Every finding on record at Piggott Healthcare & Senior Living, LLC

Based on observations, document review, and interviews the facility failed to ensure staffing information was complete and was not missing information, to ensure staffing information was accurate and current, and to maintain the posted daily nurse staffing data for a minimum of 18 months. The deficient practice had the potential to affect all residents.Based on observations, record review and interviews the facility failed to ensure staffing information was complete and accurate, and failed to maintain the posted daily nurse staffing data for a minimum of 18 months. The findings include: During an observation on 09/03/2025 at 1:49 PM, this surveyor observed a staffing schedule for CNAs and nurses for the month of September 2025 in a glass case on the wall near the main front door entrance and in a glass case on the wall near the common area front door During an observation on 09/03/2025 at 1:52 PM, outside of the Administrators (AD) office, this surveyor observed a staffing schedule for nurses for the month of September 2025. A review of the posted nursing and CNA schedules on 09/03/2025, the schedules for the CNAs and nurses did not contain the facility name, the date, the facility census nor the total number and actual areas worked per shift for licensed and unlicensed staff responsible for resident care. During an interview on 09/04/2025 at 10:42 AM, the AD reported that she was not aware that she needed to keep up with staffing assignments. She stated No, I do not keep up with the regulated staffing assignments. We don't post the staffing, and we do not keep up with where each nurse or CNA is working for each day they are working. During an interview on 09/09/2025 at 9:48 AM, the Director of Nursing indicated she indicated the staffing sheets should contain the staff's name, the hall they are assigned to and if the staff was working the day or night shift. She indicated it is important for the staffing sheets to contain all required components to ensure family members can know who was taking care of their family member.

Based on interviews, facility document review, and facility policy review, it was determined that the facility failed to provide a financial record or quarterly statement to the resident or resident's representative for the resident's funds account. This deficient practice has the potential to affect 14 residents placing their personal funds in the trust of the facility.Based on record review and interviews, it was determined that the facility failed to provide a financial record or quarterly statement to the resident or resident's representative for the resident's funds account. This deficient practice has the potential to affect 14 residents placing their personal funds in the trust of the facility. The findings include: On 09/04/2025 at 4:36 PM, Business Office Manager (BOM) provided a facility document titled Personal Funds Receipts. She reported they do not have quarterly statements available for the residents with personal funds kept by the facility. The Personal Funds Receipts document contained information regarding the resident's personal funds listed, which did not include receipts. The document listed the residents' name, cash withdrawal, and amount of transaction. During an interview, the BOM stated, We do not send out quarterly statements. She reported she was not aware quarterly statements for resident funds were to be sent to the resident or the resident representative. She reported that the facility does not have a local bank and if a resident requested money, she filled out a slip and verified with the resident or representative that it was correct and then the resident or representative gets the money. She indicated the resident would write a check made out to cash and the facility took the checks to the closest bank and then the cash would go back into the petty cash at the facility. She reported she did not like the way resident funds were set up, but the facility does not have a local bank to use for cashing checks. She reported that the facility would try to find a better way of handling resident funds. A review of admission packet indicated if the facility accepted custody of a resident's personal funds, the resident may take funds from the resident's account and accurate records shall be kept of all disbursements. On 09/09/2025 at 9:10 AM, during an interview, the Assistant Director of Nursing stated, I don't have anything to do with resident funds. On 09/09/2025 at 9:48 AM, during an interview, the Director of Nursing indicated she does not have a role in handling a resident's personal funds. On 09/09/2025, during an interview, the Administrator reported that residents request petty cash from the BOM. She indicated she was not sure how the money was repaid by the residents. When asked if she was aware checks were written out to cash, taken to the local bank and cashed by employees she reported she was recently made aware of the process. She indicated she did not consider that practice to be a proper accounting principle. She reported a resident's funds absolutely should never be mixed with employees' funds. She indicated the facility will find a more appropriate method as soon as possible.

Based on interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure Care Plans were person-centered for two residents (Resident #4 and #35) of 12 residents reviewed. The Findings include: Resident #4 A review of Resident #4's admission Record indicated, the facility currently admitted Resident #4 on 09/01/2023 and last returned on 07/11/2025, with diagnoses which included recurrent major depressive disorder (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), hypokalemia (low potassium levels), hemiplegia (partial to total paralysis on one side of the body), hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, hypertension (high blood pressure), hyperlipidemia (high cholesterol), dysuria (difficulty urinating), and constipation (infrequent or difficult bowel movements). A review of Resident #4's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/22/2025, indicated Resident #4 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. A review of Resident #4's, Care Plan, revised 08/27/2025, indicated the resident had problems regarding hypertension, left sided hemiplegia and taking. The Care Plan did not have medication interventions for antihypertensives, anxiolytics, statins, diuretics, supplemental medications, laxatives, or antipsychotic medications. Resident #4 had insulin care planned on 08/27/2025, a review of active orders indicated Resident #4 was not on any insulin medications. During an interview on 09/09/2025 at 9:10 AM, the Assistant Director of Nursing (ADON) stated that honesty, proper procedure, comfort of the resident, and safety of employees plays a part of expectations for staff with correctly documenting in the care plan. The ADON verified that the care plan drives the care of the resident. During an interview on 09/09/2025 at 9:48 AM, the Director of Nursing (DON) stated that medications should be on the care plan to keep an eye out for serious adverse reactions. During an interview on 09/09/2025 at 12:42 PM, Licensed Practical Nurse (LPN) #1 verified that medications should be on the care plan and that it was important to have medications on the care plan due to it allowing us to look up any signs or symptoms within the care plan. During an interview on 09/09/2025 at 3:26 PM, the DON verified that there was not a staff member who was completely responsible for the care plans. The DON verified that the following classifications of medication and interventions were not on the care plan for Resident #4: antihypertensives, anxiolytics, statins, diuretics, supplements, laxatives, or other antipsychotic medications. During an interview on 09/09/2025 at 10:58 AM, the Administrator indicated that it was expected that the care plan be completed correctly and timely. The Administrator verified that medications as well as the signs and symptoms of the medications should be documented in the Care Plan. She verified that it was a huge part of the resident's care. She confirmed that the purpose behind the care plan was, so staff knew how to take care of the residents. She verified that the Care Plan needed to be updated quarterly or with any change of condition. Resident #35 A review of Resident #35's Face Sheet indicated the facility admitted Resident #35 on 11/08/2024 with diagnoses which included anoxic brain damage (a condition that occurs when the brain is deprived of oxygen causing brain damage), anxiety disorder, depression, congestive heart failure (a condition where the heart cannot pump blood effectively), and hypertension (high blood pressure). A review of Resident #35's Care Plan dated 03/10/2025, indicated Resident #35 had a behavioral symptom of potential for elopement and exit seeking tendencies. Resident #35 had attempted elopements or elopements documented on 10/21/2024, 11/15/2024, 02/24/2025 and 03/23/2025. Interventions dated 02/24/2025 included to monitor and assess the residents' emotional well-being. No other updates, no new interventions and no indication of elopements dated 10/21/2024, 11/15/2024 and 03/23/2025 [DD1] were documented in the Care Plan. On 09/09/2025 at 9:10 AM during an interview, the ADON reported a resident's care plan should be updated quarterly, annually, and if a resident has a change in condition. She indicated Resident #35's care plan should have been updated each time he attempted to elope, eloped, or had any wandering behaviors. On 09/09/2025 at 9:48 AM during an interview, the DON reported Resident #35's care plan should have been updated with each elopement attempt. 09/09/2025 at 10:47 AM during an interview, the Administrator reported a resident's care plan should be updated quarterly and with any change of condition. She reported an attempted elopement would be considered a change of condition. She indicated when a new approach did not work, a new approach would be needed. The Administrator stated, I want to say we are actively going through each care plan and have been since I started here in June. During an interview on 09/09/2025 at 3:48 PM, the ADON reviewed and verified Resident #35's care plan for elopement risk and interventions had been updated one time after the 02/24/2025 elopement but had not been updated after the other elopements or elopement attempts. A review of a facility policy titled, Care Plan dated 2001 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on interview, record review, and facility policy review, it was determined the facility failed to report an alleged violation and investigation of the alleged violation involving supervision to the proper state agency within the allotted time frame for 2 (Resident # 35 and Resident #13) of 2 sampled residents reviewed for accidents/supervision and resident abuse. The deficient practice had the potential to lead to harm for Resident #35 due to repeated elopements into an unsafe environment for the resident. The deficient practice could cause a possible delay of care with the potential of more harm to Resident #13. Based on interview, record review, and facility policy review, it was determined the facility failed to report an alleged violation, and the investigation outcome of the alleged violation, involving supervision and abuse to the proper state agency within the allotted time frame for one (Resident # 35) of two residents reviewed. The findings include: A review of Resident #35's Face Sheet indicated the facility admitted Resident #35 on 11/08/2023 with diagnoses which included anoxic brain damage (a condition that occurs when the brain is deprived of oxygen causing brain damage), anxiety disorder, depression, congestive heart failure (a condition where the heart cannot pump blood effectively), and hypertension (high blood pressure). A review of the quarterly Minimum Data Set with an Assessment Reference Date of 02/10/2025 indicated Resident #35 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The assessment revealed the resident had fluctuated behaviors for disorganized thinking and altered level of consciousness and that the resident was ambulatory. A review of Resident #35's Care Plan Report, revealed the resident had an identified behavioral symptom of exit seeking tendencies with the potential for elopement and identified behavioral symptoms of exit seeking behaviors and experienced unrealistic thoughts dated 03/10/2024. Interventions dated 03/10/2024 included staff should observe resident and inform nurse for signs of restlessness or looking for exits and observe resident for safety and try to redirect resident when exit seeking. A review of Resident #35's Elopement/Wandering Risk Assessment dated 09/03/2024 indicated the resident was at risk for elopement. A review of a Progress Note dated 10/21/2024, indicated a Housekeeping Aide (unidentified) notified staff that Resident #35 was found outside near the laundry and maintenance building and it was unknown how the resident got outside. The Assistant Director of Nursing (ADON), the Director of Nursing (DON), and Administrator were notified. A review of a Progress Note dated 11/15/2025, indicated Resident #35 exited the facility via 300 hall door and was found walking down the road in front of the facility. The Progress Note indicated that the Administrator and ADON were aware of the event, and 15-minute rounding was started. A review of a Facility Event Summary Report indicated Resident #35 had an event of elopement on 11/15/2025. Evaluation of the event indicated resolved without further complications. No event was listed for elopements dated 10/21/2024, 02/24/2025 nor 03/23/2025. On 09/05/2025 at 11:40 AM, during an interview, Administrator reported she did not have a reportable for October or November 2024 for Resident #35. A review of a Accidents and Incidents-Investigating and Reporting document indicated all incidents involving residents occurring on facility premises shall be investigated and reported to the administrator. The data to be included on the report of incident/accident form in part included the date/time the injured person's family was notified and by whom, any corrective action taken, and follow up information. The supervisor shall complete a report of incident/accident form and submit the original to the DON within 24 hours of the incident or accident. The DON shall ensure the admin receives a copy of the Report of Incident/Accident form for each occurrence. On 09/05/2025 at 4:02 PM, during a phone interview, Corporate Nurse stated she was acting as Administrator at the facility from September 2024 through May 2025. She reported she was DON and Administrator concurrently at the facility. She stated she was aware of Resident #35's elopement on 02/24/2025 and 03/23/2025 and indicated reportables were filled out for those incidents. She reported she was not aware of Resident #35's elopement on 10/21/2024 or 11/15/2024, she also stated she had posted her phone number in the facility, and no one told her about those incidents. On 09/09/2025 at 9:10 AM, during an interview, ADON reported she was aware of Resident #35's elopements on 10/21/2024 and 11/15/2024. She indicated the elopements should have been reported, and verbalized, Were they not? I am sorry. On 09/09/2025 at 9:48 AM, during an interview, the DON reported she was not aware of Resident #35's elopements on 10/21/2025 and 11/15/2025 because she was not employed at the facility at that time. She reported a reportable should have been made due to potential dangers to Resident #35 and other residents. On 09/09/2025 at 10:47 AM, during an interview, Administrator reported an event of an elopement should be reported. She reported she was not at the facility at the time of the elopements. Review of a facility policy titled, PP Abuse Prohibition Policy and Procedures, dated September 2022, indicated Abuse of any kind is strictly prohibited. Possible indicators of physical abuse include an injury that is suspicious because the source of the injury is not observed, the extent or location of the injury is unusual or because of the number of injuries either at a single point in time or over time. Examples of injuries that could indicate physical abuse include but are not limited to injuries that are non-accidental or unexplained, and fractures, sprain, and dislocations. immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury Review of a facility policy titled, PP Wandering and Elopements, dated March 2019, indicated When a resident returns to the facility, the director of nursing services or the charge nurse shall: complete and file an incident report.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure that the resident's transfer/discharge was documented in the resident's medical record, failed to provide the resident and resident representative a notice of transfer/discharge in writing, and failed to send a written copy of notice of transfer/discharge to a representative of the office of the State Long-Term Care Ombudsman for 1 Resident (R #35) of 3 residents reviewed for discharge rights. Based on record review, interviews and facility policy review, it was determined the facility failed to ensure that the resident's transfer or discharge was documented in the resident's medical record, to send a written copy of notice of transfer or discharge to the Ombudsman for one (Resident #35) of three residents reviewed. The findings include: A review of Resident #35's Face Sheet indicated the facility admitted Resident #35 on 11/08/2024 with diagnoses which included anoxic brain damage (a condition that occurs when the brain is deprived of oxygen causing brain damage), anxiety disorder, depression, congestive heart failure (a condition where the heart cannot pump blood effectively), and hypertension (high blood pressure). The face sheet indicated the resident was not responsible for self. The Census Summary within the face sheet indicated the resident was discharged from the facility on 03/23/2025 at 11:56 AM. The following areas of the Census Summary were not completed: discharged to, primary discharge diagnosis, discharge reason and condition on discharge. A review of Resident #35's Care Plan Report, indicated the resident had an identified behavioral symptom of exit seeking tendencies with the potential for elopement dated 03/10/2024. Intervention dated 03/10/2024 included staff should observe the resident and inform the nurse of signs of restlessness or looking for exits. Intervention dated 02/24/2025 included staff would monitor and assess residents' emotional well-being. Intervention dated 02/28/2025 included supervisory staff will be notified if Resident #35 verbalizes their desire to go. A review of a Progress Note dated 03/23/2025, indicated Resident #35 had an incident at the facility which concluded with Resident #35 being transported in police custody to the local emergency room for evaluation and assessment. A review of a Police Department Incident Report dated 03/23/2025 indicated Resident #35 was in police custody and transported by police to the emergency room for a medical evaluation. The report indicated Resident #35 was medically cleared at the emergency room and the resident was transported by police to a different hospital and placed on the lockdown unit. A review of a Hospital Record dated 03/23/2025 indicated Resident #35 arrived at the hospital emergency room via law enforcement on 03/23/2025 at 12:29 PM, with a chief complaint of the need for a psychiatric evaluation. The assessment revealed anoxic brain injury with aggressive behavior and the plan indicated that the resident would be transferred to a different hospital for behavioral health. The record stated, facility called and states that Corporate Nurse will not accept patient back into facility until they have a psych eval, facility was requesting (behavioral hospital) be contacted. A medical doctor accepted the resident as a patient at [behavioral hospital] on 03/23/2025 at 3:07 PM. Resident #35 was transferred via law enforcement to [behavioral hospital]. A review of Resident #35's Transition of Care/Discharge Summary indicated no data. A review of Resident #35's Electronic Health Record (EHR) revealed no discharge summary. A review of Resident #35's Physician Orders, revealed no discharge order for Resident #35. During a phone interview on 09/04/2025 at 8:19 AM, the Regional Ombudsman indicated they were not receiving notification of transfers or discharges from the facility at that time. They indicated they were aware of the transfer of Resident #35 due to being informed by a complainant. They added they were not aware if the resident returned to the facility after the transfer. During a phone interview on 09/05/2025 at 8:31 AM, the psychiatric hospital Social Clinic Director indicated Resident #35 was admitted to the facility on [DATE] after being discharged from the emergency room. The director indicated that the Corporate Nurse of the facility indicated that the facility would not accept Resident #35 back into the facility. The director reported that the resident was not given 30-day notice from the facility and that Resident #35 was placed with a different long-term care facility. During an interview on 09/09/2025 at 9:48 AM, the Director of Nursing (DON) indicated the facility discharge process should include documentation of the location the resident was discharged , a discharge order from their Medical Doctor (MD), and an inventory of the resident's returned belongings. She indicated the facility does not send any documentation to the resident's MD, but the MD does fax an order for discharge to the facility. She reported Care Plans and medications could be printed, and the facility should have called the resident's representative to inform them they could pick those documents up at the facility. She indicated she did not believe the ombudsman would receive notice from the facility of a resident's discharge. DON indicated necessary emergency room transfer information would be documented in the Progress Notes and in the digital form of the discharge summary. She indicated that if the discharge information was not documented in the resident's electronic health chart it would mean someone failed to properly document the discharge. During an interview on 09/09/2025 at 10:47 AM, the Administrator indicated the facility discharge process included receiving a discharge order from the resident's MD. She reported the resident's Progress Notes would contain the resident's current status, any Durable Medical Equipment needs that were addressed, any community needs that had been set up, the disposition of the resident's inventory, the transportation details and a notification would be sent to the Ombudsman about the resident's discharge. She reported there should be documentation of a discharge summary given to the receiving facility and there should be documentation of an MD discharge order. She indicated that if the discharge information was not documented in the residents chart it would mean someone failed to properly document the discharge. A review of a facility policy titled, Admission, Transfer, and Discharge Register, revision date June 2008, indicated, Our facility maintains an admission, transfer and discharge register. The policy indicated the medical records office maintained a current admission, transfer and discharge register which should contain the reason for the transfer or discharge, a discharge summary and the place the resident was transferred or discharged to.

