offload his heels. A nurse's note, dated 11/19/18, documented the wound care nurse was notified of the resident's left lateral foot wound. The note documented the wound was a stage two and measured 4 centimeters (cm) in length and 3 cm in width and 0.1 cm in depth with moderate serosanguineous drainage with no odor. The note documented new orders were received for wound care to be performed every other day. A wound evaluation and management summary, dated 11/29/18, documented, ~ site one-unstageable deep tissue injury (DTI) pressure wound to the left lateral foot with an onset date of greater than four days with measurements of 3.5 cm length x 3.2 cm in width x the depth not measurable with light serous drainage with 10 % thick adherent devitalized necrotic (dead) tissue and 90 % granulation tissue (new connective tissue that form on the surface of healing wound). ~ site two-unstageable DTI pressure wound with intact skin to the left posterior lateral heel with an onset of greater than four days with measurements of 2.8 cm x 1.4 cm x depth not measurable with no drainage. ~site three-unstageable DTI pressure wound to the right lateral ankle with an onset of greater than four days measuring 0.9 cm x 0.7 cm x not measurable with light serous drainage with 100% thick adherent black necrotic tissue. The evaluation and management summary documented the following treatments and recommendations: ~iodosorb and gauze dressing three times a week to site one and three and apply skin prep daily to site two. ~off-load wound, float the resident's heels while in the bed, reposition per facility protocol, vitamin C and Zinc Sulfate. A physician's orders [REDACTED]. Also to float heels in bed, off-load wound. Another Physicians telephone order dated 11/20/18 documented to change the wound care order to the left lateral foot due to an unstageable DTI. A wound evaluation and management summary, dated 12/06/18, documented ~site one-unstageable DTI pressure wound to the left lateral foot with a wound size of 3.2 cm x 2.9 cm x not measurable. The evaluation documented the area around the pressure ulcer had odor, maceration and redness with moderate serosanguineous drainage and had 100 % thick adherent devitalized necrotic tissue. The wound evaluation documented the wound had deteriorated. ~site two-unstageable DTI pressure wound with intact skin to the left posterior lateral heel with an onset of greater than ten days with measurements of 2.2 cm x 1.2 cm x depth not measurable with no drainage. ~site three-unstageable DTI pressure wound to the right lateral ankle with an onset of greater than ten days measuring 1.1 cm x 0.7 cm x not measurable with light serosanguineous drainage with 100% thick adherent black necrotic tissue. The following interventions were recommended to float the resident's heels while in the bed, off-load wound, reposition per facility protocol and to administer vitamin supplements and an antibiotic. A TAR, dated 12/01/18 through 12/12/18, did not document the resident refused to have his heel off-loaded. The TAR did not document initials to indicate the heel was off-loaded or a reason why they were not off-loaded. The TAR documented circled initials on six days on the night shift indicating the task of floating the heel while the resident was in bed was not completed. The TAR did not document a reason the heel was not floated. A physician's orders [REDACTED]. The TAR did not document initials on 12/07/18 and 12/09/18 to indicate the wound care was performed to the left lateral foot wound and did not document initials on 12/08/18 and 12/09/18 to indicate the wound care was performed to the right lateral ankle as ordered. The TAR did not document a reason the wound care was not performed. The TAR documented the resident refused wound care and documented missed wound care on 12/11/18. On 12/11/18, 12/12/18 and 12/13/18 the resident was observed up in his wheelchair, the resident's left foot was resting on the wheelchair foot-rest. The resident had a yellow non-skid sock on his left foot and a shoe on his right foot. The resident did not have any padding or positioning devices to prevent pressure on the wound. On 12/12/18 at 10:09 a.m., the wound care nurse was observed to perform wound care on resident #20. The resident's left lateral dressing before being removed was dated 12/10/18. The wound was observed to have redness around the wound with a necrotic wound bed with an odor and serosanguineous drainage. The left heel wound was observed to have a black area on the heel. Neither the wound care nurse or the certified nurse aide (CNA) offered to float the resident's heels after the wound care was completed. At 10:47 a.m., the wound care nurse was asked about the resident's pressure ulcers. She stated it looked like it was a blister that had opened up and had a dried area. She stated she staged it as two because it was open and over a weekend it had become unstageable due to the pressure the resident put on the area where the wound was located. She stated the resident had heel managers and would not elevate his heels off the bed. She stated the resident would not let all the staff perform his wound care but usually would let her perform his wound care. She was asked what off-load meant. She stated it was making sure the pressure ulcer did not have pressure on that area with boots or heel manager. She was asked to describe a heel manager. She stated it was a foam cushion which prevented pressure on an area. She stated the type of off-loading device used depended on the resident. The wound care nurse stated the dressing to the left lateral foot was changed daily. She was asked if the dressing had been changed on 12/11/18. She stated no, she missed it. She stated she had been alternating the wound care with the nurses working on the hall but was now doing all the wound care on the pressure wounds. At 2:55 p.m., certified nurse aide (CNA) #1 was asked about the care provided to the resident. She stated he was independent with most of his care. She was asked if she elevated the resident's feet while he was in bed. She stated no, the resident closed his door at night and put himself to bed. On 12/13/18 at 8:19 a.m., the resident was asked about his wound care. He stated he did not refuse his wound care. The resident was asked if he had a special cushion for his heels. He stated no. He was asked if the staff offered to elevate his heels off the bed or when he was up in a wheelchair. He stated he did not remember. The resident did not have heel protectors, heel manager or other positioning devices in his room. At 8:35 a.m., the wound care nurse was asked to observe the resident's room for positioning devices. She stated he should have a heel manager. The wound care nurse stated he had one at one time, but he wasn't using it, so a staff member was going to take it out to clean it. She stated that was about a month or two ago. The wound care nurse was asked how the staff were off-loading the heels. She stated she did not know. She stated she would look for the heel manager. She was asked about the mattress. She stated it was not a low-air loss mattress but it was a pressure reducing mattress. She could not tell me the grade or when she might consider a low air loss mattress. At 9:18 a.m., the wound care nurse stated she was going to ask the wound care physician for something to off-load the resident's heels while he was up in the wheelchair.

On [DATE], an IJ situation was determined to exist for resident #1, due to the facilities failure to notify the physician of a resident's change in condition related to worsening respiratory status and episodes of nose bleeds while on [MEDICATION NAME] therapy. Failure to assess, monitor and intervene appropriately and timely for a resident on [MEDICATION NAME] therapy with history of [MEDICAL CONDITION] and [DIAGNOSES REDACTED] with mechanical valve replacement. The resident left the faciity on [DATE] at 1:11 p.m., and later expired on [DATE] at 2:59 a.m. It was determined the resident expired related to cardiopulmonary arrest. The resident's secondary diagnoses included a history of [MEDICAL CONDITION] and [MEDICAL CONDITION] The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. On [DATE] at 4:14 p.m., the administrator and the director of nursing were notified of the IJ situation. On [DATE] at 6:45 p.m., the facility verbally presented an acceptable plan of removal before the surveyors exited the facility. On [DATE] at 9:00 a.m., an acceptable written plan of removal was presented to the survey team. The Plan of Removal documented: "Immediate Jeopardy Plan of Removal: Noble Healthcare [DATE]: I. Not notifying physician of resident change in conditions Inservice all licensed nursing staff in person or by telephone by midnight on [DATE] on policy and procedure for physician notification of all change in condition and guidelines of what warrants a change of condition. Policy to include, but not limited to examples of respiratory issues. Inservice all certified medication aides by telephone or in person my midnight on [DATE] on policy regarding holding medications and signs and symptoms to report to nurse. A list was obtained of all residents on [MEDICATION NAME] therapy. Audit of these charts has been completed by nurse manager to verify PT/INR orders are in place. Physician was notified regarding any residents that required PT/INR orders, all orders have been completed at this time. Labs needed are scheduled to be collected in the AM of [DATE]. A list was obtained of all residents with [DIAGNOSES REDACTED]. Physician was notified regarding any residents that required lab orders and all orders have been completed. Labs needed are scheduled to be collected in the AM of [DATE]. New admission checklist was put in place on [DATE] for charge nurse, nurse managers, and medical records to complete within 24 hours of admission or readmission. An audit has been done on all new admissions since [DATE]. An in-service was done with all nurse managers on how to properly audit a new admit physician's orders [REDACTED]. II. Not monitoring the [MEDICATION NAME] and obtaining PT/INRs A list was obtained of all residents on [MEDICATION NAME] therapy. Audit of these charts has been completed by nurse manager to verify PT/INR orders are in place. Physician was notified regarding any residents that required PT/INR orders, all orders have been completed at this time. Labs needed are scheduled to be collected in the AM of [DATE]. A new Anti-coagulant Protocol policy was developed on [DATE]. An inservice was held with all licensed nurses on [MEDICATION NAME] therapy and policy to monitor INRs either by telephone or in person by midnight on [DATE]. Any patient on [MEDICATION NAME] must have routine monitoring of PT/INRs in place. III. Not monitoring hemoglobin and hematocrit with [MEDICAL CONDITION] and/or low hgb. A list was obtained of all residents with [DIAGNOSES REDACTED]. Physician was notified regarding any residents that required lab orders and all orders have been completed. All additional routine labs are scheduled to be collected in the month of [DATE]. All charts were audited to ensure all current residents have admission labs and yearly routine labs in place. Physician was notified regarding any residents that required lab orders and all orders have been completed. Labs needed are scheduled to be collected in the AM of [DATE]. Inservice licensed staff on monitoring hemoglobin and hematocrit for patients with low hgb./[MEDICAL CONDITION]. Orders should be obtained for routine monitoring of all patients with [MEDICAL CONDITION]." On [DATE] at 3:00 p.m., the IJ was removed after all staff had been in-serviced, a new anti-coagulant protocol was implemented, audits completed for PT/INR orders for all residents on [MEDICATION NAME], audits completed for hemoglobin and hemotocrit orders for all residents with [DIAGNOSES REDACTED]. The deficient practice remained at an isolated level of actual harm that is not immediate Jeopardy. On [DATE] at 10:00 a.m., and 3:00 p.m., nursing staff from all shifts who had attended the in-services were interviewed. All staff were knowledgeable concerning notifying the physician of changes in condition and proper documentation. All staff were knowledgeable in regards to the new anti-coagulant protocol. Staff were knowledgeable in regards to assessing and monitoring a resident on [MEDICATION NAME] therapy. All staff were knowledgeable in regards to obtaining, monitoring and reporting hemoglobin and hematocrit levels for residents with an [MEDICAL CONDITION] diagnosis. Staff were also knowledgeable concerning admission labs and yearly routine labs to include a complete blood count. Based on clinical record review, staff interviews and review of facility policy and procedure, it was determined the facility failed to: ~ assess, monitor, and intervene for [MEDICATION NAME] therapy including monitoring INR lab values, obtain physician order [REDACTED]. ~ notify physician of a resident's change in condition related to respiratory status and episodes of nose bleeds while on [MEDICATION NAME] therapy for one (#1) of four sampled residents whose records were reviewed for a change in condition. This had the potential to affect all 79 residents who resided in the facility; and ~ assess, monitor and intervene for a resident with history of [MEDICAL CONDITION] including monitoring hemoglobin and hematocrit lab values for one (#1) of four sampled residents with a [DIAGNOSES REDACTED]. This resulted in an IJ situation. Findings: A facility policy and procedure titled, Holding/Refusal to Administer Medications, documented, "...If a nurse in her/his judgment is not comfortable administering a routine medication to a resident that is ordered by the physician without parameters for administering the medication, then the nurse shall document the reason in the chart and notify the physician..." A facility policy and procedure titled, Admission Checklist, documented, "...Routine labs are ordered upon admit to include: CBC, CMP, TSH, Lipid Panel, Occult Stool, [MEDICATION NAME], and Pre-[MEDICATION NAME] next lab day...If on [MEDICATION NAME], PT/INR q monthly at a minimum..." A facility policy and procedure titled, Chart Audit, documented, " ...Labs: ...Have all routine labs been obtained, in chart...Is patient on medication requiring labs, such as [MEDICATION NAME] labs been obtained, is copy in chart...Labs: (named physician) pts: CBC, CMP, TSH, [MEDICATION NAME], Pre-[MEDICATION NAME], lipid panel, Occult Stool, on admit (one time order)..." A facility policy and procedure titled, Nursing Documentation Policy, documented, "...Change in condition: When a change in condition is noted, an assessment is done by the nurse and recorded in the nurses notes. An entry shall be made each shift until the residents condition improves..." A facility policy and procedure titled, Physician Notification for Resident Change in Condition, documented, "... The licensed nurse assigned to the resident is responsible for notification of and communication to the medical staff regarding significant changes or significant deterioration in the resident's condition and for assuring that there is physician response. Guidelines: 1. Change in the condition of the resident are determined by assessments utilizing parameters defined by physician order/instructions, the resident's previous condition and/or previous labs, and/or by resident safety factors... 3. Document in the medical record the date, time and name of each physician notified, actions taken and/or resident's response to treatment. 4. Physician notification may be indicated in the following situations: ...b. Any sudden and/or marked adverse change in signs, symptoms, or behavior exhibited by a resident... e. Any untoward response or reaction to medication or treatment..." Resident #1 was admitted to the facility with diagnoses which included [MEDICAL CONDITION], [DIAGNOSES REDACTED] with mechanical valve replacement, stage III kidney disease, abdominal hernia, hypertension, GERD, diabetes, [MEDICAL CONDITION] and [MEDICAL CONDITION]. A hospital history and physical note, dated [DATE], documented, "...Chief complaint: ...He thinks he might have passed out last night or he fell ...Past medical history: 1. Diastolic [MEDICAL CONDITION] and [DIAGNOSES REDACTED], which it sounds like he has some type of mechanical valve put in. 2. Stage III [MEDICAL CONDITION]. 3. [MEDICAL CONDITION]. 4. Hypertension. 5. Diabetes ... Physical Examination: ...Lungs: He had diminished breath sounds at the bases and some mild lateral [MEDICAL CONDITION] rubs. I really did not hear any obvious rales. His inspiratory effort looked normal... Diagnostic data: ...His hemoglobin though is quite a bit lower than at previous times he has been in our emergency room at 7.9. The last one we have from a few months ago was 10. It is microcytic. Followup hemoglobins have also shown that it is low. Coagulation panel shows he is appropriately therapeutic on his [MEDICATION NAME] considering his mechanical valve replacement...His BNP was quite a bit higher than at other visits though at 1641...Chest x-ray showed some pleural effusions that look similar to previous exams. CT scan of his abdomen showed also some bilateral effusions with some atelectasis...His echocardiogram showed a normal systolic function, confirmed the mechanical aortic valve, and increased [MEDICAL CONDITION] artery pressure which is chronic... Assessment and plan: ...1. He has what I suspect is an acute [MEDICAL CONDITION] that is microcytic. It may be chronic, as he does have [MEDICAL CONDITION] ...The last hemoglobin I have available is from 4 months ago, and it (sic) worse than at that point, and it has been checked 2 more times and remains quite low, so I believe that it is accurate...considering his [MEDICAL CONDITION], his hemoglobin needs to be higher than 10, so I am going to transfuse 2 units of packed red blood cells, followup hemoglobin and hematocrit after that, and then transfuse further if needed to get his hemoglobin greater than 10. Further treatment of [REDACTED]. He is on [MEDICATION NAME] but does not have any obvious bleeding... 2. He has some findings of possible acute exacerbation of chronic diastolic [MEDICAL CONDITION] that would be evidenced by his brain natriuretic peptide being quite higher than usual. Otherwise though, that is difficult because he really does not, at least at the time I saw him, note that his breathing is more difficult than usual, and he has some chronic pleural effusions. At least for now, I am going to go ahead and treat it as if this is an acute exacerbation. I will go ahead and give him more [MEDICATION NAME] now and then continue that..." A hospital cardiology progress note, dated [DATE], documented, "...Awake, oriented...Sats 100%...Lungs good...Echo: Mild AI (aortic insufficiency)...Ass: [MEDICAL CONDITION], multi factorial. ? (questionable) hemolysis from mech (mechanical) AVR (aortic valve replacement)...GI bleed..." A hospital physician order, dated [DATE], documented, "...ok to d/c to SNF. Advice (sic) SNF to hold [MEDICATION NAME]/Prinvil for 2 day (and) restart it. Advice (sic) SNF to keep INR ,[DATE]...Advice (sic) SNF to check BMP on Monday..." A nurse's note, dated [DATE] documented, "...Pt arrived from (named hospital) via (named ambulance). Lungs CTA (no) labored respirations ...AA (and) O x 3. Able to voice wants (and) needs..." An admission/start up record, dated [DATE] documented, "... FSBS AC (and) [MEDICATION NAME] 2.5 mg (1) po daily (at) 4 p.m. Dx: (no [DIAGNOSES REDACTED]. There was no other laboratory testing ordered for the resident. A physician's orders [REDACTED]. A skilled nurse's note, dated [DATE] documented, "...Resp even/unlabored. Continues c O2 2 L NC as ordered..." A physician's orders [REDACTED]. A skilled nurse's note, dated [DATE] documented, "...O2 needed...(checked) L/cannula 2L ...(checked) Continuous..." A skilled nurse's note, dated [DATE] documented, "...Resident had nose bleed x 1 this shift..." A nurse's PRN notes/medication notes record, dated [DATE], documented, "[MEDICATION NAME] 2.5 refused LPN notified..." There was no documentation the physician was notified of the resident's nose bleed. There was no documented physician's orders [REDACTED]. A skilled nurse's note, dated [DATE] documented, "...O2 needed ...(checked) L/cannula 2L ...O2 sats 95%..." A skilled nurse's note, dated [DATE] documented, "...O2 needed ...(checked) L/cannula 2...(checked) Continuous...O2 sats 96%..." A nurse's PRN notes/medication notes record, dated [DATE] documented, "[MEDICATION NAME] 2.5 mg held per LPN. Resident has been bleeding more than he should be..." A physician progress notes [REDACTED]. There was no documentation the physician was notified related to the resident bleeding or hold order for [MEDICATION NAME] and respiratory status. A nurse's PRN notes/medication notes record, dated [DATE] documented, "[MEDICATION NAME] held per LPN..." A skilled nurse's note, dated [DATE] documented, "...Lungs coarse thru-out (sic). Resp labored...P.O. fluids restricted by Dr. (and) followed ..." There was no documentation of physician notification of respiratory status or order to hold the [MEDICATION NAME] dose. A skilled nurse's note, dated [DATE] documented, "...Respiratory ...(checked) SOB...(checked) on exertion...O2 needed...(checked) L/cannula...O2 sats 92%..." A skilled nurse's note, dated [DATE] documented, "...Res has had occasional nosebleeds tonight..." A discharge assessment, dated [DATE] documented the resident was cognitive in skills for daily decision making. He required limited assistance with transfers, ambulation, dressing and hygiene. He required extensive assistance with bathing. He was always continent of bowel and bladder. A skilled nurse's note, dated [DATE] documented, "...Respiratory ...(checked) SOB...(checked) on exertion...O2 needed...(checked) L/Cannula...O2 sats 94%..." A skilled nurse's note, dated [DATE] documented, "...Resident states he will be leaving today even if he has to walk himself home..." A skilled nurse's note, dated [DATE] at 1:11 p.m. documented, "...Resident discharged to go home. (No) s/s of distress..." An ambulance record, dated [DATE] documented, "...Chief complaint: [MEDICAL CONDITION]; onset of event occurred 20 minutes prior to calling EMS ...Spontaneous circulation: No...First monitored rhythm: Asystole..." An emergency department report, dated [DATE] documented, "...Stated complaint: Full arrest...Chief complaint: [MEDICAL CONDITION] History of present illness: ...presents (sic) emergency department with (named EMS service) in full arrest. Reportedly was seen last about 1:00 (sic). I am (sic) nephew who stays with him checked on him and found him in the bathroom unresponsive about 120 (sic). He had no pulse and EMS was contacted. On EMS arrival the patient was asystolic. He has been given multiple rounds of medications remained asystolic throughout his emergency transfer here. Patient has long-standing history of severe [MEDICAL CONDITION] diabetes mellitus and [MEDICAL CONDITION]. He was recently hospitalized to the hospital with exacerbation of his systolic heart failure. He got out of the hospital about 10 days ago... Physicial exam: Patient is being bagged on EMS arrival. He has no pulse or blood pressure. General appearance: Patient is comatose. Patient is intubated and being ventilated. Respiratory: Breath sounds are equal bilaterally. Cardiac: Heart sounds are absent. There are no pulses. Neurological: The patient is flaccid and unresponsive... Differential Diagnosis: [REDACTED]. Laboratory Results: [DATE] 0252: Test: ...Hgb 7.8 L ...Hct 23L... Sodium 132 L... Potassium 8.0 (astrick) H... BUN 70 H Creatinine 2.2 H... pH 7.048 L... pCO2 88.3 H... pO2 42 L... HCO3 24.3... Total CO2 27.0... ED Course/Procedures: After initial ABC evaluation CPR was continued...CPR was continued throughout the patient's emergency department stay. He was given multiple doses of [MEDICATION NAME]. He was given doses of calcium glucose...And despite aggressive resuscitative measures patient failed to respond. He was pronounced at 0259 (2:59 a.m.)... Primary Diagnosis: [REDACTED]. Secondary Diagnosis: [REDACTED]. Condition: Expired..." On [DATE] at 12:50 p.m., the administrator was asked where the nursing staff documented physician communication in the medical record. She stated, "Either there is a fax or it's in the nurse's notes." She was then asked where nursing staff documented if a resident had experienced blood loss. She stated, "Nurse's notes." At 2:00 p.m., the DON was asked if a resident was on [MEDICATION NAME] would they have a [MEDICATION NAME] flowsheet. She stated, "Not necessarily to start out with. When they get a lab draw then they start the flowsheet." She was shown the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She stated, "This is a med aide and so if she was told to by the LPN there should be a telephone order and note. I don't think CMA should have charted that. Should have charted [MEDICATION NAME] held by LPN." She was then shown the nurse's note that documented coarse lungs and labored breathing and asked if a physician was notified of the findings. She stated, "If she notified the doctor it should be in the note." She was then asked if a resident was on [MEDICATION NAME] therapy and had bleeding problems, should laboratory testing be ordered. She stated, "If we don't know what's going on then we can't order it." At 2:10 p.m., LPN #1 was asked to review her charting which documented lungs coarse and respirations labored. She was asked if she documented and notified the physician of the respiratory concerns. She stated, "I didn't notify the doctor cause he told me it was normal for him and he didn't want me to notify the doctor." She was asked if she should have documented the resident's conversation related to the respiratory findings. She stated, "Yes." On [DATE] at 2:45 p.m., the DON was asked if the physician should have been notified when the resident had nose bleeds. She stated, "Yes." She was asked if a resident was on [MEDICATION NAME] therapy and began to have nose bleeds what could this mean. She stated, "They should call the doctor and document." At 3:35 p.m., CMA #1 reviewed her note on the resident's medication administration which documented, "[MEDICATION NAME] 2.5 mg held per LPN. Resident has been bleeding more than he should be." She stated, "Nurse told me day before he had had a couple of nose bleeds. The day before I talked to her I gave it to him. She told me to hold it but I don't know if she had talked to the doctor." On [DATE] at 3:45 p.m., physician #1 was asked if the nursing staff relayed to him the notes from the resident's stay in (named hospital) from [DATE], for orders to hold [MEDICATION NAME] and Prinvil for two days, keep INR between 2 and 3 and BMP on Monday. He stated, "It's been so long. I don't remember." The physician was asked if he was aware the resident was taking the medication [MEDICATION NAME]. He stated, "Yes. He was suppose to be on it. I did not stop it." The physician was asked if he routinely ordered an INR for a resident on [MEDICATION NAME]. He stated, "Definitely I do. If it's a new admit from hospital I just follow the orders from hospital. I usually don't change a thing." Physician #1 asked the surveyor if there was ever an INR done. The surveyor stated, "No." The physician stated, "Anytime a patient is bleeding the first thing I do is order an INR even the middle of the night." The physician was asked if he recalled receiving any call from the facility regarding concerns or changes in the resident's condition. He stated, "I don't want to say yes or no. It's been a long time. He's not my regular patient. Takes a few weeks for me to get familiar with them." The surveyor notified the physician of the nursing documentation which documented the resident had experienced changes with his respiratory status and nose bleeds. He was also notified of the nursing staff holding two doses of [MEDICATION NAME] because the resident experienced bleeding. The physician stated, "They probably stopped with contacting me. Next part is she should have called me and we should have gotten an INR."

