Every finding on record at Pierpont Center at Fairmont Campus

Based on record review, and staff interview the facility failed to ensure residents Minimum Data Set (MDS) assessment correctly reflected Resident #38's physical status. This failed practice was a random opportunity for discovery and had the potential to effect a limited amount of residents during the complaint survey. Resident identifier #38. Facility Census 108. Findings Include:a) Resident #38A record review on 02/17/26 at 1:30 PM revealed a current Activities of Daily Living care plan for Resident #38 that read as follows:Focus:Resident/patient requires assistant/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Limited mobility.Goal:Resident/patients ADL care needs will be anticipated and met throughout the next review period.Interventions include the following: Provide resident with dependent assistance of 2 for bed mobility.Provide resident with set up substantial/maximal assist of 1 for toileting.Provide resident with substantial/maximal assist of 1 for dressing.Provide resident with partial/moderate, substantial/maximal, dependent assistance, assist of 1 for personal hygiene (grooming).Provide resident with substantial/maximal assistance assist of 1 for bathing.Further record review of Resident #38, revealed a diagnosis that includes dependence on wheelchair, difficulty in walking, Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side. A review of Resident #38's MDS, with an Assessment Reference Date (ARD) of 11/11/25, Section GG0115 is coded as 0 upper and lower extremity limitations in range of motion. GG0120, mobility devices, is coded as none. During an interview on 02/17/26 at 4:15PM, The Director of Nursing (DON) confirmed that the MDS was coded wrong, per the residents physical status.

Based on record review, staff interview, and family interview the facility failed to provide care and services in accordance with professional standards of practice, by not providing supervision of incapacitated residents at out of facility doctor appointments. This failed practice was found true for (1) one of (3) three residents reviewed for doctor appointments during the complaint survey. Resident identifier #38. Facility Census 108. Finding include:a) Resident #38A record review on 02/17/26 at 1:30 PM, revealed Resident #38's most recent Physician's Determination of Capacity form dated 08/22/2024 indicating that he was incapacitated. Further record review of the last Brief Interview for Mental Status (BIMS) completed for Resident #38 on 02/10/26, revealed a BIMS score of 99.Resident #38's current Activities of Daily Living (ADL) care plan focus read as follows:Resident/patient requires assistant/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Limited mobility.Continued review of Resident #38's notes, revealed a general patient note dated 12/16/24 that read as follows:Resident is alert, verbal with his normal confusion, skin intact, went out today in wheelchair transported by facility van to Urology appointment. Foley catheter was changed at this appointment and scheduled in 4 weeks to be changed again 0n 1/14/25 at 10:45am with Urology. Resident returned back to facility alert, Foley intact and draining clear yellow urine, resident has no complaints. Urology reported that resident is to no longer come to his appointments alone as he became very upset, agitated and destructive when having to wait. MD and scheduler aware.Since the above incident Resident #38 has had (7) appointments to the urology center where he was transported by the facility van.During a phone interview on 02/17/26 at 1:45 PM, The Health Care Surrogate (HCS) for Resident #38 stated, Yes, they leave him at appointments all the time with no one from the facility supervising him. Urology is where he goes the most. I have taken him a time or two. I am told when they take him they just leave him sitting in the waiting room. I do not understand why it is ok to leave him unattended.During an interview on 02/17/26 at 2:00 PM, Activity Assistant (AA) #92 (who is the van driver for appointments) stated, I get a schedule weekly for who has an appointment. Typically with appointments if the resident does not have capacity an aide goes with them if the family can not come.State Agency (SA) asked AA #92 Is there anytime in particular that you can remember with Resident #38 where he was left at his Urology appointment AA #38 replied, His son is supposed to come, but I can only remember him being there once maybe twice. I take him inside and then I wait in the van in the parking lot.During a phone interview on 02/17/26 at 2:30 PM, the Receptionist at the Urology office said that she has been working there for about a year. She said that from what she can recall that resident cannot talk and he was definitely there in the waiting room by himself in March and April of last year. She said that he never says a word and just sits there looking very sad. She also said that another receptionist might know more but she is off right now.

Based on observation, staff interview, and food tray temperatures the facility failed to serve food to residents that was at an appetizingtemperature. This failed practice was true for (1) of one (1) hallways tested for food tray temperatures throughout the Long-Term CareSurvey Process. Resident identifiers: #24 and #112. Facility census: 111. Findings Included: a) During an observation on 01/06/26 at 1:25 PM of the 220 hall meals being passed with only 2 staff members delivering all trays to residents on that hall. The District dietary manager took the temperature of the food, at time of service. Temperature of the food was as follows: French Fries 110 degrees Fahrenheit. Hamburger patty 113 degrees Fahrenheit. District Dietary Manager confirmed that the food was not served at 120 Degrees Fahrenheit at time of service. b) Resident #24 On 01/05/2026 at 12:30 PM, during the initial resident interviews, Resident # 24 reported the food was cold, especially at breakfast. c) Resident #112 During an interview on 01/05/26 at 3:15 PM, Resident #112's Medical Power of Attorney (MPOA) said that Resident #112's food is always cold and feels like it is because his hall is the last to be served. During an observation on 01/06/26 at 1:25 PM of the 220 hall meals being passed. District dietary manager took the temperature of the food, at time of service. Temperature of the food was as follows: French Fries 110 degrees Fahrenheit. Hamburger patty 113 degrees Fahrenheit. District Dietary Manager confirmed that the food was not served at 120 Degrees Fahrenheit at time of service.

Based on observation and staff interviews, the facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety.This was a random opportunity for discovery and had the potential to affect multiple residents of the facility. Facility census: 111. Findings Included:On 01/05/26 at 11:45 AM, during Initial Brief Tour of Kitchen, with The Kitchen Dietary Manager, who acknowledged the kitchen the following observations:a) The kitchen refrigerator inside temperature was at 45 degrees verified via inside thermometer. b) The following was observed in the freezer :1 opened box of frozen burgers and 1 opened box of frozen fish filets, the plastic wrap was not sealed and the meat in each box were left opened to air.c) In the Prep cooler, it was discovered in the same container, stored with other produce, were over ripe oranges with brown spots on the outside peels d) On 01/06/26 at 1:50 PM a review facility policy labeled HCSG Policy 019, Food Storage: Cold Foods. Procedures, number 5 stated All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. e) Staff Interviews:On 01/06/26 11:55AM, during meal prep tray line observation, with The Corporate Dietary Manager, who acknowledged the following :silverware with dried food spots on the tray.

Based on observations, interviews, and document reviews, the facility failed to thoroughly investigate reportable incidents and report the results of those investigations to the State Agency within five (5) working days of the incident and if the alleged violation was verified to include the appropriate corrective action taken. Resident identifiers: #70, #71, #73, and #121. Facility census: 111. a) A facility reported incident dated 04/13/25 involving Resident #70 and a facility reported incident dated 06/06/25 involving Resident #71 were reviewed having a Five (5) Day Follow-up Investigation Report submitted to the state agency. The facility's documentation was reviewed and the Five (5) Day Follow-up forms for each incident were in the facility's file with no proof of submission to the state agency. On 01/07/26 at 10:15 AM, the Director of Nursing (DON) confirmed there were no documentation emails, reported the Social Worker that reported the incidents no longer worked at the facility, and corporate was trying to retrieve the emails from her computer's email. On 01/07/25, the DON reported the emails were deleted after Ninety (90) days and corporate could not retrieve the emails. The DON confirmed the Facility Reported Incidents did not have a five-day follow-up submitted to the state agency. b) There was a documented change in condition on 04/19/25 that the victim was struck in the arm by Resident #73. There were no other incidents in Resident #121's medical record that alleges any other abuse. Resident #121 had a Brief Interview for Mental Status (BIMS) of 15 and had capacity. Resident #73 was diagnosed shortly after the incident with a Urinary Tract Infection (UTI). At the time of the alleged incident on 04/19/25, Resident #73 had capacity. During the survey process the facility reported incident (FRI) documents from 04/19/25 regarding Resident #121 and Resident #73 were reviewed. There was no documentation readily available to demonstrate that the facility submitted a five (5) day follow-up investigation report to the State Agency. During an interview, on 01/08/25 at 7:35 AM with Employee #56, the employee verified that there was no evidence that a five (5) day investigation report was sent to the State Agency.

Based on observation, record review, staff interview, and resident interview the facility failed to develop and/or implement care plans related to activities, fall interventions, and Advance Directives (AD). This failed practice was found true for (3) three of 31 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers #5, #52, and #24. Facility census 111. c) Resident #24 On 01/05/2026, Resident #24 care plan was reviewed for the resident's Advanced Directive wishes. The resident's Advanced Directives were not care planned. The resident's care plan was confirmed by the Corporate Compliance Advisor. Findings include: a) Resident #52 The initial observation on 01/05/26 at 3:45 PM, revealed Resident #52's door shut, due to Covid precautions. Resident was lying in the bed. No stimulation was on in room. Further observation on 01/06/26 at 1:30 PM, revealed Resident #52's door shut. Resident was lying in bed. No stimulation was on in room. A record review on 01/07/26 at 9:45 AM, revealed an Activities care plan for Resident #52 that read as follows: Focus: (Resident #52 name) exhibits or is at risk for limitedand/or meaningful engagement related to:Cognitive loss/dementia. (Resident #52 name) does notwish to engage in group activities. He doesenjoy some individual activities such associal and pet visits, but spends most of histime resting in is room. Interventions include the following: ( Resident #52 name) will be provided 2 to 3 one on one visits weekly.Further review of Resident #52's Activity Participation sheets for the months of 11/2025, 12/2025, and 01/2025 to date revealed that the one to one visits were not completed as care planned, and the resident had not attended any group activities. During an interview on 01/07/2026 at 10:15 AM, The AD stated, Yes, we are behind on our one to one visits because I am working on getting more staff. b) Resident #5 A record review on 01/07/26 at 5:30 PM, revealed that since 10/01/25 to present, Resident #5 has had (6) six falls. One fall with serious injury, and two of the falls was from bed one causing a skin tear to her right eye. Further record review revealed a falls care plan that reads as follows: Focus: Resident is at risk for falls: Impairedmobility. Fall on 8/30/25 no injuries. Fall on 9/15/25 no injuries noted Fall on 10/31/25 no injuries noted Fall on 11/12/25 no injuries Fall on 11/13/25 no injuries Fall on 12/8/25 no injuries Fall on 12/10/25 skin tear above R eye One of the interventions for falls initiated on 12/11/25 for a fall from bed, was bilateral fall mats to both side of the bed. An observation on 01/08/2026 8:40 AM, revealed Resident #5 lying in bed, no bilateral fall mats in place. During an interview and observation on 01/08/26 at 8:41 AM, The Director of Nursing (DON), confirmed that the fall mats were not in place, and stated, They might be getting cleaned, let me check. On 01/08/26 at approximately 8:45 AM, The Assistant Director of Nursing (ADON) was asked by State Agency (SA), Does the facility have spare fall mats to use, when other fall mats are being cleaned? The ADON replied, Yeah, we do. We put an order in and Maintenance brings them up.

Based on record review and staff interview, the facility failed to ensure a complete and accurate medical records related for a Physician's Order of Treatment (POST) form and a resident's diet order. These failed practices had the potential to affect more than a limited number of residents. Resident identifier: #24 and #126. Facility Census: 111. Findings included: a) Resident #24 On [DATE], during the resident record review, Resident #24 had an order for DO NOT RESUSCITATE (DNR)-selective Do Not Intubate (DNI) which was active on [DATE]. The resident's POST form dated [DATE] stated, CPR - FULL Treatments. The documented differences between the order and care plan were confirmed by the Corporate Compliance Advisor (CCA). b) Resident #126 On [DATE], during Resident #26's record review, a diet order was not found on the resident's medical record. A diet order was not on the resident's medical record until the state surveyor intervened. On [DATE] at 01:55 PM, the CCA confirmed there was no initial diet order on the resident's medical record and stated, the Order is in there now.

Based on observation, policy review, record review and staff interview the facility failed to maintain an infection control program, designed to help prevent the spread of disease. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #52, #86, and #97. Facility census 111. Findings Include: a) Resident #52 An observation on 01/06/2026 at 12:40 PM, revealed a Droplet precautions sign on Resident #52's door that read as follows: Special Contact and Droplet Precautions Instructions for entering the room are as follows: * Perform hand hygiene before and after patient contact, contact with environment and after removal of Personal Protective Equipment (PPE). * Wear an N95 respirator, gown, face shield and gloves upon entering the room. * Keep room door closed. Encourage patient to wear a face mask when out of room and maintain social distancing. Perform all procedures/tests in patient room if able. * Pull curtain between roommates. Please do not remove dedicated or single use disposable equipment from this room. * When dedicated equipment is not possible, disinfect shared patient equipment with EPA-approved disinfectant, Further observation, revealed Laundry Aide #52 went into Resident #52's room, walked beside his bed and put socks in the drawer. No PPE was put on and no handwashing occurred. During an interview on 01/06/26 at 12:45 PM, The State Agency (SA) asked LA #52, if she had read the droplet precaution sign before she went into the room? LA #52 responded, I was told we didn't have to wear that stuff to just put up the laundry. b) The facility's policy for Patient Hand Hygiene stated, Staff should assist patients/residents (hereinafter patient) with hand hygiene after toileting and before meals, as needed. c) On 01/05/2026 at 12:25 PM, Resident #86 received her tray with no hand hygiene completed. Nursing Assistant #38 confirmed there was no hand hygiene performed prior to lunch meal and stated, I've gotta go get some resident's eating and then she would go back to sanitize the resident's hands. On 01/05/2026 at 12:36 PM, Resident #97 was not offered hand hygiene prior to being served her lunch meal. Social Worker #36 confirmed the resident did not receive hand hygiene and stated they usually have packets .we just hand out trays.

Based on observation and staff interview the facility failed to store garbage and refuse in a proper manner. Two (2) of three 3 (three) dumpsters were over filled and the lids were not closed. This had the potential to affect more than an isolated number of residents that resided in the facility. Facility census: 111.Findings Included:a) On 01/07/26 at 2:50PM, during initial observation of the dumpsters, with the Corporate Interim Administrator (CIA), the following was observed:A dumpster located on the front side of the facility was overfilled with the inability to completely close the lid.In the rear of the facility where 2 (two) dumpsters were located, the left one was observed to be overfull with the inability to completely close the lid.On 01/07/26 at 2:55 PM during an interview with the CIA, he acknowledged the dumpsters were over filled and the lids were unable to be completely closed.

Based on observation, staff interview, and record review the facility failed to keep needed items in reach of residents and provide necessary assistance to help maintain residents independence by not keeping call lights in reach of residents. This failed practice was a random opportunity for discovery and affected a limited number of residents during the Long-Term Care Survey Process. Resident identifiers: #51, and #72. Facility Census: 111. Findings Include:a) Resident #51The initial observation on 01/05/26 at 12:15 PM, revealed Resident #51 lying in bed repeatedly saying, I hurt, I hurt. Resident #51's call light was lying behind her bed.During an observation and interview, on 01/05/26 at 12:25 PM, Licensed Social Worker (LSW) #56, confirmed that Resident #51's call light was not in reach and that she felt like she could use the call light.A record review, on 01/06/26 at 1:00 AM, revealed a Fall Care plan for Resident #51 with an intervention dated 12/27/23 that reads as follows: Encourage resident to use call bell for staff assistance.b) Resident #72The initial observation on 01/05/26 at 12:15 PM revealed Resident #72 in bed. The bed was in the upright position. Residents call light was draped over the head of her bed. The call light was not in reach of the resident.During an observation and interview on 01/05/26 at 12:25 PM, LSW #56, confirmed that Resident #72's call light was not in reach and that she felt like she could use the call light.A record review on 01/06/26 at 1:15 PM, revealed a Nutritional care plan for Resident #72 with an intervention created on 10/14/25 that reads as follows: Place call light within reach at all times.

Based on record review and staff interview the facility failed to provide bed hold notification for residents being discharged /transferred. This is true for two (2) of two (2) resident's reviewed for discharge/transfer. Resident identifiers, Resident #117 and Resident #115. Facility Census 111. Findings included: b) Resident #115 Medical chart was reviewed for a hospitalization. The facility did not provide a bed hold notification for the resident being discharged to the hospital. On 01/07/26 at 01:00PM, Social Worker #56 confirmed there was no bed hold notification and reported that the resident was going to discharge anyway to another facility. Social Worker #56 reported the resident went to the hospital and discharged from the hospital to another skilled nursing facility. The social worker stated, Nurses aren't so good here about the bed hold policy. b) Resident #117 On 1/06/26 at 02:36 PM this surveyor was reviewing documentation of transfer of resident to hospital from this facility and asked for the following documents: Behold Notice, Transfer Notice and Ombudsman Notification. The Bed hold Notice was not given to tis surveyor upon request. On 01/07/26 at 10:51 AM interview with Nursing Administration #82 she reported she notified the Ombudsman but did not send a Bed Hold Notice to the resident/responsible party. Review of document titled Accounts Receivable Policies and Procedures, Policy Title AR102 Bed-Holds, second paragraph read as follows: When a resident/ patient (resident') is transferred out of the Center to a hospital or on therapeutic leave, the designee will provide the resident/representative with the written Bed Hold Notice & Authorization form.

Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with a newly evident or a possible serious mental health disorder. This was true for one (1) out of three (3) sampled residents reviewed under the PASARR pathway during the Long-Term Care Survey Process. Resident identifier: #1. Facility census: 111 Findings included: a) Resident #1 Record review revealed the most recent PASARR was completed 07/28/25. Resident #1 was given new diagnoses of Bipolar disorder, depression, anxiety on 08/06/25. During staff interview on 01/06/26 at approximately 1:00 PM, the director of Social service reported, We use meditelecare for psych services, once they update a diagnosis I am informed to update the PASSARR. At end of the week they send us a report of who was seen and any change given. Review of facility policy revealed, Social services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if: 1:1 it is learned after admission that the Pre- admission Screening and Resident Review (PASRR) was not completed or is incorrect, or2:2 There is a significant change in status that results in new evidence of possible mental disorder, intellectual disability or a related condition. There was no evidence that the Director of Social service had initiated a new PASRR once new diagnosis was given.

Based on record review and staff interview, the facility failed to ensure a baseline care plan was developed and implemented with instructions needed to provide effective and person-centered quality care. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #126. Facility Census: 111 Findings included: Resident #126 On 01/05/26, the resident's care plan was initially reviewed for diet and nutritional information due to no diet order found on Resident #126's medical record. On the resident's Care Plan Report, the only focus documented was for resident assistance for mobility related to recent hospitalization. Upon further review, no care plan focus, goals or interventions were listed for behavior/emotions, dementia care, nutrition or psychotropic medications were found on the resident's initial care plan. The resident's care plan was updated on 01/05/26 following surveyor intervention. On 01/05/26 at 1:55 PM, the Corporate Compliance Officer confirmed the care plan had only one focus for mobility

Based on record review, interview and observation the facility failed to ensure a resident's care plan was revised in the areas of dialysis catheter and activities. Resident identifiers: #15 and #51. Facility Census: 111Findings included:a) Resident #15 On 01/07/26 a review of Resident #15's care plan revealed the following: Resident is scheduled for outpatient surgery on 10/21/25 to get dialysis catheter removed. Date initiated and created 10/19/25. Goals and interventions were also listed for time of procedure. On 01/07/26 2:38 PM, Resident #15 reported he had a dialysis catheter removed from his chest a few moths ago, around October and now has a fistula in his arm. He pulled down his shirt without being prompted and exposed the cite where his catheter once was and stated it had healed and that there were no issues. On 01/07/26 3:00 PM, Corporate Nurse #129 acknowledged that resident's care plan needed to be revised. b) Resident #51 The initial observation on 01/05/26 at 1:59 PM, revealed Resident #51 lying in her bed, saying repeatedly, I hurt, I hurt. There is no stimulation on in the room. Further observation on 01/06/26 at 2:00 PM, revealed Resident #51 lying in her bed, turned toward the separation curtain. No stimulation on in the room. A review on 01/07/26 at 9:30 AM, of Resident #51's Activity participation for the months of 11/2025, 12/2025, and 01/2026 to date, revealed that the resident has had a significant decrease in her activity participation. During the month of 11/2025 Resident #51 was documented for (5) five individual activities daily, and participated in at least one group activity weekly as well as accepting the {Daily Chronical Delivery} During the months of 12/2025 and 01/2026 to date, Resident #51 was documented for (2) two individual activities daily, and had refused, was asleep, or had no documentation for group activity participation Further record review of Resident #51's care plan, revealed an Activity Care plan with the last revision date of 02/12/25 that read as follows: Focus: (Resident #51 name) states that while in the facility, it isimportant that she has the opportunity toengage in meaningful activities of herpreferences. [NAME] enjoys walking up anddown the halls using her rollator. She likesto socialize and eat in the dining room.[NAME] is often confused about where she isand what is going on. She can becomeagitated when she cannot get out of thefront door, but is usually easy to distractand redirect. Goal:[NAME] will have opportunities tomake decisions/choices relatedto/for self-directed involvementin meaningful activities throughnext review. [NAME] will express satisfactiondaily with independent pursuitsdaily through next review. Interventions: Encourage and facilitate residents activities preferences such as watching tv,relaxing, walking the halls, and religious services. I would benefit from accommodation for physical limitations by using a FWW. Resident prefers to be called by [NAME]. During an interview on 01/07/26 at 10:11 AM, The Activity Director (AD), stated, Yes, she has had a big change, We was waiting to see if she got better to add her to one to one visits, because sometimes she bounces back. The AD further confirmed that Resident #51's participation had decreased since 11/2025 and she had not been added to one on one visits. The AD further confirmed that Resident #51's Activity care plan had no additional interventions added since 02/2025.