Based on observations, interviews, record review, and facility document review it was determined that the facility failed to ensure a safe environment as free of accident hazards and each resident receives adequate supervision to prevent accidents for 3 (Resident #35, Resident #8, and Resident #3) of 3 residents reviewed for accidents and supervision. Based on observations, interviews, record review, and facility policy review it was determined that the facility failed to ensure a safe environment was free of accident hazards and each resident received adequate supervision to prevent accidents for one (Resident #35) of three residents reviewed. The findings include: A review of Resident #35's Face Sheet indicated the facility admitted Resident #35 with diagnoses that included brain damage that occurs when the brain is deprived of oxygen, anxiety disorder, depression, congestive heart failure, and high blood pressure. A review of the quarterly MDS, with an ARD of 02/10/2025, revealed Resident #35 had a BIMS score of 8 which indicated the resident had moderate cognitive impairment and had fluctuated behaviors for disorganized thinking and altered level of consciousness. The MDS also revealed Resident #35was ambulatory. A review of Resident #35's Care Plan Report revealed the resident had identified behavioral symptoms of exit seeking tendencies with the potential for elopement, identified behavioral symptoms of exit seeking behaviors and experienced unreal thoughts dated 03/10/2024. A Care Plan intervention dated 03/10/2024, indicated staff should observe resident and inform nurse for signs of restlessness or looking for exits and observe resident for safety and try to redirect resident when exit seeking. Intervention dated 02/24/2025 indicated staff would monitor and assess resident's emotional well-being. Intervention dated 02/28/2025 indicated supervisory staff will be notified if resident verbalizes their desire to go. A review of Resident #35's Elopement/Wandering Risk assessment dated [DATE], indicated the resident was at risk for elopement. A review of Resident #35's Progress Note dated 10/21/2024, indicated a housekeeping aide notified staff that Resident#35 was found outside near the laundry/maintenance building and it was unknown how the resident got outside. The Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator were notified. A review of a Progress Note dated 11/15/2025, indicated Resident #35 exited the facility via the 300-hall door and was found walking down the road in front of the facility. The note indicated the Administrator and ADON were aware of the event, and 15-minute rounding was started. A review of the Facility Event Summary Report indicated Resident #35 had an event of elopement on 11/15/2025.An evaluation of the event indicated resolved without further complications. There were no events listed for elopement dated 10/21/2024, 02/24/2025 nor 03/23/2025. A review of an Incident Report dated 02/24/2025, indicated staff observed Resident #35 crawl through the smoke [NAME] wall. The staff requested assistance, and other staff went outside to look for resident. The Corporate Nurse drove her car to the area and the resident rode back to the facility without further incident. Resident was placed on 15-minute checks for 24 hours, faded to 30-minute checks next 24 hours. A review of Resident #35's Progress Note dated 03/23/2025 indicated Resident #35 exited through the dining room door to outside of the facility at approximately 11:30 AM. Resident #35 was witnessed by staff exiting the dining room door and followed resident outside. The Progress Note indicated the resident punched and kicked staff during the altercation. The incident at facility concluded with resident being taken from facility in police custody to an emergency room for evaluation and assessment. A review of a Police Department Incident Report dated 03/23/2025, revealed Resident #35 was in police custody and transported by police to the emergency room for a medical evaluation. The report indicated Resident #35 was medically cleared at the emergency room and the resident was transported by police to a different hospital and placed on the lockdown unit. An observation on 09/04/2025 at 2:38 PM, revealed the dining room door was an exit-delay door with a sign posted EXIT-DELAYED EGRESS PUSH UNTIL ARLARM SOUNDS. DOOR CAN BE OPENED IN 15-30 SECONDS. During an interview on 09/08/2025 at 2:24 PM, the Medical Director reported he was aware Resident#35 had found ways out of the facility such as the resident had found outdoor codes or figured another way outside, he added the resident was pretty smart. He reported he was not aware the police were called during the 03/23/2025 attempted elopement. Review of a facility policy titled, Wandering and Elopements, dated March 2019, indicated The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If a resident is missing, initiate the elopement/missing resident emergency procedure, if the resident was not authorized to leave, initiate a search of the building(s) and premises. When the resident returns to the facility, the director of nursing services or charge nurse shall examine the resident for injuries, contact the attending physician and report findings and conditions of the resident, notify the resident's legal representative (sponsor), notify search teams that the resident has been located, complete and file an incident report, and document relevant information in the resident's medical record.

Based on observations, interviews, record review, facility policy review, it was determined that the facility failed to ensure food was appropriately stored and dated; refrigerator/freezers had thermometers placed on the inside for accurate temperature reading; trash receptacles had lids; kitchen equipment was clean; and meal trays were free of chips or sharp edges. The failed practice had the ability to affect all 36 people who received their meals from 1 of 1 kitchen. Findings include: A review on [DATE] at 9:16 AM of a facility policy titled, Food Receiving and Storage dated [DATE], on [DATE] at 9:16 AM indicated, Foods shall be received and stored in a manner that complies with safe food handling practices. Policy continues to outline the intention of inspecting food upon arrival to ensure quality before being accepted, that all foods stored in the refrigerator or freezer are labeled and covered and dated, and all food is monitored to ensure use prior to the use by date. A review of a facility policy titled, Sanitization on [DATE] at 9:40 AM indicated, The food service area is maintained in a clean and sanitary manner. The policy continues to outline that the fixed equipment is washed and sanitized, that items that are damaged or broken that cannot be repaired is discarded, that garbage containers are in good condition with lids or otherwise covered and disposed of daily. On [DATE] at 11:13 AM, upon entering the kitchen, the Surveyor observed three trays stacked one on top of the other. The trays contained bowls of crushed pineapple which had been portioned for lunch. The bowls contained no lids and were open to air and contaminants. On [DATE]at 11:16 AM, the Surveyor attempted to determine the temperature of the first refrigerator freezer located on the right side of the kitchen. The thermometer inside the appliance could not be located. The second refrigerator freezer had a thermometer in the freezer but not in the refrigerator. The large two door refrigerator did not have a thermometer on the inside, nor did the two large two door freezers. On [DATE] at 11:22 AM, the Surveyor observed a tray of shredded lettuce and chopped tomatoes was observed in the first refrigerator freezer. The tray was uncovered and opened to air and contaminants. On [DATE] at 11:24 AM, the Surveyor observed six, one half cup single serve cups of ice cream were located in the door of the refrigerator freezer. Approximately ,d+[DATE] inch from the bottom of the cup, the mixture appears to have been separated. The bottom ,d+[DATE] inch of the product was bright yellow in color. The rest of the contents were creamy white in color. The DM stated, That looks freezer burned and needs to be thrown out. A box of the same ice cream was opened and the cups inside the box had the same appearance including the different color and consistency. The DM described that the items were just recently delivered, however she did not feel it should be served, due to the appearance of having been melted and refrozen. She continued to report that the case of ice cream could not be returned because the poor condition of the product should have been noticed when it was received. On [DATE] at 11:26 AM, a #10 can of crushed pineapple, which had been opened to serve for lunch was observed in the refrigerator freezer. The lid of the can had been pushed ,d+[DATE] way down into the can where it met the crushed pineapple. Dietary Aide #1 came forward and described having put the can into the refrigerator due to the fact that she was unable to locate a bowl with a lid for storage. On [DATE] at 11:48 AM, the Surveyor observed a bag of bread ,d+[DATE] full, a bag of bread ,d+[DATE] full, and a bag of hamburger buns containing 5 buns, on top of the steam table. Each bag was not sealed properly leaving them open to air and contaminants. On [DATE] at 11:49 PM, a 2 quart pitcher of tea was observed on the worktable. The pitcher contained no lid leaving the contents open to air and contaminants. On [DATE] at 12:24 PM, a stack of 26 meal trays were observed sitting on the worktable in front of the steam table. Three of the trays were observed to have pieces broken off along the edges, resulting in the areas being uneven and sharp. On [DATE] at 12:48 PM, the right side of the range was observed to be covered in a sticky residue to which, what appeared to be food particles, had adhered. The residue covered the entire side of the range, in various levels of thickness. The shelf of the range which extends over the top was covered with a layer of sticky dust. The floor beneath the range and between the range and the deep fryer was discolored and had debris stuck to the floor in a variety of colors. Both sides of the deep dryer were also covered in a sticky residue, to which a variety of debris had adhered. The two wire baskets sitting on top of the deep dryer had large pieces of what appeared to be food stuck to the sides. On [DATE] at 12:52 PM, a large trash can was observed between two worktables in the middle of the kitchen. The can did not have a lid and was open to air. Two trash cans in the dish area were observed to have no lids available. The dish area opens into the kitchen and dishes were not being cleaned at this time. On [DATE] at 11:27 AM, 2 servings of apple juice were observed sitting in the refrigerator. The juice was not dated. On [DATE] at 11:30 AM, two lidded cups containing grape juice were observed on the shelf in the refrigerator. The DM reported that the juice had been poured this AM. When asked how the staff would know when the juice was poured since it was not dated. The DM identified that the age of the juice would be impossible to know without a date. On [DATE] at 11:33 AM, a 12 ounce container of grape juice concentrate was observed in the door for the refrigerator. The instructions on the container stated, keep frozen. The juice had been allowed to thaw and was not dated as to when it had been put in the refrigerator. A second container of grape juice concentrate had a use by date of [DATE]. A one-gallon pitcher of orange juice was not dated as to when it was made. On [DATE] at 11:35 AM, three pounds of cheese slices were observed on the top shelf of the 2 door refrigerator. The cheese was wrapped in plastic wrap which had failed to adhere leaving the cheese open to air and contaminants. One and one-half pounds of mozzarella cheese was also observed on the top shelf. The plastic wrap which had been used to cover the cheese had failed to adhere leaving the cheese open to air and contaminants. The DM identified that plastic bags for food storage were not purchased by the kitchen. On [DATE] at 11:38 AM, a ,d+[DATE] steam table pan of chicken noodle soup was observed in the bottom of the 2 door refrigerator. The soup was not dated. On [DATE] at 11:45 AM, the Surveyor observed a box containing frozen biscuits was in the 2 door freezer. The plastic bag containing the biscuits was not sealed leaving the biscuits open to air and contaminants. On [DATE] at 12:55 PM, a one pound box of cornstarch and a one pound box of baking soda located in a kitchen cabinet was observed to be open to air and contaminants. On [DATE] at 2:00 PM, during an interview, the DM was asked why it was important to date and store food properly in the kitchen. The DM described that it was important to prevent the residents from being served food that would make them sick, that ensuring that the food was sealed prevented germs from growing. When asked why it was important to monitor the temperature of the refrigerator and freezers, she described the need to ensure proper temperatures so the food would stay fresh, thus preventing food borne illness. The DM stated emphatically that trash containers should have lids available and in place. When asked about the importance of maintaining the kitchen/equipment in a clean manner, the DM again described the need to not spread germs, thus protecting the resident. On [DATE] at 3:10 PM, during an interview, the Administrator was asked to describe the importance of dating and storing food properly. The need to not serve any food that might have expired and make someone sick was the primary reason cited. Covering food was described as important for keeping out pests, maintaining temperatures, and to keep the food fresh. When asked to identify the importance of monitoring the temperature in the refrigerator/freezer, the Administrator verbalized the need to maintain food at the proper temperature to maintain freshness and to prevent food borne illness. The Administrator was adamant that trash receptacles have lids.

Based on observations, interviews, record review, and facility document review, it was determined that the facility failed to ensure the Arbitration agreement contained all necessary components including the right to resend the agreement within the first 30 days of admission, a declaration affirming that signing an arbitration is not a condition of admission and a statement providing for the right to communicate with state/federal surveyors, health department employees and the state Ombudsman. The failed practice had the ability to affect 4 of 4 (Residents #17, #139, #24, and #140) sampled residents who had signed arbitration agreements since the change of ownership on 04/01/2023 as documented on the Nursing Home Facility Directory page. Findings include: A review of a facility admission packet, on 06/24/2024 at 10:15 AM, revealed, Section XI. Dispute Resolution. Paragraph 2, page 10 of 14 began, Resident shall select one of the following dispute resolution options: Binding Arbitration or Legal Proceedings. A review of a Binding Arbitration agreement revealed there was: 1. No statement concerning the resident/representative's right to resend the decision to select arbitration within the first 30 days after admission; 2. No statement declaring that arbitration is not necessary for admission; 3. No confirmation of a resident's right to communicate with state/federal surveyors, the state Ombudsman or health department officials. The Administrator was provided a copy of the admission packet, Section XI on 06/26/2024 at 2:30 PM. The Administrator was asked to locate within the document the right to resend the agreement within 30 days. The Administrator described not being able to locate the information. The Administrator continued to report that she was aware of the missing information including the right to resend, the right to communicate with state or federal agencies and the right for admission without signing an arbitration agreement. She continued to report having told the owner that these changes would need to be made to the agreement.

Based on observation, record review, and interview, the facility failed to ensure residents who required assistance with personal hygiene had hair removed from their face for 3 (Residents #3, #28, and #17) of 3 sample mix residents, and fingernails were kept trimmed for 1 (Resident #17) of 3 (Resident #3, #28, and #17) sample mix residents to promote good grooming. The findings are: 1. On 06/24/2024 at 11:03 AM, the Surveyor interviewed Resident #3 and asked, Are you receiving your shower as scheduled? Resident #3 stated, I was supposed to get my shower this past Saturday. Wednesday is my other shower day so hopefully I will get it. The Surveyor observed the resident with chin hair and asked, Would you like for staff to remove the hair from your chin? Resident #3 stated, Yes, but they don't. When asked, Have you asked for it to me removed? She stated, Yes, but I still have it. a. Review of the Care Plan for Resident #3 with a date of 10/05/2022 documented, Category: Bathing & Hygiene Personal Choices I need assist of 1 with my bathing, dressing and grooming due to history of cerebral infarction and hemiplegia. b. Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/2024 revealed section GG0130. Self-Care Personal hygiene: I. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral care) coded 88: Not attempted due to medical condition or safety concerns. c. On 06/25/2024 at 2:25 PM, the Surveyor observed Resident #3 lying in bed with eyes closed. Resident #3 appeared to have been showered, but still had hair on the chin. d. On 06/25/2024 at 2:27 PM, the Surveyor interviewed Certified Nursing Assistant (CNA) at Resident #3's room and asked, Should residents have facial hair removed from their face? She stated, Yes. When asked, Why should it be removed? She stated, Because it's hygiene. 2. On 06/23/2024 at 3:02 PM, the Surveyor observed hair on Resident #28's chin. The Surveyor interviewed Resident #28 and asked, Would you like the hair on your chin shaved off? Resident #28 stated, Yes, they do it when I have a shower, but I haven't had one. My last bed bath was Tuesday, and my bath day is Tuesday, Thursday and Saturday and I didn't have one yesterday. a. Review of the Care Plan for Resident #28 dated 12/01/2022 documented, Category: ADLs [activities of daily living] Functional Status/Rehabilitation Potential . I need assistance with dressing, toileting, bed mobility, bathing, and hygiene because of my recent stroke. I have left sided hemiplegia. b. Resident #28's Quarterly MDS with an ARD of 04/30/2024 revealed section GG0130. Self-Care Personal hygiene: I. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/ drying face and hands (excludes baths, showers, and oral care) coded 03 which indicates partial/ moderate assistance. c. On 06/25/2024 at 2:24, the Surveyor observed Resident #28 with hair on the resident's chin. The Surveyor interviewed Resident #28 and asked, Did you have a shower today? Resident #28 stated, Yes, I did. When asked, Would you have liked for the staff to have removed the hair from your chin during your shower? Resident #28 stated, Yes, I would. d. On 06/25/2024 at 2:29 PM, the Surveyor interviewed CNA #5 at Resident #28's room and asked, Should residents have facial hair removed from their face? He stated, Yes. When asked, Why should it be removed? He stated, Because they can't do it themselves. 3. On 06/24/2024 at 10:19 AM, the Surveyor observed Resident #17 with chin hair and long fingernails. The Surveyor interviewed Resident #17 and asked, Are you receiving your shower as scheduled? Resident #17 stated, Yes, I got it today. When asked, Would you like the hair on your face removed? Resident #17 stated, Yes, I'd like them removed but they don't do that here. I'd also like my nails trimmed. When asked, Have you asked to have your nails trimmed and to have hair removed from your face? Resident #17 stated, Yes. a. Review of the Care Plan for Resident #17 dated 03/17/2024 documented, Category: ADLs Functional Status/Rehabilitation Potential I need some limited assistance with my ADL's, dressing and grooming, toileting and hygiene and bathing. b. Resident #17's Annual MDS with an ARD of 05/10/2024 revealed section GG0130. Self-Care Personal hygiene: I. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/ drying face and hands (excludes baths, showers, and oral care) coded 02 which indicates substantial/ maximal assistance. c. On 06/25/2024 at 2:26 PM, the Surveyor observed resident #17 in bed watching television. Resident #17 is observed with hair on chin and long fingernails. The Surveyor asked, Did you receive a bath this week? Resident #17 stated, Yes. When asked, Would you still like the hair removed from your chin? Resident #17 stated, Yes. I would also like someone to trim my nails. d. On 06/25/2024 at 2:26 PM, the Surveyor interviewed CNA #4 at Resident #17's room and asked, Should residents have facial hair removed from their face? She stated, Yes. When asked, Why should it be removed? She stated, It's part of their hygiene. When asked, Should residents have their fingernails trimmed if they ask staff to assist them? She stated, Yes. When asked, Why should residents have their nails trimmed if they choose? She stated, It's their right and they may scratch themselves. e. On 06/25/2024 at 3:00 PM, the Surveyor interviewed the Director of Nursing (DON) and asked, Should residents have facial hair removed from their face? She stated, Yes, we should remove it. If it's not, it needs to be care-planned. When asked, If a resident requests their fingernails to be trimmed should staff trim them? She stated, Yes. When asked, Why should residents have their nails trimmed if they choose? She stated, It could cause them to scratch and cut themselves. The facility provided a policy titled, Activities of Daily Living (ADLs), Supporting with a revision date of March 2018 that documented, Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate supporting and assistance with: a. hygiene (bathing, dressing, grooming, and oral care).

Based on observation, record review, and interview, the facility failed to ensure activities were provided on the weekend for all 34 residents who resided in the facility. The findings are: On 06/23/2024 at 11:47 AM, the Surveyor has not observed any weekend activities in the facility since entry. On 06/23/2024 at 3:12 PM, the Surveyor has not seen any weekend activities taking place in the facility since entry. On 06/25/2024 at 1:15 PM, the residents present in the Resident Council Meeting were asked if activities were held on the weekend. In unison the group stated, No. The group continued to report that a former employee comes in occasionally to provide a church service. Otherwise, the residents are left on their own. On 06/25/2024 at 2:00 PM, the Activity Director (AD) was asked if activities were held on the weekend. The AD described putting activities on the calendar for the weekend that require very little set up or staff assistance such as movies, coloring or puzzles. When asked if anyone was assigned to perform the weekend activities the AD denied having knowledge of any particular Certified Nursing Assistant (CNA) or nurse being assigned. When asked why activities are important, the AD described that activities help the residents have a better quality of life. When asked, Do you have a logbook? She stated, Yes. When asked, Have residents ever told you activities are not being done on the weekends? She stated, No. On 06/25/2024 at 2:19 PM, the Activities Director provided the June 2024 resident activity logs, when reviewed the activity logs had not been completely filled out to document activities and participation for June 2024. 06/26/2024 at 1:18 PM, the Surveyor interviewed the Administrator and asked, Should activities be conducted on the weekends? She stated, Yes ma'am. When asked, Why? She stated, For the resident's livelihood and it's their right to have things to do and stay busy. When asked, What are the benefits of residents participating in activities? She stated, Keep their mood up, keep their social interaction up, and it's good for their physical and weight. Keep them from getting depressed. When asked, What are the negative effects of resident not receiving activities? She stated, They could isolate, become depressed, lose weight, get sick. When asked, Who is in charge of weekend activities? She stated, At this time it was the activity director to designate. We will have a manager on duty to make sure they get done. When asked, Is it a resident's right to have daily activities provided? She stated, Yes. On 06/26/2024 at 1:30 PM, the Surveyor interviewed CNA #3 and asked, On Sunday, June 23, 2024, who conducted activities with the residents and when were they conducted? He stated, I don't remember activities taking place. I can't remember them even happening. When asked, Who normally conducts activities on the weekends? He stated, Laundry, I think. On 06/26/2024 at 1:32 PM, the Surveyor interviewed Licensed Practical Nurse (LPN) #6 and asked, On Sunday, June 23, 2024, who conducted activities with the residents and when were they conducted? She stated, Off the top of my head I don't remember them going on. When asked, Who normally conducts activities on the weekends? She stated, I don't know who the scheduled person is. The facility provided a policy titled, Activity Programs with a revision date of June 2018, that documented, Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Policy Interpretation and Implementation: 1. The activities program is provided to support the well- being of residents and to encourage both independence and community interaction. 2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. 3. The activities program is ongoing and includes facility- organized group activities, independent individual activities and assisted individual activities. 4. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. 5. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. 7. Our activity programs consist of individual, small group and large group activities that are designed to meet the needs and interests of each resident. Activity programs include activities that promote: a. self-esteem; b. comfort; c. pleasure; d. education; e. creativity; f. success; and g. independence. 8. Activities are not necessarily limited to formal activities being provided only by the activities staff. Other facility staff, volunteers, visitors, residents and family members may also provide the activities. 9. All activities are documented in the resident's medical record.

