Every finding on record at Quail Ridge Living Center, Inc

Based on observation, record review, and interview, the facility failed to ensure the ice machine was maintained in a sanitary manner. The administrator identified 85 residents received nourishment from the kitchen. Findings: On 06/29/26 at 10:03 a.m., the ice machine was observed to have a black slimy substance on the underside of the plastic rim inside the ice compartment. A maintenance log titled Monthly Deep Cleaning Schedule 2026 was reviewed. The log showed the ice machine had been cleaned in March 2026, April 2026, and May 2026. On 06/29/26 at 10:15 a.m., the dietary manager stated the black substance on the ice machine appeared to be grime and it should not have been in the ice machine. They stated the ice machine was due for a weekly cleaning.

Based on observation, record review, and interview, the facility failed to:a. ensure residents did not fall during a transfer for 1 (#84) of 2 sampled residents reviewed for accident hazards; b. ensure safety interventions were in place while smoking for 1 (#6) of 2 sampled residents reviewed for accident hazards; andc. ensure the electrical room door was secured for 1 of 1 electrical room observed.The DON identified 29 residents required two person assistance with transfer, 18 residents smoked, and 85 residents resided in the facility. Findings: 1. A policy titled Safe Lifting and Movement of Residents, dated 07/2017, read in part, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. A care plan for Resident #84, revised 10/27/23, showed they required extensive assistance of two staff members to transfer between surfaces. A quarterly assessment for Resident #84, dated 01/03/25, showed the resident had a brief interview for mental status score of 15, which indicated intact cognition for daily decision making. The assessment showed Resident #84 required maximal assistance from staff during chair to bed transfers. An incident report, dated 02/17/25, showed on 02/03/25 at approximately 10:00 p.m., CNA #1 was transferring Resident #84 without the assistance of another staff member. The report showed Resident #84 was assisted to the floor and an x-ray was obtained on 02/04/25 that did not show any injuries. On 07/02/26 at 9:45 a.m., Resident #84 stated CNA #1 was transferring them from the chair to the bed without any assistance. Resident #84 stated once they were on the side of the bed, they lost their balance and CNA #1 assisted them to the floor. On 07/02/26 at 11:25 a.m., CNA #2 stated the care plan should always be followed while transferring residents. On 07/02/26 at 11:35 a.m., CNA #3 stated they would refer to the care plan or ask the nurse if they didn't know how much assistance a resident required. On 07/02/26 at 11:40 a.m., the DON stated, at the time of the incident, Resident #84 required two-person assistance with transfers and CNA #1 had not transferred Resident #84 appropriately. 2. On 07/02/2026 at 9:20 a.m., Resident #6 was observed smoking in the designated smoking area without a smoking apron. Facility staff were observed supervising the smoking area. On 07/02/2026 at 9:23 a.m., CNA #3 was observed to enter the smoking area and assisted Resident #6 with putting on a smoking apron. On 07/02/26 at 9:42 a.m., no cigarette burn holes were observed on the clothes Resident #6 was wearing or any of the clothes in their closet. A policy titled Smoking Policy – Residents, dated 10/2023, read in part, This facility has established and maintains safe resident smoking practices. An unsigned smoking assessment for Resident #6, dated 04/19/26, showed the resident required a fire-resistant smoking apron and supervision while smoking. A care plan for Resident #6, dated 05/18/26, showed the resident required supervision, a smoking apron, and would be safe at all times while smoking. On 07/02/26 at 9:22 a.m., LPN #1 stated they did not normally supervise smoke breaks. LPN #1 stated they did not know which residents required a smoking apron. On 07/02/2026 at 9:23 a.m., CNA #3 stated a list of residents and their required safety needs was on the inside of the smoker box lid. On 07/02/2026 at 9:38 a.m., Resident #6 stated they have had no burns while smoking and had no burns on their clothing. On 07/02/26 at 10:36 a.m., the DON stated Resident #6 was required to wear a smoking apron and to be supervised by staff while smoking based on a smoking assessment completed 04/19/26 by LPN #2. The DON stated Resident #6 utilized a smoking apron as a precaution, due to being unsteady. The DON stated a list of residents that smoked and their safety needs was kept in box that contained smoking supplies. The DON stated staff were educated on smoking safety during orientation and in-services. 3. On 06/29/26 at 10:54 a.m., a door labeled Electrical Room was observed to have a locking door handle. The electrical room was observed on E hall, next door to the DON's office and in view of the nurses' desk. The DON was observed to open the door to the electrical room without a key. Items observed in the electrical room included paint, power tools, insect spray on shelves, electrical cords, and enabler bars on the floor. The DON was observed to lock the door to the electrical room. No residents were observed attempting to access the electrical room during this time. On 06/29/26 at 10:54 a.m., the DON stated the door labeled Electrical Room located on E Hall should have been locked. The DON stated the electrical room had paint, power tools, insect spray, electrical cords, enabler bars, and other items on shelves in reach of residents if the unlocked door was accessed. The DON stated the maintenance supervisor had been working on a doorknob on an adjacent door and was running an errand at that time. On 06/29/26 at 11:28 a.m., the maintenance supervisor stated the electrical room door on E Hall was kept locked most of the time and they had just been in and out of it several times this morning. The maintenance supervisor stated they had accessed the electrical room approximately 20 minutes prior to the door being found unlocked.

Based on observation, record review, and interview, the facility failed to ensure urinary catheter bags were not on the floor for 1 (#41) of 5 sampled residents reviewed for urinary catheters. The DON identified five residents with urinary catheters. Findings: On 06/29/26 at 10:30 a.m., Resident #41's urinary catheter bag was observed on the floor at the bedside, On 06/30/26 at 2:00 p.m., Resident #41's urinary catheter bag was observed on the floor at the bedside. An undated policy titled Catheter Care, Urinary, read in part, 2. Be sure the catheter tubing and drainage bag are kept off the floor. On 07/01/26 at 1:30 p.m., CNA #11 stated urinary catheter bags should be in a dignity bag, hung on the bed frame, and not on the floor. On 07/01/26 at 1:40 p.m., CNA #2 stated a urinary catheter bag should be hung on the bed frame and not in contact with the floor. On 07/01/26 at 2:03 p.m., CNA #9 stated urinary catheter bags should be hung on the side of the bed and not on the floor. On 07/01/26 at 2:07 p.m., CNA #10 stated a urinary catheter bag should not be on the floor. On 07/01/26 at 2:15 p.m., LPN 1 stated urinary catheter bags should be hung on the side of the bed and not on the floor. They stated if a urinary catheter bag was on the floor, it could cause the resident to develop a urinary tract infection. On 07/01/26 at 2:20 p.m., the DON stated urinary catheter bags should be hung on the bed frame and should not touch the floor. They stated if a catheter bag touched the floor, it could result in a urinary tract infection.

Based on record review and interview, the facility failed to ensure an allegation of physical abuse was reported for 1 (#76) of 1 sampled resident reviewed for abuse.The DON reported 85 residents resided in the facility.Findings:A policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 04/2021, read in part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.A written statement from Resident #76, dated 03/10/26, read in part, [Name withheld], my night shift C.N.A. and her helpmate, about 3 days ago, slid me up on my bed, raming [sic] my head in the head board [sic]! I hollered out in pain! But it didn't make any difference to them. Two days later I told them they hurt me, being so rough!.An email statement from CNA #8, dated 3/11/2026, read in part, Last week I'm not sure the day, [CNA #4] and I changed [Resident #76] on E Hall and afterwards pulled [them] up in the bed. [Their] head bumped the headboard. It wasn't hard but we did bump it. [Resident #76] said ow and I apologized immediately and asked if [they] were okay. [Resident #76] stated [they] were fine. I rubbed [their] head to feel if there was a bump and asked several times if [they] was okay or if it hurt and each time [they] said no. Both [CNA #4] and I apologized for using too much strength to pull [them] up.An employee counseling record, dated 03/13/26, showed CNA #4 was terminated for failure to report an allegation of abuse.An employee counseling record, dated 03/13/26, showed CNA #8, was terminated for failure to report an allegation of abuse.A document titled In-Service Sign In, dated 03/20/26, showed topics discussed during training included abuse, neglect, exploitation, and reporting to the abuse coordinator.On 07/01/26 at 11:55 a.m., the administrator stated abuse allegations and failure to report abuse were substantiated after the facility investigation for CNA #4 and CNA #8 due to Resident #76's head having been hit into headboard on 03/08/26. The administrator stated They should have reported each other. If one thought the other was being rough then the other should have reported or when the resident said they hurt them, they should have reported it immediately.

Based on record review and interview, the facility failed to ensure residents were free from physical abuse for 1 (#76) of 1 sampled resident reviewed for abuse.The DON stated 85 residents resided in the facility.Findings:A document titled ABUSE, NEGLECT AND MISAPPROPRIATION or RESIDENT'S FUND, dated 03/18/15, read in part, The resident has the right to be free from verbal, sexual, physical, mental, corporal punishment, and involuntary seclusion. The document had been signed by CNA #8.A policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 04/2021, read in part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.A document titled ABUSE, NEGLECT AND MISAPPROPRIATION or RESIDENT'S FUND, dated 06/10/24, read in part, The resident has the right to be free from verbal, sexual, physical, mental, corporal punishment, and involuntary seclusion. The document had been signed by CNA #4.A written statement from Resident #76, dated 03/10/26, read in part, [Name withheld], my night shift C.N.A. and her helpmate, about 3 days ago, slid me up on my bed, raming [sic] my head in the head board [sic]! I hollered out in pain! But it didn't make any difference to them. Two days later I told them they hurt me, being so rough!.A written statement Resident #89, dated 03/11/2026, showed the resident stated having been in the room and heard when Resident #76's head was bumped against the headboard by the CNAs. An email statement from CNA #8, dated 3/11/2026, read in part, Last week I'm not sure the day, [CNA #4] and I changed [Resident #76] on E Hall and afterwards pulled [them] up in the bed. [Their] head bumped the headboard. It wasn't hard but we did bump it. [Resident #76] said ow and I apologized immediately and asked if [they] were okay. [Resident #76] stated [they] were fine. I rubbed [their] head to feel if there was a bump and asked several times if [they] were okay or if it hurt and each time, [they] said no. Both [CNA #4] and I apologized for using too much strength to pull [them] up.An incident report, dated 03/12/26, showed on 03/11/26 around 9:00 p.m., Resident #76 reported to facility staff on 03/08/26, two CNAs were moving them up in the bed and CNA #8 pulled them up and they hit their head on the headboard.A document titled Mandatory Reporting Protocol, dated 03/12/26, showed staff education was completed over the requirements for staff reporting allegations of abuse.An employee counseling record, dated 03/13/26, showed CNA #4 was terminated for failure to report an allegation of abuse.An employee termination record, dated 03/13/26, showed CNA #4, was not recommended for re-employment at the facility due to an allegation of abuse.An employee counseling record, dated 03/13/26, showed CNA #8, was terminated for failure to report an allegation of abuse.An employee termination record, dated 03/13/26, showed CNA #8, was not recommended for re-employment at the facility due to an allegation of abuse. A document titled In-Service Sign In, dated 03/20/26, showed topics discussed during training included abuse, neglect, exploitation and reporting to the abuse coordinator.On 6/30/26 at 3:26 p.m., Resident #76 stated, I had two on the night shift that were rough with me and hit my head on the headboard when I was moved up in the bed. Resident #76 stated they did not remember the CNAs names who had provided the care.On 07/01/26 at 11:51 a.m., the DON stated Resident #76 reported their head was bumped into the headboard of their bed on 03/08/26 while care was being provided by CNA #8 and CNA #4. The DON stated Resident #76 said they reported their head was bumped into the headboard because their neck continued to hurt 03/11/26 after the incident. The DON stated during the investigation, Resident #57 stated CNA #4 and CNA #8 had provided rough care when assisting them.On 07/01/26 at 11:55 a.m., the administrator stated abuse allegations and failure to report abuse for CNA #4 and CNA #8 were substantiated after the facility investigation was completed due to Resident #76's head having been hit into the headboard on 03/08/26. The administrator stated Resident #76 never reports anything about staff for abuse. The administrator stated CNA #8 had worked at the facility for several years with no complaints concerning care provided.On 07/01/26 at 12:09 p.m., Resident #57 stated they did not recall reporting any abuse by facility staff, but they had been repositioned roughly by two CNAs a while back. Resident #57 stated they didn't remember the names of the staff that provided the care. Resident #57 stated the staff had worked on the night shift and They were gone now and I'm glad. Resident #57 stated, They were just rough with me.