Based on observation, record review, and staff interview the facility failed to provide a program of activities to meet the interest of and support the physical, mental, and psychosocial well-being of each residents. This failed practice was found true for (2) two of (2) two residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #51, and #52. Facility Census 111. Findings Include: a) Resident #51 The initial observation on 01/05/26 at 1:59 PM, revealed Resident #51 lying in her bed, saying repeatedly, I hurt, I hurt. There was no stimulation in the room. Further observation on 01/06/26 at 2:00 PM, revealed Resident #51 lying in her bed, turned toward the separation curtain. No stimulation on in the room. A review on 01/07/26 at 9:30 AM, of Resident #51's Activity participation for the months of 11/2025, 12/2025, and 01/2026 to date, revealed that the resident has had a significant decrease in her activity participation. During the month of 11/2025 Resident #51 was documented for (5) five individual activities daily, and participated in at least one group activity weekly as well as accepting the {Daily Chronical Delivery} During the months of 12/25 and 01/26 to date, Resident #51 was documented for (2) two individual activities daily, and had refused, was asleep, or had no documentation for group activity participation Further record review of Resident #51's care plan, revealed an Activity Care plan with the last revision date of 02/12/25 that read as follows: Focus:(Resident #51 name) states that while in the facility, it is important that she has the opportunity to engage in meaningful activities of her preferences. [NAME] enjoys walking up and down the halls using her rollator. She likes to socialize and eat in the dining room. [NAME] is often confused about where she is and what is going on. She can become agitated when she cannot get out of thefront door, but is usually easy to distract and redirect. Goal:(Resident #51) will have opportunities to make decisions/choices related to/for self-directed involvement in meaningful activities through next review.(Resident #51) will express satisfaction daily with independent pursuits daily through next review. Interventions:Encourage and facilitate residents activities preferences such as watching tv,relaxing, walking the halls, and religious services.During an interview on 01/07/26 at 10:11 AM, The Activity Director (AD), stated, Yes, she has had a big change, We was waiting to see if she got better to add her to one-to-one visits, because sometimes she bounces back. The AD further confirmed that Resident #51's participation had decreased since 11/25 and she had not been added to one-on-one visits. The AD further confirmed that Resident #51's Activity care plan had no additional interventions added since 02/2025. b) Resident #52 The initial observation on 01/05/26 at 3:45 PM, revealed Resident #52's door shut, due to Covid precautions. Resident was lying in the bed. No stimulation was on in room. Further observation, on 01/06/26 at 1:30 PM, revealed Resident #52's door shut. Resident was lying in bed. A record review on 01/07/26 at 9:45 AM, revealed an Activities care plan for Resident #52 that read as follows: Focus:(Resident #52 name) exhibits or is at risk for limited and/or meaningful engagement related to: Cognitive loss/dementia. (Resident #52 name) does notwish to engage in group activities. He does enjoy some individual activities such associal and pet visits but spends most of his time resting in is room. Interventions include the following:( Resident #52 name) will be provided 2 to 3 one on one visits weekly.Further review of Resident #52's Activity Participation sheets for the months of 11/25, 12/25, and 01/25 to date revealed that the one-to-one visits were not completed as care planned, and the resident had not attended any group activities. During an interview on 01/07/26 at 10:15 AM, The AD stated, Yes, we are behind on our one-to-one visits because I am working on getting more staff.

Based on observation, record review, and staff interview the facility failed to ensure the environment in which it had control of to be as free from accident hazards as possible, by not ensuring fall prevention interventions were being followed. This failed practice was found true for (1) one of (3) three residents reviewed for falls during the Long-Term Care Survey Process. Resident identifier: #5. Facility census: 111.Findings Include: a) Resident #5 A record review, on 01/07/26 at 5:30 PM, revealed that from 10/01/25 to present, Resident #5 has had (6) six falls. One (1) fall with serious injury, and two (2) of the falls were from bed one causing a skin tear to her right eye. Further record review revealed a falls care plan that read as follows:Focus: Resident is at risk for falls: Impaired mobility.Fall on 08/30/25 no injuries.Fall on 09/15/25 no injuries notedFall on 10/31/25 no injuries notedFall on 11/12/25 no injuriesFall on 11/13/25 no injuriesFall on 12/8/25 no injuriesFall on 12/10/25 skin tear above R eye One of the interventions for falls initiated on 12/11/25 for a fall from bed, was bilateral fall mats to both side of the bed. An observation on 01/08/2026 8:40 AM, revealed Resident #5 lying in bed, no bilateral fall mats in place. During an interview and observation on 01/08/26 at 8:41 AM, The Director of Nursing (DON), confirmed that the fall mats were not in place, and stated, They might be getting cleaned, let me check. On 01/08/26 at approximately 8:45 AM, The Assistant Director of Nursing (ADON) was asked by State Agency (SA), Does the facility have spare fall mats to use, when other fall mats are being cleaned? The ADON replied, Yeah, we do. We put an order in and Maintenance brings them up.

Based on record review, staff interview and resident interview, the facility failed to ensure staff supports the nutritional well-being of the residents while respecting the individual's right to make choices about their diet and taking the resident's preference into consideration. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #24 and #97. Facility Census: 111. Findings included: a) The facility's policy and procedure for Dining and Food Preferences stated the resident's Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system. b) Resident #24 On 01/05/26 at 12:40 PM, Resident #24's tray card was reviewed. Apple Juice 8 oz was printed on the tray card. The resident did not have apple juice on her tray. The resident stated, I've never gotten apple juice. When I first came in they asked my preference, but did not get it. Administration Staff #120 confirmed the resident did not get apple juice ,but reported the resident asked for punch. c) Resident #97 On 01/05/26 at 12:40 PM, Resident # 97's tray card was reviewed. Chocolate milk - 1 cup - was printed on the tray card. The resident did not receive milk. Administration Staff #120 confirmed the resident did not have milk on her tray.

Based on record review and staff interview, the facility failed to ensure the facility assessment identified the staffing levels and training requirements needed to provide the necessary care and services for their residents. This deficient practice had the potential to affect more than a limited number of residents. Facility census: 106. Findings included: a) Facility Assessment A review of the Facility Assessment was completed on 03/11/24 at 9:27 PM. On page 20, Section II. Staffing, Training, Services & Personnel A.1. Function - Sufficiency Analysis Summary had the following guidance: Considerations: Use and/or refer to: 1. Staffing and scheduling systems 2. Staff training and competency program 3. A review of individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. Please document the total #/average/range of staff required to ensure a sufficient number of qualified staff are available to meet each resident's needs. Refer to the Staffing and Personnel Worksheet spreadsheet above for documentation assistance. Other than the guidance described above, there was nothing written under this section. On page 26, Section II. Staffing, Training, Services & Personnel B.1. Acuity - Sufficiency Analysis Summary had the following guidance: Considerations: Use and/or refer to: 1. Staffing and scheduling systems 2. Staff training and competency program 3. A review of individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. Please document total #/average/range of staff required to ensure a sufficient number of qualified staff were available to meet each resident's needs. Refer to the Staffing and Personnel Worksheet spreadsheet above for documentation assistance. Other than the guidance described above, there was nothing written under this section. On page 28, Section II. Staffing, Training, Services & Personnel C.1. - Cognitive - Sufficiency Analysis Summary had the following guidance: Considerations: Use and/or refer to: 1. Staffing and scheduling systems 2. Staff training and competency program 3. A review of individual staff assignments and systems for coordination and continuity of care for residents within and across staff assignments. Please document the total #/average/range of staff required to ensure a sufficient number of qualified staff are available to meet each resident's needs. Refer to the Staffing and Personnel Worksheet spreadsheet above for documentation assistance. Other than the guidance described above, there was nothing written under this section. There was no evidence the facility identified the type of staff members, other health care professionals, and medical practitioners that were needed to provide support and care for residents. There was no evidence the facility described their staffing plan/general approach to staffing to ensure that they would have sufficient staff to meet the needs of the residents at any given time. There was no evidence the facility described the staff training/education and competencies that would be necessary to provide the level and types of support and care needed for their resident population b) Interview with Administrator During an interview, on 03/12/24 at 2:00 PM, the Administrator agreed the facility reviewed their facility-wide assessment, which was meant to include both their resident population and the resources the facility needs to care for their residents. When asked to identify the areas in the Facility Assessment where the facility had determined the staffing level needed to meet resident needs, how the facility determined the skills and competencies required by those providing care, and where the facility had addressed the facility's training program to ensure any training needs were met for all new and existing staff, the Administrator indicated he would review the Facility Assessment and report back. On 03/12/24 at approximately 4:10 PM, the Administrator reported he felt the above-mentioned questions had been addressed in the B.1. Acuity - Sufficiency Analysis Summary and C.1. - Cognitive - Sufficiency Analysis Summary sections.

Based on resident and staff interviews, the facility failed to ensure each resident had reasonable and ready access to their personal funds held by the facility. This was true for four (4) out of 11 residents that were interviewed during the resident council meeting. This had the potential to affect more than a limited number of residents. Facility census: 106. Findings included: a) Resident Council At approximately 3:00 PM on 03/12/24, a resident council meeting was held at the facility. During that meeting, four (4) residents in attendance expressed concerns about personal funds held by the facility. Residents stated that obtaining money on the evenings and weekends was difficult, with one resident stating I'm not even sure we can get the money after they leave the offices for the day, so the weekend wouldn't be possible. Another resident stated outings had to be canceled the day of the event, on more than one occasion, because the facility did not have money for the residents to take. At approximately 12:50 PM on 03/13/24, an interview was conducted with Receptionist #107 regarding personal funds for the residents. Receptionist #107 stated they handled disbursement of funds along with the business office. Receptionist #107 stated the facility kept an emergency fund in the amount of $50 in the assisted living portion of the facility for residents to access on nights and weekends. Receptionist #107 stated residents would be limited in what they could obtain on nights and weekends, and that staff would have to ration the money in case other residents wanted money out of the emergency fund. Receptionist #107 stated all staff were aware of the emergency fund and how to access it. Regarding canceled outings due to the facility not being able to provide residents with their personal funds, Receptionist #107 stated, There was a time a while ago there wasn't enough money for residents to go on the outing, so it had to be canceled. I'm not sure why there wasn't enough. As far as I know, there have been a couple different times this has happened. At approximately 12:57 PM on 03/13/24, an interview was conducted with Licensed Practical Nurse (LPN) #140 and Licensed Practical Nurse (LPN) #20 concerning resident funds. Both said they were there until at least 7:00 PM, and sometimes later if they were mandated. LPN #140 stated, I'm not going to lie, I have no idea how residents would get money in the evenings or weekends after the people leave the offices up front. I would guess they would have to wait until the next day, or if it is a weekend, they would have to wait until Monday. LPN #20 stated, I would tell them they would have to either wait until the next day, or Monday if it were a weekend, to get their money, if there wasn't anyone in the offices up front. At approximately 1:00 PM on 03/13/24, an interview was conducted with Registered Nurse (RN) #28 and LPN #37 concerning resident funds. LPN #37 stated, I have no idea what to do if a resident wants money on evenings or weekends. RN #28 stated, We are not allowed to handle resident funds. They would probably have to wait until the next day or Monday when the staff were back in the offices. We have a nurse on call that we could always call during those times and find out what to do if they asked for money, but as far as I know they would have to wait because we can't handle their money.

Based on observation, resident interview and staff interview, the facility failed to ensure the living areas for residents were clean, safe, and sanitary; failed to ensure furniture was in good repair; failed to clean and/or change the P-Tac (packaged terminal air conditioner) vents (filters on the heat and air conditioners that are in each room.); and leaving a large amount of transparent type on a resident wheelchair. Resident identifiers: #35, #90. The facility census 106. Findings included: a) P-Tac vents During a tour on 03/12/24 at 2:34 PM of Rooms #301, #302, #303, #304, and #305 it was discovered the P-Tac vents were heavily soiled with a thick layer of debris. The above findings were verified on 03/12/24 at 2:54 PM with Maintenance Helper (MH) #43. MH #43 said the P-Tacs should be cleaned or replaced monthly. He went on to say it should be documentation of when it was last done on a form, he referred to Direct Supplies Tell MH #43 did not provide this documentation at the close of the survey. According to the records provided it was last marked as done on 01/12/24. b) Poor quality furniture An interview with the Administrator (NHA) on 03/11/24 at 1:05 PM two nightstands in the hallway on top of a bed pointed out the furniture was peeling exposing particle boards and therefore could not be cleaned properly. The NHA stated the facility had more and would replace it with better quality furniture. On 03/13/24 at 1:04 PM it was pointed out to the NHA the same two (2) nightstands that were previously in the hallway on top of a bed were now in room [ROOM NUMBER] being used along with two other nightstands. All four (4) had exposed particle board. Upon further observations on 03/13/24 at 2:22 PM it was found the following rooms also had nightstands in poor condition in room [ROOM NUMBER], #205, #306, #305, and 321. On 03/13/24 at 2:35 PM the above findings were verified by the Director of Nursing. c) Damaged ceilings On 03/11/24 11:18 AM it was discovered room [ROOM NUMBER] had a leaking ceiling. Resident #90 said it has been an ongoing problem for two (2) months. There was dark brown staining on the ceiling above the windows and that was the length of the wall. It was approximately two (2) feet wide. There was a large plastic barrel trash can and two gray basins on a table to catch rainwater. Resident #90 was saying she has looked at the stains so long she sees a duck swimming to a log and a big bird flying in the stain. Resident #90 said they (maintenance) have put tar on the roof several times, but it still leaks. On 03/12/24 at 3:02 PM Housekeeping Aide (HA) stated that Resident #22 was just now moved to another room, but her clothes and other belongings were still in there. On 03/12/24 at 3:04 PM it was discovered room [ROOM NUMBER] had a leaking ceiling and the plaster had fallen from the ceiling. The ceiling was over 70 percent discolored. The discolored ceiling had rings of brown staining and a black substance showing in many places. The missing plaster and bowed exposed sheet rock was in the middle of the room. There were tall black trash cans in the middle of the floor with bath blankets under them that also had brown rings, along with chunks of plaster that had fallen from the ceiling scattered around the room. The room had a very strong odor of musky mildew. On 03/12/24 at 3:37 PM MH #43 and the District Maintenance Manager (DMM) #158 arrived at room [ROOM NUMBER]. They were asked when did the leak start? MH #43 state on Saturday 03/09/24. MH #43 was informed that Resident #90 that is in room [ROOM NUMBER] said her ceiling had been leaking for more than two (2) months. On 03/13/24 at 8:20 AM MH #43 provided a work order that was entered on 01/28/24 by the NHA for room [ROOM NUMBER]. There was not any other evidence that any other staff had informed the maintenance department of 301 was leaking as well. Resident #22 refused to be interviewed on 03/11/24 at 12:09 PM and began yelling. Therefore, not wanting to upset the resident any further, no statement was obtained. On 03/12/24 at 4:10 PM the NHA was asked when he was made aware of the condition of room [ROOM NUMBER]. The NHA stated he was told there was a leak in the room on Saturday 03/09/24. He was asked if Resident #22 should have been moved to a safer room on Saturday? The Administrator agreed the room had a very pungent odor. The large trash cans and stained peeling ceiling was also pointed out. On 03/12/24 at 4:15 PM the NHA was shown room [ROOM NUMBER] as well. Resident #90 was in her room and spoke to the NHA. On 03/13/24 at 8:20 AM the NHA informed this surveyor that Resident #90 was also moved to another room and the Maintenance crew are currently removing the ceiling in room [ROOM NUMBER] and 301 will be started on after 303 was completed. d) Wheelchair armrest On 03/11/24 at 12:22 PM, Resident #35 was seen in the hallway in his wheelchair. It was noted on the right armrest there was a large amount of tape clear (Office tape) wrapped around the armrest holding a cup holder to the armrest. Resident #35 stated one of the aides helped him put the cup holder on his wheelchair. Licensed Practical Nurse (LPN) #16 stated she would put a work order in to have it properly attached. On 03/12/24 at 2:06 PM, Cooperate Nurse #157 was shown the tape was still hanging off of the armrest. On 03/13/24 at 10:20 AM Resident #35 was in his wheelchair and was very happy about the tape not being on his wheelchair and his cup hold was now attached very securely. 42120