Based on observation, record review, and interview, the facility failed to ensure narcotic medications were stored in a permanently affixed compartment to prevent the potential of misappropriation of resident property. The findings are: On 06/26/2024 at 8:38 AM, the Surveyor accompanied by Assistant Director of Nursing (ADON) entered the main medication room. Upon checking the facility narcotic box in the refrigerator, that had no visible locking mechanism on the outside, was easily removed, and the Surveyor pulled it out of the refrigerator. The Surveyor placed the narcotic box back down in the refrigerator and asked the ADON if she would pick it up. The ADON was able to pick up the narcotic box and remove it from the refrigerator. The Surveyor interviewed the ADON and asked, Should the narcotic box be permanently affixed in the refrigerator? She stated, It should. When asked, Why should it be permanently affixed in the refrigerator? She stated, So somebody can't pick it up and take off with it. When asked, How many locks is the narcotic box secured behind? She stated, The main door and the two locks on the box. When asked, Does the refrigerator lock? She stated, No. When asked, Should it be locked? She stated, Yes. When asked, Why should the refrigerator be locked? She stated, So no one can just open it and take the box. The ADON was asked to unlock the box and she stated she didn't have the key [named nurse] has the key. On 06/26/2024 at 8:41 AM, the ADON went to the nurse and got the key and came to the medication room with the Surveyor and unlocked the narcotic box. Inside the box were 10 boxes with 1 vial each of Lorazepam for 7 of the facility's current residents. There was also 1 vial of Lorazepam labeled for the emergency kit. The facility provided a policy titled, Medication Labeling and Storage with a revision date of February 2023 documented, Medication Storage 7. Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Based on observations, interviews, facility document review, and policy review, the facility failed to ensure a written menu was followed to ensure the nutritional needs of the residents were met and that a variety of food was provided to promote consumption and enjoyment of meals for all 36 residents who receive their meals from one of one kitchen. The findings are: Review of a policy received on 06/26/2024 at 9:25 AM, entitled, Food and Nutrition Services, stated that each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. On 06/23/2024 at 11:05 AM, upon entry into the kitchen the lunch meal was reported to be: Soft shell taco's, refried beans, shredded lettuce, chopped tomatoes, sour cream, shredded cheese and crushed pineapple. No serving sizes were provided. A review of the written menu called for brown sugar meatloaf, mashed potatoes, mixed vegetables, peach upside-down cake, dinner roll and margarine. When the Dietary Manager (DM) was asked to address the change in the menu, she described that the kitchen doesn't always have the necessary ingredients due to them getting used to the schedule of deliveries associated with their new food company. When asked about the approval of the Registered Dietitian the DM stated, She said it was ok, as long as I write it down. On 06/24/2024 at 10:00 AM, the menu board in the dining room reported that the lunch meal would consist of pork with barbeque sauce, green beans, loaded mashed potatoes, vanilla pudding and a roll. The written menu called for seasoned chicken thighs, steamed rice, broccoli and fruit crisp. The pork provided was chopped. The DM reported that the pork they receive is often tough, so the residents prefer it to be cut up. On 06/25/2024 at 9:30 AM, a review of the menu board reports a lunch meal of roast beef with gravy, corn casserole, mashed potatoes and Mississippi mud cake. The DM was asked to address the serving of mashed potatoes for two consecutive days. The DM described the mashed potatoes on Monday as having been loaded due to the addition of cheese and sour cream. The potatoes on Tuesday were plain. When asked to identify the reason why the baked beans were not being served, the DM described there were not being any baked beans on the shelf, and she had not had time to check the last delivery. Upon double checking the beans were located and the potatoes were not served. On 06/25/2024 at 1:30 PM, the Resident Council described a lack of variety in the facilities meals. [NAME] beans and mashed potatoes were identified as being served multiple times during the week. They also describe a lack of options for an alternative to the planned meal. When asked about sandwich options they report that the facility typically does not have sandwich meat, only the occasional ham sandwich. On 06/26/2024 at 9:10 AM, the menu board reported pork roast, baked potato with sour cream, mixed vegetables and strawberry cake. Upon observation the pork roast was chopped in the same manner as the pork on Monday. The only difference was the placement of barbeque sauce on top of the pork on Tuesday. The DM maintains the necessity of chopping the pork due to the product being tough no matter how it is cooked. On 06/25/2024 at 2:00 PM, the DM was asked to identify the reasons why following a written planned menu would be beneficial. She identified being able to order food as needed, meeting the nutritional needs of the residents and providing a variety of food as benefits of a planned menu. On 06/25/2024 at 3:05 PM, the Administrator was asked to identify the reasons for following a planned menu. The Administrator said reducing repetition was the first reason followed by improved consumption by the resident and the need to monitor the nutritional needs of the resident including dietary needs specific to their diagnoses.

Based on observations, interviews, facility document review, facility policy review, it was determined that the facility failed to ensure food temperatures were maintained to promote consumption and to prevent food borne illness for 36 residents who receive their meals from one of one kitchen. Findings include: A review of a facility policy on 06/26/2024 at 9:45 AM entitled, Preventing Foodborne Illness, stated, food will be .served so that the risk of foodborne illness is minimized. The policy continues to describe the facility as recognizing improper holding temperatures as a critical factor in foodborne illness. A review of a facility policy on 06/26/2024 at 9:50 AM entitled, Food and Nutrition Services, reports that food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. On 06/23/2024 at 12:05 PM, observation of the temperatures of the lunch meal were taken and recorded as follows: Taco meat 195.6 degrees Fahrenheit (F); Refried beans 176.5 degrees F; Tomato Soup 165.4 degrees F; Pureed Taco Meat/Tortilla 165 degrees F; Shredded Lettuce 55.4 degrees F; Sour cream 46 degrees F; Chopped tomatoes 51.9 degrees F; Chopped onion 54.3 degrees F; Shredded cheese 54.5 degrees F; Salsa 44.4 degrees F. On 06/23/2024 at 12:18 PM, after reviewing the recorded temperatures, it was called to the attention of the Dietary Manager that the cold food items were not at 41 degrees F or below. The DM elected to discard all of the cold items that were not being held at the appropriate temperature of 41 degrees F or below. At 12:10 PM, a cart containing 6 lunch trays was delivered to the 200 Hall. The residents were observed having consumed their lunch meal including the cold food items that were recorded at above 41 degrees F. On 06/26/2024 at 12:16 PM, the DM followed the meal cart to the 300 Hall. At 12:24 PM, the last tray was removed from the cart and the following temperatures were recorded: Chopped Pork Roast 113.5 degrees F; Mixed Vegetables 126 degrees F; Baked Potato 117.3 degrees F; Sour Cream 64 degrees F. The DM verbalized the fact that each item was considered too cold to serve. The DM reported that she was aware of the two middle sections of the steam table not seeming to be as hot as the two end sections. She continued to describe her intentions of speaking to the maintenance department. On 06/26/2024 at 2:20 PM, the DM was asked to describe why maintaining appropriate food temperatures was important. The DM described the connection of food temperatures and the presence of food borne illness. She also discussed the need to maintain food temperatures, so the residents enjoy their meals and consume their food in larger amounts, thus preventing weight loss. She also identified the change of consistency which can occur when a food is too hot or cold. On 06/26/2024 at 3:15 PM, the Administrator was asked to discuss the importance of maintaining food temperatures. The Administrator started by highlighting the need to maintain temperatures to prevent food borne illness. The Administrator continued to discuss food enjoyment, good health, and weight maintenance, as being results of maintaining appropriate food temperatures.

Based on record review and interview, the facility failed to notify the resident/resident representative or Power of Attorney (POA) in writing of the resident's transfer/discharge to the hospital as required for 1 (Resident #28) of 1 sample mix residents and to ensure the ombudsman was notified of transfers to the hospital. The findings are: On 06/23/2024 at 3:07 PM, the Surveyor interviewed Resident #28 and asked, Have you recently been to the hospital or emergency room for treatment? Resident #28 stated, Yes, last Monday from bleeding in my urine after an in and out cath. Review of Residents #28's Census Report dated 06/19/2024 documented, Census Event: Discharge- Return Expected. Resident #28 Census report dated 06/21/2024 documented, Census Event: Return. Admission Source: Transfer from a hospital. Review of Residents #28's Progress Notes revealed Resident #28 was admitted to the hospital on 06/19/2024 and returned to the facility on [DATE]. On 06/25/2024 at 10:56 AM, during review of Resident #28's records, the Surveyor was unable to locate Resident #28's transfer and bed hold notices when admitted to the hospital on 06/19/2024. On 06/25/2024 at 10:58 AM, the Surveyor interviewed the Business Office Manager (BOM) and asked, Do you have a transfer notice and bed hold notice for [Resident #28's] hospital stay that was sent to the responsible part? She stated, I've never heard of those. The nurse's send those. When asked, Do you know if the notices were sent to the responsible party? She stated, Not that I know of. On 06/25/2024 at 11:14 AM, the Surveyor interviewed the Assistant Director of Nursing (ADON) and asked, Do you send a transfer notice and bed hold notice to the responsible party when a resident is sent out to the hospital and is admitted ? She stated, I'm not aware of that. On 06/25/2024 at 11:15 AM, the Surveyor interviewed the Administrator and asked, Should a transfer notice and bed hold notice be sent to the resident's responsible party when the resident is sent out to the hospital and is admitted ? She stated, Absolutely, yes ma'am. It should be kept and documented that we did so. When asked, Was a transfer notice and bed hold notice sent to Resident #28's representative? She stated, No, there wasn't. On 06/25/2024 at 1:19 PM, the Surveyor interviewed the BOM and asked, Do you notify the ombudsman monthly about residents who have discharged from the facility to the hospital? She stated, No, I've never talked to the ombudsman, and to be honest we've never notified anybody that somebody went to the hospital. Social Services might do it, talk to them. On 06/25/2024 at 1:23 PM, the Surveyor interviewed Social Services and asked, Do you notify the ombudsman monthly about residents who have discharged from the facility to the hospital? She stated, No, nobody has ever told me I needed to. The facility provided a policy titled, Transfer or Discharge Notice with a revision date of March 2021 documented, Policy Interpretation and Implementation: 4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: d. An immediate transfer or discharge is required by the resident's urgent medical needs; 5. The resident and representative are notified in writing of the following information: a. specific reason of the transfer or discharge; b. the effective date of the transfer or discharge; c. The location of which the resident is being transferred or discharged ; e. The facility bed- hold policy. 6. A copy of the notice is sent to the Office of Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on record review and interview, the facility failed to notify resident representatives or power of attorneys (POA) in writing of the bed hold policy upon a resident's transfer to the hospital and/or discharge as required for 1 (Resident #28) of 01 sampled residents. The findings are: On 06/23/2024 at 03:07 PM, the Surveyor interviewed Resident #28 and asked, Have you recently been to the hospital or emergency room for treatment? Resident #28 stated, Yes, last Monday from bleeding in my urine after an in and out cath. Review of Residents #28's Census Report dated 06/19/2024 documented, Census Event: Discharge- Return Expected. Resident #28 Census report dated 06/21/2024 documented, Census Event: Return. Admission Source: Transfer from a hospital. Review of Residents #28's Progress Notes revealed Resident #28 was admitted to the hospital on 06/19/2024 and returned to the facility on [DATE]. On 06/25/2024 at 10:56 AM, during review of Resident #28's records, the Surveyor was unable to locate Resident #28's transfer and bed hold notices when admitted to the hospital on 06/19/2024. On 06/25/2024 at 10:58 AM, the Surveyor interviewed the Business Office Manager (BOM) and asked, Do you have a transfer notice and bed hold notice for [Resident #28's] hospital stay that was sent to the responsible part? She stated, I've never heard of those. The nurse's send those. When asked, Do you know if the notices were sent to the responsible party? She stated, Not that I know of. On 06/25/2024 at 11:14 AM, the Surveyor interviewed the Assistant Director of Nursing (ADON) and asked, Do you send a transfer notice and bed hold notice to the responsible party when a resident is sent out to the hospital and is admitted ? She stated, I'm not aware of that. On 06/25/2024 at 11:15 AM, the Surveyor interviewed the Administrator and asked, Should a transfer notice and bed hold notice be sent to the residents responsible party when the resident is sent out to the hospital and is admitted ? She stated, Absolutely, yes ma'am. It should be kept and documented that we did so. When asked, Was a transfer notice and bed hold notice sent to Resident #28's representative? She stated, No, there wasn't. Facility provided a policy titled, Bed-Holds and Returns with a revision date of March 2022 that documented, Policy Statement: Residents and/ or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Policy Interpretation: 1. All residents/ representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: a. well in advance of any transfer (e.g., in the admission packet); and b. at the time of transfer (or, if the transfer was an emergency, within 24 hours). 3. The written information regarding bed-holds provided to the residents/ representatives explains in detail: a. the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility. b. the reserve bed payment policy as indicated by the state plan (for Medicaid residents); c. the facility policies regarding bed-hold periods; d. the facility per diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the return policy.

Based on observation, record review, and interview, the facility failed to ensure there was a restorative program to prevent further decline in range of motion (ROM) when residents complete occupational/physical therapy for 1 (Resident #26) of 1 sample mix resident. The findings are: On 06/24/2024 at 1:11 PM, the Surveyor observed Resident #26 in a wheelchair, the resident's right arm was flaccid, and the resident was using the left arm/hand to pick up and move right the arm/hand. The Surveyor interviewed Resident #26 and asked, Are you able to move your right arm? Resident #26 stated, Right arm is from a stroke. The therapist used to do range of motion but not now because of my insurance. When asked, Do you receive restorative from one of the Certified Nursing Assistants (CNA's)? Resident #26 stated, No, there's no restorative aide. I ran out of insurance, and they don't do it anymore, but they still check on me. Review of Resident #26's Physician Order Report dated 06/01/2024 documented, Rehab Potential: Fair Start Date: 11/29/2023; End Date: Open Ended. Rehab OT- PT- Eval and Treat Start Date: 01/18/2024; End Date: Open Ended. Review of Resident #26's Care Plan with a date of 06/15/2024 documented, ADLs Functional Status/Rehabilitation Potential. On 06/25/2024 at 01:22 PM, the Surveyor interviewed the Occupational Therapist (OT) and asked, Does the facility provide Resident #26 with physical therapy [PT]? She stated, No, it's been a minute since he's been on therapy. It was discontinued on 05/10/2024. When asked, Does the facility have a restorative program? She stated, No, as far as I know we don't. I think it would be beneficial. On 06/25/2024 at 02:51 PM, the Surveyor interviewed the Administrator and asked, Who is your restorative aide? She stated, We don't have one. When asked, Do you have a restorative program? She stated, No. When asked, Should the facility have a restorative program? She stated, Yes. When asked, Why should you have a restorative program? She stated, To prevent further decline. The facility provided a policy titled, Restorative Nursing Services with a revision date of July 2017 documented, Policy Statement: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation: 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies). 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. The facility provided a policy titled, Resident Mobility and Range of Motion with a revision date of July 2017 that documented, Policy Statement 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/ or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.

Based on observations, interviews, record review, facility document review, and facility policy review it was determined the facility failed to report an allegation of abuse and misappropriation of property for 3 (Resident #3, #5 and Resident #6) of 3 residents reviewed for abuse. Findings include: A review of a facility policy titled Abuse Investigation and Reporting dated 07/01/2017, indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management .If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source I reported, the administrator will assign the investigation to an appropriate individual . A review of a facility policy titled, Abuse Prevention Program dated 12/01/2016, indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . Identify and assess all possible incidents of abuse. Investigate and report any allegations of abuse within timeframes as required by federal requirements . A review of the resident face sheet indicated the facility admitted Resident #3 with diagnoses that included Hemiplegia and hemiparesis following cerebral infarction affecting, left non-dominant side, gastrostomy status (history of), chronic pain syndrome. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2024, revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 6 which indicated the resident has severe cognitive impairment. During an interview on 5/28/24 at 1:57 PM, Resident #3 confirmed Certified Nursing Assistant [CNA] #1 was rough over the weekend while changing resident about a month ago and notified CNA #2 later that day. Resident #3 confirmed talking with Social Service Director [SSD], Administrator and Director of Nursing [DON] the following Monday. Resident #3 confirmed not feeling safe in the facility when CNA #1 was working. A review of the resident face sheet indicated the facility admitted Resident #3 with diagnoses that included Hemiplegia and hemiparesis following cerebral infarction affecting, left non-dominant side, gastrostomy status (history of), chronic pain syndrome. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2024, revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 6 which indicated the resident has severe cognitive impairment. During an interview on 5/28/24 at 1:57 PM, Resident #3 confirmed Certified Nursing Assistant [CNA] #1 was rough over the weekend while changing resident about a month ago and notified CNA #2 later that day. Resident #3 confirmed talking with Social Service Director [SSD], Administrator and Director of Nursing [DON] the following Monday. Resident #3 confirmed not feeling safe in the facility when CNA #1 was working. A review of the resident face sheet indicated the facility admitted Resident #5 with diagnoses that included heart failure unspecified, non-ST elevation myocardial infarction (history of), and pain unspecified. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/09/2024, revealed Resident #5 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of grievance log indicated Resident #5 filed a grievance on 3/20/24 regarding someone taking cigarettes that belonged to the resident. Review of grievance form indicated Resident #5 thought someone was taking cigarettes. The resolution was locking the cigarettes up behind the nursing station. During an interview on 05/28/2024 at 3:21 PM, the Social Service Director (SSD) confirmed talking with Resident #5 but there was no investigation to determine if cigarettes were taken because resident only had three packs and confirmed the grievance form was the facilities only documentation regarding the incident. During an interview on 5/29/24 at 3:41 PM, Resident #5 confirmed having four unopened packs of cigarettes and notified SSD when two packs were missing. Resident #5 verbalized the facility did not do anything about cigarettes missing and began locking the cigarettes up. Review of resident face sheet indicated the facility admitted Resident #6 with diagnoses of Alzheimer's disease, dementia with behavioral disturbance, moderate protein-calorie malnutrition. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/09/2024, revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 0 which indicated the resident had severe cognitive impairment. A review of the grievance log revealed previous administrator filed a grievance on behalf of Resident #6 regarding Certified Nursing Assistant [CNA] #3 being rough with a resident. A review of the grievance form revealed CNA #3 grabbed Resident #6 shirt and was shaking resident. The previous administrator spoke to the resident's family and the family verbalized not feeling like it was abuse just inappropriate. The family did not want to involve the police or file abuse charges. CNA #3 was terminated immediately. Review of the termination of employment form revealed CNA #3 was terminated on 2/23/24 for sleeping and not eligible for rehire. During an interview on 5/30/24 at 11:49 AM, the Assistant Director of Nursing (ADON) confirmed the grievance documented on 4/8/24 regarding Resident #3 occurred over the weekend and SSD, Administrator and Director of Nursing (DON) followed up on Monday 4/8/24 and CNA #1 was suspended. ADON confirmed the allegation of missing cigarettes from Resident #5 should have been investigated and reported. ADON verbalized not being involved in the allegation of abuse regarding Resident #6. During an interview on 5/30/24 at 12:10 PM, the Interim DON confirmed the incident on 4/8/24 with Resident #3 should have been investigated by the facility. Interim DON confirmed allegation of missing cigarettes from Resident #5 should have been investigated and reported. Interim DON confirmed allegation of abuse from previous administrator regarding Resident #6 should have been investigated and reported. During an interview on 05/30/2024 at 12:30 PM, the Administrator confirmed the allegation of abuse from Resident #3 should have been investigated and reported. The Administrator stated the allegation has now been reported after speaking with Resident #3. The Administrator verbalized that the allegation of cigarettes missing should have been investigated and if the amount is less than $50 it does not have to be reported. Administrator confirmed employment start date of 3/15/24. The administrator verbalized the previous Administrator was still working at the facility and thought it was investigated by the previous Administrator. The Administrator confirmed the allegation of abuse from the previous Administrator should have been investigated and reported.

