Every finding on record at Oak Creek Rehabilitation Center of Kimberly

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all 33 residents who resided in the facility whose equipment and environment were observed. This deficient practice created the potential for harm if: a) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, undignified, or b) residents were injured due to unsafe areas in the facility. Findings include: The facility's Preventive Maintenance Program policy, revision date December 2025, documented preventive maintenance schedule included daily tasks of: inspecting halls, exits, lighting . On 12/1/25 at 12:00 PM, observed during dining room inspection, directly over tables where residents were eating, was 2 fluorescent lights with large cracks and broken light covers with dead insects on the inside of the light covers.On 12/3/25 at 2:50 PM, the administrator and maintenance director verified the lights needed cleaned and fixed and said they would make sure it got done.

Based on observation, interviews and record review, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment when staff did not offer or encourage residents hand hygiene prior to meals, replace resident's soiled equipment, and implement water management control and monitoring measures. This was true for the facility and 1 of 3 residents (Resident #7). These failures placed residents at risk for cross-contamination and infection. Findings include: A. The following was observed during resident meal service in the dining room. 1.On 12/1/25 at 12:40 PM, the lunch meal was served to residents in the dining room. No hand hygiene was offered to the residents prior to eating their food. On 12/1/25 at 1:20 PM, LPN #1 stated residents are usually offered hand hygiene prior to eating but the facility had run out of the hand wipes and no hand hygiene was provided today. 2. On 12/1/25 at 12:40 PM, observed staff picking up the residents' knife utensil to pry the meal plate of food out of the warmer tray and replace the knife on the table for the resident to use during the meal. On 12/1/25 at 1:10 PM, NA #1 stated the plates are hard to get out of the warmer tray, so staff use the knife to pry out the plate and serve to the residents. On 12/3/25 at 10:00 AM, the RNC stated residents should be offered hand hygiene prior to meals and had not been and staff should not be using residents' utensils to remove plates from the warmer trays. B. The following was observed in Resident #7's room. On 12/1/25 at 10:54 AM, observed Resident #7's oxygen tubing and mask on the floor next to her bed. On 12/1/25 at 10:55 AM, LPN #1 stated Resident #7 should be wearing her oxygen mask and went to the resident's bedside and picked up the oxygen mask off the floor and placed it on Resident's #7's face. On 12/3/25 at 10:02 AM, the DON stated the oxygen tubing and mask should have been discarded and replaced and had not been. C. The following was observed during the Infection Control interview and record review. On 12/3/25 at 2:25 PM, the Maintenance Supervisor stated the facility did not have an active water management program in place and the Water Management Plan had not been updated. The Maintenance Supervisor presented a document titled; Water Management Team, not dated and mark throughs on several pages, to the surveyor and stated the prior Infection Preventionist had this document and this is what would have been used. The document contained a table with 'Control' and 'Monitoring' tasks. On 12/4/25 at 3:45 PM, the surveyor requested the water management weekly logs as referenced in the 'Control' and 'Monitoring' portion of the document and the facility could not provide documentation of control measures and monitoring measures for the water management program. On 12/4/25 at 4:10 PM, the RNC stated the Water Management Plan should have been updated and had not been.

Based on record review, the State Survey Agency's Long-Term Care Reporting Portal, and staff interviews, it was determined the facility failed to ensure residents' rights were protected to be free from abuse. This was true for 1 of 3 residents (Resident #4) reviewed for abuse. This failure placed all residents at risk of ongoing abuse, potential physical, and psychosocial harm. Findings include: Resident #4 was initially admitted to the facility on [DATE] with readmission on [DATE], with multiple diagnoses including, hemiplegia (paralysis of one side of the body) and depression. A facility reported incident investigation, initiated 4/27/25 at 11:00 AM, documented CNA #3 heard CNA #2 verbally abuse Resident #4. CNA #3 immediately reported the incident to the Charge Nurse. The DON was notified, and CNA #2 was suspended pending an investigation. On 12/4/25 at 12:02 PM, during record review the facility grievances dated 5/28/25 to 9/27/25 revealed no abuse/neglect issues. On 12/4/25 at 12:32 PM, Resident Council Minutes dated June 2025 to November 2025 were reviewed. One abuse concern in June 2025 was documented with follow up by the facility administration. No other documented abuse/neglect issues. On 12/4/25 at 12:45 PM, the facility timecards for 4/1/25 to 12/4/25 were reviewed and confirmed CNA #2's last worked shift was 4/27/25 from 6:00 AM to 1:45 PM. The facility took the following actions: -Resident #4 was interviewed about his care. -Staff interviews were conducted and confirmed CNA #2 had made verbally abusive statements to Resident #4.- Terminated CNA #2 from employment on 5/1/25, and submitted findings to the State's Long-Term Care Reporting Portal.- Confirmed all employees received abuse/neglect training. Scheduled additional refresher course for all staff to take place on 5/13/25.- Behavior Care Training for all facility staff conducted on 6/3/25.These findings represent past non-compliance with this regulatory requirement. There was sufficient evidence the facility corrected the non-compliance as of 6/3/25, and there have been no further occurrences reported. At the time of this survey the facility was in substantial compliance and therefore does not require a plan of correction.

Based on interview, policy review, and record review, the facility failed to ensure a copy of the residents' discharge or transfer notices were sent to the Office of the State Long Term Care (LTC) Ombudsman. This was true for 1 of 1 Residents (Resident #2) reviewed for Ombudsman notification. This failed practice had the potential to affect all residents by; 1) denying residents the added protection from being inappropriately discharged ; 2) providing the residents with access to an advocate who can inform them of their options and rights; and 3) ensuring the Office of the State LTC Ombudsman was aware of facility practices and activities related to transfers and discharges. Findings include:Review of the facility's Discharge and Transfer policy, revision date 4/17/2025, documented a copy of the notice [of discharge] is sent to the Office of the State Long-Term Care (LTC) Ombudsman after discharge.Appendix PP states the following:S483.15(c)(3) Notice of Transfer or Discharge and Ombudsman NotificationWhen a facility transfers or discharges a resident . the facility must provide notice of discharge to the resident and resident representative along with a copy of the notice to the Office of the State LTC Ombudsman at least 30 days prior to the discharge or as soon as possible. The copy of the notice to the ombudsman must be sent at the same time notice is provided to the resident and resident representative .The facility must maintain evidence that the notice was sent to the Ombudsman.Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation (irregular heart rhythm) and urinary tract infection.On 12/3/25 at 4:07 PM, during record review Resident #2's medical record contained a physician order dated 11/28/25 for a planned discharge from the facility to home with home health services and continued physical therapy and occupational therapy. Resident #2's record included a nursing progress note dated 11/28/25, related to Resident #2's discharge to home. On 12/4/25 at 11:18 AM, the CRN stated the facility could not provide documentation indicating Resident #2's Notice of Discharge had been sent to the State LTC Ombudsman and should have been. On 12/4/25 at 11:20 AM, the Administrator presented the surveyor with 3 email notifications to the Ombudsman dated March 2025, May 2025, and July 2025, and stated there were no other documented notices to the State LTC Ombudsman.

Based on the State Operations Manual - Appendix PP, facility policy, record review, and staff interview, it was determined the facility failed to make a referral to the state mental health authority for a possible new PASRR level II evaluation when residents were diagnosed with a new serious mental disorder. This was true for 1 of 1 resident (Resident #6), whose PASRR records were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed, treated, and monitored appropriately. Findings include:The facility's Resident Assessments PASRR Screening Coordination policy, dated April 2025, documented:- The facility would notify the state designated agency when a resident with a mental disorder experiences a significant change in status.- Refer to the appropriate state designated authority any resident with newly evident or possible serious mental disorder, intellectual disability, or related condition.Resident #6 was initially admitted to the facility on [DATE], with multiple diagnoses including epilepsy (a brain disorder causing unprovoked seizures), anxiety disorder, and bipolar disorder (a mental health condition causing extreme mood swings).Resident #6's medical record documented a PASRR level II evaluation, dated 9/30/10, from the state of Nevada.Resident #6's PASRR level II documented she had a diagnosis of bipolar disorder, mild mental retardation, epilepsy, and hyperglycemia.Resident #6's medical history and physical notes dated 5/18/15, documented she had a history of asthma, schizophrenia (a severe mental disorder which may have features of paranoia, delusions, or hallucinations), and seizures.Resident #6's Schizophrenia Diagnosis Accuracy Verification Worksheet, dated 2/13/23, documented a diagnosis of paranoid schizophrenia.Resident #6's care plan problem, date initiated 1/28/19, documented she is being treated with psycho active medication for a diagnosis of paranoid schizophrenia and epilepsy.Resident #6's medical record did not document a level II evaluation to include her diagnosis of paranoid schizophrenia.On 12/3/25 at 2:50 PM, the administrator and regional nurse consultant stated the facility had not notified the state mental health authority requesting an updated PASRR level II evaluation when Resident #6 was diagnosed with paranoid schizophrenia, and they should have.

Based on record review and staff interview, it was determined the facility failed to follow physician orders of delivering specific medications when residents did not have BM within 72 hours for 2 of 8 residents (#5 and #21) whose records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include:A. Resident #5 was admitted to the facility initially on 5/5/22 with readmission on [DATE], with multiple diagnoses including depression and anxiety.Resident #5's physician orders for bowel care management were documented as: Day 3 no BM: Administer Miralax 17 grams PO in fluid of choice during medication pass as needed for constipation. Start date 7/8/25 Day 4 no BM: if no BM by 4am, give Dulcolax suppository, as needed for constipation. Start date 7/8/25 Day 5 no BM: If no BM by 2 pm, notify provider for additional instruction. Start date 7/8/25 Resident #5 had a documented bowel movement on 11/4/25 at 1:28 AM and not again until 11/10/25 at 12:17 AM, over 142 hours with no documented bowel movement.No documentation of Resident #5 receiving the physician ordered medications for constipation management on day 4. No notification to provider on day 5 as ordered, if resident had not had a BM. On 12/5/25 at 10:25 AM, the DON stated the nurse had not documented bowel medication interventions on the medication administration record as ordered by the provider for Resident #5 and should have. B. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (paralysis on one side of the body) and respiratory failure. Resident #21's physician orders for bowel care management were documented as: Day 3 no BM: Administer Miralax 17 grams PO in fluid of choice during medication pass as needed for constipation. Start date 7/7/25 Day 4 no BM: if no BM by 4am, give Dulcolax suppository, as needed for constipation. Start date 7/7/25 Day 5 no BM no BM: If no BM by 2 pm, notify provider for additional instruction. Start date 7/7/25 Resident #21 had a documented bowel movement on 11/5/25 at 2:49 PM and not again until 11/12/25 at 5:59 PM, over 168 hours with no documented bowel movement.No documentation of Resident #21 receiving the physician ordered medications for constipation management during 11/5/25 to 11/12/25. Resident #21 had a documented bowel movement on 11/12/25 at 2:49 PM and not again until 11/24/25 at 4:27 PM, over 264 hours with no documented bowel movement.No documentation of Resident #21 receiving the physician ordered medications for constipation management during 11/12/25 to 11/24/25. On 12/5/25 at 10:25 AM, the DON stated the nurse had not documented bowel medication interventions on the medication administration record as ordered by the provider for Resident #21 and should have.

Based on observation, interviews, and record review, the facility failed to ensure resident received oxygen as prescribed by the provider. This was true for 1 of 3 residents (Resident #7) reviewed for respiratory care. This failure created the potential for respiratory difficulties or impaired breathing. Findings include: Resident #7 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including respiratory failure and depression. Resident #7's medical record included physician orders for oxygen 2 liters per minute via nasal cannula at HS and PRN. Notify provider if O2 sat% < 90%. Order start date of 1/18/25. On 12/1/25 at 10:50 AM, observed Resident #7 sitting in bed with oxygen administered at 4L/min via mask. On 12/1/25 at 10:55 AM, LPN #1 stated she was unsure of Resident #7's ordered oxygen rate but knew resident was to have oxygen on while in bed and at night. On 12/2/25 at 1:10 PM, observed Resident #7 sitting in bed with oxygen at 3L/min via mask. On 12/2/25 at 1:14 PM, CNA #1 stated she was unsure what Resident #7's oxygen ordered rate was but knew Resident #7 was to receive oxygen while in bed. On 12/2/25 at 1:25 PM, the RNC stated Resident #7's oxygen rate should have been at 2L/min via nasal cannula as ordered and had not been.

Based on review of the State Operations Manual, Appendix PP, staffing schedules, and staff interviews, it was determined the facility failed to a) ensure full-time nurse aides working less than 4 months are enrolled in a State approved nurse aide training and competency evaluation program (NATCEP) and b) ensure full-time nurse aides working in the facility more than 4 months have successfully completed a NATCEP. This was true for 10 of 13 nurse aides whose personnel files were reviewed. This failure had the potential to result in negative outcomes for the 33 residents living in the facility. Findings include:On 12/5/25,13 Nurse Aide (NAs) files were reviewed with the following results:- NA #1 was hired on 1/6/25. Has not successfully completed a NATCEP.- NA #2 was hired on 1/10/25. Has not successfully completed a NATCEP.- NA #3 was hired on 6/18/25. Has not successfully completed a NATCEP.- NA #4 was hired on 9/30/25. Has not enrolled in a NATCEP.- NA #5 was hired on 10/1/25. Has not enrolled in a NATCEP. - NA #6 was hired on 10/13/25. Has not enrolled in a NATCEP. - NA #7 was hired on 10/21/25. Has not enrolled in a NATCEP. - NA #8 was hired on 11/11/25. Has not enrolled in a NATCEP. - NA #9 was hired on 11/11/25. Has not enrolled in a NATCEP. - NA #10 was hired on 11/13/25. Has not enrolled in a NATCEP. On 12/5/25 at 11:29 AM, the RNC stated NA #1, NA #2, and NA #3, had not completed the NATCEP course and NA #4, NA #5, NA #6, NA #7, NA #8, NA #9, and NA #10 had not enrolled in a NATCEP yet.

Based on review of the State Operations Manual, Appendix PP, observation, and staff interview, it was determined the facility failed to ensure the daily nurse staffing information was accurately posted for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's current staffing levels. Findings include:On 12/3/25, the daily postings of licensed and unlicensed nurse staffing were reviewed between 4/1/25 - 11/30/25. There were no adjustments to the posted staffing when the scheduled hours did not match the actual hours worked.On 12/3/25 at 9:45 AM, the RNC and DON stated the facility does not make adjustments to the daily postings with actual hours worked, they only adjust the time on the daily assignment sheets.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include:On 12/1/25 at 10:45 AM, during the 100 & 200 Hall medication cart audit, observed the narcotic accountability sheets, dated 11/5/25 to 12/1/25, with 2 licensed nurse signatures not documented on 11/25/25 and 11/26/25. On 12/1/25 at 10:47 AM, LPN #3 stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart. On 12/3/25 at 9:40 AM, during the Dining room & 300 Hall medication cart audit, observed the narcotic accountability sheets, dated 11/26/25 to 12/3/25, with 1 licensed nurse signature not documented on 12/2/25. On 12/3/25 at 9:42 AM, LPN #2 stated the two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart. On 12/3/25 at 10:05 AM, the DON stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart.

Based on record review and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors when 1 of 2 residents (Resident #6) did not receive her Invega injection (antipsychotic medication) as ordered by the physician. This failure had the potential to cause harm if the resident's psychiatric behaviors increased due to not receiving her medications timely. Findings include:Resident #6 was initially admitted to the facility on [DATE], with multiple diagnoses including epilepsy (a brain disorder causing unprovoked seizures), anxiety disorder, and bipolar disorder (a mental health condition causing extreme mood swings). Schizophrenia was added to her diagnosis on 5/18/15.Resident #6's physician order start date 2/24/24, documented the following: Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML (Paliperidone Palmitate) Inject 1 dose intramuscularly one time a day every 28 day(s) for paranoid schizophrenia.On 10/4/25, Resident #6's Medication Administration Record (MAR) documented see progress notes.On 10/4/25, Resident #6's order administration notes documented Invega sustenna IM not available at this time. Nurse called pharmacy, and it will be delivered by tonight.On 10/5/25, Resident #6's nurse's note documented she received the Invega sustenna injection but was not documented on the MAR.On 11/1/25, Resident #6's MAR documented see progress notes.On 11/1/25, Resident #6's order administration notes documented not available at facility. Nurse call pharmacy to order Invega IM, not received.On 11/3/25, Resident #6's MAR documented on she received her Invega injection (29 days after previous injection).On 12/1/25, Resident #6's MAR documented on see progress notes.On 12/1/25, Resident #6's order administration notes documented do not have the shot. Will have day shift call the pharmacy.On 12/2/25, Resident #6's nurse notes documented the Invega shot did not come tonight as well from pharmacy. Day shift nurse said she did not call on it today. I will again ask the day shift nurse to follow up on this so we can get her the shot as soon as possible.On 12/3/25 at 6:51 AM, Resident #6's medical record documented the Invega injection has not arrived from pharmacy. The pharmacy was contacted and stated there are no refills left on the prescription. Provider was notified to request updated prescription and late administration.On 12/3/25, Resident #6's MAR documented the Invega injection arrived and was administered (30 days after previous injection).On 12/3/25 at 9:45 AM, the RNC and DON stated the nurse should have documented on the MAR when the Invega injection was given on 10/5/25. The RNC verified Resident #6 received her Invega injections late in November and December due to the pharmacy not sending them to the facility. She also stated the physician should have been notified of the medications not being given on time and was not until she notified him.

Based on observations, record review and staff interviews it was determined the facility failed to ensure medications were properly stored, not expired, and biologicals were labeled when opened. This was true for the facility. This failure created the potential for residents to receive expired medications with decreased efficacy, use of expired biologicals, and the potential for theft and/or diversion. Findings include: The EvenCare ProView users Guide documented the testing solutions should be dated when bottle opened and discarded after 3 months of use or at time of printed expiration date. The State Operations Manual, Appendix PP, updated 8/8/24, Schedule II-V medications must be maintained in separately locked, permanently affixed compartments.A.The following was observed during the medication cart audits. On 12/3/25 at 10:52 AM, the dining room/300 Hall medication cart was audited with LPN #2 present. Observed the following: - one bottle of Vitamin D with an expiration date of 3/20/25- one bottle of Aspirin 81mg containing round yellow tablets and round orange tablets On 12/3/25 at 10:53 AM, LPN #2 stated, two bottles of aspirin had been combined and should not have been. On 12/4/25 at 9:15 AM, the RNC stated the expired medications should have been removed from the medication cart and had not been. B. The following was observed for biologicals.On 12/4/25 at 9:10 AM, observed one set of glucose test solutions (Lot #4ARZA14 / #4AR3A12) with no opened date. LPN #3 stated the test solutions should have been dated when opened and had not been. On 12/4/25 at 9:13 AM, observed LPN #3 date each test solution with 12/4/25 after surveyor had inquired about dating the bottle after opening. On 12/4/25 at 915 AM, observed Testing Logs dated from 5/11/25 to 11/30/25, with documentation of glucose testing solutions (Lot #4ARZA14 / #4AR3A12) had been opened on 7/5/25 and continued to be used through 11/30/25 for weekly glucometer machine testing.On 12/4/25 at 9:45 AM, the DON stated the glucose test solutions should have been removed from the cart and had not been. C. The following was observed for controlled medications. On 12/4/25 at 8:52 AM, observed in the 300 Hall medication refrigerator 2 bottles of lorazepam concentrated solution (Schedule IV controlled medication) stored in a removable metal black box on the medication refrigerator shelf. On 12/4/25 at 9:00 AM, the RNC stated the controlled medications should have been in an affixed box in the medication refrigerator and were not.