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist for resident #1, due to the facilities failure to notify the physician of the resident's change in condition related to worsening respiratory status and episodes of nose bleeds while on [MEDICATION NAME] therapy with a history of [DIAGNOSES REDACTED] with a mechanical valve replacement. The resident left the faciity on [DATE] at 1:11 p.m., and later expired on [DATE] at 2:59 a.m. It was determined the resident expired related to cardiopulmonary arrest. The resident's secondary diagnoses included a history of [MEDICAL CONDITION] and [MEDICAL CONDITION]. On [DATE] at 4:03 p.m., the (OSDH) Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. At 4:14 p.m. the administrator and the (DON) director of nursing were notified of the IJ situation. At 6:45 p.m., the facility verbally presented an acceptable plan of removal before the surveyors exited the facility. On [DATE] at 9:00 a.m., an acceptable written plan of removal was presented to the survey team. The Plan of Removal documented: "Immediate Jeopardy Plan of Removal: Noble Healthcare [DATE]: I. Not notifying physician of resident change in conditions Inservice all licensed nursing staff in person or by telephone by midnight on [DATE] on policy and procedure for physician notification of all change in condition and guidelines of what warrants a change of condition. Policy to include, but not limited to examples of respiratory issues. Inservice all certified medication aides by telephone or in person my midnight on [DATE] on policy regarding holding medications and signs and symptoms to report to nurse. A list was obtained of all residents on [MEDICATION NAME] therapy. Audit of these charts has been completed by nurse manager to verify PT/INR orders are in place. Physician was notified regarding any residents that required PT/INR orders, all orders have been completed at this time. Labs needed are scheduled to be collected in the AM of [DATE]. A list was obtained of all residents with [DIAGNOSES REDACTED]. Physician was notified regarding any residents that required lab orders and all orders have been completed. Labs needed are scheduled to be collected in the AM of [DATE]. New admission checklist was put in place on [DATE] for charge nurse, nurse managers, and medical records to complete within 24 hours of admission or readmission. An audit has been done on all new admissions since [DATE]. An in-service was done with all nurse managers on how to properly audit a new admit physician's orders [REDACTED]. II. Not monitoring the [MEDICATION NAME] and obtaining PT/INRs A list was obtained of all residents on [MEDICATION NAME] therapy. Audit of these charts has been completed by nurse manager to verify PT/INR orders are in place. Physician was notified regarding any residents that required PT/INR orders, all orders have been completed at this time. Labs needed are scheduled to be collected in the AM of [DATE]. A new Anti-coagulant Protocol policy was developed on [DATE]. An inservice was held with all licensed nurses on [MEDICATION NAME] therapy and policy to monitor INRs either by telephone or in person by midnight on [DATE]. Any patient on [MEDICATION NAME] must have routine monitoring of PT/INRs in place. III. Not monitoring hemoglobin and hematocrit with [MEDICAL CONDITION] and/or low hgb. A list was obtained of all residents with [DIAGNOSES REDACTED]. Physician was notified regarding any residents that required lab orders and all orders have been completed. All additional routine labs are scheduled to be collected in the month of [DATE]. All charts were audited to ensure all current residents have admission labs and yearly routine labs in place. Physician was notified regarding any residents that required lab orders and all orders have been completed. Labs needed are scheduled to be collected in the AM of [DATE]. Inservice licensed staff on monitoring hemoglobin and hematocrit for patients with low hgb./[MEDICAL CONDITION]. Orders should be obtained for routine monitoring of all patients with [MEDICAL CONDITION]." On [DATE] at 3:00 p.m., the Immediate Jeopardy was removed after all staff had been in-serviced, a new anti-coagulant protocol was implemented, audits completed for PT/INR orders for all residents on [MEDICATION NAME], audits completed for hemoglobin and hemotocrit orders for all residents with [DIAGNOSES REDACTED]. The deficient practice remained at an isolated level of actual harm that is not immediate Jeopardy. At 10:00 a.m., and 3:00 p.m., nursing staff from all shifts who had attended the in-services were interviewed. All staff were knowledgeable concerning notifying the physician of changes in condition and proper documentation. All staff were knowledgeable in regards to the new anti-coagulant protocol. Staff were knowledgeable in regards to assessing and monitoring a resident on [MEDICATION NAME] therapy. All staff were knowledgeable in regards to obtaining, monitoring and reporting hemoglobin and hematocrit levels for residents with an [MEDICAL CONDITION] diagnosis. Staff were also knowledgeable concerning admission labs and yearly routine labs to include a complete blood count. Based on clinical record review, staff interviews and review of facility policy and procedure, it was determined the facility failed to notify the physician of a significant change in a resident's condition related to respiratory status and episodes of nose bleeds while on [MEDICATION NAME] therapy for one (#1) of four sampled residents whose records were reviewed. This deficient practice resulted in an actual harm to the resident and an immediate jeopardy to the resident's health and safety. This had the potential to affect all 79 residents who resided in the facility. Findings: A facility policy and procedure titled, Holding/Refusal to Administer Medications, documented, "...If a nurse in her/his judgment is not comfortable administering a routine medication to a resident that is ordered by the physician without parameters for administering the medication, then the nurse shall document the reason in the chart and notify the physician..." A facility policy and procedure titled, Admission Checklist, documented, "...Routine labs are ordered upon admit to include: CBC, CMP, TSH, Lipid Panel, Occult Stool, [MEDICATION NAME], and Pre-[MEDICATION NAME] next lab day...If on [MEDICATION NAME], PT/INR q monthly at a minimum..." A facility policy and procedure titled, Nursing Documentation Policy, documented, "...Change in condition: When a change in condition is noted, an assessment is done by the nurse and recorded in the nurses notes. An entry shall be made each shift until the residents condition improves..." A facility policy and procedure titled, Physician Notification for Resident Change in Condition, documented, "...Policy: The licensed nurse assigned to the resident is responsible for notification of and communication to the medical staff regarding significant changes or significant deterioration in the resident's condition and for assuring that there is physician response. Guidelines: 1. Change in the condition of the resident are determined by assessments utilizing parameters defined by physician order/instructions, the resident's previous condition and/or previous labs, and/or by resident safety factors... 3. Document in the medical record the date, time and name of each physician notified, actions taken and/or resident's response to treatment. 4. Physician notification may be indicated in the following situations: ...b. Any sudden and/or marked adverse change in signs, symptoms, or behavior exhibited by a resident... e. Any untoward response or reaction to medication or treatment..." Resident #1 was admitted to the facility with diagnoses which included [MEDICAL CONDITION], [DIAGNOSES REDACTED] with mechanical valve replacement, stage III kidney disease, abdominal hernia, hypertension, GERD, diabetes, [MEDICAL CONDITION] and [MEDICAL CONDITION]. A hospital history and physical note, dated [DATE], documented, "...Chief complaint: ...He thinks he might have passed out last night or he fell ... Past medical history: 1. Diastolic [MEDICAL CONDITION] and [DIAGNOSES REDACTED], which it sounds like he has some type of mechanical valve put in. 2. Stage III [MEDICAL CONDITION]. 3. [MEDICAL CONDITION]. 4. Hypertension. 5. Diabetes... Physical Examination: ...Lungs: He had diminished breath sounds at the bases and some mild lateral [MEDICAL CONDITION] rubs. I really did not hear any obvious rales. His inspiratory effort looked normal... Diagnostic data: ...His hemoglobin though is quite a bit lower than at previous times he has been in our emergency room at 7.9. The last one we have from a few months ago was 10. It is microcytic. Follow up hemoglobins have also shown that it is low. Coagulation panel shows he is appropriately therapeutic on his [MEDICATION NAME] considering his mechanical valve replacement...His BNP was quite a bit higher than at other visits though at 1641...Chest x-ray showed some pleural effusions that look similar to previous exams. CT scan of his abdomen showed also some bilateral effusions with some atelectasis ...His echocardiogram showed a normal systolic function, confirmed the mechanical aortic valve, and increased [MEDICAL CONDITION] artery pressure which is chronic... Assessment and plan: ...He has what I suspect is an acute [MEDICAL CONDITION] that is microcytic. It may be chronic, as he does have [MEDICAL CONDITION] last hemoglobin I have available is from 4 months ago, and it (sic) worse than at that point, and it has been checked 2 more times and remains quite low, so I believe that it is accurate...considering his [MEDICAL CONDITION], his hemoglobin needs to be higher than 10, so I am going to transfuse 2 units of packed red blood cells, follow up hemoglobin and hematocrit after that, and then transfuse further if needed to get his hemoglobin greater than 10. Further treatment of [REDACTED]. He is on [MEDICATION NAME] but does not have any obvious bleeding... He has some findings of possible acute exacerbation of chronic diastolic [MEDICAL CONDITION] that would be evidenced by his brain natriuretic peptide being quite higher than usual. Otherwise though, that is difficult because he really does not, at least at the time I saw him, note that his breathing is more difficult than usual, and he has some chronic pleural effusions. At least for now, I am going to go ahead and treat it as if this is an acute exacerbation. I will go ahead and give him more [MEDICATION NAME] now and then continue that..." A hospital cardiology progress note, dated [DATE], documented, "...Awake, oriented...Sats 100%...Lungs good...Echo: Mild AI (aortic insufficiency)...Ass: [MEDICAL CONDITION], multi factorial. ? (questionable) hemolysis from mech (mechanical) AVR (aortic valve replacement)...GI bleed..." A hospital physician order, dated [DATE], documented, "...ok to d/c to SNF. Advice (sic) SNF to hold [MEDICATION NAME]/Prinvil for 2 day (and) restart it. Advice (sic) SNF to keep INR ,[DATE]...Advice (sic) SNF to check BMP on Monday..." A nurse's note, dated [DATE], documented, "...Pt arrived from (named hospital) via (named ambulance). Lungs CTA (no) labored respirations...AA (and) O x 3. Able to voice wants (and) needs..." An admission/start up record, dated [DATE], documented, "... [MEDICATION NAME] 2.5 mg (1) po daily (at) 4 p.m. Dx: (no [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Hold [MEDICATION NAME] (and) Prinvil for 48 hrs from time of admission..." A skilled nurse's note, dated [DATE], documented, "...Resp even/unlabored. Continues c O 2 2 L NC as ordered..." A physician's orders [REDACTED]. A skilled nurse's note, dated [DATE], documented, "... O 2 needed ...(checked) L/cannula 2 L ...(checked) Continuous ... " A skilled nurse's note, dated [DATE], documented, "...Resident had nose bleed x 1 this shift..." A nurse's PRN notes/medication notes record, dated [DATE], documented, "[MEDICATION NAME] 2.5 refused LPN notified..." There was no documentation which stated the physician was notified of the resident's nose bleed. A skilled nurse's note, dated [DATE], documented, "...O 2 needed ...(checked) L/cannula 2 L ...O 2 sats 95%... " A skilled nurse's note, dated [DATE], documented, "...O 2 needed ...(checked) L/cannula 2 ...(checked) Continuous ...O 2 sats 96%..." A nurse's PRN notes/medication notes record, dated [DATE], documented, "[MEDICATION NAME] 2.5 mg held per LPN. Resident has been bleeding more than he should be..." A physician progress notes [REDACTED]. There was no documentation of physician notification related to the resident bleeding and hold order for [MEDICATION NAME]. A nurse's PRN notes/medication notes record, dated [DATE], documented, "[MEDICATION NAME] held per LPN..." A skilled nurse's note, dated [DATE], documented, "...Lungs coarse thru-out (sic). Resp labored ...P.O. fluids restricted by Dr. (and) followed..." There was no documentation of physician notification of respiratory status or order to hold the [MEDICATION NAME] dose. A skilled nurse's note, dated [DATE], documented, "...Respiratory ...(checked) SOB...(checked) on exertion...O 2 needed...(checked) L/cannula...O 2 sats 92%..." A skilled nurse's note, dated [DATE], documented, "...Res has had occasional nosebleeds tonight..." A discharge assessment, dated [DATE], documented the resident was cognitive in skills for daily decision making. He required limited assistance with transfers, ambulation, dressing and hygiene. He required extensive assistance with bathing. He was always continent of bowel and bladder. A skilled nurse's note, dated [DATE], documented, "...Respiratory ...(checked) SOB...(checked) on exertion...O 2 needed...(checked) L/Cannula...O 2 sats 94%..." There was no documentation which stated the physician was contacted in regards to the resident's respiratory status. A skilled nurse's note, dated [DATE], documented, "...Resident states he will be leaving today even if he has to walk himself home..." A skilled nurse's note, dated [DATE] at 1:11 p.m., documented, "...Resident discharged to go home. (No) s/s of distress..." An ambulance record, dated [DATE], documented, "...Chief complaint: [MEDICAL CONDITION]; onset of event occurred 20 minutes prior to calling EMS...Spontaneous circulation: No...First monitored rhythm: Asystole ... An emergency department report, dated [DATE], documented, "...Stated complaint: Full arrest...Chief complaint: [MEDICAL CONDITION] of present illness:...presents (sic) emergency department with (named EMS service) in full arrest. Reportedly was seen last about 1:00 (sic). I am (sic) nephew who stays with him checked on him and found him in the bathroom unresponsive about 120 (sic). He had no pulse and EMS was contacted. On EMS arrival the patient was asystolic. He has been given multiple rounds of medications remained asystolic throughout his emergency transfer here. Patient has long-standing history of severe [MEDICAL CONDITION] diabetes mellitus and [MEDICAL CONDITION]. He was recently hospitalized to the hospital with exacerbation of his systolic heart failure. He got out of the hospital about 10 days ago... Physical exam: Patient is being bagged on EMS arrival. He has no pulse or blood pressure. General appearance: Patient is comatose. Patient is intubated and being ventilated. Respiratory: Breath sounds are equal bilaterally. Cardiac: Heart sounds are absent. There are no pulses. Neurological: The patient is flaccid and unresponsive ... Differential Diagnosis: [REDACTED]. Laboratory Results: [DATE] 0252: Test:...Hgb 7.8 L ...Hct 23 L... Sodium 132 L... Potassium 8.0 (astrick) H... BUN 70 H Creatinine 2.2 H... pH 7.048 L... pCO2 88.3 H... pO2 42 L... HCO3 24.3... Total CO2 27.0... ED Course/Procedures: After initial ABC evaluation CPR was continued...CPR was continued throughout the patient's emergency department stay. He was given multiple doses of [MEDICATION NAME]. He was given doses of calcium glucose...And despite aggressive resuscitative measures patient failed to respond. He was pronounced at 0259 (2:59 a.m.)... Primary Diagnosis: [REDACTED]. Secondary Diagnosis: [REDACTED]. Condition: Expired..." On [DATE] at 12:50 p.m., the administrator was asked where the nursing staff documented physician communication in the medical record. She stated, "Either there is a fax or it's in the nurse's notes." She was then asked where the nursing staff would document if a resident had experienced blood loss. She stated, "Nurse's notes. " At 2:00 p.m., the DON was asked if a resident was on [MEDICATION NAME] would they have a [MEDICATION NAME] flowsheet. She stated, "Not necessarily to start out with. When they get a lab draw, then they start the flowsheet." She was shown the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She stated, "This is a med aide and so if she was told to by the LPN, there should be a telephone order and note. I don't think CMA should have charted that. Should have charted [MEDICATION NAME] held by LPN." She was then shown the nurse note which documented coarse lungs and labored breathing and asked if a physician was notified of the findings. She stated, "If she notified the doctor it should be in the note." At 2:10 p.m., LPN #1 was asked to review her charting which documented lungs coarse and respirations labored. She was asked if she notified the physician of the respiratory concerns. She stated, "I didn't notify the doctor cause he told me it was normal for him, and he didn't want me to notify the doctor." She was then asked if she should have documented the resident's conversation related to the respiratory findings. She stated, "Yes." On [DATE] at 2:45 p.m., the DON was asked if the physician should have been notified when the resident had nose bleeds. She stated, "Yes." She was then asked if a resident was on [MEDICATION NAME] therapy and began to have nose bleeds what could this mean. She stated, "They should have called the doctor and documented it." At 3:35 p.m., CMA #1 reviewed her note on the resident's medication administration which documented, "[MEDICATION NAME] 2.5 mg held per LPN. Resident has been bleeding more than he should be." She stated, "Nurse told me day before he had had a couple of nose bleeds. The day before I talked to her I gave it to him. She told me to hold it, but I don't know if she had talked to the doctor. " On [DATE] at 3:45 p.m., physician #1 was asked if the nursing staff relayed to him the notes from the resident's stay in (named hospital) from [DATE], for orders to hold [MEDICATION NAME] and Prinvil for two days, keep INR between 2 and 3 and BMP on Monday. He stated, "It's been so long. I don't remember. " The physician was asked if he was aware the resident was taking the medication [MEDICATION NAME]. He stated, "Yes. He was suppose to be on it. I did not stop it." The physician was asked if he routinely ordered an INR for a resident on [MEDICATION NAME]. He stated, "Definitely I do. If it's a new admit from hospital I just follow the orders from hospital. I usually don't change a thing." He was then asked if the facility had contacted him regarding the resident's respiratory changes, episodes of nose bleeds or any changes in condition. He stated, "I don't want to say yes or no. It's been a long time. He's not my regular patient. Takes a few weeks for me to get to familiar with them." Physician #1 asked the surveyor if there was ever an INR done. The surveyor stated, "No." The physician stated, "Anytime a patient is bleeding the first thing I do is order an INR even the middle of the night. " The surveyor notified the physician of the nursing documentation which stated the resident had experienced changes with his respiratory status and nose bleeds. He was also notified of the nursing staff holding two doses of [MEDICATION NAME] because the resident experienced bleeding. The physician stated, "They probably stopped the [MEDICATION NAME] without contacting me. Next part is she should have called me and we should have gotten an INR."

On [DATE], an IJ situation was determined to exist for resident #1, due to the facilities failure to monitor PT/INR laboratory values for a resident on [MEDICATION NAME] therapy with a history of [DIAGNOSES REDACTED] and a mechanical valve replacement and failure to intervene for adverse consequences related to anticoagulation therapy use. The resident left the faciity on [DATE] at 1:11 p.m., and later expired on [DATE] at 2:59 a.m. It was determined the resident expired related to cardiopulmonary arrest. The resident's secondary [DIAGNOSES REDACTED]. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. At 4:14 p.m. the administrator and the director of nursing were notified of the IJ situation. On [DATE] at 6:45 p.m., the facility verbally presented an acceptable plan of removal before the surveyors exited the facility. On [DATE] at 9:00 a.m., an acceptable written plan of removal was presented to the survey team. The Plan of Removal documented: "Immediate Jeopardy Plan of Removal: Noble Healthcare [DATE]: I. Not notifying physician of resident change in conditions Inservice all licensed nursing staff in person or by telephone by midnight on [DATE] on policy and procedure for physician notification of all change in condition and guidelines of what warrants a change of condition. Policy to include, but not limited to examples of respiratory issues. Inservice all certified medication aides by telephone or in person my midnight on [DATE] on policy regarding holding medications and signs and symptoms to report to nurse. A list was obtained of all residents on [MEDICATION NAME] therapy. Audit of these charts has been completed by nurse manager to verify PT/INR orders are in place. Physician was notified regarding any residents that required PT/INR orders, all orders have been completed at this time. Labs needed are scheduled to be collected in the AM of [DATE]. A list was obtained of all residents with [DIAGNOSES REDACTED]. Physician was notified regarding any residents that required lab orders and all orders have been completed. Labs needed are scheduled to be collected in the AM of [DATE]. New admission checklist was put in place on [DATE] for charge nurse, nurse managers, and medical records to complete within 24 hours of admission or readmission. An audit has been done on all new admissions since [DATE]. An in-service was done with all nurse managers on how to properly audit a new admit physician's orders [REDACTED]. II. Not monitoring the [MEDICATION NAME] and obtaining PT/INRs A list was obtained of all residents on [MEDICATION NAME] therapy. Audit of these charts has been completed by nurse manager to verify PT/INR orders are in place. Physician was notified regarding any residents that required PT/INR orders, all orders have been completed at this time. Labs needed are scheduled to be collected in the AM of [DATE]. A new Anti-coagulant Protocol policy was developed on [DATE]. An inservice was held with all licensed nurses on [MEDICATION NAME] therapy and policy to monitor INRs either by telephone or in person by midnight on [DATE]. Any patient on [MEDICATION NAME] must have routine monitoring of PT/INRs in place. III. Not monitoring hemoglobin and hematocrit with [MEDICAL CONDITION] and/or low hgb. A list was obtained of all residents with [DIAGNOSES REDACTED]. Physician was notified regarding any residents that required lab orders and all orders have been completed. All additional routine labs are scheduled to be collected in the month of [DATE]. All charts were audited to ensure all current residents have admission labs and yearly routine labs in place. Physician was notified regarding any residents that required lab orders and all orders have been completed. Labs needed are scheduled to be collected in the AM of [DATE]. Inservice licensed staff on monitoring hemoglobin and hematocrit for patients with low hgb./[MEDICAL CONDITION]. Orders should be obtained for routine monitoring of all patients with [MEDICAL CONDITION]." On [DATE] at 3:00 p.m., the IJ was removed after all staff had been in-serviced, a new anti-coagulant protocol was implemented, audits completed for PT/INR orders for all residents on [MEDICATION NAME], audits completed for hemoglobin and hemotocrit orders for all residents with [DIAGNOSES REDACTED]. The deficient practice remained at an isolated level of actual harm that is not immediate Jeopardy. On [DATE] at 10:00 a.m., and 3:00 p.m., nursing staff from all shifts who had attended the in-services were interviewed. All staff were knowledgeable concerning notifying the physician of changes in condition and proper documentation. All staff were knowledgeable in regards to the new anti-coagulant protocol. Staff were knowledgeable in regards to assessing and monitoring a resident on [MEDICATION NAME] therapy. All staff were knowledgeable in regards to obtaining, monitoring and reporting hemoglobin and hematocrit levels for residents with an [MEDICAL CONDITION] diagnosis. Staff were also knowledgeable concerning admission labs and yearly routine labs to include a complete blood count. Based on clinical record review, staff interviews and review of facility policy and procedure, it was determined the facility failed to ensure PT/INR laboratory values were monitored and interventions for adverse consequences were implemented for one (#1) of four sampled residents who were on [MEDICATION NAME] therapy. This had the potential to affect 14 residents identified by the facility who were on [MEDICATION NAME] therapy. This resulted in an Immediate Jeopardy situation. Findings: A facility policy and procedure titled, Holding/Refusal to Administer Medications, documented, "...If a nurse in her/his judgment is not comfortable administering a routine medication to a resident that is ordered by the physician without parameters for administering the medication, then the nurse shall document the reason in the chart and notify the physician... " A facility policy and procedure titled, Admission Checklist, documented, "...Routine labs are ordered upon admit to include: CBC, CMP, TSH, Lipid Panel, Occult Stool, [MEDICATION NAME], and Pre-[MEDICATION NAME] next lab day...If on [MEDICATION NAME], PT/INR q monthly at a minimum..." A facility policy and procedure titled, Chart Audit, documented, "...Labs: ...Have all routine labs been obtained, in chart...Is patient on medication requiring labs, such as [MEDICATION NAME] labs been obtained, is copy in chart..." A facility policy and procedure titled, Physician Notification for Resident Change in Condition, documented, "...Policy: The licensed nurse assigned to the resident is responsible for notification of and communication to the medical staff regarding significant changes or significant deterioration in the resident's condition and for assuring that there is physician response. Guidelines: 1. Change in the condition of the resident are determined by assessments utilizing parameters defined by physician order/instructions, the resident's previous condition and/or previous labs, and/or by resident safety factors... 3. Document in the medical record the date, time and name of each physician notified, actions taken and/or resident's response to treatment. 4. Physician notification may be indicated in the following situations: ...b. Any sudden and/or marked adverse change in signs, symptoms, or behavior exhibited by a resident... e. Any untoward response or reaction to medication or treatment..." Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A hospital history and physical note, dated [DATE] documented, "...Chief complaint: ...He thinks he might have passed out last night or he fell ...Past medical history: 1. Diastolic [MEDICAL CONDITION] and [DIAGNOSES REDACTED], which it sounds like he has some type of mechanical valve put in. 2. Stage III [MEDICAL CONDITION]. 3. [MEDICAL CONDITION]. 4. Hypertension. 5. Diabetes... Physical Examination: ...Lungs: He had diminished breath sounds at the bases and some mild lateral [MEDICAL CONDITION] rubs. I really did not hear any obvious rales. His inspiratory effort looked normal... Diagnostic data: ...His hemoglobin though is quite a bit lower than at previous times he has been in our emergency room at 7.9. The last one we have from a few months ago was 10. It is microcytic. Follow up hemoglobins have also shown that it is low. Coagulation panel shows he is appropriately therapeutic on his [MEDICATION NAME] considering his mechanical valve replacement...His BNP was quite a bit higher than at other visits though at 1641...Chest x-ray showed some pleural effusions that look similar to previous exams. CT scan of his abdomen showed also some bilateral effusions with some atelectasis...His echocardiogram showed a normal systolic function, confirmed the mechanical aortic valve, and increased [MEDICAL CONDITION] artery pressure which is chronic... Assessment and plan: ...He has what I suspect is an acute [MEDICAL CONDITION] that is microcytic. It may be chronic, as he does have [MEDICAL CONDITION] last hemoglobin I have available is from 4 months ago, and it (sic) worse than at that point, and it has been checked 2 more times and remains quite low, so I believe that it is accurate...considering his [MEDICAL CONDITION], his hemoglobin needs to be higher than 10, so I am going to transfuse 2 units of packed red blood cells, follow up hemoglobin and hematocrit after that, and then transfuse further if needed to get his hemoglobin greater than 10. Further treatment of [REDACTED]. He is on [MEDICATION NAME] but does not have any obvious bleeding... He has some findings of possible acute exacerbation of chronic diastolic [MEDICAL CONDITION] that would be evidenced by his brain natriuretic peptide being quite higher than usual... " A hospital cardiology progress note, dated [DATE] documented, "...Awake, oriented...Echo: Mild AI (aortic insufficiency)...Ass: [MEDICAL CONDITION], multi factorial. ? (questionable) hemolysis from mech (mechanical) AVR (aortic valve replacement)...GI bleed..." A hospital physician order, dated [DATE] documented, "...ok to d/c to SNF. Advice (sic) SNF to hold [MEDICATION NAME]/Prinvil for 2 day (and) restart it. Advice (sic) SNF to keep INR ,[DATE]...Advice (sic) SNF to check BMP on Monday... " A nurse's note, dated [DATE] documented, "...Pt arrived from (named hospital) via (named ambulance). Lungs CTA (no) labored respirations...AA (and) O x 3. Able to voice wants (and) needs..." An admission/start up record, dated [DATE] documented, "...FSBS AC (and) [MEDICATION NAME] 2.5 mg (1) po daily (at) 4 p.m. Dx:..." There was no other laboratory testing ordered for the resident. A physician's orders [REDACTED]. A skilled nurse's note, dated [DATE] documented, "...Resident had nose bleed x 1 this shift..." A nurse's PRN notes/medication notes record, dated [DATE] documented, "[MEDICATION NAME] 2.5 refused LPN notified..." There was no documentation the physician was notified of the resident's nose bleed. There was no documented physician's orders [REDACTED]. A nurse's PRN notes/medication notes record, dated [DATE] documented, "[MEDICATION NAME] 2.5 mg held per LPN. Resident has been bleeding more than he should be ..." A physician progress notes [REDACTED]. There was no documentation of physician notification related to the resident bleeding and hold order for [MEDICATION NAME]. A nurse's PRN notes/medication notes record, dated [DATE] documented, "[MEDICATION NAME] held per LPN..." There was no documentation of physician notification of order to hold the [MEDICATION NAME] dose. A skilled nurse's note, dated [DATE] documented, "...Res has had occasional nosebleeds tonight..." A discharge assessment, dated [DATE] documented the resident was cognitive in skills for daily decision making. He required limited assistance with transfers, ambulation, dressing and hygiene. He required extensive assistance with bathing. He was always continent of bowel and bladder. A skilled nurse's note, dated [DATE] documented, "...Resident states he will be leaving today even if he has to walk himself home..." A skilled nurse's note, dated [DATE] at 1:11 p.m. documented, "...Resident discharged to go home. ((No) s/s of distress..." An ambulance record, dated [DATE] documented, "...Chief complaint: [MEDICAL CONDITION]; onset of event occurred 20 minutes prior to calling EMS...Spontaneous circulation: No...First monitored rhythm: Asystole..." An emergency department report, dated [DATE] documented, "...Stated complaint: Full arrest...Chief complaint: [MEDICAL CONDITION] History of present illness:...presents (sic) emergency department with (named EMS service) in full arrest. Reportedly was seen last about 1:00 (sic). I am (sic) nephew who stays with him checked on him and found him in the bathroom unresponsive about 120 (sic). He had no pulse and EMS was contacted. On EMS arrival the patient was asystolic. He has been given multiple rounds of medications remained asystolic throughout his emergency transfer here. Patient has long-standing history of severe [MEDICAL CONDITION] diabetes mellitus and [MEDICAL CONDITION]. He was recently hospitalized to the hospital with exacerbation of his systolic heart failure. He got out of the hospital about 10 days ago... Physicial exam: Patient is being bagged on EMS arrival. He has no pulse or blood pressure. General appearance: Patient is comatose. Patient is intubated and being ventilated. Respiratory: Breath sounds are equal bilaterally. Cardiac: Heart sounds are absent. There are no pulses. Neurological: The patient is flaccid and unresponsive... Differential Diagnosis: [REDACTED]. Laboratory Results: [DATE] 0252: Test: ...Hgb 7.8 L ...Hct 23 L... Sodium 132 L... Potassium 8.0 (astrick) H... BUN 70 H Creatinine 2.2 H... pH 7.048 L... pCO2 88.3 H... pO2 42 L... HCO3 24.3... Total CO2 27 L... ED Course/Procedures: After initial ABC evaluation CPR was continued...CPR was continued throughout the patient's emergency department stay. He was given multiple doses of [MEDICATION NAME]. He was given doses of calcium glucose...And despite aggressive resuscitative measures patient failed to respond. He was pronounced at 0259... Primary Diagnosis: [REDACTED]. Secondary Diagnosis: [REDACTED]. Condition: Expired..." On [DATE] at 2:00 p.m., the DON was asked if a resident was on [MEDICATION NAME] would they have a [MEDICATION NAME] flowsheet. She stated, "Not necessarily to start out with. When they get a lab draw then they start the flowsheet." She was shown the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She stated, "This is a med aide and so if she was told to by the LPN there should be a telephone order and note. I don't think CMA should have charted that. Should have charted [MEDICATION NAME] held by LPN." She was asked if a resident was on [MEDICATION NAME] therapy and had bleeding problems should laboratory testing be ordered. She stated, "If we don't know what's going on then we can't order it." On [DATE] at 2:45 p.m., the DON was asked if the physician should have been notified when the resident had nose bleeds. She stated, "Yes." She was asked if a resident was on [MEDICATION NAME] therapy and began to have nose bleeds what could this mean. She stated, "They should have called the doctor and documented it." At 3:35 p.m., CMA #1 reviewed her note on the resident ' s medication administration which documented, "[MEDICATION NAME] 2.5 mg held per LPN. Resident has been bleeding more than he should be." She stated, "Nurse told me day before he had had a couple of nose bleeds. The day before I talked to her I gave it to him. She told me to hold it but I don't know if she had talked to the doctor." On [DATE] at 3:45 p.m., physician #1 was asked if the nursing staff relayed to him the notes from the resident's stay in (named hospital) from [DATE], for orders to hold [MEDICATION NAME] and Prinvil for two days, keep INR between 2 and 3 and BMP on Monday. He stated, "It's been so long. I don't remember." The physician was asked if he was aware the resident was taking the medication [MEDICATION NAME]. He stated, "Yes. He was suppose to be on it. I did not stop it." The physician was asked if he routinely ordered an INR for a resident on [MEDICATION NAME]. He stated, "Definitely I do. If it's a new admit from hospital I just follow the orders from hospital. I usually don't change a thing." Physician #1 asked the surveyor if there was ever an INR done. The surveyor stated, "No." The physician stated, "Anytime a patient is bleeding the first thing I do is order an INR even the middle of the night." The physician was asked if he recalled receiving any call from the facility regarding concerns or changes in the resident's condition. He stated, "I don't want to say yes or no. It's been a long time. He's not my regular patient. Takes a few weeks for me to get familiar with them." The surveyor notified the physician of the nursing documentation which documented the resident had experienced changes with his respiratory status and nose bleeds. He was also notified of the nursing staff holding two doses of [MEDICATION NAME] because the resident experienced bleeding. The physician stated, "They probably stopped with contacting me. Next part is she should have called me and we should have gotten an INR."