Based on observations, interviews, record review, facility document review, and facility policy review it was determined that the facility failed to investigate an allegation of abuse and misappropriation of property for 3 (Resident #3, #5, and #6) of 3 residents reviewed for abuse. Findings include: A review of a facility policy titled Abuse Investigation and Reporting dated 07/01/2017, indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management .If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source I reported, the administrator will assign the investigation to an appropriate individual . A review of a facility policy titled, Abuse Prevention Program dated 12/01/2016, indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . Identify and assess all possible incidents of abuse. Investigate and report any allegations of abuse within timeframes as required by federal requirements . A review of the resident face sheet indicated the facility admitted Resident #3 with diagnoses that included Hemiplegia and hemiparesis following cerebral infarction affecting, left non-dominant side, gastrostomy status (history of), chronic pain syndrome. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2024, revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 6 which indicated the resident has severe cognitive impairment. During an interview on 5/28/24 at 1:57 PM, Resident #3 confirmed Certified Nursing Assistant [CNA] #1 was rough over the weekend while changing Resident about a month ago and notified CNA #2 later that day. Resident #3 confirmed talking with Social Service Director [SSD], Administrator and Director of Nursing [DON] the following Monday. Resident #3 confirmed not feeling safe in the facility when CNA #1 was working. On 5/28/24 at 2:43 PM, the Administrator was informed by surveyor that Resident #3 verbalized being mistreated and hurt by CNA in April. The administrator verbalized reviewing the grievance log at this time and was going to go talk with the Resident. On 5/28/24 at 2:46 PM, SSD provided a copy of the grievance form and SSD progress notes of incident. Requested a copy of the incident investigation with witness statements and SSD confirmed the grievance form and SSD progress notes was the only documentation the facility has. Review of grievance form indicated SSD interviewed Resident #3 on 4/8/24 and resident verbalized CNA #1 was rough with her. SSD followed up with DON and CNA #1 was put on leave pending investigation. Follow up actions included terminating CNA #1 on 4/14/24. Review of progress note dated 4/8/24 indicated SSD spoke with Resident #3 and Resident verbalized CNA #1 would not help, was hateful and hurt Resident's arm. SSD documented resident #3 did not feel safe with CNA #1. SSD documented resident began to cry and requested to call family. Review of CNA #1 employee personnel chart indicated employee was not terminated until 4/22/24. During an interview on 5/30/24 at 11:49 AM, the Assistant Director of Nursing (ADON) confirmed the grievance documented on 4/8/24 regarding Resident #3 occurred over the weekend and SSD, Administrator and Director of Nursing (DON) followed up on Monday 4/8/24 and CNA #1 was suspended. During an interview on 5/30/24 at 12:10 PM, the Interim DON confirmed the incident on 4/8/24 with Resident #3 should have been investigated by the facility. During an interview on 5/30/24 at 12:30 PM, the Administrator confirmed the incident with Resident #3 should have been investigated and confirmed not being made aware of potential abuse but being made aware of a situation regarding water. A review of the resident face sheet indicated the facility admitted Resident #5 with diagnoses that included heart failure, myocardial infarction (history of), and pain unspecified. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/09/2024, revealed Resident #5 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of grievance log indicated Resident #5 filed a grievance on 3/20/24 regarding someone taking cigarettes that belonged to the resident. Review of grievance form indicated Resident #5 thought someone was taking cigarettes. The resolution was locking the cigarettes up behind the nursing station. During an interview on 05/28/2024 at 3:21 PM, the Social Service Director (SSD) confirmed talking with Resident #5 but there was no investigation to determine if cigarettes were taken because resident only had three packs and confirmed the grievance form was the facilities only documentation regarding the incident. During an interview on 5/29/24 at 3:41 PM, Resident #5 confirmed having four unopened packs of cigarettes and notified SSD when two packs were missing. Resident #5 verbalized the facility did not do anything about cigarettes missing and began locking the cigarettes up. During an interview on 05/30/2024 at 12:10 PM, the Interim DON confirmed missing cigarettes from a resident should be investigated and reported because it is theft. During an interview on 05/30/2024 at 12:30 PM, the Administrator verbalized it should have been investigated and if the amount is less than $50 it does not have to be reported. Administrator confirmed employment start date of 3/15/24. The Administrator verbalized the previous Administrator was still working at the facility and thought it was investigated by the previous Administrator. Review of resident face sheet indicated the facility admitted Resident #6 with diagnoses of Alzheimer's disease, unspecified, dementia with behavioral disturbance, moderate protein-calorie malnutrition. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/09/2024, revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 0 which indicated the Resident had severe cognitive impairment. A review of the grievance log revealed previous administrator filed a grievance on behalf of Resident #6 regarding Certified Nursing Assistant [CNA] #3 being rough with a resident. A review of the grievance form revealed CNA #3 grabbed Resident #6 shirt and was shaking Resident. The previous Administrator spoke to the Resident's family and the family verbalized not feeling like it was abuse just inappropriate. The family did not want to involve the police or file abuse charges. CNA #3 was terminated immediately. Review of the termination of employment form revealed CNA #3 was terminated on 2/23/24 for sleeping and not eligible for rehire. During an interview on 5/30/24 at 12:10 PM, the Interim Director of Nursing [DON] confirmed this allegation should have been investigated and reported. During an interview on 5/30/24 at 12:30 PM, the Administrator confirmed the allegation should have been investigated and reported.

Based on observations and interviews it was determined that the facility failed to implement enhanced barrier precautions as recommended. Findings include: A review of a facility manual titled, Nursing Services Policy and Procedure Manual for Long-term care Infection Control, dated 03/01/2022, did not indicate any information regarding Enhanced Barrier Precautions [EBP]. During an observation on 05/28/2024 at 10:02 AM, the facility did not have any EBP signs on resident rooms and did not observe any personal protective equipment [PPE] within close proximity of resident rooms. During a concurrent observation on 05/28/2024 at 3:25 PM, the facility did not have any EBP signs on resident rooms and did not observe any personal protective equipment [PPE] within close proximity of resident rooms. During a concurrent observation on 05/29/2024 at 11:23 AM, the facility did not have any EBP signs on resident rooms and did not observe any personal protective equipment [PPE] within close proximity of resident rooms. During an interview on 05/29/2024 at 1:59 PM, the Administrator confirmed the facility has not implemented EBP. During an interview on 05/30/2024 at 11:05 AM, Certified Nursing Assistant [CNA] #4 confirmed the facility has not provided any education or training on EBP and did not know which residents required EBP. During an interview on 05/30/2024 at 11:49 AM, the Assistant Director of Nursing [ADON] confirmed the facility has not implemented EBP and did not know when the EBP was initiated. During an interview on 05/30/2024 at 12:10 PM, the Interim Director of Nursing [IDON] confirmed the facility has not implemented EBP.

Based on observations, interviews, and record review it was determined the facility failed to maintain proper temperatures in the facility to provide a safe comfortable homelike environment for 1 (Resident #4) of 3 residents reviewed for physical environment. Findings include: A review of Resident #4's face sheet indicated the facility admitted Resident #4 with diagnoses that included extended spectrum beta lactamase (ESBL) resistance, Chronic viral hepatitis C, malignant neoplasm of bronchus or lung, and diabetes mellitus due to underlying condition with diabetic neuropathy. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2024, revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A review of Resident #4's care plan initiated on 5/29/24 revealed the Resident was taking antibiotics for ESBL of urine. Interventions included administer medications as ordered by physician. Monitor and report any worsening signs/symptoms. Monitor for any adverse side effects. A review of physician's order revealed Resident #4 had orders for Meropenem solution 1 gram IV [intravenous] three times per day starting 5/22/24 and ending on 5/29/24. During an interview on 05/28/2024 at 10:46 AM., Resident #4 verbalized being cold and was wearing a fleeced lined blue jacket and thick grey gloves on both hands. Resident #4 confirmed the room was always cold. Resident resides on 100 hall. During an observation on 05/29/2024 at 9:23 AM, the thermostat on 100 hall was set at 68 degrees. The maintenance director placed a thermometer on the counter on the south end of 100 hall to obtain temperature. During an observation on 05/29/2024 at 9:39 AM, the thermostat in the dining room was set at 64 degrees and the temperature was 66 degrees according to the thermostat reading. During an observation on 05/29/2024 at 9:41 AM, the thermostat on 200 hall was set at 68 degrees. During an observation on 05/29/2024 at 9:46 AM, the thermostat on the north and south 300 hall was set at 70 degrees and the temperature was 73 degrees. During an interview on 05/29/2024 at 9:47 AM, the Maintenance Director confirmed residents have complained about being cold. During a concurrent observation and interview on 05/29/2024 at 10:06 AM, the thermometer placed on the south end of 100 hall was reading a temperature of 66 degrees. The Maintenance Director verbalized 66 degrees is a really cool temperature. The Maintenance Director changed the thermostat from 68 degrees to 72 degrees. During an observation on 5/29/24 at 12:03 PM, the thermostat on 100 hall was set at 72 degrees with a temperature reading of 69 degrees. During an observation on 5/29/24 at 12:04 PM, the thermometer placed on the south end of 100 hall was reading a temperature of 68 degrees. During an observation on 5/29/24 at 2:52 PM, the thermometer placed on the south end of 100 hall was reading a temperature of 70 degrees. During an observation on 5/30/24 at 8:47 AM, the thermometer placed on the south end of 100 hall was reading a temperature of 72 degrees. On 05/30/2024 at 9:34 AM, the Administrator stated the facility did not have a policy for physical environment and facility temperatures.

Based on observation, interview and record review, the facility failed to ensure training was provided for nursing staff prior to transporting a resident in the facility van which contributed to a resident falling on the van which resulted in a fracture of the femur for 1 (Resident #1) sampled resident. No training has been provided since the incident and staff have continued to transport residents. Two staff members provided return demonstration and failed to secure person safely. This failed practice resulted in an Immediate Jeopardy which caused serious harm to Resident #1 and could have caused death to Resident #1. The Administrator and Acting Administrator were notified of the Immediate Jeopardy on 12/13/23 at 3:57 pm and the Plan of Removal was accepted on 12/13/23 at 5:17 pm. The findings are: On 10/17/23, Resident #1 was on the facility van for transport to local hospital for Bone Density Test. Van Driver #1 slammed on the brakes of the van as someone pulled out in front of the van. Resident #1 slid forward in the wheelchair with her bottom not on the seat of the wheelchair and the seatbelt under the resident's breast per Van Driver #1's interview completed on 12/13/23 at 11:51 am. Van Driver #1 pulled over and tried to re-adjust the resident in the wheelchair and had to unlock the lap seatbelt. When unlocking the seatbelt, the resident fell to the floor of the van with Van Driver #1's assistance. During the interview Van Driver #1 confirmed Resident #1's leg looked like it had a bone sticking out toward the skin and called for an ambulance. Van Driver #1 confirmed Resident #1 was complaining of leg pain. Hospital X-ray of right knee documentation confirmed on 10/17/23, Resident #1 had an acute fracture of distal femur. Hospital surgical documentation confirmed Resident #1 had an open reduction internal fixation of the right periprosthetic distal femur completed on 10/20/23. On 12/13/23 at 11:51 am, Van Driver #1 confirmed she had been shown how to buckle a person in and how to use the lift on the van from Van Driver #2 but did not sign anything to confirm her training prior to transporting residents in the facility van. Van Driver #1 confirmed she did not receive any training following the incident on 10/17/23. Van Driver #1 confirmed she has continued to do transports without further training. On 12/13/23 at 12:56 pm, the Acting Administrator confirmed she did education with Van Driver #1 prior to the incident but failed to document the training and failed to document return demonstration. The facility cannot provide documentation of the training and return demonstration prior to the incident for Van Driver #1 or Van Driver #2. The facility confirmed they do not have a policy on transporting residents. On 12/13/23 at 12:57 pm, the Director of Nursing (DON) confirmed she delegated the training following the van incident on 10/17/23 to the Assistant Director of Nursing (ADON). On 12/13/23 at 1:02 pm, the ADON confirmed she did not do training with Van Driver #1 following the van incident on 10/17/232. The ADON confirmed she did training with Van Driver #2 after the van incident but does not have documentation to support the training was completed. On 12/13/23 at 2:43 pm, Van Driver #2 confirmed she did not get any training on how to buckle a person in the van but did get training on how to use the van lift prior to transporting residents in the facility van. Van Driver #2 confirmed she did not receive any training following the van incident on 10/17/23. Van Driver #2 confirmed she went to the van with the ADON but did not receive any training on the use of the seatbelts. Van Driver #2 confirmed she basically learned how to use the buckles herself and has had wheelchairs shift in the van during transports. On 12/13/23 at 3:05 pm, Van Driver #1 provided a return demonstration of how to connect seat belts for a resident in the facility transport van for transport. Upon completion Van Driver #1, only connected the shoulder strap. Van Driver #1 did not place a lap belt around the waist of the resident during demonstration. Van Driver #1 confirmed she was ready transport. Van Driver #1 was asked if a lap belt should be provided, and Van Driver #1 confirmed the lap belt should have been secured. During the return demonstration, Van Driver #1 confirmed Resident #1 only had a lap belt secured during the transport that resulted in a fall with major injury. On 12/13/23 at 3:17 pm, Van Driver #2 provided a return demonstration of how to connect seatbelts for a resident in the facility transport van for transport. Upon completion Van Driver #2 only connected the lap belt. Van Driver #2 did not place a shoulder strap around the resident during the demonstration. Van Driver #2 confirmed she was ready for transport. Van Driver #2 was asked if a shoulder strap should be provided, and Van Driver #2 confirmed the shoulder strap should have been secured. On 12/14/23 at 11:15 am, the Acting Administrator confirmed she is not confident that Van Driver #1 and Van Driver #2 can safely transport residents until proper training has been completed. On 12/15/23 at 3:16 pm, the facility provided training completed on 12/15/23, for the van drivers The facility provided the Van Inspection completed on 12/14/23. On 12/13/23 at 5:17 pm, the Administrator provided a Plan of Removal with the following measures: Abatement Plan The following plan is being submitted to address the concern brought forth for [Facility Name]. The submission of this plan is not an admission of guilt or wrongdoing, but this plan is being submitted in good faith. The facility has taken the following actions of removal. Immediate Corrective Action: Review of Inservice Training policy, with emphasis on Transportation aide training will be completed by 12/15/23. All pertinent staff will be reeducated on the safety, and correct application of safety devices on the transport van per manufactures specifications with return demonstrations. All transportation aides will be educated prior to continuation of any transport appointments for [Facility Name]. To be completed by 12/15/23 and ongoing. Identifying other residents with potential for being affected and interventions to prevent this from occurring in the future. All residents who need to go out for an appointment are at risk. Measures put in place to prevent reoccurrence. System revision. All transportations have been stopped at this time and staff will be thoroughly educated and return demonstrations of understanding how to correctly secure a wheelchair and resident in the transportation van by 12/15/23 and before resuming any transports. How Facility Will Monitor System and Corrective Action: Administrator/ DON or other designee will conduct reviews of all transports x 4 weeks. These reviews will include proper placement of safety devices and residents. Quarterly Education and random audits will be completed, and negative findings will be addressed immediately. QAPI All audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine if any further staff education or facility policy changes are needed. Any deficiencies will be corrected immediately and reviewed again by the Quality Assurance Performance Improvement Committee monthly. All above measures will be subject to review, assessment, and modification.