Based on observation, interview, and review of the Idaho Food Code, the facility failed to ensure food was appropriately stored, distributed, and labeled. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination, use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The Idaho Food Code, revised February 2021, documented, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. On 12/1/25 at 10:10 AM, during the initial observation of the kitchen, the following was observed with cook #1 present. Reach-in refrigerator: - uncovered, undated container of shaved parmesan cheese. - open bag of shredded cheddar cheese with no opened or use by date. - open bag of Swiss cheese with no opened or use by date. - a can of dairy whipped topping with no cap and no open or use by date. Storage room: - an open bag of hotdog buns with no open or use by date. - an open bag of hamburger buns with no open or use by date. On 12/1/25 at 10:30 AM, the cook removed the uncovered and the undated items and stated the items should have been covered and dated but were not. On 12/4/25 at 8:25 AM, during a second observation of the kitchen the following was observed with the FSM present: Reach-in refrigerator: - Cooked shredded turkey in Ziplock bag dated 11/26/25 and a use by date of 2/1/26. The FSM stated the turkey should have been discarded after the use by date, but was not. - A container with approximately 10 egg salad half sandwiches in a Ziplock bags with smeared, unreadable writing on the bags. The FSM stated the sandwiches were made that morning, but the dates were not readable and should have been. - A pan of pureed corn covered in plastic wrap with must use tonight written on it. It did not have a date made or use by date. The FSM stated the pureed corn was made the day before and should have been used the day it was made. - A carton of potato salad with an expiration date of 12/2/25. FSM removed from refrigerator and stated it should have been discarded. - A container of yogurt with an expiration by date of 10/20/25. FSM removed from refrigerator and stated it should have been discarded. In storage room: - A chest freezer had an open bag of corn inside an open box. Corn was not sealed and had no open or use by dates. The FSM removed the corn from the freezer and stated it should have been put into a sealed container and dated but was not. Dish room: - The dish machine log was filled out 2 days in advance with wash temperatures, the rinse temperatures, and the PPM. On 5/4/25 at 8:40 AM, the FSM stated the dish machine log should not have been filled out in advance and had been. The facility's Foods Brought by Family/Visitors/Personal Refrigerators policy dated, Revised May 2024, documented For perishable foods, containers will be labeled with the resident's name, and the use by date.The nursing staff will discard perishable foods on or before the use by date. On 12/4/25 at 11:40 AM, observed in the resident refrigerator: - - One 2-pack Jello pudding cups with an expiration date of 11/6/25 - - One 4-pack Jello pudding cups with an expiration date of 11/22/25On 12/4/25 at 11:45 AM, LPN #2 stated the pudding cups should have been discarded and had not been. On 12/4/25 at 11:47 AM, observed the resident refrigerator with dark brown dried material, approximately 12 inches in length, on floor of refrigerator under crisper drawers, each refrigerator shelf front had dark brown splattered spills, and shelves with dried dark material. On 12/4/25 at 12:29 AM, LPN #2 stated the refrigerator should have been cleaned and had not been.

Based on observation, interview and record review the facility failed to provide a safe, clean and comfortable environment for residents in 2 of 2 shower rooms (200 hall and 300 hall). This failure had the potential to put residents at risk for a diminished quality of life. Findings included:On 12/3/25 at 1:17 PM, observed the shower room on the 200 hall, the following was noted: 10-inch x 5-inch x1.25-inch jagged shaped hole in floor by shower stall with the area of the flooring peeling off the surface of the floor and not cleanable. 4 holes in middle of shower room floor; 3 of the holes measured 2-inch circle, and 1 hole measured 4-inch jagged circular shape with each of the four areas of the flooring peeling off the surface of the floor and not cleanable. The floor had soiled and darkened matter in the gaps and crevices. On 12/3/25 at 1:37 PM, observed the shower room on the 300 hall, the following was noted: The left shower stall was filled with equipment; lift, large bucket, and chair. A 16-inch x7-inch x 2-inch jagged hole in flooring by entry of the left shower stall with the area of the flooring peeling off of the surface of the floor and not cleanable. The deepest portion of the open area filled with dark looking matter. A 12-inch x 2 inch 'T' shaped hole in the floor near base of the right shower stall with the flooring peeling off of the surface of the floor and not cleanable. The deepest portion of the open area filled with dark looking matter. The right shower stall circular drain had soft brown stool looking material caught in 3 of the drain screen holes The large, jetted tub had a side panel removed and was not functioning A salon chair and workstation placed at the end of the shower room On 12/3/25 at 1:47 PM, the Maintenance Supervisor acknowledged the shower rooms on the 200 and 300 halls needed repairs and a work plan had been submitted but not yet approved for the needed repairs. On 12/3/25 at 1:57 PM, the DON stated the shower rooms on the 200 and 300 halls needed to be cleaned and repaired.

Based on policy review, record review, facility investigation review, and staff interview, the facility failed to prevent physical abuse, verbal abuse, and neglect for 1 of 3 residents (Resident #15) reviewed for abuse. This deficient practice placed Resident #15 in immediate jeopardy of serious harm, impairment, or death when the facility did not protect him from physical and verbal abuse and neglect from LPN #1. Findings include: The facility's Abuse policy, undated, stated residents are to be free from abuse, neglect misappropriation of resident property, and exploitation. The policy further stated staff or management accused employees were immediately removed from resident contact and suspended from duty. Resident #15 was admitted on [DATE], with multiple diagnoses including personal history of a traumatic brain injury. A quarterly MDS assessment, dated 5/17/24, documented Resident #15 was severely cognitively impaired. Resident #15's care plan, dated 5/17/24, documented he had behaviors related to repetitive episodes of putting himself on the floor requiring assistance from staff to get him up had increased and had become more difficult for the staff, taking two staff members and sometimes a third staff member. The care plan documented before the staff left the area, Resident #15 would put himself on the floor again. The care plan further documented Resident #15 did not assist the staff to get him up; however, at times he was witnessed getting off the floor and back into his wheelchair. Interventions included activities and using a mechanical lift to get Resident #15 off the floor. A facility investigation report, undated, documented an incident occurred on 2/28/24. The report documented NA #1 was assisting LPN #1 to get Resident #15 off the floor and back into his wheelchair. LPN #1 attached the [gait] belt [an assistance safety device that can be used to help a patient sit, stand, or walk around, as well as to transfer them from a bed to a wheelchair] around Resident #15's chest to get him up and she was yelling at him to get up and get on his feet. NA #1 went to grab him under his arm to help him and LPN #1 said no, he can do it, he knows how. After about a minute of LPN #1 pulling on Resident #15 and yelling, LPN #1 said, I'm not [expletive] doing this tonight and proceeded to pull him to the floor and as she was doing so, he hit his head on the door frame of his room as a result of her being rough and yanking him around. LPN #1 took the belt off, grabbed under his arms and pulled him part way into his room. He was holding his head in pain and LPN #1 said to NA #1 to leave him there. NA #1 did as she was told and left the room. NA #1 returned 45 minutes later to check on Resident #15 who was still on the floor. Resident #15 was soaked in urine and his shirt was pulled over his head. The shirt was soaked in saliva. NA #1 called for help to change Resident #15 and put him to bed. The investigation report documented the incident was reported to Human Resources on 2/29/24 by NA #1. The conclusion of the investigation documented abuse could not be substantiated. The facility investigation report documented the former Administrator was unable to substantiate. The RVP presented a copy of the former Administrator's email to the staffing agency that employed LPN #1 dated 3/1/24 at 7:54 PM, documenting the former Administrator wrote I want to terminate LPN #1's contract due to verbal abuse. During an interview on 7/3/24 at 5:19 PM, the RVP stated she thought the former Administrator thought that LPN #1 was overwhelmed. She did not have an explanation as to why the facility investigation did not substantiate abuse, however the email indicated verbal abuse did occur. During an interview on 7/3/24 at 6:29 PM, RN #1 stated when she came on duty at 6:00 AM on 2/29/24, NA #1, NA #2 and NA #3 approached her and reported what happened the night before (2/28/24). RN #1 stated that she, NA #2, and NA #3 wrote a statement, and the statements were given to the former Administrator. During a follow up interview on 7/3/24 at 6:47 PM, the RVP stated there was no documentation regarding a physical assessment or monitoring of Resident #15 after the incident. Resident #15 was not sent to the hospital emergency room for an evaluation. The RVP was unsure whether the attending physician was notified, and there was no incident report. The RVP stated they knew RN #1 had completed an assessment of Resident #15 but did not document the assessment because the former Administrator told RN #1 that she would take care of it. During an interview on 7/3/24 at 7:00 PM, the HR Personnel stated she recalled NA #1 reported the incident on 2/29/24 to her. She asked NA #1 to write a statement then she took it to the former Administrator personally. During an interview on 7/4/24 at 12:23 PM, NA #1 confirmed she did not report the incident that occurred on 2/28/24 until the next morning, 2/29/24. On 7/4/24, an Immediate Jeopardy (IJ) was determined at Past Non-Compliance for the facility's failure to ensure residents were safe from abuse by a staff member. The IJ was determined to exist on 2/28/24 when Resident #15 was verbally abused, physically abused, and neglected by LPN #1. The IJ was removed on 6/25/24. On 7/4/24 at 5:40 PM, the survey team notified the Administrator and DON of the Immediate Jeopardy and provided them a copy of the CMS Immediate Jeopardy (IJ) Template. On 7/4/24 at 7:30 PM, the facility provided a copy of their Corrective Action Plan. The facility's actions included the following: - LPN #1 was terminated on 3/1/24. No statement obtained. Agency notified. - NA #1 was educated on abuse and when and how to report it according to the report. - The former Administrator's employment was terminated on 5/8/24. Steps taken by Current Administrator since 5/13/24: - On 5/24/24, the Administrator had mandatory all staff in-service and included in the agenda was Grievance policy and procedure, Abuse Coordinator, types of abuse and abuse reporting policy. - On 6/1/24, information was placed in common areas with Key Personnel that specifically named Current Administrator as abuse coordinator and phone number. - On 6/2/24, 27 residents were interviewed and asked if they felt safe and who they report concerns to. If they did not know, they were educated. - On 6/6/24, Abuse Training education was placed in the information book. - On 6/25/24, a QAPI [Quality Assurance and Performance Improvement] meeting was held. Reviewed Reportable incidents and grievances with Medical Director and Interdisciplinary Team (IDT) were reviewed. - On 7/4/24 at 8:30 PM, the survey team validated that the facility removed the IJ on 6/25/24 before the survey entrance. There were no other instances of abuse to residents after 6//24/24. Therefore, the facility was cited at IJ at F600, at past non-compliance, and found to be in compliance as of 6/25/24.

Based on policy review, record review, facility investigation review, and staff interview, it was determined the facility failed to report an allegation of physical and verbal abuse and neglect to the State Survey Agency. This was true for 1 of 3 residents (Resident #15) reviewed for abuse. This failure resulted in harm to Resident #15 when the allegation of physical and verbal abuse was not acted on in a timely manner, investigated, and measures implemented to protect residents during the investigation. Findings include: The facility's Abuse policy, undated, stated, All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriate of resident property, and exploitation are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where State law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Resident #15 was admitted on [DATE], with multiple diagnoses including personal history of a traumatic brain injury. A quarterly MDS assessment, dated 5/17/24, documented Resident #15 was severely cognitively impaired. A facility investigation report, undated, documented an incident occurred on 2/28/24. The report documented NA #1 was assisting LPN #1 to get Resident #15 off the floor and back into his wheelchair. LPN #1 attached the [gait] belt [an assistance safety device that can be used to help a patient sit, stand, or walk around, as well as to transfer them from a bed to a wheelchair] around Resident #15's chest to get him up and she was yelling at him to get up and get on his feet. NA #1 went to grab him under his arm to help him and LPN #1 said no, he can do it, he knows how. After about a minute of LPN #1 pulling on Resident #15 and yelling, LPN #1 said, I'm not [expletive] doing this tonight and proceeded to pull him to the floor and as she was doing so, he hit his head on the door frame of his room as a result of her being rough and yanking him around. LPN #1 took the belt off, grabbed under his arms and pulled him part way into his room. He was holding his head in pain and LPN #1 said to NA #1 to leave him there. NA #1 did as she was told and left the room. NA #1 returned 45 minutes later to check on Resident #15 who was still on the floor. Resident #15 was soaked in urine and his shirt was pulled over his head. The investigation report documented the incident was reported by NA #1 to the facility's HR personnel on 2/29/24, the day after the incident occurred. During an interview on 7/3/24 at 6:29 PM, RN #1 stated when she came on duty at 6:00 AM on 2/29/24 (the next day), NA #1, NA #2 and NA #3 reported what happened the evening before. RN #1 stated that she, NA #2, and NA #3 wrote a statement, and the statements were given to the former Administrator. During an interview on 7/4/24 at 12:23 PM, NA #1 confirmed that she did not report the alleged incident until the next morning, 2/29/24. On 7/4/24 at 7:30 PM, the facility provided a copy of their Corrective Action Plan. The facility's actions included the following: Steps taken by Current Administrator since 5/13/24: - On 5/24/24, the Administrator had mandatory all staff in-service and included in the agenda was Grievance policy and procedure, Abuse Coordinator, types of abuse and abuse reporting policy. - On 6/1/24, information was placed in common areas with Key Personnel that specifically named Current Administrator as abuse coordinator and phone number. - On 6/2/24, 27 residents were interviewed and asked if they felt safe and who they report concerns to. If they did not know, they were educated. - On 6/6/24, Abuse Training education was placed in the information book. - On 6/25/24, a QAPI [Quality Assurance and Performance Improvement] meeting was held. Reviewed Reportable incidents and grievances with Medical Director and Interdisciplinary Team (IDT) were reviewed. The survey team validated the Corrective Action Plan was in place before the survey entrance and there were no further instances of failure to report alleged abuse to the State Agency. Therefore, the facility was cited at Past Non-Compliance and was found to be in compliance as of 6/25/24.

Based on staff interview and record review, it was determined the facility failed to ensure residents received PRN [MEDICAL CONDITION] medications only when clinically indicated for the treatment of [REDACTED].#1) sampled for [MEDICAL CONDITION] medication use and had the potential for harm should residents receive psychoactive medications that were unwarranted, ineffective, or used for excessive duration without benefit to the resident. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including dementia with behavioral disturbance and anxiety disorder. A physician order, dated 2/23/18, directed staff to provide [MEDICATION NAME] 0.5 mg by mouth twice daily at 8:00 AM and 8:00 PM. A physician's orders [REDACTED]. This was provided to Resident #1 on 2/14/18 at 9:51 PM and on 2/15/18 at 8:03 AM. A nursing progress note, dated 3/15/18, documented Resident #1 was medicated 3 times with [MEDICATION NAME] ([MEDICATION NAME]) sublingual (under the tongue.) The Narcotic Log noted the times given were 6:00 AM, 12:00 noon, and 4:00 PM. The nursing note did not document anxiety was exhibited by Resident #1 prior to the medication being administered. A nursing progress note, dated 3/16/18, documented Resident #1 was medicated with [MEDICATION NAME] 0.5 mg 4 times with good results. The Narcotic Log documented the medication was provided at 6:00 AM, 10:00 AM, 2:00 PM, and 6:00 PM. The nursing note did not document anxiety was exhibited by Resident #1 prior to the medication being provided. A nursing progress note, dated 3/17/18, documented Resident #1 refused to get out of bed, declined fluids and food, slept most of the day. On 7/10/18 at 11:45 AM, the nursing progress notes and Narcotic Log was reviewed with the Administrator. The Administrator stated she was not able to see where the indication of need was documented prior to Resident #1 being administered the antianxiety medication.

Based on observation, interview, and policy review, it was determined the facility failed to ensure infection control measures were consistently implemented. This was true for 2 of 15 sampled residents (#6 and #16), when staff failed to perform effective hand hygiene during resident cares, and failed to practice universal precautions for 13 random residents observed during meal service in the dining room. These failures created the potential for harm if infections spread among residents. Findings include: 1. Hand hygiene observations during cares and interviews: On 1/8/18 at 4:38 PM, CNA #1 and CNA #6 were observed assisting Resident #16 with pericare, the CNAs took turns from their respective sides. CNA #6 removed her gloves after completing pericare, entered Resident #16's bathroom, applied soap to her hands, ran her hands under the water for 5 seconds before turning off the water, and dried her hands. CNA #6 left the room to acquire a Hoyer lift and CNA #2 replaced CNA #6 in Resident #16's room. On 1/8/18 at 5:00 PM, CNA #1 and CNA #2 were observed assisting Resident #16 out of bed with a mechanical lift and stopped due to Resident #16's pants were saturated again. The CNAs laid Resident #16 down to perform pericare again, each from their respective sides. CNA #1 and CNA #2 donned gloves and assisted Resident #16 with pericare. CNA #1 removed her soiled gloves and placed new gloves on her hands, without first performing hand hygiene, and assisted Resident #16 put on undergarments. CNA #2 did not remove her soiled gloves or perform hand hygiene until after the CNAs had clothed Resident #16. CNA #2 entered Resident #16's bathroom, applied soap to her hands, ran her hands under the water for 7 seconds before turning off the water, and dried her hands. During the observation, CNA #1 was observed coughing on to her wrist, and continued with cares without hand hygiene or changing gloves. CNA #1 was observed coughing again and not covering her mouth. CNA #1 was facing Resident #16. On 1/10/18 at 10:58 AM, CNA #4 and CNA #3 were observed assisting Resident #6 with pericare. CNA #3 and CNA #4 donned gloves and assisted Resident #16 with pericare, the CNAs took turns from their respective sides. CNA #4 removed her gloves after completing pericare, entered Resident #6's bathroom, applied soap to her hands, ran her hands under the water for 8 seconds before turning off the water, and dried her hands. CNA #3 did not remove her soiled gloves or perform hand hygiene until the CNAs clothed Resident #6. CNA #3 removed her gloves, exited the room, utilized hand sanitizer in the hall, where she rubbed the palms of her hands together three times, and then wrung her hands in the air. CNA #3 then went to a sink in the small dining room, and applied soap to her hands, ran her hands under the water for 4 seconds before turning off the water, and dried her hands. On 1/12/18 at 8:50 AM, the ADON stated the proper process to complete pericare was as follows: * wash hands and put gloves on, * perform pericare, wiping from front to back, * remove gloves after pericare, and * then perform hand hygiene and reapply clean gloves. The ADON stated staff were encouraged to utilize soap and water when performing hand hygiene. The ADON stated staff were to wash their hands for 20 seconds or more when utilizing soap and water. The ADON stated if staff utilized hand sanitizer they should rub all the surfaces of their hands and continue rubbing until their hand were dry. The ADON stated staff were to perform hand hygiene when transitioning from dirty to clean processes. The ADON stated the observations described above were not appropriate hand hygiene practices. The ADON stated the facility was currently working on their infection control program to ensure hand hygiene practices were performed appropriately and he would increase audits. 2. Hand hygiene observations during dining: On 1/8/18 from 5:35 PM to 5:56 PM, CNA #1, CNA #5, the Activities Director and the DON were observed assisting 10 residents in the dining room with delivering trays, cutting up food, inserting straws into drinks, filling up drinks, and assisting residents with eating without consistent hand hygiene practices. CNA #5 was observed grasping 3 residents' cups by the rim with no hand hygiene practice performed. The Activities Director was observed touching 3 residents' backs, and then inserting straws into other residents' drinks. The Activities Director performed hand hygiene periodically throughout the observations, which lasted for 3 - 8 seconds. CNA #1 was observed assisting two residents to eat without performing hand hygiene between moving from resident to resident. The DON was observed delivering trays and assisted 2 residents with setting up their meals to eat. The DON performed hand hygiene periodically throughout the observations which lasted for 3 seconds. On 1/10/18 from 5:43 PM to 6:04 PM, Registered Nurse (RN) #1 was observed delivering trays, assisting 3 residents with tray set up needs, and then assisted a resident with eating her meal, all without performing hand hygiene. On 1/12/18 at 8:50 AM, the ADON stated staff were encouraged to utilize soap and water when performing hand hygiene. The ADON stated staff were to wash their hands for 20 seconds or more when utilizing soap and water. The ADON stated if staff utilized hand sanitizer they should rub all the surfaces of their hands and continue rubbing until their hand were dry. The ADON stated staff were to perform hand hygiene when transitioning from dirty to clean processes. The ADON stated the observations described above were not appropriate hand hygiene practices.

Based on observation and interview, it was determined the facility failed to ensure measures were in place to prevent possible cross-contamination a) of dirty to clean areas in the kitchen; b) areas of the kitchen had cleanable surfaces; and c) prevent pests from entering the kitchen. This affected 14 of 15 (#'s 3-6, 8-11, 14, 16, 18, and 20-22) sampled residents and had the potential to affect all residents who dined in the facility. This failure created the potential for harm if residents contracted food-born illnesses or contagious diseases. Findings include: 1. Kitchen Inspection: On 1/11/18 at 10:27 AM, the kitchen was observed with multiple uncleanable surfaces and pest entry points as follows: * The floor contained three raised cracks, measuring approximately 4 inches in length, and multiple small holes in the floor. * The 20-foot in length white cabinet surfaces, were observed with flaking and missing paint, and a greasy substance covering their surfaces. The wood was exposed in areas; which created a porous surface for bacteria to reside. Approximately 15 feet of the cabinets were observed with a separation of varying degrees between the cabinets and the counter-top. * The counter-top was observed loose at a seam, which created a separation between counter-tops. * Multiple white shelves in the pantry were observed with flaking and missing paint, and a greasy substance covered the surfaces. The wood was exposed in areas which created a porous surface for bacteria to reside. * The wall between the dishroom and the cooking area was observed with flaking and missing paint, and the floor boards contained 2 cracks in the seams approximately 6 inches in length. * Food debris and a layer of dirt was observed under the three-compartment sink. * Small dark pellets resembling mouse droppings, food particles, a grease film, and a dust layer were observed behind the oven and grill. The catch tray for the grill contained approximately a 2-centimeter-thick layer of dust, food particles, and grease. * The floor under the refrigerators contained food debris, dust, and grease spills. An unknown food fragment, approximately 1 inch by 2 inches, which appeared partially eaten on both sides, was observed under the refrigerators. * Baked on food debris and a brown film were observed on at least twenty pots and pans. * Multiple cracks were observed on the ceiling. The longest crack was approximately 20 feet in length, and where it intersected with the wall there was a sag point. * Two exhaust fans were observed without a proper seat. One of the fans had approximately a 2 inch by 4 inch opening where a pest could potentially enter the kitchen. * The windows in the kitchen were observed without a proper seal where a pest could potentially enter. Each of the surfaces described above presented potential areas for bacterial growth, pest entry, and subsequent spread of food-born illnesses. On 1/11/18 at 11:06 AM, the CDM stated the cabinets, walls, and shelves outlined above, were not cleanable. The CDM stated the food debris, food particles, and grease should be cleaned up. The CDM stated she was unsure if the floor, walls, and ceiling had water damage, however, the cracks were entry points for liquids. The CDM stated the window did not seal and this was a potential entry point for pests. 2. Dishware Washing: On 1/11/18 at 9:20 AM, Cook #1 was observed during the dishwashing process wearing gloves and a disposable apron. Cook #1 cleaned the soiled dishes, and sent them through the dishwasher. Cook #1 entered the clean dishware side of the area without taking her gloves and apron off, and without performing hand hygiene. The CDM in Training, present during the observation, stated this was not the correct procedure for cleaning dishware. She stated Cook #1 should have taken her gloves off, washed her hands, and removed her apron before touching the clean dishware.