Based on record review and interview, the facility failed to inform the residents and their representatives of their right to rescind an arbitration agreement within 30 calendar days of signing it. The administrator reported the census was 84 and all the residents had signed an arbitration agreement. Findings: An undated excerpt from the facility admission packet, titled Arbitration read in part, .this Arbitration Provision may be rescinded by written notice to the facility from the resident within 3 business days of signature. If not rescinded within 3 business days, this Arbitration Provision shall remain in effect . On 08/23/24 at 8:11 a.m., the Administrator stated residents had not given 30 days to rescind the arbitration agreement after it was signed.

Based on record review and interview, the facility failed to have RN coverage for two days, 01/22/24 and 01/26/24. The administrator identified 84 residents living in the facility. Findings: Based on record review, and interview the facility failed to submit accurate direct care staffing payroll data for the PBJ report for 01/01/24 to 03/31/24 (Quarter 2). The Administrator identified 84 residents resided in the facility. Findings: On 08/22/24 at 1:37 p.m., HR#1 was asked about the five dates listed on the PBJ report (01/20/24, 01/22/24. 01/25/24. 01/27/24 and 02/25/24 . HR#1 stated they were unsure of why there was no RN coverage listed on those reports. HR#1 then provided punch detail for scheduled RN coverage for three of the five dates listed on the PBJ report. HR#1 provided punch detail for RN coverage for 1/20, 1/27 and 2/25 but not for 1/22/24, or 1/26/24. When asked why there was no RN coverage for the dates listed, HR#1 stated they based the PBJ report on punch detail and did not have records for the scheduled RN . On 08/22/24 at 8:37 a.m., the administrator stated they did not know why there was no RN data for those dates.

Based on record review and interview, the facility failed to submit accurate direct care staffing payroll data for the PBJ report for 01/01/24 to 03/31/24 (Quarter 2). The Administrator identified 84 residents resided in the facility. Findings: The PBJ Staffing Data Report, dated 01/01/24 through 03/31/24, for Quarter 2 read in part Four or More Days Within the Quarter with no RN. Hours. On 08/22/24 at 1:37 p.m., HR#1 was asked about the five dates listed on the report (01/20/24, 01/22/24. 01/25/24. 01/27/24 and 02/25/24 . HR#1 stated they were unsure of why there was no RN coverage listed on those reports. They stated the PBJ report is based on the facility punch detail. HR#1 then provided punch detail for scheduled RN coverage for three of the five dates listed on the PBJ report. The HR was able to provide punch detail for RN coverage for 1/20, 1/27 and 2/25 but not for 1/22/24, or 1/26/24. When asked if the data submitted for the PBJ was correct, HR#1 stated no. On 08/22/24 at 8:37 a.m., the administrator stated they did not know why the inaccurate data was submitted. .

Based on record review and interview, the facility failed to provide written notices of transfer or discharge prior to residents being transfer or discharged from the facility for three (#2, #9, and #228) of four sampled residents reviewed for hospitalization s. The DON denitrified 71 residents who had been discharged or transferred to from the facility to a hospital in the previous six months. Findings: A facility policy titled Transfer or Discharge, Facility Initiated, dated 2001, documented under the subheading Notice of Transfer or Discharge (Emergent or Therapeutic Leave that the resident would be given the notice as soon as practicable but before the transfer or discharge. 1. Resident #2 had diagnoses which included bipolar disorder. A progress note dated 12/12/23 at 10:05 a.m., documented facility staff transferred the resident to a hospital for behaviors on that date. A review of the resident's records did not find a written notice of transfer or discharge had been given to the resident. 2. Resident #9 had diagnoses which included type 2 diabetes mellitus. A progress note dated 06/02/24 at 10:15 p.m., documented the facility staff transferred the resident to a hospital for a medical emergency on that date. A review of the resident's records did not find a written notice of transfer or discharge had been given to the resident. 3. Resident #228 had diagnoses which included atherosclerotic heart disease. A progress note, dated 8/3/2024 at 5:33 p.m., documented facility staff had transferred the resident to the hospital for a medical emergency on that date. A review of the resident's records did not find a written notice of transfer or discharge had been given to the resident. 08/22/24 at 9:38 a.m. The DON stated residents #2, #9, and #228 had not been given written notices of transfer or discharge prior to being sent from the facility because they were unaware it was required.

Based on record review and interview, the facility failed to ensure a resident who received an antipsychotic medication had an appropriate diagnosis/indication for the use of the medication for one (#63) of five residents sampled for unnecessary medications. The DON identified five residents who received antipsychotic medications. Findings: An undated policy titled Unnecessary Drugs and Psychotropic Drugs read in part, .Antipsychotic medications will not be given to residents who have not previously used the drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record . Resident #63 had diagnoses which included Alzheimer's disease and major depressive disorder. A physician's order dated 03/26/24, documented Resident #63 was to receive quetiapine fumarate ER (an antipsychotic medication) 200 mg by mouth once a day for Alzheimer's disease. On 08/21/24 at 1:31 p.m., the DON stated Alzheimer's disease is not an appropriate diagnosis for an antipsychotic medication.

Based on record review and interview, the facility failed to ensure the physician documented a rationale for not implementing a GDR for one #63 of five residents reviewed for unnecessary medications. The DON reported five residents were on antipsychotic medication. Findings: An undated policy titled Unnecessary Drugs and Psychotropic Drugs read in part, .Dose reductions will occur in modest increments over adequate periods of time .Approved clinical contraindications include but are not limited to .Physician has documented clinical rationale why any additional attempted dose reduction at that time would likely impair resident's function or increase distressed behavior . Resident #63 had diagnoses which included Alzheimer's disease and major depressive disorder. A Note to Attending Physician/Prescriber, dated 04/18/24, documented Resident #63 was receiving Mirtazapine (an antidepressant medication) 15 mg at bedtime and Trazadone (an antidepressant medication) 50 mg at bedtime. The pharmacist indicated this was possibly a duplicate therapy and asked the physician to consider using only one of the medications, changing the medication administration time or providing a risk/benefit statement. The physician did not order any changes and did not provide a rationale. On 08/21/24 at 1:31 p.m., The DON stated the physician did not provide a rationale, they also stated a rationale should have been provided.

Based on observation, record review, and interview, the facility facile to ensue staff implemented interventions in a resident care plan for one (#9) of 18 sampled residents reviewed for care plans. The DON reported 84 resident resided at the facility. Findings: Resident #9 had diagnoses which included hemiplegia and hemiparesis of the right dominant side, muscle weakness, and tremors. Resident #9's comprehensive care plan, revised date 06/24/24, documented Resident #9 had a care plan intervention for the resident was to wear a smoking apron while smoking. The intervention had a initiated date of 07/09/19. On 08/21/24 at 11:20 a.m., Resident #9 was observed smoking in the designated smoking area outside of the facility dining hall. The resident was not wearing a smoking apron. The resident was supervised by CNA #1. On 08/21/24 at 1:18 p.m., CNA #1 stated Resident #9 had not worn a smoking apron during the smoking session because they were unaware the resident was suppose to wear one. When asked where someone would find the care needs of each resident they stated they could ask the DON. When asked about the care plans CNA #1 stated they were unaware of the smoking apron intervention in the care plan. They stated they did not know where to find the resident's care plan. On 08/21/24 at 1:37 p.m., DON stated CNA #1 had not been following policy and procedure and would educate the CNA about the care plan.

Based on record review and interview, the facility failed to ensure resident assessments were submitted to CMS for one (#69) of one resident reviewed for assessments. The administrator reported the census was 84. Findings: An undated facility policy titled MDS Completion and Submission Timeframes read in part, Our facility will conduct and submit resident assessments in accordance with current federal and state submission time frames . Resident #69 had diagnoses which included acute respiratory failure and diabetes mellitus. A review of Resident #69's medical record indicated the 5-day assessment dated [DATE] and the discharge assessment dated [DATE] were completed but never transmitted to CMS. On 08/21/24 at 1:47 pm, the MDS coordinator stated they were not sure why the assessments had not been sent to CMS.