Complaint # (AR 747) was substantiated all or in part with these findings: Based on record review and interview, the facility failed to ensure adequate supervision was provided to prevent elopement, as evidenced by failure to develop and implement ongoing interventions to prevent elopement after exit-seeking behaviors were identified and failure of the 1 staff member assigned to Resident #1's hall to remain on the hall to provide supervision to residents for 1 (Resident #1) of 5 (Resident #1 - #5) case mix residents who resided on the secured unit. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who had a history of [REDACTED]. 1. Resident #1 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 5/20/18 documented the resident scored 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status, exhibited wandering behavior daily, was independent with transfers, ambulation on the unit, and had a history of [REDACTED]. a. The Care Plan dated 12/21/15 documented, I am at risk for wandering/elopement due to my dx (diagnosis) of disorder of psychological development; Goal: I will reduce my risk of harm by instructions given to me through next review period; Approach Start Date: 05/20/18 - Attempt to distract me from wandering/elopement by offering pleasant diversions, structured activities, food, conversation, television or with books. Approach Start Date: 05/20/18 - I will be placed on 30 minute observations for 24 hours . The Care Plan did not document approaches to observe the resident's whereabouts at a specific frequency after the 24-hour monitoring period ended. b. A Nurse's Note dated 3/9/18 at 6:25 p.m. documented, Called to 100 hall by CNA (Certified Nurse Assistant). Resident had exited the facility out the 100 hall emergency door. (Three) CNAs and 1 nurse went to look for resident. Resident was behind the building on facility grounds. Resident redirected to 300 hall emergency exit doors and assisted back into facility and back to 100 hall. Resident never went off facility grounds. Resident was combative with staff at first but eventually calmed down. Contacted DON (Director of Nursing), emergency contact, and (Physician). No new orders at this time. Resident will be on 30 minute observations for this weekend. No further attempts to exit facility at this time. Resident is now resting in bed, eyes closed. No acute distress noted. Clwr (Call light within reach). c. A facility Event Report dated 3/9/18 at 7:02 p.m. documented, .Description Exited out 100 hall emergency doors. Event Details: Physical Observation: When and where was resident found? 6:20 pm resident was on facility grounds behind building by 300 hall exit door . Did resident exhibit any of the following behaviors prior to elopement? Wandering with no rational purpose and attempting to open doors. Interventions - Immediate measures taken. Placement in Secured Unit, Other: 30 minute observations . BIMS 04; In-service; 1) I will be put on 30 minute observations. 2) Attempt to distract me from wandering / elopement by offering pleasant diversions, structured activities, food, conversation, television or books. d. A facility Event Report dated 7/9/18 at 10:47 a.m. documented, .Description Elopement; Event Details Physical Observation; When and where was resident found? Resident on (local street) east of building walking east by staff members . Did resident exhibit any of the following behaviors prior to elopement: Anger regarding Facility Placement, Elopement Attempts in Past - Unsuccessful, Elopement Successes in Past, Describe, if necessary, Resident is angry due to not being able to participate in school activities . Interventions - Immediate measures taken, Placement in Secured Unit, Other-q (every) 30 minute checks . BIMS 05, Intervention 1) 30 minute observations until behavior subsides. 2) CP (Care Plan) updated. The interventions included placement on the secured unit; however, the resident already resided on the secured unit at the time of this elopement and, based on the record review and interviews below, the back door of the secured unit is the exit the resident used for this elopement. e. Nursing Progress Notes dated 7/9/18 at 11:28 a.m. documented, Staff member alerts this nurse that resident has gotten outside through back door, alarms were sounding. Code brown called. Facility is searched by all available staff members. Back door is secured per staff. Outside perimeter is searched by all available staff members, resident is not found on grounds. Resident observed per staff to be ambulating east of facility located on (local) street. Transportation van driven by personnel x (times) 2 staff members locates resident. Resident resistant to get off van to go back in facility, states she wants to go to her house. Resident safely back into facility between 10:00 and 10:15 a.m. No injuries noted. Resident without s/s (signs/symptoms) acute distress @ (at) this time. f. An Office of Long Term Care (OLTC) Witness Statement form dated 7/9/18 and signed by CNA #2 documented, Was going to take my break walked down 100 hall to go out patio doors heard alarm on back door going off. I went out back door to see if anyone got out, ran to front of building outside and back of building, looked down street, came back in, done sweep on 100 hall, asked (CNA #1) where (Resident #1) was, she said in recliner, I then let everyone know resident not on hall then went off 100 hall while (CNA #1) stayed on hall. g. An OLTC Witness Statement form dated 7/9/18 and signed by CNA #1 documented, Left hall to get ice chest and (Resident #1) was in recliner in Day Room asleep when I left hall. I got back on hall and (CNA #2) stated that the alarm was going off and that (Resident #1) had gotten out. Resident was nowhere in building. h. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & (and) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762, dated 7/10/18, documented, Section III-Findings and Actions Taken .On 07/09/18 at approximately 09:50 a.m., (CNA #1) came off 100 Hall secure unit to fill up ice chest in dietary department at which time (Resident #1) was asleep in the Day Room recliner. Soon after this point in time, (CNA #2), went to the 100 Hall secure unit to take a smoke break and heard and observed south door alarming. (CNA #2) exited door and performed a front and back yard search with no resident being observed outside. (CNA #2) performed a hall search and noticed that (Resident #1) was not on hall. (CNA #2) immediately informed (Licensed Practical Nurse (LPN) #1) and a code brown, (elopement) was initiated. Outside, (Facility Grounds) and surrounding area search was initiated with staff and vehicles. (Resident #1) was observed by (CNA #3) and (CNA #2) in facility van approximately 3 blocks east of facility. (CNA #3) and (CNA #2) assisted (Resident #1) into van and assisted (Resident #1) into facility upon return at approximately 10:10 am. ACTIONS: A (sic) immediate investigation was initiated / (Resident #1) was placed on 30 minute observations / In-service on Elopement Policy, (Code Brown), was conducted / (CNA #1) was issued an immediate one day suspension for leaving hall before replacement was on hall before exiting. i. The 30-minute observation form documented the resident was observed every 30 minutes from 7/9/18 at 10:10 a.m. until 7/10/18 at 7:30 a.m., a period of 19 hours and 20 minutes after she successfully eloped from the facility. No further ongoing interventions were documented to prevent further potential elopements for this resident. j. On 7/11/18 at 12:44 p.m., CNA #1 was asked, How did (Resident #1) get out of the building? She stated, She got out that door (pointing to the door at the end on the hall) Monday. She wanted to go to school that day, but she had a [MEDICAL CONDITION] that morning and she was mad. The CNA was asked, How did she get out the door? She stated, She pushed on it. The CNA was asked, By standing there and pushing on it for a while (delayed egress door)? She stated, Yes. The CNA was asked, Who is on this hall (secured unit) today, just you? She stated, Yes, I am on it every day I work. I went to get ice for the ice chest; they usually bring it back here, and snacks, but Monday they didn't. When I went to leave, (Resident #1) was on the recliner sound asleep, so I left to get ice. I was only gone two minutes. I came back; the other aide heard the alarm going off and she said 'Where's (Resident #1) and I said 'She's in the recliner asleep.' Well she wasn't, she had gotten out. We searched every room, every closet, everyone searched out there, outside. The CNA was asked, Where did they find her? She stated, They found her right down the road. The CNA was asked, Has she attempted to get out the back door before? She stated, Not back here, but when she was on the other unit. The CNA was asked, When she was on the other unit, she tried to get out? She stated, Yes. The CNA was asked, She went to other doors? She stated, Yes. The CNA was asked, Did you receive any in-services? She stated, Never leave the hall unattended. If I need something, holler out there and have someone sit back here while I go get it. The CNA was asked, What if you have to change someone? She stated, I have to yell at somebody out there and wait till they can come back here. The CNA was asked, Are you the only one working back here? She stated, Yes, when I work, there used to be two back here, but when the census went down there is only one. The CNA was asked, How long have you been the only one back here? She stated, About four months now. k. On 7/11/18 at 2:15 p.m. the Administrator was asked, When was (Resident #1) placed on the secured unit? He stated, I'm not sure of the date, I will have to check. The Administrator was asked, Why was she placed on the secured unit? He stated, Because she was a wanderer. The Administrator was asked, Had she gotten out while she was not on the secured unit? He stated, I'm not sure. She goes to school. She had a [MEDICAL CONDITION] that morning and she didn't go to school. She's smarter than what you think, and she wanted to go to school and she was going. The Administrator was asked, On 3/9(/18) what interventions did you put into place to try to prevent further elopements? He stated, I don't know; I will have to check. The Administrator was asked, After she eloped on 7/9 (/18), where did they find her? He stated, Three blocks down on (local street). She was on the roadway, walking on the grass beside the roadway. The Administrator was asked, What interventions did you put into place after the elopement on 7/9? He stated, We did 30-minute observation checks, with people sitting in the hallway, in-serviced all staff on the elopement policy. l. On 7/11/18 at 2:27 p.m., the DON was asked, After (Resident #1) eloped on 3/9, what interventions did you put into place to try to prevent further elopement? He stated, This is not a jail. The DON was asked, After (Resident #1) eloped on 7/9, what interventions did you put into place to attempt to prevent further elopements? He stated, Thirty-minute observations until the exit seeking behavior subsided. The DON was asked, You have only one staff member working in the secured unit. If there is an emergency or the staff person is busy in a resident's room, does that leave residents unattended? He stated, The way you stated it, yes. The Administrator stated, Every employee is allowed to have their cell phone on them for emergencies . There is an alarm that will sound at the nurse's station if someone pushes on the door on the unit. m. On 7/11/18 at 2:43 p.m., an unidentified staff member was asked to go down the secured unit hall and push on the exit door with the Administrator, DON and Activities Director present at the desk with the surveyor. An alarm with a light and a slightly faster beep than a call light was heard. Licensed Practical Nurse (LPN) #2 stated, That is not very loud, and it is like a call light, and you get complacent with hearing them. The staff members present were asked, if you were standing down the hallway or in the dining room, would you hear that alarm? LPN #2 stated, Probably not. The Administrator and DON were observed shaking their heads, 'No'. The Activities Director stated, No. n. On 7/11/18 at 3:19 p.m., CNA #2 stated she was unsure the route walked by (Resident #1). The area where resident was located on 7/9/18 was observed by the surveyor. The road was a paved, two-lane road, with a sidewalk running parallel to the road, approximately three feet from the pavement. The CNA was asked, Was she (Resident #1) walking on the sidewalk? The CNA stated, No, she was walking on the edge of the road, where the pavement meets the grass. She was booking it, carrying her back pack and a bag in each hand. o. On 7/11/18 at 3:30 p.m. CNA #2 was asked, Can you tell me what happened when (Resident #1) eloped? She stated, I was going out to take a smoke break and I was going out the patio doors, and I noticed the alarm was going off back there, because back there, it is pretty loud. So, I immediately went to the back door, because the other aide that was there was off the hall getting ice. I went outside, looked out the back of the building, down the road. Ran up the front side of the building, looked up and down the road, came back in the same door. At that time, the aide came back to the hall. I looked in the rooms to see if residents were there because (Resident #3) is a wanderer and hits that door. I asked the aide, 'where is (Resident #1)?' because I didn't see her. She said she was in recliner in the day room. I looked in there and she wasn't there. I proceeded to come out the doors from the secured unit to let everyone know she was not down there. I went down 300 hall, because sometimes if she gets out, she will come out and sit where the birds are. I didn't see her. I told the DON. We still could not find her. Then I went out the main door by the bird cage and started running down Ninth Street. By that time everyone was outside looking for her. Then (CNA #3) was in our transport van, she told me to get in and we will look for her, she met me half way down Ninth Street. I said, 'we better turn right' and we seen (sic) (Resident #1) three blocks up. I jumped out of the van and got (Resident #1) and she was right on the edge of the road. I said 'What are you doing sis?' and she said, 'nothing'. I said, 'let's go for a ride' and she said 'okay' and she got in the van. The CNA was asked, Did you hear the alarm going off out at the nurse's station? She stated, I don't remember. I know when I went through those doors that the back door alarm was going off; you can really hear it back there. p. As of 7/11/18, the resident's Care Plan did not document any new / revised interventions to, on an ongoing basis, protect the resident from further potential elopement. 1. The Immediate Jeopardy was removed and the scope/severity reduced to E on 7/11/18 at 6:35 p.m. when the facility implemented the following Plan of Removal: Facility failed to ensure adequate supervision was provided to prevent elopement. 1. On 07/11/2018, upon notification of deficient practice, the Administrator/Director of Nursing did ensure that there was staff member on the 100-hall supervising 5 residents, three of which have potential for elopement at all times. No additional negative findings were found. 2. On 07/11/2018, Director of Nursing and Administrator through observation identified the three residents who have the potential to be affected from the deficient practice and observed/checked to ensure that two staffed (sic) members are always on 100 halls at all times. Any negative findings were corrected immediately. Elopement risk assessment completed on all five residents located in the 100 hall secure unit, on 07/11/2018. 3. To ensure deficient practice does not reoccur on 07/11/2018, the administrator/director of Nursing in-serviced current facility staff to ensure that two staff members will be present on the 100 at all times. All incoming and new hire staff will be in-serviced. 4. On 07/11/2018, the Director of Nursing/Designee will observe and monitor to ensure that two staff members are on 100 halls at all times to prevent the potential of elopement. Check off of visual observation form, each shift for 8 weeks or until compliance is verified by OLTC. 5. The Administrator and Director of Nursing/Designee will present all negative findings to the monthly QA (Quality Assurance) Committee for further review and recommendations.

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure Residents #1, #6, #7 and #8 who were cognitively impaired were free from abuse. The facility failed to ensure allegations of staff to resident abuse involving CNA #6 were thoroughly investigated and residents were protected from the potential of further abuse for 8 (Residents #1 - #8) case mix residents who resided on the 200 and 300 halls and could receive care from CNA #6 and staff promptly reported all allegations of staff to resident abuse involving CNA #2 to the Administrator/Designee to ensure prompt and thorough investigation and residents were protected from the potential of further abuse for 4 (Residents #1, #6, #7 and #8) of 6 (Residents #1, #2, #5, #6, #7 and #8) case mix residents who were cognitively impaired. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Residents #1, #6, #7 and #8 who were cognitively impaired and the subjects of unreported allegations of staff to resident abuse. The facility was informed of the Immediate Jeopardy on 10/10/12 at 12:05 p.m. The findings are: 1. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) -762 form dated 7/31/12 documented, "On Tuesday, July 31st, (Certified Nursing Assistant (CNA) #5) told me that she and (CNA #7) heard (CNA #6) say to some unknown resident 'sit down and shut up'... DON (Director of Nursing) and I questioned many people. We talked to residents on 100 hall, even though it is the locked down unit, some residents know who (CNA #6) is and tell us that they love her. We talked to family members and they say they love her. The two CNAs who say they heard her say 'shut up' didn't see a resident and therefore do not know who she was talking to... I do not feel that there is evidence to consider (CNA #6) abusive to residents..." a. On 10/9/12 at 3:28 p.m., RN #2 was interviewed per telephone. She stated, "I spoke with (Administrator) and (DON) about (CNA #6) telling a resident to sit down and shut up. I went straight to (Administrator) and told her I had had enough. She went to (CNA #6) and then came to me and said 'if you ever hear that again, you tell me'. Then 2 weeks later, (CNA #5) comes to me and said she (CNA #6) was down there telling another resident to sit down and shut up. I went to (Administrator) again and she kept saying 'well I guess we'll have to take the deficiency on it'. They suspended her (CNA #6) for like two hours, until I left, then they let her come back. I just don't think they handled it properly. Another nurse here told me not too long ago that (CNA #6) was heard yelling at a resident and she didn't know the intercom button was pushed so it went all over the facility." b. On 10/10/12 at 10:19 a.m., Licensed Practical Nurse (LPN) #1 was interviewed. She stated, "(CNA #6)... I've never worked with personally, but two to three weeks ago, I was passing meds. The loud speaker came on, and all over the facility you could hear her screaming at a resident... she was saying something like 'I told you to get out right now, get out of this room! Get over here so I can change these pants!' Then apparently she realized it was on speaker and she turned it off. I looked at (RN #1) and said this needs to be reported. She went to (Administrator)." LPN #1 was asked if she felt what she heard CNA #6 do was abuse. She stated, "Yes. If someone was screaming at my family like that... you better believe it. I was told it was discussed in the morning meeting and that (Administrator) was more upset that it was over the loud speaker than how the CNA acted." LPN #1 also provided a hand written witness statement that documented, "...As far as (CNA #6), I don't work with her but, I did hear her yelling at a pt (patient) over the intercom one day. That was reported and (Administrator) heard it herself over the intercom." c. On 10/10/12 at 10:47 a.m., CNA #7 was asked if she had ever witnessed anything in the facility that she would consider abuse. She stated, "I was coming out of the locked unit break room and I heard (CNA #6's) voice... I didn't see a resident though. I heard her say 'sit down and shut up'. She has a gruff, manly voice." CNA #7 was asked if she felt what she heard was abuse. She stated, "Yes. It was reported to someone. I can't really remember who. It's been a while. I can't even tell you which room she was in." d. On 10/10/12 at 11:07 a.m., RN #1 was asked if she had observed anything in the facility that she would consider abuse. She stated, "One day we were on the hall and the over head speaker came on... and you could hear (CNA #6) yelling and talking very rough, very rough. I was with another girl and we both just stopped in the hall and we both said 'go to (Administrator)'. It was discussed in the morning meeting and what was said is that a resident was messing around with the page button and she was at the nurses' station. The resident hit the button and then everything was heard over the speaker. The focus wasn't how the CNA treated the resident." RN #1 was asked if she considered what she heard to be abuse. She stated, "Yes. It was rough. If she had been talking to me that way, I would've told her that was not acceptable." RN #1 was asked if she was questioned or was asked to fill out witness statements on the incident. She stated, "No." 2. On 10/9/12 at 11:28 a.m., CNA #2 was asked if he had heard anything regarding a resident being sprayed in the face with a spray bottle. He stated, "Someone said I did that. (CNA #1) and (CNA #3) said I had sprayed (Resident #1) with a spray bottle. I had been off a couple of days and it was apparently reported to (Registered Nurse (RN) #2), (CNA #3's) wife." CNA #2 was asked why the other CNAs would accuse him of doing that. He stated, "I don't know. I didn't think I had a problem with them. I was upset about it so I texted the DON (Director of Nursing) about it and she said she didn't know anything about it. I was and am extremely upset about it. I would never do anything like that to a resident. (Resident #1) has a spray bottle that is used to fix her hair and I've used her spray bottle to fix her hair, but I have never sprayed her in the face. I did tell (CNA #1) one time to be sure and not spray her face." CNA #2 was asked if anyone had questioned him about the allegation or if he had filled out any type of witness statement. He stated, "No. I think it is protocol that I should have been suspended and an investigation done and State called." The CNA was asked if the DON questioned him more in depth when he sent her the text message. He stated, "No." a. On 10/9/12 at 1:30 p.m., CNA #1 was asked if she had ever observed any abuse in the facility. She stated, "Well, not really abuse but, I saw (CNA #2) squirt water in (Resident #1) face until she cried. She has her own squirt bottle because you have to wet down her hair sometimes." The CNA was asked if it was possible that CNA #2 was using the squirt bottle to wet the resident's hair, and the water accidentally hit the resident in the face. CNA #1 stated, "No, he literally stuck it in her face and squirted her until it was dripping off of her face. I also saw him dump a cup of ice water in another resident's lap... (Resident #7)." The CNA was asked if that was done on purpose. CNA #1 stated, "Yes. I was feeding her and he came in and said 'did you give her water to her?' And I said not yet, and the resident started saying 'No, no, please don't'. He dumped it on her lap and then turned around and walked off. I had to do a complete bed change. I guess he's done that to her before because she started saying 'No, no'. And he also dumped water on (Resident #8). He likes to hear her scream. Another resident accidentally spilled her milk and he went to get her another one and then looked around.... I knew he was going to do something, and he dumped it on her." CNA #1 was asked if she reported any of this to anyone. She stated, "Well it's not really abuse. He didn't touch them. He didn't lay his hands on them." CNA #1 was asked if someone had to literally touch a resident in order for it to be considered abuse. The CNA stated, "Well, no. There's mental, I guess." CNA #1 was asked why CNA #2 would do any of these things to the residents. The CNA stated, "I don't know. But he pulled me into a room the other day and said that he heard that me and (CNA #3) were stabbing him in the back and trying to get him fired and that he needed to know whose ass to kick." CNA #1 was asked if she had any personal problems with CNA #2. CNA #1 stated, "No, I don't have any problems with him personally. I just don't like the way he treats the residents." CNA #1 was asked if there were any residents who could verify the information that she had shared with me. The CNA stated, "(Resident #1) - no, (Resident #8) - no. (Resident #7) might could." CNA #1 was asked if there were any employees who could verify the information she shared. She stated, "(CNA #4) might have been there when he dumped water on (Resident #8) but, she's a friend of his so I don't know if she would say anything." b. On 10/9/12 at 3:28 p.m., RN #2 was asked during a telephone interview if she had received a report of a CNA squirting a resident in the face with water. She stated, "I heard from a CNA who had heard from a CNA that had happened. So I talked to the CNA who supposedly saw it... and she wouldn't give me any details." RN #2 was asked if she questioned the CNA specifically about the alleged water spraying incident. She stated, "Well, no I didn't because it was through the grapevine. What I told her was if she felt uncomfortable about anything, then she needed to call someone on duty because I had already clocked out..." RN #2 was asked if she had ever observed CNA #2 do anything inappropriate. She stated, "Well... (sigh) I did see him once spray (Resident #7) with peri wash, from a distance, like 3 feet away..." The RN was asked why the CNA did that. She stated, "Because it's colder that way. I told him not to do that, and he said 'she called me fat', and I said 'I don't care what she calls you, you can't do that' and I've not seen him do that again. But, anything involving him wouldn't surprise me." RN #2 was asked if she reported any of this to administration. She stated, "No, but the reason for that is because of the way they handled another incident. I don't feel that it was handled appropriately." RN #2 was asked what she was referring to and she related reporting incidents involving CNA #6. c. On 10/9/12 at 3:38 p.m., CNA #3 was asked if he had ever observed CNA #2 do anything inappropriate. He stated, "I've seen him talk to residents in an inappropriate manner in the dining room and I did report it. The conversation was of an inappropriate sexual nature with other employees in front of residents." CNA #3 was asked if he had ever observed CNA #2 do things such as dump water on residents or spray water in a resident's face. He stated, "I have heard that from multiple employees. I went to (RN #2) and reported what (CNA #1) had told me. I told (CNA #1) that I didn't care for the way he treated residents, and then she said he sprayed (Resident #1) in the face until she screamed and then sprayed her hair and said 'oh I'm just showing you what not to do'. (Resident #7)... I heard he had poured cold water on her; and the way he talks to her... (CNA #5) also said she had witnessed him squirting (Resident #1) in the face and pour water on other residents. (CNA #5) said she had reported things before but, that it doesn't do any good. She was talking about the (CNA #6) incident where they turned it around and made (CNA #5) look like the bad person for reporting it." d. On 10/10/12 at 10:19 a.m., Licensed Practical Nurse (LPN) #1 was asked if she had ever witnessed CNA #2 do anything inappropriate in the facility. She stated, "It wasn't abuse but, one time we were in the dining room and he got flustered and slammed a spoon down and sighed. I pulled him out and explained to him that he couldn't do that and he said 'I didn't say anything'. I told him that didn't matter." LPN #1 was asked if she had heard anything about a resident being sprayed with a spray bottle. She stated, "(CNA #2) actually told me about it like three days after the fact because he thought I already knew about it since I am friends with (RN #2). He told me that (CNA #1) and (CNA #3) went to (RN #2) and said he sprayed (Resident #7) with a spray bottle. I asked him if it had been taken care of, meaning did administration know about it. He said he sent the DON a text, and that's the last I heard. I do know that if something is reported to (DON) or (Administrator), nothing is done about it." LPN #1 was asked what she meant by that and she related reported incidents involving CNA #6. e. On 10/10/12 at 11:30 a.m., CNA #5 was asked if she had observed anything in the facility that she would consider abuse. The CNA immediately started crying and stated, "It needs to be fixed. I know I'll get in trouble but, it needs to be fixed." CNA #5 was asked what she was referring to. She stated, "There's been a couple of incidents with (CNA #2) spraying a couple of residents with water and I've seen him take a full pitcher of ice cold water and dump it on a resident." CNA #5 was asked which resident CNA #2 dumped water on. She stated, "(Resident #6) and she is a bed-bound resident. I was his (CNA #2) partner that day." CNA #5 was asked again if she actually witnessed CNA #2 dump water on the resident on purpose. She stated, "Yes, he did it. Well, it wasn't ice water. It was a pitcher of room temperature water... she's a tube feeder." CNA #5 was asked how the resident reacted when this happened. She stated, "She cried but, she didn't scream. When he did it, he said 'I don't like this resident'. I said '(CNA #2) shame on you!' " CNA #5 was asked if she reported this to anyone. She stated, "I didn't tell anyone (sobbing). I'm just as guilty. I thought he would hang himself and basically he has." CNA #5 was asked what she had witnessed regarding CNA #2 spraying a resident in the face with water. She stated, "He sprayed (Resident #1) in the face with her spray bottle. She screamed." CNA #5 was asked if it was possible that CNA #2 accidentally sprayed the resident in the face since the water is used to wet down the resident's hair. She stated, "He was standing in front of her. He purposefully sprayed her in the face. I don't know what the other CNAs have seen but, they talk about it. I'm not sure if administration is aware but, I did hear that (CNA #1) got upset over it and told (CNA #3) then, he told his wife (RN #2). (RN #2) told me that if I had seen or heard anything then, I need to report it but, because of the (CNA #6) incident, I didn't want to say anything." CNA #5 was asked what she was talking about. She stated, "(CNA #6) told a resident to sit down and shut up and nothing was done about it. That was verbal abuse. I reported it and nothing got done." CNA #5 was asked if she understood when and what to report to administration. She stated, "Yes, we are trained to report. Yes, I understand what abuse is but, how do you report something when nobody wants to know. I am sorry." A handwritten witness statement dated 10/10/12 at 11:30 a.m. and signed by CNA #5, documented, "Was working 100 hall with (CNA #2) and went into (Resident #6) room and (CNA #2 ) poured water onto resident's body from water pitcher. Resident started to cry. Resident was still in bed and we went into her room to change her. Was working 300 hall with (CNA #2) . We went into resident's room (Resident #1) to change her and (CNA #2) sprayed water into her face. He was standing in front of resident. She screamed." f. On 10/10/12 at 3:10 p.m., CNA #8 stated during an interview, "(CNA #1) came in the other day and wanted to write out some stuff but, didn't know what to do. I asked her what kind of stuff and she said that (CNA #2) sprayed (Resident #1) in the face with water and dumped a cup of water on (Resident #7) while she was in bed. I told her to go talk to (DON) right then. I told her she should've told her charge nurse right then so they could send him home. So the next day when I saw (DON), I asked her if (CNA #1) had came and talked to her and she said 'no and I don't want to hear it'. I don't want any more on me right now. I am tired." 3. Residents involved in the allegations of staff to resident abuse: a. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, had verbal behavioral symptoms directed toward others and was totally dependent on staff for activities of daily living. b. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/18/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status and was totally dependent on staff for activities of daily living. c. Resident #7 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 9/6/12 documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), had verbal behaviors directed towards others and was totally dependent on staff for activities of daily living. d. Resident #8 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/16/11 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status and was totally dependent on staff for activities of daily living. 4. On 10/10/12 at 9:40 a.m., the Administrator was asked how the facility monitored the effectiveness of their abuse in-services and ensured staff understood to report suspected abuse. She stated, "Before we leave the meeting, we ask if they have any questions or ask for feedback." At 9:46 a.m., the DON was asked during a telephone interview how the facility monitored the effectiveness of their abuse in-services and ensured staff understood to report suspected abuse. She stated, "We had a recent complaint of abuse and that is evidence that they understand reporting." 5. On 10/10/12 at 12:15 p.m., the Administrator was asked if anything had been reported to her about a resident being sprayed in the face with water. She stated she knew nothing of this allegation until yesterday. She was asked about the incident involving CNA #6 and yelling at a resident over the intercom and whether it had been reported. She stated she heard it but, did not consider it abuse. She was asked about the incident involving CNA #6 and telling a resident to sit down and shut up and why it would make a difference that the two witnesses did not see which resident CNA #6 was talking to. She stated that was investigated and was unfounded. 6. The Immediate Jeopardy was removed on 10/11/12 and the scope and severity reduced to an E when the facility implemented the following plan of removal: a. 10/9/12 - 12:00 p.m. - (CNA #2) was suspended upon notification of suspected abuse. On 10/10/12 - 2:10 p.m., (CNA #6) was suspended upon notification of suspected abuse. b. On 10/10/12 at 3:50 p.m., Administrator and (RN #1) assessed (Residents #6 and #7) for any signs/symptoms of abuse. c. On 10/10/12 at 1:30 p.m., inservicing began on identifying and reporting allegations of resident abuse per federal, state and facility policy and procedure. All staff will be inserviced on the penalties for failing to report elder abuse in a long term care facility. As each shift begins, staff will be inserviced prior to providing resident care. Employees who are not present for the inservice will be inserviced prior to providing resident care. New employees will be inserviced on abuse prevention, identifying and reporting abuse prior to providing resident care. Inservicing will be done by Administrator and RN #1 on 10/10/12. At 4:15 p.m., the Administrator was inserviced by the RN consultant on identifying and reporting allegations of abuse. d. Beginning 10/10/12 the facility will initiate one-on-one interviews with all residents to assess staff treatment. Physical assessments will be done on residents who are not interviewable. This will be done by the Administrator, Director of Nursing, MDS Coordinator, Social Service Director or administrative nurse designated. This is to be completed by 10/11/12. e. The Administrator, DON or member of the administrative staff designated by the Administrator will monitor for compliance by interviewing three (3) randomly selected staff members and residents on all shifts daily for three (3) weeks, then three (3) staff members and residents weekly for three (3) weeks, and four (4) staff members and residents monthly ongoing as part of the monthly facility Quality Assurance Program to ensure compliance.