Based on observation, interview the facility failed ensure the kitchen was free from pests. This affected 14 of 15 (#'s 3-6, 8-11, 14, 16, 18, and 20-22) sampled residents and all residents who dined in the facility. This had the potential for psychosocial from potential infestation of pests. Findings include: On 1/11/18 at 10:27 AM, the kitchen was observed with multiple pest entry points as follows: * The floor boards in the dishroom contained 2 cracks in the seams, approximately 6 inches in length. * Small dark pellets resembling mouse droppings, food particles, a grease film, and a dust layer were observed behind the oven and grill. * The floor under the refrigerators contained an unknown food fragment, approximately 1 inch by 2 inch, which appeared partially eaten on both sides. * Two exhaust fans were observed without a proper seat. One of the fans had approximately a 2 inch by 4 inch opening where pests could potentially enter the kitchen. * The windows in the kitchen were observed without a proper seal where pests could potentially enter. Each of the areas described above presented potential areas for pests to enter and food for the pest to eat. On 1/11/18 at 11:06 AM, the CDM stated the food debris, food particles, were potential food for pests. The CDM stated the window did not seal and this was a potential entry point for pests. On 1/12/18 at 1:10 PM, the Maintenance Director stated a routine visit had been conducted by their pest control company recently, and stated he would schedule a spot visit for the following week.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents diagnosed with [REDACTED]. This was true for 2 of 4 (#5 and #7) residents reviewed for diabetic management, and 1 of 1 closed record ( Resident #1) reviewed for diabetic management. As a result: * Residents' blood glucose (BG) levels were not monitored as ordered or in a timely manner * Hyper/hypoglycemic BG levels were not reported to physicians as ordered * Insulin refusals, meal refusals, and BG assessment refusals were not reported to the physician * The facility's hyper/[DIAGNOSES REDACTED] policies were not followed * Insulin was administered inconsistent with physician orders * Glucometers were used without completing controls to ensure readings were accurate * Care plans did not provide direction for how staff was to manage residents' diabetes * Residents did not have specific physician-ordered parameters for physician notification These systemic practice failures placed the health and safety of Resident #5 and 17 other residents in the facility with a [DIAGNOSES REDACTED]. In addition, the facility failed to ensure: * Insulin administration sites were rotated per professional standards of practice * Self-testing glucometers were not used for multiple residents * Insulin and BG testing orders were clarified as needed Findings include: The facility's May 2017 Diabetes Management- [DIAGNOSES REDACTED] and [MEDICAL CONDITION] Protocols documented all diabetic testing would be conducted and reported per physician orders. The protocol documented: * Individualized care plans would be developed outlining residents' diabetic care needs * Glucometers would be calibrated per manufacturer specifications and those calibrations would be logged * Residents with diabetes should have resident specific physician ordered parameters for [MEDICAL CONDITION]. For those residents who do not have a physician ordered parameter, notify the physician for any one blood glucose greater than 250 mg/dl (all measurements in milligrams/deciliters). * Staff was to administer insulin in accordance with physician orders * Staff were to repeat BG assessments in 15 minutes or as directed by the physician for hyperglycemic episodes. * Staff were to repeat BG assessments in 15 minutes for hypoglycemic episodes and instructed to notify the physician for hypoglycemic episodes per parameters. According to the American Diabetes Association, Standards of Medical Care in Diabetes - 2016, from the Diabetes Care Journal, Volume 39 Supplement 1, BG levels in the elderly who were very complex with end stage chronic illnesses and poor health should be 100-180 mg/dl before meals. The journal documented BG levels in the elderly who were complex with multiple comorbidities should have BG levels in the 90-150 mg/dl range. The journal documented older adults with diabetes in a long term care (LTC) facility were at higher risk of experiencing hypoglycemic episodes, and providers should be called immediately in case of hypoglycemic episodes or when BG levels were less than 70 mg/dl. A position statement from the American Diabetes Association documented LTC facilities should increase the frequency of glucose monitoring, call the practitioner, and confirm high glucose values by laboratory testing. These steps were to be completed if residents experienced BG's greater than 300 during all or part of 2 consecutive days. In addition, the position statement documented monitoring frequency should be based on complexity of residents and their risk for [DIAGNOSES REDACTED]. (Munshi, M. N., Florez, H., Huang, E. S., et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care, vol. 39, Feb. 2016, pp. 308-318.) 1a. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's Admission Minimum Data Set (MDS) assessment, dated 6/19/17, documented moderate cognitive impairment and the use of insulin required daily. Resident #5's care plan did not include an individualized care plan outlining diabetes care. An Altered Diet Care Plan, dated 6/16/17, documented Resident #5 required a diabetic diet related to diabetes. This was the only care plan in the resident's clinical record addressing DM. Resident #5's July 2017 Physician's Orders, documented: * BG before meals and at bedtime for Type II DM, ordered 6/12/17. * Staff were to follow hypoglycemic protocols for BG levels less than 80 mg/dl and document all interventions and results in a progress note, ordered 6/12/17. * 27 units of Insulin [MEDICATION NAME] solution once daily for DM, ordered 6/23/17. * 10 units of Insulin [MEDICATION NAME] solution before meals for DM, ordered 6/12/17. * Insulin [MEDICATION NAME] solution after meals per sliding scale (SSI) for BGs of: 151-199 = 1 unit 200-249 = 2 units 250-299 = 3 units 300-349 = 4 units 350+ = 7 units for diabetes, ordered 6/15/17. * 1000 milligrams (mg) of [MEDICATION NAME] two times a day for DM, ordered 6/12/17. Resident #5's physician orders did not include parameters for when staff was to notify the physician of hyperglycemic episodes. Resident #5's Medication Administration Record (MAR) from 6/12/17 through 7/8/17 documented 10 units of [MEDICATION NAME]was to be given at 7:00 am before meals, and the SSI [MEDICATION NAME]was to be administered at 8:00 am after meals. Resident #5's MAR from 7/8/17 through 7/17/17 documented the 10 units of [MEDICATION NAME]that was to be given before meals and the SSI [MEDICATION NAME]that was to be given after meals were both administered at 8:00 am. On 7/18/17 at 8:24 am Resident #5 was observed eating breakfast. At 8:41 am, Resident #5 stated staff always gave her insulin after her meals and that she never received insulin before her meals while at the facility. Resident #5 stated she only received insulin four times a day, after meals and before bed. On 7/18/17 at 8:46 am, Licensed Nurse (LN) #2 was observed drawing into a syringe 13 units of [MEDICATION NAME] insulin. LN #2 stated she drew up 10 units of (before meals) insulin and 3 units of (after meals) SSI [MEDICATION NAME]for Resident #5's pre-breakfast BG of 271 mg/dl. LN #2 administered the 13 units of insulin and stated she always provided Resident #5's insulin in this manner as directed by the DNS. At 9:30 am, Resident #5 stated she sensed the facility was not managing her diabetes insulin therapy appropriately. On 7/18/17 at 11:55 pm, Resident #5 was observed in the dining room eating cottage cheese and fruit. At 12:35 pm, Resident #5 received 11 units of insulin from LN #2. LN #2 stated Resident #5's pre-meal BG level was 163 mg/dl, which required 1 unit of post meal sliding scale insulin in addition to the 10 units of pre-meal scheduled insulin. b. On 7/18/17 at 8:41 am, Resident #5 stated staff always woke her up to assess BG levels at 5:00 am, which she did not like. Resident #5 said she received her first dose of insulin after she ate breakfast and the staff did not recheck her BG level until just before lunch. She stated she had been diabetic for [AGE] years and she didn't know why the facility waited so long to recheck her BG level or why there was an extended period of time between her first BG assessment and her first insulin administration. On 7/18/17 at 8:46 am, LN #2 stated BG levels were assessed at 6:00 am, 11:00 am, 5:00 pm and before bed. LN #2 stated the first time she checked residents' BG levels was at 11:00 am and that night nurses were responsible for assessing the 6:00 am BG level. She said she did not reassess residents' BG levels before breakfast unless a resident's clinical condition indicated a reassessment may be necessary. c. Resident #5's MAR from 6/12/17 through 6/30/17 documented: * BG levels ranged from 119 to HI (high - above 600 mg/dl). * 40 BG results greater than 250 mg/dl, including 8 BGs greater than 400 mg/dl and 2 BGs greater than 500 mg/dl. * Resident #5's MAR did not document BG assessments were performed on 6 of 72 opportunities; there was no explanation on the MAR for 4 of the 6 missed opportunities. Resident #5's clinical record documented the physician was notified on 1 of 40 hyperglycemic assessments (6/13/17) from 6/12/17 through 6/30/17. A Nurse's Note, dated 6/13/17 at 5:24 pm, documented Resident #5's physician was notified of an elevated BG and the physician directed staff to administer additional insulin. The BG was reassessed as 576 mg/dl. When notified of this BG assessment, the physician provided additional direction to staff. The 576 mg/dl BG was not documented on the 6/13/17 MAR. Resident #5's MAR from 7/1/17 through 7/17/17 documented BG levels ranging from 115 mg/dl to 379 mg/dl; 37 BG results were greater than 250 mg/dl. Resident #5's record did not contain documentation of staff interventions from 7/1/17 through 7/17/17 or whether the physician was notified of the 37 hyperglycemic BG assessments. A Nurse's Note, dated 7/7/17 at 5:44 pm, documented Resident #5's BG was 59 mg/dl. The note documented the facility followed the hypoglycemic protocol and her BG level was 165 mg/dl when checked a half hour later. The clinical record did not document whether the physician was notified, or what, if any, interventions were provided. The 59 mg/dl BG was not documented on the 7/7/17 MAR or BG record. On 7/17/17 at 5:14 pm, Resident #5 stated the facility did not recheck her hyperglycemic BG levels, staff might have reassessed her hypoglycemic BG levels. d. Resident #5's Food Intake log from 6/12/17 through 6/30/17 documented she refused meals or was not provided a meal 6 of 48 opportunities on 6/15/17, 6/16/17, 6/19/17, 6/24/17, 6/29/17, and 6/30/17. The 6/12/17 through 6/30/17 MAR did not document post-meal insulin was withheld on these days related to the meal refusal. The MAR documented post-meal insulin was not administered on 6/18/17, twice on 6/25/17, 6/28/17 and 6/29/17 as it was not warranted per parameters (150 mg/dl or lower did not require insulin therapy). The clinical record did not contain evidence the resident's physician was notified of the refused meals. Resident #5's Food Intake log from 7/1/17 through 7/17/17 documented she refused meals or was not provided a meal 9 of 27 opportunities on 7/5/17 - 7/10/17, 7/12/17, 7/13/17, and 7/16/17. The 7/1/17 through 7/17/17 MAR did not document post-meal insulin was withheld on these days related to the meal refusal. The MAR documented post-meal insulin was withheld on 7/5/17 and 7/14/17 as it was not warranted per parameters. The clinical record did not contain evidence the resident's physician was notified of the refused meals. On 7/18/17 at 4:55 pm, Resident #5 stated staff administered insulin on those occasions when she refused meals. On 7/19/17 at 6:00 pm, the Medical Director stated he expected staff to notify him when a resident refused to eat a meal and that staff would withhold the post-meal insulin until he had been notified a meal had been refused. e. Resident #5's 6/12/17 through 6/30/17 MAR Insulin Administration Location Record documented the site of administration was not rotated 9 of 19 opportunities on 6/20/17 - 6/24/17, 6/26/17, 6/27/17, 6/29/17, and 6/30/17. Resident #5's 7/1/17 through 7/17/17 MAR Insulin Administration Location Record documented the site of administration was not rotated 6 of 17 opportunities on 7/2/17, 7/5/17 - 7/8/17, and 7/11/17. On 7/19/17 at 4:39 pm, the DNS stated staff should rotate the site of insulin administration every time they administer insulin. f. Resident #5's clinical record did not document: * Reassessment of BG levels for 76 of 78 hyperglycemic episodes. * Physician notification, per facility protocol, for 76 of 78 hyperglycemic episodes. * Evidence the facility followed its hyperglycemic and hypoglycemic protocols when applicable. * Evidence the facility followed professional standards of practice with insulin administration and the withholding of insulin. * Development of a complete care plan for Resident #5's diabetes management. * Parameters for when staff was to notify the physician of hyperglycemic episodes. On 7/18/17 at 2:56 pm, the Director of Nursing Services (DNS) stated facility staff were to notify the physician per parameters identified by the physician. She stated she could not find specific parameters identified for Resident #5 and that she referred to the protocol for direction as to when the physician should be notified. The DNS stated staff were expected to reassess hyperglycemic BGs within 15 minutes of interventions or as directed by the physician when BG levels exceeded physician-specified parameters. For a resident experiencing a hypoglycemic episode, the DNS said staff was to recheck the BG 15 minutes after administering 15 grams (g) of carbohydrates and that this process would be repeated until the BG level reached 70 mg/dl or greater. The DNS stated she did not know why the facility's protocols were not followed for Resident #5's hypoglycemic and hyperglycemic episodes. On 7/18/17 at 4:13 pm, the Clinical Regional Director (CRD) LN stated there should be BG-insulin parameters identified by the physician and if there were none identified staff was to refer to the protocol and notify the physician for any BG level greater than 250 mg/dl. The CRD LN stated staff should not have combined Resident #5's pre- and post-meal insulin dosages. She stated the after meal insulin administration was to be based on post-meal BG assessment and that there should not be more than a 30- to 60 minute interval between BG assessment and insulin administration. On 7/19/17 at 6:45 pm, LN #2 stated she would notify a physician when BG levels were outside established parameters and document that she called the physician in a Nurses Note. She stated she would reassess BG levels depending on physician orders and document those reassessments in a Nurses Note or on the MAR. On 7/19/17 at 5:45 pm, the Medical Director stated when staff called to notify him of BG levels outside of parameters he would order insulin and instruct staff to reassess residents' BG levels in 1 hour. He stated he hoped there would be evidence of these conversations in the record and although there were no parameters identified in Resident #5's orders, this was not an excuse for not calling and notifying the physician. The Medical Director stated he expected Resident #5's post-meal insulin to be administered immediately after meals. The Medical Director said the post-meal insulin should have been based on the BG level before meals and if they ate the meal. The Medical Director stated if a resident refused a meal, he expected facility staff to hold the post-meal insulin and notify him for further instructions. On 7/20/17 at 2:12 pm, the facility was informed Resident #5, as well as all 17 residents in the facility diagnosed with [REDACTED]. On 7/25/17 at 1:07 mthe facility provided evidence that an acceptable plan to remove the immediacy had been developed and implemented with an effective date of midnight on July 25, 2017. The plan included: * BG levels and diabetic medication orders for Resident #5 and all other diabetic residents were reviewed with their physicians and changes made as necessary. * Care plans were reviewed and updated related to diabetic management. * Physician orders, including those for insulin, and MARs were audited for those residents diagnosed with [REDACTED]. * Guidelines for managing hyper/hypoglycemic incidents were approved by the Medical Director. * The Interim Director of Nursing Services was to provide education to nursing staff prior to their next shift on BG level parameters for hypo/[MEDICAL CONDITION]; treatment guidelines for hypo- and [MEDICAL CONDITION]; notification to the physician and responsible party; appropriate documentation of notification and interventions for hyper/hypo glycemic episodes, meal refusal, insulin refusals and BG assessments; withholding insulin when residents refused meals; glucometer testing and calibration; and BGs not taken more than 30 minutes prior to a meal. * The MDS Coordinator was to audit BG levels at each clinical meeting Monday through Friday and audits were to be conducted weekly for 4 weeks, and then monthly for 3 months by the IDNS. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's quarterly MDS (Minimum Data Set) assessment, dated 5/30/17, documented severe cognitive impairment, delusions, extensive staff assistance required for bed mobility, transfers, dressing and hygiene, and insulin required daily. Resident #1's care plan directed staff to assess BGs every morning as allowed and administer insulin per physician order, as well as to observe for- and report to the physician any signs and symptoms of excessive appetite/voiding/thirst, and changes in level of consciousness, mood, and diaphoresis (sweating). Resident #1's care plan did not include interventions to notify the physician when the resident refused BG assessments, insulin administrations, meals, and/or nutritional supplements. Resident #1's June 2017 and July 2017 Physician's Orders directed staff to assess BGs every morning as allowed (initiated 11/24/15) and administer 20 units of [MEDICATION NAME] daily for Type II diabetes. The Physician's Orders specified the insulin was not to be withheld (initiated 4/18/17). a. Resident #1's physician orders did not include parameters for when staff was to notify the physician of hypo/hyperglycemic episodes. The facility Diabetic Management Protocol, revised May 2017, documented residents with diabetes should have resident specific physician ordered parameters for [MEDICAL CONDITION]. For those residents who do not have a physician ordered parameter, notify the physician for any one blood glucose greater than 250 mg/dl. Resident #1's June 2017 MAR documented her BG was assessed 5 times that month with results exceeding 250 mg/dl without physician notification as follows: * 6/11/17 - 4:52 am: BG = 307 mg/dl. * 6/12/17 - 3:38 am: BG = 345 mg/dl. * 6/20/17 - 4:00 am: BG = 345 mg/dl. Resident #1's MAR from 7/1/17 to 7/10/17 documented her BG was assessed 3 times that month with results exceeding 250 mg/dl without physician notification as follows: * 7/8/17 - 5:07 am: BG = 471 mg/dl. * 7/9/17 - 3:43 am: BG = 263 mg/dl. b. The June 2017 MAR documented Resident #1 refused BG assessments on 25 of 30 days, of which the physician was not notified on 6/2/17, 6/4/17 - 6/10/17, 6/13/17 - 6/19/17 and 6/21/17 - 6/30/17. Resident #1's record did not include documentation of BG reassessments at a time closer to breakfast for the following days: 6/2/17, 6/8/17, 6/9/17, 6/13/17, 6/14/17, 6/15/17, 6/16/17, 6/19/17, 6/21/17, 6/22/17, 6/26/17, 6/28/17, 6/29/17 and 6/30/17. The July 1-10, 2017 MAR documented Resident #1 refused BG assessment on 7 days, of which the physician was not notified, reassessments attempted, and education provided. c. Resident #1's June 2017 MAR directed staff to administer 20 units of [MEDICATION NAME] once daily with the note, Do not hold. Resident #1's June 2017 MAR included 9 dates insulin was not administered without physician notification; the resident refused insulin on 8 of those dates and staff withheld the insulin on one occasion that was not explained in the resident's clinical record. Resident #1's July 2017 MAR included 2 dates insulin was not administered without physician notification. On 7/19/17 at 5:10 am, when asked why Resident #1's BG was scheduled and assessed at 4:00 am, LN #4 stated, I really don't know why, I wondered that myself. When I worked, I would try to get her BG after I gave report at the end of night shift. She didn't like getting a fingerstick for BG, it is painful and I wouldn't want it done at 4:00 am either. On 7/19/17 at 4:13 pm, the Clinical Regional Director (CRD) stated there should have been BG parameters identified by the physician, but if there were none identified then staff was to refer to the protocol and notify the physician of any BG level greater than 250 mg/dl. On 7/19/17 at 5:45 pm, the Medical Director stated when staff called to notify him of BG levels outside of parameters he would order insulin and instruct staff to reassess residents' BG levels in 1 hour. He stated he hoped there would be evidence of these conversations in the clinical record and that he would expect the facility to notify him or his associates of any elevated BG results or refusals of BG testing and/or insulin administration. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Resident #7's admission orders [REDACTED]. Meal times for the facility's main dining room where Resident #7 ate were posted as 7:40 am for breakfast, 12:05 pm for lunch, and 5:50 pm for dinner. Resident #7's MAR and BG summary documented BGs were assessed after meals on 7/3/17, 7/4/17, 7/8/17, 7/9/17, and 7/12/17; no BG result was documented on 7/6/17, 7/10/17, 7/11/17, and 7/12/17; and that insulin was administered when not indicated by BG assessment on 7/5/17 and 7/9/17 on two occasions. On 7/18/17 at 11:15 am, the DNS stated Resident #7's MAR and BG record did not include all BG assessment results, however she was unable to determine whether BGs assessments were performed and not documented, or not performed. The DNS stated if times were given for BG assessment and insulin administration were on the MAR, then both procedures should be performed and documented at that time.