Based on medical record review, policy and procedure review, accident/incident reports review, resident interviews and staff interviews, the facility failed to ensure incidents of verbal abuse, physical abuse and sexual harassment were identified, thoroughly investigated and reported to the appropriate State agencies. The facility's failure to identify and investigate allegations of verbal abuse, physical abuse, psychological abuse, and sexual harassment also resulted in a failure to ensure alleged victims were protected from further abuse, resulting in actual harm. These finding affected more than a limited number of residents residing in the facility. Resident identifiers: #127, #13, #96, #136, and #45. Alleged perpetrator: #86. Facility census: 88. Findings include: The following information was discovered in a review of Resident #86's nursing progress notes of occurrences of behaviors toward other residents. a) Resident #13 Review of the resident's medical record on 08/02/17 at 1:35 p.m. revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) performed on 06/05/17 revealed a score of 11 meaning Moderately impaired cognition. Review of the grievances/concern forms on 08/02/17 at 8:00 a.m. found grievance/concern forms dated: -- 06/15/17 (typed as written): (Name of Resident #13) stated that when he is going by room [ROOM NUMBER] (room of Resident #86 and near the dining room), that the man in the cowboy hat yells things at me. He (Resident #86) said, Get the f---- out of the hallway! (Name of Resident #13) said that he shouldn't have to listen to that or worry about it. -- 06/16/17 (typed as written): MSW (Masters of Social Work) and CED (Administrator) met with resident (Resident #86) to discuss another resident's (Resident #13) concern that he (Resident #86) had been cursing and yelling at him (Resident #13) in the hallway. Informed resident (Resident #86) that this behavior is inappropriate and cannot continue. Resident (Resident #86) verbalized understanding but also indicated the behavior would continue should he feel it needed AEB (as evidenced by) him stating And I'll do it again. Resident (Resident #86) verbalized he felt as if he were protecting another resident. SS (social services) will follow as needed. Resident #13 stated during an interview on 08/07/17 at 3:30 p.m., regarding the incident that occurred on 06/15/17, that it, Made me afraid because didn't know what he was going to do. That was abusive to me and my roommate told me that is called verbal abuse and that is exactly what it was. Didn't feel the facility did that much about it. The staff did not tell me anything other than they did speak to him. Well it didn't help because once or twice since then he has yelled and cussed at me when I went out in the hall even with staff. Now I am afraid to come out of my room and to go down the hallway even with staff. His room is close to the dining room so I don't want to go there for meals either because I don't know what he will do to me. This grievance/concern was not recognized or identified as abuse by the facility, lacked a thorough investigation including witness statements, and was not reported to the appropriate State agencies as per facility policy and federal guidelines. Furthermore, the failure to identify these occurrences as abuse and to protect Resident #13 from additional abuse resulted in psychological harm to Resident #13. b) Resident #127 Review of the resident's medical record on 08/02/17 at 10:30 a.m. revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A BIMS performed on 07/26/17 revealed a score of 03 meaning severe impaired cognition. He was unable to be interviewed during the survey due to impaired cognition. On 08/02/17 at 1:35 p.m. a review of the nursing progress notes for Resident #86 revealed the following occurrences involving Resident #127: -- 05/11/17 late entry for 05/09/17 (typed as written): Resident (Resident #86) was done eating and was sitting at his table and usually he leaves right after he is done. Brought in resident (Resident #127) to sit at his table for second seating at the empty space he (Resident #86) yelled and stated let me get the hell out of here. He isn't suppose to sit at my table. Informed nursing. -- 05/11/17 (typed as written): Today at lunch resident (Resident #86) was yelling at another resident (Resident #127) for standing up. Resident (Resident #86) goes over to the resident (Resident #127) standing up calling him names and stated if he (Resident #127) didn't sit down he (Resident #86) would knock him down. Went back and got the social worker again. Informed nursing of the incident. -- 06/22/17 (typed as written): During lunch today (first name of Resident #86 was done eating and his tablemate was done eating and had already left. Went to bring in the second seating and sat him (Resident #127) at the table and (first name of Resident #86) started yelling and threw his clothing protector at the other resident (Resident #127). Told (first name of Resident #86) that was inappropriate to throw something at another resident. The other resident's (Resident #127) wife was with him. He (Resident #86) does this at the lunch meal and at times at dinner. Reported to the Administrator. -- 06/23/17 (typed as written): During lunch today (first name of Resident #86) and his table mate was finished with their lunch and his table mate had already left. I asked (first name of Resident #86) if he was finished with his lunch and he stated yes. When I went to clear the table (first name of Resident #86) started yelling that no bastard was sitting at the table and he would flip the f***king table over if I tried to sit someone there. I explained to him that he was finished and other residents needed their lunch, he left the dining room saying if he came back up the hall and the bastard was sitting there he would flip the f***king table over. This incident involved Resident #127 coming to sit at the table and for a cognitively intact person, would result in psychological harm. c) Resident #96 On 08/02/17 at 1:35 p.m. a review of the nursing progress notes for Resident #86 revealed the following occurrences involving Resident #96: -- 07/15/17 (typed as written): Resident (Resident #86) in room in wheelchair when another resident (Resident #96) coming down hallway, nurse on right side of other resident (Resident #96) in between other resident (Resident #96) and this resident's (Resident #86) door. (Name of Resident #86) began yelling and making threats directed toward other resident (Resident #96). This nurse proceeded to keep conversation with other resident (Resident #96) as to avoid other resident (Resident #96) calling attention to (name of Resident #86). (Name of Resident #86) continued to verbally threatened other resident (Resident #96) until other resident (Resident #96) was out of hearing distance. All attempts at redirection unsuccessful, resident (Resident #86) continues to yell out doorway cursing fell ow resident at this time Review of the medical record on 08/07/17 at 3:45 p.m. revealed Resident #96 was admitted on [DATE] with a recent re-admission on 02/16/17. His [DIAGNOSES REDACTED]. His most recent BIMS was coded as 13 on 06/29/17 indicating he was cognitively intact. During an interview with Resident #96 on 08/08/17 at 10:11 a.m., he stated, (Name of Resident #86) tried to ram me with his wheelchair, yelling and cursing when I was going down the hallway and has really been terrorizing other residents. The incident made me angry that this would happen because he had a shoe horn which he threatened to hit me with and cut me. He did hit my chair and would have hit my arm if I hadn't moved it off of the arm rest. I went to the nurses about it and all they said was that he wouldn't give it to them so they said there is nothing they can do about it. When inquired if he had reported this to the administrator or social services he stated, There is no need they never do anything about it, just say that is the way he is. Next time I will just call the cops because my brother is a retired cop and now a magistrate in (name of a nearby town) and he said that is verbal abuse and assault. Will just let the cops do something about it since this place won't do anything and doesn't care that we are being abused and terrorized by him. It is very upsetting to have to go down the hall and wonder if he is going to verbally or physically attack you. I am afraid for other residents like those people that are confused and won't go down the hallway just stay in their room. For me just don't like it is right to be in a nursing home and worry about being abused or assaulted. The medical record review for Resident #96 and #86 was found silent for the occurrence referenced as assault in Resident #96's interview. The facility's failure to identify abuse and to protect residents resulted in psychological harm, and fear of physical harm to Resident #96. In addition, Resident #96 expressed fear for cognitively impaired residents residing in the facility. d) Resident #136 On 08/02/17 at 1:35 p.m. a review of the nursing progress notes for Resident #86 revealed the following occurrences involving Resident #136: -- 07/13/17 (typed as written) SW (social worker) and Administrator met with (first name of Resident #86) regarding verbalizations from an alert but confused female resident that she feels uncomfortable around the man in the cowboy hat. Resident (Resident #86) initially did not acknowledge which resident we were talking about but then did recall trying to help get a tangle out of her (Resident #136) hair one day. Resident verbalized understanding of request and said he would not have any contact with her. A review of the incident/accident forms, grievances/concern forms did not reveal any forms related to the previous progress note documentation. The facility failed to recognize this occurrence as sexual harassment although the definition for sexual harassment includes, unwanted physical touching that makes a person uncomfortable. Review of the medical record on 08/07/17 at 3:20 p.m. revealed Resident #136 was admitted on [DATE] with a recent re-admission on 07/25/17. Her [DIAGNOSES REDACTED]. Her most recent BIMS was coded as 03 on 06/28/17, indicating severe cognitive impairment. She was unable to be interviewed during the survey due to impaired cognition. e) Resident #86 Review of the resident's medical record on 08/02/17 at 1:35 p.m. revealed Resident #86 was originally admitted on [DATE] and the most recent re-admission on 04/08/17 following a hospitalization . His [DIAGNOSES REDACTED]. He had been determined by his attending physician to have capacity to make his own medical decisions. Most recently assessed on 07/05/17 to have a BIMS score of 15 showing him to be cognitively intact Employee #K reported during a confidential interview that Resident #86 is rude and mean to other residents especially the residents with dementia like (name of Resident #127). It is certainly considered verbal abuse and he is sometimes physically abusive to other residents, I know that, but it just keeps happening with no consequences. We all report it to the nurses, supervisors, and social service, but no one does anything about it. They just say, 'Oh, that is just the way he is,' but one of these days he is going to really hurt someone. He has targeted (Resident #13) because of his race to the point he (Resident #13) is scared to come out of his room. Those are just a few of the residents afraid of him, but you will never find out who they are because none of the nurses chart anything anymore because they said is a waste of their time when nothing is ever done about it. I hope this new administrator changes things because the residents should not have to put up with abuse all the time. During a confidential interview with Employee #W, she stated, (Name of Resident #86) perceives himself as a southern gentleman and seemed to target (name of Resident #13) due to his race according to (Resident #13). Which could be due to his (Resident #86) upbringing and culture, but should not have been allowed to happen. It should have been documented as an incident and reported to the state as verbal abuse at least. No psychiatric services or treatment have been attempted or made available for this resident since he has been here, I think he was here since 2014. Not really sure he would be receptive to any psychiatric services, but it should have at least been attempted and offered because of how he treats other residents. He yells, screams and curses other residents, rams them with his wheelchair and threatens to hit them or cause bodily harm. I agree that we as a facility have not been protecting residents from abuse as a whole by (Resident #86) or any other resident with behaviors like this. The progress notes you found are probably only a handful of actual incidents that have occurred in the facility for all residents because most of them don't even get documented anywhere by staff. Yes, the dining room incident and also any incident involving where (Resident #86) was yelling, screaming and cursing at a resident is considered verbal abuse and should have been reported because every staff member here is a mandatory reporter, but we dropped the ball on all of the reporting of behaviors by residents. We have just really been lax and have not addressed resident behaviors in this facility because we just say that is just the way they are and let it go. We should not have been as lax or accepting of these behaviors because we did put our other residents at risk and allowed them to be abused. Agree that no psychiatric evaluations or treatment were initiated for the residents with behaviors which caused not only neglect on the facility part for treatment and management but also allowed abuse of other residents in our facility under our watch. I do admit this is sad and shameful on all of the staff and management here to have allowed this to happen because we did not think about it being abuse and could have helped all residents by getting the residents with behaviors help and keep the other residents safe. Some of the residents (Resident #86) has had incidents with were residents who have dementia and not able to help their actions. These other residents are not cognitively able to defend themselves and depend on the facility to keep them safe. On 08/08/17 at 8:55 a.m., Social Worker (SW) #5 explained social services had not been involved in clinical meetings in the past and were unaware of behavioral incidents because these were handled by nursing. Under the new administration, social services would be included not only in morning meetings, but also daily clinical meetings so they would have knowledge of incidents and could report them as they were brought to the attention of Social Services. After review of the progress notes for Resident #86 involving incidents of behaviors directed toward other residents and staff, SW #5 stated, I was not aware of all of these, would have completed incidents reports for these and reported them to the state agencies for verbal abuse. She further stated, The previous administrator attempted to involve the daughter with his behaviors, but it didn't go anywhere. Upon inquiry regarding her role in the treatment of [REDACTED].#86, she stated, My hands were tied by the previous administration. The new facility Administrator (who began this position on 07/31/17) acknowledged residents' behaviors and reported their needs were not being met, during an interview on 08/08/17 at 10:10 a.m. He stated, This is something that will be a priority due to having several residents with behaviors that need to be evaluated and their actions addressed. After review of the previously referenced progress notes he agreed all of these should have been documented, investigated and reported. This will certainly be done under my administration. On 08/08/17 at 10:30 a.m., review of the facility's policy titled OPS300 Abuse Prohibition found it included the following excerpts (typed as written): POLICY (Name of corporation) will prohibit abuse, mistreatment . for all residents . The center will implement an abuse prohibition program through the following: -- Prevention of occurrences; -- Identification possible incidents or allegations which need investigation; -- Investigation of incidents and allegations; -- Reporting of incidents, investigations and Center response to the results of their investigations. Federal Definitions: Abuse is defined as the willful inflicting injury, .or mental anguish . Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . It includes verbal abuse . Willful, as used in this definition of abuse, means the individual must have have acted deliberately . -- Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families . -- Sexual Abuse is a non-consensual sexual contact of any type with a resident. It includes but is not limited to sexual harassment, sexual coercion or sexual assault. -- Mental Abuse includes, but not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur either verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation , or degradation . -- Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Process 5.1 Anyone who witnesses an incident of suspected abuse, neglect . is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED or designee will perform the following . 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made . Review of the incident/accident forms, grievances/concerns forms, and incidents reported to State agencies, found them silent for the previously referenced nursing progress notes except where identified - indicating the facility did not document on the appropriate forms, did not conduct investigations and/or thorough investigations including witness statements, and did not report allegations of abuse which include allegations of verbal and physical abuse, and an allegation of possible sexual harassment. e) Resident #45 The resident was [AGE] years of age. He was admitted to the facility on [DATE] and subsequently discharged on [DATE]. He went into [MEDICAL CONDITION] during [MEDICAL TREATMENT] and passed away at the hospital. Review of complaints/grievances on 08/07/17 at 11:47 a.m. found a complaint filed by Resident #45 on 05/10/17. He told a Licensed Practical Nurse (LPN) a Nursing Assistant was rude to him and cursed at him when he attempted to get a cup from the drinking cart (nurses' cart) and a couple of cups fell on to the floor. Neither the LPN or the Nursing Assistant were current employees. The investigation included a witness statement by the Nursing Assistant who allegedly cursed at him. She stated he was getting cups off the nurses' cart and she told him he could not get into the nurses' cart. She also said, I didn't curse at resident. The investigator met with the resident and told him the issue was addressed with the employee and explained infection control issues. He was told if he needs a cup to ask staff for it related to infection control. The investigator wrote He voiced understanding and I assured him administration would speak with said CNA. He was ok with this. The complaint was not recognized as an allegation of verbal abuse and therefore was never reported. During an interview on 08/08/17 at 11:21 a.m., Administrator #111 agreed the complaint was an allegation of verbal abuse and should have been reported.

Based on medical record review, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, the facility failed to implement its written policies and procedures for the prohibition and prevention of allegations of verbal and physical abuse and/or neglect. The facility failed to identify and/or recognize allegations resident to resident behavior as verbal abuse, physical abuse, or sexual harassment. In addition, the facility failed to complete documentation of incidents, have evidence of investigations and/or thorough investigations, and failed to report allegations to the appropriate State agencies of occurrences involving alleged resident to resident abuse. Resident #86, had documented behaviors in the nursing progress notes of yelling, screaming, cursing, and physical aggression toward other residents including an allegation of possible sexual harassment. Residents (#127, #13, and #96) were subjected to repeated verbal and/or physical abuse and Resident #136 experienced possible sexual harassment. These types of behaviors caused actual and potential psychosocial harm, mental anguish and/or emotional harm to residents, using the terms and verbiage afraid, uncomfortable, verbal abuse and physical assault causing them to be fearful in the facility and afraid to come out of their rooms. Additionally, the facility failed to report and investigate an allegation of verbal abuse of a resident (#45) by staff. These finding affected more than a limited number of residents residing in the facility. Resident identifiers: #127, #13, #96, #136, and #45. Alleged perpetrator: #86. Facility census: 88. Findings include: The following information was discovered in a review of Resident #86's nursing progress notes of occurrences of behaviors toward other residents. a) Resident #13 b) Resident #13 Review of the resident's medical record on 08/02/17 at 1:35 p.m. revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) performed on 06/05/17 revealed a score of 11 meaning Moderately impaired cognition. Review of the grievances/concern forms on 08/02/17 at 8:00 a.m. found grievance/concern forms dated: -- 06/15/17 (typed as written): (Name of Resident #13) stated that when he is going by room [ROOM NUMBER] (room of Resident #86 and near the dining room), that the man in the cowboy hat yells things at me. He (Resident #86) said, Get the f---- out of the hallway! (Name of Resident #13) said that he shouldn't have to listen to that or worry about it. -- 06/16/17 (typed as written): MSW (Masters of Social Work) and CED (Administrator) met with resident (Resident #86) to discuss another resident's (Resident #13) concern that he (Resident #86) had been cursing and yelling at him (Resident #13) in the hallway. Informed resident (Resident #86) that this behavior is inappropriate and cannot continue. Resident (Resident #86) verbalized understanding but also indicated the behavior would continue should he feel it needed AEB (as evidenced by) him stating And I'll do it again. Resident (Resident #86) verbalized he felt as if he were protecting another resident. SS (social services) will follow as needed. Resident #13 stated during an interview on 08/07/17 at 3:30 p.m., regarding the incident that occurred on 06/15/17, that it, Made me afraid because didn't know what he was going to do. That was abusive to me and my roommate told me that is called verbal abuse and that is exactly what it was. Didn't feel the facility did that much about it. The staff did not tell me anything other than they did speak to him. Well it didn't help because once or twice since then he has yelled and cussed at me when I went out in the hall even with staff. Now I am afraid to come out of my room and to go down the hallway even with staff. His room is close to the dining room so I don't want to go there for meals either because I don't know what he will do to me. This grievance/concern was not recognized or identified as abuse by the facility, lacked a thorough investigation including witness statements, and was not reported to the appropriate State agencies as per facility policy and federal guidelines. Furthermore, the failure to identify these occurrences as abuse and to protect Resident #13 from additional abuse resulted in psychological harm to Resident #13. c) Resident #127 Review of the resident's medical record on 08/02/17 at 10:30 a.m. revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A BIMS performed on 07/26/17 revealed a score of 03 meaning severe impaired cognition. He was unable to be interviewed during the survey due to impaired cognition. On 08/02/17 at 1:35 p.m. a review of the nursing progress notes for Resident #86 revealed the following occurrences involving Resident #127: -- 05/11/17 late entry for 05/09/17 (typed as written): Resident (Resident #86) was done eating and was sitting at his table and usually he leaves right after he is done. Brought in resident (Resident #127) to sit at his table for second seating at the empty space he (Resident #86) yelled and stated let me get the hell out of here. He isn't suppose to sit at my table. Informed nursing. -- 05/11/17 (typed as written): Today at lunch resident (Resident #86) was yelling at another resident (Resident #127) for standing up. Resident (Resident #86) goes over to the resident (Resident #127) standing up calling him names and stated if he (Resident #127) didn't sit down he (Resident #86) would knock him down. Went back and got the social worker again. Informed nursing of the incident. -- 06/22/17 (typed as written): During lunch today (first name of Resident #86 was done eating and his tablemate was done eating and had already left. Went to bring in the second seating and sat him (Resident #127) at the table and (first name of Resident #86) started yelling and threw his clothing protector at the other resident (Resident #127). Told (first name of Resident #86) that was inappropriate to throw something at another resident. The other resident's (Resident #127) wife was with him. He (Resident #86) does this at the lunch meal and at times at dinner. Reported to the Administrator. -- 06/23/17 (typed as written): During lunch today (first name of Resident #86) and his table mate was finished with their lunch and his table mate had already left. I asked (first name of Resident #86) if he was finished with his lunch and he stated yes. When I went to clear the table (first name of Resident #86) started yelling that no bastard was sitting at the table and he would flip the f***king table over if I tried to sit someone there. I explained to him that he was finished and other residents needed their lunch, he left the dining room saying if he came back up the hall and the bastard was sitting there he would flip the f***king table over. This incident involved Resident #127 coming to sit at the table and for a cognitively intact person, would result in psychological harm. d) Resident #96 On 08/02/17 at 1:35 p.m. a review of the nursing progress notes for Resident #86 revealed the following occurrences involving Resident #96: -- 07/15/17 (typed as written): Resident (Resident #86) in room in wheelchair when another resident (Resident #96) coming down hallway, nurse on right side of other resident (Resident #96) in between other resident (Resident #96) and this resident's (Resident #86) door. (Name of Resident #86) began yelling and making threats directed toward other resident (Resident #96). This nurse proceeded to keep conversation with other resident (Resident #96) as to avoid other resident (Resident #96) calling attention to (name of Resident #86). (Name of Resident #86) continued to verbally threatened other resident (Resident #96) until other resident (Resident #96) was out of hearing distance. All attempts at redirection unsuccessful, resident (Resident #86) continues to yell out doorway cursing fell ow resident at this time Review of the medical record on 08/07/17 at 3:45 p.m. revealed Resident #96 was admitted on [DATE] with a recent re-admission on 02/16/17. His [DIAGNOSES REDACTED]. His most recent BIMS was coded as 13 on 06/29/17 indicating he was cognitively intact. During an interview with Resident #96 on 08/08/17 at 10:11 a.m., he stated, (Name of Resident #86) tried to ram me with his wheelchair, yelling and cursing when I was going down the hallway and has really been terrorizing other residents. The incident made me angry that this would happen because he had a shoe horn which he threatened to hit me with and cut me. He did hit my chair and would have hit my arm if I hadn't moved it off of the arm rest. I went to the nurses about it and all they said was that he wouldn't give it to them so they said there is nothing they can do about it. When inquired if he had reported this to the administrator or social services he stated, There is no need they never do anything about it, just say that is the way he is. Next time I will just call the cops because my brother is a retired cop and now a magistrate in (name of a nearby town) and he said that is verbal abuse and assault. Will just let the cops do something about it since this place won't do anything and doesn't care that we are being abused and terrorized by him. It is very upsetting to have to go down the hall and wonder if he is going to verbally or physically attack you. I am afraid for other residents like those people that are confused and won't go down the hallway just stay in their room. For me just don't like it is right to be in a nursing home and worry about being abused or assaulted. The medical record review for Resident #96 and #86 was found silent for the occurrence referenced as assault in Resident #96's interview. The facility's failure to identify abuse and to protect residents resulted in psychological harm, and fear of physical harm to Resident #96. In addition, Resident #96 expressed fear for cognitively impaired residents residing in the facility. e) Resident #136 On 08/02/17 at 1:35 p.m. a review of the nursing progress notes for Resident #86 revealed the following occurrences involving Resident #136: -- 07/13/17 (typed as written) SW (social worker) and Administrator met with (first name of Resident #86) regarding verbalizations from an alert but confused female resident that she feels uncomfortable around the man in the cowboy hat. Resident (Resident #86) initially did not acknowledge which resident we were talking about but then did recall trying to help get a tangle out of her (Resident #136) hair one day. Resident verbalized understanding of request and said he would not have any contact with her. A review of the incident/accident forms, grievances/concern forms did not reveal any forms related to the previous progress note documentation. The facility failed to recognize this occurrence as sexual harassment although the definition for sexual harassment includes, unwanted physical touching that makes a person uncomfortable. Review of the medical record on 08/07/17 at 3:20 p.m. revealed Resident #136 was admitted on [DATE] with a recent re-admission on 07/25/17. Her [DIAGNOSES REDACTED]. Her most recent BIMS was coded as 03 on 06/28/17, indicating severe cognitive impairment. She was unable to be interviewed during the survey due to impaired cognition. f) Resident #86 Review of the resident's medical record on 08/02/17 at 1:35 p.m. revealed Resident #86 was originally admitted on [DATE] and the most recent re-admission on 04/08/17 following a hospitalization . His [DIAGNOSES REDACTED]. He had been determined by his attending physician to have capacity to make his own medical decisions. Most recently assessed on 07/05/17 to have a BIMS score of 15 showing him to be cognitively intact Employee #K reported during a confidential interview that Resident #86 is rude and mean to other residents especially the residents with dementia like (name of Resident #127). It is certainly considered verbal abuse and he is sometimes physically abusive to other residents, I know that, but it just keeps happening with no consequences. We all report it to the nurses, supervisors, and social service, but no one does anything about it. They just say, 'Oh, that is just the way he is,' but one of these days he is going to really hurt someone. He has targeted (Resident #13) because of his race to the point he (Resident #13) is scared to come out of his room. Those are just a few of the residents afraid of him, but you will never find out who they are because none of the nurses chart anything anymore because they said is a waste of their time when nothing is ever done about it. I hope this new administrator changes things because the residents should not have to put up with abuse all the time. During a confidential interview with Employee #W, she stated, (Name of Resident #86) perceives himself as a southern gentleman and seemed to target (name of Resident #13) due to his race according to (Resident #13). Which could be due to his (Resident #86) upbringing and culture, but should not have been allowed to happen. It should have been documented as an incident and reported to the state as verbal abuse at least. No psychiatric services or treatment have been attempted or made available for this resident since he has been here, I think he was here since 2014. Not really sure he would be receptive to any psychiatric services, but it should have at least been attempted and offered because of how he treats other residents. He yells, screams and curses other residents, rams them with his wheelchair and threatens to hit them or cause bodily harm. I agree that we as a facility have not been protecting residents from abuse as a whole by (Resident #86) or any other resident with behaviors like this. The progress notes you found are probably only a handful of actual incidents that have occurred in the facility for all residents because most of them don't even get documented anywhere by staff. Yes, the dining room incident and also any incident involving where (Resident #86) was yelling, screaming and cursing at a resident is considered verbal abuse and should have been reported because every staff member here is a mandatory reporter, but we dropped the ball on all of the reporting of behaviors by residents. We have just really been lax and have not addressed resident behaviors in this facility because we just say that is just the way they are and let it go. We should not have been as lax or accepting of these behaviors because we did put our other residents at risk and allowed them to be abused. Agree that no psychiatric evaluations or treatment were initiated for the residents with behaviors which caused not only neglect on the facility part for treatment and management but also allowed abuse of other residents in our facility under our watch. I do admit this is sad and shameful on all of the staff and management here to have allowed this to happen because we did not think about it being abuse and could have helped all residents by getting the residents with behaviors help and keep the other residents safe. Some of the residents (Resident #86) has had incidents with were residents who have dementia and not able to help their actions. These other residents are not cognitively able to defend themselves and depend on the facility to keep them safe. On 08/08/17 at 8:55 a.m., Social Worker (SW) #5 explained social services had not been involved in clinical meetings in the past and were unaware of behavioral incidents because these were handled by nursing. Under the new administration, social services would be included not only in morning meetings, but also daily clinical meetings so they would have knowledge of incidents and could report them as they were brought to the attention of Social Services. After review of the progress notes for Resident #86 involving incidents of behaviors directed toward other residents and staff, SW #5 stated, I was not aware of all of these, would have completed incidents reports for these and reported them to the state agencies for verbal abuse. She further stated, The previous administrator attempted to involve the daughter with his behaviors, but it didn't go anywhere. Upon inquiry regarding her role in the treatment of [REDACTED].#86, she stated, My hands were tied by the previous administration. The new facility Administrator (who began this position on 07/31/17) acknowledged residents' behaviors and reported their needs were not being met, during an interview on 08/08/17 at 10:10 a.m. He stated, This is something that will be a priority due to having several residents with behaviors that need to be evaluated and their actions addressed. After review of the previously referenced progress notes he agreed all of these should have been documented, investigated and reported. This will certainly be done under my administration. On 08/08/17 at 10:30 a.m., review of the facility's policy titled OPS300 Abuse Prohibition found it included the following excerpts (typed as written): POLICY (Name of corporation) will prohibit abuse, mistreatment . for all residents . The center will implement an abuse prohibition program through the following: -- Prevention of occurrences; -- Identification possible incidents or allegations which need investigation; -- Investigation of incidents and allegations; -- Reporting of incidents, investigations and Center response to the results of their investigations. Federal Definitions: Abuse is defined as the willful inflicting injury, .or mental anguish . Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . It includes verbal abuse . Willful, as used in this definition of abuse, means the individual must have have acted deliberately . -- Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families . -- Sexual Abuse is a non-consensual sexual contact of any type with a resident. It includes but is not limited to sexual harassment, sexual coercion or sexual assault. -- Mental Abuse includes, but not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur either verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation , or degradation . -- Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Process 5.1 Anyone who witnesses an incident of suspected abuse, neglect . is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED or designee will perform the following . 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made . Review of the incident/accident forms, grievances/concerns forms, and incidents reported to State agencies, found them silent for the previously referenced nursing progress notes except where identified - indicating the facility did not document on the appropriate forms, did not conduct investigations and/or thorough investigations including witness statements, and did not report allegations of abuse which include allegations of verbal and physical abuse, and an allegation of possible sexual harassment. g) Resident #45 The resident was [AGE] years of age. He was admitted to the facility on [DATE] and subsequently discharged on [DATE]. He went into [MEDICAL CONDITION] during [MEDICAL TREATMENT] and passed away at the hospital. Review of complaints/grievances on 08/07/17 at 11:47 a.m. found a complaint filed by Resident #45 on 05/10/17. He told a Licensed Practical Nurse (LPN) a Nursing Assistant was rude to him and cursed at him when he attempted to get a cup from the drinking cart (nurses' cart) and a couple of cups fell on to the floor. Neither the LPN or the Nursing Assistant were current employees. The investigation included a witness statement by the Nursing Assistant who allegedly cursed at him. She stated he was getting cups off the nurses' cart and she told him he could not get into the nurses' cart. She also said, I didn't curse at resident. The investigator met with the resident and told him the issue was addressed with the employee and explained infection control issues. He was told if he needs a cup to ask staff for it related to infection control. The investigator wrote He voiced understanding and I assured him administration would speak with said CNA. He was ok with this. The complaint was not recognized as an allegation of verbal abuse and therefore was never reported. During an interview on 08/08/17 at 11:21 a.m., Administrator #111 agreed the complaint was an allegation of verbal abuse and should have been reported.