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure allegations of staff to resident abuse involving CNA #6 were thoroughly investigated and residents were protected from the potential of further abuse for 8 (Residents #1 - #8) case mix residents who resided on the 200 and 300 Halls and received care from CNA #6 and staff promptly reported all allegations of staff to resident abuse involving CNA #2 to the Administrator/Designee to ensure prompt and thorough investigation and residents were protected from the potential of further abuse for 4 (Residents #1, #6, #7 and #8) of 6 (Residents #1, #2, #5, #6, #7 and #8) case mix residents who were cognitively impaired. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Residents #1, #6, #7 and #8 who were cognitively impaired and the subjects of unreported allegations of staff to resident abuse. The facility was informed of the Immediate Jeopardy on 10/10/12 at 12:05 p.m. The findings are: 1. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) -762 form dated 7/31/12 documented, "On Tuesday, July 31st, (Certified Nursing Assistant (CNA) #5) told me that she and (CNA #7) heard (CNA #6) say to some unknown resident 'sit down and shut up'... DON (Director of Nursing) and I questioned many people. We talked to residents on 100 hall, even though it is the locked down unit, some residents know who (CNA #6) is and tell us that they love her. We talked to family members and they say they love her. The two CNAs who say they heard her say 'shut up' didn't see a resident and therefore do not know who she was talking to... I do not feel that there is evidence to consider (CNA #6) abusive to residents..." a. On 10/9/12 at 3:28 p.m., RN #2 was interviewed per telephone. She stated, "I spoke with (Administrator) and (DON) about (CNA #6) telling a resident to sit down and shut up. I went straight to (Administrator) and told her I had had enough. She went to (CNA #6) and then came to me and said 'if you ever hear that again, you tell me'. Then 2 weeks later, (CNA #5) comes to me and said she (CNA #6) was down there telling another resident to sit down and shut up. I went to (Administrator) again and she kept saying 'well I guess we'll have to take the deficiency on it'. They suspended her (CNA #6) for like two hours, until I left, then they let her come back. I just don't think they handled it properly. Another nurse here told me not too long ago that (CNA #6) was heard yelling at a resident and she didn't know the intercom button was pushed so it went all over the facility." b. On 10/10/12 at 10:19 a.m., Licensed Practical Nurse (LPN) #1 was interviewed. She stated, "(CNA #6)... I've never worked with personally, but two to three weeks ago, I was passing meds. The loud speaker came on, and all over the facility you could hear her screaming at a resident... she was saying something like 'I told you to get out right now, get out of this room! Get over here so I can change these pants!' Then apparently she realized it was on speaker and she turned it off. I looked at (RN #1) and said this needs to be reported. She went to (Administrator)." LPN #1 was asked if she felt what she heard CNA #6 do was abuse. She stated, "Yes. If someone was screaming at my family like that... you better believe it. I was told it was discussed in the morning meeting and that (Administrator) was more upset that it was over the loud speaker than how the CNA acted." LPN #1 also provided a hand written witness statement that documented, "...As far as (CNA #6), I don't work with her but, I did hear her yelling at a pt (patient) over the intercom one day. That was reported and (Administrator) heard it herself over the intercom." c. On 10/10/12 at 10:47 a.m., CNA #7 was asked if she had ever witnessed anything in the facility that she would consider abuse. She stated, "I was coming out of the locked unit break room and I heard (CNA #6's) voice... I didn't see a resident though. I heard her say 'sit down and shut up'. She has a gruff, manly voice." CNA #7 was asked if she felt what she heard was abuse. She stated, "Yes. It was reported to someone. I can't really remember who. It's been a while. I can't even tell you which room she was in." d. On 10/10/12 at 11:07 a.m., RN #1 was asked if she had observed anything in the facility that she would consider abuse. She stated, "One day we were on the hall and the over head speaker came on... and you could hear (CNA #6) yelling and talking very rough, very rough. I was with another girl and we both just stopped in the hall and we both said 'go to (Administrator)'. It was discussed in the morning meeting and what was said is that a resident was messing around with the page button and she was at the nurses' station. The resident hit the button and then everything was heard over the speaker. The focus wasn't how the CNA treated the resident." RN #1 was asked if she considered what she heard to be abuse. She stated, "Yes. It was rough. If she had been talking to me that way, I would've told her that was not acceptable." RN #1 was asked if she was questioned or was asked to fill out witness statements on the incident. She stated, "No." 2. On 10/9/12 at 11:28 a.m., CNA #2 was asked if he had heard anything regarding a resident being sprayed in the face with a spray bottle. He stated, "Someone said I did that. (CNA #1) and (CNA #3) said I had sprayed (Resident #1) with a spray bottle. I had been off a couple of days and it was apparently reported to (Registered Nurse (RN) #2), (CNA #3's) wife." CNA #2 was asked why the other CNAs would accuse him of doing that. He stated, "I don't know. I didn't think I had a problem with them. I was upset about it so I texted the DON (Director of Nursing) about it and she said she didn't know anything about it. I was and am extremely upset about it. I would never do anything like that to a resident. (Resident #1) has a spray bottle that is used to fix her hair and I've used her spray bottle to fix her hair, but I have never sprayed her in the face. I did tell (CNA #1) one time to be sure and not spray her face." CNA #2 was asked if anyone had questioned him about the allegation or if he had filled out any type of witness statement. He stated, "No. I think it is protocol that I should have been suspended and an investigation done and State called." The CNA was asked if the DON questioned him more in depth when he sent her the text message. He stated, "No." a. On 10/9/12 at 1:30 p.m., CNA #1 was asked if she had ever observed any abuse in the facility. She stated, "Well, not really abuse but, I saw (CNA #2) squirt water in (Resident #1) face until she cried. She has her own squirt bottle because you have to wet down her hair sometimes." The CNA was asked if it was possible that CNA #2 was using the squirt bottle to wet the resident's hair, and the water accidentally hit the resident in the face. CNA #1 stated, "No, he literally stuck it in her face and squirted her until it was dripping off of her face. I also saw him dump a cup of ice water in another resident's lap... (Resident #7)." The CNA was asked if that was done on purpose. CNA #1 stated, "Yes. I was feeding her and he came in and said 'did you give her water to her?' And I said not yet, and the resident started saying 'No, no, please don't'. He dumped it on her lap and then turned around and walked off. I had to do a complete bed change. I guess he's done that to her before because she started saying 'No, no'. And he also dumped water on (Resident #8). He likes to hear her scream. Another resident accidentally spilled her milk and he went to get her another one and then looked around.... I knew he was going to do something, and he dumped it on her." CNA #1 was asked if she reported any of this to anyone. She stated, "Well it's not really abuse. He didn't touch them. He didn't lay his hands on them." CNA #1 was asked if someone had to literally touch a resident in order for it to be considered abuse. The CNA stated, "Well, no. There's mental, I guess." CNA #1 was asked why CNA #2 would do any of these things to the residents. The CNA stated, "I don't know. But he pulled me into a room the other day and said that he heard that me and (CNA #3) were stabbing him in the back and trying to get him fired and that he needed to know whose ass to kick." CNA #1 was asked if she had any personal problems with CNA #2. CNA #1 stated, "No, I don't have any problems with him personally. I just don't like the way he treats the residents." CNA #1 was asked if there were any residents who could verify the information that she had shared with me. The CNA stated, "(Resident #1) - no, (Resident #8) - no. (Resident #7) might could." CNA #1 was asked if there were any employees who could verify the information she shared. She stated, "(CNA #4) might have been there when he dumped water on (Resident #8) but, she's a friend of his so I don't know if she would say anything." b. On 10/9/12 at 3:28 p.m., RN #2 was asked during a telephone interview if she had received a report of a CNA squirting a resident in the face with water. She stated, "I heard from a CNA who had heard from a CNA that had happened. So I talked to the CNA who supposedly saw it... and she wouldn't give me any details." RN #2 was asked if she questioned the CNA specifically about the alleged water spraying incident. She stated, "Well, no I didn't because it was through the grapevine. What I told her was if she felt uncomfortable about anything, then she needed to call someone on duty because I had already clocked out..." RN #2 was asked if she had ever observed CNA #2 do anything inappropriate. She stated, "Well... (sigh) I did see him once spray (Resident #7) with peri wash, from a distance, like 3 feet away..." The RN was asked why the CNA did that. She stated, "Because it's colder that way. I told him not to do that, and he said 'she called me fat', and I said 'I don't care what she calls you, you can't do that' and I've not seen him do that again. But, anything involving him wouldn't surprise me." RN #2 was asked if she reported any of this to administration. She stated, "No, but the reason for that is because of the way they handled another incident. I don't feel that it was handled appropriately." RN #2 was asked what she was referring to and she related reporting incidents involving CNA #6. c. On 10/9/12 at 3:38 p.m., CNA #3 was asked if he had ever observed CNA #2 do anything inappropriate. He stated, "I've seen him talk to residents in an inappropriate manner in the dining room and I did report it. The conversation was of an inappropriate sexual nature with other employees in front of residents." CNA #3 was asked if he had ever observed CNA #2 do things such as dump water on residents or spray water in a resident's face. He stated, "I have heard that from multiple employees. I went to (RN #2) and reported what (CNA #1) had told me. I told (CNA #1) that I didn't care for the way he treated residents, and then she said he sprayed (Resident #1) in the face until she screamed and then sprayed her hair and said 'oh I'm just showing you what not to do'. (Resident #7)... I heard he had poured cold water on her; and the way he talks to her... (CNA #5) also said she had witnessed him squirting (Resident #1) in the face and pour water on other residents. (CNA #5) said she had reported things before but, that it doesn't do any good. She was talking about the (CNA #6) incident where they turned it around and made (CNA #5) look like the bad person for reporting it." d. On 10/10/12 at 10:19 a.m., Licensed Practical Nurse (LPN) #1 was asked if she had ever witnessed CNA #2 do anything inappropriate in the facility. She stated, "It wasn't abuse but, one time we were in the dining room and he got flustered and slammed a spoon down and sighed. I pulled him out and explained to him that he couldn't do that and he said 'I didn't say anything'. I told him that didn't matter." LPN #1 was asked if she had heard anything about a resident being sprayed with a spray bottle. She stated, "(CNA #2) actually told me about it like three days after the fact because he thought I already knew about it since I am friends with (RN #2). He told me that (CNA #1) and (CNA #3) went to (RN #2) and said he sprayed (Resident #7) with a spray bottle. I asked him if it had been taken care of, meaning did administration know about it. He said he sent the DON a text, and that's the last I heard. I do know that if something is reported to (DON) or (Administrator), nothing is done about it." LPN #1 was asked what she meant by that and she related reported incidents involving CNA #6. e. On 10/10/12 at 11:30 a.m., CNA #5 was asked if she had observed anything in the facility that she would consider abuse. The CNA immediately started crying and stated, "It needs to be fixed. I know I'll get in trouble but, it needs to be fixed." CNA #5 was asked what she was referring to. She stated, "There's been a couple of incidents with (CNA #2) spraying a couple of residents with water and I've seen him take a full pitcher of ice cold water and dump it on a resident." CNA #5 was asked which resident CNA #2 dumped water on. She stated, "(Resident #6) and she is a bed-bound resident. I was his (CNA #2) partner that day." CNA #5 was asked again if she actually witnessed CNA #2 dump water on the resident on purpose. She stated, "Yes, he did it. Well, it wasn't ice water. It was a pitcher of room temperature water... she's a tube feeder." CNA #5 was asked how the resident reacted when this happened. She stated, "She cried but, she didn't scream. When he did it, he said 'I don't like this resident'. I said '(CNA #2) shame on you!' " CNA #5 was asked if she reported this to anyone. She stated, "I didn't tell anyone (sobbing). I'm just as guilty. I thought he would hang himself and basically he has." CNA #5 was asked what she had witnessed regarding CNA #2 spraying a resident in the face with water. She stated, "He sprayed (Resident #1) in the face with her spray bottle. She screamed." CNA #5 was asked if it was possible that CNA #2 accidentally sprayed the resident in the face since the water is used to wet down the resident's hair. She stated, "He was standing in front of her. He purposefully sprayed her in the face. I don't know what the other CNAs have seen but, they talk about it. I'm not sure if administration is aware but, I did hear that (CNA #1) got upset over it and told (CNA #3) then, he told his wife (RN #2). (RN #2) told me that if I had seen or heard anything then, I need to report it but, because of the (CNA #6) incident, I didn't want to say anything." CNA #5 was asked what she was talking about. She stated, "(CNA #6) told a resident to sit down and shut up and nothing was done about it. That was verbal abuse. I reported it and nothing got done." CNA #5 was asked if she understood when and what to report to administration. She stated, "Yes, we are trained to report. Yes, I understand what abuse is but, how do you report something when nobody wants to know. I am sorry." A handwritten witness statement dated 10/10/12 at 11:30 a.m. and signed by CNA #5, documented, "Was working 100 hall with (CNA #2) and went into (Resident #6) room and (CNA #2 ) poured water onto resident's body from water pitcher. Resident started to cry. Resident was still in bed and we went into her room to change her. Was working 300 hall with (CNA #2) . We went into resident's room (Resident #1) to change her and (CNA #2) sprayed water into her face. He was standing in front of resident. She screamed." f. On 10/10/12 at 3:10 p.m., CNA #8 stated during an interview, "(CNA #1) came in the other day and wanted to write out some stuff but, didn't know what to do. I asked her what kind of stuff and she said that (CNA #2) sprayed (Resident #1) in the face with water and dumped a cup of water on (Resident #7) while she was in bed. I told her to go talk to (DON) right then. I told her she should've told her charge nurse right then so they could send him home. So the next day when I saw (DON), I asked her if (CNA #1) had came and talked to her and she said 'no and I don't want to hear it'. I don't want any more on me right now. I am tired." 3. Residents involved in the allegations of staff to resident abuse: a. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, had verbal behavioral symptoms directed toward others and was totally dependent on staff for activities of daily living. b. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/18/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status and was totally dependent on staff for activities of daily living. c. Resident #7 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 9/6/12 documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), had verbal behaviors directed towards others and was totally dependent on staff for activities of daily living. d. Resident #8 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/16/11 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status and was totally dependent on staff for activities of daily living. 4. On 10/10/12 at 9:40 a.m., the Administrator was asked how the facility monitored the effectiveness of their abuse in-services and ensured staff understood to report suspected abuse. She stated, "Before we leave the meeting, we ask if they have any questions or ask for feedback." At 9:46 a.m., the DON was asked during a telephone interview how the facility monitored the effectiveness of their abuse in-services and ensured staff understood to report suspected abuse. She stated, "We had a recent complaint of abuse and that is evidence that they understand reporting." 5. On 10/10/12 at 12:15 p.m., the Administrator was asked if anything had been reported to her about a resident being sprayed in the face with water. She stated she knew nothing of this allegation until yesterday. She was asked about the incident involving CNA #6 and yelling at a resident over the intercom and whether it had been reported. She stated she heard it but, did not consider it abuse. She was asked about the incident involving CNA #6 and telling a resident to sit down and shut up and why it would make a difference that the two witnesses did not see which resident CNA #6 was talking to. She stated that was investigated and was unfounded. 6. The Immediate Jeopardy was removed on 10/11/12 and the scope and severity reduced to an E when the facility implemented the following plan of removal: a. 10/9/12 - 12:00 p.m. - (CNA #2) was suspended upon notification of suspected abuse. On 10/10/12 - 2:10 p.m., (CNA #6) was suspended upon notification of suspected abuse. b. On 10/10/12 at 3:50 p.m., Administrator and (RN #1) assessed (Residents #6 and #7) for any signs/symptoms of abuse. c. On 10/10/12 at 1:30 p.m., inservicing began on identifying and reporting allegations of resident abuse per federal, state and facility policy and procedure. All staff will be inserviced on the penalties for failing to report elder abuse in a long term care facility. As each shift begins, staff will be inserviced prior to providing resident care. Employees who are not present for the inservice will be inserviced prior to providing resident care. New employees will be inserviced on abuse prevention, identifying and reporting abuse prior to providing resident care. Inservicing will be done by Administrator and RN #1 on 10/10/12. At 4:15 p.m., the Administrator was inserviced by the RN consultant on identifying and reporting allegations of abuse. d. Beginning 10/10/12 the facility will initiate one-on-one interviews with all residents to assess staff treatment. Physical assessments will be done on residents who are not interviewable. This will be done by the Administrator, Director of Nursing, MDS Coordinator, Social Service Director or administrative nurse designated. This is to be completed by 10/11/12. e. The Administrator, DON or member of the administrative staff designated by the Administrator will monitor for compliance by interviewing three (3) randomly selected staff members and residents on all shifts daily for three (3) weeks, then three (3) staff members and residents weekly for three (3) weeks, and four (4) staff members and residents monthly ongoing as part of the monthly facility Quality Assurance Program to ensure compliance.