Based on record review, resident and staff interview, and review of facility policies, Incident Reports, and investigations, it was determined the facility failed to ensure 1 of 7 residents (#1 reviewed for quality of care concerns were not neglected by staff. Specifically: a) Resident #1 sustained harm when she fell from a wheelchair in the dining room as staff failed to offer repositioning, toileting, and physician-ordered interventions, or provide any other meaningful interaction, cares, or services for 7-hours. The resident sustained [REDACTED]. Findings include: The facility's Abuse policy, revised 5/31/17, defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur, such as: the deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual resident's care needs. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's quarterly MDS (Minimum Data Set) assessment, dated 5/30/17, documented severely impaired cognition, delusions, bowel/bladder incontinence, and extensive-to-total assistance of 2 staff required for bed mobility, transfers, dressing and hygiene. Resident #1's Care Plan directed staff to offer toileting, check for incontinence every 2 hours, turn and reposition every 2 hours, notify the Resident Services Director when mood/behavior changes took place, and provide assistance at meals as needed. An Incident Report, dated 7/5/17 and revised 7/14/17, documented Resident #1 fell from a wheelchair to the dining room floor at 1:41 pm. The Report documented Resident #1's fall was due to weakness/fainted. Res(ident) had sudden onset weakness, slumping to right side in chair and leaning forward in w/c (wheelchair) when overbalanced and fell to floor. Res(ident #1) was in dining room leaning in chair and fell forward hitting face/head on floor landing on left hip/side. Nursing was immediately notified and assessment started. Pressure held to stop nose bleed, skin tear cleansed and treated. Due to limited ROM (Range of Motion) in LLE (left lower extremity), order obtained, records copied and 911 was called to transport res(ident) to emergency room . MD and family notifications complete. The 7/5/17 Incident Report documented LN (Licensed Nurse) #1, who was assigned to care for Resident #1 that day, completed the facility's I&A Report, however LN #1 stated on 7/18/17 at 9:48 am that she did not witness Resident #1's fall. A 7/5/17 emergency room Provider Note documented Resident #1 sustained a [MEDICAL CONDITION] hand and lower left leg, and she presented with a hematoma to the right forehead and a skin tear with bruising to the right hand. On 7/17/17 at 1:33 pm, the Administrator stated his review of a closed circuit visual recording of the 7/5/17 incident documented Resident #1 was in the main dining room from 6:43 am until she fell at 1:41 pm. A written statement from a State Ombudsman, dated 7/13/17, documented s/he reviewed a facility video that documented very brief staff contact with Resident #1 and that the resident was not taken from the dining room or provided with cares or services. The Ombudsman documented the video showed Resident #1's head dropping to the table and back to the chair, and the resident rocking side-to-side for about 10 minutes prior to the fall. The Ombudsman's written statement documented Resident #1 leaned to the left side of the wheelchair and in what appeared to be an attempt to reach something on the ground fell to the floor. The written statement documented Resident #1 did not move after the fall, and that nursing staff was rather slow and uncertain in their clinical response to the resident. On 7/19/17 at 4:30 pm, the Administrator provided an undated Root Cause Analysis (RCA) of the fall that documented a CNA unable to work as scheduled on 7/5/17 was replaced by another staff member who arrived late to the facility. The RCA documented CNA assignments were adjusted for the CNA's late arrival, but the CNA whose assignment was adjusted was not informed of the change, which created confusion related to staff-resident assignments. The facility's 7/5/17 schedule and time cards documented CNA #8, who was assigned to the 100 hall, arrived at the facility at 6:01 am; CNA #7, who was assigned to the 200 hall, arrived at the facility at 5:57 am; and CNA #6, who was also assigned to the 200 hall, arrived at the facility at 6:09 am. Resident #1's room was located in the 200 hall; facility staffing records documented there were 2 Licensed Practical Nurses, 2 Registered Nurses (Director of Nursing Services and Assistant DNS) and 6 CNAs on duty in the facility at the time of Resident #1's fall in the main dining room. On 7/18/17 at 9:48 am, LN#1 stated she was assigned to care for residents on both the 100- and 200 halls, including Resident #1, who she stated was in the main dining room from before breakfast until after the fall that afternoon. She stated Resident #1 was usually incontinent of bowel and bladder, but was able to tell the CNA staff when she needed pericare. LN #1 stated Resident #1 did not receive any medications on her shift, nor assessed for pain and/or pain medications. LN #1 stated she did not know whether Resident #1 was provided incontinent care or offered a scheduled nutritional supplement that morning. On 7/19/17 at 10:52 am, CNA #8 stated she was on duty at the facility at the time Resident #1 fell , and remembered talking briefly that day with Resident #1, but was not in the dining room at the time of the fall. CNA #8 said she did not provide incontinent care or offer fluids or nutrition to Resident #1 on 7/5/17. On 7/19/17 at 2:40 pm, CNA #4 stated she observed Resident #1 leaning in her wheelchair at approximately 9:30 am to 10 am on 7/5/17 so she asked an Activities Assistant to help her reposition the resident. CNA #4 stated she walked by Resident #1 multiple times that day, but did not provide incontinent care, or offer fluids and/or nutrition. On 7/20/17 at 12:45 pm, CNA #6 stated she saw Resident #1 leaning over in her wheelchair at 1:30 pm and requested help from CNA #8 to reposition and provide incontinent care for Resident #1. CNA #6 stated she heard a thud about 15 minutes later and saw Resident #1 on the floor. CNA #6 stated she did not provide incontinent care, or offer fluids/nutrition to Resident #1 on 7/5/17. On 7/20/17 at 5:30 pm, LN #3 stated she saw Resident #1 during an activity in the morning, and that she was leaning forward in her chair. LN #3 stated she told both LN #1 and the Director of Nursing Services (DNS) that Resident #1 was leaning in the wheelchair and that she thought a CNA had returned Resident #1 to her room after lunch. LN #3 stated she was surprised when she heard and then realized Resident #1 had fallen to the floor. LN #3 stated Resident #1 was lying on her left side in a pool of blood from injuries to the face and right hand. LN #3 said she was not familiar with Resident #1 and left the area for assistance from LN #1. She stated 2 CNAs were with Resident #1 at the time and the DNS was providing care to the resident upon her return. LN #3 stated she did not know what contributed to the fall. LN #3 stated she saw Resident #1 leaning in her wheelchair that morning, but the resident appeared fine when she last observed her in the wheelchair. Resident #1 was in a wheelchair in the main dining room from before 7:00 am until her fall at 1:41 pm. There were 4 nurses and 6 CNAs on duty in the facility at the time of the fall. During that time, Resident #1 was not offered toileting, incontinent care, physician-ordered nutritional supplements, pain assessments, [MEDICATION NAME] medication, supervision, or any type of meaningful interaction with staff. Resident #1 fell and sustained a fractured left leg and right hand, as well as wounds to her face and right hand.

Based on observation, resident and staff interview, and clinical record review, it was determined the facility failed to: * Ensure residents were provided nutritional care and assistance with meals consistent with their assessed needs. This was true for 2 of 7 sampled residents (#1 and #3) reviewed for nutritional and dietary concerns; Resident #3 sustained psychosocial harm when the facility failed to provide dinner meals on a consistent basis and the resident lost weight. Resident #1 had the potential for harm from unplanned weight loss due to compromised nutritional status. * Provide necessary grooming, as well as personal and oral hygiene. This was true for 3 of 7 residents (#1, #2 and #3) reviewed for hygiene and could have resulted in harm from embarrassment or rejection by others due to appearance and/or personal odor. * Provide necessary repositioning and floating of heels in bed for residents who were dependent upon staff assistance for Activities of Daily Living (ADL) needs. This was true for 1 of 1 resident (#3) sampled for pressure ulcer prevention and repositioning. Resident #3 developed 3 pressure-related injuries to the dorsal 3rd, 4th, and 5th toes of his right foot. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 7/4/17, documented Resident #3 was cognitively intact, and required extensive assistance or was totally dependent on staff for all ADLs, including eating, bathing, transfers, and bed mobility. Resident #3's Admission Nursing Assessment, dated 3/29/17, documented range-of-motion (ROM) impairments affecting both hands and ankles, bedfast, and very limited ability to change body position. An Admission Skin Risk Predictor Assessment, dated 3/29/17, documented Resident #3 was at high risk for developing skin related issues. The Assessment defined high risk as the need for frequent repositioning, pressure-reducing devices, foam wedges for lateral positioning, floating of heels, nutrition, and moisture management. The ADL Care Plan, dated 3/29/17, documented Resident #3 required the assistance of 2 staff members for positioning. The care plan did not provide instruction for how often staff members were to reposition, offer toileting/pericare, and bathe Resident #3. The care plan also did not document the level of assistance Resident #3 required to eat. The Certified Nursing Assistant (CNA) ADL Flowsheet did not document that Resident #3 was repositioned from 5/1/17 through 7/18/17. Resident #3's CNA Bathing Sheets from 5/1/17 through 7/18/17 documented he was not showered/bathed from 5/9/17 to 5/16/17, 5/16/17 to 5/22/17, 6/13/17 to 6/20/17 and 7/11/17 to 7/18/17. The Bathing Sheets did not document staff offered to shower/bathe or Resident #3 or whether staff reapproached the resident if/when he refused to shower on the above dates. Resident #3's Resident Food Intake Sheets from 5/1/17 through 7/18/17 did not document meals were consistently offered and provided. The records documented Resident #3 was not provided breakfast 9 of 77 opportunities, lunch 9 of 77 opportunities, and dinner 51 of 77 opportunities. There was no explanation documented for the missed and (4) refused meals, and no documentation that staff offered either alternate meals or nutritional supplements. Resident #3's Weight Summary Log documented a 3.3-pound loss in 20 days, from 124 pounds on 6/29/17 to 120.7 pounds on 7/18/17. On 7/17/17 at 12:39 pm, Resident #3 was observed lying in bed on his back with a neck pillow under his neck and a small blue pillow separating his ankles. Resident #3's heels were touching the bed, his feet were pointing inward towards each other, and his right foot was touching the hard material of the foot board. Resident #3 stated he had remained in this position all day because no staff had repositioned him in bed. He stated his foot really hurt and he wanted assistance with repositioning. He stated he was totally dependent on staff for almost everything. Resident #3 stated staff did not reposition him frequently enough and that he was lucky if he saw staff 2 - 3 times a day. Resident #3's right hand was contracted with the fingers closed in a fist. The resident stated he was right hand dominant, but he could not open his right hand. Resident #3's bed was positioned against the wall of his left side. Resident #3 stated staff always took his extra pillow away during the day despite his desire to have pillows behind his head and body. Resident #3 stated he was supposed to have showered the previous Friday, but that he had been forgotten, and that the facility forgets him often on shower day. Resident #3 stated he enjoyed receiving showers. On 7/17/17 at 12:41 pm, CNA #6 entered Resident #3's room and assisted Resident #3's roommate. At 12:53 pm, CNA #6 entered Resident #3's room and emptied his urinal, but did not offer to reposition Resident #3 or float his heels. On 7/17/17 at 1:00 pm, Resident #3 activated his call light, which was answered by CNA #3 and CNA #6 at 1:08 pm. Resident #3 stated his right foot really hurt and he needed help moving up in bed. CNA #3 and CNA #6 assisted Resident #3 with repositioning. The resident's 3rd, 4th, and 5th toes on the right foot presented with a 1 centimeter (cm) rectangular dark red area on each toe. CNA #3 stated, You need a pillow under your feet to make sure your heels are floating to prevent skin breakdown. On 7/17/17 at 1:15 pm, two surveyors observed a 1 cm dark red area on each of Resident #3's 3rd, 4th, and 5th toes on the right foot. On 7/17/17 at 4:55 pm, Resident #3's heels were observed touching the bed with the pillow used earlier to float his heels next to the wall. The resident stated the nurse who applied lotion to his feet did not replace the pillow to its original position. On 7/18/17 from 4:06 am to 4:27 am, Resident #3 was observed in bed on his back without a pillow floating his heels or behind his back. On 7/18/17 from 5:40 am to 8:26 am, Resident #3 was observed in bed with no changes to his positioning. The resident was awakened by Licensed Nurse (LN) #2, who entered the room to administer morning medications, but soon left the room to retrieve the medications. At 8:26 am, Resident #3 stated staff often did not come in and reposition him at night. Resident #3's feet were observed in contact with the bed and not floated. On 7/18/17 at 8:31 am, LN #2 returned to Resident #3's room with medications and lotion for the resident's feet and face. LN #2 administered the medications and applied lotion, but did not offer to reposition him or attempt to float his heels. On 7/18/17 from 8:40 am to 9:08 am, CNA #4 was observed assisting Resident #3 with breakfast in bed. When CNA #4 finished assisting Resident #3 with his meal she neither offered to reposition him nor attempted to float his heels. On 7/18/17 at 9:16 am, CNA #4 was observed checking Resident #3's blood pressure, pulse, and blood-oxygen saturation. CNA #4 did not offer to reposition or attempt to float his heels. On 7/18/17 at 9:23 am, Resident #3 told CNA #4 he did was not showered on his scheduled day the previous Friday and asked asked when he would receiving a shower, telling the CNA he wanted to be sure he was not forgotten again. CNA #4 stated she would check with the shower aides. CNA #4 then left the room without first offering to reposition or float his heels. On 7/18/17 at 11:21 am, Resident #3 was observed lying in bed on his back with a neck pillow under his neck and a small blue pillow separating his ankles. Resident #3's heels were in contact with the bed and his feet were pointing inward towards each other. There were no other pillows on the bed. Resident #3 stated he just returned from his shower and said he had been placed in the same position as before his shower. Resident #3 stated his right arm was aching and that he wished it was positioned differently. No staff members were observed offering to reposition Resident #3 or float his heels from 11:21 am to 12:00 pm. On 7/18/17 from 12:38 pm to 12:43 pm, Resident #3 was observed in bed with no changes. At 12:43 pm, LN #2 provided Resident #3 with pain medications, but did not offer to reposition or float his heels. On 7/18/17 from 12:44 pm to 1:06 pm, Resident #3 was observed in bed with no changes. At 1:06 pm CNA #4 and LN #6 offered to reposition Resident #3 and placed a pillow behind his back. The staff members did not attempt to float his heels. On 7/18/17 at 1:15 pm, Resident #3 said the assistance he received at 1:06 pm was the first that staff had repositioned him that day. On 7/19/17 at 5:25 am, Resident #3 was observed lying in bed on his back with a neck pillow under his neck, pillows covering his face, and a small blue pillow separating his ankles. Resident #3's heels were in contact with the bed and his feet were pointing inward towards each other. On 7/19/17 at 9:15 am, Resident #3 was observed lying in bed on his back with a neck pillow under his neck and a small blue pillow separating his ankles. Resident #3's heels were in contact with the bed and his feet were pointing inward towards each other. There were no other pillows on his bed. Resident #3 stated he was not sure if he was always offered three meals a day. He stated there might have been days when he was asleep for dinner and was not awakened for the meal. Resident #3 stated he knew he had lost weight while in the facility and that he did not like how the staff seemed to forget him by not providing showers, fluids, food, repositioning and adult brief changes. He stated it made him feel worthless and sometimes he wishes he was dead. He stated his legs and arms would start hurting severely because he could not move them himself. He stated he was dependent on staff for all ADLs and that just because he could not perform ADLs without help did not mean he should be forgotten. On 7/19/17 at 4:39 pm, the Director of Nursing Services (DNS) stated staff should reposition Resident #3 every two hours minimally and offer fluids with every contact. The DNS stated staff did not inform her about the reddened areas on Resident #3's toes and she was not aware that he was not repositioned on a routine schedule. She stated Resident #3's feet should be floated for skin protection while he was in bed, and that he should be showered each Tuesday and Friday. The DNS stated she could not determine whether Resident #3 received adequate nutrition or hydration. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's quarterly MDS assessment, dated 5/1/17, documented severe cognitive impairment and total dependence upon staff for bathing and other ADLs. Resident #2's ADL Care Plan, dated 1/24/17, documented he was to receive a shower twice a week and required total care. Resident #2's CNA Bathing Sheets from 5/1/17 through 7/19/17 documented the resident was not showered on scheduled days from 6/8/17 to 6/16/17 (8 days), 6/16/17 to 6/27/17 (11 days), 6/27/17 to 7/4/17 (7 days) and 7/11/17 to 7/19/17 (8 days). The Bathing Sheets did not document consistent offers to bathe or whether the resident was reapproached on any of the 3 occasions he refused to shower/bathe. On Tuesday (shower day) 7/18/17 at 4:55 pm, Resident #2 was observed in the dining room with greasy hair and a notable urine odor emanating from him. On 7/19/17 at 4:39 pm, the DNS stated Resident #2 should be showered each Tuesday and Friday. 3. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's quarterly MDS (Minimum Data Set) assessment, dated 5/30/17, documented severe cognitive impairment, delusions, and staff assistance required for bed mobility, transfers, dressing, and hygiene. The MDS documented the resident was at high risk for developing skin-related issues and defined high risk as needing frequent repositioning, pressure reducing devices, floating of heels, nutrition, and moisture management. A Chronic Pain Care Plan, dated 12/19/11, documented Resident #1 was non-weight bearing and required staff assistance with mobility and repositioning. An ADL Care Plan, dated 12/19/11, documented Resident #1 required full assistance with bed mobility and positioning, eating, incontinent care and locomotion. The care plan stated the resident was to be turned and repositioned at least every 2 hours, assessed for incontinence every 2 hours, and provided pericare as needed. Certified Nursing Assistant (CNA) ADL Flowsheets from 5/1/17 through 7/18/17 documented Resident #1 required extensive assistance for bed mobility and transfers, but did not include documentation that Resident #1 was being repositioned or the frequency of repositioning. Bath Sheets from 6/1/17 to 7/10/17 documented staff did not bathe/shower Resident #1 from 6/21/17 to 7/10/17, with refusals recorded for 6/28/17 and 7/5/17. The Bath Sheets did not document whether the resident was reapproached following the refusals. Food Intake Sheets for 5/1/17 through 7/18/17 did not document staff offered Resident #1 assistance during meals on a consistent basis. The Food Intake Sheets documented Resident #1 refused breakfast 53 of 71 opportunities, lunch 17 of 71 opportunities, and dinner 11 of 70 opportunities. Resident #1's record did not include documentation she was offered alternative meals, additional snacks, or nutritional supplements during this period. A Weight Summary Log documented Resident #1 weighed 150 pounds on 5/31/17, 148 pounds on 6/21/17, and 144.8 pounds on 7/5/17. On 7/19/17 at 10:30 am, the DNS stated the Food Intake Sheets documented Resident #1 refused most breakfasts, noting Resident #1 often slept late in the morning. The DNS was unable to determine whether Resident #1 was reapproached when bathing/showering was refused and that the 20-day span staff did not bathe/shower the resident was unacceptable.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure adequate supervision was provided for residents at risk for falls. This was true for 2 of 4 residents (#1 & #5) reviewed for falls and resulted in harm to Resident #1, who sustained a fractured leg and hand, and other injuries requiring hospitalization from a fall in the dining room. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's quarterly MDS (Minimum Data Set) assessment, dated 5/30/17, documented severe cognitive impairment, delusions, bowel/bladder incontinence, and staff assistance required for bed mobility, transfers, dressing and hygiene. A Risk For Impaired Skin Integrity Care Plan, revised 11/13/16, documented Resident #1 had both urinary and bowel incontinence and directed staff to offer toileting and monitor possible incontinence every two hours. A Chronic Pain Care Plan, revised 11/20/16, directed staff to complete a pain assessment for Resident #1 every shift and apply topical medication to her knee every 6 hours as needed for arthritis pain. A Falls Care Plan, revised on 11/13/16, documented staff was to assist Resident #1 with all transfers in- and out of bed. The Care Plan did not include interventions related to the prevention of falls from a wheelchair. An Incident Report, dated 7/5/17 and revised 7/14/17, documented Resident #1 fell from a wheelchair to the dining room floor at 1:41 pm. The Report documented Resident #1's fall was due to weakness/fainted. Res(ident) had sudden onset weakness, slumping to right side in chair and leaning forward in w/c (wheelchair) when overbalanced and fell to floor. Res(ident #1) was in dining room leaning in chair and fell forward hitting face/head on floor landing on left hip/side. Nursing was immediately notified and assessment started. Pressure held to stop nose bleed, skin tear cleansed and treated. Due to limited ROM (Range of Motion) in LLE (left lower extremity), order obtained, records copied and 911 was called to transport res(ident) to emergency room . MD and family notifications complete. The 7/5/17 Incident Report documented LN (Licensed Nurse) #1, who was assigned to care for Resident #1 that day, completed the report, however LN #1 stated on 7/18/17 at 9:48 am that she did not witness Resident #1's fall. A 7/5/17 emergency room Provider Note documented Resident #1 sustained a fracture of the right hand and lower left leg, and she presented with a hematoma to the right forehead and a skin tear with bruising to the right hand. A written statement from a State Ombudsman, dated 7/13/17, documented a video at the facility from the main dining room on 7/5/17 documented staff had very brief contact with Resident #1, who was left in the dining room unattended for approximately 7 hours (Please refer to F223). The Ombudsman documented Resident #1's head was dropping to the table and back to the chair. Approximately 10 minutes prior to the fall, Resident #1 was rocking side to side in her wheelchair before she leaned to the left side, reached down to the floor as if to retrieve an object and fell to the floor. Resident #1 was described as not having any visible movement once she was on the floor. The Ombudsman reported the response by nurses to Resident #1's fall was rather slow and staff appeared uncertain as how to clinically respond to the event. On 7/17/17 at 1:33 pm, the 7/5/17 video from 6:00 am to 2:10 pm was reviewed with the Administrator and Director of Nursing Services (DNS). During the 7 hours Resident #1 was in the dining room, it did not appear she was offered toileting assistance, physician-ordered supplements, fluids, or repositioning. The video did not include any meaningful interaction between Resident #1 and staff, nor was the resident assessed for pain or offered medications. During the observation of the video, the DNS stated LN #1 was assigned to Resident #1 and did not come into the main dining room during the time Resident #1 was there. On 7/19/17 at 10:30 am, the DNS stated Resident #1 was not offered toileting assistance and pain assessments were not performed. The DNS stated there was confusion that day regarding nursing staff assignments and Resident #1's toileting, personal care, and pain assessments were not provided prior to the resident's fall in which she sustained a fractured left leg and right hand, as well as a hematoma to her face and a skin tear with bruising to her right hand. Refer to F223 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's Admission MDS assessment, dated 6/19/17, documented moderate cognitive impairment and history of falls prior to admission. A Convulsions and History of Falls Care Plan, dated 7/14/17, documented staff was to monitor Resident #5 for convulsions, ensure her safety, record the length of time during the convulsions, complete neuro checks if there was a potential for head injury, and report convulsions to the physician. The care plan did not include interventions to prevent falls from a wheelchair or what safety measures should be in place for seizures. An Activities of Daily Living (ADL) Care Plan, initiated 6/12/17, documented Resident #5 required the assistance of 1 staff for transfers. A 6/18/17 (11:00 am) Incident and Accident Report (I&A) documented Resident #5 lost her balance, fell , and bumped her head on the way to her bathroom. The report documented the resident sustained [REDACTED]. The I&A documented neurological checks where initiated. The Admission Fall Assessment Report, dated 6/18/17 at 11:42 am, documented Resident #5 had a history of [REDACTED]. She was identified at moderate risk for falls. The Admission Fall Assessment Report was completed 6 days after admission and after Resident #5 sustained a fall at the facility. Resident #5's clinical record did not contain evidence her care plan was updated following the 6/18/17 fall or Admission Fall Assessment report. A Nurse's Note, dated 6/24/17 at 3:47 am, documented, Resident had a seizure after supper . Resident had to be lowered to the floor as she began to have a seizure lasting 2-3 minutes . Resident c/o (complained of) black out periods . spots before her eyes . headaches . Resident had two seizures during the day shift. Resident #5's clinical record did not contain evidence that her care plan was updated, interventions implemented, or neurological checks initiated following three seizures on 6/23/17. A Nurse's Note, dated 6/25/17 at 3:47 pm, documented Resident #5 was FOF (Found on floor) with seizure like activity. The note documented Resident #5 complained of a headache and neurological assessments were initiated. Resident #5's clinical record did not contain evidence that her care plan was updated, interventions implemented, the physician notified, or whether an I&A was completed. On 7/18/17 at 2:56 pm, the DNS stated she did not complete an I&A for the 6/25/17 incident because Resident #5 was lowered to the floor during the seizure. She could not explain why a Nurse's Note documented the resident was found on the floor. A 7/2/17 (7:45 pm) I&A documented Resident #5 fell in her room while trying to transfer from a wheelchair to her bed. The report documented the resident hit her head and her back, which caused an injury to the top of her scalp and complaints of a headache. The I&A documented staff were transferring Resident #5 from a lying to a sitting position when she began to seize. Following the seizure, the I&A documented, Resident #5 exhibited slow and garbled speech. The I&A documented neurological checks were initiated and Resident #5 was transferred to a hospital. Following the 7/2/17 fall, Resident #5's clinical record did not contain evidence that the care plan was updated, interventions implemented, or that the facility performed timely post-fall risk assessments for Resident #5 to determine the cause of the fall and how to prevent future falls. A quarterly Fall Assessment, dated 7/10/17, documented Resident #5 was at moderate risk for falls related to the same identified issues as the Admission assessment. A Nurse's Note, dated 7/11/17 at 10:07 pm, documented Resident #5 experienced a seizure at 11:00 am and was assisted to the floor as she was sliding out of her wheelchair. The note documented Resident #5 complained of a headache after she regained consciousness. Following the 7/11/17 seizure, Resident #5's clinical record did not contain evidence that her care plan was updated, interventions implemented, or that the physician was notified. A 7/15/17 (9:05 pm) I&A documented Resident #5 fell while walking out of her bathroom and hit her eye on the sink. The report document another resident in the facility was looking for a nurse because she saw Resident #5 on the floor. The I&A documented neurological checks where initiated. Following the 7/15/17 fall, Resident #5's clinical record did not contain evidence that her care plan was updated, interventions implemented, or that the facility performed timely post-fall risk assessments for Resident #5 to determine the cause of the fall and how to prevent future falls. A Nurse's Note, dated 7/16/17 at 10:23 am, documented Resident #5 had no significant changes in behavior r/t (related to a) fall this am (morning). Following the 7/16/17 fall, Resident #5's clinical record did not contain evidence that her care plan was updated, interventions implemented, the physician notified, neurological checks initiated and/or that an I&A was completed. A 7/16/17 (9:14 pm) I&A documented Resident #5 fell while walking out of her bathroom and hit her head at approximately 8:30 pm. The I&A documented neurological checks where initiated. Following the 7/16/17 fall, Resident #5's clinical record did not contain evidence that the care plan was updated, interventions implemented, or whether the facility performed timely post-fall risk assessments for Resident #5 to determine the cause of the fall and how to prevent future falls. A Behavior Note, dated 7/17/17 at 10:20 am, documented Resident #5 was concerned with the number of falls she had experienced. The note documented she gets up by herself without help because she could not get aides there fast enough. On 7/17/17 at 5:14 pm, Resident #5 stated she had experienced multiple falls, which the facility had not addressed until that day. She stated she often activated her call light for assistance, but staff would not respond fast enough. The resident stated she wanted a fall mat, but the facility had not offered one. Resident #5 stated she would also like a transfer pole, which had been offered to her that day. Resident #5's clinical record did not contain evidence that the facility had discussed her falls with her and different interventions attempted until 7/17/17. The facility failed to ensure Resident #5 was provided sufficient supervision and care plan updates to prevent repeated falls. The facility failed to perform timely post-fall risk assessments for Resident #5 to determine the cause of the fall as well as how to prevent future falls, and failed to consistently notify Resident #5's physician of the seizures and falls.