Based on observation, clinical record review, review of policies and procedures, review of guidelines from the CDC (Centers for Disease Control), and staff and resident interviews, it was determined the facility failed to provide care and services to maintain residents' highest practicable well-being. The facility failed to: a. assess, monitor and properly intervene for residents with a [DIAGNOSES REDACTED].#6, 7, 11, 17 and #19) of five sampled residents with rashes. This had the potential to affect 32 residents identified by the facility as having rashes and/or itching. b. assess, monitor and intervene for an unidentified skin wound for one (#8) of five sampled residents with skin wounds. This had the potential to affect six residents with wounds who were identified on the facility census and condition report. c. provide heel protectors as ordered for one (#2) of three sampled residents who had orders for heel protectors. This had the potential to affect five residents who the facility identified as requiring heel protectors. d. assess and monitor a blood pressure and pulse weekly for one (#5) of sixteen sampled residents who required weekly blood pressure and pulse monitoring. This had the potential to affect all residents in the facility. e. provide TED hose and/or ace wraps as ordered for two (#1 and #5) of two sampled residents who had orders for TED hose and/or ace wraps. This had the potential to affect six residents identified by the facility as having orders for TED hose and/or ace wraps. f. provide hand splints as ordered for one (#3) of one sampled resident who required hand splints. This had the potential to affect three residents identified by the facility who required hand splints. g. implement a dietary recommendation for a resident with weight loss for one (#6) of three sampled residents with weight loss. This had the potential to affect 21 residents the facility identified who had a weight loss in the last six months. Findings: A facility policy and procedure, titled Scabies Protocol, documented, "...The most common method of transmission is skin to skin contact however, transmission does occur through bed linens and clothing... Scabies Treatment Protocol: Any resident with a suspected case of scabies will be treated following the treatment protocol, unless otherwise ordered by the physician: Residents will be treated within 24 hours of symptoms being reported. If the resident resides in a semi-private room, his or her roommate will also be treated. This will be done after notifying the physician and family and requesting a treatment order. Nursing will monitor the resident for 24 hours post treatment for [REDACTED]. For 24 hours post treatment, the resident and/or residents will be confined to their rooms. This includes meals and activities. 1. Notify physician and resident's family. Explain to the family the need for confinement and the washing of all bedding and clothing. 2. Write order and obtain treatment. 3. The treatment of [REDACTED]. 4. All washable clothing and linens will be bagged and sent to laundry. Note: the water temperature must be hot in order to disinfect effectively. If there are items that cannot be washed in the laundry, they must be bagged for ten (10) days without exception. 5. Bedside tables, countertops, bed frames and mattresses will be deep cleaned at the same time the resident is being treated. Floors are to be vacuumed and/or mopped. Fumigation is not necessary. 6. During this process and the 24 hr confinement, employees delivering care must wear a long-sleeved gown with gloves pulled up over the cuff. This includes laundry and housekeeping staff involved in the deep cleaning process. 7. Residents treated are to be monitored and charted on for 24 hrs after treatment. They are to be confined to their room for this period of time. There is little risk for transmission after treatment." A CDC (Centers of Disease Control and Prevention) guideline for scabies outbreaks in institutional settings, [DATE], documented, "Multiple Cases... Surveillance: -Have an active program for early detection of infested patients and staff. -Maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rash: suspected cases should be evaluated and confirmed by obtaining skin scrapings... -Notify local health department of outbreak and determine if any evidence of increased scabies in the general community... Diagnostic Services -Consult with an experienced dermatologist for assistance in differentiating skin rashes and confirming the [DIAGNOSES REDACTED]. -Ensure someone on-staff is trained and experienced in obtaining and examining a skin scraping to identify scabies mites. Control and Treatment -...Avoid direct skin-to-skin contact with any patient who is suspected or confirmed to have scabies. -Use gloves when giving hands-on care to any patient who is suspected or confirmed to have scabies; wash hands thoroughly after providing care to any patient. -Avoid skin-to-skin contact with person with scabies for at least 8 hours after application of scabicide treatment. -Identify and treat all persons (e.g. staff, relatives, patients, etc.) having prolonged, direct skin-to-skin contact with an infested person before he/she was treated... Environmental Disinfection -Machine wash and dry bedding and clothing of scabies patients using the hot water and hot dryer cycles..." 1. Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated [DATE], documented the resident had no short or long term memory problems and was independent in her cognitive skills for daily decision making. She was able to make herself understood and was able to understand others. She required supervision with her activities of daily living. A physician's telephone order, dated [DATE] at 6:00 p.m., documented, "1. Skin scrape as directed Diagnosis: [REDACTED]. A physician's progress note, dated [DATE] (untimed), documented, "...Had skin scrapings sent to lab for scabies (secondary) to skin rash... skin [DIAGNOSES REDACTED]tous rash - no excoriations noted..." A nurse's note, dated [DATE] at 10:00 a.m., documented, "Family brought [MEDICATION NAME] body wash for res. T/O written + Tx sheet noted." A nurse's note, dated [DATE] at 2:00 p.m., documented, "Phoned (physician) about skin condition, small bite like bumps on BLE (bilateral lower extremities) + trunk. Res has c/o of itching. T.O. for [MEDICATION NAME] 12.5 mg bid x 5 days." A nurse's note, dated [DATE] at 3:40 p.m., documented, "Rash noted to res ABD (abdomen) & continues to chest area. Res c/o itch at this x. Called (physician) for n/o...'[MEDICATION NAME] 25mg i po TID x 2 d (days).' " A nurse's note, dated [DATE] at 11:35 a.m., documented, "Res continue to c/o of rash to trunk & BLE. Called (physician) for n/o 1. Stop all meds x 5 d." The resident's medications were manipulated, held, or discontinued between [DATE] and [DATE]. A nurse's note, dated [DATE] at 8:30 p.m., documented, "(Physician) will do a skin biopsy next Tuesday ,[DATE] if rash not improved." A physician's progress note, dated [DATE], documented, "...C/o Itching/skin rash... Assessment: Skin Rash leucocytosis Rec: (Recommendation) Skin BX (biopsy) if rash still + p (after) 1 week..." A nurse's note, dated [DATE] at 2:00 p.m., documented, "Res conts to have rash over chest + abd. Excoriation (beneath) bl (bilateral breasts), N/O for [MEDICATION NAME] cream to (beneath) breasts." A nurse's note, dated [DATE] at 2:00 p.m., documented, "Res called this nurse into room & showed this nurse that rash had (decreased) on chest, ABD area. Red rash not very visible at this time. (No) c/o of itch." A nurse's note, dated [DATE] at 8:00 p.m., documented, "CMA came to this nurse + stated that res rash is very noticeable to res trunk/chest @ this x. Small red raised bumps noted to previously stated area." A nurse's note, dated [DATE] at 10:20 a.m., documented, "...res up to nurse's station c c/o extreme itch. Gave res a shower to attempt to assist. Called (physician) to inform him rash is on bilateral thighs, trunk, breast, bilat arms & a few bumps were noted to back..." A nurse's note, dated [DATE] at 8:30 p.m., documented, "...Res states that [MEDICATION NAME] assisted c itch. Rash less red to trunk, bilat (upper) arms, bilateral thighs and back. Res states p 3 hrs of taking med, itch begins again. Fluids encouraged. Res in room on bed c OU (both eyes) open." A nurse's note, dated [DATE] at 10:25 p.m., documented, "[MEDICATION NAME] rec'd from pharmacy & given at this time for itch. Rash has noted redness (decreased) at this x. Res cont. to c/o of itch..." A nurse's note, dated [DATE] at 2:45 a.m., documented, "...Raised areas to chest and neck noted. Cont to monitor." A physician's progress note, dated [DATE], documented, "...Still has some itching but mostly resolved... skin biopsy allergic vasculitis...cont to hold meds." A physician's telephone order, dated [DATE] at 2:00 p.m., documented, "Make Dermatologist appt..." A nurse's note, dated [DATE] at 10:00 p.m., documented, "...Res rash noted to trunk BLE, bilat thighs. PRN [MEDICATION NAME] as ordered..." A nurse's note, dated [DATE] at 10:00 a.m., documented, "Rash continues to trunk, BLE & bilat (upper) thighs. PRN med order as ordered." A nurse's note, dated [DATE] at 4:30 p.m., documented, "...Res does continue to have rash to trunk, (bilateral upper extremities), bilat (upper) thighs. PRN med admin as ordered." A physician's telephone order, dated [DATE] at 9:20 a.m., documented, "Dermatologist to evaluate and treat." A nurse's note, dated [DATE] at 11:00 a.m., "...Res [MEDICATION NAME] d/c'ed d/t s/e (side effects)-rash." A facility fax form, dated [DATE] at 8:10 p.m., documented the resident was diagnosed with [REDACTED].#7 (the roommate) for the prevention of scabies. A Skin Rash Log - Hall 500, undated, documented the resident received [MEDICATION NAME] while in the hospital on [DATE] as ordered by a dermatologist. A physician's telephone order, dated [DATE], documented, "1. Ivermectin 6mg iii tab po x1 2. TMC 0.1% oint BID on AA (affected areas) until healed 3. [MEDICATION NAME] 10 mg i tab po q day 4. [MEDICATION NAME] DC Diagnosis: [REDACTED]. A physician's telephone order, dated [DATE] at 1:00 p.m., documented, "...3. [MEDICATION NAME] 10 mg ii po qd x 3d then start [MEDICATION NAME] 10 mg i po qd Diagnosis: [REDACTED]. A physician's progress note, dated [DATE], documented, "... A: (assessment) Scabies resolved, [MEDICAL CONDITION] "... P: (plan) TMC 0.1% oint BID PRN. [MEDICATION NAME] 10 mg daily. Cont. gentle cleansers & moisturizers. RTC (Return to Clinic) PRN." A physician's telephone order, dated [DATE], documented, "Monitor Rash to bilat arms, chest, ABD and bilat (upper) thighs + hips. Notify physician for s/s of infection or if becomes worse." On [DATE] at 9:56 a.m., the medical director was interviewed about the infection control practices at the facility. He stated, "There were a lot of cases of rashes a few months ago." He stated he performed three skin biopsies on residents. He was asked about resident #11 specifically. He stated she was seen by a dermatologist while she was in the hospital and even though tests for scabies came back negative, he and the dermatologist wanted to treat everybody empirically. On [DATE] at 10:55 a.m., the resident was observed sitting on the side of her bed with her arms crossed. Her left hand was scratching her right arm and her right hand was scratching her left arm. She was asked if she was itching and she stated, "Yes." She was asked if she still had her rash and she stated she had had it for weeks and weeks. 2. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. An admission nursing assessment, dated [DATE] at 3:15 p.m., documented the resident was identified as having a rash to the right bicep and anterior forearm. The assessment documented the resident was to have [MEDICATION NAME] cream applied to the rash every morning. A Head-To-Toe Skin Review, dated [DATE] on the 7 a.m. - 3 p.m. shift, documented, "Findings rash noted to (upper) body- [MEDICATION NAME] cream Q am + [MEDICATION NAME] to arms and legs + chest [MEDICATION NAME] to (left) inner arm BID scratching..." A care plan, dated [DATE], documented, "Problem (Resident) has skin rash Short term Goal (1) (Resident's) skin will be free of rash by 90 day review Approach (1) Administer treatments as ordered by (physician) (2) Administer medications as ordered by (physician) (3) Keep site clean and dry at all times (4) Keep (resident) off affected area(s) as much as possible." There were no Comments/Outcomes documented for the rash. A Head-To-Toe Skin Review, dated [DATE] on the 7 a.m. - 3 p.m. shift, documented, "Rash spread all over. (Physician) here. N.O. for [MEDICATION NAME] dose pack & [MEDICATION NAME] cream to everywhere every shift con't with (left) arm sore tx." A physician's telephone order, dated [DATE], documented, "TX: [MEDICATION NAME] - Apply twice daily PRN rash Apply to affected areas." A Head-To-Toe Skin Review, dated [DATE], documented, "Cont c tx as ordered." A nurse's note, dated [DATE] at 9:05 a.m., documented, "(Physician) in facility c n/o for [MEDICATION NAME] cream. Apply cream after shower, apply head to toe leave on for 24 (hr) then shower off and reapply in 1 week. Diagnosis: [REDACTED]. A Head-To-Toe Skin Review, dated [DATE] on the 7 a.m. - 3 p.m. shift, documented, "[MEDICATION NAME] Cream [DATE] re-apply weekly, cont c tx..." A Head-To-Toe Skin Review, dated [DATE] on the 7 a.m. - 3 p.m. shift, documented, "DC tx as ordered - resolved skin cont to be sensitive." A nurse's note, dated [DATE] at 1:35 a.m., documented, "...Res cont to have rash on trunk and extremities." A nurse's note, dated [DATE] at 2:00 p.m., documented, "Res itching + scratching, whelping up. CN (Charge nurse) phoned (physician) + left message about res condition." A nurse's note, dated [DATE] at 9:20 p.m., documented, "...Res cont to scratch all over." A nurse's note, dated [DATE] at 1:45 a.m., documented, "...C/o itching and cont to scratch arms & legs..." A Head-To-Toe Skin Review, dated [DATE] on the 7 a.m. - 3 p.m. shift, documented, "[MEDICATION NAME] tx again, skin inflamed." A nurse's note, dated [DATE] at 9:00 a.m., "(Physician) in + wants another TX of [MEDICATION NAME] given to res + repeat in 2 wks (weeks). Res skin has dry whelps on BL (bilateral) arms, spots that are drying on BL legs. Has routine [MEDICATION NAME] cream to trunk and all extremities." A physician's telephone order, dated [DATE], documented, "[MEDICATION NAME] head-to-toe, leave on for 24 (hr) then wash off. Repeat in 1 wk. Diagnosis: [REDACTED]. A nurse's note, dated [DATE] at 6:00 p.m., documented, "...cont to scratch all over red marks from scratches." A nurse's note, dated [DATE] at 3:50 a.m., documented, "...Cont to c/o itching. Cont to scratch all extremities." A nurse's note, dated [DATE] at 1:20 p.m., documented, "Some itching this shift [MEDICATION NAME] cream applied to body and extremities." A Head-To-Toe Skin Review, dated [DATE] on the 7 a.m. to 3 p.m. shift, documented, "rash resolved, cont to monitor weekly." A 30 day resident summary, dated [DATE] - 30, 2010, documented, "...-[MEDICATION NAME] cream apply to body and extrem (extremities) q shift rash -[MEDICATION NAME] Apply to affected area BID..." A significant change assessment, dated [DATE], documented the resident had short term memory problems and was moderately impaired in her cognitive skills for daily living and required extensive to total assistance in her activities of daily living. A physician's telephone order, dated [DATE] at 10:30 a.m., documented, "[MEDICATION NAME] 0.5mg i PO TID/PRN x 3 d Diagnosis: [REDACTED]. A nurse's note, dated [DATE] at 2:20 a.m., documented, "...Res in bed c eyes closed. Cont to be restlessness, scratching arms and shoulders." The resident expired on [DATE] at 7:58 p.m. The resident's roommate was resident #19. 3. Resident #19 was admitted to the facility with [DIAGNOSES REDACTED]. A Head-To-Toe Skin Review, dated [DATE] on the 7:00 a.m. to 3:00 p.m. shift, documented, "Rash on whole body N.O. for [MEDICATION NAME] as directed." A physician's telephone order, dated [DATE] at 9:00 a.m., documented, "After shower apply [MEDICATION NAME] cream head to toe leave on for 24 (hr) then shower off + repeat in one week." A care plan, dated [DATE], documented, "Problem (Resident) has rash and allergy to medications Goal Skin will be without infection Approach (1) Observe and report any s/s of infection (2) Administer Tx as ordered (3) Weekly skin check (4) Medications as needed" A physician's telephone order, dated [DATE] at 10:45 a.m., documented, "TMC 0.1% cream to be applied from neck to feet BID. Diagnosis: [REDACTED]. A Head-To-Toe Skin Review, dated [DATE] on the 7:00 a.m. to 3:00 p.m. shift, documented, "N.O. TMC 1% cream BID from neck to feet." A Head-To-Toe Skin Review, dated [DATE] on the 7:00 a.m. to 3:00 p.m. shift, documented, "Cont c tx as ordered, rash resolving." A physician's telephone order, dated [DATE] at 3:40 p.m., documented, "DC TMC 0.1% cream BID (change) to PRN BID neck to feet Diagnosis: [REDACTED]. A physician's progress note, dated [DATE], documented, "Has rash on r arm - R arm rash start [MEDICATION NAME]." A Head-To-Toe Skin Review, dated [DATE] on the 7:00 a.m. to 3:00 p.m. shift, documented, "[MEDICAL CONDITION] & itching to R arm." A physician's telephone order, dated [DATE] at 11:45 a.m., documented, " 1. [MEDICATION NAME] 25 mg i po TID PRN Diagnosis: [REDACTED]. A physician's telephone order, dated [DATE] at 8:00 a.m., documented, "1. Skin scrape as directed. Diagnosis: [REDACTED]. A Head-To-Toe Skin Review, dated [DATE] on the 7:00 a.m. to 3:00 p.m. shift, documented, "Scrape for scabies - " A physician's telephone order, dated [DATE] at 4:15 p.m., documented, "Skin biopsy next physician visit. Diagnosis: [REDACTED]. A Head-To-Toe Skin Review, dated [DATE] on the 7:00 a.m. to 3:00 p.m. shift, documented, "Scratching noted - (no) openings just irritated." A physician's progress note, dated [DATE], documented, "Skin rash (scabies testing negative) / Try Ivermectin 3 mg." A physician's telephone order, dated [DATE] at 3:00 p.m., documented, "Ivermectin i po 3 mg x 1 dose Diagnosis: [REDACTED]. A Head-To-Toe Skin Review, dated [DATE] on the 7:00 a.m. to 3:00 p.m. shift, documented, "Skin irritated." A Head-To-Toe Skin Review, dated [DATE] on the 7:00 a.m. to 3:00 p.m. shift, documented, "Skin [MEDICAL CONDITION] cont to itch (no) openings noted." A nurse's note, dated [DATE] at 2:00 p.m., documented, "[MEDICAL CONDITION] noted to BUE (non pitting) Rash continues to trunk & bilat (upper) and (lower) ext. (extremities)." A nurse's note, dated [DATE] at 9:00 p.m., documented, "Res c/o of itch this evening PRN TAO (triple antibiotic ointment) and [MEDICATION NAME] admin as ordered." A physician's telephone order, dated [DATE] at 3:25 p.m., documented, "[MEDICATION NAME] 3 mg Albut. ([MEDICATION NAME]) 3 ml (one nebule) per nebulizer four times qd PRN Diagnosis: [REDACTED]. A nurse's note, dated [DATE] at 3:00 a.m., documented, "...c/o itching all over. PRN [MEDICATION NAME] given." A physician's telephone order, dated [DATE] at 1:30 p.m., documented, "DC [MEDICATION NAME] q 4 (hours) d/t allergy Diagnosis: [REDACTED]. A physician's telephone order, dated [DATE] at 3:10 p.m., documented, "Do not D/C [MEDICATION NAME] 25 mg i po Diagnosis: [REDACTED]. A quarterly resident assessment, dated [DATE], documented the resident had no long or short term memory problems and was independent in her cognitive skills for daily living. She required moderate assistance to total dependence in her activities of daily living. A facility fax form, dated [DATE] at 4:20 p.m., documented, "...Assessment: Res obtained 2 small S/T (skin tears) to L arm (upper) elbow, res arm was itching + she used w/c arm to scratch..." A nurse's note, dated [DATE] at 1:10 p.m., documented, "Res is itching + TMC cream and [MEDICATION NAME] for relief." A physician's telephone order, dated [DATE] at 10:25 p.m., documented, "DC all PO meds except [MEDICATION NAME] (may crush) Diagnosis: [REDACTED]." The resident expired on [DATE] at 10:45 a.m. 4. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented the resident was independent in cognitive skills for daily decision-making and had no problems with memory. The resident required limited assistance of one person for transfers, bed mobility, ambulation, dressing, and bathing, required a wheelchair for her primary locomotion, and had no [MEDICAL CONDITION] or rashes present. A nurse's note, dated [DATE] at 10:00 p.m., documented, "As a preventative tx, res was treated for [REDACTED]. A nurse's note, dated [DATE] at 6:50 p.m., documented, "Res called nurse to room. Res c/o itch 'all over.' Viewed res skin numerous small red dots noted to inner left arm, minimal small red dots noted to right inner thigh. Call Dr. (name deleted), on call for Dr. (name deleted) & rec'd n/o 1) [MEDICATION NAME] 25 mg i po q 6 prn itch. 2) 1% [MEDICATION NAME] apply to rash areas bid prn..." A physician's telephone order, dated [DATE] at 7:00 p.m., documented, "Clarification: Monitor rash to left arm & armpit, right wrist. Notify physician if s/s of infection or if it becomes worse." A nurse's note, dated [DATE] at 9:45 p.m., documented, "...Res c/o itching on right wrist no bumps noted..." A physician's telephone order, dated [DATE] at 9:12 a.m., documented, "[MEDICATION NAME] apply from neck to toes. Leave on for 24 hours, then shower off. Clean all bedding & clothing @ that time. Diagnosis: [REDACTED]. A nurse's note, dated [DATE] at 3:30 p.m., documented, "Res has order for [MEDICATION NAME] r/t rash on arms, observed rash, drying [MEDICATION NAME] ordered from pharmacy per ,[DATE] shift will shower tomorrow & [MEDICATION NAME] will be applied. Res denied itching today." A nurse's note, dated [DATE] at 11:30 a.m., documented, "...CN (charge nurse) applied [MEDICATION NAME] from neck down after res bath...Res has a cluster of red areas under left arm." At 1:50 p.m., the resident was observed in her room scratching her left underarm and the inner area of her upper left arm. A three inch raised linear streak or tract and two small circular areas were observed to be reddened and raised at the above sites. She was also observed to scratch her right wrist area. No rash was seen on her wrist. The resident stated the staff gave her [MEDICATION NAME] for itching. The resident was asked if the staff had put any medication on the rash. She shook her head in a motion indicating no. At 5:50 p.m., the DON was asked what was the protocol for scabies. She stated, "We would isolate the resident, treat the roommate, notify families, really clean the room, deep clean their room, and wash clothing." On [DATE] at 8:30 a.m., the resident was observed in the main dining room. At 9:20 a.m., the resident was observed out in the smoking area. At 12:15 p.m., the resident was observed in the main dining room. At 1:30 p.m., the resident was observed wheeling herself near the nursing station. At 1:45 p.m., staff was observed to enter the resident's room without protective gowns or gloves within the 24 hour period after [MEDICATION NAME] administration. On [DATE] at 2:00 p.m., the resident was asked how was her rash that day. She stated, "Better." She further stated, "I was up all night itching." The resident was asked if the staff told her what she was being treated for [REDACTED]." She further stated, "Then they told me 'no,' it wasn't." The resident was asked if the staff told her of any limitations about being out of her room after the administration of the [MEDICATION NAME] cream. She stated, "No." The facility did not confine the resident to her room for the 24 hour post treatment time per policy. The administrator was informed the facility's policy stated the resident was not supposed to leave her room for 24 hours post treatment. The administrator stated, "I know. She leaves her room." 5a. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. The Infection Report form, dated [DATE], documented, "On Hall 300, 2 of the 3 skin infections were reported in an earlier months report, they are not new infections." The report continued. It also documented, ..."(room number deleted) (Resident) skin (no culture) abrasien (sic) LE (lower extremities) ,[DATE] [MEDICATION NAME]/Keflex qid x 7 d (days) ,[DATE] Emolite (sic) cream." A nurse's note, dated [DATE], documented, "Res in shower room. CNA + nurse noted red area on back. Res c/o itching over area..." A physician's telephone order, dated [DATE], documented, "[MEDICATION NAME] 150mg - po now + repeat after 5th day; [MEDICATION NAME] 25 mg po now + repeat in am x 1 dose." A nurse's note, dated [DATE], documented, "[MEDICATION NAME] started this shift. Res (illegible) c/o. continue to c/o itching on back..." A 30 day resident summary, dated [DATE], documented in the margin, "...Rash itching..." A physician's telephone order, dated [DATE], documented, "Emolite cream apply neck down and rinse in 12 (hours) 1 application only...Rash." There was no documentation in the nurse's notes on [DATE] or [DATE] which showed the resident was treated with Emolite, whether she was placed on contact isolation, whether she was confined to her room for twenty-four hours after treatment, whether a deep cleaning was performed in her room, whether her clothing was handled appropriately, and whether or not her roommate was treated at the same time as the resident. A skin rash log for Hall 300, documented resident #27, the resident's roommate, was last treated with [MEDICATION NAME] on [DATE]. There were no nurse's notes for [DATE] which documented whether the resident had a rash or complaints of itching. The Infection Report form, dated [DATE], documented, "...Skin infections were thrush, yeast on skin, toes, lip, tooth, and a couple of rashes." A quarterly assessment, dated [DATE], documented the resident had modified independence in cognitive skills for daily decision making and required supervision only to move about the facility. She also had a weight loss of 5% or more in the last 30 days or 10% or more in the last 180 days. On [DATE] at 2:15 p.m., a tour of the laundry room was conducted. There was a sign on the washing machine which documented, "...Wash res clothes cold-no bleach." At 4:20 p.m., laundry aide #1 was asked how the resident's clothing was washed. She stated the resident's clothing was washed in cold water and rinsed in cold water with no bleach added. At 4:40 p.m., the maintenance/laundry supervisor was asked what was used to wash the resident's clothing. He stated personal clothing was washed with laundry detergent and softener. He stated he did not know if there was a disinfectant in the detergent but would find out. At 5:22 p.m., the maintenance/laundry supervisor stated he had talked to the supply company and was informed there was no disinfectant in the detergent used by the facility, but the agitation of the washing machines in the rinse cycle caused germs to release from clothing and be washed out. A nurse's note, dated [DATE] at 6:15 p.m., documented, "(Physician's) office notified about rash on arms, back, torso and bilateral extrem. New orders rec (received), Pharm (pharmacy) notified..." On [DATE] at 9:30 a.m., bath aide #2 was asked if she had seen any residents with unexplained rashes. She stated she had seen many rashes. She stated, "Seems like it would get cleared up and then it comes right back. We started giving people more baths." At 9:55 a.m., an interview was conducted with the medical director about the number of infections in the facility. He stated there were a lot of cases with unexplained itching. He stated three residents had scrapings done and they were all negative. He stated the facility treated the residents for scabies as a blind. He stated resident #11 had a rash for two to three weeks and she was seen by a dermatologist even though a skin scraping came back negative. He stated the dermatologist's recommendation was to start [MEDICATION NAME], as he wanted to treat her for scabies. The medical director then stated there were four or five unexplained skin rashes. He stated it might be contact [MEDICAL CONDITION] from soap or the chemicals the facility used while washing. He stated, "I can't explain it." Residents were treated with [MEDICATION NAME] to make sure everything was covered. The medical director stated, "I did not want to take chances." He stated two residents went to the dermatologist and no specific [DIAGNOSES REDACTED]. The medical director was asked if clothes were being washed appropriately. He stated he had asked and the facility informed him that they were. He was asked if he thought the skin rashes were an infection control problem. The medical director stated, "Don't have an idea. I treated them." He stated that everyone had to do the standards and he would ask if it was being done, especially sanitation. On [DATE] at 1:00 p.m., resident #6 was asked if she had a rash. She stated she had a rash on her arms, legs, back, and abdomen. She was asked how long she had had the rash. The resident stated she had been itching since about the time of her fractures ([DATE]). Small pinpoint red open areas were observed on her right forearm. The resident was observed scratching her arms and head. The resident had what appeared to be a three inch long line of scabs on her left shin. The resident's abdomen and back were not observed per resident request. On [DATE] at 5:00 p.m., LPN #2 was asked if she had checked her hall for rashes on residents. She stated she had observed resident #6 to have a red raised small rash on her torso, arms, and legs. LPN #2 stated the resident was scratching. LPN #2 was asked when the rash first started. She stated it started on [DATE]. LPN #2 was asked if she knew about the rash before she checked residents. She stated she had not known about the resident's current rash. LPN #2 was asked if anyone else on hall 300 had rashes. She stated the resident's roommate, resident #27, had the same type of rash on her arms, legs, and torso about one month ago. LPN #2 stated resident #27 had been treated twice with [MEDICATION NAME]. She stated at that time, the resident's mattress had been changed, all her belongings dry cleaned, and medications were stopped and restarted to check for an allergic reaction. A skin rash log for Hall 300, documented resident #27 was last treated with [MEDICATION NAME] on [DATE]. On [DATE] at 5:30 p.m., LPN #2 was asked what she thought the rashes were caused by. She stated there had been several rashes throughout the building and treatments had been different. She stated she thought the rashes may be caused b