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to implement the facility's Abuse Policy and Procedures as evidenced by the facility's failures to ensure allegations of staff to resident abuse involving CNA #6 were thoroughly investigated and residents were protected from the potential of further abuse for 8 (Residents #1 - #8) case mix residents who resided on the 200 and 300 Halls and could receive care from CNA #6 and staff promptly reported all allegations of staff to resident abuse involving CNA #2 to the Administrator/Designee to ensure prompt and thorough investigation, and residents were protected from the potential of further abuse for 4 (Residents #1, #6, #7 and #8) of 6 (Residents #1, #2, #5, #6, #7 and #8) case mix residents who were cognitively impaired. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Residents #1, #6, #7 and #8 who were cognitively impaired and the subjects of unreported allegations of staff to resident abuse. The facility was informed of the Immediate Jeopardy on 10/10/12 at 12:05 p.m. The findings are: 1. The facility's policy titled "Recognizing and Reporting Resident Abuse", provided by the Administrator on 10/11/12, documented, "POLICY All residents shall be free of mental and physical abuse and shall receive considerate care and treatment at all times. ...1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm/pain or mental anguish or deprivation by an individual of goods or services that are necessary to attain or maintain one's physical, mental or psychosocial we-being by staff, visitors or residents. 2. To assist in recognizing incidents of abuse the following definitions are provided; a. VERBAL ABUSE: Any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families. ... c. PHYSICAL ABUSE: Includes but is not limited to hitting, slapping, pinching, kicking, etc. ... e. MENTAL ABUSE: Humiliation, harassment, and threats of punishment or deprivation of treatment or services. Threats of punishment may include but are not limited to voiced comments/ threats ...without actual physical contact ..." The facility's policy and procedure titled "Abuse Investigation, Reporting and Prevention Policy", provided by the Administrator on 10/11/12, documented, "PROCEDURE: ... If a report of abuse is received, the administrator will immediately begin an investigation. In his/her absence, the person in charge of nursing services at the time will initiate the investigation... At the discretion of the administrator, the employee may re-assigned to another unit of the building, or the employee may be suspended, pending further investigation. Investigation will include questioning any and all persons involved in the alleged happening. The area ombudsman will be notified, and in most cases, the local law enforcement agency. The Office of Long term Care will also be notified ... All incidents must be reported to the administrator immediately, or in his/her absence, the person designated in charge ..." 2. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) -762 form dated 7/31/12 documented, "On Tuesday, July 31st, (Certified Nursing Assistant (CNA) #5) told me that she and (CNA #7) heard (CNA #6) say to some unknown resident 'sit down and shut up'... DON (Director of Nursing) and I questioned many people. We talked to residents on 100 hall, even though it is the locked down unit, some residents know who (CNA #6) is and tell us that they love her. We talked to family members and they say they love her. The two CNAs who say they heard her say 'shut up' didn't see a resident and therefore do not know who she was talking to... I do not feel that there is evidence to consider (CNA #6) abusive to residents..." a. On 10/9/12 at 3:28 p.m., RN #2 was interviewed per telephone. She stated, "I spoke with (Administrator) and (DON) about (CNA #6) telling a resident to sit down and shut up. I went straight to (Administrator) and told her I had had enough. She went to (CNA #6) and then came to me and said 'if you ever hear that again, you tell me'. Then 2 weeks later, (CNA #5) comes to me and said she (CNA #6) was down there telling another resident to sit down and shut up. I went to (Administrator) again and she kept saying 'well I guess we'll have to take the deficiency on it'. They suspended her (CNA #6) for like two hours, until I left, then they let her come back. I just don't think they handled it properly. Another nurse here told me not too long ago that (CNA #6) was heard yelling at a resident and she didn't know the intercom button was pushed so it went all over the facility." b. On 10/10/12 at 10:19 a.m., Licensed Practical Nurse (LPN) #1 was interviewed. She stated, "(CNA #6)... I've never worked with personally, but two to three weeks ago, I was passing meds. The loud speaker came on, and all over the facility you could hear her screaming at a resident... she was saying something like 'I told you to get out right now, get out of this room! Get over here so I can change these pants!' Then apparently she realized it was on speaker and she turned it off. I looked at (RN #1) and said this needs to be reported. She went to (Administrator)." LPN #1 was asked if she felt what she heard CNA #6 do was abuse. She stated, "Yes. If someone was screaming at my family like that... you better believe it. I was told it was discussed in the morning meeting and that (Administrator) was more upset that it was over the loud speaker than how the CNA acted." LPN #1 also provided a hand written witness statement that documented, "...As far as (CNA #6), I don't work with her but, I did hear her yelling at a pt (patient) over the intercom one day. That was reported and (Administrator) heard it herself over the intercom." c. On 10/10/12 at 10:47 a.m., CNA #7 was asked if she had ever witnessed anything in the facility that she would consider abuse. She stated, "I was coming out of the locked unit break room and I heard (CNA #6's) voice... I didn't see a resident though. I heard her say 'sit down and shut up'. She has a gruff, manly voice." CNA #7 was asked if she felt what she heard was abuse. She stated, "Yes. It was reported to someone. I can't really remember who. It's been a while. I can't even tell you which room she was in." d. On 10/10/12 at 11:07 a.m., RN #1 was asked if she had observed anything in the facility that she would consider abuse. She stated, "One day we were on the hall and the over head speaker came on... and you could hear (CNA #6) yelling and talking very rough, very rough. I was with another girl and we both just stopped in the hall and we both said 'go to (Administrator)'. It was discussed in the morning meeting and what was said is that a resident was messing around with the page button and she was at the nurses' station. The resident hit the button and then everything was heard over the speaker. The focus wasn't how the CNA treated the resident." RN #1 was asked if she considered what she heard to be abuse. She stated, "Yes. It was rough. If she had been talking to me that way, I would've told her that was not acceptable." RN #1 was asked if she was questioned or was asked to fill out witness statements on the incident. She stated, "No." 3. On 10/9/12 at 11:28 a.m., CNA #2 was asked if he had heard anything regarding a resident being sprayed in the face with a spray bottle. He stated, "Someone said I did that. (CNA #1) and (CNA #3) said I had sprayed (Resident #1) with a spray bottle. I had been off a couple of days and it was apparently reported to (Registered Nurse (RN) #2), (CNA #3's) wife." CNA #2 was asked why the other CNAs would accuse him of doing that. He stated, "I don't know. I didn't think I had a problem with them. I was upset about it so I texted the DON (Director of Nursing) about it and she said she didn't know anything about it. I was and am extremely upset about it. I would never do anything like that to a resident. (Resident #1) has a spray bottle that is used to fix her hair and I've used her spray bottle to fix her hair, but I have never sprayed her in the face. I did tell (CNA #1) one time to be sure and not spray her face." CNA #2 was asked if anyone had questioned him about the allegation or if he had filled out any type of witness statement. He stated, "No. I think it is protocol that I should have been suspended and an investigation done and State called." The CNA was asked if the DON questioned him more in depth when he sent her the text message. He stated, "No." a. On 10/9/12 at 1:30 p.m., CNA #1 was asked if she had ever observed any abuse in the facility. She stated, "Well, not really abuse but, I saw (CNA #2) squirt water in (Resident #1) face until she cried. She has her own squirt bottle because you have to wet down her hair sometimes." The CNA was asked if it was possible that CNA #2 was using the squirt bottle to wet the resident's hair, and the water accidentally hit the resident in the face. CNA #1 stated, "No, he literally stuck it in her face and squirted her until it was dripping off of her face. I also saw him dump a cup of ice water in another resident's lap... (Resident #7)." The CNA was asked if that was done on purpose. CNA #1 stated, "Yes. I was feeding her and he came in and said 'did you give her water to her?' And I said not yet, and the resident started saying 'No, no, please don't'. He dumped it on her lap and then turned around and walked off. I had to do a complete bed change. I guess he's done that to her before because she started saying 'No, no'. And he also dumped water on (Resident #8). He likes to hear her scream. Another resident accidentally spilled her milk and he went to get her another one and then looked around.... I knew he was going to do something, and he dumped it on her." CNA #1 was asked if she reported any of this to anyone. She stated, "Well it's not really abuse. He didn't touch them. He didn't lay his hands on them." CNA #1 was asked if someone had to literally touch a resident in order for it to be considered abuse. The CNA stated, "Well, no. There's mental, I guess." CNA #1 was asked why CNA #2 would do any of these things to the residents. The CNA stated, "I don't know. But he pulled me into a room the other day and said that he heard that me and (CNA #3) were stabbing him in the back and trying to get him fired and that he needed to know whose ass to kick." CNA #1 was asked if she had any personal problems with CNA #2. CNA #1 stated, "No, I don't have any problems with him personally. I just don't like the way he treats the residents." CNA #1 was asked if there were any residents who could verify the information that she had shared with me. The CNA stated, "(Resident #1) - no, (Resident #8) - no. (Resident #7) might could." CNA #1 was asked if there were any employees who could verify the information she shared. She stated, "(CNA #4) might have been there when he dumped water on (Resident #8) but, she's a friend of his so I don't know if she would say anything." b. On 10/9/12 at 3:28 p.m., RN #2 was asked during a telephone interview if she had received a report of a CNA squirting a resident in the face with water. She stated, "I heard from a CNA who had heard from a CNA that had happened. So I talked to the CNA who supposedly saw it... and she wouldn't give me any details." RN #2 was asked if she questioned the CNA specifically about the alleged water spraying incident. She stated, "Well, no I didn't because it was through the grapevine. What I told her was if she felt uncomfortable about anything, then she needed to call someone on duty because I had already clocked out..." RN #2 was asked if she had ever observed CNA #2 do anything inappropriate. She stated, "Well... (sigh) I did see him once spray (Resident #7) with peri wash, from a distance, like 3 feet away..." The RN was asked why the CNA did that. She stated, "Because it's colder that way. I told him not to do that, and he said 'she called me fat', and I said 'I don't care what she calls you, you can't do that' and I've not seen him do that again. But, anything involving him wouldn't surprise me." RN #2 was asked if she reported any of this to administration. She stated, "No, but the reason for that is because of the way they handled another incident. I don't feel that it was handled appropriately." RN #2 was asked what she was referring to and she related reporting incidents involving CNA #6. c. On 10/9/12 at 3:38 p.m., CNA #3 was asked if he had ever observed CNA #2 do anything inappropriate. He stated, "I've seen him talk to residents in an inappropriate manner in the dining room and I did report it. The conversation was of an inappropriate sexual nature with other employees in front of residents." CNA #3 was asked if he had ever observed CNA #2 do things such as dump water on residents or spray water in a resident's face. He stated, "I have heard that from multiple employees. I went to (RN #2) and reported what (CNA #1) had told me. I told (CNA #1) that I didn't care for the way he treated residents, and then she said he sprayed (Resident #1) in the face until she screamed and then sprayed her hair and said 'oh I'm just showing you what not to do'. (Resident #7)... I heard he had poured cold water on her; and the way he talks to her... (CNA #5) also said she had witnessed him squirting (Resident #1) in the face and pour water on other residents. (CNA #5) said she had reported things before but, that it doesn't do any good. She was talking about the (CNA #6) incident where they turned it around and made (CNA #5) look like the bad person for reporting it." d. On 10/10/12 at 10:19 a.m., Licensed Practical Nurse (LPN) #1 was asked if she had ever witnessed CNA #2 do anything inappropriate in the facility. She stated, "It wasn't abuse but, one time we were in the dining room and he got flustered and slammed a spoon down and sighed. I pulled him out and explained to him that he couldn't do that and he said 'I didn't say anything'. I told him that didn't matter." LPN #1 was asked if she had heard anything about a resident being sprayed with a spray bottle. She stated, "(CNA #2) actually told me about it like three days after the fact because he thought I already knew about it since I am friends with (RN #2). He told me that (CNA #1) and (CNA #3) went to (RN #2) and said he sprayed (Resident #7) with a spray bottle. I asked him if it had been taken care of, meaning did administration know about it. He said he sent the DON a text, and that's the last I heard. I do know that if something is reported to (DON) or (Administrator), nothing is done about it." LPN #1 was asked what she meant by that and she related reported incidents involving CNA #6. e. On 10/10/12 at 11:30 a.m., CNA #5 was asked if she had observed anything in the facility that she would consider abuse. The CNA immediately started crying and stated, "It needs to be fixed. I know I'll get in trouble but, it needs to be fixed." CNA #5 was asked what she was referring to. She stated, "There's been a couple of incidents with (CNA #2) spraying a couple of residents with water and I've seen him take a full pitcher of ice cold water and dump it on a resident." CNA #5 was asked which resident CNA #2 dumped water on. She stated, "(Resident #6) and she is a bed-bound resident. I was his (CNA #2) partner that day." CNA #5 was asked again if she actually witnessed CNA #2 dump water on the resident on purpose. She stated, "Yes, he did it. Well, it wasn't ice water. It was a pitcher of room temperature water... she's a tube feeder." CNA #5 was asked how the resident reacted when this happened. She stated, "She cried but, she didn't scream. When he did it, he said 'I don't like this resident'. I said '(CNA #2) shame on you!' " CNA #5 was asked if she reported this to anyone. She stated, "I didn't tell anyone (sobbing). I'm just as guilty. I thought he would hang himself and basically he has." CNA #5 was asked what she had witnessed regarding CNA #2 spraying a resident in the face with water. She stated, "He sprayed (Resident #1) in the face with her spray bottle. She screamed." CNA #5 was asked if it was possible that CNA #2 accidentally sprayed the resident in the face since the water is used to wet down the resident's hair. She stated, "He was standing in front of her. He purposefully sprayed her in the face. I don't know what the other CNAs have seen but, they talk about it. I'm not sure if administration is aware but, I did hear that (CNA #1) got upset over it and told (CNA #3) then, he told his wife (RN #2). (RN #2) told me that if I had seen or heard anything then, I need to report it but, because of the (CNA #6) incident, I didn't want to say anything." CNA #5 was asked what she was talking about. She stated, "(CNA #6) told a resident to sit down and shut up and nothing was done about it. That was verbal abuse. I reported it and nothing got done." CNA #5 was asked if she understood when and what to report to administration. She stated, "Yes, we are trained to report. Yes, I understand what abuse is but, how do you report something when nobody wants to know. I am sorry." A handwritten witness statement dated 10/10/12 at 11:30 a.m. and signed by CNA #5, documented, "Was working 100 hall with (CNA #2) and went into (Resident #6) room and (CNA #2 ) poured water onto resident's body from water pitcher. Resident started to cry. Resident was still in bed and we went into her room to change her. Was working 300 hall with (CNA #2) . We went into resident's room (Resident #1) to change her and (CNA #2) sprayed water into her face. He was standing in front of resident. She screamed." f. On 10/10/12 at 3:10 p.m., CNA #8 stated during an interview, "(CNA #1) came in the other day and wanted to write out some stuff but, didn't know what to do. I asked her what kind of stuff and she said that (CNA #2) sprayed (Resident #1) in the face with water and dumped a cup of water on (Resident #7) while she was in bed. I told her to go talk to (DON) right then. I told her she should've told her charge nurse right then so they could send him home. So the next day when I saw (DON), I asked her if (CNA #1) had came and talked to her and she said 'no and I don't want to hear it'. I don't want any more on me right now. I am tired." 4. Residents involved in the allegations of staff to resident abuse: a. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, had verbal behavioral symptoms directed toward others and was totally dependent on staff for activities of daily living. b. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/18/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status and was totally dependent on staff for activities of daily living. c. Resident #7 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 9/6/12 documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), had verbal behaviors directed towards others and was totally dependent on staff for activities of daily living. d. Resident #8 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/16/11 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status and was totally dependent on staff for activities of daily living. 5. On 10/10/12 at 9:40 a.m., the Administrator was asked how the facility monitored the effectiveness of their abuse in-services and ensured staff understood to report suspected abuse. She stated, "Before we leave the meeting, we ask if they have any questions or ask for feedback." At 9:46 a.m., the DON was asked during a telephone interview how the facility monitored the effectiveness of their abuse in-services and ensured staff understood to report suspected abuse. She stated, "We had a recent complaint of abuse and that is evidence that they understand reporting." 6. On 10/10/12 at 12:15 p.m., the Administrator was asked if anything had been reported to her about a resident being sprayed in the face with water. She stated she knew nothing of this allegation until yesterday. She was asked about the incident involving CNA #6 and yelling at a resident over the intercom and whether it had been reported. She stated she heard it but, did not consider it abuse. She was asked about the incident involving CNA #6 and telling a resident to sit down and shut up and why it would make a difference that the two witnesses did not see which resident CNA #6 was talking to. She stated that was investigated and was unfounded. 7. The Immediate Jeopardy was removed on 10/11/12 and the scope and severity reduced to an E when the facility implemented the following plan of removal: a. 10/9/12 - 12:00 p.m. - (CNA #2) was suspended upon notification of suspected abuse. On 10/10/12 - 2:10 p.m., (CNA #6) was suspended upon notification of suspected abuse. b. On 10/10/12 at 3:50 p.m., Administrator and (RN #1) assessed (Residents #6 and #7) for any signs/symptoms of abuse. c. On 10/10/12 at 1:30 p.m., inservicing began on identifying and reporting allegations of resident abuse per federal, state and facility policy and procedure. All staff will be inserviced on the penalties for failing to report elder abuse in a long term care facility. As each shift begins, staff will be inserviced prior to providing resident care. Employees who are not present for the inservice will be inserviced prior to providing resident care. New employees will be inserviced on abuse prevention, identifying and reporting abuse prior to providing resident care. Inservicing will be done by Administrator and RN #1 on 10/10/12. At 4:15 p.m., the Administrator was inserviced by the RN consultant on identifying and reporting allegations of abuse. d. Beginning 10/10/12 the facility will initiate one-on-one interviews with all residents to assess staff treatment. Physical assessments will be done on residents who are not interviewable. This will be done by the Administrator, Director of Nursing, MDS Coordinator, Social Service Director or administrative nurse designated. This is to be completed by 10/11/12. e. The Administrator, DON or member of the administrative staff designated by the Administrator will monitor for compliance by interviewing three (3) randomly selected staff members and residents on all shifts daily for three (3) weeks, then three (3) staff members and residents weekly for three (3) weeks, and four (4) staff members and residents monthly ongoing as part of the monthly facility Quality Assurance Program to ensure compliance.