Based on medical record review, facility behavior policy review, abuse prohibition policy review, resident interview, and staff interview, the facility failed to ensure that a resident who displays behaviors and/or is diagnosed with [REDACTED]. This was found for residents with ongoing and/or worsening behaviors within the past twelve (12) months without evidence of routine or initial psychiatric treatment and/or services. Residents #86, #92, and #24 had documented behaviors in the nursing progress notes of yelling, screaming, cursing, and of physical aggression toward other residents and staff. These types of behaviors caused psychosocial and/or emotional harm to other residents, who used the terms and verbiage verbal abuse and physical assault causing them to be fearful in the facility and afraid to come out of their rooms. This practice was found for three (3) of three (3) Stage 2 sample residents reviewed for the care area of behaviors during the QIS survey. Resident identifiers: #86, #92, and #24. Resident identifiers for recipients of resident behaviors: #127, #13, and #96. Facility census: 88. Findings include: a) Resident #86 Medical record review on 08/02/17 at 1:35 p.m. revealed Resident #86 was originally admitted on [DATE] and the most recent re-admission was on 04/08/17 following a hospitalization . His [DIAGNOSES REDACTED]. He was determined by his attending physician to have the capacity to make his own medical decisions and assessed to have a Brief Interview for Mental Status (BIMS) score of 15 showing him to be cognitively intact. His current medications included [MEDICATION NAME] 10 milligrams (mg) by mouth (po) for major [MEDICAL CONDITION]. The nursing progress notes from 05/11/17 to 07/23/17 contained documentation of incidents involving Resident #86 yelling, cursing, throwing clothing protectors at other residents, and verbally threatening other residents. In addition, Resident #86 displayed verbal and physical aggression toward staff from 10/13/16 to 07/23/17. This included screaming, yelling, cursing, pulling staffs' hair and hitting staff who were providing, or attempting to provide, care. Also, contained in the nursing progress notes was documentation of verbal and physical aggression toward staff from 10/13/16 to 07/23/17. This included screaming, yelling, cursing, pulling staff's hair, and hitting staff providing, or attempting to provide, care. The most recent incident occurred on 07/23/17 involving Resident #86 .cursing at another resident (Resident #96) while in dining room waiting for lunch to be served and was asked to leave the dining room . Resident returned to his room and cursing at staff and residents . Further behavior included: -- 10/13/16 late entry (typed as written): Resident (Resident #86) was sitting by his door and asked this nurse to come over and talk to him. Resident stated he was very angry that (name of former employee) spoke to him the way she did. He also stated that he did not take physical action toward her today but the next time she came in his room and put herself into a man's shoes that he would knock out her pearly whites. RN (Registered Nurse) told Resident that any kind of physical violence was not allowed in this facility. Resident stated he did not care. RN encouraged resident not to attempt to hurt anyone in the facility. Resident stated he would take care of things his way and that the conversation was done. RN exited the room and reported incident to SW . -- 11/08/16 (typed as written): When CNA (certified nurse aide) and I went to answer call light resident (Resident #86) refused to let CNA assist him stating, I am tired of training these people, and she is not doing anything for me cause she lied on me, she said I molested her. -- 03/07/17 (typed as written): CNA notified nurse that resident (Resident #86) pulled her hair and cussed her during getting him out of bed. Incident reported to unit manager. -- 05/11/17 late entry for 05/09/17 (typed as written): Resident (Resident #86) was done eating and was sitting at his table and usually he leaves right after he is done. Brought in resident (Resident #127) to sit at his table for second seating at the empty space he (Resident #86) yelled and stated let me get the hell out of here. He isn't suppose to sit at my table. Informed nursing. -- 05/11/17 (typed as written): Today at lunch resident (Resident #86) was yelling at another resident (Resident #127) for standing up. Resident (Resident #86) goes over to the resident (Resident #127) standing up calling him names and stated if he (Resident #127) didn't sit down he (Resident #86) would knock him down. Went back and got the social worker again. Informed nursing of the incident. A grievance/concern form dated 06/15/17 revealed documentation (typed as written): (Name of Resident #13) stated that when he is going by room [ROOM NUMBER](room of Resident #86 and near the dining room), that the man in the cowboy hat yells things at me. He (Resident #86) said, Get the f---- out of the hallway! (Name of resident #13) said that he shouldn't have to listen to that or worry about it. -- 06/16/17 (typed as written): MSW (Master of Social Work) and CED (Administrator) met with resident (Resident #86) to discuss another resident's (Resident #13) concern that he (Resident #86) had been cursing and yelling at him (Resident #13) in the hallway. Informed resident (Resident #86) that this behavior is inappropriate and cannot continue. Resident (Resident #86) verbalized understanding but also indicated the behavior would continue should he feel it needed AEB (as evidenced by) him stating And I'll do it again. Resident (Resident #86) verbalized he felt as if he were protecting another resident. SS (social services) will follow as needed. -- 06/22/17 (typed as written): During lunch today (first name of Resident #86 was done eating and his tablemate was done eating and had already left. Went to bring in the second seating and sat him (Resident #127) at the table and (first name of Resident #86) started yelling and threw his clothing protector at the other resident (Resident #127). Told (first name of Resident #86) that was inappropriate to throw something at another resident. The other resident's (Resident #127) wife was with him. He (Resident #86) does this at the lunch meal and at times at dinner. Reported to the Administrator. -- 06/23/17 (typed as written): During lunch today (first name of Resident #86) and his table mate was finished with their lunch and his table mate had already left. I asked (first name of Resident #86) if he was finished with his lunch and he stated yes. When I went to clear the table (first name of Resident #86) started yelling that no bastard was sitting at the table and he would flip the f***king table over if I tried to sit someone there. I explained to him that he was finished and other residents needed their lunch, he left the dining room saying if he came back up the hall and the bastard was sitting there he would flip the f***king table over. This incident was involving Resident #127 coming to sit at the table. -- 07/15/17 (typed as written): Resident (Resident #86) in room in wheelchair when another resident (Resident #96) coming down hallway, nurse on right side of other resident (Resident #96) in between other resident (Resident #96)and this resident's (Resident #86) door. (Name of Resident #86) began yelling and making threats directed toward other resident (Resident #96). This nurse proceeded to keep conversation with other resident (Resident #96) as to avoid other resident (Resident #96) calling attention to (name of Resident #86). (Name of Resident #86) continued to verbally threatened other resident (Resident #96) until other resident (Resident #96) was out of hearing distance. All attempts at redirection unsuccessful, resident (Resident #86) continues to yell out doorway cursing fell ow resident at this time . A significant change minimum data set (MDS) with an assessment reference date (ARD) of 07/05/17 identified and increase in the resident's behaviors. According to the assessment, the resident's verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) and rejection of care occurred 1 to 3 days during the 7-day look back period. For the assessment item asking how the resident's current behavior status compared to the prior assessment, the response was Worse. The 30-day MDS with an ARD of 05/05/17 and 14-day MDS with an ARD of 04/21/17 did not reflect any behaviors during the assessment reference periods. The 5-day MDS with an ARD of 04/10/17 and quarterly MDS with an ARD of 02/02/17 did identify the resident exhibited verbal behaviors directed toward others 1 to 3 days in the last 7 days. Review of the resident's care plan revealed: -- Focus (problem) statement created on 01/09/15 and revised on 06/23/17 (typed as written): Behavioral symptoms AEB (as evidenced by) verbal and physical aggression, being socially inappropriate to staff and other residents, refusing care and selective meals preference and table mates. Interventions include (typed as written): .Divert resident by giving alternative objects or activity (coffee), (created on 01/09/15 and revision on 01/09/15) .Remove resident from environment if unable to redirect (created on 01/09/15 and revision on 02/09/16) . -- Focus created on 06/19/16 and revised on 06/19/16 (typed as written): Resident/patient exhibits, or has the potential to exhibit physical behaviors related to: History of harm to others: throwing hot coffee (specify: assaultive actions toward other residents such as running into another wheelchair, slapping. Interventions include (typed as written): Evaluate the nature and circumstances (i.e. triggers) of the physical behavior with resident/patient and family members/caregivers, e.g. provoked/not provoked, offensive, defensive, purposeful, during specific activities, involvement of others, patterned, easily startled, etc. Discuss findings with resident/patient and family members/caregivers and adjust care delivery appropriately .created on 06/19/16. The medical record was silent for any psychiatric care and services during Resident #86's stay in the facility. The names of the residents' who were recipients of the previously described behaviors by Resident #86 was provided by Director of Nursing (DON) #112 on 08/07/17 at 9:00 a.m. On 08/07/17 at 12:15 p.m., review of the facility's policy titled, NSG206 Behaviors: Management of Symptoms found it included the following (typed as written) under the sub-title of POLICY: Patients exhibiting behavioral symptoms will be individually evaluated to determine the behavior. The interdisciplinary team identifies underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes that contribute to changes in the patient's behavior. Based on the comprehensive assessment, staff must ensure that a patient: -- Who displays or is diagnosed with [REDACTED]. Resident #13 stated during an interview on 08/07/17 at 3:30 p.m. regarding the incident that occurred on 06/15/17, .made me afraid because didn't know what he was going to do. That was abusive to me and my room mate told me that is called verbal abuse and that is exactly what it was. Didn't feel the facility did that much about it. The staff did not tell me anything other than they did speak to him. Well it didn't help because once or twice since then he has yelled and cussed at me when I went out in the hall even with staff. Now I am afraid to come out of my room and to go down the hallway even with staff. His room is close to the dining room so I don't want to go there for meals either because I don't know what he will do to me. During a confidential interview with Employee #W, she stated, (Name of Resident #86) perceives himself as a southern gentleman and seemed to target (name of Resident #13) due to his race according to (Resident #13). Which could be due to his (Resident #86) upbringing and culture, but should not have been allowed to happen. It should have been documented as an incident and reported to the state as verbal abuse at least. No psychiatric services or treatment have been attempted or made available for this resident since he has been here, I think he was here since 2014. Not really sure he would be receptive to any psychiatric services, but it should have at least been attempted and offered because of how he treats other residents. He yells, screams and curses other residents, rams them with his wheelchair and threatens to hit them or cause bodily harm. I agree that we as a facility have not been protecting residents from abuse as a whole by (Resident #86) or any other resident with behaviors like this. The progress notes you found are probably only a handful of actual incidents that have occurred in the facility for all residents because most of them don't even get documented anywhere by staff. Yes, the dining room incident and also any incident involving where (Resident #86) was yelling, screaming and cursing at a resident is considered verbal abuse and should have been reported because every staff member here is a mandatory reported but we dropped the ball on all of the reporting of behaviors by residents. We have just really been lax and have not addressed resident behaviors in this facility because we just say that is just the way they are and let it go. We should not have been as lax or accepting of these behaviors because we did put our other residents at risk and allowed them to be abused. Agree that no psychiatric evaluations or treatment were initiated for the residents with behaviors which caused not only neglect on the facility part for treatment and management but also allowed abuse of other residents in our facility under our watch. I do admit this is sad and shameful on all of the staff and management here to have allowed this to happen because we did not think about it being abuse and could have helped all residents by getting the residents with behaviors help and keep the other residents safe. Some of the residents (Resident #86) has had incidents with were residents who have dementia and not able to help their actions. These other residents are not cognitively able to defend themselves and depend on the facility to keep them safe. On 08/08/17 at 8:55 a.m. Social Worker (SW) #5 explained social services has not been involved in clinical meetings in the past and were unaware of behavioral incidents because these were handled by nursing. Under the new administration social services will be included not only in morning meetings but also daily clinical meetings so we have knowledge of incidents and can report them as they are brought to our attention. After review of the progress notes for Resident #86 involving incidents of behaviors directed toward other residents and staff, she stated, I was not aware of all of these, would have completed incidents reports for these and reported them to the state agencies for verbal abuse. She further stated, The previous administrator attempted to involve the daughter with his behaviors, but it didn't go anywhere. Upon inquiry regarding her role in the treatment of [REDACTED].#86, she stated, My hands were tied by the previous administration. The new facility Administrator (who began his positon on 07/31/17) acknowledged Residents' behaviors and reported their needs were not being met, during an interview on 08/08/17 at 10:10 a.m. He also stated, This is something that will a priority due to having several residents with behaviors that need to be evaluated. During an interview with Resident #96 on 08/08/17 at 10:11 a.m., he stated, (Name of Resident #86) tried to ram me with his wheelchair, yelling and cursing when I was going down the hallway and has really been terrorizing other residents. The incident made me angry that this would happen because he had a shoe horn which he threatened to hit me with and cut me. He did hit my chair and would have hit my arm if I hadn't moved it off of the arm rest. I went to the nurses about it and all they said was that he wouldn't give it to them so they said there is nothing they can do about it. When inquired if he had reported this to the administrator or social services he stated, There is no need, they never do anything about it, just say that is the way he is. Next time I will just call the cops because my brother is a retired cop and now a magistrate in (name of a nearby town) and he said that is verbal abuse and assault. Will just let the cops do something about it since this place wont do anything and doesn't care that we are being abused and terrorized by him. It is very upsetting to have to go down the hall and wonder if he is going to verbally or physically attack you. I am afraid for other residents like those people that are confused and wont go down the hallway just stay in their room. For me just don't like it is right to be in a nursing home and worry about being abused or assaulted. Review of the facility policy on 08/08/17 at 10:30 a.m. titled: OPS300 Abuse Prohibition reveled: sub title of PR(NAME)ESS: --5.2 If the suspected abuse is patient to patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation. --5.2.1 The family and physician will be notified and any follow-up recommended will be completed (e.g., psychiatric evaluation) . The new facility Administrator acknowledged Resident #24's behaviors and reported his needs were not being met, during an interview on 08/08/17 at 10:10 a.m. The new Administrator reported he was aware of Resident #24's threat to stab someone and noted he is independent in mobility, has capacity and can refuse psychiatric care. The medical records need to show the psychiatric services were offered and the resident refused. The lack of appropriate treatment and services for Resident #86 resulted in mental, emotional and psychosocial harm to other residents as evidenced by residents being afraid to leave their rooms, to go down the hallway to the dining room, fear of being verbally abused or physically assaulted and being fearful for other residents who were not cognitively intact. Behaviors of this type for Resident #86 were long term and seen by the facility as Just the way he is, without thought by the facility of his behaviors being detrimental to other residents' well-being whether physical, emotional or mental. No recommendations for psychiatric evaluations were evident in the medical record. ) Resident #92 On 08/02/17 at 8:00 a.m., a review of the medical record revealed Resident #92 was admitted to the facility in January 2017. Her current [DIAGNOSES REDACTED]. She lacks capacity and the progress notes identify a history of suicidal idealizations since 03/02/17. The Nursing Home to Hospital Transfer form dated 04/21/17 notes Resident #92 was transferred to an acute care hospital for evaluation after she began yelling and cursing, following staff and kicking doors and staff. She was returned to the facility with plans for follow up in 2-3 days. The Nursing Home to Hospital Transfer form dated 04/23/17 notes Resident #92 was again transferred for a psychiatric evaluation after she knocked over a water pitcher and went after another resident. She was diagnosed with [REDACTED]. Resident #92 was admitted to an acute care hospital from 07/06/17 through 07/15/17. The cardiology note dated 07/11/17 notes Resident #92 was displaying a flat affect with bouts of aggression. Psychiatry was consulted for recommendations. The discharge summary dated 07/15/17 states .Patient's hospital stay was complicated by [MEDICAL CONDITION] which appears improved 07/15. Patient did use [MEDICATION NAME] (antipsychotic) 2.5 prn (as needed) nightly however patient can resume her home Trazadone (antidepressant) on discharge. The progress notes from 04/23/17 through 07/31/17 note the following behaviors: --04/23/17 Resident got into a verbal altercation and charged another resident unprovoked .When squad arrived she made the statement to everyone in the vicinity that she has been trying to kill herself all morning. --04/24/17 Resident was told by staff that someone needs to be with her when she roams the facility. Resident laughed and said because I am such a dangerous character. --05/24/17 Resident informed of smoke break cancellation due to inclement weather conditions. Resident became verbally and physically aggressive toward staff at this time. Staff attempting to explain safety issues with resident. Resident continues to scream and direct verbal aggression toward staff. Resident attempting to exit facility into rain, staff able to intervene and redirect resident back into facility at this time . --05/30/17 .Resident to med cart with request for smoke break. States she didn't get one earlier in the day. CNA (certified nurse aide) states that resident was observed outside smoking. Resident then became upset, tearful and verbally aggressive towards CNA . --06/08/17 Resident witnessed outside at this time out back of building. Resident was trying to bum cigarettes from staff that were outside. When she was denied, she began cursing at staff. --06/09/17 . Resident stated If I had a gun, I'd shoot my head off. --06/10/17 Resident witnessed by housekeeping exiting facility to smoke area . --07/19/17 Alert with some confusion .requested to smoke .became upset when reminded she could not smoke per physician orders after recent surgery. Resident sat in the hallway and was yelling out. --07/20/17 Resident exhibits periods of confusion to time/place as well as multiple outbursts of profanity directed towards staff. --07/21/17 .Resident alert, verbal with confusion. Propelling self in w/c (wheel chair) Occasional outbursts of cursing toward staff .Uncooperative with staff at times . --07/22/17 .Resident cursing and screaming at staff. Resident refused morning meds . --07/23/17 .Cursing at roommate for snorting. --07/23/17 12:32 p.m. Resident removed from dining room and wheeled back to room due to cursing at staff and other residents and being disruptive while waiting on lunch to be served. While attempting to change dressings to right and left lower extremities, resident kicking at this nurse and stated get the ___out of my room. MD (doctor) made aware of refusal and behaviors. --07/23/17 2150 (9:50 p.m.) Resident was yelling at roommate and cursing out her roommate . --07/27/17 Resident was up in wheelchair in the hallway and yelling at another resident to shut the f*** up . The physician progress notes [REDACTED]. --04/21/17 written by Doctor #132 chief complaint/nature of presenting problem: .delusional combative non-cooperative to staff. History of presenting illness: .h/o (history of) [MEDICAL CONDITION] smoking Psychiatric: insight poor --05/13/17 written by Doctor #132 states no increased nervousness or depression. [DIAGNOSES REDACTED]. --06/09/17 Psychiatric: :Judgement/insight: Impaired --07/16/17 note written by Nurse Practitioner #133 states .She is pleasant today during our examination, but is confused, which causes her demeanor to quickly change to offensive. She believes she is selling realestate .Psychiatric: Confused, can be pleasant at time . The resident's Behavioral Monitoring and Interventions Sheets were silent. No information was documented related to Resident #92's behaviors. During an interview on 08/02/17 at 9:00 a.m., Licensed Practical Nurse (LPN)/Unit Manager #19 reported Resident #92 continues to display verbal and physical aggression towards residents and staff. LPN #119 reviewed the hospital records for the period of 07/06/17 through 07/15/17 and acknowledged there were references to psychiatric services during Resident #92's stay that the facility was unaware of. Unsuccessful attempts were made to retrieve these records during this survey. Clinical Records Coordinator #95 reviewed the records during an interview on 08/07/17 at 3:20 p.m. and confirmed no arrangement had been made for Resident #92 to receive out patient psychiatric services. Resident #92 has a history of [MEDICAL CONDITION] and nicotine addiction. She began voicing suicidal idealizations in March 2017. Her verbal and physical aggressions towards others escalated to the point that she was transferred for immediate psychiatric evaluations on two (2) separate occasions. Psychiatric services were consulted during her recent hospitalization in July and the discharge summary notes an improvement with a temporary change in medication. Resident #92 returned to the facility and was placed on her previous antidepressant Trazadone. The facility was unaware of any psychiatric care during this recent stay. No psychiatric records were obtained and no changes in her medications were identified. No efforts had been made to offer any psychiatric treatment or services to Resident #92. c) Resident #24 Review of the medical record on 08/02/17 at 11:25 a.m., revealed Resident #24 was initially admitted to the facility in 2012. [DIAGNOSES REDACTED]. The primary care physician declined a pharmacist's dose reduction recommendation on 09/13/16 stating Patient follows with outpatient psych. at this time the patient's psychoactive state is stable a decrease would likely cause psychiatric instability will make specialist aware of recommendations. The physician progress notes [REDACTED]. [MEDICAL CONDITION] disorder. Continue [MEDICATION NAME] (antianxiety [MEDICATION NAME]) and [MEDICATION NAME] (antidepressant [MEDICATION NAME]), and follow up with Doctor (name) in the outpatient setting. Resident #24's last out patient psychiatric was visit was on 01/13/17. The psychiatric note dated 01/13/17 identified the [DIAGNOSES REDACTED]. Parts of this note were illegible and no follow up appointment was identified. The risk management event form generated on 08/07/17, identifie combative behavior by Resident #24 on 03/03/17 at 8:30 p.m. Note stated, Resident has been getting more violent/aggressive with staff members. On this shift he managed to put his hands around the mail CNA (certified nurse aide) that was working with roommate. Resident put his hands around CNAs neck as if he was trying to choke him. Corrective action note stated Spoke with resident about why he was upset and what we needed to do for him and that he shouldn't hurt the staff they are just trying to help. Resident was okay with maybe seeing a new physician (about) his problems.) The progress notes dated 06/06/17, noted Resident #24 was notified his primary physician changed to Dr. #132 the current Medical Director. The staff progress notes for 01/24/17 through 08/08/17 note the following behaviors: -- 01/16/17 Resident (#24) followed another resident down hallway stating I'm going to kick his ass. This nurse attempted to redirect to his room. Resident refused continuing to go towards other resident. Another nurse and CNA (certified nurse aide) arrived to help direct resident back to his room. Once inside resident's room he stated he would get the other resident before the night is over. Will continue to monitor. -- 01/21/17 Resident had increased behaviors throughout shift. Resident would come to the nurse's station and see other residents and start cursing and being loud. Resident went down main hall and stopped in front of room (number) three times this shift and was verbally yelling obscenities at him. Resident was redirected many times. Resident would go in his room and color pictures then he would stand in his doorway and yell out at staff and other residents. -- 02/15/17 Care plan evaluation note states .(name) Resident #24 can be inappropriate with his conversations and can cause altercations with other residents . -- 03/03/17 A change in condition has been noted. The symptoms include: Behavioral symptoms (e.g. agitation, [MEDICAL CONDITION]) 03/03/17 at night .Change reported to primary care clinician (name). -- 03/15/17 Resident noted to be playing music loud enough to be heard coming down hallway, stopped into resident's room and asked him to turn it down a little. resident seemed agitated that roommate had company, . -- 03/22/17 Passed by resident in the hall and he said It's going to be a bad night. When I asked why is that he replied, I'm mad as hell. -- 05/16/17 MSW (Masters of Social Work) s/w (sat with) resident in regards to verbal altercation with another resident in the hallway. Resident displayed verbal aggression and was cursing after he says he was being taunted by the other resident for merely walking passed his room. Will follow as needed. -- 05/21/17 MD (medical doctor) in to see resident regarding increased aggression, new orders to increase [MEDICATION NAME] 1 mg (milligram) po (by mouth) BID (twice a day) and also to see the podiatrist next time he is in . -- 05/23/17 Care plan evaluation note states .(name) Resident #24 can be inappropriate with his conversations and can cause altercations with other residents . -- 06/12/17 MSW and Administrator met with this resident to discuss behaviors/complaints from another resident and discussed resident's excessively loud music that he plays at times. Reiterated to resident that the behaviors are in violation of other residents' rights. Resident verbalized understanding and stated it's my fault however management has had this discussion with the resident several times in the past. Will follow as needed. -- 07/09/17 Resident came to nurses station and yelled at this nurse and two aides for stealing his jar of mayonnaise. Staff calmed resident and assured him that we didn't steal his mayonnaise. Resident went to kitchen and requested mayo. He came back to the nurses station to show staff, and began yelling again. He then saw another resident in the hallway, and yelled that the resident never gets his items stolen, that we only steal from him. He kept yelling at staff and the other resident, with (typed as written) staff finally able to get him into his room. Resident finally able to admit that staff did not steal his items. MD aware. Will continue to monitor. -- 07/27/17 Resident complaining about another resident in an aggressive manor. Resident states they give him every thing. Why do they kiss his ass? Assured resident no one was receiving special treatment. Redirected resident to listen to some music in room. -- 08/07/17 Resident having behavior issues tonight. CNAs (certified nurse aides) were trying to clean out resident's roommate's side of closet .Resident (#24) became very loud and cursing at staff. 3 CNA and this nurse tried to explain to resident what was happening and redirect to take a walk and resident refu (TRUNCATED)