Based on record review, resident and staff interview, and review of facility policies and Incident Reports and investigations, it was determined the facility failed to ensure 3 of 6 (#1, #5, and #6) sampled residents were free from all forms of abuse, including verbal and mental abuse. Specifically: a) Resident #1 sustained psychosocial harm when she was verbally and mentally abused by the Regional Vice-President of Operations (RVPO), when he threatened her in a loud derogatory manner, with involuntary discharge from the facility. Following the abuse Resident #1 began to exhibit physical assault, socially inappropriate behavior, and refusal of meals and cares, and her incidents of verbal assault increased. Resident #1 was remained visibly upset when interviewed on 4/12/17, and continued to cry during daily counseling sessions when recounting the abuse. b) When the investigation into the abuse of Resident #1 identified potential abuse of Residents #5 and #6 by the RVPO, the facility did not interview, or otherwise review, all residents in the facility to identify, or rule out, further abuse. c) Resident #5 was at risk of psychosocial harm when the RVPO confronted her and the Activity Aide and told them the activity they were engaged in was stupid and when Resident #5 asked who he was, his response to her was I'm the donut man. Resident #5 reported she was very upset by the interaction. d) Resident #6 was at risk of psychosocial harm when the RVPO threatened her with discharge from the facility if she did not start taking showers, as the smell was offending other residents. Resident #6 reported she was ashamed and afraid she would have to leave the facility. The above deficient practices placed all 38 residents residing in the facility at risk of abuse. Findings include: The facility's Abuse Prohibition Policy and Procedure, revised 11/21/16, defined verbal or mental abuse as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents .examples include humiliation, threats of physical abuse or deprivation, or use of derogatory names. The policy documented the facility would not tolerate any abuse of a resident. 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Initial Minimum Data Set assessment, dated 3/23/17, documented Resident #1 had moderate cognitive impairment and exhibited moderate-to-severe signs of depression. Resident #1's Behavior Care Plan, dated 3/28/17, documented she experienced frustration and became destructive towards property when she was not understood by staff. Interventions directed staff to: * Offer and assist her to call a family member * Sit and visit one-on-one with her * Take her for a walk, weather permitting * Offer her a hug. A Behavior Tracking Log documented that between 3/23/17 and 4/2/17 (11 days), Resident #1 displayed 5 episodes of verbal assault. Resident #1's Nurse's Notes and Behavior Tracking Log, between 3/21/17 and 4/2/17, did not include documentation that she refused meals or cares, or attempted physical aggression towards staff. There was a 3/23/17 Nurse's Note which documented she threw an item at a staff member when she first arrived at the facility. Resident #1 threw something at staff when admitted and engaged in verbal assault 5 times, and no other behaviors were documented between 3/23/17 and 4/2/17. A 4/10/17 Incident Report documented that on 4/3/17, Resident #1 had a verbal outburst and was brought into the DNS' office to de-escalate. A staff member, (RVPO) upon hearing of the resident's outburst, came into the office to assist. The staff member (RVPO) became loud and forceful in his attempts to help the resident; informing (Resident #1) of discharge from the facility if the resident wasn't able to calm herself. The resident did calm down, but was visibly upset by the encounter. Even though the outcome had the desired result of calming the resident, we elect to report and investigate the incident as potential abuse due to the staff member's raised voice and posturing. The Report concluded the RVPO had verbally and mentally abused Resident #1. Behavior Tracking Logs for 4/3/17 through 4/12/17 (10 days) documented Resident #1: * Experienced refused meals or cares on 8 occasions after 4/3/17. * Experienced 18 episodes of depression after 4/3/17. * Displayed 30 incidents of verbal assault after 4/3/17. * Attempted physical assault 10 times after 4/3/17. * Exhibited 18 incidents of socially inappropriate behavior after 4/3/17. A 4/8/17 Speech Therapy Note, documented Resident #1 appeared despondent and .depressed and had exhibited violent behavior toward others. On 4/12/17 at 10:36 am, Resident #1 stated, The man (RVPO) told her she was out of control and that she was going to have to go to jail. She stated the RVPO cussed at her and pointed his finger in her face. Resident #1 said she was shocked that someone would talk to her in that manner and that the incident made her feel at the end of my rope. Resident #1 stated she did not feel safe with the RVPO in the building, but was not fearful of other staff or residents in the facility. Resident #1 looked down at her folded hands and began to stammer while making these statements, and said she stammered when she was worked up. On 4/12/17 at 11:05 am, the Licensed Clinical Social Worker (LCSW) stated he provided counseling to Resident #1 daily except on weekends. The LCSW stated he believed Resident #1 had sustained psychosocial harm from the 4/3/17 incident, which she continued to cry about when recounting details in her counseling session as it reminded her of other abuse issues from her past. On 4/13/17 at 11:30 pm, the Director of Nursing (DNS) stated Resident #1's behaviors occurred when she could not articulate her needs to staff. She stated the Speech Therapist working with Resident #1 suggested staff use a calm voice and sit and talk to de-escalate her behaviors. On 4/13/17 at 12:21 pm, the DNS stated she had witnessed the 4/3/17 interaction between Resident #1 and the RVPO. The DNS stated that at approximately 10:00 am she heard Resident #1 yelling loudly and swearing. She approached Resident #1, saw that her hands were clenched and her jaw tense, and asked the resident to come to her office to calm down. She stated LPN #1 accompanied Resident #1 into the DNS's office, where Resident #1 then began to calm down. The DNS stated Resident #1's jaw slackened, and her hands were no longer clenched, when the RVPO came into the office without knocking and stood over the DNS and Resident #1, pointed his finger, and said in a loud voice to Resident #1, What is your f*cking problem. I'm going to ship your a** out of here! The DNS stated the RVPO then turned to her and said in a loud, raised voice, You get on the phone to the doctor and get her out of here; I don't care where, the hospital, away, or locked up! The DNS stated the RVPO told her to take Resident #1 to the shower and shook Resident #1's hand before excusing her and the DNS. The DNS stated she took Resident #1 to her room and went to check whether the shower was available. The DNS said that when she re-entered the resident's room, Resident #1 was rocking back and forth and crying. The DNS stated she was shocked that he (RVPO) was yelling and threatening a resident. She said the RVPO told her that this speak in a calm, quiet voice, and get at their level, is ineffective sh*t. You need (to) get above them, shock them and get their attention, and then let them know what you want. On 4/13/17 at 4:45 pm, the LCSW stated the Chief Operations Officer assigned him the task of interviewing 10% of the resident population as part of the investigation into the above verbal abuse of Resident #1. The LCSW provided a copy of five interviews he conducted with residents on 4/7/17. Two of the five residents interviewed described derogatory and demeaning statements made to them by the RVPO. They included: * Resident #5 stated the RVPO confronted her and an Activity Aide and said the activity they were both engaged in was stupid. When Resident #5 asked the RVPO who he was, the RVPO responded, I'm the donut man. Resident #5 stated she was very upset by the RVPO's response and asked the Activity Aide why the RVPO had treated her like she was stupid. * Resident #6 stated the RVPO told her she would need to leave the facility unless she showered because her smell was offending other residents. Resident #6 stated she felt ashamed and afraid she was going to have to leave (the facility) as a result of the RVPO's comments. When the investigation into the abuse of Resident #1 identified potential abuse of Residents #5 and #6 by the RVPO, the facility did not interview, or otherwise review, all residents in the facility to identify, or rule out, further abuse. The facility failed to ensure residents were free from abuse.

Based on observation, staff, family, and resident interview, record review, employee file review, employee time card reports, and review of the facility's video records, it was determined the facility failed to ensure a resident's report of mistreatment was identified as an allegation of abuse, the allegation was investigated, and residents were protected from further contact with the alleged perpetrator. The deficient practice directly impacted 2 of 12 sampled residents (#3 and #11). The failures placed Resident #3, Resident #11, and all residents receiving services from AA #1, in immediate jeopardy of psychological and/or physical abuse. Findings include: Resident #3 was admitted to the facility on [DATE]. Resident #3's Quarterly MDS assessment, dated 6/20/16, documented her cognition was moderately impaired. On 9/19/16 at 2:45 pm, Resident #3 stated she was upset by the way AA #1 treated Resident #11 during a Bingo game a couple of months ago. Resident #3 stated she was sitting at a table in the dining room with Resident #11, playing Bingo, when AA #1 approached Resident #11 and took his Bingo card away in the middle of the game to give to another resident who had just joined the game. Resident #3 stated when she objected to the removal of the card, AA #1 stated, It doesn't matter. He (Resident #11) doesn't know how to play anyway. Resident #3 stated when she continued to object, AA #1 became angry, began to point her finger in Resident #3's face, and told her she could either calm down or leave the activity. Resident #3 stated when she refused to leave, AA #1 came closer to her, and began to pound on the table and she was yelling at me. Resident #3 stated she stayed in the activity for a few minutes, but was so upset she left to call a family member. Resident #3 stated, (Resident #11) shouldn't be treated like that. And (AA #1) shouldn't have yelled at me. On 9/19/16 at 3:00 pm, Resident #3's family member stated she remembered the day of the event, and identified the date as Friday 7/22/16. Resident #3's family member stated Resident #3 was so upset when she called that the family member immediately came to the facility, and went with Resident #3 to talk to the RSM. The family member stated the RSM assured them she would take care of this, and that AA #1 left the building shortly after the report was made, but she was back at work the following Monday morning, as usual, and nothing happened. The family member stated, They caught it all on the video camera they have in the dining room. The family member stated she repeatedly went to the Administrator to report a concern that both Resident #3 and Resident #11 had been abused during this event, and to ask what had been done to follow up. The family member stated she could not get a response as to the results of the facility's investigation into the incident. There was no documentation of this report in Resident #3's clinical record, Resident #11's clinical record, the facility's grievance file, or the facility's incident investigations. There was no documentation of this event in the State Agency's reportable incident file. On 9/20/16 at 10:00 am, the 4 residents in the Resident Group expressed concern over AA #1's conduct in the exercise group the previous day. The group stated a confused resident had tried to join the circle of residents exercising, but AA #1 would not let her into the circle. One resident stated, There was plenty of room for her, and she would do the best she could to do the same thing as the rest of us. (AA #1) should have let her in. On 9/20/16 at 10:01 am, AA #1 was observed in the dining room, preparing for an activity. AA #1 was standing less than 5 paces from a resident who was repeatedly trying to stand from his wheelchair. AA #1 was asked if the resident was safe to stand unassisted, and stated, No. But he always does that. AA #1 continued preparing for the activity without addressing the resident or summoning someone else to assist him. On 9/21/16 at 10:00 am, the AD stated she was AA #1's direct supervisor. The AD stated she was aware of a complaint regarding AA #1 in July, but was not in the facility at the time the allegation occurred. The AD stated she became aware of some kind of issue the following Monday morning (7/25/16) and, when somebody wrote her up and I had to sit in when it was presented. The AD stated she was not exactly sure what the write-up entailed, but (AA #1) said she knew she over-reacted and was annoyed towards (Resident #3). On 9/21/16 at 11:00 am, AA #1 stated she recalled the event. AA #1 stated when she conducted a Bingo game in the facility, all of the residents playing had to have the same color of cards so as to not have duplicates. AA #1 stated Resident #11 was sitting at a table that day with a Bingo card, but was not playing the game correctly. AA #1 stated shortly after the game started, another resident wanted to join, and could play the game correctly, so AA #1 took the Bingo card from Resident #11 and gave it to the other resident. AA #1 stated this action caused Resident #3 to become upset. AA #1 stated, The rule is, if a resident becomes upset in an activity they have to leave, so I told her to calm down or leave. I got angry, and you could see it in my face, but I didn't yell at her. It was investigated. and all they found out was that I was angry. I know that wasn't right. During the above interview, AA #1 stated the resident was barred from joining the exercise class, as described by the Resident Group, because she rocks back and forth in her wheelchair and might bump into someone. I had her sit at a table across the room and watch. On 9/21/16 at 12:55 pm, the current Administrator stated he had only been working in the facility for 20 days, and was not familiar with the event. The Administrator stated he would look to see if the facility had done an investigation, and any resulting employee actions. The Administrator looked in AA #1's personnel file and found a Documented Penalty for a Class 2 Offense form, dated 7/27/16. The form documented AA #1 received a Final Written Warning. Three of 23 potential violations were circled, with hand-written explanations of each. One of the violations selected was, Inconsiderate care of any resident/patient of the facility not considered by management to be abuse. A hand-written explanation documented, Mishandled situation during an activity causing it to escalate. The Supervisor Comments area of the form documented, Emphasis must be on professional attitude (and) body language. The form was signed by the facility's previous Administrator, the AD, the DNS, and AA #1. There was no documentation as to the nature of the inconsiderate care, which resident or residents were impacted, when it occurred, how abuse was ruled out, or whether AA #1 was suspended while the issues were investigated. On 9/21/16 at 1:30 pm, the RSM stated she remembered getting a report from one of the nurses that, (Resident #3) was upset with (AA #1). The RSM stated the DNS and Administrator did interviews, and did an education with AA #1. At 1:45 pm, the RSM stated she recalled talking to Resident #3 and her family member the day of the event. The RSM stated Resident #3's family member reported AA #1 was in (Resident #3's) face, and that Resident #3 was so upset at the time she had to go outside to try to calm down. The RSM stated she did not know whether or how the facility ruled this out as an allegation of abuse. The RSM stated she believed she suspended AA #1 at the time, although did not document the suspension. The RSM stated she was not AA #1's immediate supervisor or the facility's abuse coordinator, and was not authorized to suspend AA #1. The RSM stated she did not document the interaction with Resident #3 or her family member in Resident #3's clinical record or on a grievance form. The RSM indicated she did not know where it would be documented that AA #1 was removed from resident contact or suspended when the allegation was received. AA #1's Individual Employee Time Card documented she worked until 4:24 pm on Friday, 7/22/16; returned to work on Monday, July 25 at 9:24 am; and worked the remainder of the work week. The Time Card documented AA #1 worked Monday through Friday throughout the month of August, 2016. In September 2016, AA #1's Time Card documented she worked 9/1/16, 9/2/16, 9/12/16 - 9/16/16, and 9/19/16 - 9/21/16. On 9/21/16 at 1:35 pm, the DNS stated she recalled that the event was reported to her, as the former Administrator was on vacation at the time. The DNS stated she viewed the video from the event. The DNS stated her recollection was that Resident #11 was sedated, and that there was, a transition of (Bingo) cards for some reason just beforehand. The DNS recalled AA #1 approached Resident #3 with her hand out, but the facility ruled out abuse. The DNS stated, We couldn't show intent, just bad body language. The DNS stated if there was an investigation, the former Administrator would have kept that information. The DNS stated she thought the former Administrator had conducted an investigation into the event, and would look for the documentation. On 9/21/15 at 1:50 pm, the DNS stated she could not find evidence that the allegation had been investigated. The DNS stated her recollection was that Resident #3 did not seem scared or intimidated when the event was reported, but could not recall for sure. The DNS stated, I'm not sure why (AA #1) did what she did .I was definitely unhappy with (AA #1's) performance, and I worked as closely as I could with her supervisor. The DNS stated the former Administrator made the final decision as to how the matter should be handled. On 9/21/16 at 2:45 pm, the surveyors and the current Administrator, DNS, and Systems Consultant reviewed the video recording from the Bingo game starting on 7/22/16 at 3:00 pm. There was no audio recording of the event. The video showed AA #1 initiate a Bingo activity. Resident #3 and Resident #11 were sitting at a table together. Each had a pink Bingo card in front of them. The table was square, with Resident #11 sitting on the north side of the table, and Resident #3 to his right, on the west side of the table. AA #1 was shown moving between the table where Resident #3 and Resident #11 were sitting, and an adjacent table to the west. Resident #11 was seen sitting upright in his wheelchair, placing chips on his Bingo card. Approximately 5 minutes into the game, AA #1 approached the table where Resident #3 and Resident #11 were sitting and removed a Bingo card from Resident #11. While AA #1 took the card to a resident at the table to the west, Resident #3 turned abruptly in her chair towards AA #1 and appeared to be speaking. AA #1's back was to the video camera. AA #1 was seen to point forcefully multiple times in Resident #3's direction. Resident #3's face displayed a distressed expression, and she appeared to continue talking to AA #1. AA #1 then walked to the table where Resident #3 was sitting, and stood on the east side of the table, facing Resident #3. At this point, Resident #3's body blocked the camera's view of AA #1's abdomen. AA #1 was observed to lean forward into the table with an angry expression on her face. She reached out with her right arm, and made a repetitive, firm and abrupt pounding motion on the table in front of Resident #3. Resident #11 was also at the table. Resident #3 flinched each time AA #1 made the pounding motion on the table. Resident #3 continued to verbally respond to AA #1. The Bingo game was observed to continue for a minute or so, then Resident #3 suddenly stood and walked quickly and forcefully from the room. The video recording showed AA #1 to continue conducting the Bingo activity until 4:00 pm. On 9/22/16 at 3:00 pm, Resident #3 was in her room, seated at the edge of her bed, fidgeting and restless. Resident #3 stated, Did you see the video? Did it happened the way I remember? I worry that no one believes me or that I made it up, because I told them and told them about it and nothing happened. Resident #3 stated the current Administrator and DNS had come to talk to her on 9/21/16 and asked her about the event. Resident #3 stated, They asked me if (AA #1) yelled at me, and I told them, 'I've told you and told you. Yes, she did yell at me.' The facility's failure to recognize the allegation of abuse, investigate it, report it, and protect residents from further exposure to the identified abuser, placed Resident #3 and Resident #11 at risk of further abuse, and all residents receiving services from AA #1 at risk of abuse. Removal of Immediate Jeopardy: On 9/22/16 at 12:10 pm, the facility's Administrator was informed in writing of the immediate jeopardy and the need to develop and implement a plan to remove the immediacy. On 9/23/16 at 1:05 pm, the facility provided an acceptable removal plan and evidence the immediacy had been removed. The removal plan included: * AA #1 was suspended from duty pending a complete investigation from the event. * The facility's Abuse Prevention Policy and Procedure was updated to designate the facility Administrator as the responsible party for coordinating the investigation and reporting of all allegations of abuse, neglect, or mistreatment of [REDACTED]. * The facility's grievance policy was updated to include verbal as well as, written grievances. * All residents and family members were provided with the updates above. * All staff were in-serviced, or will be in-serviced prior to working, regarding the above policy changes. * Resident #3 and Resident #11 were assessed by the facility social worker for latent effects of the event. The facility social worker will continue to follow up with Resident #3. * All residents who attended the 7/22/16 Bingo game were interviewed for latent effects of the event. * All residents having contact with AA #1 between 7/22/16 and 9/23/16 were interviewed to rule out further allegations of abuse, neglect, and mistreatment. * All staff were interviewed, or will be interviewed prior to working again, to rule out further allegations of abuse, neglect, or mistreatment.