Based on observation, record review, and interview, the facility failed to ensure a resident who required a non-flammable apron to be worn during smoking was wearing one when smoking for one (#9) of three residents reviewed for accident hazards. The DON identified 15 resident that required supervision while smoking who resided at the facility. Findings: A facility policy titled Smoking Policy, undated, read in part, Resident who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether supervision is required for smoking, or if the resident is safe to smoke at all. Resident #9 had diagnoses which included hemiplegia and hemiparesis of the right dominant side, muscle weakness, and tremors. Resident #9's comprehensive care plan, revised date 06/24/24, documented a care plan focus of smoking with a corresponding intervention that the resident was to wear a smoking apron while smoking. A facility Smoking - Safety Screen document, dated 08/01/24, documented the resident was to be supervise during smoking and they were to wear a smoking apron. On 08/21/24 at 11:20 a.m., Resident #9 was observed smoking in the designated smoking area outside of the facility dining hall. The resident was not wearing a smoking apron. They were using their left hand to hold a cigarette. Twice during the smoking session Resident #9's left hand was observed to shake violently for approximately 10 to 15 seconds. The resident was not holding the cigarette during the time of the hand movements. CNA #1 was observed supervising the residents during the entire smoking sessions. When Resident #9 reentered the facility there were no burn marks on the resident's clothing or exposed skin. On 08/21/24 at 11:40 a.m. Resident #9 stated they usually work a smoking apron and did not know why they did not that day. On 08/21/24 at 1:18 p.m., CNA #1 stated they were unaware Resident #9 had not worn a smoking apron earlier during the smoke break. They stated they were unaware the resident required one. On 08/21/24 at 1:37 p.m., DON stated CNA #1 was a PRN employee and new to the facility. They stated by not providing the smoking apron to Resident #9 the CNA had not been following facility policy.

Based on record review and interview, the facility failed to complete a new PASRR level I assessment when a new diagnosis was received for two (#1 and #43) of four sampled residents reviewed for PASRR assessments. The Resident Census and Census and Conditions of Residents report, dated 07/13/23, documented 82 residents resided in the facility. 1. A level I PASRR, dated 04/12/22, documented Res #1 did not have a serious mental illness. On 03/29/23, the resident had a new diagnosis of bipolar disorder. There was no documentation the OHCA had been contacted to see if a level II PASRR was required. On 07/17/23 at 3:07 p.m., the DON was asked to provide documentation the OHCA was notified when the resident had a new diagnosis of bipolar disorder to see if a level II PASSAR was required. On 07/17/23 at 3:28 p.m., the DON stated they did not reach out to the OHCA. 2. A level I PASRR, dated 07/13/22, documented Res #43 did not have a serious mental illness. On 09/22/22, the resident had a new diagnosis of psychotic disorder with hallucinations due to known physiological condition. On 07/17/23 at 3:48 p.m., the DON was asked to provide documentation the OHCA was notified when the resident had a new diagnosis of psychotic disorder with hallucinations due to known physiological condition to see if a level II PASSAR was required. On 07/17/23 at 4:01 p.m., the DON stated they did not reach out to the OHCA.

Based on record review and interview, the facility failed to complete a significant change assessment after a resident started hospice services for two (#15 and #48) of 18 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents form, dated 07/13/23, documented 82 residents resided in the facility. Findings: 1. Res #15 had diagnoses which included CHF. A physician order, dated 04/19/23, documented to admit Res #15 to hospice for CHF. An annual assessment, dated 06/10/23, documented Res #15 was receiving hospice services. On 07/19/23 at 8:29 a.m., MDS coordinator #1 stated a significant change should be completed when a resident starts hospice. The MDS coordinator reviewed Res #15's chart and stated they did not complete a significant change assessment but should have. 2. Res #48 had diagnoses which included diabetes, HTN, and hemiplegia. A nurse progress note, dated 01/27/23 documented Res #48 was admitted to hospice services. An quarterly assessment, dated 06/14/23, documented Res #48 was receiving hospice services. On 07/19/23 at 8:27 a.m., MDS coordinator #1 stated a significant change should be completed when a resident starts hospice. The MDS coordinator reviewed Res #48's chart and stated they did not complete a significant change assessment but should have.

Based on observation and interview, the facility failed to ensure the kitchen was maintained to promote food safety and sanitation. The Resident Census and Conditions of Residents report, dated 07/13/23, documented 82 residents resided in the facility. The DON identified one resident who received nutrition and hydration solely through a feeding tube. Findings: On 07/18/23 at 7:03 a.m., a tour of the kitchen was conducted. The following observations were made: a. there was an accumulation of lint on the heat/air and return vents, b. there was an accumulation of brown and black residue on the floor in the chemical storage room, c. there were floor tiles missing in front of the chemical storage room, d. water was leaking from the neck of the faucet on the three compartment sink, e. there was lint on the oven hood filters, f. there were ceiling lights burned out and/or not working, g. the wall around the serve out window was not sealed. The wood was bare, h. there were two spray bottles of a clear and yellow liquid not labeled in the dish wash area, i. material was peeling off of the walls and the sheetrock was exposed in the dish wash area. There was black residue on the wall, j. there was an accumulation of white residue on the dish machine, k. base board tiles were missing in the dish wash area, l. there were no test strips available for the hot water mechanical warewashing machine to measure the utensil surface temperature of the water, m. there were three perforated baskets of clean clothes stored on the floor in the dish wash area, n. there was lint on the fan guards in the walk in cooler, and o. there was food and carpeted rugs on the floor in the walk in cooler and the walk in freezer. On 07/18/23 at 2:16 p.m., the DM was asked how staff ensured the kitchen was kept clean and maintained in good repair. They stated they cleaned every day and reported maintenance concerns to the maintenance department for repairs. They were asked what was the protocol when liquids were taken out of their original container and placed in spray bottles. They stated they should be labeled. The DM was asked how clean cloths were to be stored. They stated they were currently stored on the floor in containers. They were asked what was used to measure the utensil surface temperature of the water in the high temperature warewashing machine. They stated they used the gauges on the warewashing machine. The DM was made aware of the above observations.

Based on record review and interview, the facility failed to ensure the physician responded to a MRR in a timely manner for one (#29) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 07/13/23, documented 82 residents resided in the facility. Findings: Res #29 had diagnoses which included depression. A Consultant Pharmacist Reports policy, dated 06/25/18, documented in part .If the prescriber does not respond to recommendation directed to him/her within 30 days the Director of Nursing and/or the consultant pharmacist may contact the Medical Director . A physician order, dated 08/11/22, documented to administer Lexapro 10 mg at bedtime for depression. A physician order, dated 09/23/22, documented to administer Remeron 15 mg at bedtime for depression. A MRR, dated 01/20/23, documented a request for a GDR on the resident's Lexapro. A MRR, dated 03/22/23, documented a request for a GDR on the resident's Remeron. The physician documented a declination of the GDR on 05/15/23. There was no documented response to the 01/20/23 GDR request. On 07/17/23 at 4:00 p.m., the DON stated there was no response to the January 2023 GDR request. They stated the response to the March 2023 request was received late. They stated the physician should have responded within 30 days, and if the facility was unable to reach the physician they should have contacted the medical director.

Based on observation, record review, and interview, the facility failed to ensure a physician order was followed to prevent a resident from elopement for one (#42) of one sampled resident reviewed for wandering. The Resident Census and Conditions of Residents report, dated 07/13/23, documented 82 residents resided in the facility. The DON identified eight residents who had wander guards. Findings: Res #42 had diagnoses which included unspecified dementia without behavioral disturbance. A physician order, dated 06/08/23, documented the resident was to wear a wander guard on left wrist every shift. On 07/17/23 at 1:35 p.m., Res #42 was observed walking up and down the hall, and wandering in and out of residents' rooms. There was no wander guard observed on their left wrist. On 07/17/23 at 1:43 p.m., CNA #1 was asked if the resident had a wander guard. They stated they did not think so. On 07/17/23 at 1:145 p.m., CNA #2 was asked if the resident had a wander guard. They stated if they did it would be on their ankle. CNA #2 checked both of the resident's ankles and stated they did not see a wander guard. They were asked if the resident had orders to wear a wander guard. They stated they did not know. On 07/17/23 at 1:52 p.m., LPN #1 was asked if the resident had a wander guard. They stated they had orders for the resident to wear a wander guard on their left wrist. LPN #1 checked the resident's wrists and ankles and stated they did not see where they were wearing a wander guard.

Based on record review and interview, the facility failed to ensure a PASRR level I assessment included the resident had a serious mental illness for one (#54) of four sampled residents reviewed for PASRR assessments. The Resident Census and Census and Conditions of Residents report, dated 07/13/23, documented 82 residents resided in the facility. Findings: Res #54 was admitted to the facility on [DATE] with diagnoses which included unspecified affective mood disorder. A level I PASRR, dated 12/02/21, documented the resident had a primary diagnosis of PTSD and a secondary diagnosis of type II DM. It was documented there was no evidence or diagnosis of a serious mental illness. On 07/17/23 at 4:02 p.m., the DON was made aware the resident's level I PASRR did not document the resident had evidence or diagnosis of a serious mental illness, and the resident was admitted to the facility with unspecified affective mood disorder. They stated they would look into the reason why it was not documented. On 07/18/23 at 9:04 a.m., the DON stated the PASRR should have documented the resident had diagnosis of a serious mental illness.