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility's Administration and Nursing Administration failed to ensure the facility's abuse policies and procedures were implemented and staff were diligent in reporting allegations of staff to resident abuse as evidenced by the facility's failures to ensure allegations of staff to resident abuse involving CNA #6 were thoroughly investigated and residents protected from the potential of further abuse for 8 (Residents #1 - #8) case mix residents who resided on the 200 and 300 Halls and could receive care from CNA #6 and staff promptly reported all allegations of staff to resident abuse involving CNA #2 to the Administrator/Designee to ensure prompt and thorough investigation, and residents were protected from the potential of further abuse for 4 (Residents #1, #6, #7 and #8) of 6 (Residents #1, #2, #5, #6, #7 and #8) case mix residents who were cognitively impaired. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Residents #1, #6, #7 and #8 who were cognitively impaired and the subjects of unreported allegations of staff to resident abuse. The facility was informed of the Immediate Jeopardy on 10/10/12 at 12:05 p.m. The findings are: 1. The facility's "Administrator Job Description", provided by the Administrator on 10/11/12 at 9:15 a.m., documented, "Major duties and responsibilities: ...Plan and maintain written policies and procedures that govern the operation of the facility... Assure that all employees, residents, visitors, and the general public follow established policies and procedures... " The facility's "Director of Nursing" job description, provided by the Administrator on 10/11/12 at 9:15 a.m., documented, "Job Summary: The Director of Nursing manages the Nursing Department with high professional and personal standards. He/She plans, organizes, coordinates and directs all the nursing functions for professional and nonprofessional nursing personnel to ensure the highest quality of care is provided in a cost effective manner with the residents in the facility... exercises administrative authority, responsibility and accountability for nursing service objectives, policies and procedures, nursing functions and activities, nursing care, and the nursing staff and their training." 2. The facility's policy titled "Recognizing and Reporting Resident Abuse", provided by the Administrator on 10/11/12, documented, "POLICY All residents shall be free of mental and physical abuse and shall receive considerate care and treatment at all times. ...1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm/pain or mental anguish or deprivation by an individual of goods or services that are necessary to attain or maintain one's physical, mental or psychosocial we-being by staff, visitors or residents. 2. To assist in recognizing incidents of abuse the following definitions are provided; a. VERBAL ABUSE: Any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families. ... c. PHYSICAL ABUSE: Includes but is not limited to hitting, slapping, pinching, kicking, etc. ... e. MENTAL ABUSE: Humiliation, harassment, and threats of punishment or deprivation of treatment or services. Threats of punishment may include but are not limited to voiced comments/ threats ...without actual physical contact ..." The facility's policy and procedure titled "Abuse Investigation, Reporting and Prevention Policy", provided by the Administrator on 10/11/12, documented, "PROCEDURE: ... If a report of abuse is received, the administrator will immediately begin an investigation. In his/her absence, the person in charge of nursing services at the time will initiate the investigation... At the discretion of the administrator, the employee may re-assigned to another unit of the building, or the employee may be suspended, pending further investigation. Investigation will include questioning any and all persons involved in the alleged happening. The area ombudsman will be notified, and in most cases, the local law enforcement agency. The Office of Long term Care will also be notified ... All incidents must be reported to the administrator immediately, or in his/her absence, the person designated in charge ..." 3. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) -762 form dated 7/31/12 documented, "On Tuesday, July 31st, (Certified Nursing Assistant (CNA) #5) told me that she and (CNA #7) heard (CNA #6) say to some unknown resident 'sit down and shut up'... DON (Director of Nursing) and I questioned many people. We talked to residents on 100 hall, even though it is the locked down unit, some residents know who (CNA #6) is and tell us that they love her. We talked to family members and they say they love her. The two CNAs who say they heard her say 'shut up' didn't see a resident and therefore do not know who she was talking to... I do not feel that there is evidence to consider (CNA #6) abusive to residents..." a. On 10/9/12 at 3:28 p.m., RN #2 was interviewed per telephone. She stated, "I spoke with (Administrator) and (DON) about (CNA #6) telling a resident to sit down and shut up. I went straight to (Administrator) and told her I had had enough. She went to (CNA #6) and then came to me and said 'if you ever hear that again, you tell me'. Then 2 weeks later, (CNA #5) comes to me and said she (CNA #6) was down there telling another resident to sit down and shut up. I went to (Administrator) again and she kept saying 'well I guess we'll have to take the deficiency on it'. They suspended her (CNA #6) for like two hours, until I left, then they let her come back. I just don't think they handled it properly. Another nurse here told me not too long ago that (CNA #6) was heard yelling at a resident and she didn't know the intercom button was pushed so it went all over the facility." b. On 10/10/12 at 10:19 a.m., Licensed Practical Nurse (LPN) #1 was interviewed. She stated, "(CNA #6)... I've never worked with personally, but two to three weeks ago, I was passing meds. The loud speaker came on, and all over the facility you could hear her screaming at a resident... she was saying something like 'I told you to get out right now, get out of this room! Get over here so I can change these pants!' Then apparently she realized it was on speaker and she turned it off. I looked at (RN #1) and said this needs to be reported. She went to (Administrator)." LPN #1 was asked if she felt what she heard CNA #6 do was abuse. She stated, "Yes. If someone was screaming at my family like that... you better believe it. I was told it was discussed in the morning meeting and that (Administrator) was more upset that it was over the loud speaker than how the CNA acted." LPN #1 also provided a hand written witness statement that documented, "...As far as (CNA #6), I don't work with her but, I did hear her yelling at a pt (patient) over the intercom one day. That was reported and (Administrator) heard it herself over the intercom." c. On 10/10/12 at 10:47 a.m., CNA #7 was asked if she had ever witnessed anything in the facility that she would consider abuse. She stated, "I was coming out of the locked unit break room and I heard (CNA #6's) voice... I didn't see a resident though. I heard her say 'sit down and shut up'. She has a gruff, manly voice." CNA #7 was asked if she felt what she heard was abuse. She stated, "Yes. It was reported to someone. I can't really remember who. It's been a while. I can't even tell you which room she was in." d. On 10/10/12 at 11:07 a.m., RN #1 was asked if she had observed anything in the facility that she would consider abuse. She stated, "One day we were on the hall and the over head speaker came on... and you could hear (CNA #6) yelling and talking very rough, very rough. I was with another girl and we both just stopped in the hall and we both said 'go to (Administrator)'. It was discussed in the morning meeting and what was said is that a resident was messing around with the page button and she was at the nurses' station. The resident hit the button and then everything was heard over the speaker. The focus wasn't how the CNA treated the resident." RN #1 was asked if she considered what she heard to be abuse. She stated, "Yes. It was rough. If she had been talking to me that way, I would've told her that was not acceptable." RN #1 was asked if she was questioned or was asked to fill out witness statements on the incident. She stated, "No." 4. On 10/9/12 at 11:28 a.m., CNA #2 was asked if he had heard anything regarding a resident being sprayed in the face with a spray bottle. He stated, "Someone said I did that. (CNA #1) and (CNA #3) said I had sprayed (Resident #1) with a spray bottle. I had been off a couple of days and it was apparently reported to (Registered Nurse (RN) #2), (CNA #3's) wife." CNA #2 was asked why the other CNAs would accuse him of doing that. He stated, "I don't know. I didn't think I had a problem with them. I was upset about it so I texted the DON (Director of Nursing) about it and she said she didn't know anything about it. I was and am extremely upset about it. I would never do anything like that to a resident. (Resident #1) has a spray bottle that is used to fix her hair and I've used her spray bottle to fix her hair, but I have never sprayed her in the face. I did tell (CNA #1) one time to be sure and not spray her face." CNA #2 was asked if anyone had questioned him about the allegation or if he had filled out any type of witness statement. He stated, "No. I think it is protocol that I should have been suspended and an investigation done and State called." The CNA was asked if the DON questioned him more in depth when he sent her the text message. He stated, "No." a. On 10/9/12 at 1:30 p.m., CNA #1 was asked if she had ever observed any abuse in the facility. She stated, "Well, not really abuse but, I saw (CNA #2) squirt water in (Resident #1) face until she cried. She has her own squirt bottle because you have to wet down her hair sometimes." The CNA was asked if it was possible that CNA #2 was using the squirt bottle to wet the resident's hair, and the water accidentally hit the resident in the face. CNA #1 stated, "No, he literally stuck it in her face and squirted her until it was dripping off of her face. I also saw him dump a cup of ice water in another resident's lap... (Resident #7)." The CNA was asked if that was done on purpose. CNA #1 stated, "Yes. I was feeding her and he came in and said 'did you give her water to her?' And I said not yet, and the resident started saying 'No, no, please don't'. He dumped it on her lap and then turned around and walked off. I had to do a complete bed change. I guess he's done that to her before because she started saying 'No, no'. And he also dumped water on (Resident #8). He likes to hear her scream. Another resident accidentally spilled her milk and he went to get her another one and then looked around.... I knew he was going to do something, and he dumped it on her." CNA #1 was asked if she reported any of this to anyone. She stated, "Well it's not really abuse. He didn't touch them. He didn't lay his hands on them." CNA #1 was asked if someone had to literally touch a resident in order for it to be considered abuse. The CNA stated, "Well, no. There's mental, I guess." CNA #1 was asked why CNA #2 would do any of these things to the residents. The CNA stated, "I don't know. But he pulled me into a room the other day and said that he heard that me and (CNA #3) were stabbing him in the back and trying to get him fired and that he needed to know whose ass to kick." CNA #1 was asked if she had any personal problems with CNA #2. CNA #1 stated, "No, I don't have any problems with him personally. I just don't like the way he treats the residents." CNA #1 was asked if there were any residents who could verify the information that she had shared with me. The CNA stated, "(Resident #1) - no, (Resident #8) - no. (Resident #7) might could." CNA #1 was asked if there were any employees who could verify the information she shared. She stated, "(CNA #4) might have been there when he dumped water on (Resident #8) but, she's a friend of his so I don't know if she would say anything." b. On 10/9/12 at 3:28 p.m., RN #2 was asked during a telephone interview if she had received a report of a CNA squirting a resident in the face with water. She stated, "I heard from a CNA who had heard from a CNA that had happened. So I talked to the CNA who supposedly saw it... and she wouldn't give me any details." RN #2 was asked if she questioned the CNA specifically about the alleged water spraying incident. She stated, "Well, no I didn't because it was through the grapevine. What I told her was if she felt uncomfortable about anything, then she needed to call someone on duty because I had already clocked out..." RN #2 was asked if she had ever observed CNA #2 do anything inappropriate. She stated, "Well... (sigh) I did see him once spray (Resident #7) with peri wash, from a distance, like 3 feet away..." The RN was asked why the CNA did that. She stated, "Because it's colder that way. I told him not to do that, and he said 'she called me fat', and I said 'I don't care what she calls you, you can't do that' and I've not seen him do that again. But, anything involving him wouldn't surprise me." RN #2 was asked if she reported any of this to administration. She stated, "No, but the reason for that is because of the way they handled another incident. I don't feel that it was handled appropriately." RN #2 was asked what she was referring to and she related reporting incidents involving CNA #6. c. On 10/9/12 at 3:38 p.m., CNA #3 was asked if he had ever observed CNA #2 do anything inappropriate. He stated, "I've seen him talk to residents in an inappropriate manner in the dining room and I did report it. The conversation was of an inappropriate sexual nature with other employees in front of residents." CNA #3 was asked if he had ever observed CNA #2 do things such as dump water on residents or spray water in a resident's face. He stated, "I have heard that from multiple employees. I went to (RN #2) and reported what (CNA #1) had told me. I told (CNA #1) that I didn't care for the way he treated residents, and then she said he sprayed (Resident #1) in the face until she screamed and then sprayed her hair and said 'oh I'm just showing you what not to do'. (Resident #7)... I heard he had poured cold water on her; and the way he talks to her... (CNA #5) also said she had witnessed him squirting (Resident #1) in the face and pour water on other residents. (CNA #5) said she had reported things before but, that it doesn't do any good. She was talking about the (CNA #6) incident where they turned it around and made (CNA #5) look like the bad person for reporting it." d. On 10/10/12 at 10:19 a.m., Licensed Practical Nurse (LPN) #1 was asked if she had ever witnessed CNA #2 do anything inappropriate in the facility. She stated, "It wasn't abuse but, one time we were in the dining room and he got flustered and slammed a spoon down and sighed. I pulled him out and explained to him that he couldn't do that and he said 'I didn't say anything'. I told him that didn't matter." LPN #1 was asked if she had heard anything about a resident being sprayed with a spray bottle. She stated, "(CNA #2) actually told me about it like three days after the fact because he thought I already knew about it since I am friends with (RN #2). He told me that (CNA #1) and (CNA #3) went to (RN #2) and said he sprayed (Resident #7) with a spray bottle. I asked him if it had been taken care of, meaning did administration know about it. He said he sent the DON a text, and that's the last I heard. I do know that if something is reported to (DON) or (Administrator), nothing is done about it." LPN #1 was asked what she meant by that and she related reported incidents involving CNA #6. e. On 10/10/12 at 11:30 a.m., CNA #5 was asked if she had observed anything in the facility that she would consider abuse. The CNA immediately started crying and stated, "It needs to be fixed. I know I'll get in trouble but, it needs to be fixed." CNA #5 was asked what she was referring to. She stated, "There's been a couple of incidents with (CNA #2) spraying a couple of residents with water and I've seen him take a full pitcher of ice cold water and dump it on a resident." CNA #5 was asked which resident CNA #2 dumped water on. She stated, "(Resident #6) and she is a bed-bound resident. I was his (CNA #2) partner that day." CNA #5 was asked again if she actually witnessed CNA #2 dump water on the resident on purpose. She stated, "Yes, he did it. Well, it wasn't ice water. It was a pitcher of room temperature water... she's a tube feeder." CNA #5 was asked how the resident reacted when this happened. She stated, "She cried but, she didn't scream. When he did it, he said 'I don't like this resident'. I said '(CNA #2) shame on you!' " CNA #5 was asked if she reported this to anyone. She stated, "I didn't tell anyone (sobbing). I'm just as guilty. I thought he would hang himself and basically he has." CNA #5 was asked what she had witnessed regarding CNA #2 spraying a resident in the face with water. She stated, "He sprayed (Resident #1) in the face with her spray bottle. She screamed." CNA #5 was asked if it was possible that CNA #2 accidentally sprayed the resident in the face since the water is used to wet down the resident's hair. She stated, "He was standing in front of her. He purposefully sprayed her in the face. I don't know what the other CNAs have seen but, they talk about it. I'm not sure if administration is aware but, I did hear that (CNA #1) got upset over it and told (CNA #3) then, he told his wife (RN #2). (RN #2) told me that if I had seen or heard anything then, I need to report it but, because of the (CNA #6) incident, I didn't want to say anything." CNA #5 was asked what she was talking about. She stated, "(CNA #6) told a resident to sit down and shut up and nothing was done about it. That was verbal abuse. I reported it and nothing got done." CNA #5 was asked if she understood when and what to report to administration. She stated, "Yes, we are trained to report. Yes, I understand what abuse is but, how do you report something when nobody wants to know. I am sorry." A handwritten witness statement dated 10/10/12 at 11:30 a.m. and signed by CNA #5, documented, "Was working 100 hall with (CNA #2) and went into (Resident #6) room and (CNA #2 ) poured water onto resident's body from water pitcher. Resident started to cry. Resident was still in bed and we went into her room to change her. Was working 300 hall with (CNA #2) . We went into resident's room (Resident #1) to change her and (CNA #2) sprayed water into her face. He was standing in front of resident. She screamed." f. On 10/10/12 at 3:10 p.m., CNA #8 stated during an interview, "(CNA #1) came in the other day and wanted to write out some stuff but, didn't know what to do. I asked her what kind of stuff and she said that (CNA #2) sprayed (Resident #1) in the face with water and dumped a cup of water on (Resident #7) while she was in bed. I told her to go talk to (DON) right then. I told her she should've told her charge nurse right then so they could send him home. So the next day when I saw (DON), I asked her if (CNA #1) had came and talked to her and she said 'no and I don't want to hear it'. I don't want any more on me right now. I am tired." 5. Residents involved in the allegations of staff to resident abuse: a. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, had verbal behavioral symptoms directed toward others and was totally dependent on staff for activities of daily living. b. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/18/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status and was totally dependent on staff for activities of daily living. c. Resident #7 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 9/6/12 documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), had verbal behaviors directed towards others and was totally dependent on staff for activities of daily living. d. Resident #8 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/16/11 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status and was totally dependent on staff for activities of daily living. 6. On 10/10/12 at 9:40 a.m., the Administrator was asked how the facility monitored the effectiveness of their abuse in-services and ensured staff understood to report suspected abuse. She stated, "Before we leave the meeting, we ask if they have any questions or ask for feedback." At 9:46 a.m., the DON was asked during a telephone interview how the facility monitored the effectiveness of their abuse in-services and ensured staff understood to report suspected abuse. She stated, "We had a recent complaint of abuse and that is evidence that they understand reporting." 7. On 10/10/12 at 12:15 p.m., the Administrator was asked if anything had been reported to her about a resident being sprayed in the face with water. She stated she knew nothing of this allegation until yesterday. She was asked about the incident involving CNA #6 and yelling at a resident over the intercom and whether it had been reported. She stated she heard it but, did not consider it abuse. She was asked about the incident involving CNA #6 and telling a resident to sit down and shut up and why it would make a difference that the two witnesses did not see which resident CNA #6 was talking to. She stated that was investigated and was unfounded. 8. The Immediate Jeopardy was removed on 10/11/12 and the scope and severity reduced to an E when the facility implemented the following plan of removal: a. 10/9/12 - 12:00 p.m. - (CNA #2) was suspended upon notification of suspected abuse. On 10/10/12 - 2:10 p.m., (CNA #6) was suspended upon notification of suspected abuse. b. On 10/10/12 at 3:50 p.m., Administrator and (RN #1) assessed (Residents #6 and #7) for any signs/symptoms of abuse. c. On 10/10/12 at 1:30 p.m., inservicing began on identifying and reporting allegations of resident abuse per federal, state and facility policy and procedure. All staff will be inserviced on the penalties for failing to report elder abuse in a long term care facility. As each shift begins, staff will be inserviced prior to providing resident care. Employees who are not present for the inservice will be inserviced prior to providing resident care. New employees will be inserviced on abuse prevention, identifying and reporting abuse prior to providing resident care. Inservicing will be done by Administrator and RN #1 on 10/10/12. At 4:15 p.m., the Administrator was inserviced by the RN consultant on identifying and reporting allegations of abuse. d. Beginning 10/10/12 the facility will initiate one-on-one interviews with all residents to assess staff treatment. Physical assessments will be done on residents who are not interviewable. This will be done by the Administrator, Director of Nursing, MDS Coordinator, Social Service Director or administrative nurse designated. This is to be completed by 10/11/12. e. The Administrator, DON or member of the administrative staff designated by the Administrator will monitor for compliance by interviewing three (3) randomly selected staff members and residents on all shifts daily for three (3) weeks, then three (3) staff members and residents weekly for three (3) weeks, and four (4) staff members and residents monthly ongoing as part of the monthly facility Quality Assurance Program to ensure compliance.