Based on observation, record review, review of the facility grievance file, review of accident and incident reports, and resident, family, and staff interviews, it was determined the facility failed to ensure its policies and procedures to identify, investigate, and report allegations of abuse were operationalized, training was provided to the facility Abuse Preventionist, and residents were protected from further abuse while an investigation was conducted. These deficient practices directly impacted 2 of 12 sampled residents (#3 and #11). The failures placed Resident #3 and Resident #11 and all other residents receiving services from AA #1, in immediate jeopardy of serious harm, injury or death. Findings include: The facility's undated Abuse Prevention Program Policies and Procedures, revised February 2008, documented: * Overview .The resident has the right to be free from mistreatment .verbal abuse .mental abuse .and involuntary seclusion .All reports of resident abuse, mistreatment .shall be promptly and thoroughly investigated . * Implementation .The Director of Nursing Services who is designated as the facility's Abuse Prevention Coordinator .assumes the responsibility for the overall coordination and implementation of the facility Abuse Prevention Program policies and procedures . * Identification .all employees are mandated to report immediately any signs and symptoms of abuse/neglect or suspected alleged violations to their supervisor, the Director of Nursing Services and the Director of Nursing Services (sic) .When in doubt, report it .Signs of/Actual or Potential Abuse .Involuntary Seclusion .Caregiver indifferent to resident's personal care and needs . * Investigation .All reports of resident abuse, neglect .shall be promptly and thoroughly investigated by the Director of Nursing or his/her designee .The Director of Nursing Services will provide to the person in charge of the investigation a copy of the investigation and any supporting documents relative to the alleged incident . * Protection .employees accused of participating in the alleged resident abuse .will be suspended immediately .The Director of Nursing or his/her designee will keep the resident and his/her representative informed of the progress of the investigation .The Director of Nursing shall inform the resident and his/her representative of the results if the investigation and any corrective action taken . * Reporting .When an alleged or suspected case of mistreatment .or abuse is reported, the Director of Nursing Services .shall notify .The State licensing/certification agency responsible for surveying/licensing the facility .A person shall not knowingly .Attempt .to induce another to fail to report an incident of mistreatment or other offense .Fail to report an incident of mistreatment or other offense .destroy or render unavailable a report made by another .Screen reports or withhold information to reporting agencies . The facility's Organizational Chart, dated March 2008, documented the Medical Director, DNS, and RSM answered directly to the facility Administrator. On 9/19/16 at 2:45 pm, Resident #3 stated she had witnessed AA #1 deprive Resident #11 of supplies during an activity on 7/22/16, then was intimidated and threatened with involuntary seclusion when she objected to Resident #11's treatment. Resident #3 stated she reported this event to the RSM within minutes of its occurrence, but nothing happened. Resident #3 called a family member to come to the facility and help make a report. On 9/19/16 at 3:00 pm, Resident #3's family member stated when Resident #3 called on 7/22/16, she was angry, upset, and tearful due to the event Resident #3 witnessed, and her treatment afterwards. The family member stated over the next few days and weeks, she asked the former Administrator over and over what happened, but she never told me. And (AA #1) kept working as if nothing happened. Resident #3's family member stated Resident #3 continued to be upset about the event for a number of weeks, and stopped attending activities for a while. On 9/21/16 at 11:00 am, AA #1 stated she recalled the event. AA #1 stated the former Administrator had asked her some questions afterwards and had made some notes. AA #1 stated, It was investigated, and all they found out was that I was angry. I know that wasn't right. On 9/21/16 at 12:55 pm, the current Administrator stated he had only been working at the facility for 20 days, and the allegations took place prior to his employment. The Administrator reviewed the facility's abuse investigation file, but did not find evidence of the allegations or investigation. The Administrator was unable to locate documentation the allegations had been reported to the State Agency. On 9/21/16 at 1:30 pm, the RSM stated she recalled sometime in July, one of the facility nurses came to her to report that Resident #3 was upset with AA #1. The RSM stated she told the former Administrator and the DNS about the LN's report, but that was the extent of her involvement. The RSM returned at 1:45 pm, and stated she now recalled that she was approached by Resident #3 and her family member after the LN's report. The RSM stated Resident #3 and her family member wanted to report that AA #1 had been inappropriate. The RSM stated Resident #3 was upset, and excused herself to go outside and smoke. The RSM stated after Resident #3 left, her family member reported Resident #3 was so upset because, (AA #1) was in (Resident #3's) face after she objected to the way (Resident #11) was treated. On 9/21/16 at 1:35 pm, the DNS stated she was aware of the allegation at the time it was made. The DNS stated she called the former Administrator to inform her of the allegation. The DNS stated she recalled viewing the facility's video recording of the event the following Monday (7/25/16) with the former Administrator. The DNS stated the former Administrator made the determination that abuse had not occurred and the allegation should not be reported to the State Agency. The DNS stated she believed the former Administrator had spoken to some of the staff and residents, and the documentation should be included in the facility's abuse allegations log. The DNS was unable to locate documentation of the allegation, investigation, or report to the State Agency in the facility's abuse investigation log. On 9/21/16 at 2:45 pm, two surveyors, the current Administrator, the Systems Consultant, and the DNS viewed the facility's video recording of the event. The Administrator, DNS, and Systems Consultant all stated the facility should have reported the event as an allegation of abuse, and should have conducted an investigation. On 9/21/16 at 3:00 pm, the DNS stated she had only been in her current position for approximately 3-4 months, and this event occurred shortly after she had assumed her duties. The DNS stated she was aware the facility's abuse policy designated her as the Abuse Preventionist, but she had encountered some barriers in being successful in that role. The DNS stated while she was trained on abuse recognition and reporting requirements in her role as a nurse, she had not received any formalized training on what, specifically, the role of the facility Abuse Preventionist entailed. The DNS stated she had also not received training on what needed to be reported as it pertained to the regulatory requirement of reporting allegations and investigations to the State Agency. The DNS stated the most difficult barrier to overcome, however, was the facility's organizational structure and administrative chain of command. The DNS stated she reported directly to the facility's Administrator. The DNS stated she did not necessarily agree with the way the investigation was conducted in this event, the conclusion of the investigation, or the decision not to report the allegation to the State Agency. The DNS stated the former Administrator had made it clear the decision of what and when to report was the Administrator's role. The DNS stated because the Administrator was her direct supervisor, she was concerned taking any further steps in this instance could cost her job. The DNS stated she had placed many calls to the former Administrator since the issue was brought to the facility's attention by the survey team, and had received a number of conflicting responses from that person. The facility placed all residents in immediate jeopardy of serious injury, impairment, or death when staff failed to operationalize its policies and procedures for Abuse Prevention. The facility failed to provide specialized training to their Abuse Preventionist; failed to recognize, investigate, or report allegations of abuse; and failed to protect residents from the risk of further abuse from an employee accused of abuse. Removal of Immediate Jeopardy: On 9/22/16 at 12:10 pm, the facility's Administrator was informed in writing of the immediate jeopardy and the need to develop and implement a plan to remove the immediacy. On 9/23/16 at 1:05 pm, the facility provided an acceptable removal plan and evidence the immediacy had been removed. The removal plan included: * AA #1 was suspended from duty pending a complete investigation from the event. * The facility's Abuse Prevention Policy and Procedure was updated to designate the facility Administrator as the responsible party for coordinating the investigation and reporting of all allegations of abuse, neglect, or mistreatment of [REDACTED]. * The facility's grievance policy was updated to include verbal as well as, written grievances. * All residents and family members were provided with the updates above. * All staff were in-serviced, or will be in-serviced prior to working, regarding the above policy changes. *Resident #3 and Resident #11 were assessed by the facility social worker for latent effects of the event. The facility social worker will continue to follow up with Resident #3. * All residents who attended the 7/22/16 Bingo game were interviewed for latent effects of the event. * All residents having contact with AA #1 between 7/22/16 and 9/23/16 were interviewed to rule out further allegations of abuse, neglect, and mistreatment. * All staff were interviewed, or will be interviewed prior to working again, to rule out further allegations of abuse, neglect, or mistreatment. Please also refer F225 as it relates to the above abuse allegations.

Based on observation, review of Activity Department financial records, and resident, family member, and staff interview, it was determined the facility failed to ensure sufficient supplies were provided to the activities program to help residents achieve their highest physical, mental, and psychosocial well-being. This was true for 2 of 12 sampled residents (#3 and #11), 1 random resident (#13), 4 of 4 residents who attended the resident group, and had the potential to negatively impact all resident wishing to participate in the facility's activities program. Resident #3 experienced psychosocial harm when she was intimidated and threatened with involuntary seclusion when objecting to Resident #11 being deprived of supplies during an activity. This also created the potential for all residents to experience psychosocial harm due to loss of social stimulation, inability to continue life-long hobbies and enjoyed activities, and loss of interest in activities due to lack of variety. Findings include: 1. Individual Resident Interview: a. On 9/19/16 at 2:45 pm, Resident #3 reported during a facility Bingo activity in July 2016, she observed AA #1 remove a Bingo card from Resident #11 and give it to another resident while the Bingo game was in process. Resident #3 stated when she objected to Resident #11's treatment, AA #1 spoke and gestured to her in an intimidating manner, threatened to exclude her from the remainder of the activity, and threatened her with involuntary seclusion. Resident #3 stated she reported the event to the facility, but there was no follow-up. Resident #3 stated she stopped participating in the facility's activities program for a few weeks following that event. Resident #3 stated, I still think about it. It was not fair to (Resident #11.) During the same interview, Resident #3 also reported an important aspect of her quality of life was to have a pleasant place to be outdoors. Resident #3 stated many of the other residents felt that way as well, as the facility was in a rural farming community. Resident #3 stated the residents had suggested in the spring that the facility allow them to plant flowers in pots on the facility patio. Resident #3 stated the former Administrator had told them such things were not in the budget. Resident #3 stated one of her family members ended up purchasing supplies and donating her labor in order to update the facility's patio to provide a pleasant outdoor space for residents. b. On 9/19/16 at 1:55 pm, Resident #13 stated she had recently been admitted to the facility and missed her home very much. Resident #13 was tearful as she described her adjustment to the facility. Resident #13 stated one of the things at the facility that gave her comfort was her garden. Resident #13 asked if she could show the surveyor her garden, and led the surveyor out to the patio area, where there was a lawn, flowers, garden decor, and lawn furniture. Resident #13 stated, This is the one place outside I can go by myself, where I can't get lost because there is a fence. I love my garden. 2. Resident Family Interview: On 9/19/16 at 3:00 pm, Resident #3's family member stated Resident #3 had a [DIAGNOSES REDACTED]. Resident #3's family member stated she felt Resident #3 was growing increasingly depressed as the weather turned nice in the spring, as there was nowhere at the facility to sit outside or maintain plants. Resident #3's family member stated she repeatedly requested the facility buy pots and flowers, and create a safe walking surface, in the facility's fenced-in patio area, but was told several times such expenses were not in the budget. Resident #3's family member stated, I even told them I would do all the work. But they still said no. I ended up buying everything myself and doing all the work, just for (Resident #3's) sake. But they all love it. During the same interview, Resident #3's family member stated she was upset by the event that took place between Resident #3, Resident #11, and AA #1 during the 7/22/16 Bingo game. The family member stated, (Resident #3) didn't go to activities for a long time after that. She was really bothered by what happened to (Resident #11). 3. Resident Group Interview: On 9/20/16 at 10:00 am, 4 of the 4 residents in the Resident Group Interview stated: *The facility activities program lacked variety. *There were not enough activities in the evening. *They activities program was repetitive, with the same games over and over. One resident stated, I used to like the games. But we've been playing the same ones for so long it just gets old. I asked them to get new games, but they just keep saying it's not in the budget. *There were not enough supplies for all residents who wanted to participate in activities, and the supplies available were worn or in disrepair. *When the residents made suggestions for greater variety of activities, requested updated supplies, or asked for outings or outdoor activities, but were always told, It's not in the budget. *The residents stated someone had to donate money and time to make the facility's patio area safe and enjoyable, as the facility did not respond to their request for an outdoor area for activities. 4. Staff Interviews: a. On 9/21/16 at 10:00 am, the AD stated she was aware the residents were unhappy with the availability of supplies for activities, but her budgetary restrictions made developing and maintaining a program difficult. The AD stated, I've been through the course and got my certification to be an activities director, and I know what I should be doing, but I just can't with the budget they've got me on. The AD stated her budget for the facility activities program was $100.00 per month, but she did not always get the money every month, nor was there a set day of the month when she received the money. The AD stated, The money comes from (the facility's) petty cash, and I only get it when there's money there, which is not every month. Sometimes I don't get any money, and sometimes I get less than the $100. The AD stated the activities budget had to cover special snack items requested by the residents, as the facility kitchen would only supply brownies, ice cream, or pies, and the residents get tired of the same stuff all the time. The AD stated the Activities budget also had to cover decor for the rooms of residents who did not have family to bring in personal items, and prizes for the Bingo games. The AD stated, I try to make it stretch as far as I can, but by the time I pay for all that other stuff, I don't have money left over for new supplies. And that's even if I get the activity budget every month, which I don't. Many times, I go to yard sales to see what I can find, and I use my own money. It's really hard to try to do everything I know I should be doing. On 9/21/16 at 11:30 am, the AD provided her Monthly Spend Down ledger for the past year. Between 9/1/15 and 9/21/16, the facility had provided a total of $900 as follows: * 10/6/15, for the month of October 2015, $100. * 12/21/15, for November and December 2015, $200. * 1/19/16, for January 2016, $100. * 2/25/16, for partial February 2016 budget, $60. * 3/19/16, for rest of February and March 2016, $140. * There was no allowance for April 2016. * 5/23/16, for May 2016, $100. * 8/19/16, for June, July, and August 2016, $200. This was 1/3 less than should have been provided, per the budget described by the AD, and there was no record of monies being received for Activities for September 2016. b. On 9/21/16 at 11:00 am, AA #1 stated there were not always enough Bingo cards for every resident who wanted to play. AA #1 recalled the Bingo game from 7/22/16 with Resident #3 and Resident #11. AA #1 stated she had removed Resident #11's Bingo card because he wasn't playing the game correctly, and there were no more Bingo cards available. When another resident joined the game who could play correctly, AA #1 stated, I needed (Resident #11's) card for another resident, so I took it. c. Administrative Interview: On 9/21/16 at 12:55 pm, the current Administrator stated he had only been working in the facility for 20 days, and had not yet had a chance to review the Activities budget. The Administrator stated he did not think $100 per month would be enough to fund the Activities program, and he would review that figure to make sure the facility Activities program had sufficient funding.