Based on observation, clinical record review, review of policy and procedure, and staff interview, it was determined the facility failed to ensure the residents' enviroments were free of accident hazards and/or ensure residents received adequate supervision and assistance devices to prevent accidents. The facility failed: a. to prevent burns related to hot liquids for three (#4, #13, and #19) of sixteen sampled residents. b. to provide supervision and effective interventions to prevent falls resulting in injury for one (#1) of seven sampled residents with falls. This had the potential to affect 21 residents identified by the facility who had fallen in the last three months. c. to ensure motorized wheelchairs were operated in a safe manner for one (#13) of two sampled residents with motorized wheelchairs. This had the potential to affect two residents identified by the facility as having motorized wheelchairs. d. to supervise and provide smoking aprons for two (#7 and #12) of two sampled residents who required smoking aprons. This had the potential to affect both residents who required smoking aprons and supervision while smoking. Findings: BURNS 1. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 03/18/10, documented the resident was moderately impaired in cognitive skills for daily decision-making, required assistance with transferring and ambulation, and required assistance with all aspects of activities of daily living. An incident report, dated 09/25/10, documented resident #13 received second degree burns from hot chocolate she spilled in her lap. She required daily wound treatment for [REDACTED]. On 10/01/10 at 8:35 a.m., CNA #2 was asked how residents were protected from burns from hot liquids. She stated, "We put ice in the hot liquids to cool it down." At 11:05 a.m., the dietary manager was asked how residents were being protected from scalding injuries. She stated, "Hot chocolate and coffee are served with ice. CNAs add ice from the coffee cart. We just got styrofoam cups with lids yesterday afternoon." The dietary manager was asked to take the temperature of the hot water used to make hot chocolate. The temperature was 176 degrees F. At 4:00 p.m., RN #1 was asked what interventions were being used by nursing staff to prevent hot liquid burns in the future. She stated, "We have lids for the cups now. We just got them today." 2. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. An incident/accident report, dated 03/24/10 at 8:30 a.m., documented, "Resident's condition before incident/accident Normal (checked)... Exact location of incident/accident Specify (dining room)... Describe exactly what happened; why it happened; what the causes were. If any injury, state part of body injured...Res stated that she had knocked drink over onto her. Res taken to room to change clothes & had streaks of red on abd...Accidentally knocked cup over lid or sippy cup not required... Type of injury: Burn (checked)... Indicate on diagram location of injury: Red streaks on upper left abd... Level of consciousness: Awake, alert & oriented... Was first aid administered? Yes (checked) If Yes, type of care provided and by whom: cool clothe (sic) Additional comments and/or steps taken to prevent recurrence: Give res cooler hot chocolate. Talked c dietary Re temp of chocolate served." An incident report form to OSDH, dated 03/24/10, documented, "...Incident Type: (checked) Incident resulting in injury...There is a sign on the wall by the coffee pot re: icing all hot fluids. Resident's have been identified that might spill their drinks, and they either have lids on their cups, or the sippy cups. Dietary Supervisor has met with myself (DON) re: possibly unplugging coffee pot before serving coffee, and will monitoring the temp. Staff will be inserviced today also re: icing coffee, and hot chocolate..." A quarterly assessment, dated 09/08/10, documented the resident had a short-term memory problem and modified independence in cognitive skills for daily decision-making; was totally dependent on staff for transfers; required extensive assistance for bed mobility, dressing, and bathing; required limited assistance for hygiene; and required supervision for eating. On 10-01-10 at 11:00 a.m., CNA #10 was asked if he had noticed the coffee or hot chocolate had been too hot. He stated, "Steaming hot." He further stated, "The water is extremely hot for hot chocolate from the machine." He further stated, "We are to put a couple of cubes of ice in the hot water or top it off with cool water." He stated, "We tell the residents to be careful." He stated, "If the resident is not with it, we wait and let it cool off." When asked if he knew of any time a resident had gotten burned, he stated, "Yes." 3. Resident #19 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/21/10, documented the resident had no short or long term memory problems and was independent in cognitive skills for daily decision making. She required extensive to total assistance with her activities of daily living. An incident/accident report, dated 07/11/10 at 12:35 p.m., documented, "...dinning (sic) room 300... Res. in dinning (sic) room c staff present during lunch and spilled hot coffee on R hand c no apparent injury. Coffee to be iced before serving... Additional comments and/or steps taken to prevent recurrence: informed CNA's to allow coffee to sit & cool before serving to res..." A nurse's note, dated 07/11/10 at 12:35 p.m., documented, "Res was in DR (dining room) being fed + res spilled hot coffee on her R hand. (No) redness or blistering noted @ this (time). Rec'd n/o for silvadene if resident has redness or blistering...(no) c/o of pain or discomfort." A nurse's note, dated 07/12/10 at 4:25 a.m., documented, "...72 (hour) observation d/t spilling coffee on r arm. (No) blisters or red areas noted." A nurse's note, dated 07/13/10 at 2:40 p.m., documented, Res on observation for spilling coffee on hand, (no ) redness or blistering @ this x." A nurse's note, dated 07/13/10 at 4 a.m., documented, "Res cont on observation for previous IR (incident report) r/t spilling coffee on R arm. (No) blisters or redness noted. On 10/01/10 at 11:00 a.m., CNA #10 was asked who was responsible for serving residents hot chocolate or coffee. She stated we normally ask the kitchen. She stated, "We get it and it usually comes with a lid on it." At 11:02 a.m., CNA #11 was asked who was responsible for serving residents hot chocholate or coffee. She stated, "The dietary department serves it. We can go get it. It is always supposed to have a lid on it." The CNAs did not mention the cooling of the hot liquids or the facility policy of adding ice to the beverages. FALLS 4. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An Incident/Accident Report, dated 07/02/10 at 6:50 a.m., documented, "...Resident found sitting in floor on buttocks in rm 1/2 way between B/R (bathroom) + bed. Awake c/o pain on L (upper) arm. Noted skin tear. ROM of extrem (extremities) x4 WNL. Was naked barefooted-urine on floor. Was sitting on pair of slacks that were wet... Additional comments and/or steps taken to prevent recurrence: CNAs to (check) res more freq (frequently) for BRPs." An Incident/Accident Report, dated 07/07/10 at 2:48 p.m., documented, "...Found sitting on floor of rm on buttocks beside bed + leaning against it. Denies pain. ROM of extrem x 4 WNL. Up to chair c assist. (No) injury noted. Stated, 'I just slid off bed.' Noted to be bare footed. Alarm not sounding d/t resident was not far enough away... Additional comments and/or steps taken to prevent recurrence: Shorten body alarm string freq. Instructions to use call light. (Check) q 2 (hours) for BRPs + transfers." A physical therapy evaluation, dated 07/14/10, documented, "...Prior Level of Function: Nsg reports pt amb c RW (rolling walker); forgetting RW; recent falls; in w/c now (secondary) fall risk. Reason for Referral: Unsteady gait per nsg... Gait: CGA (caregiver assist) (approximately) 150 (feet) Assistive device: RW Weight Bearing Status: WNL... Patient/Family Agreement with treatment plan: A physical therapy daily treatment note, dated 07/16/10, documented, "Pt amb c RW 150 (feet) c CGA (care giver assistance)..." An Incident/Accident Report, dated 07/16/10 at 8:00 a.m., documented, "...Found sitting on floor on buttocks in rm by closet. Noted laceration to L eyebrow. Skin tear to L forearm. C/o pain in Lt knee. ROM of extrem WNL x4. Assisted up to w/c. Res c/o of hurting in pelvic area... Additional comments and/or steps taken to prevent recurrence: Body alarm in place. LOW bed ordered. Toilet more frequently-eval for Restorative if not on it." An Incident/Accident Report, dated 07/17/10 at 2:00 p.m., documented, "...Resident in TV area sitting in w/c. Leaned forward and fell from w/c landing on L side. (No injury apparent). Additional comments and/or steps taken to prevent recurrence: VS obtained after assisting resi (resident) back to w.c. Shorten alarm string." An Incident Management Report, dated 07/17/10, documented, "...List any instructions given to staff at time of incident: Constant observation. Resident placed @ N (Nursing) Station to be inview @ all times... Charge Nurse comments: Res has alt (altered) memory & M (mental) status. Is not oriented to own physical limitations. Gait is unsteady and will fall if not supervised constantly." A physician's telephone order, dated 07/20/10, documented, "Send res to (Hospital name deleted). Direct admit per (physician)." A nurse's note, dated 07/23/10 at 4:00 p.m., documented, "Res arrived via ambulance for admit to SNF (skilled nursing facility)...Res unsteady on feet. Needs assist to amb..." A nurse's note, dated 07/25/10 at 5:00 p.m., documented, "Up in day room c family member. Mood calm. Some redirection needed to remind res to remain in w/c due to unsteady gait..." An Incident/Accident Report, dated 07/25/10 at 11:07 p.m., documented, "...Resident found sitting in doorway of room on floor. Appears to have scooted from low bed out of the door of room. (No) injury noted. Denies hitting head... Additional comments and/or steps taken to prevent recurrence: (Check) @ beginning of each toileting time. If not voided, re-check in 10." A physical therapy evaluation, dated 07/26/10, documented, "...Prior Level of Function: Amb c RW, LTC (long term care) resident, not safe-leaves RW around facility + amb c it. Unsafe. Reason for Referral: Recent hospitalization (secondary) (bilateral) heel ulcers. Gait: HHA (hand held assistance) / min (minimum) (approximately) 20 (feet) Assistive device: HHA Weight Bearing Status: WNL... Patient/Family Agreement with treatment plan: [REDACTED]." A physical therapy daily treatment note, dated 07/27/10, documented, "Pt amb 5-10 (feet) c HHA max cues to (increase) overall extension (increase) upright posture..." A form titled, Personalized Restorative Monitoring Dc'd Residents, dated 07/10, documented, "Resident has had falls this month. Resident is now in w/c with body alarm on. Resident is very confused and will try to stand up from w/c and bed. Will continue to monitor resident for any more changes." A nurse's note, dated 08/01/10 at 11:00 a.m., documented, "Up in w/c calm. (Decreased) memory. Confused thoughts. Gait unsteady. Requires redirection to sit in w/c due to unsteady gait..." An Incident/Accident Report, dated 08/04/10 at 9:59 a.m., documented, "...Pt found c purple bruise to R foot 2nd digit. Pt unable to verbalized about incident d/t dementia. C/o pain, however unable to describe on pain scale (1-10). Appears 2 on (illegible) scale. Heel lift boot in place. Cause unknown... Additional comments and/or steps taken to prevent recurrence: Foot protectors are to be on when OOB + Res (checked) frequently." A physical therapy daily treatment note, dated 08/05/10, documented, "Pt amb 10 (feet) c HHA c max cues for (increased) posture..." An untimed nurse's note, dated 08/06/10, documented, "Pt confused + disoriented...Pt freq attempts to stand. Redirection is effective but constantly required..." A nurse's note, dated 08/07/10 at 10:00 a.m., documented, "Up in day area in w/c. Mood calm. Conversation nonsensical @ times. Requires redirection to sit in w/c due to unsteady gait..." An untimed nurse's note, dated 08/07/10, documented, "Compliant c shower. Mood aggitated (sic). Prior voices she's 'tired' of sitting..." A nurse's note, dated 08/08/10 at 10:00 a.m., documented, "Res up in w/c in day area. Mood calm...Request to get up walk however gait remains unsteady. Res unable to stand upright w/o (without) holding onto w/c. PT for strength gains ordered." A physician's telephone order, dated 08/09/10, documented, "Pt discharged from PT intervention (secondary) meeting max level of function at this time." No restorative care was ordered at this time. The resident did not receive restorative care until 09/14/10. An Incident/Accident Report, dated 08/09/10 at 7:30 a.m., documented, "...Res stood up out of w/c, turned then fell ... Additional comments and/or steps taken to prevent recurrence: CNAs to (check) length of cord on alarm + function @ least q 2 (hours)." An Incident/Accident Report, dated 08/12/10 at 7:20 a.m., documented, "...Sitting beside low bed on buttocks. Bed pad was 1/2 on bed, (lower) half off + she was sitting on it. Floor around her wet-denies pain or discomfort. ROM of extrem x4 WNL. (No) inj (injury) noted @ this time... Additional comments and/or steps taken to prevent recurrence: (Check) on res q 2 (hours) + toilet + prn." A care plan, dated 08/12/10, documented, Problem: (Resident) is at risk for additional falls related to internal and external risk factors: i.e. physical health, functional status, medications side effects, decline in mental functioning. Goals: (Resident) will reduce risk for falls by 90 day review. Approach: 1) Teach and encourage (resident) to request assistance when needed. 2) Supervise (resident) and assist appropriately with transfers. 3) Provide (resident) with w/c as ordered by Dr. 4) Encourage (resident) to rest every afternoon. 5) Encourage safety percautions (sic) such as locking brakes on w/c before getting up and waiting for assistance before transferring. 6) Teach (resident) correct use of appliance such as w/c. 7) Monitor for signs of increased agitation. 8) Monitor (resident) for pattern of risk factors or tendency to fall. 9) Respond promptly to request for assistance to toilet. 10) Teach and remind (resident) when standing up from chair to push off with arms. 11) Show (resident) how to adapt to certain disabilities. 12) Teach (resident) how to propel wheelchair. 13) Staff to check body alarm q shift and prn to ensure proper working order. i.e.; Batteries and clamps to secure device to (resident) or any other surface. 14) Place (resident) on falling leaves program to remind staff of potential for falls. 15) Place on low bed to reduce falls from bed." A significant change assessment, dated 08/13/10, documented the resident was moderately impaired in cognitive skills for daily decision making, wandered in the facility, was unable to ambulate in her room or corridor and required limited assistance with mobility out of her room. The resident's wheelchair was her primary means of locomotion. The resident also had falls in the past 30 days and in the past 31-180 days. A RAP narrative report, signed on 08/13/10, documented, "Falls: (Resident) has had repeated falls with injury in last 30-90 days. Resident has Dx of dementia and poor short/long term memory. Staff must provide for safety by making sure body alarm is on at all times, monitoring closely when wandering and when attempting to get up unassisted. Call light needs to be kept in easy reach and staff needs to look in room with each pass to see that resident is not attempting to rise on own." A nurse's note, dated 08/14/10 at 10:00 a.m., documented, 'Res up awake & alert. Memory (decreased). Confused thoughts. Gets aggitated (sic) when redirected to sit in her w/c. Restless most of a.m..." A nurse's note, dated 08/14/10 at 6:00 p.m., documented, "...Requires constant redirection while awake to remain seated due to (increased) falls..." A nurse's note, dated 08/15/10 at 6:00 p.m., documented, "Res @ N Station. Requiring constant redirection to remain seated in w/c. Restless aggitates (sic) easily. Voices 'I don't like all this sitting I have to do. I want to get up.' Staff remind Res that her gait is unsteady and has several falls. Res states, 'I don't believe you.' Ativan prn given per order." An untimed nurse's note, dated 08/16/10, documented, "...Needs assist of one for transfers, ADLs. Up + about facility in w/c. Tries to stand up frequently. Pressure alarm in place..." An Incident/Accident Report, dated 08/20/10 at 1:45 p.m., documented, "...Chair alarm sounded. Staff was (up) to get her but she was on the floor sitting on buttocks. Noted skin tears + hemorrhagic area L inside + lat (lateral). ROM WNL x 4 quads. (Up) c assist. (No) inj noted @ this time... Additional comments and/or steps taken to prevent recurrence: Has chair alarm working properly. Forgets instructions. Walk res c gait belt q 2 (hours) for (increased) ROM + strengthening as can tolerate." A nurse's note, dated 08/22/10 at 11:00 a.m., documented, "...Very often redirection required to remain seated in w/c..." An Incident/Accident Report, dated 08/23/10 at 11:45 p.m., documented, "...Res stood up out of w/c and fell . Sat on bottom. While doing assessment found a hematoma on L hip. Called for mobile x-ray... Additional comments and/or steps taken to prevent recurrence: Resident's heels are healed. May wear reg shoes. Walk res q 2 (hours) if needed." An untimed nurse's note, dated 08/27/10, documented, "...Seems to be doing better staying seated in w/c..." A nurse's note, dated 08/28/10 at 1:00 p.m., documented, "Up in day area in w/c. Has required some redirection to remain seated due to unsteady gait..." An untimed nurse's note, dated 09/03/10, documented, "...Attempts to stand up freq (frequently)..." A form titled, Restorative Care Program, dated 09/14/10, documented, "Pt is discharged from: PT Goals for Restorative Program: Maintain LE (lower extremity) ROM (bilateral) attempt standing to (increase) ease c x-fers (transfers), (increase) pt's general endurance. Approach/Recommendations for Implementation of Above Goals: Use platform walker or parallel bars. Assist Pt c standing-attempt to (increase) posture-working towards (increased) ease c standing & (increased) standing endurance..." An Incident/Accident Report, dated 09/17/10 at 5:00 a.m., documented, "...CNA heard bed alarm. Upon entering res room, found her sitting in the floor next to her bed... Additional comments and/or steps taken to prevent recurrence: Get resident up + into w/c when ready to get up + do not leave her awake in room." On 09/28/10 at 10:15 a.m., restorative aide #2 was asked if any staff members were walking with the resident. She stated, "No. No one." At 10:20 a.m., OTA #1 (occupational therapy assistant) was asked if anyone was walking with the resident. She stated the resident did not understand safety issues with walking. She stated she was concerned the resident did not understand the difference between walking with assistance and walking without. She stated she was concerned the resident would attempt to walk more if the staff walked the resident with assistance. At 2:55 p.m., the DON was informed the resident's interventions on her incident/accident report forms, were frequently repeated. She was asked why the staff didn't try new interventions since the resident continued to fall. She stated, "We would rather try interventions that might work." She was reminded the interventions were not working. No further comment was made. She was then asked why the staff was not following their listed interventions such as walking the resident. She stated she thought the staff had tried to walk her at one point. She was asked if her heel wound would prohibit the resident from walking. She stated, "No. It wouldn't." MOTORIZED WHEELCHAIR A facility policy titled, "Motorized Wheelchair Policy," documented, "... Residents will be allowed to use a motorized vehicle in the facility, only after being assessed and determined to be competent and safe to operate the vehicle..." 5. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 03/18/10, documented the resident was moderately impaired in cognitive skills for daily decision-making, required assistance with transferring and ambulation, and required assistance with all aspects of activities of daily living. An incident report, dated 03/15/10, documented the resident received two large lacerations to both lower legs when she ran her electric scooter into a wheelchair. The lacerations required sutures at a local hospital. An incident report, dated 04/13/10, documented the resident was operating the electric scooter in her room and received an unwitnessed laceration to the left hand. The laceration required sutures at a local hospital. A physician's telephone order, dated 06/24/10, documented, "... OT clarification: OT eval for electric w/c (wheelchair) safety/mobility. Will recommend pt use electric w/c c supervision only (secondary) to (decreased) safety awareness & (decreased) cognition... PT evaluation completed. Eval only: Pt unsafe c power chair. Recommend constant supervision when pt in power chair (secondary) to safety concerns for pt & others..." At 4:00 p.m., RN #1 was asked why it took over three months to evaluate the resident for use of the electric scooter. She stated she did not know. She stated she believed the family brought in the scooter without the staff's knowledge and the resident would use it as she wanted. She was asked if she believed this was a safety hazard. She stated, "Yes." SMOKING A smoking policy, dated 03/24/03, documented, "Resident Smoking Guidelines: 1. All residents will be assessed on admission by the Interdisciplinary Team and as needed for their ability to smoke independently or with assistance on the Smoking Evaluation and Consent Form. 2. The Team will decide what conditions the resident may smoke for their own safety and the safety of other residents. 3. A smoking apron will be utilized for residents when indicated by the Interdisciplinary Team to prevent injury. 4. Any resident requiring assistance with smoking will not be allowed to smoke alone, one-on-one supervision will be provided. An individualized smoking care plan will be with each resident to meet their needs..." A facility smoking disclosure form documented, "...The resident's desire to smoke may present hazardous conditions to the resident, staff and visitors. 1. Burns to clothing 2. Accidental burns to self 3. Burns to property..." 6. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 03/12/10, documented the resident was independent in cognitive skills for daily decision-making with no problems with memory. The resident required limited assistance of one person for transfers, bed mobility, ambulation, dressing, and bathing, and required a wheelchair for her primary locomotion. A care plan, dated 03/11/2010, documented, "Problem: Resident smokes (safety hazard). Short term goal: Resident will not cause injury to self or others while smoking. Approach: (1) Give resident repeated reminders of safety hazards. (2) Allow resident to smoke in designated areas only. (3) While smoking, will have supervision by staff. (4) While smoking res will wear smoking apron per facility policy." On 09/27/10 at 9:20 a.m., a sign was observed on the exit door to the smoking area which read, "All residents are to be supervised." At 9:20 a.m., LPN #8 was observed to open the door to the smoking patio for two residents. Resident #7 proceeded out to the smoking area with another resident without any smoking apron applied. The resident was observed with a lighted cigarette in her hand and without staff being in the smoking area. At 9:28 a.m., CNA #4 was observed to put a smoking apron on resident #7. The resident was observed to have a lit cigarette in her right hand while the CNA applied the smoking apron. CNA #4 came in from outside and told CNA #5, who was in the main dining room, to keep an eye on the resident. The main dining room had windows that looked out to the smoking patio. At 9:30 a.m., CNA #5 was asked if she could observe the smokers from the dining room window. She stated, "Yeah, or we go outside with them." She further stated, "We can't leave these (pointing to the residents still in the dining room.)" At 11:30 a.m., the DON was asked if she could locate the resident's smoking evaluation or any documentation such as a smoking consent or contract. No documentation was located in the clinical record. At 2:00 p.m., the DON returned with a Smoking Disclosure form, a Consent and Release for Smoking form, a resident's smoking contract, and a smoking evaluation and consent. All of these forms were dated 09/27/10. A Smoking Disclosure form, dated 09/27/10, documented, "This is a re-do. Originals misplaced." A resident's smoking consent form, dated 09/27/10, documented, "Gave policy to resident." A Smoking Evaluation and Consent form, dated 09/27/10, documented, "The Interdisciplinary Team determines the above named resident may smoke under following conditions: Staff will get resident her cigs (cigarettes) @ smoke times & lit (sic) them out & in of smoke area. Must wear apron." On 09/28/10 at 2:15 p.m., LPN #8 was asked who lights the cigarettes for the two smokers. She stated, "(Resident #7) has a lighter." The LPN was informed about the observation of the resident smoking without an apron. She stated, "That was my fault. They (the residents) were in a hurry to get outside and they (the aprons) weren't put on." 7. Resident #12 was admitted to facility with [DIAGNOSES REDACTED]. A nurse's note, dated 07/16/10, documented, "...Smoker c supervision @ assigned smoke times..." An annual assessment, dated 07/26/10, documented the resident had a short-term memory problem, was moderately impaired in cognitive skills for daily decision-making. The resident was totally dependent for transfers, hygiene and bathing and required extensive assist for dressing. He had limited range of motion and full loss of voluntary movement on one side. On 09/27/10 at 9:20 a.m., a sign was observed on the exit door to the smoking area which read, "All residents are to be supervised." At 9:20 a.m., LPN #8 was observed to open the door to the smoking patio for two residents. Resident #12 proceeded out to the smoking area with another resident without any smoking apron applied. The resident was observed with a lighted cigarette in his hand and without staff being in the smoking area. At 11:00 a.m., LPN #2 was asked if the residents were to be supervised while smoking. She stated, "Yes, I say so." She further stated, "We make sure he has an apron on and someone watching him." At 11:30 a.m., the DON was asked if the resident needed an apron to smoke. She stated, "He will get ashes on his pants without it." At 2:00 p.m., the DON provided a Smoking Evaluation and Consent form for the resident. The smoking evaluation documented, "...The Interdisciplinary Team determines the above named resident may smoke under following conditions: Must wear smoking apron & staff assist him in & out of smoke area..." On 09/28/10 at 2:15 p.m., LPN #8 was asked who lights the cigarettes for the two smokers. She stated, "(Resident #7) has a lighter." She was informed about the observation of resident #12 smoking without a smoking apron. She stated, "That was my fault. They (the residents) were in a hurry to get outside and they (the aprons) weren't put on."