On 09/04/18, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure residents were free from sexual abuse and inappropriate touching and sexually inappropriate behavior by a staff member. A staff member was observed on multiple occasions to touch and kiss a cognitively impaired resident in an inappropriate manner and to touch her breast on one occasion. The Oklahoma State Department of Health was notified and verified the IJ situation. At 6:27 p.m., the administrator and assistant director of nursing were informed of the IJ situation regarding the failure of the facility to ensure residents were free from sexual abuse and inappropriate touching and sexual behavior by a staff member. They were informed this placed the facility in an extended survey. At 9:22 p.m., an acceptable plan of removal was received from the administrator and director of nursing. The plan of Removal documented: Plan of Removal: 9-4-2018 In-service will be held for all staff concerning reporting any type of abuse or neglect immediately to the Director of Nursing and Administrator. This will be provided from, an outside RN Nurse who does not work for Quail Ridge. No employee will be allowed to step foot into Quail Ridge without receiving this in-service on abuse, neglect and reporting regulations. In-service training will be provided based off facility policy and procedure. In-service will include what constitutes abuse and neglect and the time frame for reporting to the Director of Nursing and Administrator. In-service will be held beginning on 9-4-2018 at 9:15 p.m. All staff that we have contacted and are able to get in here at this time will receive in-servicetraining (sic). The next group of employee's (sic) will begin showing up for work at 4:30 a.m. on 9-5-2018. This should be completed by 12:00 noon on 9-5-2018. We will continue to give in-services throughout the morning until all employees have received in-service training. WE hope to be done by 12:00 noon on 9-5-2018. The outside RN will also in-service the Administrator and Director of Nursing and ADON on facility policies of reporting and investigating abuse and neglect. This will be completed on 9-4-2018 by 10:00 p.m. The administrator and Director of Nursing will suspend the employee if an allegation of abuse is alleged against said employee. The DON and/or Administrator will protect all residents in the Facility by not allowing the alleged perpetrator in the bldg until the investigation is complete. The Director and/or Administrator will report to the reporting agenciess(sic) mandated by regulation. Investigation will include interviewing employees and residents in the facility who reside on different halls and shifts to get an accurate picture. (name deleted) was suspended on 9-4-18 at 7:30 p.m. via phone until complete investigation is performed. On 09/05/18 at 3:10 p.m., the investigation was reviewed. The administrator, director of nursing, and assistant director of nursing were asked if all staff who worked on the memory unit had been interviewed. They stated they had only interviewed the staff who had worked on the shift when the alleged abuse had occurred. They were asked if all interviewable residents had been interviewed. They stated, No. At 3:35 p.m., the administrator, director of nursing, and assistant director of nursing were informed additional staff and resident interviews were required. They were also informed an addendum to the Plan of Removal was required related to their plan to in-service staff who were on vacation, medical leave, or who could not be notified of the in-service. They were also informed the interviews with staff and residents had to actually contain questions to be answered, not just statements. On 09/06/18 at 9:50 a.m., an addendum to the Plan of Removal was accepted. The addendum to the Plan of Removal documented: .September 5, (YEAR), Re: Addendum to Plan of Removal 9/4/2018 with Plan of Removal date 9/6/2018 . On 9/5/2018, interviews were conducted with every interviewable resident throughout the facility. On 9/5/2018, interviews were conducted with staff on all shifts, in all departments and in all areas of the facility on any knowledge they had of suspected abuse or neglect. Interviews with several family members of residents were completed on 9/5/2018 asking about any knowledge they had about the Maintenance Supervisor inappropriately touching a resident or other action that could be considered abuse or neglect . The following are Employees who have not been in-serviced as of 9/5/2018 will not be allowed to work until they have been in-serviced on Signs and Symptoms of Abuse/Neglect and on Abuse Investigation: (name deleted), cook, vacation, returns 09/14/2018 (name deleted), LPN, 09/06/2018 (name deleted), LPN, 09/07/2018 (name deleted), CMA, Not scheduled. Unavailable by phone. (name deleted), Dietary Aide, medical leave. No return date. (name deleted), Physical Therapy Assistant, 09/10/2018 . The IJ was removed on 09/06/18 at 2:30 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on interview, and record review it was determined the facility failed to ensure residents were free from sexual abuse and/or inappropriate touching and sexually inappropriate behaviors for one (#2) of three sampled residents whose records were reviewed for abuse. A staff member was observed on multiple occasions to touch and kiss resident #2, a cognitively impaired resident, in an inappropriate manner and to touch her breast on one occasion. Findings: A policy for Abuse and Neglect - Clinical Protocol, revised (MONTH) (YEAR), documented: .'Sexual abuse' is defined .as 'non-consensual sexual contact of any type with a resident'. An Abuse, Neglect and Misapproriation of Resident's Funds policy documented: .Prevention: The facility will provide staff, resident's or residents representative on how and to whom to report concerns, grievances and incidents without fear of retributuion. The facility will identify, correct and intervene in situation in which abuse, neglect or misappropriation of property have occurred . Identification: The facility will investigate all alleged allegations. Including but not limited to occurrences, patterns, trends that may constitute abuse . A facility policy for abuse investigation and reporting, revised (MONTH) (YEAR), documented, .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 identified by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported . Role of the Administrator: .if an incident or suspected incident of resident abuse .is reported, the Administrator will assign the investigation to an appropriate individual .will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation .will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented . 1. Resident #2 had [DIAGNOSES REDACTED]. An annual assessment, dated 04/16/18, documented the resident had a BIMs score of three. This score indicated the resident was severely impaired with skills for daily decision making. The assessment documented the resident required extensive assistance with bed mobility, transfers, personal hygiene, bathing, and toileting, and set up and supervision only for eating. An incident report, dated 08/28/18, documented an allegation of abuse/mistreatment. The report documented, .Per CMA, she was passing medication to a resident in the dining room of Alzheimer's unit. She states she witnessed a male employee (identified as maintenance supervisor) inappropriately touch (resident #2's name deleted) on the breast. She stated that she also witnessed the employee rub the shoulders of (resident #2 name deleted) and another resident (resident #3 name deleted) .After reviewing camera footage, no inappropriate touching or other misconduct towards any resident was noted . Documentation revealed the incident report had been faxed to Oklahoma State Department of Health on 08/29/18 at 11:42 a.m. Upon entrance to the facility, on 09/04/18 at 12:50 p.m., the maintenance supervisor was present in the faciltiy. The DON and administrator were asked to provide their investigation of the incident. The DON provided seven statements written by staff members, a copy of a police report and her documentation of notifying two family members. There was no documentation any staff had been interviewed regarding the incident. There was no documentation any residents had been interviewed regarding the incident. On 09/04/18 at 1:40 p.m., CNA #7, who worked on the memory unit, was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, Yes, hugging, kissing her on the mouth, and rubbing her neck. He comes down (to the memory unit) several times a day for no reason. She was asked if she had reported her concerns to anyone. She stated she had reported it to the ADON two or three weeks ago but nothing had been done. She was asked if other instances of inappropriate sexual behaviors had been reported prior to this incident on 08/28/18. She stated, One time I reported it, another time myself and another CNA reported it, and then a CMA reported an incident on 08/28/18. After the incident on 08/28/18, we were told we would be terminated if we talked about any incidents between the maintenance supervisor (name deleted) and resident #2. She was asked if she had been asked to write a statement or answer any questions regarding the inappropriate sexual behaviors of the maintenance supervisor toward the resident. She stated, No. She was asked if the maintenance supervisor still came to the memory unit to see the resident after the incident of inappropriate sexual behavior had been reported. She stated, Yes. She was asked if the resident was being protected when the maintenance supervisor continued to go to the memory unit to see her. She stated, No. At 1:45 p.m., housekeeper #1 was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, I saw him kiss her on the forehead, and he comes down to the unit frequently just to see her. She stated she felt it was strange that he came to see her so much. She was asked if he visited other residents frequently, like he did this resident. She stated, No. She was asked if she had reported her concerns to anyone. She stated, No, I had heard it had been reported at least three times already. She was asked if anything had been done to investigate the reported incidents. She stated, No, but after the incident on 08/28/18 we were told we would be terminated if we talked about it. She was asked if she had been asked to write a statement or answer any questions regarding the inappropriate sexual behaviors of the maintenance supervisor toward the resident. She stated, No. She was asked if the maintenance supervisor still came to the memory unit to see the resident after the incidents had been reported. She stated, Yes. She was asked if the resident was being protected when the maintenance supervisor continued to go to the memory unit to see her. She stated, No. At 3:10 p.m., CNA #5, who stated she sometimes worked on the memory unit, was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward this resident. She stated she had seen him hugging and sitting with her holding her hand. She stated she felt it was odd for him to be down on the memory unit so often just to see her (the resident). She was asked if the maintenance supervisor visited other residents like he did this resident. She stated, No. She was asked if she had reported her concerns to anyone. She stated the charge nurse had told us to let her know if he (the maintenance supervisor) came to the unit. She was asked what happened when she informed the charge nurse the maintenance supervisor was on the Alzheimer's unit. She stated the charge nurse would ask him what he was doing there. She was asked what the maintenance supervisor would do when the charge nurse questioned him. She stated he would leave after she talked with him and then come back. She stated at times he would come by the unit at 10:00 p.m., at night to see if she was asleep. She was asked if she was aware of the incident of alleged sexual abuse that had occurred on 08/28/18. She stated, Yes, a CNA told me that we would be terminated if we talked about it. She was asked if she had been asked to write a statement or answer any questions regarding the inappropriate sexual behaviors of the maintenance supervisor toward the resident. She stated, No. At 3:30 p.m., CNA #1, who stated she had worked