Based upon observation, staff interview, and clinical record review, the facility failed to manage pain for one (1) of three (3) residents observed for pressure ulcer dressing changes. A staff member reported the resident cried out when her right foot was touched. Without assessing the resident for pain or premedicating her for pain, a nurse proceeded to provide wound care. During the nineteen (19) minutes the nurse provided care to the wounds, the resident cried out, pulled away, clutched her fists, and grimaced. Although the nurse providing the treatment had told the nurse administering medications she would stop the treatments and let her know if the resident needed something for pain, she did not stop until the care was completed. This resulted in a determination of physical harm and mental anguish for Resident #21. Facility census: 97. Findings include: a) Resident #21 Clinical record review revealed Resident #21 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment with an assessment reference date of 04/06/17 indicated Resident #21 had short-term and long-term memory problems and was severely impaired in decision-making. The resident required extensive one-person assistance with toileting, personal hygiene, dressing, and bathing and the extensive assistance of 2 persons for bed mobility. This incontinent resident had an unstageable pressure ulcer on her coccyx measuring 7 by 5 centimeters (cm) and a suspected deep tissue injury (SDTI) to right heel. On 04/19/17 at 10:10 a.m., Nurse Aide (NA) #39 came to nurses' station and reported to Licensed Practical Nurse (LPN) #69 and Unit Manager (UM) LPN #60 that Resident #21 was crying in pain, .whenever I touched her right foot. I think she needs something for pain. LPN #69 stated, while standing by the medication cart, I need to see if she needs Tylenol before you do the dressing change. UM #60 stated, I will check before I start, if she complains of pain, I will stop and do it later. On 04/19/17 at 10:12 a.m., UM #60 entered Resident #21's room to perform the resident's wound treatment. UM #60 touched Resident #21's right heel to apply Sureprep to the SDTI. Resident #21 closed her eyes, made a facial grimace as though in pain, open her mouth, cried out, pulled her arms to her chest, and clenched her fists. She shook her arms. UM #60 continued the treatment stating to resident, It is alright. UM #60 kept talking to resident about her family members, but continued with the treatment. UM #60 then performed the wound treatment to the unstageable coccyx wound. Resident #21 continued with facial grimacing and moaning. UM #60 then turned Resident #21 from side to side to change incontinence pad. Resident #21 cried out, grabbed at UM #60's ID badge, and pulled the badge with her closed fists. UM #60 completed the procedure at 10:30 a.m. and said to the resident, We will bring you some Tylenol now. At 10:35 a.m., UM #60 reported to LPN #69 that Resident #21 had some intermittent pain during the dressing change and, You can check to see if she needs some Tylenol. During an interview on 04/19/17 at 10:35 a.m., UM #60 stated Resident #21 does not like to be touched and that she would cry out. She stated it was difficult to determine when the resident was having pain. UM #60 she did not identify the resident's behaviors as signifying any possible pain. UM #60 stated she guessed should have just let the LPN premedicate the resident for pain and do the dressing change later. When observed on 04/19/17 at 12:00 p.m., Resident #21 was lying in bed on her left side. Her eyes were open, she exhibited no facial grimacing, and was not crying out. Her hands were no longer clenched, but were open and relaxed. During an interview on 04/20/17 at 9:30 am, the Administrator stated UM #60's behavior during Resident #21's dressing change did not meet facility standards and was unacceptable staff behavior. The administrator stated she could provide no explanation for the staff member's behavior.

Based on record review, review of information from the National Pressure Ulcer Advisory Panel (NPUAP), review of information from Wound Educators, and staff interview, the facility failed to ensure Resident #141 who entered the nursing home with a deep tissue injury (DTI) to her coccyx and intact boggy heels. The facility failed to ensure the resident received care and services to promote healing of existing pressure areas and to prevent the development of new, or worsening of existing pressure sores, unless unavoidable. The facility failed to implement any preventative measures for Resident #141, until she developed pressure sores on her right and left heels, which were identified as unstageable black blood blisters when discovered. The resident's pressure ulcers could not be determined to be unavoidable due to the facility's failure to provide appropriate and timely interventions. The right heel wound required debridement and became infected, necessitating treatment with antibiotics. The facility's failure to provide needed care and services to Resident #141 resulted in actual harm to the resident. This practice was found for one (1) of three (3) sample residents reviewed for the care area of pressure ulcers during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #141. Facility Census: 102. Findings include: a) Resident #141 Review of the resident's medical record on 09/15/16 at 8:59 a.m., revealed this [AGE] year-old, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Her initial admitting nursing assessment, dated 06/17/16, identified a deep tissue injury (DTI) to her coccyx and bilateral (right and left) boggy heels. Resident #141 developed in-house unstageable pressure ulcers with the appearance of a black blood blister identified on both the right heel and left heel on 06/22/16. The right heel measurements were 3 centimeters (cm) by (x) 3 cm and the left heel measured 1.5 cm x 2 cm. The medical record was silent for an admission Braden Scale for Predicting Pressure Sore Risk assessment tool on 06/17/16, but the resident scored 15 on the one completed on 06/24/16, indicating she was at risk for developing a pressure ulcer. The admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 06/24/16, identified that the resident was at risk of developing pressure ulcers. The MDS also identified the resident required the extensive assistance of 2 or more persons for bed mobility, transfers and toilet use. The care plan revealed no individualized measurable goals or established interventions to meet the immediate needs of the resident at the time of admission for the identified boggy heels. The care plan lacked any interventions for the prevention of pressure ulcers for this resident who was identified to be at risk for the development of pressure ulcers due to already having a DTI to her coccyx and boggy heels on admission. The care plan did display individualized measurable goals and interventions initiated on 06/22/16 (when the unstageable heel wounds were identified) for heel protectors wib (while in bed). On 06/30/16, the facility initiated, heels up cushion while in bed. The National Pressure Ulcer Advisory Panel (NPUAP) defines a Suspected Deep Tissue Injury (SDTI) as, Purple or maroon localized area of discolored intact skin (or blood-filled blister) due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. According to The National Wound Educators (NWE), Heels are particularly vulnerable to skin breakdown due to the fact that the posterior heel is covered only by a thin layer of skin and fat. When patients lie supine (on their backs), all of the pressure of their lower legs and feet rest on the heels, which have relatively poor skin perfusion and a paucity (lack of) of muscle tissue to absorb stress. The NWE further provides information in Preventing Heel Ulcers: The best offense is a good defense, and this saying holds true for preventing heel pressure ulcers. Preventing heel ulcers begins with anticipating that they may occur when patients have one or more of the listed risk factors and are supine for any length of time. How are pressure ulcers prevented? The following can be used to prevent heel pressure ulcers from developing: · Pillows- pillows can be used for offloading heel pressure in cooperative patients for short periods of time, according to the NPUAP. It is recommended that pillows be placed length-wise under the calf to completely elevate the heel off the supporting surface. It can be difficult to maintain proper positioning when patients move around in bed, which is the reason that the NPUAP recommends this treatment modality only for cooperative patients, and only for short duration. · Heel offloading devices- devices made of sheepskin, splints and bunny boots are all acceptable offloading devices, which can stay in place around the clock and can be used for all patients, regardless of how much they move in bed. These devices pad the heel and prevent friction and shear; they also remove some pressure from the heel, preventing heel pressure ulcers. Heel pressure ulcers can cause significant morbidity and mortality. They should be anticipated and prevented in patients at risk for pressure ulcers. Preventing heel ulcers involves the use of simple devices such as pillows and offloading devices to protect delicate heels. The wound nurse (who was no longer employed at the facility) initiated a wound flow sheet for each heel wound on 06/22/16. Review of these flow sheets found the following: 1. Left heel - 06/22/16-- described as an unstageable wound, appearance as black blood blister, measuring 1.5 cm x 2.0 cm - 06/28/16--described as an unstageable wound, appearance as necrotic blood blister, measuring 2.0 cm x 3.0 cm - 07/05/16--described as a DTI (changed from unstageable), appearance as intact deep purple dry callous, measuring 2.0 cm x 2.0 cm - 07/11/16--described as a DTI, appearance as intact deep purple dry callous, measuring 2.0 cm x 3.0 cm - 07/19/16--described as a DTI, appearance as hard dry callous, measuring 2.0 cm x 3.0 cm - 07/26/16--described as a DTI, appearance as intact hard dry callous, measuring 2.0 cm x 3.0 cm - 08/02/16--described as a DTI, appearance as intact deep purple callous, measuring 1.0 cm x 1.0 cm - 08/09/16--described as a DTI, appearance as intact deep purple callous, measuring 1.5 cm x 1.4 cm - 08/17/16--described as a DTI, appearance as intact deep purple callous, measuring 1.5 cm x 2.0 cm - 08/22/16--described as a DTI, appearance as intact deep purple callous, measuring 1.2 cm x 1.0 cm - 08/29/16--described as a DTI, appearance as intact purple, measuring 0.4 cm x 0.4 cm - 09/05/16--described as a DTI, appearance as intact, measuring 0.3 cm x 0.4 cm - 09/13/16--described as a DTI, appearance as intact, measuring 0.3 cm x 0.3 cm This wound was showing signs of healing with appropriate measures and interventions. 2. Right heel 06/22/16-- described as an unstageable wound, appearance as necrotic/blister/Serous black blood blister, measuring 3.0 cm x 3.0 cm. 06/28/16--described as an unstageable wound, appearance as necrotic/blister/Serous black blood blister, measuring 3.0 cm x 3.5 cm. 07/05/16--described as an unstageable wound, appearance as necrotic black callous dry blister, measuring 3.0 cm x 3.5 cm. 07/11/16--described as an unstageable wound, appearance as necrotic black dry callous, measuring 3.0 cm x 5.0 cm 07/19/16--described as an unstageable wound, appearance as necrotic black dry callous, measuring 3.0 cm x 4.0 cm. 07/26/16--described as an unstageable wound, appearance as necrotic black dry callo us, measuring 2.8 cm x 3.8 cm 08/02/16--described as an unstageable wound, appearance as necrotic, measuring 3.5 cm x 3.2 cm 08/09/16--described as an unstageable wound, appearance as necrotic, measuring 3.0 cm x 5.0 cm 08/17/16--described as an unstageable wound, appearance as necrotic, measuring 3.0 cm x 4.5 cm 08/22/16--described as an unstageable wound, appearance as necrotic, measuring 3.0 cm x 4.0 cm 08/29/16--described as an unstageable wound, appearance as necrotic, measuring 3.2 cm x 4.4 cm, drainage purulent and macerated wound edges. 09/05/16--described as an unstageable wound, appearance as slough, measuring 4.0 cm x 4.4 cm, drainage max purulent and healthy wound edges 09/13/16--described as an unstageable wound, appearance as slough, measuring 3.8 cm x 3.8 cm, drainage mod purulent and healthy wound edges. Review of the physician orders [REDACTED]. Resident #141 was prescribed an antibiotic medication [MEDICATION NAME] 875-125 mg (milligrams) 1 po (by mouth) twice a day for one (1) week for wound infection of right heel. On 09/13/16 the antibiotic was changed to [MEDICATION NAME] 300 mg po every 8 hours for seven (7) days for right heel ulceration. During an interview with the Director of Nursing (DON) on 09/15/2016 at 12:17 p.m., she explained wounds are checked weekly by the charge nurses on the unit, DON or Nurse Educator, but we only look at the large wounds. The DON commented, currently in the process of transitioning with a new wound nurse. She stated, this is the third (3rd) wound nurse since you were here last, there have been some issues with the previous wound nurses, but now have a new wound nurse and things are much better. On 09/19/2016 at 10:40 a.m., Licensed Practical Nurse (LPN) #29 reported in the interview, I would hope that the intervention of elevating heels would be on the initial admission care plan, since she was admitted with boggy heels. After reviewing the initial admission care plan, she agreed there were no interventions and/or preventative interventions in place to prevent the development of pressure ulcers to the resident's heels. Upon inquiry LPN #29 stated, Yes if prevention would have been initiate on admission, perhaps the wounds could have been prevented. Perhaps if we would have been aggressive or at least had preventative measures in place on admission, the wounds (heels) would not have gotten as bad, required wound clinic intervention or lasted this long. Resident #141 was admitted with boggy heels, which often precedes the development of pressure ulcers of the heels. No preventative measures were implemented until approximately one week after admission. The lack of preventative measures/interventions implemented for Resident #141 on admission, resulted in actual harm to the resident when pressure ulcers developed, one of which had to be debrided.

Based on observation, record review, and staff interviews, the facility failed to ensure the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being as evidenced by unmanaged pain. This affected one (1) of (6) residents reviewed for pain. Resident identifier: #95. Facility census: 97. Findings include: a) Resident #95 On 06/21/16 at 10:55 a.m. review of minimum data set (MDS) with an assessment reference date (ARD) dated 03/26/16 identified Resident #95 assigned the following relevant [DIAGNOSES REDACTED]. On 06/21/16 at 11:15 a.m. a review of care plan note dated 04/21/16 read, Reviewed in care conference for 04/05/16 related to significant changes, falls and overall decline in activities of daily living (ADL's). On 06/21/16 at 11:30 a.m., a review of nursing pain management assessment dated [DATE] indicated the resident did not receive schedule pain medication, did not receive as need pain medication, and did not receive any non-pharmacological interventions for pain. On 06/21/16 at 12:00 p.m., a review of care plan evaluation note dated 06/09/16 read: Resident #95 restorative exercises to both lower legs discontinued as a result of Resident #95 multiple refusals. The note read, She says that it hurt her and she will not do them. The note as from a Licensed Practical Nurse (LPN) #5. On 06/21/16 at 12:40 p.m., a review of physician progress notes [REDACTED]. She does report some pain and discomfort to her toes . On 06/21/16 at 12:55 p.m., a review of physician progress notes [REDACTED]. On 06/21/16 at 1:10 p.m., a review of physician progress notes [REDACTED]. She reports that she is having some active discomfort of her second right toes. (It) is worse with movement and palpation. On 06/21/16 at 1:30 p.m., a review of wound consult note dated 06/08/16 read, Right great toe redness but no open ulcer, right second toe dorsal ulcer with redness and swelling and severe pain. The note further read, The patient reports a wound pain level 0 . On 06/21/16 at 1:53 p.m., an interview with Nurse Aide (NA) #6 revealed when Resident #95 cries and asks for something, the nurse is notified. During and interview with NA #132, on 06/21/16 at 4:20 p.m., explained when Resident #95 feet hurt, she cries and refuses to stand resulting in using the hoyer lift. The nurse aide further stated Resident #95 will stick her feet straight out trying to avoid anything touching her feet, and light touch of her feet can make her cry. NA #132 stated the intervention to relieve pain for Resident #95 to lay down, elevate feet, and notify the nurse. On 06/21/16 at 4:35 p.m. an interview with NA #91 revealed restorative exercises Resident #95 included applying ankle weights. She further stated the resident cried when with the application of the ankle weights. NA #91 said the resident would also say her ankles and feet hurt. NA #91 explained she reported this to the nurse and the restorative exercises were discontinued. During an interview with Resident #95 and Resident #95's spouse, on 06/21/16 at 4:45 p.m., Resident #95 stated that she has a lot of trouble with her feet. When Resident #95 was asked whether she has pain in her feet she nodded her head yes. Resident #95's spouse stated, She has a lot of pain, sometimes she cries all day long. Resident #95 responded by saying, I do cry a lot about them. Nurse surveyor acknowledged that Resident #95 returned from a wound clinic appointment within the past few hours. Resident #95 and spouse acknowledged attending a wound center appointment earlier in the day with a nod of the head yes. The husband commented, They do a better job at the wound clinic than here. Her feet don't hurt as much. I don't know why, but they do. On 06/22/16 at 3:00 p.m. a review of restorative nursing records dated: 04/26/16, 05/09/16, 05/17/16, 05/20/16, 05/23/16 and 05/25/16 reflect Resident #95 refusing to participate in restorative exercises intended for legs due to pain. During an interview with LPN #129, on 06/23/16 at 10:00 a.m. explained the treatment process. She stated, she inserts gauze between the residents' toes. Nurse surveyor clarified the answer by asking, Between each toe, Is it effective? LPN #129 replied, Resident #95 hates it. Employee #129 further stated, when Resident #95 is approached regarding anything to do with her feet, the resident becomes anxious because of pain. On 06/23/16 at 11:30 a.m., a review of nursing progress notes dated 04/22/16 and 04/26/16 lacked documentation supporting further evaluation of physician assessment of Resident #95 pain findings. On 06/23/16 at 11:45 a.m., a review of nursing progress notes dated 05/04/16, 05/16/16, 05/23/16 and 05/25/16 lacked further assessment of Resident #95 pain occurrences documented in restorative exercise refusals. On 06/23/16 at 1:30 p.m., a review of Medication Administration Record [REDACTED]. During an interview with the administrator, on 06/23/16 at 1:32 p.m., the administrator expressed surprise regarding the findings of unmanaged pain. The Nurse Practice Educator (NPE) provided a laminated pain scale for viewing. The NPE explained that the Director of Nursing created the pain assessment scale and was working on the pain program. The NPE noted that a pain scale was not consistently being utilized by staff.