Based on observations, clinical record reviews, policy/procedure reviews, and staff and resident interviews, it was determined the facility failed to: a. perform adequate identification, appropriate surveillance, and adequate infection control interventions for five (#6, 7, 11, 17, and #19) of five sampled residents diagnosed with [REDACTED]. This had the potential to affect all residents residing in the facility; b. provide contact isolation for one (#5) of one sampled resident with contact isolation orders. This had the potential to affect all residents residing in the facility; c. track and monitor employees with communicable diseases, including scabies; d. launder, sanitize and disinfect residents' personal clothing, facility linens, mop heads, and cleaning rags appropriately; e. use facility disinfectants according to the manufacturer's recommendations; f. ensure medications were administered in a sanitary manner for one (#23) of one resident whose medication was placed on an unsanitized surface; g. ensure facility glucometers were disinfected before and after use for one (#24) of one resident who was observed receiving a fingerstick blood sugar. This had the potential to affect 18 residents identified by the facility with fingerstick blood sugar orders; and Findings: A Centers for Disease Control and Prevention Guideline for Scabies Outbreaks in Institutional Settings, November 2008, documented, "...Surveillance... ...Have an active program for early detection of infested patients and staff... ...Maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rash: suspected cases should be evaluated and confirmed by obtaining skin scrapings... ...Notify local health department of outbreak and determine if any evidence of increased scabies in the general community... Diagnostic Services... ...Consult with an experienced dermatologist for assistance in differentiating skin rashes and confirming the [DIAGNOSES REDACTED]. ...Ensure someone on-staff is trained and experienced in obtaining and examining a skin scraping to identify scabies mites... Control and Treatment... ...Avoid direct skin-to-skin contact with any patient who is suspected or confirmed to have scabies... ...Use gloves when giving hands-on care to any patient who is suspected or confirmed to have scabies; wash hands thoroughly after providing care to any patient... ...Avoid skin-to-skin contact with person with scabies for at least 8 hours after application of scabicide treatment... ...Identify and treat all persons (e.g. staff, relatives, patients, etc.) having prolonged, direct skin-to-skin contact with an infested person before he/she was treated... Environmental Disinfection... Machine wash and dry bedding and clothing of scabies patients using the hot water and hot dryer cycles..." A facility policy and procedure titled, Scabies Protocol, documented, "...The most common method of transmission is skin to skin contact. However, transmission does occur through bed linens and clothing... Scabies Treatment Protocol: ...Any resident with a suspected case of scabies will be treated following the treatment protocol, unless otherwise ordered by the physician... Residents will be treated within 24 hours of symptoms being reported. If the resident resides in a semi-private room, his or her roommate will also be treated... Nursing will monitor the resident for 24 hours post treatment for [REDACTED]. For 24 hours post treatment, the resident and/or residents will be confined to their rooms. This includes meals and activities... The treatment of [REDACTED]. All washable clothing and linens will be bagged and sent to laundry. Note: the water temperature must be hot in order to disinfect effectively. If there are items that cannot be washed in the laundry, they must be bagged for ten (10) days without exception... Bedside tables, countertops, bed frames and mattresses will be deep cleaned at the same time the resident is being treated. Floors are to be vacuumed and/or mopped. Fumigation is not necessary... ...During this process and the 24 hr confinement, employees delivering care must wear a long-sleeved gown with gloves pulled up over the cuff. This includes laundry and housekeeping staff involved in the deep cleaning process..." A facility policy titled, Employee Health & Recordkeeping, documented, "...The facility will maintain employee health records and shall include, but are not limited to:... PPD testing and results of chest x-rays, hepatitis B records and/or declination, any incident reports of exposure incidents..., other misc. health reports as indicated..." A facility policy titled, Care of Linen, documented, "...Linen bags from isolation rooms should be handled with gloves... placed directly into the laundry bin...and labeled with a biohazard sticker..." A product information sheet, titled,Virex II 256, documented, "... A quaternary disinfectant cleaner to clean and disinfect hard surfaces...No rinse formula...for use on hard, inanimate, nonporous surfaces such as floors, walls, porcelain and plastic surfaces...Add the product at 1/2 oz. per gallon of water (1:256)...Pre-clean heavily soiled areas...To disinfect, all surfaces must remain wet for 10 minutes...rinsing is not necessary...All surfaces must remain wet for 10 minutes..." A facility policy titled, Determination of Type of Isolation Required During a Communicable Disease Episode, documented, "... Contact precautions are designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact... Contact precautions apply to specified residents known or suspected to be infected or colonized (presence of microorganisms in or on resident but without signs and symptoms of infection) with epidemiologically important microorganisms that can be transmitted by direct or indirect contact... Examples of Such Illnesses:.. ...Skin infections that are highly contagious or that may occur on dry skin, including...herpes simplex virus...major (non-contained) abcesses, cellulitis,...pediculosis (head lice)...scabies...(herpes) [MEDICATION NAME] [MEDICATION NAME] infections with a low infectious or prolonged environmental survival including: a. Clostridium difficile..." A facility policy titled, Setting Up An Isolation Room, documented, "Purpose: To separate an infected or colonized person from others during the period of communicability. To prevent direct and indirect transmission of the infectious agent... Equipment: Outside the Room: a stocked isolation cabinet, antiseptic hand wash, isolation door sign... Inside the Room:...disposable thermometer, blood pressure cuff and stethoscope, disposable blue pads, if the resident is incontinent with infectious material in urine or stool... ...Obtain an isolation cart and place it just outside the room near the room door...Explain the necessary precautions to the infected patient...and family members..." ...Special Instructions:...Identify the chart with an isolation sticker...the furniture and other surfaces within an isolated resident's room are considered contaminated...items that cannot be disinfected or are not disposable should remain outside the room whenever possible...disposable items are to be used whenever available... ...Gloves and Handwashing: In addition to wearing gloves as outlined in Standard Precautions, wear gloves (clean non-sterile) when entering the room... ...Remove gloves before leaving the resident's environment and wash hands immediately with an antimicobial agent or a waterless antiseptic agent... ...After glove removal and handwashing, ensure hands do not touch potentially contaminated environmental surfaces or items in the resident's room to avoid transfer of microorganisms to other residents or environments... ...Gown: In addition to wearing gowns as outlined in standard precautions, wear a gown (a clean non-sterile gown is adequate) when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or items in the resident's room, or if the resident is incontinent, or has diarrhea... ...Resident Transport: Limit the movement and transport of the resident from the room to essential purposes only. If the resident is transported out of the room, ensure that precautions are transported out of the room; ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other residents and contamination of environmental surfaces or equipment... ...Resident-Care Equipment: When possible, dedicate the use of non-critical resident-care equipment to a single resident (or cohort) to avoid sharing between residents... ...If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use of another resident... ...The Director of Nursing will be responsible for assuring that all personnel who will be caring for the resident in isolation are knowledgeable in all phases of isolation technique... The Director of Nursing or Charge Nurse will see that the isolation area is properly set up, properly identified and the isolation technique is maintained at all times... " A facility policy titled, [DIAGNOSES REDACTED] Prevention & Testing, documented, "... an annual facility [DIAGNOSES REDACTED] risk assessment is to be performed by a licensed nurse or physician using an OSHA (Occupational Safety and Health Administration) approved risk assessment tool. The results of the TB Risk Assessment will be reviewed by the Infection Control Committee/Medical Director annually..." 1. Resident #6, who resided on Hall 300, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nurse's note, dated 07/03/10, documented, "Res in shower room. CNA + nurse noted red area on back. Res c/o itching over area..." A physician's telephone order, dated 07/03/10, documented, "[MEDICATION NAME] 150mg - po now + repeat after 5th day; [MEDICATION NAME] 25 mg po now + repeat in am x 1 dose." A nurse's note, dated 07/04/10, documented, "[MEDICATION NAME] started this shift. Res (illegible) c/o. continue to c/o itching on back..." A 30 day resident summary, dated 07/08/10, documented in the margin of the form, "...Rash itching..." A physician's telephone order, dated 07/10/10, documented, "Emolite (sic) cream apply neck down and rinse in 12 (hours) 1 application only...Rash." There was no documentation in the nurses' notes on 07/10/10 or 07/11/10, which showed the resident was treated with [MEDICATION NAME] whether she was placed on contact isolation, whether she was confined to her room for twenty-four hours after treatment, whether a deep cleaning was performed in her room, whether her clothing was laundered per policy and whether or not her roommate was treated at the same time as the resident. A skin rash log for Hall 300, documented resident #27, the resident's roommate, was last treated with [MEDICATION NAME] on 06/11/10. The July 2010 infection report documented, "On Hall 300, 2 of the 3 skin infections were reported in an earlier months report, they are not new infections." The July 2010 monthly infection control report, dated July 2010, documented the resident had an abrasion and a skin rash. The report documented the abrasion was treated with [MEDICATION NAME] and Keflex QID for seven days on 07/03/10 and the rash was treated with "Emolite (sic) cream" on 07/10/10. There were no nurses' notes for August 2010 which documented whether the resident had a rash or complaints of itching. A quarterly assessment, dated 09/06/10, documented the resident had modified independence in cognitive skills for daily decision making and required supervision only to move about the facility. A nurse's note, dated 09/28/10 at 6:15 p.m., documented, "(Physician's) office notified about rash on arms, back, torso and bilateral extrem. New orders rec (received), Pharm (pharmacy) notified..." On 09/30/10 at 9:55 a.m., an interview was conducted with the medical director about the number of infections in the facility. He stated there were a lot of cases with unexplained itching. He stated three resident's had scrapings done and they were all negative. He stated the facility treated the residents for scabies as a blind. He stated (resident #11) had a rash for two to three weeks and she was seen by a dermatologist even though skin scraping came back negative. He stated the dermatologist recommendation was to start [MEDICATION NAME] as he wanted to treat her for scabies. He then stated there were four or five unexplained skin rashes. He stated it might be contact dermatitis from soap or the chemicals the facility used while washing. He stated, "I can't explain it." Residents were treated with [MEDICATION NAME] to make sure everything was covered. He stated, "I did not want to take chances." He stated two residents went to the dermatologist and no specific [DIAGNOSES REDACTED]. He was asked if clothes were being washed appropriately. He stated he had asked and the facility informed him that they were. He was asked if he thought the skin rashes were an infection control problem. He stated, "Don't have an idea. I treated them." He stated that everyone had to do the standards and he would ask if it was being done, especially sanitation. At 1:00 p.m., resident #6 was asked if she had a rash. She stated she had a rash on her arms, legs, back and abdomen. She was asked how long she had the rash. She stated she had been itching since about the time of her fractures (July 2010). Small pinpoint red open areas were observed on her right forearm. She was observed scratching her arms and head. It was also observed the resident had what appeared to be a three inch long line of scabs on her left shin. The resident's abdomen and back were not observed per resident request. At 5:00 p.m., LPN #2 was asked if she had checked her hall for rashes on residents. She stated she had observed resident #6 to have a red raised small rash on her torso, arms and legs. She stated the resident was scratching. She was asked when the rash first started. She stated it started on 07/10/10. She was asked if she knew about the rash before she checked residents. She stated she had not known about the resident's rash. She was asked if anyone else on hall 300 had rashes. She stated the resident's roommate, resident #27, had the same type of rash on her arms, legs and torso about one month ago. She stated resident #27 had been treated twice with [MEDICATION NAME]. She stated at that time, the resident's mattress had been changed, all her belongings dry cleaned and medications were stopped and restarted to check for an allergic reaction. A skin rash log for Hall 300, documented resident #27 was last treated with [MEDICATION NAME] on 06/11/10. At 5:30 p.m., LPN #2 was asked what she thought the rashes were caused by. She stated there had been several rashes throughout the building and treatments had been different. She stated she thought the rashes may be caused by Tylenol which was coming into the building. She was asked if they had considered scabies as a diagnosis. She stated the facility had considered it. She stated skin scrapings were done five times and came back negative, but that the residents had first been treated with [MEDICATION NAME]. She was asked if she had done a skin scraping before. She stated she read the instructions on the medication insert on how to perform a skin scraping. She stated she had never done one before. At 5:45 p.m., the DON was asked what she thought caused the rashes in the facility. She stated they had tried to think about everything, such as open windows, soaps, lotions and sprays, allergy season, beds, any changes in the laundry room and medication changes. She stated she had even considered the rashes were caused by Monarch butterflies and she had gone online to research it. She then stated two resident's families stated they had had scabies and were treated in March or April. She stated one CNA had scabies on her finger and that the facility caught it quickly. She was asked if it occurred after they had been informed about the family members with scabies. She stated it was close to that time, but no rashes had been diagnosed for scabies. She stated the CNA was treated but did not know with what. She stated there was nothing different going on at the time. She stated the CNA was identified with scabies over a weekend and the weekend RN sent her home. She was asked if she knew what caused the rash. She stated, "Don't have a clue." She stated they looked at clothing and it was being washed correctly. She was asked if anything special should be done about washing clothing. She stated she didn't know and that we should ask the laundry. She was asked if the facility had any type of surveillance program for employee illnesses or infections. She stated they did not track employee illnesses or infections. She was asked if she had any knowledge that scrapings could be a false negative. She stated she did not. She stated they know only what the doctors know and depend on the doctors to lead them. She stated a couple residents had scrapings done twice. One resident (#11) had scrapings done twice. She stated they were negative before and then she got tested two more time in the hospital. She stated the the resident would keep going out in the sun and the rash would increase. She was asked if they had documented all they had done for treatment of [REDACTED]." She stated, "We would be writing all day long." She was asked how scabies was treated. She stated [MEDICATION NAME] was applied for twenty-four hours and then repeat treatment in seven days. She stated clothes and linens would be washed and the room deep cleaned. She was asked if she ever suspected scabies was the cause of the rashes. She stated, "No." She stated the physician chose to treat for scabies because [MEDICATION NAME] was not helping. She stated the [MEDICATION NAME] was more soothing to the residents. She was asked if any of the resident's had been treated with [MEDICATION NAME] only once. She stated she did not recall anyone treated only once. She stated all the residents had been treated within the same month period. She stated, "We're not used to having these rashes." She was informed that while at the hospital, resident #11 was diagnosed with [REDACTED]. She stated, "No." She was asked if scabies was suspected, was she aware of how the laundry had to wash clothes. She stated clothing needed to be washed in hot water. She stated the rashes were at different times and that [MEDICATION NAME] worked for the itching. She stated, "If we had thought it was scabies, the whole nursing home would be treated. We would be treated." On 10/01/10 at 11:30 a.m., the administrator and the nurse consultant were interviewed. The nurse consultant stated there were no active infections on Hall 200. She stated resident #6 was being retreated and was the only unidentified rash on Hall 300. Resident #27, who was her roommate, was not being treated. She stated there were no infections on Hall 400. She stated residents #17 and #19, who were roommates, had their rashes resolved in May. She also stated residents #7 and #11 were treated with [MEDICATION NAME] but not on the same day. The administrator was asked how the facility handled isolation carts and contact isolation. She stated they moved the supplies for contact isolation into the resident's rooms because they were informed by life safety the carts could not be in the halls. 2. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 03/12/10, documented the resident was independent in cognitive skills for daily decision-making. The resident had problems with memory, required limited assistance of one person for transfers, bed mobility, ambulation, dressing, and bathing, required a wheelchair for her primary locomotion, and had no skin lesions or rashes present. A nurse's note, dated 09/19/10 at 10:00 p.m., documented, "As a preventative tx, res was treated for [REDACTED]. A nurse's note, dated 09/20/10 on the 3:00 p.m.-11:00 p.m. shift, documented, "Resident out to smoking areas @ regular times. Up in w/c for meals & smoke breaks." A nurse's note, dated 09/25/10 at 6:50 p.m., documented, "Res called nurse to room. Res c/o itch "all over." Viewed res skin numerous small red dots noted to inner left arm, minimal small red dots noted to right inner thigh. Call Dr. (name deleted), on call for Dr. (name deleted) & rec'd n/o 1) [MEDICATION NAME] 25 mg i po q 6 prn itch. 2) 1% [MEDICATION NAME] apply to rash areas bid prn..." A physician's telephone order, dated 09/28/10 at 7:00 p.m., documented, "Clarification: Monitor rash to left arm & armpit, right wrist. Notify physician if s/s of infection or if it becomes worse." A nurse's note, dated 09/28/10 at 9:45 p.m., documented, "...Res c/o itching on right wrist no bumps noted..." A physician's telephone order, dated 09/29/10 at 9:12 a.m., documented, "[MEDICATION NAME] apply from neck to toes. Leave on for 24 hours, then shower off. Clean all bedding & clothing @ that time. Diagnosis: [REDACTED]. A nurse's note, dated 09/29/10 at 3:30 p.m., documented, "Res has order for [MEDICATION NAME] r/t rash on arms, observed rash, drying [MEDICATION NAME] ordered from pharmacy per 7-3 shift will shower tomorrow & [MEDICATION NAME] will be applied. Res denied itching today." A nurse's note, dated 09/30/10 at 11:30 a.m., documented, "...CN (charge nurse) applied [MEDICATION NAME] from neck down after res bath...Res has a cluster of red areas under left arm." On 09/30/10 at 1:50 p.m., the resident was observed in her room scratching her left underarm and the inner area of her upper left arm. A three inch raised linear streak or tract, and two small circular areas were observed to be reddened and raised at the above sites. She was also observed to scratch her right wrist area. No rash was seen on her wrist. The resident stated the staff gave her [MEDICATION NAME] for itching. The resident was asked if the staff had put any medication on the rash. She shook her head, "No." At 5:50 p.m., the DON was asked what was the protocol for scabies. She stated, "We would isolate the resident, treat the roommate, notify families, really clean the room, deep clean their room and wash clothing." On 10/01/10 at 8:30 a.m., the resident was observed to be in the main dining room. At 9:20 a.m., the resident was observed to be out in the smoking area. At 12:15 p.m., the resident was observed to be in the main dining room. At 1:30 p.m., the resident was observed to be wheeling herself near the nursing station. At 1:45 p.m., staff were observed to enter the resident's room without protective gowns or gloves within the 24 hour period after [MEDICATION NAME] administration. At 2:00 p.m., the resident was asked how was her rash today. She stated, "Better." She further stated, "I was up all night itching." The resident was asked if the staff told her what she was being treated for [REDACTED]." She further stated, "Then they told me 'no,' it wasn't." The resident was asked if the staff told her of any limitations about being out of her room after the administration of the [MEDICATION NAME] cream. She stated, "No." The facility did not confine the resident to her room for the 24 hour post treatment time per policy. On 10/01/10 at 5:00 p.m., the administrator was informed the facility's policy stated the resident was not to leave her room for 24 hours post treatment. The administrator stated, "I know. She leaves her room." 3. Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. An annual assessment, dated 03/03/10, documented the resident had no or short or long term memory problems and was independent in her cognitive skills for daily decision making. She was able to make herself understood and was able to understand others. She required supervision with her activities of daily living. A physician's telephone order, dated 06/17/10 at 6:00 p.m., documented, "1. Skin scrape as directed Diagnosis: [REDACTED]. A physician's progress note, dated 06/22/10, documented, "...Had skin scrapings sent to lab for scabies (secondary) to skin rash...skin [DIAGNOSES REDACTED]tous rash - no excoriations noted..." A nurse's note, dated 06/28/10 at 10:00 a.m., documented, "Family brought [MEDICATION NAME] body wash for res. T/O written + Tx sheet noted." A nurse's note, dated 07/01/10 at 2:00 p.m., documented, "Phoned (physician) about skin condition, small bite like bumps on BLE (bilateral lower extremities) + trunk. Res has c/o of itching. T.O. for [MEDICATION NAME] 12.5 mg bid x 5 days." A nurse's note, dated 07/17/10 at 3:40 p.m., documented, "Rash noted to res ABD (abdomen) & continues to chest area. Res c/o itch at this x. Called (physician) for and n/o 1. CBC, CMP 2. [MEDICATION NAME] 25mg i po TID x 2d." A nurse's note, dated 07/25/10 at 11:35 a.m., documented, "Res continue to c/o of rash to trunk & BLE. Called (physician) for n/o 1. Stop all meds x 5 d." The resident's medications were manipulated, held or discontinued between 07/25/10 and 08/01/10. A nurse's note, dated 07/26/10 at 8:30 p.m., documented, "(Physician) will do a skin biopsy next Tuesday 8-3 if rash not improved." A physician's progress note, dated 07/27/10, documented, Sub: (Subjective) Currently in stable health. C/o Itching/skin rash... Assessment: Skin Rash leucocytosis Rec: (Recommendation) Skin BX (biopsy) if rash still + p (after) 1 week..." A nurse's note, dated 07/29/10 at 2:00 p.m., documented, "Res conts to have rash over chest + abd. Excoriation (beneath) bl (bilateral breasts), N/O for [MEDICATION NAME] cream to (beneath) breasts." A nurse's note, dated 07/31/10 at 2:00 p.m., documented, "Res called this nurse into room & showed this nurse that rash had (decreased) on chest, ABD area. Red rash not very visible at this time. (No) c/o of itch." A nurse's note, dated 07/31/10 at 8:00 p.m., documented, "CMA came to this nurse + stated that res rash is very noticeable to res trunk/chest @ this x. Small red raised bumps noted to previously stated area." A nurse's note, dated 08/01/10 at 10:20 a.m., documented, "...res up to nurse's station c c/o extreme itch. Gave res a shower to attempt to assist. Called (physician) to inform him rash is on bilateral thighs, trunk, breast, bilat arms & a few bumps were noted to back..." A nurse's note, dated 08/01/10 at 8:30 p.m., documented, "...Res states that [MEDICATION NAME] assisted c itch. Rash less red to trunk, bilat (upper) arms, bilateral thighs and back. Res states p 3 hrs of taking med, itch begins again. Fluids encouraged. Res in room on bed c OU (both eyes) open." A nurse's note, dated 08/01/10 at 10:25 p.m., documented, "[MEDICATION NAME] rec'd from pharmacy & given at this time for itch. Rash has noted (decreased) redness at this x. Res cont. to c/o of itch..." A nurse's note, dated 08/02/10 at 2:45 a.m., documented, "...Raised areas to chest and neck noted. Cont to monitor." A physician's progress note, dated 08/19/10, documented, "...Still has some itching but mostly resolved... skin biopsy allergic vasculitis...cont to hold meds." A physician's telephone order, dated 08/25/10 at 2:00 p.m., documented, "Make Dermatologist appt..." A nurse's note, dated 08/28/10 at 10:00 p.m., documented, "...Res rash noted to trunk BLE, bilat thighs. PRN [MEDICATION NAME] as ordered..." A nurse's note, dated 08/29/10 at 10:00 a.m., documented, "Rash continues to trunk, BLE & bilat (upper) thighs. PRN med order as ordered." A nurse's note, dated 08/29/10 at 4:30 p.m., documented, "...Res does continue to have rash to trunk, (bilateral upper extremities), bilat (upper) thighs. PRN med admin as ordered." A physician's telephone order, dated 08/30/10 at 9:20 a.m., documented, "Dermatologist to evaluate and treat." A nurse's note, dated 09/04/10 at 11:00 a.m., "...Res [MEDICATION NAME] d/c'd d/t s/e (side effects)-rash." A physician's telephone order, dated 09/21/10, documented, "1. Ivermectin (an antiparasitic medication sometimes used to treat Scabies) 6mg iii tab po x1 2. TMC 0.1% oint BID on AA (affected areas) until healed 3. [MEDICATION NAME] 10 mg i tab po q day 4. [MEDICATION NAME] DC Diagnosis: [REDACTED]. An undated Skin Rash Log for Hall 500 documented the resident received [MEDICATION NAME] while in the hospital on [DATE] as ordered by a Dermatologist. A facility fax form, sent to the physician and dated 09/19/10 at 8:10 p.m., documented resident #11 was diagnosed with [REDACTED].#7 (the roommate) for the prevention of scabies. A physician's telephone order, dated 09/25/10 at 1:00 p.m., documented, "...3. [MEDICATION NAME] 10 mg ii po qd x 3d then start [MEDICATION NAME] 10 mg i po qd Diagnosis: [REDACTED]. A physician's progress note, dated 09/28/10, documented, "... A: (assessment) Scabies resolved, Dermatitis ... P: (plan) TMC 0.1% oint BID PRN. [MEDICATION NAME] 10 mg daily. Cont. gentle cleansers & moisturizers. RTC (Return to Clinic) PRN." A physician's telephone order, dated 09/28/10, documented, "Monitor Rash to bilat arms, chest, ABD and bilat (upper) thighs + hips. Notify physician for s/s of infection or if becomes worse." On 09/29/10 at 9:56 a.m., the medical director was interviewed about the infection control practices at the facility. He stated, "There were a lot of cases of rashes a few months ago." He stated he performed three skin biopsies on residents. He was asked about resident #11 specifically. He stated she was seen by a dermatologist while she was in the hospital and even though tests for scabies came back negative. He and the dermatologist wanted to treat everybody empirically. He then stated, "We found she had a medication allergy." On 09/30/10 at 10:55 a.m., the resident was observed sitting on the side of her bed with her arms crossed. Her left hand was scratching her right arm and her right hand was scratching her left arm. She was asked if she was itching and she stated, "Yes." She was asked if she still had her rash and she stated she had had it for weeks and weeks. 4. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. An admission nursing assessment, dated 03/11/10 at 3:15 p.m., documented the resident was identified as having a rash to the right bicep and anterior forearm. The assessment documented the resident was to have [MEDICATION NAME] cream applied to the rash every morning. A Head-To-Toe Skin Review, dated 03/12/10 on the 7 a.m - 3 p.m. shift, documented, "Findings rash noted to (upper) body- [MEDICATION NAME] cream Q am + [MEDICATION NAME] to arms and legs + chest [MEDICATION NAME] to (left) inner arm BID scratching..." A care plan, dated 03/17/10, documented, "Problem (Resident) has skin rash Short term Goal (1) (Resident's) skin will be free of rash by 90 day review Begin Target 03/22/10 06/20/2010 Approach (1) Administer treatments as ordered by (physician) (2) Administer medications as ordered by (physician) (3) Keep site clean and

Based on observation, review of clinical records, review of policies and procedures and resident and staff interviews, it was determined the facility failed to implement its abuse policy to: a. ensure staff reported allegations of abuse or observations of suspected abuse to administration for two (#1 and #3) of two sampled residents for whom allegations or observations of suspected abuse were made; b. thoroughly investigate allegations of abuse for two (#1 and #3) of two sampled residents for whom allegations of abuse were made; c. ensure the protection of residents during investigations of abuse for two (#1 and #3) of two sampled residents; and d. thoroughly investigate an incident of bruising of unknown origin for one (#2) of one sampled residents who had bruising of unknown origin. These deficient practices constituted an Immediate Jeopardy situation. This had the likelihood to affect all residents in the facility. Findings: A policy and procedure, titled, Identification and Investigation of Abuse, documented, "Early warning signs of abuse may be unexplained bruises and/or fractures...Any of the above warning signs, even in the absence of allegations of abuse will be thoroughly investigated including: interviewing the individuals involved; interviewing all witnesses; notifying the physicians and where appropriate, the families of the involved residents, and recording all relevant physical findings... Facility Investigation should include: 1. Observations, interviews and record reviews of all residents involved; 2. Interviews of all witnesses, including resident, staff and family members; 3. Notifying the physicians and where appropriate, the families or responsible parties of the involved resident, and 4. Recording all physical findings." A policy and procedure, titled, Protection of Resident During Investigation Of Abuse, documented, "If an allegation of abuse by a particular employee has been made, that employee will be suspended until a thorough investigation is completed to ensure the protection of the resident and to prevent reprisal..." A policy and procedure, titled, "Employee Reporting of Possible Abuse, Neglect, or Misappropriation of Resident Property, documented, "...Employees should report any suspected verbal or physical abuse of a resident, any suspected neglect of a resident, or any suspected misappropriation (theft) of resident property to the administrator or DON immediately..." 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/17/10, documented the resident was moderately impaired in cognitive skills for daily decision making, was easily distracted with periods of restlessness, could sometimes make herself understood and usually could understand others. She had no behavioral symptoms and was identified as having no falls in the past 180 days. A nurse's note, dated 07/10/10 at 10:30 a.m., documented, "Received call from resident's family member regarding resident's condition. Family reports (increased) confusion, (increased) anxiety, behaviors such as tearing things up and [MEDICAL CONDITION] such as people coming to chop her up with an axe. Family member reports (increased) anxiety as well. Resident evaluated. Appears to have (increased) anxiety this am but is alert + oriented per her usual orientation..." A care plan, dated 07/12/10, documented, "Problem: Alteration in mood and behavior patterns: (Resident) demonstrates observable signs of mental distress; (i.e. tearing up napkins and Kleenex, stating that someone in her room is there to chop her up and hurt her.) Goals: Will interact with staff members and other residents. Approach: 1. Capitalize on (resident's) strengths and maximize independence 2. Counsel with (resident) regarding feelings; be supportive 3. Encourage (resident) to socialize with other residents on a daily basis 4. Approach calmly and allow ventilation of feelings 5. Administer medications as ordered 6. Allow quiet calm environment during acute phase" A nurse's note, dated 07/19/10 at 6:20 p.m., documented, "Resident has anxiety when leaving dinner table. Ripped apart clothing protector, clawed nurse aide, pinched nurse aide, grabbing at tables, door frames and wall railing. Does not want to go to room d/t thinks there are people in there who want to chop her into dog food. Prn [MEDICATION NAME] given." A nurse's note, dated 07/24/10 at 9:00 a.m., documented, "Resident has (increased) anxiety this am when leaving dining room. Does not want to go into her room. States she believes there is someone in her room that wants to hurt her. Prn [MEDICATION NAME] given c minimal effect." A nurse's note, dated 08/01/10 at 10:55 a.m., documented, "...cont to show s/s anxiety AEB (as evidenced by) fearfulness that someone is going to come out of her closet and kill her..." An incident/accident report, dated 08/06/10 at 3:30 a.m., documented, "...Resident's condition before incident/accident: confused, disoriented... Describe exactly what happened:...CNA was bedchecking res. Noted bruising c swelling to L side of face/under L eye, cheek + mouth. Cause unknown. Lights to be on to view each resident @ bed check. Proper transfers must be done... Name of physician notified: (name deleted) faxed. Time of notification: 0420 a.m. (4:20 a.m.). Time responded: (left blank). Name and relationship of family member/resident representative notified: dtg (daughter). Time of notification 7:15 a.m... Additional comments and/or steps taken to prevent recurrence: (X-ray company) for facial x-rays. Daughters wanted her sent out to (hospital name deleted)." A nurse's note, dated 08/06/10 at 4:10 a.m., documented, "...CNA came to N.S. (nurses' station) and informed this LPN that res had bruising + swelling to face. LPN went to check res and noted dark purple bruising to mouth + L eye. Swelling to L eye, cheek, and upper lip. L eye swollen shut unable to assess pupil. Cause of bruising unknown. Res personal alarm in place. Floor mat in place. Alarm on + opreating (sic). Alarm has not sounded this shift. Res has not gotten out of bed. When asked res what happened, first (sic) stated 'He did it. He hit me.' then stated to CMA that 'they did it. That it was after dinner + before bed.' 'This evening.' CNA stated that he did not notice it @ 0100 (1:00 a.m.) bedcheck but that he had not turned light on. Res has base of alarm in bed and hard plastic sip cup in bed. Per CMA who worked 7-3 shift on 08/05/10, res has had (increased) anxiety and behaviors. Had hand towel wrapped around neck + was pulling it tight. Also had clothing protector on and was tieing (sic) it in knot and pulling the ends tight around throut (sic). Res did this 2 more (times). Dr. faxed. Neuro (checks) + 72 (hour) obs (observation) started along c behavior monitoring." An x-ray form, dated 08/06/10, documented, "Impression: Limited study of the facial bones. The patient is edentulous. Facial bones appear intact without fracture or gross destruction within the limitations of this study..." A form titled, Initial Report (sent to OSDH), dated 08/06/10, documented, "It was reported to the charge nurse by CNA (#1) on 11-7, (LPN #1), at approximately 3:30 a.m., that during bed check the resident was noticed to having bruising and swelling to the left side of her face under her eye, cheek and mouth. The Charge Nurse went to check on the resident, she was noted to have red dark purple bruising to mouth and left eye, swelling to left eye, cheek, and upper lip. Her left eye was swollen shut and she was unable to assess pupil. When the Charge Nurse asked her what happened, she stated, 'He did it, he hit me.' Then when she spoke with the CMA (#1), she stated 'they did it.' Also at that time, she stated, 'it was after dinner and before bed this evening.' The 11-7 CNA (#1) did not identify any injury at 0100 (1:00 a.m.) bed check and did not turn on the light at that time to keep from waking her. The physician was notified. Neuro-checks were started and ice pack was applied face. At 7:30 a.m., the 7-3 charge nurse, (LPN #2) notified physician who stated to send her to ER to rule out facial fractures. The family, Administrator and Director of Nurses was also notified. Family did not want resident sent out at this time, but wanted mobile x-ray notified to come out to facility for facial views. Physician was notified of family wishes and mobile x-ray ordered. Mobile X-ray Diagnostic Report was received and was clear. No fractures. (Physician) was notified of results. Then upon family arriving at 10:30 am, they decided they indeed wanted to have resident sent out for more testing. Physician made aware. (Ambulance company name deleted) was contacted and resident taken to (hospital ER name deleted). Director of Nursing, (name deleted) contacted (hospital ER name deleted) at 10:45 am and spoke with (nurse's name deleted) and gave him detailed report of the situation and that we were very concerned about resident and had notified all the appropriate agencies and to contact us if they had any questions or if we could assist with her care. At 11:00 am, the DON called the Noble Police Dept notifying them of the incident. (Officer's names deleted) came out for our initial report around 1:20 pm. (Physician name deleted) called and spoke with the DON around 1:00 pm and asked further questions regarding the incident and stated he would contact his social worker and they would have to also contact APS (Adult Protective Services)... Resident is an 86 y/o female with a dx. of Dementia with behavioral disturbances, constipation, anxiety, [MEDICAL CONDITIONS], ASCVD, [MEDICAL CONDITIONS], OA ([MEDICAL CONDITION]), OP ([MEDICAL CONDITION]),[MEDICAL CONDITION]& [MEDICAL CONDITION]. She is non-ambulatory, contractures in both legs at knees, oriented to family, disoriented x2. She is anxious, she has [MEDICAL CONDITION] at times. Will continue to investigate and conduct interviews, and finalize report upon its completion. Care plan will be updated with new interventions upon residents return from hospital. Will continue to check resident Q 2 hrs and prn, and answer alarm promptly. Resident is already on the Falling Leaves Program and is monitored per Program requirements." A physician's telephone order, dated 08/06/10, documented, "Sent to ER for eval + tx. L side of face hematoma." A form titled, Incident Management Report, dated 08/06/10, documented, "Were there any witnesses to the fall? N/A Where and in what position was resident found: In bed on R side. Site & Description on Injury, if any: bruising + swelling to L side of face CNA(s) assigned to resident: (CNA #1 and #2) Possible reason for injury: Unknown: Res has had (increased) behavior problems. May have hit self c hard plastic cup. Alarm base (illegible)... Resident mental status at time of incident: confused/disoriented List any instruction given to staff at time of incident: (CNA #1) to stay out of room. Two adies (sic) @ all times..." An undated, untimed and hand written report by CNA #4, documented, "3-11. I went on break at a little after 8:00 p.m. when I left (resident) was still up and in her wheelchair when I came back from break she was already in bed. We did bed check. She was fine when I went in. I didn't see anything wrong with (resident). No marks or swelling. A little after 10:30 I went in the room was dark so I didn't see anything." An undated, untimed and hand written report by CNA #3, documented, "11:15 (pm) Res sipping cup was laying in the floor and she was reaching for it and you sat her up in bed + raised head - put ice water in cup - she got a drink and layed the bed back down - no bruising - nothing..." An undated, untimed and hand written report by CNA #2, documented, "Clocked in + passed ice from middle of the hall. Around 1 am she stood in door way of (resident). Around 3 am, he (CNA #1) came + told her about (resident's) face. No interactions c (resident) until after incident of 3 am." An untimed handwritten report, dated 08/06/10, documented, " (LPN #1) - interviewed. (CNA #1) reported @ 3 something about face swelling + bruising. Neuro checks not able to do swelling of L eye." An untimed handwritten report by an unknown writer, dated 08/06/10, documented, "(Resident). Family in rm (room) during interview. Asked resident what happened + she stated her Father-in-law hit her. When daughter asked her she said Brother-in-law hit her. Residents other daughter started asking her questions 'Who hit you Momma?' Resident mumbling at this point." A Police Department Report, written by police officer #1, dated 08/08/10, documented, "On August 8, 2010 at approximately 1340 hours (1:40 p.m.) I contacted (the DON) at Noble Health Care, in reference to possible abuse of a resident at the living center. (The DON) stated a report has been filed with the state and she investigating the incident... (Police officer #2) contacted (the resident) at the (hospital name deleted) on Saturday, August 7, 2010 and obtained photographs of (the resident's) injuries. The photographs showed (the resident) to have serious bruising covering the majority of her face. The bruising was purple and blue in color and appeared to be caused from some sort of [MEDICATION NAME] trauma. (The resident) had bruises over and around both eyes, over and under her lip and over both cheeks... I then contacted (the resident) at the (hospital name deleted). I observed (the resident) to have severe bruising around her eyes, nose, cheeks and chin. The bruises appeared to be several days old. Based on (the resident's) mental condition I was unable to obtain a clear explanation as to how the injuries occurred. (The resident) did say that a man had hit her twice in the face... I was able to obtain a video and statement from (a family member). (The family member) advised that they spoke with (the resident) about the incident and he documented it via audio/video recording. I viewed the video and it shows the following. (The resident) clearly states that she was standing when a black employee hit her twice knocking her out. (The resident) stated it occurred in the evening and that the male person told her it was 'payback'. The statements made by (the resident) are consistent with the injuries she received... I spoke with (CNA #3) who is also a CNA. (The CNA) informed me that she passed ice out in the 400 hallway. (The CNA) advised that she contacted (the resident) at approximately 11:30 p.m. and refilled her soppy (sippy) cup with water and ice. (The CNA) stated she spoke with (the resident) briefly and did not observe any injuries to (the resident's) face. (The CNA) stated the (the resident) was very corporative (sic) and did not give her any problems. I spoke with (CNA #5) who was the 3 p.m. to 11 p.m. CNA for (the resident) that night...(The CNA) advised that (the resident) did not have any injuries on his shift, nor did she have any accidents... On August 11, 2010 I conducted an interview with (CNA #2) at the (City Name) Police Department. (The CNA) advised that she was new to hall 400, so (CNA #1) advised her that he would take care of (the resident) because of her tendencies to be hard to deal with...(The CNA) stated she did not know how (the resident) obtained her injuries. All parties interviewed in reference to this incident advised that (the resident) was very corporative (sic) and did not cause any problems that day... I spoke with head nurse (corporate nurse) and showed her the video and photographs that I obtained. (The corporate nurse) agreed that the injuries are consistent with (the resident's) statements and it does appear they were due to [MEDICATION NAME] force trauma to the cheek and chin of (the resident)... On August 12, 2010 I was contacted by (CNA #1) at the (City name) Police Department in reference to our scheduled interview...(CNA #1) stated he contacted (the resident) in her room at approximately 0100 hours (1:00 a.m.) on Friday August 6, 2010 to change a urine pad. (The CNA) stated he did not see visible injuries to (the resident) at that time. (The CNA) admitted that he did not turn on the main light, but used the night light that is not very bright. (The CNA) stated he really did not check (the resident's) face at that time...(The CNA) was very nervous during the interview. He was shaking, his lip was quivering and I could see his throat swallow as if his mouth was very dry. I asked (The CNA) if he would take a polygraph test and he agreed after some hesitation. I showed (the CNA) the video tape of (the resident's) interview and he advised the (the resident) was communicating more than normal... On August 24, 2010 I met with (CNA #1) at the (Name deleted) Forensic Center in Oklahoma City for a scheduled polygraph. (Agent's name deleted) conducted the polygraph examination. At the conclusion of the polygraph, (the agent) informed me that (CNA #1) showed to be deceptive on his test and on the questions if he caused the injuries to (the resident). After the polygraph (the agent) and I conducted a follow up interview. During the interview, (the CNA) denied ever hitting (the resident) but indicated that he might have been in a hurry and rolled her over to (sic) hard, causing her head to hit the wall..." A form titled Time/Attendance Detail Report, documented CNA #1 worked the 11:00 p.m. to 7:00 a.m., shift on 08/08/10, 08/09/10 and 08/10/10. A handwritten report, dated 08/09/10 at 2:25 p.m., documented, "(CMA #1) worked 11-7 as med aide extra shift. (CMA #1) was at nsg (nursing) station - (CNA #1) came out + told C.N. (charge nurse) that res face was swollen. (CMA #1) went in also. (CMA #1) told her to call (DON) + (administrator), hospital. (LPN #1) stated that she's not suppose to contact family before 7 am. (Resident) said, 'I'm a human being.' (Resident) said someone came + hit me + pointed to (CNA #1) + saying 'He did it.' Kept repeating 'I'm a human being.' Then stated 2 people beat her up. Came thru the window. Window was locked. 