Based on observation, resident, family member, and staff interview, and review of clinical records and a facility video recording, it was determined the facility failed to ensure the provision of medically-related social services. This was true for 1 of 6 residents (Resident #3) sampled for social services. Resident #3 was harmed when the facility did not assess her psychosocial status following an allegation of abuse, or monitor for ongoing emotional needs after the allegation. Findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 9/19/16 at 2:45 pm, Resident #3 stated she was upset by the way AA #1 treated Resident #11 during a Bingo game a couple of months ago. Resident #3 stated she was sitting at a table in the dining room with Resident #11, playing Bingo, when AA #1 approached Resident #11 and took his Bingo card away from him in the middle of the game to give to another resident who had just joined the game. Resident #3 stated when she objected to the removal of the card, AA #1 stated, It doesn't matter. He (Resident #11) doesn't know how to play anyway. Resident #3 stated when she continued to object, AA #1 became angry, began to point her finger in Resident #3's face, and told her she could either calm down or leave the activity. Resident #3 stated when she refused to leave, AA #1 came closer to her, and began to pound on the table and she was yelling at me. Resident #3 stated she stayed in the activity for a few minutes, but was so upset she left to call a family member. Resident #3 stated, (Resident #11) shouldn't be treated like that. And (AA #1) shouldn't have yelled at me. On 9/19/16 at 3:00 pm, Resident #3's family member stated she remembered the day of the event, and identified the date as Friday 7/22/16. Resident #3's family member stated Resident #3 was so upset when she called that the family member immediately came to the facility, and went with Resident #3 to talk to the RSM. The family member stated the RSM assured them she would take care of this, and that AA #1 left the building shortly after the report was made, but she was back at work the following Monday morning, as usual, and nothing happened. There was no documentation of Resident #3's concern in her clinical record, the facility's grievance file, or incident reports. On 8/5/16 at 1:17 pm, a Resident Services (Social Services) Progress Note in Resident #3's record documented, Monthly behavior note - (Resident #3) has had episodes of verbal aggression, nonadherence, hallucinations, and attempted trespass since the last review .getting agitated and becomes aggressive with staff .attends activities that she likes and can tolerate .refuses most group activities . This was the only Resident Services progress note in Resident #3's record between 7/22/16 and 9/20/16. On 9/20/16 at 10:00 am, Resident #3 stated she was upset with the way the RSM had reacted to the report she made of the 7/22/16 Bingo game. Resident #3 stated, She didn't believe me, and as much as told me so. She made me feel like I was crazy for even saying anything about it. On 9/21/16 at 1:45 pm, the RSM stated she remembered Resident #3 and her family member coming to her office to let her know of the event that took place during the 7/22/16 Bingo game. The RSM stated she told the DNS about the event, but that was the extent of her involvement. The RSM stated she did not feel the need to follow up with Resident #3 about the event. On 9/21/16 at 1:50 pm, the Administrator, DNS, Systems Consultant, and 2 surveyors viewed the video recording of a 7/22/16 Bingo game. The recording was consistent with Resident #3's description of the event. On 9/22/16 at 3:00 pm, Resident #3 was in her room, seated at the edge of her bed, fidgeting and restless. Resident #3 stated, Did you see the video? Did it happened the way I remember? I worry that no one believes me or that I made it up, because I told them and told them about it and nothing happened. Resident #3 experienced psychosocial harm when she reported an allegation of abuse towards both herself and Resident #11, with no social services assessment, monitoring, or follow-up.

Based on observation, resident and staff interview, and record review, it was determined the facility failed to ensure pressure ulcers did not develop in the facility and interventions to promote the healing of pressure ulcers were initiated and monitored for effectiveness. This was true for 2 of 6 residents (#1 and #2) sampled for pressure ulcer prevention. Resident #1 was harmed when she developed an unstageable pressure ulcer to her left heel. Resident #2 had the potential for harm when she was not repositioned as her care plan instructed. Findings include: Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 had a history of [REDACTED]. Resident #1's quarterly MDS assessment, dated 7/15/16, documented Resident #1 had short term and long term memory impairment; rejected cares 1-3 days in the past 7 days; was dependent on 2 persons for bed mobility and transfers using a Hoyer Lift; and had impaired ROM to both lower extremities. The MDS identified Resident #1 as being at risk of pressure ulcers. A nursing note on 7/15/16 documented Resident #1 had no ability to move her lower extremities. Resident #1's Care Plan documented she was at risk for pressure ulcers related to her refusal to change positions, refusal of treatments, and refusing baths. Resident #1 had a history of [REDACTED]. The Care Plan goal documented Resident #1 would have no areas of skin breakdown due to her refusal of cares. Interventions in place as of 7/15/16, included complete body assessment weekly per LN, notify LN of refusals to reposition or bathe, LN to educate on risks caused by her refusal, use of a bariatric alternating low air loss bed, and the LN was to check Resident #1's weight and the air bed settings daily. Nursing notes, dated from 8/10/16 through 9/21/16, documented Resident #1 refused showers, vital signs, meals, and repositioning, at times on a daily basis. Resident #1's medical record did not document investigation of the reasons for her refusals, or what interventions were implemented to try to overcome them. On 8/31/16 Resident #1's TAR documented her skin was intact. On 9/6/16 at 3:09 pm, a nursing note documented Resident #1's skin assessment was completed as scheduled and there was a new skin issue observed to her left heel. The area was documented to have discoloration and a mushy appearance. There was no drainage at the site and the area was unopened. The physician was notified and orders to have the WOCN evaluate Resident #1 were received. The Wound or Pressure Sore Identification and Progress Record dated 9/6/16 documented an unstageable wound to Resident #1's left heel. On 9/6/16, Resident #1's TAR documented orders to treat the wound with Skin Prep and to ensure Resident #1's heels were not touching the bed or pillows. The TAR provided space twice daily for the LN to document the number of times Resident #1 refused these measures. For 28 opportunities 9/6/16-9/20/16, there were 4 blank boxes. The remaining 24 boxes documented a check mark and initials. It could not be determined from the documentation how often Resident #1 refused these measures, for what duration, what was done to attempt to overcome her objections, or whether she was more agreeable to the treatment after her objections were addressed. On 9/6/16, Resident #1's Care Plan was updated to include skin breakdown to her left heel, with a goal to resolve it in a timely manner and for her to have no signs or symptoms of infection at the site. The interventions added included the application of Skin Prep to both heels twice daily, treatment from a WOCN, and weekly measurements of the area. The care plan did not include direction for staff to float the Resident #1's heels as ordered on [DATE]. On 9/8/16, a Nutrition Risk Progress Note documented the recommendation to increase Resident #1's nutritional supplement to one can three times a day. Documentation showed the recommendation was implemented 9/22/16 at 10:46 am, 2 weeks after the recommendation was made. On 9/12/16, the WOCN documented, new heel breakdown discovered 9/6/16 by skin LPN measured 2 x 1.5, black, boggy without any open skin . Is on alternating low air loss bed. Eats poorly and very resistant to repositioning of any type. Does not get out of bed for meals. Does not allow staff to weigh her. Has been floating heels 80% of time. Will not wear any type of heel protection. Wound area measures 0.8 x 1.4 cm, purple area is hard but with no drainage. Has scaling at medial edge-probable SDTI-improving. Continue to float heel as much as possible, continue Skin Prep. Encourage turning side to side. Whether Resident #1 was experiencing pain related her [MEDICAL CONDITION] arthritis, or other medical conditions was not addressed as one of the potential reasons for her reluctance to reposition. The WOCN's assessment and those of LNs did not addressed how the mattress settings were to be determined, in light of Resident #1's preference not to be weighed. The WOCN's assessment did not document whether Resident #1 was made aware of the correlation between her weight and the determination of an effective setting for the mattress. On 9/14/16, the LN completed a weekly skin assessment with no change in physician orders [REDACTED]. On 9/17/16, the LN completed a weekly skin assessment with no change in physician orders [REDACTED]. On 9/19/16 at 10:15 am, Resident #1 was observed in bed with her eyes closed. Both of her heels rested directly on the bed. On 9/19/16 at 1:50 pm, Resident #1 was lying on her back in bed with a pillow under her head and one to her left side. She was awake and watching television. Resident #1 was lying on an alternating pressure/low air loss bed. Resident #1 stated the bed was hard as a rock. The mattress was firm to solid when touched. There was no visible movement or alternation on the surface of the mattress. Her left heel was directly on the mattress and her right foot was turned so the outer aspect of her foot was directly on the mattress. There were no pillows on the bed near Resident #1's legs or feet, and no pillows on the floor near the bed. Resident #1 stated she often experienced arthritic pain, which made it difficult for her to find a comfortable position. Resident #1's September 2016 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #1 received the as needed medication on 3 occasions during the month of September. Documentation of Resident #1's pain level or of staff offering her pain medication prior to position changes or wound care was not found in the MAR indicated [REDACTED]. On 9/19/16 at 4:00 pm, Resident #1 was lying in bed on her back with her left heel directly on the mattress. Pillows were not on the bed near Resident #1's legs or feet, nor on the floor near her bed. She stated she had not been repositioned that afternoon. On 9/20/16 at 9:00 am, Resident #1 was in bed, lying on her back with her eyes closed. Both feet were directly on the mattress. Pillows were not observed on the bed near Resident #1's legs or feet or on the floor near her bed. On 9/20/16 at 1:10 pm, Resident #1 was in bed, lying on her back. Both of her feet showed 3+ [MEDICAL CONDITION]. Resident #1's left heel was in direct contact with the mattress. Resident #1 stated her feet were painful to touch. Resident #1 stated the pressure ulcer to her heel was almost gone, and that staff wanted her to elevate her heels off the surface of the bed to keep her legs from falling asleep. On 9/20/16, the LN completed a weekly skin assessment with no change in physician orders [REDACTED]. On 9/21/16 at 4:06 pm, CNA #1 and CNA #4 provided cares to Resident #1. Resident #1 was positioned on her back with her heels directly on the mattress before cares began. When cares were completed, she was lying on her back in bed, with her heels positioned directly on the mattress. When the CNAs exited the room Resident #1 was in the same position. They did not offer or attempt to position Resident #1 so her heals did not touch the mattress. On 9/22/16 at 8:00 am, Resident #1 was observed in her room lying on her back with her left heel directly on the mattress. She was in the same position at 9:00 am. On 9/22/16 at 10:30 am, the treatment nurse stated Resident #1's as needed pain medication should be used to try to minimize her pain prior to care. The treatment nurse also stated the facility did not know what the manufacturer's recommendation was for the correct inflation of an alternating low air los bed for Resident #1. The treatment nurse indicated she was not sure how the settings on Resident #1's air mattress were being adjusted in light of her refusals to be weighed. The treatment nurse was not aware of Resident #1's complaints of the mattress being too hard and uncomfortable. She stated she checked 3 to 4 times daily to ensure pillows were placed under Resident #1's legs to keep her heels from lying directly on the mattress. The treatment nurse stated, at times, she would find the pillow on or near the bed, removed from under Resident #1's legs, and stated this was because Resident #1 removed it. On 9/22/16, the WOCN documented Resident #1's left heel wound was worsening, with Resident #1 frequently refusing to be repositioned. The left heel wound was documented as 2.1 X 1.4 cm, deep purple, with no drainage. The wound was documented as not open. The WOCN documented Resident #1 had refused pressure-relieving boots and all treatment except Skin Prep. The note documented Resident #1 complained her bed was hard and uncomfortable. The note directed staff to continue to offer boots and try different approaches for Resident #1 to keep her heels elevated. The note did not address pain as a potential factor in Resident #1's refusal of interventions, or direct staff as to what different approaches might be effective to overcome Resident #1's objections. Resident #1 was harmed when the facility failed to implement pressure ulcer prevention interventions, assess the effectiveness of those interventions, and revise interventions as needed. 2. Resident #2 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #2's Quarterly MDS assessment, dated 7/13/16, documented she had severe cognitive impairment, required the assistance of two staff with toileting and transfer, one staff with dressing, hygiene and bathing, and set-up only for eating. The MDS also documented Resident #2 was frequently incontinent of bowel and bladder and at risk of pressure ulcer development. Resident #2's care plan, dated 1/24/12, documented an intervention Turn at least q 2 hr and prn for restlessness when in bed and reposition when up in w/c . On 9/20/16, between 10:10 am and 2:05 pm, the following observation were made: * At 10:10 am, two CNAs were observed assisting Resident #2 to bed. Resident #2 was lying on her back. * At 1:05 pm, Resident #2 was observed sleeping, lying on her back. The CNA who was providing 1:1 care to her roommate said Resident #2 was in bed since 10:00 am. * At 1:45 pm, Resident #2 was observed in bed sleeping, lying on her back. * At 2:05 pm, Resident #2 was observed in bed sleeping, lying on her back. On 9/22/16 at 10:10 am, the DON said Resident #2 had a tendency to be combative when awakened from sleep, but CNAs should try to repositioned her at least every 2 hours to prevent pressure ulcer development.

Based on a complaint from the general public received by the Bureau of Facility Standards (BFS) on 2/5/15; review of the facility's abuse and incident/accident policy and procedures; staff, resident, and family interviews; review of Certified Nursing Aide (CNA) schedules; the facility's abuse investigations and incident/accident forms; and employee files, it was determined the facility failed to investigate six allegations of abuse involving 1 of 4 sampled residents (#1), 5 of 5 Random Resident (RR) (#s 5, 6, 7, 8, & 10); and failed to completely investigate one allegation of abuse for sampled Resident #2. These allegations of abuse were reported to the Staff Development Coordinator/ Human Resource Coordinator (SDC/HRC), the Administrator/Abuse Coordinator, and attempts were made to notify the Director of Nursing Services (DNS). CNA #1 was reported in all seven allegations of abuse. The Administrative staff's lack of protective response and investigation of the reported allegations placed six residents on both halls and the remaining twenty-six residents at the facility at risk for potential abuse and/or harm. This failed practice constituted Immediate Jeopardy. The facility was notified of the Immediate Jeopardy in writing on 2/11/15 at 6:20 PM. The facility's abatement plan was accepted on 2/13/15 at 2:46 PM. The abatement included: re-education to the facility administrator, DNS, and other management staff on policies and procedures for recognizing abuse, reporting requirements, and investigation procedures; employ an interim consultant who will review clinical and administrative systems with a focus on abuse and hiring practices; and provide a written test to all scheduled staff and facility management related to recognizing abuse, zero-tolerance policy, chain-of-command reporting procedures, company-wide compliance hotlines and grievance procedures. Findings included: The facility's Abuse Policy and Procedure, revised on 6/7/13, documented: · When an incident or suspected incident occurs, the Administrator, Director of Nursing, or designee investigates the allegation to include: · - Interviews with any witnesses; the resident; employee accused; resident's roommate; family members; other residents for whom the accused employee provides care or services; and staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. · Witness statements are documented in writing by the investigator and are signed and dated by both the interviewer and witness. In the event an employee is accused of abuse and/or neglect, the interview must be documented and the facility must attempt to get a signed, written statement from the accused. If the accused refuses to give a signed written statement, the facility must document that refusal along with the interview. · Review the personnel records of the suspected or accused employee(s). · Accused employees are immediately removed from resident contact and suspended from duty. The accused employee will not be taken off suspension until the conclusions of the investigation have been reached. · All allegations must be immediately reported to the State Agency's hotline. "Immediately means as soon as reasonably possible, and no later than 24 hours from the discovery of the incident." On 1/21/15, the BFS received a "completed" abuse investigation report from the facility's Administrator which included the following allegations against CNA #1: · Kissed an identified resident on the neck and/or lips four to five times while providing cares; · Tickled residents to wake them up; · Rough while providing cares to the residents; and · Uses profanity towards staff and/or while providing cares to residents. The investigation documented CNA #1 had denied all allegations of abuse, except CNA #1 stated that she, "may have used profanity." Six additional allegations of abuse were reported, however these allegations were not investigated and included: · Resident #1's wheelchair was allegedly pushed by CNA #1 into CNA #2 possibly causing Resident #1 to become upset. · Resident #5 had been placed in a Hoyer lift and CNA #1 allegedly stated "Maybe we'll let you hang there awhile." · Resident #6 was allegedly bounced up and down in a Hoyer lift, had his socks and pants pulled up too hard, was tickled and CNA#1 was rough with him during cares. · Resident #7 was allegedly rolled back and forth in a rough manner by CNA #1, causing tears to well up in the resident's eyes. · Resident #8 allegedly had CNA #1 blowing "raspberries" on her face/neck to wake her up and did not stop when Resident #8 asked her to stop. · Resident #10 was referred to in derogatory terms in front of another resident by CNA #1. When asked on 2/11/15 at 1:05 PM, the Administrator stated she did not know why the above allegations had not been investigated, but that they should have been investigated. The facility failed to ensure all allegations of abuse were thoroughly investigated. This failure directly impacted six residents and had the potential to place the remaining twenty-six residents at the facility at risk for potential abuse and/or harm. This failed practice created an Immediate Jeopardy situation.