Based on resident interview, observation, medical record review and staff interview, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. Resident #159 tearfully stated she was bored and had nothing to do except walk the hall or lie in bed and watch television (TV). This resulted in actual harm to Resident #159. In addition, the fourteen (14) residents eating in the restorative dining room were not provided activities prior to the meal service. This practice hae the potential to affect more than a limited number of residents. Resident identifiers: #159, #13, #17, #135, #93, #86, #32, #124, #24, #63, #112, #15, #125, #90, and #30. Facility census: 99. Findings include: a) Resident #159 Resident #159 was interviewed on 07/21/15 at 10:55 a.m. after she requested to speak with a surveyor. She was intermittently tearful during this interview and reported she normally has a very active social life, but since being admitted to the facility she was extremely bored and had nothing to do except lay on the bed and watch television or walk in the halls. Random observations on 07/20/15 and 07/21/15 found Resident #159 crying in the hall of the facility adjacent to the nurses' station. On both occasions, she was observed being escorted back to her room and heard saying she was bored and wanted to go home. Review of the medical record on 07/21/15 at 2:30 p.m., revealed Resident #159 was admitted to the facility on [DATE], she was transferred to acute care on 05/13/15 and returned to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/12/15, identified her activity preferences as having something to read such as books, paper and magazines, news and animals as somewhat important and music as very important. Resident #159's current care plan, marked as reviewed on 06/22/15, was silent in regards to activities for this resident and her activity preferences. Activity Director #198 reviewed the resident's care plan during an interview on 07/22/15 at 11:00 a.m., and confirmed she had not developed an activities care plan for Resident #159. b) Restorative dining room - Residents #13, #17, #135, #93, #86, #32, #124, #24, #63, #112, #15, #125, #90, and #30 1. On 07/20/15 at 12:00 p.m., an observation of the restorative dining room, found six (6) staff members standing near the sink and talking to each other. Staff did not interact with the fourteen (14) residents sitting at the tables, except when Resident #93 attempted to leave the room twice and when Resident #15 pulled the tablecloth off and backed away from his table. The television located at the end of the room away from the dining tables was on the Disney channel until the meal was served and no other activities were provided prior to lunch. 2. An observation of the noon meal service on 07/21/15 began at 11:51 a.m. Nurse Aides (NA) #52, #127, #124, #120, #171, and #221 were found standing near the sink and conversing while one (1) resident was in front of the television with the Disney channel on and thirteen (13) other residents were seated at their tables. At 12:07 p.m., the television was turned off and again no other activities were offered. At 12:10 p.m., Resident #15 crashed his wheelchair into the activities cart knocking games and puzzles onto the floor. He was redirected and offered coffee after he pulled additional games off the activity cart. At 12:20 p.m. Resident #93, left the table and started to exit the dining room. She was redirected and offered coffee. Lunch was served at 12:30 p.m. and Resident #93 left the restorative dining room without eating. NA #171 and #127 were interviewed on 07/21/15 at 12:29 p.m. They acknowledged there were no activities for the residents prior to lunch except the television with the Disney channel and agreed they should be interacting more with the residents to keep them occupied. The activities director was interviewed on 07/22/15 at 11:00 a.m. She reported the activities department did not provide activities for the residents that eat in this dining room prior to lunch.

Based upon resident interview, family interview, staff interview, record review, and review of facility documents, the facility failed to ensure residents were free from abuse and neglect, resulting in actual harm to Resident #120. The facility failed to immediately report all allegations as required by law, failed to consistently conduct thorough, complete investigations, failed to consistently follow its past practice for the protection of residents during investigations, and failed to identify an allegation of neglect. This was found for four (4) of twenty-two (22) allegations of abuse/neglect reviewed. Resident identifiers: #120, #183, #14, and #90. Facility census: 99. Findings include: a) Resident #120 Abuse/neglect reports submitted by the facility were reviewed on 07/22/15 at 1:00 p.m. There were three (3) reports of alleged abuse/neglect perpetrated against resident #120 between 02/01/15 and 07/06/15. Another allegation initially took place on 07/23/14. Resident #120's Brief Interview for Mental Status (BIMS) score, as assessed on 09/27/13 was 15. This indicated he was cognitively intact. He was determined by a physician to possess the capacity to make informed medical decisions and act as his own responsible party. His [DIAGNOSES REDACTED]. He was partially paralyzed and ambulated in a motorized wheelchair. He was being followed by a consultant psychiatrist for his anxiety, depression, and post-traumatic stress disorder ([MEDICAL CONDITION]). The review of reportable allegations found Resident #120 made allegations of verbal and emotional abuse by a physician and a nurse practitioner. Resident #120 was initially interviewed on 07/20/15 at 2:00 p.m. During this interview, he voiced both those allegations documented in the facility's abuse investigation files and had several other complaints as well. Two (2) of the reported allegations were reviewed and are described separately: 1. Allegation #1: The facility's report of alleged abuse documented Resident #120 claimed he was a victim of verbal/emotional abuse by a nurse practitioner on 07/23/14. Review of the facility's investigative documentation found a Follow-Up Summary of their investigation which stated in part the nurse practitioner initiated an interaction with the resident by stopping in his doorway and telling him that He needed to grow up. The summary statement says she did this because Resident #120 had kept his new roommate up all night yelling and cursing at him. The Social Services Director (#154) was actually in the room at the time attempting to address the events of the previous night. Following her statement at the door, the situation escalated immediately with Resident #120 followed the nurse practitioner to the hallway outside his room, cursing and screaming at her. The summary statement said the nurse practitioner instead of removing herself from the situation . remained in the hall and continued to engage the resident in an argumentative tone. This allegation was reported as required in a timely manner. An extension of the investigation past the usual five (5) day follow-up deadline was requested and granted on 07/25/14 because administration has requested direction from the corporate RVP (regional vice president) regarding this incident since it involved a NP (nurse practitioner) and the RVP is currently on vacation. The nurse practitioner was employed by the parent governing corporation rather than by the facility. There were eleven (11) written signed statements included with the investigative documents. These generally supported the summary or said they did not witness the incident. There was no statement from the nurse practitioner in the record. There was a witness statement signed by the activities director and her assistant that said in part (Resident #120 was cussing & yelling at (nurse practitioner) and she was yelling and then started laughing at him continuously which appeared unprofessional. (Administrator) intervened and had (nurse practitioner) to remove herself from the situation which she continued to laugh and made comment that he is an a______ (expletive) as she walked away. (Administrator) and (Social Services Director) continued to talk with (Resident #120) trying to calm him down. Resident #120 was interviewed on 07/20/15 at 2:00 p.m., again on 07/22/15 at 1:30 p.m., and on 07/23/15 at 1:20 p.m. He stated he was verbally and psychologically abused by the nurse practitioner. He was in his room talking with the Social Services Director and she stuck her head in the door and told him to grow up. She screamed at him, laughed at him, cursed at him, called him a drug addict, and said you're all messed up. He said she continued to mock him and make faces at him and he has isolated himself to his room to avoid her. There was a Report of Consultation in the medical record dated 07/09/15 by a local Psychiatrist treating Resident #120. The report said in part (typed as written): Agitation D/T (due to) some issues at the nursing home with (symbol for with) a Physician and a nurse practitioner. Speech pressured and rapid . The situation at the nursing home is causing some flashbacks, sweats & nightmares. Not on every day or night but just when he sees these people . This is impacting his recovery. In an interview on 07/27/15 at 3:00 p.m., Nurse Practitioner #217 said she was out of line because she should have just walked away when the incident began, but she did not curse and she did not yell at Resident #120. She said he continued to make unfounded accusations against her and other residents, staff, and Physicians as well. Activities Director #198, was interviewed on 07/27/15 at 11:27 a.m. She was asked about the incident and her written statement. She said she stood by what was written. She said the nurse practitioner yelled back at Resident #120, laughed at him loudly and continually, called him an a______ (expletive), and he heard it. Activities Assistant #201, who co-signed the written statement with activities director #198, was interviewed on 07/28/15 at 9:00 a.m. She said the activities director had written the statement, but she was there with her and she agreed with what was written. She said the nurse practitioner yelled back at Resident #120, laughed at him, and called him an a______ (expletive). Administrator #153, was initially asked on 07/22/15 at 1:05 p.m. why there was no written statement from the nurse practitioner in the investigative record. She said the parent corporation had interviewed her (the nurse practitioner) and obtained a written statement, but the facility was not provided the document. She was asked to obtain the statement. The statement was provided on 07/23/15 at 3:05 p.m. The statement recounted she had gone to the room around 9:45 a.m. She asked the newly admitted resident, who was her patient, how he was feeling. He said he needed to get out of here right away. He described being cursed and taunted all night by Resident #120 and being chilled because Resident #120 turned the thermostat way down. She observed him to have six (6) blankets on him. She went to get the medical record and upon her return, the Social Services Director was in the room attempting to deal with the issues of the previous night. She told (Resident #120) he had to act like an adult. Before she could finish her statement, Resident #120 began yelling, cursing, and coming toward her. She felt extremely threatened and turned and walked down the hall toward the lobby. He followed her cursing and screaming until the Administrator intervened at the main desk and told her to just keep walking. The summary document stated Although we validate that (Nurse Practitioner #217's) interaction was unprofessional, the resident's allegation of verbal abuse is not being substantiated. Per a follow-up with (corporate) HR (human resources) manager, and administration, (Nurse Practitioner #217) has received formal counseling regarding this incident and was instructed she may return to work on Monday 07/28/14. It was verified that Nurse Practitioner #217 was suspended pending the conclusion of the investigation for the protection of residents in accordance with the facility's past practice and procedure. Documentation of the counseling received by Nurse Practitioner #217 showed she had been counseled by facility administration, and also by a corporate director. She was reported to the West Virginia Licensing Board of Examiners for Registered Nurses. The referral to the board included the statement that the allegation was unsubstantiated and counseling was provided, and the facility did not feel any action from the board was necessary. There was no evidence of documentation in the investigative record of any corporate questioning or speaking with witnesses or discussing the investigation findings with the Social Services Director or the Administrator. During an interview on 07/28/15 at 9:30 a.m., Administrator #153 said the investigation of the allegation was conducted partly at the facility level and partly at the corporate level because the nurse practitioner was not an employee of the facility. She acknowledged the ultimate responsibility for reporting, investigation, protection and resolution of allegations of abuse/neglect rested with the facility management regardless of who the alleged perpetrator might be. She said corporate had some of the investigative documents, but not all. She was asked if corporate staff had interviewed any of the witnesses (other than the nurse practitioner) and she said they did not. She again confirmed that the facility did not have the nurse practitioner's written statement. She said the facility staff normally involved in investigations, such as the Social Worker, did not speak with any corporate persons to clarify any issues or offer any opinions regarding the decision whether to substantiate the allegation. Social Services Director #154 was interviewed on 07/28/15 at 9:48 a.m. She said the investigation was handled differently than most. It was not handled exclusively by the facility. The action to be taken was ultimately determined at the corporate level. There was sufficient evidence to indicate the facility did not thoroughly investigate the allegation of abuse made by Resident #120 against Nurse Practitioner #217 before reaching a conclusion that the allegation was unsubstantiated. All of the available information was not fully investigated and considered by all parties in a comprehensive manner. 2. Allegation #2: The facility's report of alleged abuse documented Resident #120 claimed he was a victim of psychological/emotional abuse by a physician on 07/02/15. The immediate report stated Resident (#120) feels the facility's in-house Physician (Physician #218) is deliberately mocking him. According to the resident, (Physician #218) makes faces, smirks, and makes fun of him when he passes him in the halls. Review of the facility's investigative documentation found the allegation had not been reported to all applicable agencies until 07/06/15. Reporting of allegations of abuse/neglect are to be immediately, not to exceed twenty-four (24) hours. A written statement submitted on 07/02/15 by Social Worker #145, stated in part, (Administrator #153) told (Resident #120) that she is going to wait until Monday to discuss issue with (corporate regional vice president of operations). (Administrator #153) feels this needs reported but wants to speak to (corporate regional vice president of operations) first. There was a Follow-Up Summary that stated (typed as written): After an investigation we do not substantiate abuse or any type of mistreatment toward (Resident #120). On 07-2-15 the resident alleged that the facility's in house Physician, (Physician #218) was deliberately mocking him/trying to cause him psychological distress AEB (as evidenced by) smirking at him while he was trying to have a conversation with another staff member. Per a statement obtained from (#213), Guest Services Director while having a conversation with (Resident #120) in the front lobby around 4:15 p.m. on 072/2/15, (Resident #120) stopped mid-sentence and yelled out I'm talking to (Guest Services Director #213), not you. When she turned to see what was going on she reports that she saw (Physician #218) going around the corner toward the social service office. According to (Guest Services Director #213), while talking to the resident she did notice the doctor looking around the comer several times and smirking prior to leaving the building. In a statement obtained from SW #145, she indicated she did hear the resident yelling and cursing at (Physician #218) on the date/time in question. She reported that at the time of this incident (Physician #218) had been joking with her about something else and was laughing when he left the office. (Physician #218) confirmed that when walking past the resident in the front lobby, (Resident #120) yelled an offensive profane comment toward him, but indicated that he did not respond. In a follow up interview with the resident, he acknowledged that (Physician #218) did not make any verbal comments toward him, but continued to indicate that he was offended by his smirking and planned to sue both the Doctor and the facility secondary to this incident. Please note that this resident had a long history of exhibiting open conflict/paranoid behaviors which were being addressed on his plan of care. A written statement was submitted by Social Worker #145. This statement contained both a typewritten section and a handwritten section below it. The typewritten section stated (typed as written): (Resident #120) complained that when he was in the lobby around 4:15 he was talking to (Guest Services Director #213) when (Physician #218) walked by and was mocking him. (Resident #120 is upset because this has happened in the past and feels (Physician #218) deliberately makes faces, smiles, smirks, and makes fun of him when he walks past (Resident #120). (Guest Services Director #213) did witness (Physician #218)'s actions in the lobby today. SS (Social Services), GS (Guest Services), ADM (Administrator) met with (Resident #120) afterwards and he is planning on taking legal action against (Physician #218) since he has a witness. (Administrator #153) told (Resident #120) that she is going to wait until Monday to discuss incident with (corporate regional vice president). (Administrator #153) feels this needs to be reported but wants to speak with (corporate regional vice president) first. The statement was signed. Below this was a handwritten statement that said (typed as written): I did hear (Resident #120) cussing and calling (Physician #218) names (inserted a reference to a profanity) when the Dr. (doctor) was in my office. We were joking about something else when (Physician #218) left my office and he was laughing when he left the door. This second statement was also signed. There was a written statement from Resident #120 which stated Physician #218 walked past him in the lobby and smirked at him, then went to the social services office and peeked around the corner four or five times and smirked at him, then opened the front door, turned around and walked out backwards facing him and kept smirking at him. Resident #120 was interviewed on 07/20/15 at 2:00 p.m., again on 07/22/15 at 1:30 p.m., and on 07/23/15 at 1:20 p.m. He confirmed his written statement, and said (Physician #218) said he would put something on my record to make it look like nothing is wrong with me and I'm a bad patient. He stated (Physician #218) and (Nurse Practitioner #217) also, play mental games with me such as being cordial and friendly to other staff around, but ignore him. He said he has been diagnosed with [REDACTED]. He said he has resided at the facility for two years and he is tired of being treated this way. There was a Report of Consultation in the medical record dated 07/9/15 by a local Psychiatrist treating Resident #120. The report says in part (typed as written): Agitation D/T some issues at the nursing home with (letter c with a horizontal line above.) a Physician and a nurse practitioner. Speech pressured and rapid . The situation at the nursing home is causing some flashbacks, sweats & nightmares. Not on every day or night but just when he sees these people . This is impacting his recovery. There was a written statement submitted by Guest Services Director #213, which stated she was talking with Resident #120 in the lobby when Physician #218 walked past them. She did not see him make any facial expressions as he passed by them. She said Resident #120 said to (Physician #218) I'm talking to (Guest Services Director #213), not you. She saw Physician #218 go toward the social work office. Three more times while she was speaking with Resident #120, Physician #218 came around the corner smirking at Resident #120. The resident asked her to go to the social work office because she witnessed these things. As they were going to the office, Physician #218 walked out the doors backwards and smirked at Resident #120. Guest Services Director #213 was interviewed on 07/27/15 at 11:05 a.m. She confirmed the events in her written statement. She was asked to describe the facial expression she saw and called a smirk. She said it was an exaggerated fake smile, which she interpreted as (Physician #218) mocking Resident #120, especially since #218 peeked around the corner three separate times while she was speaking with the resident and then backed out the automatic front door making the same face. She said she felt it was deliberate, intentional, and directed at Resident #120. There was a written statement in the record from Physician #218, which stated in part (typed as written): I am responding to (facility)'s (Resident #120)'s unfounded and fabricated complaint about me to (corporate) administration. A resident at (facility) (Resident #120) has complained that I had a facial expression of a 'smirk' toward him and he is going to file suit against (corporation) and me over my said 'smirk'. He admitted that I uttered no actual words toward him but that I looked back at him and 'smirked' and he feels this was offensive. I was however offended when he told (#213) of guest services very loudly in the (facility) lobby 'I hate that (profanity)' after he felt that I had looked back and smirked at him. I did not respond to his offensive profane comment . (Resident #120 is well known for his almost daily fabricated written complaints about employees and residents alike, and I have overheard him multiple times stating to other residents 'I wonder who I can get fired this week.' . It is concerning to me, due to (Resident #120)'s well known track record of fabricating stories to his liking that we continue to embolden him by catering to all of his demands and complaints without any proof, as well as refuse to place another resident in his room due to the fear that he will bully the other resident, as he has done in the past every time he acquires a roommate. Physician #218 was interviewed on 7/27/15 at 3:14 p.m. He said he questioned Resident #120's ability to interpret facial expressions. While he was in the vicinity of Resident #120 and the Guest Services Director, he heard him talking about his patient (Resident #129) and saying he had the ability to hurt him. Being concerned, he was trying to listen to protect his incapacitated dependent resident. He said he was also lingering in case Guest Services Director #213 needed protection. He said Resident #120 terrorizes staff and residents and no one protects them. He expressed frustration with being advised not to talk to Resident #120 and just walk away, feeling it hinders his ability to perform the functions of his position. Administrator #153 was asked if there was any documentation available at the corporate level regarding their involvement in the investigation. She subsequently furnished a copy of an email from the corporate vice president of operations dated 07/27/15. It stated in part (typed as written): This email is to verify that on July 8, 2015 at 4:00 p.m. Dr. (Senior vice president of medical affairs) and I held a telephone meeting with (Physician #218) concerning the allegation made by (Resident #120). 1. Initially, I reviewed the allegation with the group. (Physician #218) denied the allegation (in agreement with the statement that he supplied to the center). 2. Secondly, I reviewed the Abuse and Neglect regulations and the (corporate) policy. 3. In addition, I reviewed policy on Resident's rights with specific emphasis on the right to register complaints. 4. We also discussed the general difficulty in finding appropriate discharge arrangements for residents with unusual circumstances or behavioral issues. Administrator #153 was asked whether there was any documentation of counseling or disciplinary action at the corporate level. She subsequently furnished an email from the corporate vice president of operations dated 07/28/15 that stated (typed as written): Our conversation was not a formal counseling in a disciplinary manner but more of a re-education in regard to the areas I listed. This decision was made for several reasons. 1. (Physician #218) denied that he 'smirked' - he indicates that he may or may not have smiled (he simply cannot recall) but did not smirk or verbalize anything to (Resident #120). 2. Dictionary.com defines 'smirk' as 'to smile in an affected, smug, or offensively familiar way.' 3. Per this definition, in order to substantiate the concern, one would have to conclude that (Resident #120) could, in some way, accurately determine the intent of any smile that (Physician #218) may or may not have expressed. There was simply no way to prove that. The conclusion was that the allegation was unsubstantiated but that (Physician #218) should avoid any unnecessary contact or interaction with (Resident #120). Dr. (Senior vice president of medical affairs) did not document in addition to what I provided in the summary and he validated. There was no evidence of documentation in the investigative record of any corporate questioning or speaking with witnesses or discussing the investigation findings with the Social Services Director or the Administrator. Administrator #153, was interviewed on 7/28/15 at 9:30 a.m. She said the investigation of this allegation, like the one involving the nurse practitioner, was conducted partly at the facility level and partly at the corporate level because the physician was not an employee of the facility. She acknowledged the ultimate responsibility for reporting, investigation, protection and resolution of allegations of abuse/neglect rests with the facility management regardless of who the alleged perpetrator may be. She said corporate had some of the investigative documents, but not all. She was asked if corporate staff had interviewed any of the witnesses (other than the nurse practitioner) and she said they did not. She was asked if Physician #218 had been suspended pending the outcome of the investigation and she said he was not. She acknowledged this was contrary to her expectation and facility past practice for its policy to protect residents during an investigation. She said the facility staff normally involved in investigations, such as the Social Services Director, did not speak with any corporate persons to clarify any issues or offer any opinions regarding the decision whether to substantiate the allegation. Guest Services Director #213 was again interviewed on 07/29/15 at 9:14 a.m. She was asked whether facility staff or corporate staff had interviewed her following her submission of her written statement which appeared to support to some degree the allegations of Resident #120, to clarify anything, ask her opinion about any of the events she witnessed, etc. She said no one had spoken to her at all. She was asked to write a statement, which she did. No one followed up with her in any way, so she never informed anyone of her belief the Physician was mocking Resident #120. Social Services Director #154, was interviewed on 07/28/15 at 9:48 a.m. She said this investigation, like the one involving the nurse practitioner, was handled differently than most. It was not handled exclusively by the facility. The action to be taken was ultimately determined at the corporate level. There was sufficient evidence to indicate the facility failed to thoroughly investigate the allegation of verbal abuse made by Resident #120 against Physician #218. The investigation was not fully investigated and considered by all parties in a comprehensive manner. The allegation was not reported in a timely manner as required by law, and the alleged perpetrator was not suspended pending the outcome of the investigation for the protection of residents which the Administrator confirmed was the standard of practice in such situations. b) Resident #183 1) Resident #183 was admitted to the facility on [DATE]. The next morning she made an allegation she was treated roughly by two (2) nursing assistants when they took her off the bedpan the night she was admitted . Review of the reporting and investigation found the immediate reporting of the allegation was not made to all applicable agencies as required by law until 05/12/15. Social Services Director (SSD) #154 was interviewed on 07/28/15 at 9:48 a.m. She acknowledged the allegation was not reported in a timely manner as required. She said facility staff did not report the allegation, which the resident made on Saturday, 05/09/15. SSD #154 waited until she returned to work on Monday 05/11/15 to inform her of the allegation. She then completed the required referral forms and faxed them to all applicable agencies. c) Resident #14 1) On 06/27/15 at 9:00 a.m., Resident #14 made an allegation to nursing staff that a nursing assistant had stolen $32.00 from a drawer in her room. Review of the reporting and investigation found the immediate reporting of the allegation was not made to all applicable agencies as required by law until 06/29/15 at 4:45 p.m. Social Services Director #154 was interviewed on 07/28/15 at 9:48 a.m. She acknowledged the allegation was not reported in a timely manner as required. She said facility staff did not report the allegation as reported on Saturday, 06/27/15. She reported it on Monday, 06/29/14 when the resident repeated it to her. She then completed the required referral forms and faxed them to all applicable agencies. She also reported the allegation to the police, and an officer met with Resident #14 on 06/29/15. d) Resident #90 Review the past six (6) months complaints, on 07/27/15 at 3:30 p.m., found a complaint dated 01/19/15 regarding Resident #90's bed sheets being brown ringed, a condition where the sheets had a dried brown circular area, presumably of old urine. This matter was discussed with Social Worker #145 on 07/27/15 4:30 p.m. She said she did not know this was a matter that should have been reported to the State, nor did she understand why it should have been reported, therefore, she did not report it. During an interview with the responsible party of Resident #90, on 07/28/15 at 11:00 a.m., she said she had complained many times in the past about Resident #90's bed being wet at various times of day. She said one (1) weekend, Resident #90's bed was so wet, she went to nursing staff and told them it was neglect. She was unable to provide a date or names for this particular incident and no reportable documentation was found describing any incident regarding urinary incontinence of Resident #90 during a record review on 07/27/15 at 3:30 p.m.