4 am pain med offered + refused. (CNA #2) told them R (resident) c/o pain R hip, Rcd (received) [MEDICATION NAME] for hip + face. (CNA #1) was kept out of room for rest of shift. Then looked @ (CNA #2) evil. Denies seeing new resident on hall. HOB (down) lying on R side (illegible)." A nursing home form, dated 08/10/10, documented, "Employee (LPN #1) neglected contacting family, DON, Administrator at 3 am of possible abuse/unknown bruising of facial area to resident. Failed to address resident accusation of employee..." A five day report, dated 08/11/10, for resident #1, documented, "The investigation into (the resident') injuries is ongoing. She remains hospitalized at (hospital name deleted) at this time. The facility is in contact and fully cooperating with the (city name) Police Department. (The resident's) family have obtained a video interview of (the resident) which indicated that a black male worker was involved in her care when the injuries occurred. At this time according to (police officer #1) the police investigation is focusing on interviews of two black male employees who worked with (the resident) on the 3-11 and 11-7 shifts the day of and the evening before the noted injuries. Therefore, both of these male employees will be suspended pending the outcome of the police investigation. The two CNAs in question are (CNA #5) and (CNA #1). The nurse Aide Registry form 718 has been completed and filed with the Nurse Aide Registry as required. We will send a final report upon completion of the investigation." On 09/08/10 at 8:55 a.m., the DON and administrator approached the surveyors and started to talk about resident #1 and the allegation of abuse which occurred on 08/06/10. The administrator stated the (city name) Police were investigating the allegation and lie detector tests had been given to CNA #1 and CNA #5. She also stated CNA #1's test showed deception. She stated CNA #1 was on suspension and CNA #5 had resigned. The administrator was asked when the CNA accused of the assault was suspended. She stated, "Immediately. (CNA #1) was suspended on 08/11/10. (The corporate nurse) called the corporate office and we suspended him at that time." She was asked since the resident's swelling and bruising were found at approximately 3:00 a.m., did CNA #1 work the rest of the night. She stated, "The charge nurse didn't notify us, so (CNA #1) worked the rest of the night. She was asked if he worked after that night and until his suspension on 08/11/10. She stated she would have to check. They were asked why LPN #1 did not notify them earlier of the bruising and swelling. The administrator stated, "It didn't look like it was bad at the time. It got worse as the night progressed." She stated she was told there was bruising present at 3:00 a.m., just not as bad as it was when she saw it at 7:30 a.m. She stated the 11-7 charge nurse reported the bruising on the resident, to the 7-3 charge nurse. The DON and administrator were not informed until the 7-3 nurse got in touch with them the next shift. The administrator stated that initially, the resident's eye and upper lip were bruised and swollen, but several days later, the whole side of her face was bruised. The DON and the administrator offered several explanations on how the resident's injury might have occurred. They were asked if they ever suspected abuse. They both stated CNA #1 was well liked and they had never had any problems with him. The DON and the administrator were asked how CNA #1 reacted when he was interviewed about the events of 08/06/10. The DON stated, "He (CNA #1) was sweating. His lip was quivering and he was swallowing alot. He looked nervous or scared." When asked what she thought about his behavior, she stated, "I think he was worried that he was going to be fired." The administrator stated the resident did not report it was a black male employee until 08/09/10, when the resident reported it to the family. The administrator stated the events of the night were as follows: -On 08/05/10 at 11:15 p.m., CNA #3 stated there was no bruising or swelling of the resident's face. She was covering hall 400 for CNA #1 until he got there. CNA #3 passed ice until then. -At 11:27 p.m., CNA #1 arrived and started doing the laundry. -On 08/06/10 at 1:00 a.m., CNA #1 changed the resident's wet brief. He did not turn on the light so he did not notice anything about the resident's face. CNA #2 was standing in the doorway talking to him while care was given. She reported she saw him kneeling on the floor beside the bed with the curtain closed. -At 3:00 a.m., the resident was soiled. CNA #1 turned on the light to change her and saw the bruising. The administrator stated he reported the bruising to CNA #2, then to LPN #1. The nursing home investigative folder was reviewed. There was a sticky note in the folder which documented, "(LPN #1) Ask her if she wasn't concerned when (the resident) said, 'He hit me. He did it.' At 2:30 p.m., at the (city name deleted) Police Department, police officer #1 who investigated the incident of 08/06/10, was asked how his department was notified of the incident. He stated, "They (the facility) faxed the department a report. That's what they always do. They didn't call a report. Anything could happen with a fax. It could be misplaced or lost. They didn't call." He was asked to give his assessment of the resident's injuries. He stated it appeared she had been struck with [MEDICATION NAME] force to her face, probably twice. He was asked if the injuries could be the result of a fall, or bump into a wall or door. He stated, "No. They (the facility) kept coming up with scenarios on how she could have been injured. I went back to the facility and watched them re-enact it. It didn't make sense. I told them it didn't happen like that." At 3:10 p.m., CMA #1 was asked what happened the night of 08/06/10. She stated she passed medications that night. She stated at 3:00 a.m., CNA #1 came out of the resident's room and asked LPN #1 if she knew about the bump or bruise on the resident. She stated both LPN #1 and herself entered the resident's room. She described the resident's face as being swollen with the resident's nose pushed to the side. She stated the resident's vital signs were taken and neuro checks were started. The resident was given a [MEDICATION NAME] as she was restless and 'grabby' which was not unusual for her. CMA #1 stated the resident said that someone came in through the window and hit her in the face. Later on, the resident told her that two men came in and hit her in the face. The CMA stated the resident 'glared' at CNA #1 and pointing at him stated 'He did it.' The CMA continued and stated the resident's cheek bone was hard, with her nose to the side. She stated her left eye was swollen like a water blister and it was a little purple. She stated the resident could open her eye slightly. She stated the resident's lip was slightly discolored and swollen. "You could tell something wasn't right. I was shocked." She was asked if she thought the injury was significant. She stated, "Yes." The CMA stated she checked on the resident through out the night. She was asked if she was instructed to do this. She stated, "No, I did it on my own." She stated the resident asked her, "Why did you let them do this?" She was asked if any of the CNAs were asked to go home. She stated that all staff finished the night as normal. She stated CNA #1 did not re-enter the room because of the resident glaring and pointing at him. She stated it was CNA #1's decision not to re-enter the room, and that he was not asked to do this. At 3:30 p.m., the administrator was asked if she had interviewed any other residents in the course of her investigation. She stated she had called a special resident council meeting on 08/11/10, five days after the incident. She stated none of the residents had any complaints of mistreatment by staff members. She was asked if she had asked specifically about CNA #1. She stated she had not asked about the CNA in particular, but did narrow it down to 3-11 and 11-7 CNAs. She again stated no complaints were made. She was asked when CNA #1 was suspended. She stated, not until 08/11/10, the same day as the five day state report. She was asked why the CNA identified by the resident wasn't suspended immediately. She stated, "We didn't know who it was at first." She was asked why it took five days before he was suspended. She stated, "We did it as soon as she said a black male, when we watched the video." She was asked if she suspected abuse when she was first made aware of the injuries. She stated she did not suspect abuse at first. She stated, "I still don't want to think that happened." At 4:10 p.m., the administrator and the DON were asked why they had not suspected abuse. No answer was given. The administrator was asked if she had spoken with the 11-7 charge nurse the day the bruising and swelling was observed. She stated, "She was gone when I came in." At 4:15 p.m., the DON was asked if she was aware of resident #1's mental status prior to the discovery of the injury on 08/06/10. She stated, "She was the most cooperative and calmer than we have ever seen her that whole evening and night." At 4:45 p.m., CNA #2 was contacted by telephone for an interview. She was asked to recount the events when she began her shift on 08/06/10. She stated, "At about 11:00 (p.m.) on the hall (Hall 400) where (CNA #3) left off, I started passing ice to residents in the middle of the hall. I didn't see the residents that (CNA #3) had already seen. That was my fault. I should have looked at them all when I got there. (CNA #1) got there around 11:30 (p.m.). We started bed check at 1:00 (a.m.). Earlier, he (CNA #1) said he would handle (resident #1) because she might try to fight during care. (CNA #1) went in to change (resident #1) a little after 1:00 a.m.. I was doing bed checks on the rest of the hall." CNA #2 was asked what happened next. She stated, "At one point I finished what I was doing and went to (resident #1's) room because I knew (CNA #1) was in there. I knocked and opened the door. I didn't go in because I could see the curtain pulled around the bed and (CNA #1) on his knees at the bedside. I could see him because the curtain doesn't go all the way to the floor. I stood in the doorway. The room was dark. He said he was doing incontinent care." CNA #2 was asked what happened after CNA #1 finished care for resident #1. She stated, "We just did regular jobs like folding pads and checking on residents." CNA #2 was asked what happened next. She stated, "At 3:00 a.m. bed checks, I was in the room next to (resident #1) doing incontinent care. (CNA #1) came in and asked me if I had seen (resident #1's) face. I said, 'No, what about it?' (CNA #1) said, 'Her face is swollen'. I told him to go tell the charge nurse." CNA #2 was asked if she saw or heard anything when she was in the room next to resident #1 at about 3:00 a.m.. She stated, "No. But after I finished incontinent care, I went into (resident #1's) room. The charge nurse and (CNA #1) were in there with (resident #1)." CNA #2 was asked what she saw. She stated, "Her (resident #1's) jaw was swollen on the left. It was like a softball size. Her lip was puffy on one side." CNA #2 was asked what the resident was doing and saying at this time. She stated, "She was pointing at (CNA #1) and said, 'He hit me.'" CNA #2 was asked again if she saw or heard anything unusual while she was in the room next to resident #1, or at any time during that night. She stated, "No. I didn't hear anything, no bumps, no yelling, no screaming." CNA #2 stated she was in resident #1's room off and on throughout the remainder of the night. She was providing care such as obtaining vital signs and sitting with her. She stated CMA #1 brought an ice pack to put on resident #1's eye. CNA #2 was asked to describe the resident's injury as she stayed with her during the night. She stated, "Her (left) eye kept swelling and started to bruise up. I asked her what hurts. She said, 'My hip, my hip.' Her face kept getting worse and worse. The CMA gave her a pain pill. Later she (resident #1) said, 'I'm a person. I wanna be treated like a person.'" CNA #2 was asked if she had any conversation with CNA #1 during the night of 08/06/10. She stated, "He said, 'I wonder what happened (to resident #1)?' He asked me a couple of times what I thought happened to her." CNA #2 was asked what other care was provided to the resident during the night. She stated the ice pack was kept on. She stated they were trying to do neuro checks but the eye was so swollen they couldn't check the pupil. CNA #2 was asked if anyone ever talked about sending the resident to the hospital. She stated the (7a.m.-3p.m.) charge nurse called the resident's family and they decided to get an x-ray of her face at the facility. CNA #2 stated, "I thought she should have gone to the hospital. Later, a male nurse (LPN #4) working the morning shift came up to a group of us standing outside the resident's room. He asked what was going on. We told him that the resident had swelling in her face and eye and that she (the resident) kept saying (CNA#1) hit her." CNA #2 was asked what LPN #4 did then. She stated, "He went into the resident's room to look at her. He came out and said, 'It looks like someone hit her. Her nose may be broken. It looks like there are two injuries.' " CNA #2 was asked if any other day shift charge nurse had been in to see the resident. She stated, "No. The day shift charge nurse was on the phone calling people. It was around 7 or 7:15 (a.m.)." CNA #2 was asked if CNA #1 worked the remainder of that night shift. She stated, "Yes. He didn't go into the resident's room. He said he was not comfortable going in there after what she said. He just worked doing other things, with other residents." CNA #2 was asked if she worked with CNA #1 on any subsequent night shifts after 08/06/10. She stated, "Yes. Until I heard he got suspended."

Based on observation, review of clinical records, review of policies and procedures and resident and staff interviews, it was determined the facility failed to: a. ensure staff reported allegations of abuse or observations of suspected abuse to administration for two (#1 and #3) of two sampled residents for whom allegations or observations of suspected abuse were made; b. thoroughly investigate allegations of abuse for two (#1 and #3) of two sampled residents for whom allegations of abuse were made; c. ensure the protection of residents during investigations of abuse for two (#1 and #3) of two sampled residents; and d. thoroughly investigate an incident of bruising of unknown origin for one (#2) of one sampled residents who had bruising of unknown origin. These deficient practices constituted an Immediate Jeopardy situation. This had the likelihood to affect all residents in the facility. Findings: A policy and procedure, titled, Identification and Investigation of Abuse, documented, "Early warning signs of abuse may be unexplained bruises and/or fractures...Any of the above warning signs, even in the absence of allegations of abuse will be thoroughly investigated including: interviewing the individuals involved; interviewing all witnesses; notifying the physicians and where appropriate, the families of the involved residents, and recording all relevant physical findings... Facility Investigation should include: 1. Observations, interviews and record reviews of all residents involved; 2. Interviews of all witnesses, including resident, staff and family members; 3. Notifying the physicians and where appropriate, the families or responsible parties of the involved resident, and 4. Recording all physical findings." A policy and procedure, titled, Protection of Resident During Investigation Of Abuse, documented, "If an allegation of abuse by a particular employee has been made, that employee will be suspended until a thorough investigation is completed to ensure the protection of the resident and to prevent reprisal..." A policy and procedure, titled, "Employee Reporting of Possible Abuse, Neglect, or Misappropriation of Resident Property, documented, "...Employees should report any suspected verbal or physical abuse of a resident, any suspected neglect of a resident, or any suspected misappropriation (theft) of resident property to the administrator or DON immediately..." 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/17/10, documented the resident was moderately impaired in cognitive skills for daily decision making, was easily distracted with periods of restlessness, could sometimes make herself understood and usually could understand others. She had no behavioral symptoms and was identified as having no falls in the past 180 days. A nurse's note, dated 07/10/10 at 10:30 a.m., documented, "Received call from resident's family member regarding resident's condition. Family reports (increased) confusion, (increased) anxiety, behaviors such as tearing things up and [MEDICAL CONDITION] such as people coming to chop her up with an axe. Family member reports (increased) anxiety as well. Resident evaluated. Appears to have (increased) anxiety this am but is alert + oriented per her usual orientation..." A care plan, dated 07/12/10, documented, "Problem: Alteration in mood and behavior patterns: (Resident) demonstrates observable signs of mental distress; (i.e. tearing up napkins and Kleenex, stating that someone in her room is there to chop her up and hurt her.) Goals: Will interact with staff members and other residents. Approach: 1. Capitalize on (resident's) strengths and maximize independence 2. Counsel with (resident) regarding feelings; be supportive 3. Encourage (resident) to socialize with other residents on a daily basis 4. Approach calmly and allow ventilation of feelings 5. Administer medications as ordered 6. Allow quiet calm environment during acute phase" A nurse's note, dated 07/19/10 at 6:20 p.m., documented, "Resident has anxiety when leaving dinner table. Ripped apart clothing protector, clawed nurse aide, pinched nurse aide, grabbing at tables, door frames and wall railing. Does not want to go to room d/t thinks there are people in there who want to chop her into dog food. Prn [MEDICATION NAME] given." A nurse's note, dated 07/24/10 at 9:00 a.m., documented, "Resident has (increased) anxiety this am when leaving dining room. Does not want to go into her room. States she believes there is someone in her room that wants to hurt her. Prn [MEDICATION NAME] given c minimal effect." A nurse's note, dated 08/01/10 at 10:55 a.m., documented, "...cont to show s/s anxiety AEB (as evidenced by) fearfulness that someone is going to come out of her closet and kill her..." An incident/accident report, dated 08/06/10 at 3:30 a.m., documented, "...Resident's condition before incident/accident: confused, disoriented... Describe exactly what happened:...CNA was bedchecking res. Noted bruising c swelling to L side of face/under L eye, cheek + mouth. Cause unknown. Lights to be on to view each resident @ bed check. Proper transfers must be done... Name of physician notified: (name deleted) faxed. Time of notification: 0420 a.m. (4:20 a.m.). Time responded: (left blank). Name and relationship of family member/resident representative notified: dtg (daughter). Time of notification 7:15 a.m... Additional comments and/or steps taken to prevent recurrence: (X-ray company) for facial x-rays. Daughters wanted her sent out to (hospital name deleted)." A nurse's note, dated 08/06/10 at 4:10 a.m., documented, "...CNA came to N.S. (nurses' station) and informed this LPN that res had bruising + swelling to face. LPN went to check res and noted dark purple bruising to mouth + L eye. Swelling to L eye, cheek, and upper lip. L eye swollen shut unable to assess pupil. Cause of bruising unknown. Res personal alarm in place. Floor mat in place. Alarm on + opreating (sic). Alarm has not sounded this shift. Res has not gotten out of bed. When asked res what happened, first (sic) stated 'He did it. He hit me.' then stated to CMA that 'they did it. That it was after dinner + before bed.' 'This evening.' CNA stated that he did not notice it @ 0100 (1:00 a.m.) bedcheck but that he had not turned light on. Res has base of alarm in bed and hard plastic sip cup in bed. Per CMA who worked 7-3 shift on 08/05/10, res has had (increased) anxiety and behaviors. Had hand towel wrapped around neck + was pulling it tight. Also had clothing protector on and was tieing (sic) it in knot and pulling the ends tight around throut (sic). Res did this 2 more (times). Dr. faxed. Neuro (checks) + 72 (hour) obs (observation) started along c behavior monitoring." An x-ray form, dated 08/06/10, documented, "Impression: Limited study of the facial bones. The patient is edentulous. Facial bones appear intact without fracture or gross destruction within the limitations of this study..." A form titled, Initial Report (sent to OSDH), dated 08/06/10, documented, "It was reported to the charge nurse by CNA (#1) on 11-7, (LPN #1), at approximately 3:30 a.m., that during bed check the resident was noticed to having bruising and swelling to the left side of her face under her eye, cheek and mouth. The Charge Nurse went to check on the resident, she was noted to have red dark purple bruising to mouth and left eye, swelling to left eye, cheek, and upper lip. Her left eye was swollen shut and she was unable to assess pupil. When the Charge Nurse asked her what happened, she stated, 'He did it, he hit me.' Then when she spoke with the CMA (#1), she stated 'they did it.' Also at that time, she stated, 'it was after dinner and before bed this evening.' The 11-7 CNA (#1) did not identify any injury at 0100 (1:00 a.m.) bed check and did not turn on the light at that time to keep from waking her. The physician was notified. Neuro-checks were started and ice pack was applied face. At 7:30 a.m., the 7-3 charge nurse, (LPN #2) notified physician who stated to send her to ER to rule out facial fractures. The family, Administrator and Director of Nurses was also notified. Family did not want resident sent out at this time, but wanted mobile x-ray notified to come out to facility for facial views. Physician was notified of family wishes and mobile x-ray ordered. Mobile X-ray Diagnostic Report was received and was clear. No fractures. (Physician) was notified of results. Then upon family arriving at 10:30 am, they decided they indeed wanted to have resident sent out for more testing. Physician made aware. (Ambulance company name deleted) was contacted and resident taken to (hospital ER name deleted). Director of Nursing, (name deleted) contacted (hospital ER name deleted) at 10:45 am and spoke with (nurse's name deleted) and gave him detailed report of the situation and that we were very concerned about resident and had notified all the appropriate agencies and to contact us if they had any questions or if we could assist with her care. At 11:00 am, the DON called the Noble Police Dept notifying them of the incident. (Officer's names deleted) came out for our initial report around 1:20 pm. (Physician name deleted) called and spoke with the DON around 1:00 pm and asked further questions regarding the incident and stated he would contact his social worker and they would have to also contact APS (Adult Protective Services)... Resident is an 86 y/o female with a dx. of Dementia with behavioral disturbances, constipation, anxiety, [MEDICAL CONDITIONS], ASCVD, [MEDICAL CONDITIONS], OA ([MEDICAL CONDITION]), OP ([MEDICAL CONDITION]),[MEDICAL CONDITION]& [MEDICAL CONDITION]. She is non-ambulatory, contractures in both legs at knees, oriented to family, disoriented x2. She is anxious, she has [MEDICAL CONDITION] at times. Will continue to investigate and conduct interviews, and finalize report upon its completion. Care plan will be updated with new interventions upon residents return from hospital. Will continue to check resident Q 2 hrs and prn, and answer alarm promptly. Resident is already on the Falling Leaves Program and is monitored per Program requirements." A physician's telephone order, dated 08/06/10, documented, "Sent to ER for eval + tx. L side of face hematoma." A form titled, Incident Management Report, dated 08/06/10, documented, "Were there any witnesses to the fall? N/A Where and in what position was resident found: In bed on R side. Site & Description on Injury, if any: bruising + swelling to L side of face CNA(s) assigned to resident: (CNA #1 and #2) Possible reason for injury: Unknown: Res has had (increased) behavior problems. May have hit self c hard plastic cup. Alarm base (illegible)... Resident mental status at time of incident: confused/disoriented List any instruction given to staff at time of incident: (CNA #1) to stay out of room. Two adies (sic) @ all times..." An undated, untimed and hand written report by CNA #4, documented, "3-11. I went on break at a little after 8:00 p.m. when I left (resident) was still up and in her wheelchair when I came back from break she was already in bed. We did bed check. She was fine when I went in. I didn't see anything wrong with (resident). No marks or swelling. A little after 10:30 I went in the room was dark so I didn't see anything." An undated, untimed and hand written report by CNA #3, documented, "11:15 (pm) Res sipping cup was laying in the floor and she was reaching for it and you sat her up in bed + raised head - put ice water in cup - she got a drink and layed the bed back down - no bruising - nothing..." An undated, untimed and hand written report by CNA #2, documented, "Clocked in + passed ice from middle of the hall. Around 1 am she stood in door way of (resident). Around 3 am, he (CNA #1) came + told her about (resident's) face. No interactions c (resident) until after incident of 3 am." An untimed handwritten report, dated 08/06/10, documented, " (LPN #1) - interviewed. (CNA #1) reported @ 3 something about face swelling + bruising. Neuro checks not able to do swelling of L eye." An untimed handwritten report by an unknown writer, dated 08/06/10, documented, "(Resident). Family in rm (room) during interview. Asked resident what happened + she stated her Father-in-law hit her. When daughter asked her she said Brother-in-law hit her. Residents other daughter started asking her questions 'Who hit you Momma?' Resident mumbling at this point." A Police Department Report, written by police officer #1, dated 08/08/10, documented, "On August 8, 2010 at approximately 1340 hours (1:40 p.m.) I contacted (the DON) at Noble Health Care, in reference to possible abuse of a resident at the living center. (The DON) stated a report has been filed with the state and she investigating the incident... (Police officer #2) contacted (the resident) at the (hospital name deleted) on Saturday, August 7, 2010 and obtained photographs of (the resident's) injuries. The photographs showed (the resident) to have serious bruising covering the majority of her face. The bruising was purple and blue in color and appeared to be caused from some sort of [MEDICATION NAME] trauma. (The resident) had bruises over and around both eyes, over and under her lip and over both cheeks... I then contacted (the resident) at the (hospital name deleted). I observed (the resident) to have severe bruising around her eyes, nose, cheeks and chin. The bruises appeared to be several days old. Based on (the resident's) mental condition I was unable to obtain a clear explanation as to how the injuries occurred. (The resident) did say that a man had hit her twice in the face... I was able to obtain a video and statement from (a family member). (The family member) advised that they spoke with (the resident) about the incident and he documented it via audio/video recording. I viewed the video and it shows the following. (The resident) clearly states that she was standing when a black employee hit her twice knocking her out. (The resident) stated it occurred in the evening and that the male person told her it was 'payback'. The statements made by (the resident) are consistent with the injuries she received... I spoke with (CNA #3) who is also a CNA. (The CNA) informed me that she passed ice out in the 400 hallway. (The CNA) advised that she contacted (the resident) at approximately 11:30 p.m. and refilled her soppy (sippy) cup with water and ice. (The CNA) stated she spoke with (the resident) briefly and did not observe any injuries to (the resident's) face. (The CNA) stated the (the resident) was very corporative (sic) and did not give her any problems. I spoke with (CNA #5) who was the 3 p.m. to 11 p.m. CNA for (the resident) that night...(The CNA) advised that (the resident) did not have any injuries on his shift, nor did she have any accidents... On August 11, 2010 I conducted an interview with (CNA #2) at the (City Name) Police Department. (The CNA) advised that she was new to hall 400, so (CNA #1) advised her that he would take care of (the resident) because of her tendencies to be hard to deal with...(The CNA) stated she did not know how (the resident) obtained her injuries. All parties interviewed in reference to this incident advised that (the resident) was very corporative (sic) and did not cause any problems that day... I spoke with head nurse (corporate nurse) and showed her the video and photographs that I obtained. (The corporate nurse) agreed that the injuries are consistent with (the resident's) statements and it does appear they were due to [MEDICATION NAME] force trauma to the cheek and chin of (the resident)... On August 12, 2010 I was contacted by (CNA #1) at the (City name) Police Department in reference to our scheduled interview...(CNA #1) stated he contacted (the resident) in her room at approximately 0100 hours (1:00 a.m.) on Friday August 6, 2010 to change a urine pad. (The CNA) stated he did not see visible injuries to (the resident) at that time. (The CNA) admitted that he did not turn on the main light, but used the night light that is not very bright. (The CNA) stated he really did not check (the resident's) face at that time...(The CNA) was very nervous during the interview. He was shaking, his lip was quivering and I could see his throat swallow as if his mouth was very dry. I asked (The CNA) if he would take a polygraph test and he agreed after some hesitation. I showed (the CNA) the video tape of (the resident's) interview and he advised the (the resident) was communicating more than normal... On August 24, 2010 I met with (CNA #1) at the (Name deleted) Forensic Center in Oklahoma City for a scheduled polygraph. (Agent's name deleted) conducted the polygraph examination. At the conclusion of the polygraph, (the agent) informed me that (CNA #1) showed to be deceptive on his test and on the questions if he caused the injuries to (the resident). After the polygraph (the agent) and I conducted a follow up interview. During the interview, (the CNA) denied ever hitting (the resident) but indicated that he might have been in a hurry and rolled her over to (sic) hard, causing her head to hit the wall..." A form titled Time/Attendance Detail Report, documented CNA #1 worked the 11:00 p.m. to 7:00 a.m., shift on 08/08/10, 08/09/10 and 08/10/10. A handwritten report, dated 08/09/10 at 2:25 p.m., documented, "(CMA #1) worked 11-7 as med aide extra shift. (CMA #1) was at nsg (nursing) station - (CNA #1) came out + told C.N. (charge nurse) that res face was swollen. (CMA #1) went in also. (CMA #1) told her to call (DON) + (administrator), hospital. (LPN #1) stated that she's not suppose to contact family before 7 am. (Resident) said, 'I'm a human being.' (Resident) said someone came + hit me + pointed to (CNA #1) + saying 'He did it.' Kept repeating 'I'm a human being.' Then stated 2 people beat her up. Came thru the window. Window was locked. 