on the memory unit for one month, was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, He's just always back there (on the memory unit) to see the resident. She was asked if she had reported this to anyone. She stated, I told the charge nurse and she said she would take it to the ADON. She was asked if there had been an investigation conducted to find out why the maintenance supervisor had been going to the memory unit frequently just to see the resident. She stated, Not that I know of. She was asked if she had been asked to write a statement or answer any questions regarding the inappropriate sexual behaviors of the maintenance supervisor toward the resident. She stated, No. She was asked if the maintenance supervisor continued to frequent the memory unit after she had reported her concerns to the charge nurse. She stated, Yes. She was asked if the resident was being protected when the maintenance supervisor continued to go to the memory unit to see her. She stated, No. At 4:16 p.m., CMA #2 was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, I haven't seen it with my own eyes, but two years ago I had a resident confide in me because she was concerned about her roommate. The resident had told me she saw the maintenance man leaning over her roommate's bed hugging her. The resident was so upset by the incident she was crying. The CMA was asked what she did after the resident had confided in her. She stated, I reported it to the ADON with the resident who had reported it to me. She was asked if the maintenance supervisor had been suspended. She stated, No. She was asked if she had been asked to write a statement or answer any questions regarding the inappropriate sexual behaviors of the maintenance supervisor toward the resident. She stated, No. She was asked if she had been aware of the incident that had occurred on 08/28/18 of alleged inappropriate sexual behavior with the maintenance supervisor and the resident. She stated she had been told by the activity director they would be terminated if they talked about anything related to the incident. She was asked if the maintenance supervisor continued to frequent the memory unit after the incident of alleged sexual abuse had been reported. She stated, Yes. She was asked if the resident was being protected when the maintenance supervisor continued to go to the memory unit to see her. She stated, No. At 4:35 p.m., LPN #2 was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, I was told by a CMA about an incident on 08/28/18 where she allegedly saw the maintenance supervisor put his hand on the resident's breast. I didn't see it. She was asked if she had reported the incident to the administrator or the DON. She stated, No. She was asked why she had not reported the incident. She stated, I didn't know this girl (CMA) or how reliable she was. She was a new employee still in training. I wasn't sure if it would be considered abuse. If it had been verbal or physical abuse it would have been easy to tell and know what to do. I waited and talked with the other evening shift nurse. She was asked what happened after she talked with the other nurse. She stated, She reported it to the MDS coordinator. She was asked if she had protected the resident by not reporting the allegation of sexual abuse as soon as she had been made aware of it. She stated, No. At 5:15 p.m., LPN #1 was asked if she had been made aware of the staff on the memory unit being concerned about the behavior of the maintenance supervisor toward resident #2. She stated, It had been reported to me that he was down there (on the memory unit) all the time and the staff were concerned, feeling it was odd behavior. She was asked if she had reported the staff concerns. She stated, No, I knew staff had already told the ADON and the administrator before and nothing had been done. I wasn't sure they would do anything if I told. She was asked if she had been aware of the incident that occurred on 08/28/18 where a CMA allegedly saw the maintenance supervisor put his hand on the resident's breast. She stated, Yes, the other evening nurse told me it had been reported to her and she wasn't sure what to do. We waited awhile and then I told her we have to do something. I called the MDS coordinator, who was our former DON. She was asked why she called the MDS coordinator instead of the administrator or the DON. She stated, I was concerned because it continued to be reported repeatedly and I couldn't see that anything was being done. I knew her (the MDS coordinator) and I told her so that someone else that I trusted would know. She was asked if she had protected the resident when she waited to report the allegation of sexual abuse that had occurred on 08/28/18. She stated, No. She was asked if she had been aware of any other specific incidents regarding the maintenance supervisor being sexually inappropriate with other residents. She stated, Yes, a day shift charge nurse told me that a resident had said the maintenance man, (name deleted) had come into her room and changed his clothes. She was asked if she had reported it. She stated she did not report the incident because she had not witnessed it herself. She was asked if she had protected the resident when she failed to report the incident as soon as she had been made aware. She stated, No. She was asked if she had been told not to talk about any incidents regarding the maintenance supervisor and resident #2. She stated, Yes, after the incident on 08/28/18, we were told not to discuss anything or we would be terminated. At 6:37 p.m., the administrator was asked if the maintenance supervisor had been suspended after she had been notified of the allegation of sexual abuse. She stated he had been suspended. She was asked where the suspension had been documented. She stated, I don't know, I'd like to wait and find out from the DON. At 6:45 p.m., the administrator was asked if there had been any staff who had voiced concerns related to the maintenance supervisor being sexually inappropriate with resident #2. She stated, No. At 7:10 p.m., the DON was asked if the maintenance supervisor had been suspended after the allegation of sexual abuse. She stated, It was my oversight. I marked on the 'Notification of Nurse Aides and Non-Technical Workers' document that he hadn't been suspended. He was suspended the next day on 08/29/18. No documentation was provided showing the maintenance supervisor had been suspended as soon as the administrator and DON had been notified of the allegation of sexual abuse. The DON was asked why she had not interviewed any residents and staff in other areas of the facility as part of her investigation for the allegation of sexual abuse. She stated, Because we didn't see any inappropriate behavior when we viewed the surveillance video. The administrator and the DON were asked if staff had been in-serviced on their abuse policy. The DON provided the sign-in sheet for an in-service, dated 08/29/18 at 2:00 p.m., conducted by the DON, on the topic of abuse and neglect reporting. The sign-in sheet was signed by the two LPNs who had reported the allegation of abuse. The DON was asked why only the two LPNs who had reported the allegation of abuse were in-serviced on the abuse policy and not the entire staff. She stated, Because they were the only ones involved and we had done a facility wide in-service on 08/07/18 on abuse. On 09/05/18 at 11:10 a.m., the administrator and DON were asked if there were any allegations of abuse currently under investigation. The administrator stated, No. At 1:15 p.m., LPN #3 was asked if she had been made aware of the allegation of sexual abuse on 08/28/18 where the maintenance supervisor allegedly put his hand on the resident's breast. She stated, I wasn't here the week the alleged abuse occurred with the resident. I was informed in report of the allegation of abuse. I was told the new CMA who had been here two days in the unit saw him touch her breast. The morning of 08/29/18, when I had received report of the incident, the administrator had started an investigation the night before. We were told there was no proof of abuse. The LPN was asked if she had been interviewed by the administrator or DON during the investigation. She stated, No. At 1:40 p.m., CNA #9 was asked if she had observed the maintenance supervisor in the memory unit interacting with resident #2. She stated, Yes, a couple of weeks ago I had the resident doing a one on one activity in the dining room. He came back (to the memory unit) and stood in front of us. I asked him what he wanted. He said he had to check her wheelchair. He didn't ever check her wheelchair. He then pulled up a chair and sat down directly across from her with a table between them. He was helping her do the the one on one activity. He was there less than ten minutes, he then bent over, hugged her and kissed her on the side of the face. It made me feel uncomfortable. She was asked if she had reported this incident to anyone. She stated, I told the charge nurse, but she never followed up with me. She was asked if the nurse had her write out a statement. She stated, No, she said she would take care of it. I also talked about the incident with another CNA who works on the memory unit and she said it wasn't the first time. I asked (CNA #7 name deleted) if this had been going on before. She stated the behaviors had been going on for a few weeks now, and made her feel uncomfortable. She stated she had reported it to the ADON. She was asked if the CNA had told her why it made her feel uncomfortable. She stated, Just that he had started coming back frequently to check her wheelchair when she'd been in the same wheelchair since she's been here. I never saw him check the wheelchair before. She was asked if she had noticed any abnormal behavior from the maintenance supervisor before. She stated, I had never noticed any strange behavior from him until this episode. I've never seen him interact with the residents that much really. This was just different, not his normal behavior. At 2:00 p.m., CNA #10 was asked if she had observed the maintenance supervisor interacting with resident #2 in the memory unit. She stated, Yes, he comes to the (memory) unit to visit her three or four times during the day until he goes home. He sits beside her chair and holds her hand, and talks to her. He holds her hand and puts his arm on the resident's shoulders. She was asked if she had reported his inappropriate sexual behavior to anyone. She stated, I reported it to the ADON. The ADON told me she would talk with the DON. She was asked if she had been told to write a statement or had been asked any questions about the incident of inappropriate sexual behavior. She stated, No. She stated she had also talked with the administrator approximately two weeks ago to see if anyone had talked with her about the maintenance supervisor going to the memory unit frequently to visit the resident. She stated the administrator told her she had been made aware of her concerns. The CNA was asked if the administrator had her answer any questions regarding her concerns, or write out a statement regarding her concerns. She stated, No. At 3:10 p.m., the administrator and DON were asked if all the staff who worked on the memory unit had been interviewed as part of their investigation for the incident on 08/28/18 of alleged inappropriate sexual behavior. The DON stated, No just those who were working at the time of the alleged abuse. At 3:40 p.m., the DON was asked if it was appropriate behavior for the maintenance supervisor to be hugging and kissing residents. She stated, No. On 09/06/18 at 3:28 p.m.,the ADON was asked if she had received any reports from staff regarding the inappropriate sexual behavior of the maintenance supervisor going to the memory unit frequently to see resident #2. She stated, I know that he goes down there frequently to check wander guards. Staff have told me that he goes there frequently, but they didn't say they felt it was odd. She was asked what the maintenance supervisor's work schedule consisted of. She stated she didn't know because she was over nursing, not the other facility staff. She was asked if it was normal for the maintenance supervisor to go to see the resident on the memory unit at 10:00 p.m., after he had already gone home for the night. She stated, No.