Based on a complaint from the general public received by the Bureau of Facility Standards (BFS) on 2/5/15; review of the facility's abuse and incident/accident policy and procedures; staff interviews; the facility's abuse investigations and incident/accident forms; and employee files, it was determined the facility failed to ensure residents were protected from abuse. The facility failed to operationalize its policies and procedures for screening employees; protecting residents from an accused employee; and reporting all allegations to the State Agency (BFS). This was true for 2 of 4 sampled residents (#s 1 & 2), 5 of 5 Random Residents (RR) (#s 5, 6, 7, 8, & 10), and had the potential to affect all residents residing in the facility. Seven allegations of abuse involving CNA #1 were reported to the Staff Development Coordinator/ Human Resource Coordinator (SDC/HRC), the Administrator/Abuse Coordinator, and attempts were made to notify the Director of Nursing Services (DNS). This failed practice placed seven residents on both halls and the remaining twenty-six residents in the facility in immediate jeopardy and at risk for abuse and/or serious harm. On 2/11/15 at 6:20 PM, the administrator and DNS were notified in writing of the immediate jeopardy situation. The facility submitted an acceptable abatement plan to the BFS on 2/13/15 at 2:46 PM, which included: Re-education to the facility administrator, DNS, and other management staff on policies and procedures for recognizing abuse, reporting requirements, and investigation procedures; employ an interim consultant who will review clinical and administrative systems with a focus on abuse and hiring practices; and provide a written test to all scheduled staff and facility management related to recognizing abuse, zero-tolerance policy, chain-of-command reporting procedures, company-wide compliance hotlines, and grievance procedures. Findings included: On 1/29/15, the BFS received an investigation report from the facility which documented CNA #2 had verbalized concerns that CNA #1 "tickled residents to wake them up; kissed Resident #2 on the mouth; was rough with residents while providing cares; and used profanity." The facility documented CNA #1 was disciplined per policy for using profanity in the work place and was removed from the 300 hall where Resident #2 resided. On 2/5/15 the Bureau of Facility Standards received the following complaint from the general public: The complainant alleged that an abuse investigation was not conducted related to an incident in which CNA #1 was observed to be " too friendly and had said inappropriate things" to Resident #2 while providing personal cares. The Administrator and DON were told about the incident, however the complainant stated no statements were obtained from the witnesses. The complainant stated CNA #1 had been rehired by the facility about two months prior and was placed on "strict probation," for being rough with resident(s) in the past. On 2/10/15 at 8:35 AM, the administrator provided the survey team with CNA #2's written statement dated 1/21/15. The written statement included the allegation of abuse by CNA #1 towards Resident #2 and identified six additional allegations of abuse by CNA #1 towards six unidentified residents. When asked if the facility had identified the above residents and investigated the additional allegations, the Administrator stated the facility had not. On 2/10/15 at 11:45 AM, CNA #2 provided the name and allegation for each of the six unidentified residents. The following residents were identified as #s 1, 5, 6, 7, 8 & 10 and the allegations were as follows: * CNA #1 pushed Resident #1 in her wheel chair to the dining room and ran the wheel chair into CNA #2's leg, causing Resident #1 to become upset. CNA #1 told CNA #2 she was going to "punch her face and kick her a** (profanity)." * Resident #5 had been placed in a Hoyer lift and CNA #1 stated, "Maybe we'll let you hang there awhile. What do you think about that?" * Resident #6 was bounced up and down in a Hoyer lift and CNA #1 stated, "How do you like that?" Additionally, CNA #1 would pull the resident's socks and pants up in an aggressive manner causing the resident to yell, "OUCH, STOP IT!" Finally, CNA #1 would tickle or shake the resident to wake him up and the resident would become combative. * Resident #7 was unable to verbalize pain/discomfort, however CNA #1 was observed to roll the resident back and forth in such an aggressive manner the resident had tears well up in his eyes. * CNA #1 was observed to "blow raspberries" on Resident #8's face/neck to wake her up for breakfast. The resident yelled, "STOP IT! STOP IT," however, CNA #1 did not cease when Resident #8 asked her to stop. *While CNA #1 and CNA #2 were providing cares for two other residents in another room, CNA #1 referred to Resident #10 as a "B**ch (profanity)" and a "piece of s**t (profanity)." On 2/9/15 at 11:05 AM, CNA #3 stated while she was not an eyewitness to any of the alleged incidents, she had heard about them from CNA #2. CNA #3 said CNA #2 approached her with concerns related to CNA #1 inappropriately kissing Resident #2, using profanity around/towards residents, and the rough handling of residents. CNA #3 said she told CNA #2 to report the concerns to the SDC. When asked if the SDC was the abuse coordinator, CNA #3 said she did not know and was never educated to whom allegations of abuse were to be reported. On 2/9/15, at 11:45 AM, CNA #2 stated she went to the DNS's office on 1/19/15 to report her concerns and was told the DNS was in a meeting. The CNA stated she went home and called the facility and left a message for the DNS to call her, but received no return call. The CNA called the DNS back at approximately 7:00 PM and was told he was eating dinner and would call her back. The CNA waited until 10:00 PM for a call back and did not receive a call from the DNS. CNA #2 stated that on 1/20/15 she saw the DNS during her shift, but he did not approach her to discuss her concerns. The CNA said she felt like the DNS ignored her and she did not attempt to report her concerns to anyone else. CNA #2 stated, "I just couldn't take (CNA #1's) mouth anymore," and reported her concerns to the SDC on 1/21/15. CNA #2 stated she had never been educated regarding to whom allegations of abuse should be reported. On 2/10/15 at 6:00 AM, CNA #4 confirmed she was aware of the incident which occurred between CNA #1 and Resident #2 in mid-January 2015. When asked if she was interviewed by the facility's administrative staff about the incident, CNA #4 stated she and another CNA were sitting at a table when the DNS told them CNA #1 was under investigation and asked the CNAs if they had "ever noticed anything." CNA #4 stated she did not remember the date and/or time the DNS asked the questions about CNA #1. CNA #4 stated she heard CNA #1 use profanity towards staff and residents prior to the investigation and after the investigation. When asked if she reported her concerns to the DNS or administrator, CNA #4 stated, "No, when I have brought concerns up in the past, they have not been addressed." CNA #1's employee file docmented the CNA had at least two separate employment periods with the facility over a two year period. The employee's file included 3 disciplinary actions. The disciplinary action forms documented the following under supervisor comments: * "On 12/30/13 you failed to replace a tabs alarm on a resident. Shortly after that the resident self-transferred out of his wheelchair and fell , resulting in a minor injury. If you fail to follow a care plan again in the future, your employment at the facility will be terminated." *"On 3/10/14, you were observed walking out of a resident's room that you were assigned as 1:1. You walked down the hallway, talked to another CNA and walked back to the room. This violates the 1:1 job description and this resident's care plan. Effective today 3/10/14 your employment at the facility is terminated." NOTE: The CNA was re-hired in December 2014 and placed on "strict probation" by the facility related to identified "behavioral and attitude problems" observed and identified during her previous employment. *"On 1/23/15, (the) use of profanity and Inappropriate (sic) interactions with residents. (CNA #1) will not use profanity at (the) work place. (CNA #1) will work only (on) the 200 hall. Any violations will result in discharge." The facility's Abuse Policy and Procedure, dated 6/7/13, documented: When an incident or suspected incident occurs, the Administrator, Director of Nursing, or designee investigates the allegation to include: *Interviews with any witnesses; the resident; employee accused; resident's roommate; family members; other residents for whom the accused employee provides care or services; and staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. * Witness statements are documented in writing by the investigator and are signed and dated by both the interviewer and witness. In the event an employee is accused of abuse and/or neglect, the interview must be documented and the facility must attempt to get a signed, written statement from the accused. If the accused refuses to give a signed written statement, the facility must document that refusal along with the interview. * Review the personnel records of the suspected or accused employee. * Accused employees are immediately removed from resident contact and suspended from duty. The accused employee will not be taken off suspension until the conclusions of the investigation have been reached. * All allegations must be immediately reported to the State Agency's hotline. "Immediately means as soon as reasonably possible, and no later than 24 hours from the discovery of the incident." This is also a requirement per Health and Welfare Informational Letter #2014-04. On 2/11/15 at 1:05 PM, the administrator stated the facility did not follow its policy and procedure for abuse in the following manner: * The facility did not notify the BFS within 24 hours of the reported allegation. (See BSF Informational Letter 2014-14) *The six additional allegations of abuse by CNA #1 reported by CNA #2 were not investigated. The Administrator stated she did not attempt to identify who the additional residents were or when the alleged events took place. * The SDC did not complete an Incident Report upon notification of the reported allegation. * CNA #1 was moved to the 200 hall and continued to work with Resident #1 and Resident #8. * The facility did not attempt to get a signed, written statement from the accused employee and/or document the accused employee's refusal to provide a signed written statement. * The facility did not interview family members or other residents for whom the accused provided care and services. * The facility did not interview staff members on all shifts who had contact with the identified residents during the period of the alleged incidents. * The facility did not review the identified residents' clinical record and personnel record of the accused employee. * The facility did not document in writing the staff witnesses' statements, or include the date and signature of the interviewer and witness. * Resident # 2's Power of Attorney was not notified until 19 days after the allegations were reported. Family members and or representatives of Residents 1, 5, 6, 7, 8, & 10 were not notified of the allegations of abuse. *Due to the lack of a complete investigation for Resident #2 and the lack of any investigation for the six additional identified residents, the accused employee continued to work with Resident #s 1 and 8, as well as all other residents residing on the 200 hall. The facility did not suspend CNA #1 pending the need for ongoing investigations to rule out abuse related to all the allegations. The administrator stated CNA #2 was terminated from the facility on 2/10/15 for excessive absenteeism. On 2/11/15 at 1:30 PM, the DNS confirmed CNA #2 had made several attempts on 1/19/15 to talk with him. When the DNS was asked why he did not follow-up with CNA #2 on 1/19/15, he stated, "I did not feel it was an urgent critical need. I assumed she would come and talk to me about it (on 1/20/15) if it was a critical issue." When asked if the employee file for CNA #1 had been reviewed prior to her rehire in December 2014, the administrator and DNS stated it had not, however the DNS stated when CNA #1 was rehired she was placed on "strict probation" for three months related to concerns about her behavior, attitude, and absences. When asked why an employee would be rehired when concerns related to behavior and attitude were identified, the DNS stated, "Everyone makes mistakes and I felt like giving her another chance." The DNS did not identify what "strict probation" was or how it was to be implemented. No additional information was provided by the facility to resolve this concern. On 2/13/15 at 2:46 PM, the facility submitted an acceptable abatement plan to the BFS. On 2/12/15 the additional 6 allegations of abuse were reported to the BFS State Hotline. The facility failed to follow its own policy and procedures for investigating abuse; failed to immediately notify the BFS when an allegation of abuse was reported; failed to investigate six allegations of abuse involving sampled Resident #1, and Random Resident (RR) #s 5, 6, 7, 8, & 10; and failed to completely investigate one allegation of abuse for sampled Resident #2. This failed practice placed 7 residents on both halls and the remaining twenty-six residents in the facility in immediate jeopardy and at risk for abuse and/or serious harm.

Based on observation, review of clinical records and Incident Reports, and staff interviews, it was determined the facility failed to ensure 1 of 2 residents (#3) reviewed for pressure ulcers (PU) did not develop avoidable recurrent PU. Resident #3, who had a history of [REDACTED]." Findings included: The resident was readmitted to the facility in 2011 with multiple [DIAGNOSES REDACTED]. The resident's 4/6/13 annual MDS and 7/5/13 quarterly MDS assessments coded, in part: * Total dependence for bed mobility/transfers/dressing/toileting/hygiene/bathing; * Always incontinent of bowel and bladder; * At risk for PU; and, * One unhealed stage 2 PU, dated 3/24/13. The resident's PU CAA Analysis of Findings, dated 4/9/13, documented, "CAA triggered for multiple reasons. Bed mobility is dependent, she is always incontinent of bowel and bladder, she has a past hx (history) of having a stage IV pressure area which took a very long time to resolve and she has developed a new stage II area...in the coccyx area..." The resident's 10/4/13 and 1/4/14 quarterly MDS assessments, differed from the 2 aforementioned MDSs, in part, as follows: * No unhealed PU; and, * PU present on the prior assessment. The resident's care plan identified the following focus areas: * "At risk of pressure areas due to scarring of coccyx area from previous events of pressure areas. Risk factors include: refusal to take supplements hight (sic) in protein, refusal to lay off her buttocks when in bed, incontinence of B/B (bowel and bladder), impaired mobility and "picky" with dietary intake." It was initiated 1/10/12 and revised 1/16/14. Interventions included alternating air cushion in wheelchair (w/c) and air mattress on bed, draw sheet between the resident's skin and a Hoyer (mechanical lift) sling during transfers, pillows for positioning, and weekly skin checks by the LN. * ADL functioning, initiated 1/10/12. Interventions included, "Peri-care after each episode of incontinence... (and) Use of hoyer (sic) lift for all transfers." Review of the resident's clinical record revealed the 3/24/13 stage 2 PU was unavoidable. However, an Incident Report (IR), dated 10/29/13, contained documentation that a recurrent stage 2 PU to the resident's coccyx was avoidable. The 10/29/13 IR documented the following, in part, "Brief narrative of what happened... Upon skin assessment it was noted that there is an open area to coccyx 1 cm (centimeter) x (by) 1 cm." The undated Accident Team Recommendations included, "(Resident's name) has poor nutritional status overall and thin skin. Hx (history) of pressure ulcer and has scar tissue to coccyx that has lost it's (sic) elasticity which puts her at risk for breakdown to the same place. Upon investigation it was found that Housekeeping staff was placing soaker pads between mattress (and) cover when sanitizing beds. Pads removed (and) Housekeeping Supervisor notified to educate her staff...Protective dressing placed to res(ident's) coccyx..." On 1/28/14 at 5:00 p.m., during incontinence care by CNAs #4 and #5, a reddened but intact and blanchable area was noted on the resident's coccyx. A draw sheet was the only bed linen between the resident and the cover on the low air loss mattress. On 1/29/14 at 3:55 p.m., the DON was asked about the 10/29/13 IR regarding the resident's stage 2 coccyx PU. The DON said she would get back with the surveyor. On 1/30/14 at 8:40 a.m., the DON and MDS nurse were interviewed together. The DON stated, "We discovered housekeeping was putting draw soaker pads between the low air loss bladders and the cover over the mattress." The DON said the Housekeeping Supervisor in-serviced her staff. When asked to provide documentation of the in-service, the DON stated, "She may have just talked to her staff." The DON said she would check to see if it was documented or not. When asked if the resident had refused cares, the MDS nurse, who was reviewing the resident's clinical record at the time, said there was no documented evidence the resident had refused care, except once on 10/16/13. At that time, the DON was asked to provide documentation regarding the resident's PU risk assessments, the 3/24/13 and 10/29/13 PU tracking forms and nurses' notes (NN). Note: Regarding the use of absorbent pads, Potter and Perry's The Fundamentals of Nursing, 7th edition, page 1304, stated, in part,"...Use underpads with caution because some of these pads do not wick the drainage away from the client's skin and will cause skin damage." On 1/30/13 at about 10:30 a.m., the DON stated the Housekeeping Supervisor was the only housekeeping staff when the PU was found 10/29/13. The DON said she talked to the Housekeeping Supervisor about the soaker pad issue herself but did not document the conversation. The DON provided the requested information and a 10/31/13 progress note by a Wound Ostomy Certified Nurse (WOCN). The WOCN's progress note documented, in part, "New open area coccyx. Pt (patient) has scar tissue from previous area of breakdown...is on low air loss bed, on turn schedule, (with) limited time sitting... It measures 0.5 x 0.1 cm today...has old scar tissue in wound. This area could be a skin tear vs (versus) stage II pressure area..." The resident's Skin Impairment records dated 10/29/13, 11/5/13, 11/11/13, and 11/19/13, the open area on the resident' coccyx was consistently documented as pressure related. On 1/30/14 at about 3:00 p.m., when asked for evidence the 10/29/13 open area on the resident's coccyx was not pressure related, the DON did not provide any documentation to that effect. The DON was informed of the concern the resident was harmed related to the 10/29/13 avoidable recurrent stage 2 coccyx PU. On 1/30/14 at about 11:15 a.m., the Administrator was also informed of harm related to the PU issue. No other information or documentation was received from the facility which resolved the issue in which Resident #3, who had a history of [REDACTED].

Based on observations, record review and staff interview, it was determined that the facility failed to ensure Resident #3 did not acquire multiple pressure sores on her heel, buttocks and coccyx areas. The resident was harmed when she acquired multiple sores on the left and right buttocks and coccyx area while a resident in the facility. This was true for 1 of 9 (# 3) sampled residents. Findings include: 1. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 9/15/11, documented the resident, * had moderate cognitive impairment (BIMS = 9) * had daily behavioral symptoms not directed toward others * had moderate depression ( Mood severity = 10) * required total dependence of one to two staff for with transfers, dressing, eating, personal hygiene and bathing. * was receiving an antidepressant. * did not have a pressure sore. a. A physician on 3/25/11, documented in an office visit progress note that, "The nursing staff has just noticed her right heel stage II decubitus yesterday. They have started putting heel protectors on. They are trying to encourage p.o.(oral) intake." In the "Physical Exam" section the physician documented, " MUSCULOSKELETAL:....A 3 x 3 cm (centimeter) stage II blistered right posterior lateral heel decubitus is noted....Skin exam: ....Right lateral heel stage II decubitus with 3 x 3 cm bullous lesion noted." The Treatment Administration Record (TAR) documented that on 3/24/11 the nursing staff started a treatment of [REDACTED]." The TAR also documented a plan to "Float Heels while in bed every shift" starting on 3/25/11. The resident's "Skin Impairment" form documentation started on 3/28/11, four days after the sore was discovered. It documented a 3 cm x 2.5 cm brown area on the right lateral heel. The area was to be covered with [MEDICATION NAME] dressing. The resident was seen 3/31/11 by the wound nurse who documented," OBJECTIVE: ...removed [MEDICATION NAME] from right foot and under there is a firm, brownish area without any fluid in it. No fluctuance and it is located on the lateral right heel. This measured 3.5 x 2.9 and is dry. There is no periwound redness or evidence of pressure in the area. She is wearing a fairly heavy boot to protect probably mostly from friction. ASSESSMENT: This is a dried blister on the right heel without evidence of infection or ongoing pressure, probably more from friction....PLAN: Keep the area open to air and dry. Paint it with either an alcohol pad or [MEDICATION NAME] so it stays dry and monitor it daily. Also, I recommend protecting both heels from possibility of friction when she is in bed or in chairs...." The resident's "Skin Impairment" form documented weekly treatment and size of the blister at the right heel until 4/29/11 when the area resolved. The TAR continued to state, "Apply heel protector and keep off bed with pillow to R (right) heel at bedtime." The resident's care plan did not have any documentation of approaches for staff to follow for the heel. b. On 4/27/11 at 5:00 p.m. an "Incident Report" was completed by a LN who documented, "CNA reported resident to have red coccyx and blister is healing." The "Licensed Nurse Incident Analysis" documented, "resident coccyx is red in color and blister that is healing. Will apply [MEDICATION NAME] cream to coccyx bid (twice a day) until resolved." The "Accident Prevention Team Recommendations" dated 5/2/11documented, "Resident is incontinent now relies on staff for ADLs. Area assessed coccyx is pink in color (and) top layer of skin beginning to peel r/t chronic [MEDICAL CONDITION]. (No) blister noted. Resident is repositioned Q 2 (hours and) PRN (as needed) as she allows. Resident has [MEDICATION NAME] to coccyx bid and notify provider...." The LN faxed a note to the physician on 4/29/11 that documented, "resident has red area to coccyx (and) a healing blister will apply [MEDICATION NAME] cream bid until resolved..." The TAR reflected that the resident had treatment done bid to the coccyx with [MEDICATION NAME]. The treatment continued to the area until 5/28/11 when the resident was discharged from the facility. The facility did not do a "Skin Impairment" form for the coccyx or any other type of compromised skin form, and there was no documentation that the resident's care plan had been changed to reflect the increased skin at risk. c. On 6/10/11 Resident #3 was readmitted to the facility. The nursing staff completed a "Braden Scale For Predicting Pressure Sore Risk." The resident scored a 13 which translated to "Moderate Risk (13 - 14). The resident care plan for "Risk - Skin Breakdown ...." was completed on 6/28/11 and documented the following approaches: "1. Licensed nurse to check nails q week with skin assessment and clip/trim/file as needed FYI (information only). 2. Treatments per provider order PRN.... 3. Lotion skin after bathing , with AM/PM cares and prn AM & PM.... 4. Care givers report any skin problems to licensed nurse for assessment of area - licensed nurse will notify provider of problem after assessment of area PRN... 5. Keep skin folds to abdomen, breasts, etc dry- use body powder and soft cloth prn to absorb excess moisture QS (every shift)...." On 6/30/11 at 8:30 p.m. an "Incident Report" was completed by an LN that documented, "CNAs doing cares @ 2030 (8:30 p.m.) notified LN of bleeding noted to buttocks during incont(inence) cares while in bed. Open areas noted." The LN further documented, "Other comments or narrative continued: Res(ident) had [MEDICATION NAME] orders BID for redness to bilat buttocks, but areas have peeling skin and are fragile and painful to the res. Scant sanguinous drainage to areas. L(eft) buttock area is 3 x 1.5 cm, Coccyx area is 1 x 0.5 cm, R(ight) area is 0.7 x 0.5 cm." The LN documented in a Nurses Note on 6/30/11 at 10:00 p.m. the "Res noted @ 2030 to have open, red excoriation to bilat(eral) buttocks and coccyx. L buttock is 3 x 1.5 cm, R buttock is 0.7 x 0.5 cm, coccyx is 1 x 0.5 cm. Areas are superficial (with) peeled skin @ edges, skin is dry and pink, blanchable. Scant sanguinous drainage. [MEDICATION NAME] cream gently cleansed from areas, areas are tender/painful, irritated. Res is incont(inent) of urine (and) bowel. Allevyn adhesive applied to areas...." The LN started three "Skin Impairment" forms for the three areas on 6/30/11. The documentation of size was the same as the Nurses Note. Depth for all three areas was documented as, "superficial." The drainage for the L and R Buttock was noted to be "sanguinous red, scant" and the coccyx was "sanguinous scant." On 7/5/11 the resident was seen by the wound nurse. The nurse documented, "...(the resident had) an area of breakdown on her mid gluteal fold which is less than 0.5 cm diameter and is kind of dark but it is on the fold and not really low enough to be ischial. She also has a lot of maceration around the coccyx area. She did have a dressing which I loosened and she is wet. I think the problem, probably for the most part, is moisture. She probably does not turn well either....I removed the OptiForm from her coccyx area and really the most noticeable factor is that she is wet. I think we need to try to control the moisture first. The macerated area is not even broken down so unless there is something lower, that and the little dark spot over on the left side of the gluteal fold....need to be very vigorous in keeping her dry...every 1 to 2 hours of checking her for moisture and changing her....keep her medication on that is to keep the moisture off the area...needs to constantly having (sic) that on, not just when she is wet...." The wound nurse recommendations were noted to be on the July 2011 TAR. They documented, "[MEDICATION NAME] or [MEDICATION NAME] bid and prn incontinence," "must keep attends dry check (every) 1-2 hours. No attends (at night)" and "keep barrier on skin at all times." The resident's "Skin Impairment" forms documented: Left Buttock -for 7/7/11: 1 x .5 cm for length, superficial for depth, and red for drainage. Right Buttock - for 8/4/11: 0.7 x 0.5 cm for length, superficial for depth, and no drainage. NOTE: This was the first documentation of these two wounds since the initial documentation on 6/30/11. Coccyx - for 9/8/11: 0.5 x 0.5 cm for length, superficial for depth, and no drainage. NOTE: This was the first documentation of the coccyx wound since the initial documentation on 6/30/11. Documentation of the left buttock wound continued weekly until 7/28/11 when the nurse documented "no open area noted." Weekly skin checks were done with no documentation of an open area until 9/1/11 when the resident was noted to have an open area 0.3 x 0.1 in length, superficial in depth and no drainage. On 9/15/11 the LN documented 0.4 x 0.2 cm length and .5 cm in depth, no drainage and comment of "open, (no) (sign/symptom) of infection." The right buttock had additional documentation for 8/11 and 8/18/11. On 8/18/11 the LN documented 0.6 x 0.4 in length, red superficial for depth and no drainage noted. The resident's care plan remained without changes from the 6/28/11 care plan. Resident #3 was observed on 9/20/11 from 7:30 a.m. until 11:45 a.m. to be sitting in the Broda chair. The observation of the resident started in the dining room and at 8:25 a.m. the resident was moved back to her room. The resident required a mechanical lift for her to be put into bed so she could be checked and changed as needed. The resident sat in the Broda chair watching the television in her room from 8:25 a.m. until 11:45 a.m. The DON was informed at 11:45 a.m. about the odor in the room and the staff was instructed to put the resident to bed and check her. The resident was changed, lifted to the Broda chair and taken to the dining room for lunch. The DON was interviewed on 9/21/11 at 1:15 p.m. The DON provided additional information and it was included in the report. The facility revised the resident's care plan and it was dated 9/21/11. The revised care plan did not incorporate all the wound nurse recommendations. The facility failed for Resident #3 to: * prevent a stage II pressure sore on the right heel, * revise the care plan after the heel pressure sore was discovered, * prevent the three open areas on the buttocks and coccyx from occurring on 6/30/11 even after the resident had an excoriation and blister on the coccyx on 4/27/11, * revise the care plan to include the wound nurse recommedations for the left and right buttocks and coccyx skin breakdown prevention, *ensure the resident was checked for wetness every hour per wound nurse recommendations as noted during observation. The Administrator and DON were informed on 9/22/11 at 4:00 p.m. No further information was provided.