4 am pain med offered + refused. (CNA #2) told them R (resident) c/o pain R hip, Rcd (received) [MEDICATION NAME] for hip + face. (CNA #1) was kept out of room for rest of shift. Then looked @ (CNA #2) evil. Denies seeing new resident on hall. HOB (down) lying on R side (illegible)." A nursing home form, dated 08/10/10, documented, "Employee (LPN #1) neglected contacting family, DON, Administrator at 3 am of possible abuse/unknown bruising of facial area to resident. Failed to address resident accusation of employee..." A five day report, dated 08/11/10, for resident #1, documented, "The investigation into (the resident') injuries is ongoing. She remains hospitalized at (hospital name deleted) at this time. The facility is in contact and fully cooperating with the (city name) Police Department. (The resident's) family have obtained a video interview of (the resident) which indicated that a black male worker was involved in her care when the injuries occurred. At this time according to (police officer #1) the police investigation is focusing on interviews of two black male employees who worked with (the resident) on the 3-11 and 11-7 shifts the day of and the evening before the noted injuries. Therefore, both of these male employees will be suspended pending the outcome of the police investigation. The two CNAs in question are (CNA #5) and (CNA #1). The nurse Aide Registry form 718 has been completed and filed with the Nurse Aide Registry as required. We will send a final report upon completion of the investigation." On 09/08/10 at 8:55 a.m., the DON and administrator approached the surveyors and started to talk about resident #1 and the allegation of abuse which occurred on 08/06/10. The administrator stated the (city name) Police were investigating the allegation and lie detector tests had been given to CNA #1 and CNA #5. She also stated CNA #1's test showed deception. She stated CNA #1 was on suspension and CNA #5 had resigned. The administrator was asked when the CNA accused of the assault was suspended. She stated, "Immediately. (CNA #1) was suspended on 08/11/10. (The corporate nurse) called the corporate office and we suspended him at that time." She was asked since the resident's swelling and bruising were found at approximately 3:00 a.m., did CNA #1 work the rest of the night. She stated, "The charge nurse didn't notify us, so (CNA #1) worked the rest of the night. She was asked if he worked after that night and until his suspension on 08/11/10. She stated she would have to check. They were asked why LPN #1 did not notify them earlier of the bruising and swelling. The administrator stated, "It didn't look like it was bad at the time. It got worse as the night progressed." She stated she was told there was bruising present at 3:00 a.m., just not as bad as it was when she saw it at 7:30 a.m. She stated the 11-7 charge nurse reported the bruising on the resident, to the 7-3 charge nurse. The DON and administrator were not informed until the 7-3 nurse got in touch with them the next shift. The administrator stated that initially, the resident's eye and upper lip were bruised and swollen, but several days later, the whole side of her face was bruised. The DON and the administrator offered several explanations on how the resident's injury might have occurred. They were asked if they ever suspected abuse. They both stated CNA #1 was well liked and they had never had any problems with him. The DON and the administrator were asked how CNA #1 reacted when he was interviewed about the events of 08/06/10. The DON stated, "He (CNA #1) was sweating. His lip was quivering and he was swallowing alot. He looked nervous or scared." When asked what she thought about his behavior, she stated, "I think he was worried that he was going to be fired." The administrator stated the resident did not report it was a black male employee until 08/09/10, when the resident reported it to the family. The administrator stated the events of the night were as follows: -On 08/05/10 at 11:15 p.m., CNA #3 stated there was no bruising or swelling of the resident's face. She was covering hall 400 for CNA #1 until he got there. CNA #3 passed ice until then. -At 11:27 p.m., CNA #1 arrived and started doing the laundry. -On 08/06/10 at 1:00 a.m., CNA #1 changed the resident's wet brief. He did not turn on the light so he did not notice anything about the resident's face. CNA #2 was standing in the doorway talking to him while care was given. She reported she saw him kneeling on the floor beside the bed with the curtain closed. -At 3:00 a.m., the resident was soiled. CNA #1 turned on the light to change her and saw the bruising. The administrator stated he reported the bruising to CNA #2, then to LPN #1. The nursing home investigative folder was reviewed. There was a sticky note in the folder which documented, "(LPN #1) Ask her if she wasn't concerned when (the resident) said, 'He hit me. He did it.' At 2:30 p.m., at the (city name deleted) Police Department, police officer #1 who investigated the incident of 08/06/10, was asked how his department was notified of the incident. He stated, "They (the facility) faxed the department a report. That's what they always do. They didn't call a report. Anything could happen with a fax. It could be misplaced or lost. They didn't call." He was asked to give his assessment of the resident's injuries. He stated it appeared she had been struck with [MEDICATION NAME] force to her face, probably twice. He was asked if the injuries could be the result of a fall, or bump into a wall or door. He stated, "No. They (the facility) kept coming up with scenarios on how she could have been injured. I went back to the facility and watched them re-enact it. It didn't make sense. I told them it didn't happen like that." At 3:10 p.m., CMA #1 was asked what happened the night of 08/06/10. She stated she passed medications that night. She stated at 3:00 a.m., CNA #1 came out of the resident's room and asked LPN #1 if she knew about the bump or bruise on the resident. She stated both LPN #1 and herself entered the resident's room. She described the resident's face as being swollen with the resident's nose pushed to the side. She stated the resident's vital signs were taken and neuro checks were started. The resident was given a [MEDICATION NAME] as she was restless and 'grabby' which was not unusual for her. CMA #1 stated the resident said that someone came in through the window and hit her in the face. Later on, the resident told her that two men came in and hit her in the face. The CMA stated the resident 'glared' at CNA #1 and pointing at him stated 'He did it.' The CMA continued and stated the resident's cheek bone was hard, with her nose to the side. She stated her left eye was swollen like a water blister and it was a little purple. She stated the resident could open her eye slightly. She stated the resident's lip was slightly discolored and swollen. "You could tell something wasn't right. I was shocked." She was asked if she thought the injury was significant. She stated, "Yes." The CMA stated she checked on the resident through out the night. She was asked if she was instructed to do this. She stated, "No, I did it on my own." She stated the resident asked her, "Why did you let them do this?" She was asked if any of the CNAs were asked to go home. She stated that all staff finished the night as normal. She stated CNA #1 did not re-enter the room because of the resident glaring and pointing at him. She stated it was CNA #1's decision not to re-enter the room, and that he was not asked to do this. At 3:30 p.m., the administrator was asked if she had interviewed any other residents in the course of her investigation. She stated she had called a special resident council meeting on 08/11/10, five days after the incident. She stated none of the residents had any complaints of mistreatment by staff members. She was asked if she had asked specifically about CNA #1. She stated she had not asked about the CNA in particular, but did narrow it down to 3-11 and 11-7 CNAs. She again stated no complaints were made. She was asked when CNA #1 was suspended. She stated, not until 08/11/10, the same day as the five day state report. She was asked why the CNA identified by the resident wasn't suspended immediately. She stated, "We didn't know who it was at first." She was asked why it took five days before he was suspended. She stated, "We did it as soon as she said a black male, when we watched the video." She was asked if she suspected abuse when she was first made aware of the injuries. She stated she did not suspect abuse at first. She stated, "I still don't want to think that happened." At 4:10 p.m., the administrator and the DON were asked why they had not suspected abuse. No answer was given. The administrator was asked if she had spoken with the 11-7 charge nurse the day the bruising and swelling was observed. She stated, "She was gone when I came in." At 4:15 p.m., the DON was asked if she was aware of resident #1's mental status prior to the discovery of the injury on 08/06/10. She stated, "She was the most cooperative and calmer than we have ever seen her that whole evening and night." At 4:45 p.m., CNA #2 was contacted by telephone for an interview. She was asked to recount the events when she began her shift on 08/06/10. She stated, "At about 11:00 (p.m.) on the hall (Hall 400) where (CNA #3) left off, I started passing ice to residents in the middle of the hall. I didn't see the residents that (CNA #3) had already seen. That was my fault. I should have looked at them all when I got there. (CNA #1) got there around 11:30 (p.m.). We started bed check at 1:00 (a.m.). Earlier, he (CNA #1) said he would handle (resident #1) because she might try to fight during care. (CNA #1) went in to change (resident #1) a little after 1:00 a.m.. I was doing bed checks on the rest of the hall." CNA #2 was asked what happened next. She stated, "At one point I finished what I was doing and went to (resident #1's) room because I knew (CNA #1) was in there. I knocked and opened the door. I didn't go in because I could see the curtain pulled around the bed and (CNA #1) on his knees at the bedside. I could see him because the curtain doesn't go all the way to the floor. I stood in the doorway. The room was dark. He said he was doing incontinent care." CNA #2 was asked what happened after CNA #1 finished care for resident #1. She stated, "We just did regular jobs like folding pads and checking on residents." CNA #2 was asked what happened next. She stated, "At 3:00 a.m. bed checks, I was in the room next to (resident #1) doing incontinent care. (CNA #1) came in and asked me if I had seen (resident #1's) face. I said, 'No, what about it?' (CNA #1) said, 'Her face is swollen'. I told him to go tell the charge nurse." CNA #2 was asked if she saw or heard anything when she was in the room next to resident #1 at about 3:00 a.m.. She stated, "No. But after I finished incontinent care, I went into (resident #1's) room. The charge nurse and (CNA #1) were in there with (resident #1)." CNA #2 was asked what she saw. She stated, "Her (resident #1's) jaw was swollen on the left. It was like a softball size. Her lip was puffy on one side." CNA #2 was asked what the resident was doing and saying at this time. She stated, "She was pointing at (CNA #1) and said, 'He hit me.'" CNA #2 was asked again if she saw or heard anything unusual while she was in the room next to resident #1, or at any time during that night. She stated, "No. I didn't hear anything, no bumps, no yelling, no screaming." CNA #2 stated she was in resident #1's room off and on throughout the remainder of the night. She was providing care such as obtaining vital signs and sitting with her. She stated CMA #1 brought an ice pack to put on resident #1's eye. CNA #2 was asked to describe the resident's injury as she stayed with her during the night. She stated, "Her (left) eye kept swelling and started to bruise up. I asked her what hurts. She said, 'My hip, my hip.' Her face kept getting worse and worse. The CMA gave her a pain pill. Later she (resident #1) said, 'I'm a person. I wanna be treated like a person.'" CNA #2 was asked if she had any conversation with CNA #1 during the night of 08/06/10. She stated, "He said, 'I wonder what happened (to resident #1)?' He asked me a couple of times what I thought happened to her." CNA #2 was asked what other care was provided to the resident during the night. She stated the ice pack was kept on. She stated they were trying to do neuro checks but the eye was so swollen they couldn't check the pupil. CNA #2 was asked if anyone ever talked about sending the resident to the hospital. She stated the (7a.m.-3p.m.) charge nurse called the resident's family and they decided to get an x-ray of her face at the facility. CNA #2 stated, "I thought she should have gone to the hospital. Later, a male nurse (LPN #4) working the morning shift came up to a group of us standing outside the resident's room. He asked what was going on. We told him that the resident had swelling in her face and eye and that she (the resident) kept saying (CNA#1) hit her." CNA #2 was asked what LPN #4 did then. She stated, "He went into the resident's room to look at her. He came out and said, 'It looks like someone hit her. Her nose may be broken. It looks like there are two injuries.' " CNA #2 was asked if any other day shift charge nurse had been in to see the resident. She stated, "No. The day shift charge nurse was on the phone calling people. It was around 7 or 7:15 (a.m.)." CNA #2 was asked if CNA #1 worked the remainder of that night shift. She stated, "Yes. He didn't go into the resident's room. He said he was not comfortable going in there after what she said. He just worked doing other things, with other residents." CNA #2 was asked if she worked with CNA #1 on any subsequent night shifts after 08/06/10. She stated, "Yes. Until I heard he got suspended." CNA #2 was asked if she had r

Based on clinical record review, hospice record review, facility staff, hospice staff and physician interviews, it was determined the facility failed to coordinate care with hospice services for the administration of pain and antianxiety medication, as ordered by the physician for one (#1) of three samples residents who received hospice services. This had the potential to effect 8 residents identified by the facility receiving hospice care benefits. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. An admission assessment, dated 06/11/10, documented, the resident had moderately impaired cognitive skills for daily living. She displayed repetitive verbalizations e.g. calling out for help. She expressed a fear of being abandoned and had repetitive health complaints. The resident also experienced pain daily. There were times when the pain was horrible or excruciating. A care plan, dated 06/14/2010, documented, "Problem (23) 06/14/2010 *Hospice Care: (Resident) has been admitted to hospice care for [MEDICAL CONDITIONS] Goal (1) (Resident) quality of life and dignity will be maintained. Approach (1) 06/21/2010 Work with hospice staff to coordinate care (2) 06/14/2010 Monitor for changes in resident's condition and report to physician and hospice (3) 06/14/2010 Monitor for changes in pain management and notify hospice (4) 06/14/2010 Be accepting of residents wishes for end of life: refusal of food and/or water; isolation, withdrawal from family and/or friends. (5) 06/14/2010 Be willing to listen to resident verbalize thoughts about death and dying. Be supportive Problem (24) 06/14/2010 (Resident) has pain daily in right shoulder Goal (1) 06/14/2010 Will be comfortable and pain free on daily basis by 90 day review. Approach (1) 06/14/2010 Administer routine pain medication as ordered (2) 06/14/2010 Report c/o pain and site of pain to charge nurse (3) 06/14/2010 Observe for s/s of pain (moaning, crying, facial grimacing, restlessness, agitation, etc.) (4) 06/14/2010 Administer PRN pain medication as ordered and monitor for effectiveness using pain scale (5) 06/14/2010 Notify physician if present pain management is not effective (6) 06/14/2010 Do pain assessment on admission, readmits, and when resident not having relief on current pain meds. Notify Dr. accordingly." Problem (25) 06/14/10 *Coping: Alters (sic) in: Anxiety related to SOB (shortness of breath) and end of life decision. Goal (1) Will have minimal episodes of acute anxiety. Approaches (1) 06/21/2010 Administer medications as ordered (2) 06/14/2010 Aid in avoiding stressful situations..." A physician's telephone order, dated 06/22/10 at 2:00 p.m., documented, "1 ml. [MEDICATION NAME] in 3 ml. (amp) of sodium chloride solution nebulized via nebulized treatment for [REDACTED]." A physician's telephone order, dated 06/27/10 at 7:15 p.m., documented, "[MEDICATION NAME] 1 mg q 4 (hours) PRN po for (increased anxiety may give ii 0.5mg to = 1 mg." A nurse's note, dated 07/04/10 at 11:00 a.m., "C/o generalized pain requested [MEDICATION NAME] 1mg SL." A physician's telephone order, dated 07/01/10 at 3:00 p.m., documented, "Increase [MEDICATION NAME] to [MEDICATION NAME] tabs, two and one half tab (to equal 5mg.) p.o. every four hours while awake for agitation and restlessness. Hold if BP is less than 80/40 or more than 250/150." A physician's telephone order, dated 07/06/10 at 4:00 p.m., documented, "Clarification Order (change) [MEDICATION NAME] 5 mg to routine q 4 (hour) when awake. Hold if B/P is <80/40 or >250/150 Diagnosis: [REDACTED]. A nurse's note, dated 07/10/10 at 1:55 a.m., documented, "S/s of pain PRN Roxinal 20mg/1ml given SL (sublingual). Family states res not (resident) swallowing well. (Increased) agiation (sic) noted." A physician' telephone order, dated 07/10/10 at 2:00 p.m., documented, "Administer [MEDICATION NAME] 20 mg per ml. (one and 1/2) sublingual every four hours. Alternate with [MEDICATION NAME] application. -administer Tylenol 325 mg supp (suppository) prn temp." A physician's telephone order, dated 07/10/10 at 2:00 p.m., documented, "[MEDICATION NAME] 5mg/ml. topical gell (sic) apply to carotid areas or pulse points every 4 hours for restlessness + anxiety, agitation. *DC (discontinue) Blood pressure parameters." A physician's telephone order, dated 07/10/10 at 2:00 p.m., documented, "May administer 20 mg [MEDICATION NAME]/[MEDICATION NAME] per ml in 3 ml sodium chloride vial for nebulized breathing treatment for [REDACTED]. or agitation c SOB." A physician's telephone order, dated 07/10/10 at 2:00 p.m., documented, "Pt unable to swallow. Discontinue all oral meds except for [MEDICATION NAME], kcl crushed in yogurt, and sublingual [MEDICATION NAME] 30 mg/ ml q 4 hours or nebulized prn." Apply [MEDICATION NAME] topically. A nurse's note, dated 07/10/10 at 1:55 a.m., documented, "S/s of pain PRN [MEDICATION NAME] 20mg/1ml given SL (sublingual). Family states res not (resident) swallowing well. (Increased) agiation (sic) noted. A nurse's note, dated 07/10/10 at 7:30 a.m., documented, "Rhonchi present in upper lobes... Res (c/o) pain to Family." A nurse's noted, dated 07/10/10 at 11:00 a.m., documented, "[MEDICATION NAME] & [MEDICATION NAME] more frequent so res can stay sedated..." A nurse's note, dated 07/11/10 at 1:00 a.m., documented, "Stated pain level at #10. Conts (continues) on pain meds." The hospice and/or physician were not notified the current pain regimen was not relieving the resident's pain. A nurse's note, dated 07/11/10 at 1:00 p.m., documented, "O2 @ 2L C/o of pain in chest. Continues to take pain meds rt (routinely)." Twelve hours later, the resident was complaining of pain. The hospice and/or physician were not notified of the resident's complaints of pain. A nurse's note, dated 07/12/10 at 7:00 a.m., documented, "[MEDICATION NAME] held (secondary) to sedation. Responds to verbal stimuli...VS T98.2, P96, R19, BP 112/72." The hospice was not notified the medication was withheld. There was no coordination between the facility and the hospice regarding routine, around the clock medications. A hospice document titled, "Progress Notes from 06/01/10 to 08/10/10", documented, "Skilled Nursing on 07/12/2010, Pt unable to swallow without difficulty. AM nurse said she did not give [MEDICATION NAME] because pt. was asleep and 'not in any pain'. Pt. grimaces and moans when touched and repositioned. [MEDICATION NAME] administered by hospice nurse as ordered. [MEDICATION NAME] cream applied topically, 1 mg. (Physician) notified of pt's condition and facility staff reluctance to administer meds. as ordered." A hospice document titled, "Team Care Plan as of 07/13/10 at 3:45p.m.", documented, "07/12/2010 ...Pt unable to swallow without difficulty. AM nurse (LPN #1) states she didn't give [MEDICATION NAME] because pt was asleep and 'not in any pain'. Pt grimaces and moans when touched and repositioned... [MEDICATION NAME] administered by hospice nurse as ordered. [MEDICATION NAME] cream applied topically, 1 mg. (Physician) notified of pt's condition and facility staff reluctance to administer meds. as ordered." A nurse's note, dated 07/13/10 at 9:40 a.m., documented, "Hospice nurse (name deleted) here inquiring when res had [MEDICATION NAME] and [MEDICATION NAME] last. Informed 9am [MEDICATION NAME] was held D/T (due to) unresponsiveness... Informed me that I was non compliant not following Dr orders. I informed her I did not feel comfortable giving med with her current cond. (condition)... Nurse manager made aware of situation & checked res. DON notified & stated hospice nurse could give meds if I (LPN #1) didn't feel comfortable giving meds." A nurse's note, dated 07/13/10 at 1:00 p.m., documented, "routine [MEDICATION NAME] per order p (after) Nurse Manager spoke to (physician) & was instructed to give meds per order." On 08/09/10 at 3:21 p.m., the hospice case manager was asked to explain the circumstances surrounding the imminent death of resident #1. The hospice nurse stated, "LPN #2 refused to administer the meds due to not understanding why the meds are to be administered around the clock." The hospice nurse was asked, based on her clinical opinion, if the resident was comfortable. The hospice nurse stated, "She was very, very uncomfortable." She explained the physician was there at the time and reinforced that the resident's medications were to be given as ordered. The hospice nurse further stated, "We were behind the ball on the last day due to her not receiving her medications as scheduled." The hospice nurse stated the resident expressed non-verbal signs of discomfort and pain. The resident moaned when repositioned and displayed facial grimacing when touched. On 08/09/10 at 3:40 p.m., the DON was asked about the LPN's reluctance to administrate medication to resident #1 as ordered by the physician. She stated, "He felt uncomfortable in giving the [MEDICATION NAME] when she (the resident) was not in distress. It (the [MEDICATION NAME]) will lower the blood pressure." The DON stated, "We have rules and policies about about medication administration and nursing guidelines about over-sedating. Sometimes hospice will order things against state regulations and our policy." The DON further stated, "They (nurses) have certain guidelines, they were raised in nursing school regarding parameters. The male nurse did not have a lot of long term care experience." The DON was asked what were expected of the nurses if parameters had been discontinued by the physician and yet the nurse felt uncomfortable administering the medication. She stated, "I would expect them to call the doctor." If it goes against our policies, the Dr. will write (the order). (If the doctors) don't know our policies, we will educate them." The DON continued by stating, "(We) will meet with the hospice nurse to tell them what kind of orders scare us and what we can do and communicate better." The facility and hospice failed to communicate the resident's wishes. The facility failed to notify the hospice staff regarding the withheld routine physician ordered medications. On O8/10/10 at 9:40 a.m., LPN #2 was asked if he could recall the incidents surrounding the end of life for resident #1. He stated he was in her room quite often and the resident was sedated. He stated, "(She was a) hospice patient (and) had [MEDICAL CONDITION] and [MEDICAL CONDITION]." LPN #2 was asked about his interaction with the resident's family. He stated, "The family was fine with me." He stated there was an incident with the family. LPN #2 stated they wanted her to have [MEDICATION NAME] and he stated to the family that he needed to see evidence of pain. He stated the family came between him and his ethics. LPN #2 was asked if the hospice nurse or doctor were notified or contacted about him not being comfortable in the administration of routinely ordered medications. He stated the DON went down and then the hospice nurse came to take control. The hospice nurse stated there was a need to consult the doctor. The hospice called the doctor and he gave orders to leave routine medication administration the same way. On 08/10/10 at 10:47 a.m., the DON was asked for the facility policy and procedure(s) on withholding medications and end of life care. The DON stated, "We are about living. They're (hospice services) more about dying." She further added, "Our plan of care needs to match their plan of care. Emotions were sparked. (We) need to be supportive and this type of thing scares our nurses." At 08/10/10 at 11:00, LPN #1 was asked about the assessment and subsequent care resident #1 had received on 07/12/10. She stated, "The morning in question, there were two residents passing. I didn't give her the medicine, the [MEDICATION NAME]. She was asked why she did not follow the physician's written orders for the medicine. She stated, "It is a nursing judgement." She further added, "I told the aide if she (the resident) is lethargic, then she could the not give the medicine." LPN #1 stated the family member said over and over she wanted the resident to have her medication. LPN #1 stated, "Have you ever heard of assisted suicide? I tried to explain (to the family member why I could hold the medicine)." The LPN was asked if the physician was notified and she stated, "Yes. The doctor said to give the medication." On 08/10/10 at 1:43 p.m., the hospice case manager was asked about the condition of the resident on 07/12/10 and 07/13/10. She stated, "She was having a lot of pain and anxiety in the last days." She was asked if she directed the facility to call the physician. She stated, "Yes. I told them to call the doctor." On 08/10/10 at 3:20 p.m., the DON was asked what she told the family in regards to the nurses "feeling uncomfortable" about administering the medication. She stated, "At that time, it wasn't about administering the meds, it was about the blood pressure. I told LPN #1 if (she) felt uncomfortable (to administer medication) to let hospice give it. The hospice nurse was not notified about the resident's status or the withheld medication until she arrived at the facility for her routine visit. On 08/10/10 at 5:15 p.m., the resident's attending physician was contacted regarding resident #1. He stated, "She has been my patient for a long time." He was asked about the routine orders for the resident's pain, anxiety and agitation. He stated, "The hospice nurses are my eyes and ears. She was going through a lot of suffering." He was asked about the order to discontinue the blood pressure parameters for the medication ordered. He stated, "(We) don't worry about about the blood pressure. We want her peaceful and to go. She has been suffering for a long time."