Based upon observation, medical record review, review of the facility's abuse and reporting information, review of staff in-services, and staff interview, the facility failed to ensure the resident environment remained as free from accident hazards as possible for two (2) of two (2) residents reviewed for safety issues, in a facility sample of fourteen (14). The facility failed to ensure Resident #98 received adequate supervision and assistance devices to prevent accidents. The facility failed to monitor this resident who eloped, and sustained injuries during the elopement. His whereabouts were unknown for an hour, until notified by emergency responders, that he was found and was undergoing emergency treatment. In addition, the facility failed to repair a damaged wall which Resident #42 may have been ingesting. Resident identifiers: #98 and #42. Facility census: 95. Findings include: a) Resident #98 Medical record review revealed Resident #98 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. According to the facility's abuse/neglect reporting information, reviewed on 04/22/13 at 10:07 a.m., this resident eloped from the facility on 04/09/13. During the survey, an investigation of exit doors was conducted as to their design, their function, the types in use, and their maintenance and testing. Review of maintenance logs and tests, on 04/23/13 at 2:30 p.m., found no documented concerns to suggest there was a malfunction on the afternoon of 04/09/13. There were three (3) doors designed to automatically lock when approached by a resident wearing a WanderGuard device, such as the one ordered for Resident #98. In addition, if a resident wearing a WanderGuard followed someone out an already opened door, an audible alarm sounded. These doors were at the main entrance, a door leading outside from the main dining room, and a door that was located on the hallway toward the assisted living unit, where staff exited to the outside to smoke. If the WanderGuard was not in place, was not functioning, and/or the doors were disarmed, Resident #98 could have exited, without being noticed, any of the three (3) doors designed for automatic locking. All the remaining doors, when armed, were of the type that required one to push the "panic bar" type of release, wait fifteen (15) seconds, and the door would open, whether or not one was wearing a WanderGuard. A loud audible alarm sounded as soon as the bar was touched, and did not stop until reset by a key pad. If one went out these doors, he/she could not get back inside unless someone reset the door from the inside. The resident's closed medical record was reviewed, beginning on 04/23/13 at 4:10 p.m. Prior to the elopement incident, Resident #98's care plan included a focus item for the risk of elopement due to dementia and cognitive loss. One of the interventions was to utilize and monitor the resident's security bracelet according to protocol. His care plan indicated he could ambulate independently. Review of physician's orders [REDACTED]. The treatment administration record (TAR) indicated the placement of his WanderGuard was not checked by the assigned nurse on the day shift or the afternoon shift of 04/09/13, the date of the elopement. Restorative nursing documentation contained documentation of weekly checks to ensure the units were operating and batteries were sufficiently charged. Such a check was documented for Resident #98 on 04/09/13. Also contained in this restorative information was a hand written note stating (as written): "(Resident #98) document on cutting wander guards off." A second handwritten note stated (as written): "Cuts wander guard off Hosp 3/14 " Multiple recordings in the incident report, the facility's investigation, and nurses' notes concerning the elopement stated the WanderGuard was in place. The incident report completed by a former registered nurse (RN), Employee #196, stated (typed as written): "(local rescue squad) called to inform us that the resident was discovered. Wanderguard was in place to left ankle." A nurse's note, also by Employee #196, dated 04/09/13 at 4:54 p.m., stated (typed as written): "Resident exited the facility by himself, UTD time of elopement. He was discovered at (local country club). Facility was called at 1500 by (local rescue squad). Was informed by staff at the field club that the resident had fallen and was found in the golfing area by two golfers. the golfers placed the resident on their golf cart and took him to the office. This nurse went to visualize the resident and his current status. Resident was noted to be lying on the stretcher, verbal and confused. Emergency treatment was provided by (local rescue squad). Transported to (local acute care hospital) by (local rescue squad). (Name) MPOA, was called at 15:15. Wanderguard was noted to be in place to the left ankle." Medical record review revealed a summary of the situation completed by the social worker, Employee #37 (typed as written): "At approximately 3:00 pm on 4/9/13, it was reported that (Resident #98) had eloped from the facility and was found by golfers at the (local golf club) down the road. He was found lying on the ground, and (Local Rescue Squad) was called and notified the facility upon recognizing the resident. It was reported that his wander guard was in place on his left ankle. The resident was noted as having a superficial laceration to his face and low blood sugar, but he was not seriously injured." According to staff statements, the resident was last seen at approximately 2:00 p.m. that afternoon attending an activity in the assisted living area of the facility. A band was playing from 2-3:00 pm, the time during which the resident eloped. Since his wander guard was in place and working, we can only assume that the door alarm was not heard. . . ." b) The facility's investigation regarding the resident's elopement included two (2) pertinent statements: 1) A statement from an activities staff member, Employee #56 (typed as written) included: "Resident 320 Bed 2. Had come to the 2 oclock activitie "music" in Chessey (the assisted living unit within the facility). He stayed about 5, maybe 10 mins. Then came up back to the front " 2) A statement from a registered nurse (RN), Employee #148 (typed as written) included: "On April 9th 2013 at approximately 2pm, I saw and spoke with (Resident #98). He stated he was going to go take a nap because his roommate was quiet (Resident #98) walked towards his room and I went to lunch He was in his room. I did not hear any door alarms other than the aide going out for oxygen." Statement #1 and #2 call into question the social worker's conclusion that the resident exited from the assisted living unit while the band was playing and therefore, staff may not have heard the alarm. It appears just as likely the last place any staff saw the resident was in his hallway. The acute care medical record of Resident #98's emergency room visit was reviewed at the hospital on [DATE] at 8:15 a.m. These hospital medical records revealed the resident sustained [REDACTED]. During the investigation, a visit was made to the local rescue squad, on 04/25/13 at 10:30 a.m. The two (2) emergency medical technicians (EMTs) who had responded to the call were interviewed. They said Resident #98 was found lying face down on a putting area of the golf course. They said the location was about a half mile from the facility. When asked if the resident had on a Wander Guard, EMT #1 said they cut the resident's pants off, as he was wet and covered in mud, to determine the extent of his injuries. EMT #1 said he knew what a wander guard was, and Resident #98 definitely did not have one on his leg. Other information obtained during the complaint investigation gave rise to additional questions about the actual circumstances which may have provided the opportunity for Resident #98 to elope undetected by facility staff: Review of the facility's in-servicing of staff in elopement procedures and one-on-one care for Resident #98 following his elopement led to the discovery of in-servicing of staff related to the disarming and propping open of doors. An interview with the RN staff educator, Employee #59, on 04/24/13 at 1:48 p.m., found there had been concerns with staff disarming and propping open doors so they could go outside to procure portable oxygen and get back in on their own without sounding any alarms. A document was presented that showed nineteen (19) staff members still had not been in-serviced as of 04/24/13. A trip around the building confirmed there were two (2) doors used by staff to obtain oxygen. One (1) was at the end of one of the hallways in assisted living. The other was at the end of the hallway on the unit where Resident #98 resided. This doorway lead in the general direction of the country club. The elopement and the investigation were discussed with the administrator, Employee #45, on 04/26/13 at 9:40 a.m. She confirmed adequate supervision was not provided, and the resident was injured as a result. She confirmed the facility did not know where the resident was, how he eloped, or what exit was used. It was verified no one saw the resident for approximately an hour and the facility was unaware he was not in the building until called by rescue personnel. At the close of the complaint investigation, there was still no conclusive evidence regarding what happened; however, several questions were raised during the investigation as to the presence of the wander guard and the consistent, correct use of the doors in the facility. . b) Resident #42 Observations of Resident #42 were made on 04/22/13 at 1:00 p.m., 04/22/13 at 4:30 p.m., 04/23/13 at 9:10 a.m., 04/23/13 at 2:00 p.m., and 04/23/13 at 3:00 p.m. Resident #42's bed was placed with one side against the wall of the room. He was always found lying on his right side with his face within a foot of the wall. There were two (2) main areas where the wall was damaged. Those areas were around four (4) inches in diameter, and the outer finished layer of the wall was gone. Toward the center, the depth of the damage increased, to include the inside of the wall itself. There were several, eighteen (18) to twenty (20) small areas where small pieces of the outer finish layer of the wall were missing and the inside of the wall material was exposed. These were roughly circular and ranged from around one fourth inch (?") to one inch (1") in width. Also noted were many marks on the wall around and through these damaged areas, that appeared to be linear scratches. These were jagged in appearance, not perfectly straight marks. All of this damage was adjacent to the area where Resident #42's face and hands were observed. He appeared debilitated, perhaps contracted, nearly in a fetal position, but was seen to be restless and moving about in his bed. Resident #42's medical record was reviewed on 04/23/13 at 9:12 a.m. He was admitted to the facility on [DATE]. He had a [DIAGNOSES REDACTED]. He was to be kept at a ninety (90) degree upright position when swallowing food or drink. The resident was also at risk for respiratory infections due to respiratory infiltrate. A registered nurse (RN), Employee #148, was interviewed on 04/23/13 at 3:15 p.m. She was asked to observe the damage to the wall in Resident #42's room. She was asked if she knew how the damage occurred. Employee #148 stated Resident #42 picked at the wall all the time. She also said the resident had been observed putting some of the pieces in his mouth. When asked if any other staff members were aware of this, she said she had spoken to the unit manager about it, and she said the two (2) of them went to the director of nursing (DON), Employee #133, either "the beginning of last week, or the end of the week before" and informed him of this situation. According to Employee #148, the DON said he would take care of it. A nursing assistant (NA), Employee #51, was interviewed on 04/23/13 at 4:13 p.m. She was asked to observe the damage to the wall in Resident #42's room. She was asked if she knew how the damage occurred. She said the resident gets mad and hits the wall. Employee #51 stated the resident made the two (2) big places hitting it. According to Employee #51, the resident picked at the wall a lot. She was asked if the nursing assistants had told anyone about this. She said she had told the nurses, and that all the afternoon shift nurses knew about it. Maintenance work orders were requested from the maintenance supervisor, Employee #134, on 4/22/13 at 1:00 p.m. Review of these work orders found no work orders for March or April 2013 involving the wall in Resident #42's room. The director of nursing, Employee #133, was interviewed on 04/24/13 at 9:30 a.m. He was asked about the wall damage, and the concern that Resident #42 may be placing debris from the wall in his mouth. He said he had no knowledge of the situation; that if he did, he would have taken care of it immediately. He denied any meeting with any nursing staff had ever taken place on the subject. During the day, on 04/24/13, after the condition of the wall was brought to the facility's attention during the survey, the facility placed a wall covering on the affected wall and rearranged the layout of the furniture in the resident's room, in an attempt to ensure a safe, comfortable sanitary environment for Resident #42, and to ensure Resident #42 did not ingest non-food items. .

Based on medical record review, resident interview, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for eight (8) of fourteen (14) residents reviewed. Resident #98 was admitted with a history of an identified reaction/allergy to [MEDICATION NAME] and [MEDICATION NAME]. The facility flushed the resident's percutaneous intravenous central line (PICC) with [MEDICATION NAME] on three (3) separate occasions. This resulted in harm to Resident #98, as the resident had a reaction and was taken to the emergency room for treatment. Residents #20, #35, #71, and #84 did not have blood pressures taken as ordered. The facility failed to obtain necessary information to ensure pacemaker checks were completed as required for Residents #69 and #83. Wound treatments for Resident #27 were not completed as ordered. Resident identifiers: #98, #20, #35, #71, #84, #69, #83, and #27. Facility census: 95 Findings include: a) Resident #98 This [AGE] year old male was admitted on [DATE] after a recent hospital stay for an acute illness and surgery. During his stay at the acute care facility, he experienced an acute reaction to [MEDICATION NAME] and [MEDICATION NAME] (anticoagulants) . Because of this reaction, the medical records sent with the resident on admission clearly identified the resident's allergy to [MEDICATION NAME] and [MEDICATION NAME]. The records specifically stated, "Consult hematology prior to future [MEDICATION NAME] or [MEDICATION NAME] (a low molecular form of [MEDICATION NAME])" and "Would avoid all [MEDICATION NAME] products in the immediate future." The resident's admission orders See central line protocol." The central line catheter protocol form was completed on 03/21/13, and signed at 5:50 p.m., by Employee #22, a registered nurse (RN). Despite the notation in the allergy box, of an allergy to [MEDICATION NAME] and [MEDICATION NAME], the nurse marked the flushing protocol section to ". . . flush unused lumens of the percutaneous intravenous central line (PICC) with 5 milliliters (ml) of normal saline and 5 mls of [MEDICATION NAME]. . . ." Review of the medical record, on 04/24/13 at 9:00 a.m., verified the resident received three (3) doses of [MEDICATION NAME] flush through the red port of his central line catheter. The first dose was on 03/20/13 at 9:00 p.m., the second dose was given on 03/21/13 at 09:00 a.m. and the last dose was at 9:00 p.m. on 03/21/13. An order was written to discontinue the [MEDICATION NAME] flush, on 03/23/13 at 4:00 p.m., by Employee #22. A note written by a licensed practical nurse (LPN), Employee #129, stated the resident was transferred out by ambulance, on 03/23/13, for an unplanned evaluation and treatment. Medical record review revealed the resident had been spiking fevers of 99.1 to 104.1., and had two (2) critical lab values: hemoglobin (Hgb) 8.6 (the reference range 12.5 - 16.3) and platelet (plt) count of 63 (reference range 140 - 450) on 03/21/13. Review of the care plan, on 04/24/13, identified the facility had added the notation of the [MEDICATION NAME] allergy to the care plan on 03/26/13, three (3) days after the resident was discharged from the facility. This information was not a part of the care plan when the resident was given [MEDICATION NAME] flushes. During an interview with a registered nurse, Employee #78, on 04/24/13, she acknowledged the care plan was changed on 03/26/13 after the resident was discharged . She stated she had added it because, "It had not been care planned." Copies of medical records were obtained from the tertiary care center on 04/24/13 at 9:00 a.m. According to these records, the physicians at the tertiary center were unable to completely rule out a [DIAGNOSES REDACTED]. Due to this, the resident was treated with Argatroban, a direct [MEDICATION NAME] inhibitor. . b) Thirteen (13) residents' medical records were reviewed, on 4/23/13 at 9:00 a.m., related to physician's orders [REDACTED]. The review found four (4) of the thirteen (13) residents did not have their blood pressure checks done as ordered. The facility's policy on vital signs, when reviewed on 04/23/13 at 2:55 p.m., revealed vital signs included blood pressure, pulse, respiration, and temperature. The four (4) residents whose blood pressure checks and/or vital signs were not completed as ordered included: 1) Resident #20 A seventy (70) year old woman, was admitted to the facility on [DATE]. She had an active physician's orders [REDACTED]. As of 04/23/13, there was no evidence vital signs (including blood pressure checks) had been taken since 03/04/13. 2) Resident #35 This resident had an active physician's orders [REDACTED]. As of 04/23/13, the only evidence vital signs (including blood pressure checks) were taken were on 03/14/13, 04/17/13, and 04/19/13. 3) Resident #71 This resident had an active physician's orders [REDACTED]. As of 04/23/13, there was no evidence vital signs (including blood pressure checks) had been taken since 02/13/13. 4) Resident #84 A fifty-three (53) year old woman, was admitted to the facility on [DATE]. She had a physician's orders [REDACTED]. As of 04/23/13, the only evidence vital signs (including blood pressure checks) had been taken were on 03/28/13 at 5:05 p.m., 03/28/13 at 10:10 p.m., 03/29/13 at 5:17 a.m., and 03/31/13 at 3:19 a.m. 5) An interview was conducted with the director of nursing, Employee #133, on 04/23/13 at 2:45 p.m. He reviewed the documentation related to blood pressures for Residents #20, #35, #71, and #84, and agreed blood pressures had not been taken as ordered by the physician. c) Two (2) current residents at the facility had pacemakers, Resident #69 and Resident #83. Their medical records were reviewed on 4/23/13 at 10:38 a.m. 1) Resident #69 This resident was admitted to the facility on [DATE]. She had a cardiac pacemaker. There was an active physician's orders [REDACTED]." No cardiologist recommendations or documentation were found in the medical record, and there was no evidence pacemaker checks were done since admission. 2) Resident #83 This resident had a cardiac pacemaker. She had an active physician's orders [REDACTED]." There were notes under the orders that stated "last check 3/12/12." There was also a handwritten note that stated, "next scheduled pacer check 5/7/13." The care plan stated pacemaker checks were to be done according to cardiologist recommendations; however, no cardiologist recommendations or other details were found in the medical record. 3) The facility policy and procedure for pacemakers was requested. It was reviewed on 04/23/13 at 1:00 p.m. The document, "Procedure: Pacemaker Effective Date: 06/01/96 Revision Date: 10/01/12" stated in part: "1.1 Identify type and identification number of pacemaker and document in medical record. 1.2 Review instruction booklet or contact cardiologist for specifics regarding patient's pacemaker. 1.2 Contact pacemaker clinic/physician to schedule regular pacemaker checks. 1.4 Document schedule/instructions for patient's pacemaker checks in patient's care plan and on Treatment Administration Record (TAR) 5. Monitor for function of pacemaker. 5.1 Perform pacemaker checks according to schedule and instructions of pacemaker clinic/physician." 4) The director of nursing, Employee #133, was interviewed on 04/23/13 at 2:45 p.m. He reviewed the documentation and agreed that neither resident's record contained the type, identification number, instructions or specifics regarding the pacemaker. He acknowledged the type of pacemaker determined how often it must be checked. Employee #133 confirmed the facility did not know the type of either resident's pacemaker. He also agreed there was no evidence of pacemaker checks in the Treatment Administration Record (TAR) of either resident. d) Resident #27 This seventy-five (75) year old woman was admitted to the facility on [DATE]. She was admitted for rehabilitation procedures following traumatic fracture of a bone. Her brief interview for mental status (BIMS) score,assessed on 03/13/13 was "15," indicating she was cognitively intact. She was also indicated as interviewable by the facility, on the resident roster they completed. Her medical record was reviewed on 04/24/13 at 8:30 a.m. Resident #27 suffered a fall at home, fracturing her left leg. There were pins in place to secure the fracture. She had a physician's orders [REDACTED].? peroxide and ? normal saline, apply gauze around the pins, and secure them with Kling (gauze bandages that cling to themselves and stretch to conform to body contours) twice each day and more often if needed. The order was written on 02/26/13, and was still active. On 04/24/13, the resident's TARs for March and April 2013 were reviewed: - During March 2013, the treatments were not completed during day shift on March 1, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 23, and 24. The record also showed treatments were not completed during the afternoon shift on March 5, 21, and 25. - During April 2013, the record showed the treatments were not completed during the day shift on April 1, 7, 8, 9, 17, and 22. T he record also showed treatments were not completed during the afternoon shift on April 6, 9, 13, 14, 17, 18, 19, and 21. Resident #27 was interviewed on 04/24/13 at 10:30 a.m. She was asked about her injury and about the treatments that were ordered for her twice each day, and more often as needed. She replied they "don't always do it every day. They miss a few days at times." The director of nursing, Employee #133, was interviewed on 04/24/13 at 11:00 a.m. He was shown the physician's orders [REDACTED]. Employee #133 confirmed the evidence indicated Resident #27 did not consistently receive the physician ordered wound care treatments. .