On 09/04/18, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure staff immediately reported inappropriate touching and sexually inappropriate behaviors to the administrator. Facility staff failed to immediately report to administration observations of sexually inappropriate behavior when a staff member was observed to kiss and hug a resident on numerous occasions and touch her breast on one occasion. The Oklahoma State Department of Health was notified and verified the IJ situation. At 6:27 p.m., the administrator and assistant director of nursing were informed of the IJ regarding the failure of facility staff to immediately report allegations of sexual abuse, inappropriate touching and inappropriate sexual behaviors by a male staff member to resident #2. At 9:22 p.m., an acceptable plan of removal was received from the administrator and director of nursing. The plan of Removal documented: Plan of Removal: 9-4-2018 In-service will be held for all staff concerning reporting any type of abuse or neglect immediately to the Director of Nursing and Administrator. This will be provided from, an outside RN Nurse who does not work for Quail Ridge. No employee will be allowed to step foot into Quail Ridge without receiving this in-service on abuse, neglect and reporting regulations. In-service training will be provided based off facility policy and procedure. In-service will include what constitutes abuse and neglect and the time frame for reporting to the Director of Nursing and Administrator. In-service will be held beginning on 9-4-2018 at 9:15 p.m. All staff that we have contacted and are able to get in here at this time will receive in-servicetraining (sic). The next group of employee's (sic) will begin showing up for work at 4:30 a.m. on 9-5-2018. This should be completed by 12:00 noon on 9-5-2018. We will continue to give in-services throughout the morning until all employees have received in-service training. WE hope to be done by 12:00 noon on 9-5-2018. The outside RN will also in-service the Administrator and Director of Nursing and ADON on facility policies of reporting and investigating abuse and neglect. This will be completed on 9-4-2018 by 10:00 p.m. The administrator and Director of Nursing will suspend the employee if an allegation of abuse is alleged against said employee. The DON and/or Administrator will protect all residents in the Facility by not allowing the alleged perpetrator in the bldg until the investigation is complete. The Director and/or Administrator will report to the reporting agenciess(sic) mandated by regulation. Investigation will include interviewing employees and residents in the facility who reside on different halls and shifts to get an accurate picture. (name deleted) was suspended on 9-4-18 at 7:30 p.m. via phone until complete investigation is performed. On 09/05/18 at 3:10 p.m., the investigation was reviewed. The administrator, director of nursing, and assistant director of nursing were asked if all staff who worked on the memory unit had been interviewed. They stated they had only interviewed the staff who had worked on the shift when the alleged abuse had occurred. They were asked if all interviewable residents had been interviewed. They stated, No. At 3:35 p.m., the administrator, director of nursing, and assistant director of nursing were informed additional staff and resident interviews were required. They were also informed an addendum to the Plan of Removal was required related to their plan to in-service staff who were on vacation, medical leave, or who could not be notified of the in-service. They were also informed the interviews with staff and residents had to actually contain questions to be answered, not just statements. On 09/06/18 at 9:50 a.m., an addendum to the Plan of Removal was accepted. The addendum to the Plan of Removal documented: .September 5, (YEAR), Re: Addendum to Plan of Removal 9/4/2018 with Plan of Removal date 9/6/2018 . On 9/5/2018, interviews were conducted with every interviewable resident throughout the facility. On 9/5/2018, interviews were conducted with staff on all shifts, in all departments and in all areas of the facility on any knowledge they had of suspected abuse or neglect. Interviews with several family members of residents were completed on 9/5/2018 asking about any knowledge they had about the Maintenance Supervisor inappropriately touching a resident or other action that could be considered abuse or neglect . The following are Employees who have not been in-serviced as of 9/5/2018 will not be allowed to work until they have been in-serviced on Signs and Symptoms of Abuse/Neglect and on Abuse Investigation: (name deleted), cook, vacation, returns 09/14/2018 (name deleted), LPN, 09/06/2018 (name deleted), LPN, 09/07/2018 (name deleted), CMA, Not scheduled. Unavailable by phone. (name deleted), Dietary Aide, medical leave. No return date. (name deleted), Physical Therapy Assistant, 09/10/2018 . The IJ was removed on 09/06/18 at 2:30 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on interview, and record review, it was determined the facility failed to immediately report allegations of sexual abuse and/or inappropriate sexual behavior to administration and failed to report the same within two hours to the Oklahoma State Department of Health for two (#1 and #2) of three sampled residents who had allegations of sexual abuse. Facility staff failed to immediately report to administration observations of sexually inappropriate behavior when a staff member was observed to kiss and hug a resident on numerous occasions and touch her breast on one occasion. Findings: A policy for Abuse, Neglect and Misappropriation of Resident's Funds documented: .Investigation: The Administrator and Director of Nursing will be notified immediately of any abuse or neglect is suspected . A policy for abuse investigation and reporting, revised (MONTH) (YEAR), documented, .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 identified by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported . Reporting .All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies .The State licensing/certification agency responsible for surveying/licensing the facility .the local/State Ombudsman .The Resident's Representative (Sponsor) of Record .Adult Protective Services (where state law provides jurisdiction in long-term care) .Law enforcement officials .The resident's Attending Physician .The facility Medical Director . An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than .two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . Notices will include, as appropriate .the name of the resident .the number of the room in which the resident resides .the type of abuse that was committed .the date and time the alleged incident occurred .the name(s) of all persons involved in the alleged incident .what immediate action was taken by the facility . 1. Resident #2 had [DIAGNOSES REDACTED]. An annual assessment, dated 04/16/18, documented the resident had a BIMs score of three. This score indicated the resident was severely impaired with skills for daily decision making. The assessment documented the resident required extensive assistance with bed mobility, transfers, personal hygiene, bathing, and toileting, and set up and supervision only for eating. An incident report, dated 08/28/18, documented an allegation of abuse/mistreatment. The report documented, .Per CMA, she was passing medication to a resident in the dining room of Alzheimer's unit. She states she witnessed a male employee (identified as maintenance supervisor) inappropriately touch (resident #2 name deleted) on the breast. She stated that she also witnessed the employee rub the shoulders of (resident #2 name deleted) and another resident (resident #3 name deleted) .After reviewing camera footage, no inappropriate touching or other misconduct towards any resident was noted . Documentation revealed the incident report had been faxed to Oklahoma State Department of Health on 08/29/18 at 11:42 a.m. On 09/04/18 at 1:40 p.m., CNA #7, who worked on the memory unit, was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, Yes, hugging, kissing her on the mouth, and rubbing her neck. He comes down (to the memory unit) several times a day for no reason. She was asked if she had reported her concerns to anyone. She stated she had reported it to the ADON two or three weeks ago but nothing had been done. She was asked if other instances of inappropriate sexual behaviors had been reported prior to this incident on 08/28/18. She stated, One time I reported it, another time myself and another CNA reported it, and then a CMA reported an incident on 08/28/18. After the incident on 08/28/18, we were told we would be terminated if we talked about any incidents between the maintenance supervisor (name deleted) and resident #2. At 1:45 p.m., housekeeper #1 was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, I saw him kiss her on the forehead, and he comes down to the unit frequently just to see her. She stated she felt it was strange that he came to see her so much. She was asked if he visited other residents frequently, like he did this resident. She stated, No. She was asked if she had reported her concerns to anyone. She stated, No, I had heard it had been reported at least three times already. She was asked if anything had been done to investigate the reported incidents. She stated, No, but after the incident on 08/28/18 we were told we would be terminated if we talked about it. At 3:10 p.m., CNA #5, who stated she sometimes worked on the memory unit, was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward this resident. She stated she had seen him hugging and sitting with her holding her hand. She stated she felt it was odd for him to be down on the memory unit so often just to see her (the resident). She was asked if the maintenance supervisor visited other residents like he did this resident. She stated, No. She was asked if she had reported her concerns to anyone. She stated the charge nurse had told us to let her know if he (the maintenance supervisor) came to the unit. She was asked what happened when she informed the charge nurse the maintenance supervisor was on the Alzheimer's unit. She stated the charge nurse would ask him what he was doing there. She was asked what the maintenance supervisor would do when the charge nurse questioned him. She stated he would leave after she talked with him and then come back. She stated at times he would come by the unit at 10:00 p.m., at night to see if she was asleep. She was asked if she was aware of the incident of alleged sexual abuse that had occurred on 08/28/18. She stated, Yes, a CNA told me that we would be terminated if we talked about it. At 3:30 p.m., CNA #1, who stated she had worked on the memory unit for one month, was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, He's just always back there (on the memory unit) to see the resident. She was asked if she had reported this to anyone. She stated, I told the charge nurse and she said she would take it to the ADON. She was asked if there had been an investigation conducted to find out why the maintenance supervisor had been going to the memory unit frequently just to see the resident. She stated, Not that I know of. At 4:16 p.m., CMA #2 was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, I haven't seen it with my own eyes, but two years ago I had a resident confide in me because she was concerned about her roommate. The resident had told me she saw the maintenance man leaning over her roommate's bed hugging her. The resident was so upset by the incident she was crying. The CMA was asked what she did after the resident had confided in her. She stated, I reported it to the ADON with the resident who had reported it to me. She was asked if the maintenance supervisor had been suspended. She stated, No. She was asked if she had been aware of the incident that had occurred on 08/28/18 of alleged inappropriate sexual behavior with the maintenance supervisor and the resident. She stated she had been told by the activity director they would be terminated if they talked about anything related to the incident. At 4:35 p.m., LPN #2 was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, I was told by a CMA about an incident on 08/28/18 where she allegedly saw the maintenance supervisor put his hand on the resident's breast. I didn't see it. She was asked if she had reported the incident to the administrator or the DON. She stated, No. She was asked why she had not reported the incident. She stated, I didn't know this girl (CMA) or how reliable she was. She was a new employee still in training. I wasn't sure if it would be considered abuse. If it had been verbal or physical abuse it would have been easy to tell and know what to do. I waited and talked with the other evening shift nurse. She was asked what happened after she talked with the other nurse. She stated, She reported it to the MDS coordinator. She was asked if she had protected the resident by not reporting the allegation of sexual abuse as soon as she had been made aware of it. She stated, No. At 5:15 p.m., LPN #1 was asked if she had been made aware of the staff on the memory unit being concerned about the behavior of the maintenance supervisor toward resident #2. She stated, It had been reported to me that he was down there (on the memory unit) all the time and the staff were concerned, feeling it was odd behavior. She was asked if she had reported the staff concerns. She stated, No, I knew staff had already told the ADON and the administrator before and nothing had been done. I wasn't sure they would do anything if I told. She was asked if she had been aware of the incident that occurred on 08/28/18 where a CMA allegedly saw the maintenance supervisor put his hand on the resident's breast. She stated, Yes, the other evening nurse told me it had been reported to her and she wasn't sure what to do. We waited awhile and then I told her we have to do something. I called the MDS coordinator, who was our former DON. She was asked why she called the MDS coordinator instead of the administrator or the DON. She stated, I was concerned because it continued to be reported repeatedly and I couldn't see that anything was being done. I knew her (the MDS coordinator) and I told her so that someone else that I trusted would know. She was asked if she had protected the resident when she waited to report the allegation of sexual abuse that had occurred on 08/28/18. She stated, No. She was asked if she had been aware of any other specific incidents regarding the maintenance supervisor being sexually inappropriate with other residents. She stated, Yes, a day shift charge nurse told me that a resident had said the maintenance man, (name deleted) had come into her room and changed his clothes. She was asked if she had reported it. She stated she did not report the incident because she had not witnessed it herself. She was asked if she had protected the resident when she failed to report the incident as soon as she had been made aware. She stated, No. She was asked if she had been told not to talk about any incidents regarding the maintenance supervisor and resident #2. She stated, Yes, after the incident on 08/28/18, we were told not to discuss anything or we would be terminated. At 6:45 p.m., the administrator was asked if there had been any staff who had voiced concerns related to the maintenance supervisor being sexually inappropriate with resident #2. She stated, No. On 09/05/18 at 11:10 a.m., the DON was asked why she had waited until the next day, 08/29/18 at 11:42 a.m., to send in the incident report to the Oklahoma State Department of Health when the incident had occurred on 08/28/18. She stated, We got here to investigate as soon as it was reported to us. The incident wasn't reported to me when it should have been by the LPNs on duty. At 1:40 p.m., CNA #9 was asked if she had observed the maintenance supervisor in the memory unit interacting with resident #2. She stated, Yes, a couple of weeks ago I had the resident doing a one on one activity in the dining room. He came back (to the memory unit) and stood in front of us. I asked him what he wanted. He said he had to check her wheelchair. He didn't ever check her wheelchair. He then pulled up a chair and sat down directly across from her with a table between them. He was helping her do the the one on one activity. He was there less than ten minutes, he then bent over, hugged her and kissed her on the side of the face. It made me feel uncomfortable. She was asked if she had reported this incident to anyone. She stated, I told the charge nurse, but she never followed up with me. She was asked if the nurse had her write out a statement. She stated, No, she said she would take care of it. I also talked about the incident with another CNA who works on the memory unit and she said it wasn't the first time. I asked (CNA #7 name deleted) if this had been going on before. She stated the behaviors had been going on for a few weeks now, and made her feel uncomfortable. She stated she had reported it to the ADON. She was asked if the CNA had told her why it made her feel uncomfortable. She stated, Just that he had started coming back frequently to check her wheelchair when she'd been in the same wheelchair since she's been here. I never saw him check the wheelchair before. She was asked if she had noticed any abnormal behavior from the maintenance supervisor before. She stated, I had never noticed any strange behavior from him until this episode. I've never seen him interact with the residents that much really. This was just different, not his normal behavior. At 2:00 p.m., CNA #10 was asked if she had observed the maintenance supervisor interacting with resident #2 in the memory unit. She stated, Yes, he comes to the (memory) unit to visit her three or four times during the day until he goes home. He sits beside her chair and holds her hand, and talks to her. He holds her hand and puts his arm on the resident's shoulders. She was asked if she had reported his inappropriate sexual behavior to anyone. She stated, I reported it to the ADON. The ADON told me she would talk with the DON. She was asked if she had been told to write a statement or had been asked any questions about the incident of inappropriate sexual behavior. She stated, No. She stated she had also talked with the administrator approximately two weeks ago to see if anyone had talked with her about the maintenance supervisor going to the memory unit frequently to visit the resident. She stated the administrator told her she had been made aware of her concerns. The CNA was asked if the administrator had her answer any questions regarding her concerns, or write out a statement regarding her concerns. She stated, No. At 3:40 p.m., the DON was asked if it was appropriate behavior for the maintenance supervisor to be hugging and kissing residents. She stated, No. On 09/06/18 at 3:28 p.m.,the ADON was asked if she had received any reports from staff regarding the inappropriate sexual behavior of the maintenance supervisor going to the memory unit frequently to see resident #2. She stated, I know that he goes down there frequently to check wander guards. Staff have told me that he goes there frequently, but they didn't say they felt it was odd. She was asked what the maintenance supervisor's work schedule consisted of. She stated she didn't know because she was over nursing, not the other facility staff. She was asked if it was normal for the maintenance supervisor to go to see the resident on the memory unit at 10:00 p.m., after he had already gone home for the night. She stated, No. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 02/06/18 documented the resident had a BIMs score of 12. This score indicated the resident was moderately intact with skills for daily decision making. On 09/04/18 at 5:15 p.m., LPN #1 was asked was asked if she had been aware of any other specific incidents regarding the maintenance supervisor being sexually inappropriate with other residents. She stated, Yes, a day shift charge nurse told me that a resident had said the maintenance man, (name deleted) had come into her room and changed his clothes. She was asked if she had reported it. She stated she did not report the incident because she had not witnessed it herself. Nurses' notes from 03/20/18 through 09/05/18 were reviewed. No documentation was found of nurses being informed of the resident complaint of the maintenance supervisor coming into her room to change his clothing. On 09/05/18 at 1:15 p.m., LPN #3 was asked if she had been made aware of any allegations of inappropriate sexual behavior between the maintenance supervisor and any resident. She stated, The activity director had told me about an incident where a resident had stated the maintenance man (name deleted) had come into her room and changed clothes. She was asked how long ago this had occurred. She stated, Approximately a month ago. She was asked if the activity director had reported the incident. She stated, I don't know, I think that she told the maintenance supervisor that she (the resident) had said that. She was asked if she had reported the incident. She stated, I did not. She was asked if she thought it was appropriate behavior for a male maintenance supervisor to go into a resident's room to change clothes. She stated, No. She was asked if she should have reported the incident with the maintenance supervisor changing clothing in a resident's room. She stated, Yes, I should have. It didn't throw up a red flag to me. She was asked if she, as a charge nurse, should have investigated further with the activity director to see if the incident had been reported. She stated, Yes. She was asked if she had protected the resident when she failed to report the allegation of inappropriate sexual behavior. She stated, No. On 09/06/18 at 12:10 p.m., the administrator stated during their re-investigation of the incident that occurred on 08/28/18, a nurse had stated that approximately two months ago a resident had stated the maintenance supervisor, (name deleted) had come into her room and changed clothes. The administrator stated she had begun her investigation regarding the incident. At 3:25 p.m., the activity director was asked if she had been aware of an alleged incident where the maintenance supervisor had gone into a resident's room and changed his clothing. She stated, I had not been aware until today. At 3:28 p.m., the ADON was asked if the nurses had followed the facility's abuse policy when they failed to report the incident where the maintenance supervisor had allegedly gone into a resident's room and changed his clothing. She stated, No. At 4:00 p.m., the DON was asked if the nurses had followed the facility's abuse policy when they failed to report the incident where the maintenance supervisor had allegedly gone into a resident's room and changed his clothing. She stated, No, it should have been reported immediately. She was asked if they were protecting the resident. She stated, No. She was asked if they had followed the facility's abuse policy. She stated, No.

On 09/04/18, an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to thoroughly investigate allegations of sexual abuse and prevent further potential abuse after allegations of abuse had been reported. Multiple allegations of sexually inappropriate behavior and inappropriate touching was reported by multiple staff members by the Maintenance Supervisor towards resident #2. An allegation of sexual abuse related to the staff member touching resident #2's breast, was reported to the administrator on 08/28/18. No documentation of the alleged perpetrator being suspended pending investigation was found. A thorough investigation had not been conducted. The Oklahoma State Department of Health was notified and verified the IJ situation. At 6:27 p.m., the administrator and assistant director of nursing were informed of the IJ situation regarding failure to complete a thorough investigation and failure to protect residents from further abuse after an allegation of abuse was made by staff. They were informed this placed the facility in an extended survey. At 9:22 p.m., an acceptable plan of removal was received from the administrator and director of nursing. The plan of Removal documented: Plan of Removal: 9-4-2018 In-service will be held for all staff concerning reporting any type of abuse or neglect immediately to the Director of Nursing and Administrator. This will be provided from, an outside RN Nurse who does not work for Quail Ridge. No employee will be allowed to step foot into Quail Ridge without receiving this in-service on abuse, neglect and reporting regulations. In-service training will be provided based off facility policy and procedure. In-service will include what constitutes abuse and neglect and the time frame for reporting to the Director of Nursing and Administrator. In-service will be held beginning on 9-4-2018 at 9:15 p.m. All staff that we have contacted and are able to get in here at this time will receive in-servicetraining (sic). The next group of employee's (sic) will begin showing up for work at 4:30 a.m. on 9-5-2018. This should be completed by 12:00 noon on 9-5-2018. We will continue to give in-services throughout the morning until all employees have received in-service training. WE hope to be done by 12:00 noon on 9-5-2018. The outside RN will also in-service the Administrator and Director of Nursing and ADON on facility policies of reporting and investigating abuse and neglect. This will be completed on 9-4-2018 by 10:00 p.m. The administrator and Director of Nursing will suspend the employee if an allegation of abuse is alleged against said employee. The DON and/or Administrator will protect all residents in the Facility by not allowing the alleged perpetrator in the bldg until the investigation is complete. The Director and/or Administrator will report to the reporting agenciess(sic) mandated by regulation. Investigation will include interviewing employees and residents in the facility who reside on different halls and shifts to get an accurate picture. (name deleted) was suspended on 9-4-18 at 7:30 p.m. via phone until complete investigation is performed. On 09/05/18 at 3:10 p.m., the investigation was reviewed. The administrator, director of nursing, and assistant director of nursing were asked if all staff who worked on the memory unit had been interviewed. They stated they had only interviewed the staff who had worked on the shift when the alleged abuse had occurred. They were asked if all interviewable residents had been interviewed. They stated, No. At 3:35 p.m., the administrator, director of nursing, and assistant director of nursing were informed additional staff and resident interviews were required. They were also informed an addendum to the Plan of Removal was required related to their plan to in-service staff who were on vacation, medical leave, or who could not be notified of the in-service. They were also informed the interviews with staff and residents had to actually contain questions to be answered, not just statements. On 09/06/18 at 9:50 a.m., an addendum to the Plan of Removal was accepted. The addendum to the Plan of Removal documented: .September 5, (YEAR), Re: Addendum to Plan of Removal 9/4/2018 with Plan of Removal date 9/6/2018 . On 9/5/2018, interviews were conducted with every interviewable resident throughout the facility. On 9/5/2018, interviews were conducted with staff on all shifts, in all departments and in all areas of the facility on any knowledge they had of suspected abuse or neglect. Interviews with several family members of residents were completed on 9/5/2018 asking about any knowledge they had about the Maintenance Supervisor inappropriately touching a resident or other action that could be considered abuse or neglect . The following are Employees who have not been in-serviced as of 9/5/2018 will not be allowed to work until they have been in-serviced on Signs and Symptoms of Abuse/Neglect and on Abuse Investigation: (name deleted), cook, vacation, returns 09/14/2018 (name deleted), LPN, 09/06/2018 (name deleted), LPN, 09/07/2018 (name deleted), CMA, Not scheduled. Unavailable by phone. (name deleted), Dietary Aide, medical leave. No return date. (name deleted), Physical Therapy Assistant, 09/10/2018 . The IJ was removed on 09/06/18 at 2:30 p.m., when all components of the plan of removal had been completed. The deficient practice remained at a pattern level with a potential for more than minimal harm. Based on interview, and record review it was determined the facility failed to: ~ conduct thorough investigations when allegations of abuse had been reported by staff and residents for four (#2, 9, 10 and #11) of six sampled residents whose records were reviewed for allegations of abuse; and ~ protect residents from further potential abuse after allegations of abuse had been reported for one (#2) of six sampled residents reviewed for allegations of abuse. Multiple allegations of sexually inappropriate behavior and inappropriate touching was reported by multiple staff members by the Maintenance Supervisor towards resident #2. An allegation of sexual abuse related to the staff member touching resident #2's breast, was reported to the administrator on 08/28/18. No documentation of the alleged perpetrator being suspended pending investigation was found. A thorough investigation had not been conducted. Findings: A facility policy for abuse investigation and reporting, revised (MONTH) (YEAR), documented, .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 identified by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported . Role of the Administrator: .if an incident or suspected incident of resident abuse .is reported, the Administrator will assign the investigation to an appropriate individual .will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation .will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented . Role of Investigator: .interview the person(s) reporting the incident .interview any witnesses to the incident .interview the resident (as medically appropriate) .interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition .interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .interview the resident's roommate, family members, and visitors .interview other residents to whom the accused employee provides care or services; and review all events leading up to the alleged incident . A policy for Abuse and Neglect - Clinical Protocol, revised (MONTH) (YEAR), documented: .'Sexual abuse' is defined .as 'non-consensual sexual contact of any type with a resident'. An Abuse, Neglect and Misapproriation of Resident's Funds policy documented: .Identification: The facility will investigate all alleged allegations. Including but not limited to occurrences, patterns, trends that may constitute abuse . 1. Resident #2 had [DIAGNOSES REDACTED]. An annual assessment, dated 04/16/18, documented the resident had a BIMs score of three. This score indicated the resident was severely impaired with skills for daily decision making. The assessment documented the resident required extensive assistance with bed mobility, transfers, personal hygiene, bathing, and toileting, and set up and supervision only for eating. An incident report, dated 08/28/18, documented an allegation of abuse/mistreatment. The report documented, .Per CMA, she was passing medication to a resident in the dining room of Alzheimer's unit. She states she witnessed a male employee (identified as maintenance supervisor) inappropriately touch (resident #2 name deleted) on the breast. She stated that she also witnessed the employee rub the shoulders of (resident #2 name deleted) and another resident (resident #3 name deleted) .After reviewing camera footage, no inappropriate touching or other misconduct towards any resident was noted . Documentation revealed the incident report had been faxed to Oklahoma State Department of Health on 08/29/18 at 11:42 a.m. Upon entrance to the facility, on 09/04/18 at 12:50 p.m., the maintenance supervisor was present in the faciltiy. The DON and administrator were asked to provide their investigation of the incident. The DON provided seven statements written by staff members, a copy of a police report and her documentation of notifying two family members. There was no documentation any staff had been interviewed regarding the incident. There was no documentation any residents had been interviewed regarding the incident. On 09/04/18 at 1:40 p.m., CNA #7, who worked on the memory unit, was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, Yes, hugging, kissing her on the mouth, and rubbing her neck. He comes down (to the memory unit) several times a day for no reason. She was asked if she had reported her concerns to anyone. She stated she had reported it to the ADON two or three weeks ago but nothing had been done. She was asked if other instances of inappropriate sexual behaviors had been reported prior to this incident on 08/28/18. She stated, One time I reported it, another time myself and another CNA reported it, and then a CMA reported an incident on 08/28/18. After the incident on 08/28/18, we were told we would be terminated if we talked about any incidents between the maintenance supervisor (name deleted) and resident #2. She was asked if she had been asked to write a statement or answer any questions regarding the inappropriate sexual behaviors of the maintenance supervisor toward the resident. She stated, No. She was asked if the maintenance supervisor still came to the memory unit to see the resident after the incident of inappropriate sexual behavior had been reported. She stated, Yes. She was asked if the resident was being protected when the maintenance supervisor continued to go to the memory unit to see her. She stated, No. At 1:45 p.m., housekeeper #1 was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, I saw him kiss her on the forehead, and he comes down to the unit frequently just to see her. She stated she felt it was strange that he came to see her so much. She was asked if he visited other residents frequently, like he did this resident. She stated, No. She was asked if she had reported her concerns to anyone. She stated, No, I had heard it had been reported at least three times already. She was asked if anything had been done to investigate the reported incidents. She stated, No, but after the incident on 08/28/18 we were told we would be terminated if we talked about it. She was asked if she had been asked to write a statement or answer any questions regarding the inappropriate sexual behaviors of the maintenance supervisor toward the resident. She stated, No. She was asked if the maintenance supervisor still came to the memory unit to see the resident after the incidents had been reported. She