Based on observation, record review, policy review, staff interviews, and review of the facility's emergency / disaster preparedness records, the governing body failed to ensure the facility was administered in an efficient and effective manner as evidenced by the presence of system failures in the areas of quality of care, infection control, and emergency / disaster training, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. This failure placed more than an isolated number of residents in immediate jeopardy related to the failure to ensure all staff was knowledgeable concerning the dangers / hazards associated with resident smoking, placed all residents at risk for more than minimal harm related to an ineffective infection control program that was not based on current standards of professional practice, and presented the potential for more than minimal harm to all residents related to the facility's failure to appropriately train employees in emergency preparedness. These actions resulted in findings of immediate jeopardy and substandard quality of care. The administrator of this facility was ultimately responsible for the operation of this facility, as this individual alone possessed the authority to manage the facility and make needed changed to facility systems. Facility census: 97. Findings include: a) Findings of immediate jeopardy Review of facility documents found that, on 07/03/11, Resident #10 suffered severe [MEDICAL CONDITION] treatment in an out-of-state burn unit. Resident #10 was supervised while smoking by a staff member who had not been trained in the hazards / dangers of smoking while utilizing oxygen. The staff member lit Resident #10's cigarette while the resident was receiving supplemental oxygen via a nasal cannula. The oxygen was ignited by the lit cigarette, which caused grievous injury to Resident #10. Observation of the area designated for resident smoking, on 07/12/11, noted the absence of a readily available device to smother flames (e.g., smoking blanket). Further observation noted an unsecured fire extinguisher sitting on the concrete walk by a resident's chair who was smoking. An inspection of the tag attached to the fire extinguisher noted no documentation of an inspection for proper working order since February 2011. The administrator was informed at 12:40 p.m. on 07/12/11 that the failure to provide safety devices in the resident smoking area, failure to assure adequate staff training, and failure to develop policies related to staff training regarding safety measures to be employed during resident smoking placed more than an isolated number of residents in immediate jeopardy of injury or death. (See also citation at F323.) -- b) Infection control 1. During random observations of the resident environment on 07/12/11 at 10:00 a.m., a nursing assistant (NA - Employee #128) was observed to enter a resident's room who was in contact isolation due to a [MEDICAL CONDITIONS] infection. Employee #128 did not don personal protective equipment (PPE) prior to entering the room to replace a pillow case, nor did she wash her hands after exiting the room. She then crossed the hallway and accessed the clean linen on the clean linen cart. On 07/13/11 at 2:00 p.m., a physical therapy assistant (PTA - Employee #127) was observed to be sitting on the unoccupied bed of a resident's who was placed in contact isolation due to a [MEDICAL CONDITION] infection. Employee #127 did not have on PPE to prevent contamination of his hands and clothing, and he did not wash his hands prior to exiting the contact isolation room. - Review of the facility's policy entitled "3.1 Contact Precautions" (revision date 09/01/10), in Section 4, found the following information: "Use barrier precautions for all contact with patient and patient's immediate environment. 4.1 Wear gown and gloves when entering the room... 4.4 Remove and bag gown and gloves and wash hands upon exiting the room." - An interview with the infection control registered nurse (RN - Employee #5) following each of these observations elicited that the individuals did not provide care in accordance with the facility's infection control policies. Employee #5 provided immediate inservice education to the individuals and their respective departments. -- 2. During a random observation, a housekeeping aide (Employee #113) was observed to prepare to clean an isolation room of a resident in contact isolation due to a [MEDICAL CONDITION] infection. Employee #113 was interviewed at 10:10 a.m. on 07/12/11. When asked what cleaner he utilized for the surface, floor and commode of this particular room, he reported he utilized the facility's standard cleaning products. When specifically asked about the procedure for cleaning the commode, he stated he utilized a commode brush located on his cart, then rinsed it out and used it in other rooms. - An interview with the housekeeping supervisor (Employee #6), on 07/12/11 at 10:15 a.m., confirmed the cleaning products utilized by the housekeeping staff were not effective in killing [MEDICAL CONDITION] spores. Employee #6 acknowledged the facility did not utilize a 1:10 dilution of sodium hypochlorite (nine parts water to one part bleach) solution when cleaning contact isolation rooms potentially contaminated with [MEDICAL CONDITION] spores. - Review of the facility policy 2.1 entitled "Cleaning and Disinfecting" (revised 09/01/10) found, in Section 5, the following requirements: "5. Clean environmental surfaces, floors, walls, furniture using EPA approved, hospital grade disinfectant according to schedule and need. For patients with [DIAGNOSES REDACTED]icile or norovirus use a 1:10 dilution of sodium hypochlorite (nine parts water to one part bleach)." -- c) Emergency / Disaster Preparedness Review of the facility's inservices record for employees in 2010 and 2011 found the facility had not conducted their annual training on the Emergency Preparedness Plan for all employees, as required by their policy titled "1.37 Emergency Preparedness" (dated 04/01/03). Review of this emergency plan found the following topics to be covered: "Accident Prevention / Safety and Fire and Safety Rules and Prevention". According to the facility's inservice records, the last time the facility had provided staff training on emergency preparedness covering the topics of accident prevention and fire and safety rules and prevention was in May 2010. During an interview on 07/13/11 at 10:30 a.m., the facility's administrator (Employee #1) confirmed the emergency preparedness inservice training had not been provided annually for all employees as the facility's policy required. Failure of the facility to train all staff on the hazards of having open flames around oxygen resulted in Resident #10 sustaining severe [MEDICAL CONDITION] smoking a cigarette while receiving supplemental oxygen via a nasal cannula. At the time of this occurrence, the staff member who was providing supervision while Resident #10 was smoking had not received any such training. (See also citation at F323.)

Part I -- Based on the review of incident / accident reports, medical record review, family interview, staff interview, policy review, review of staff inservice training records, personnel record review, observations, and review of the facility's emergency preparedness plan, the facility failed to provide adequate supervision while smoking to one (1) of two (2) residents who required the use of supplemental oxygen. On 07/03/11, Resident #10 was permitted to smoke while receiving oxygen from a portable oxygen tank via a nasal cannula; a lit cigarette ignited the oxygen resulting in severe facial burns to Resident #10 which required treatment at an out-of-state burn unit. Resident #10 had been assessed by the facility as requiring staff supervision while she smoked, and the individual assigned to provide this supervision on the morning of 07/03/11 was a receptionist. The receptionist was not on the list of staff whose departments were routinely assigned the responsibility for supervising resident smoke breaks, and there was no evidence the receptionist had received training on the dangers / hazards of smoking in the presence of oxygen. This practice placed Resident #10 in immediate jeopardy and presented the potential for more than minimal harm to the other four (4) residents and any staff members in the designated resident smoking area at the time of the occurrence. After the incident involving Resident #10 occurred on 07/03/11, the facility provided training to staff on how to extinguish residents who are on fire using a blanket, sheet, or other large covering (and NOT a fire extinguisher). Observation of the resident smoking area found the only device available to smother a fire was a fire extinguisher, which the policy specifically instructed staff to not use to smother fire on a resident. No large covering was readily available for use by staff if it were again necessary to smother fire on a resident. Although a fire blanket was available in a storage cabinet in the employee smoking area, a staff member would have to travel 228 feet from the resident smoking area to the fire blanket in the employee smoking area. For this reason, immediate jeopardy was determined to have been on-going since the incident on 07/03/11, with the potential to affect all residents who smoke. On 07/12/11 at 12:40 p.m., the administrator was informed that immediate jeopardy had been present at the time of the incident on 07/03/11 and was on-going. During a subsequent meeting with the administrator on 07/12/11 at 2:50 p.m., the administrator provided evidence of having implemented the following actions steps: (1) an addendum to the facility's resident smoking policy to include staff training on the prohibition against the presence of oxygen within 5 feet of any smoking, staff training on how to extinguish a fire utilizing the extinguisher and fire blankets, and staff training on how to safely monitor and assist residents with smoking (including but not limited to the possible need for smoking aprons and assisting residents to properly extinguish materials as needed); and (2) relocation of resident smoking to the area previously designated for employee smoking, where the fire blanket in a storage cabinet was readily available for use in an emergency. The survey team verified resident smoking was moved to the area where the fire blanket was located and that employees were inserviced in its use, and a randomly selected staff member was able to demonstrate the proper use of the fire blanket. At 3:25 p.m. on 07/12/11, the nursing home administrator was notified the immediate jeopardy had been removed with no deficient practice remaining with respect to these concerns. Resident identifier: #10. Facility census: 97. Findings include: a) Resident #10 Review of the facility's incident / accident reports, on 07/11/11, found a report dated 07/11/11 (and identified as a late entry for 07/03/11 at 10:10 a.m.), providing the following description of the incident (quoted as written): "Res (resident) was taken out of smoke /c (with) staff member & oxygen NC (nasal cannula) remained on resulting in burn to lower lip, (L) (left) cheek, & RLE (right lower extremity). Entire area around nose & mouth noted to be black in color. Resident immediately given cold washcloth & pain medication then 911 was notified of need for transport. Staff remained /c resident til squad arrived." Review of Resident #10's medical record found a late entry nursing note dated 07/03/11 at 10:26 a.m., stating: "Resident was taken out to smoke with staff member & oxygen remained on resulting in cigarette catching on fire. Entire area around mouth & nose noted to be black, burn noted to bottom lip as well as right lower leg. Unable to assess any other injuries r/t (related to) blackened area around mouth & nose. ..." A nursing note, dated 07/05/11 at 22:15 (10:15 p.m.), revealed the resident was readmitted to the facility from a hospital burn center. A nursing assessment of the resident's facial burns stated,"... Large 2nd degree burn noted to facial area around mouth. Lips edematous with blistered areas. Slight facial edema noted. Denies any difficulty swallowing at present. 2 small circular burns noted to left forearm and 3 small burns noted to right forearm. 1 small circular burn to top of right foot and 1 medium sized burn to top of right foot. ..." Further review of the medical record found Resident #10 was a [AGE] year old female with medical [DIAGNOSES REDACTED]. The resident was currently receiving hospice services. Both before and after her hospitalized from [DATE] through 07/05/11, she had physician's orders [REDACTED]. -- During an interview on 07/11/11 at 2:30 p.m., the resident's daughter reported Resident #10 had been declared to lack capacity to make medical decisions and she was the resident's medical power of attorney representative (MPOA). Random staff interviews, conducted during the course of this survey, found the resident was alert, verbal and oriented most of the time, but she had some confusion at intervals. Review of a smoking evaluation, completed on 06/01/11, found Resident #10 was evaluated as having dementia, poor memory, and being unable to demonstrate knowledge of the location of the designated smoking area. The evaluation also stated she required supervised smoking. -- Review of the facility's internal investigation into the above incident found the following: In a statement dated 07/03/11, the receptionist (Employee #106) wrote (quoted as written): "I (name of Employee #106), was asked to go back and sit with (Resident #10) due to being short on staffing. (Resident #10) had her breakfast and after she was done eating she asked to go out and have a cigarette. I turned her call light on and (Employee #117, a nursing assistant) came in and assisted (Resident #10) with getting dressed. As I was escorting (Resident #10) down the hallway to get her cigarettes from the nurse, (Resident #10) requested that her oxygen be put back on. When we arrived to (Employee #63, a licensed practical nurse)'s cart she placed the oxygen back onto (Resident #10) and turned the setting on 3. She then handed me two cigarettes and I took (Resident #10) onto the patio. I lit the first cigarette for (Resident #10) and once she was finished with that cigarette, she asked if she could smoke her second one, I replied yes. I lit the second cigarette and about halfway through, the cigarette burst into flames and caught (Resident #10)'s O2 (oxygen) tubing on fire. Immediately, I ripped the tubing off of (Resident #10) and threw it to the ground and multiply stepped on it to put it out. I ran (Resident #10) back into the building and told (Employee #99, a registered nurse) which was standing outside of room 207. She then motioned (Employee #63) to come over. (Resident #10) was then escorted to her room and aides applied cold washcloths / ice to (Resident #10)'s face." - In a statement dated 07/05/11, the licensed practical nurse (LPN) who was assigned to provide care for this resident on 07/03/11 on the 7-3 shift (Employee #63) wrote that Resident #10 had required one-to-one supervision on this day to prevent falls with injury. Her statement contained the following (quoted as written): "... I then asked a CNA (certified nursing assistant) to sit with her to give her one on one to prevent a fall with injury. CNA then proceeded to provide one on one care. I explained situation to the weekend manager who stated she would attempt to find someone who wasn't a CNA to provide one on one care so that this CNA could continue to assist on the floor as previously assigned. The receptionist, (name of Employee #106), then provided one on one care as requested by manager. When resident was finished with breakfast she then asked to go smoke a cigarette. The CNA assisted resident with toileting & dressing & assisted her into her w/c (wheelchair). (Name of Employee #106) then wheeled her to my cart in the hall where I was doing my med pass. She asked me to turn on her oxygen, which I did due to her SOB (shortness of breath) from ADLs (activities of daily living). When a resident is on continuous oxygen, my nursing judgment tells me to turn on the oxygen. She then asked for 2 cigarettes which are kept locked up on med cart. I handed her the cigarettes as requested. I then proceeded to continue my med pass. A little while later I was pulled out of a resident's room to assess (Resident #10) who had been injured while outside smoking. ..." - Review of the facility's follow-up summary (which was not dated) found the following (quoted as typed): "... Upon completing the investigation, it has been determined that the LPN, (Employee #63), failed to act prudently which resulted in injury to this resident. "Per (Employee #63)'s statement and interview, she stated that the facility receptionist had asked her to turn on (Resident #10)'s oxygen. She stated that she did so due to the resident being short of breath from completing her ADL's. The receptionist then asked (Employee #63) for 2 cigarettes which were kept locked up on the medication cart. (Employee #63) then stated that she proceeded to continue her medication pass. She indicated during interview that she assumed the oxygen would be removed prior to the resident smoking. The receptionist should not adjust, apply or remove oxygen from a resident. Therefore, (Employee #63), failed to assure that oxygen would not be in use while this resident was smoking. ..." -- An interview was conducted with a registered nurse (RN - Employee #71) at 4:15 p.m. on 07/11/11. She relayed that, on a previous occasion in April or May 2011, she had observed Resident #10 in the employee smoking area while being supervised by a nursing assistant; her nasal cannula in place and her oxygen on. Approximately eight (8) staff members were smoking in that area while Resident #10 was using oxygen, and Resident #10 was seated approximately 3 feet away from the nearest smoker. Neither the nurse aide nor any of the other staff members present removed Resident #10 from the area. When asked if she reported this incident, she conveyed that she took care of the situation and did not report it. -- Review of the facility's resident smoke break schedule (dated 02/22/11) revealed the following (quoted as typed with handwritten corrections): "To all staff & residents: "The following schedule will be effective for all Residents that smoke starting 3/1/2011 9:30 am Housekeeping to Supervise 11:00 am Activities to Supervise 1:30 pm Activities to Supervise 5:00 pm Housekeeping to Supervise 8:00 pm Nursing to Supervise "The schedule is to be followed by all staff and residents. The resident is to be able to smoke two cigarettes for each break period. Thanks for all your cooperation in setting this plan in place." The receptionist was not employed in any of the departments that routinely provide supervision to residents during smoke breaks. -- Review of Employee #106's personnel file revealed that, although she had received basic information during general orientation, there was no mention in the Fire Safety portion of the orientation packet that specifically advised this non-nurse of any prohibition against smoking near oxygen. -- Review of the facility's inservice records revealed the last time any facility-wide training had been provided on the emergency preparedness plan (including fire and safety rules and prevention) was in May 2010. Review of the list of employees who attended this training found Employee #106 was not among them. An interview with the administrator, on 07/13/11 at 10:30 a.m., revealed this in-service should have been provided annually to all employees according to facility policy. (See also citation at F518.) -- Immediate jeopardy existed at the time of the incident involving Resident #10 on the morning of 07/03/11, due to the fact that the facility assigned a non-nursing employee (who received no training on the dangers / hazards of smoking around oxygen) to supervise a resident (who had a physician's orders [REDACTED]. --- b) Review of information provided by the facility, identifying action steps taken after the incident involving Resident #10 on 07/03/11, revealed the following staff inservices were provided: - On 07/03/11, 07/04/11, 07/05/11, 07/06/11, and 07/08/11 - Resident Smoking Policy (with an addendum specifically stating do not take O2 tanks into the smoking area) - On 07/05/11, 07/06/11, and 07/08/11 - Resident Smoker Audit Tool - On 07/05/11, 07/06/11, 07/07/11, 07/08/11, and 07/11/11 - Oxygen Therapy and Hazards Petroleum-based Products (with attached policies titled "11.8 Liquid Oxygen System" and "11.9 Nasal Cannula") - On 07/05/11, 07/06/11, 07/07/11, 07/08/11, and 07/11/11 - Emergency Care of Patient on Fire (with attached policy titled "6.4 Burns: Fire / Heating Source") - On 07/06/11, 07/07/11 and 07/11/11 - New Resident Smoking Area -- Review of the facility's policy titled "6.4 Burns: Fire / Heating Source" (dated 01/01/04), found the following: "1. Stop the burning process: "1.1 If customer is on fire, smother fire with sheet, blanket, or other large covering. Shield the customer's face and pat away from the fire. Keep head outside covering. Call out for help. Instruct to call 911. "1.1.1 CAUTION: DO NOT use a fire extinguisher on a customer. ..." -- Observations of the resident smoking area in the courtyard, on the afternoon of 07/11/11 and the morning of 07/12/11, found residents continued to smoke in that area, but no large covering (like a fire blanket) was available for use if a resident were to catch on fire. The only device available for smothering a fire was a fire extinguisher, which the facility's policy specifically directs staff to NOT use on a person. -- Observation of the employee smoking area (which, based on staff interviews, had also been used by residents when smoking) found a fire blanket in a storage cabinet was available at the entrance to the employee smoking area. The travel distance between the smoking area in use by residents on 07/03/11 and to the fire blanket stored in a cabinet in the smoking area in use by employees on 07/03/11 was 228 feet, as reported by the maintenance director (Employee #120) during a telephone interview on 07/28/11. -- On 07/12/11 at 12:40 p.m., the facility's administrator was informed that immediate jeopardy was present at the time of the incident involving Resident #10 and was on-going, due to the lack of availability appropriate equipment to extinguish a fire on a person in the resident smoking area, as identified in the facility's policy. --- c) During a subsequent meeting with the administrator on 07/12/11 at 2:50 p.m., the administrator provided evidence of having implemented the following actions steps: (1) an addendum to the facility's resident smoking policy to include staff training on the prohibition against the presence of oxygen within 5 feet of any smoking, staff training on how to extinguish a fire utilizing the extinguisher and fire blankets, and staff training on how to safely monitor and assist residents with smoking (including but not limited to the possible need for smoking aprons and assisting residents to properly extinguish materials as needed); and (2) relocation of resident smoking to the area previously designated for employee smoking, where the fire blanket in a storage cabinet was readily available for use in an emergency. The survey team verified that resident smoking was moved to the area where the fire blanket was located and that employees were inserviced in its use, and a randomly selected staff member was able to demonstrate the proper use of the fire blanket. At 3:25 p.m. on 07/12/11, the nursing home administrator was notified the immediate jeopardy had been removed with no deficient practice remaining with respect to these concerns. --- Part II -- Based on observation and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible, by failing to secure against unauthorized access a clean utility room in which potentially hazardous substances were stored. This had the potential to affect more than an isolated number of residents. Facility census: 97. Findings include: a) During the initial tour of the facility upon entrance on 07/11/11 at 2:00 p.m., observation found the door to the clean utility room standing wide open. An inspection of this room found tubes of zinc oxide, hydrocortisone cream, bottles of hydrogen peroxide, bottles of isopropyl alcohol, tubes of Calmoseptine ointment, sterile dressing supplies, and sterile indwelling catheter supplies. The room was accessible to visitors and wandering residents. The director of nursing (DON) was notified of this accident hazard at 2:20 p.m. The facility subsequently installed a lock on the door to prevent unauthorized access. .