stated, Yes. She was asked if the resident was being protected when the maintenance supervisor continued to go to the memory unit to see her. She stated, No. At 3:10 p.m., CNA #5, who stated she sometimes worked on the memory unit, was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward this resident. She stated she had seen him hugging and sitting with her holding her hand. She stated she felt it was odd for him to be down on the memory unit so often just to see her (the resident). She was asked if the maintenance supervisor visited other residents like he did this resident. She stated, No. She was asked if she had reported her concerns to anyone. She stated the charge nurse had told us to let her know if he (the maintenance supervisor) came to the unit. She was asked what happened when she informed the charge nurse the maintenance supervisor was on the Alzheimer's unit. She stated the charge nurse would ask him what he was doing there. She was asked what the maintenance supervisor would do when the charge nurse questioned him. She stated he would leave after she talked with him and then come back. She stated at times he would come by the unit at 10:00 p.m., at night to see if she was asleep. She was asked if she was aware of the incident of alleged sexual abuse that had occurred on 08/28/18. She stated, Yes, a CNA told me that we would be terminated if we talked about it. She was asked if she had been asked to write a statement or answer any questions regarding the inappropriate sexual behaviors of the maintenance supervisor toward the resident. She stated, No. At 3:30 p.m., CNA #1, who stated she had worked on the memory unit for one month, was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, He's just always back there (on the memory unit) to see the resident. She was asked if she had reported this to anyone. She stated, I told the charge nurse and she said she would take it to the ADON. She was asked if there had been an investigation conducted to find out why the maintenance supervisor had been going to the memory unit frequently just to see the resident. She stated, Not that I know of. She was asked if she had been asked to write a statement or answer any questions regarding the inappropriate sexual behaviors of the maintenance supervisor toward the resident. She stated, No. She was asked if the maintenance supervisor continued to frequent the memory unit after she had reported her concerns to the charge nurse. She stated, Yes. She was asked if the resident was being protected when the maintenance supervisor continued to go to the memory unit to see her. She stated, No. At 4:16 p.m., CMA #2 was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, I haven't seen it with my own eyes, but two years ago I had a resident confide in me because she was concerned about her roommate. The resident had told me she saw the maintenance man leaning over her roommate's bed hugging her. The resident was so upset by the incident she was crying. The CMA was asked what she did after the resident had confided in her. She stated, I reported it to the ADON with the resident who had reported it to me. She was asked if the maintenance supervisor had been suspended. She stated, No. She was asked if she had been asked to write a statement or answer any questions regarding the inappropriate sexual behaviors of the maintenance supervisor toward the resident. She stated, No. She was asked if she had been aware of the incident that had occurred on 08/28/18 of alleged inappropriate sexual behavior with the maintenance supervisor and the resident. She stated she had been told by the activity director they would be terminated if they talked about anything related to the incident. She was asked if the maintenance supervisor continued to frequent the memory unit after the incident of alleged sexual abuse had been reported. She stated, Yes. She was asked if the resident was being protected when the maintenance supervisor continued to go to the memory unit to see her. She stated, No. At 4:35 p.m., LPN #2 was asked if she had ever observed the maintenance supervisor exhibiting inappropriate sexual behavior toward resident #2. She stated, I was told by a CMA about an incident on 08/28/18 where she allegedly saw the maintenance supervisor put his hand on the resident's breast. I didn't see it. She was asked if she had reported the incident to the administrator or the DON. She stated, No. She was asked why she had not reported the incident. She stated, I didn't know this girl (CMA) or how reliable she was. She was a new employee still in training. I wasn't sure if it would be considered abuse. If it had been verbal or physical abuse it would have been easy to tell and know what to do. I waited and talked with the other evening shift nurse. She was asked what happened after she talked with the other nurse. She stated, She reported it to the MDS coordinator. She was asked if she had protected the resident by not reporting the allegation of sexual abuse as soon as she had been made aware of it. She stated, No. At 5:15 p.m., LPN #1 was asked if she had been made aware of the staff on the memory unit being concerned about the behavior of the maintenance supervisor toward resident #2. She stated, It had been reported to me that he was down there (on the memory unit) all the time and the staff were concerned, feeling it was odd behavior. She was asked if she had reported the staff concerns. She stated, No, I knew staff had already told the ADON and the administrator before and nothing had been done. I wasn't sure they would do anything if I told. She was asked if she had been aware of the incident that occurred on 08/28/18 where a CMA allegedly saw the maintenance supervisor put his hand on the resident's breast. She stated, Yes, the other evening nurse told me it had been reported to her and she wasn't sure what to do. We waited awhile and then I told her we have to do something. I called the MDS coordinator, who was our former DON. She was asked why she called the MDS coordinator instead of the administrator or the DON. She stated, I was concerned because it continued to be reported repeatedly and I couldn't see that anything was being done. I knew her (the MDS coordinator) and I told her so that someone else that I trusted would know. She was asked if she had protected the resident when she waited to report the allegation of sexual abuse that had occurred on 08/28/18. She stated, No. She was asked if she had been aware of any other specific incidents regarding the maintenance supervisor being sexually inappropriate with other residents. She stated, Yes, a day shift charge nurse told me that a resident had said the maintenance man, (name deleted) had come into her room and changed his clothes. She was asked if she had reported it. She stated she did not report the incident because she had not witnessed it herself. She was asked if she had protected the resident when she failed to report the incident as soon as she had been made aware. She stated, No. She was asked if she had been told not to talk about any incidents regarding the maintenance supervisor and resident #2. She stated, Yes, after the incident on 08/28/18, we were told not to discuss anything or we would be terminated. On 09/04/18 at 6:37 p.m., the administrator was asked if the maintenance supervisor had been suspended after she had been notified of the allegation of sexual abuse. She stated he had been suspended. She was asked where the suspension had been documented. She stated, I don't know, I'd like to wait and find out from the DON. At 6:45 p.m., the administrator was asked if there had been any staff who had voiced concerns related to the maintenance supervisor being sexually inappropriate with resident #2. She stated, No. At 7:10 p.m., the DON was asked if the maintenance supervisor had been suspended after the allegation of sexual abuse. She stated, It was my oversight. I marked on the 'Notification of Nurse Aides and Non-Technical Workers' document that he hadn't been suspended. He was suspended the next day on 08/29/18. No documentation was provided showing the maintenance supervisor had been suspended as soon as the administrator and DON had been notified of the allegation of sexual abuse. The DON was asked why she had not interviewed any residents and staff in other areas of the facility as part of her investigation for the allegation of sexual abuse. She stated, Because we didn't see any inappropriate behavior when we viewed the surveillance video. On 09/05/18 at 1:15 p.m., LPN #3 was asked if she had been made aware of the allegation of sexual abuse on 08/28/18 where the maintenance supervisor allegedly put his hand on the resident's breast. She stated, I wasn't here the week the alleged abuse occurred with the resident. I was informed in report of the allegation of abuse. I was told the new CMA who had been here two days in the unit saw him touch her breast. The morning of 08/29/18, when I had received report of the incident, the administrator had started an investigation the night before. We were told there was no proof of abuse. The LPN was asked if she had been interviewed by the administrator or DON during the investigation. She stated, No. At 1:40 p.m., CNA #9 was asked if she had observed the maintenance supervisor in the memory unit interacting with resident #2. She stated, Yes, a couple of weeks ago I had the resident doing a one on one activity in the dining room. He came back (to the memory unit) and stood in front of us. I asked him what he wanted. He said he had to check her wheelchair. He didn't ever check her wheelchair. He then pulled up a chair and sat down directly across from her with a table between them. He was helping her do the the one on one activity. He was there less than ten minutes, he then bent over, hugged her and kissed her on the side of the face. It made me feel uncomfortable. She was asked if she had reported this incident to anyone. She stated, I told the charge nurse, but she never followed up with me. She was asked if the nurse had her write out a statement. She stated, No, she said she would take care of it. I also talked about the incident with another CNA who works on the memory unit and she said it wasn't the first time. I asked (CNA #7 name deleted) if this had been going on before. She stated the behaviors had been going on for a few weeks now, and made her feel uncomfortable. She stated she had reported it to the ADON. She was asked if the CNA had told her why it made her feel uncomfortable. She stated, Just that he had started coming back frequently to check her wheelchair when she'd been in the same wheelchair since she's been here. I never saw him check the wheelchair before. She was asked if she had noticed any abnormal behavior from the maintenance supervisor before. She stated, I had never noticed any strange behavior from him until this episode. I've never seen him interact with the residents that much really. This was just different, not his normal behavior. At 2:00 p.m., CNA #10 was asked if she had observed the maintenance supervisor interacting with resident #2 in the memory unit. She stated, Yes, he comes to the (memory) unit to visit her three or four times during the day until he goes home. He sits beside her chair and holds her hand, and talks to her. He holds her hand and puts his arm on the resident's shoulders. She was asked if she had reported his inappropriate sexual behavior to anyone. She stated, I reported it to the ADON. The ADON told me she would talk with the DON. She was asked if she had been told to write a statement or had been asked any questions about the incident of inappropriate sexual behavior. She stated, No. She stated she had also talked with the administrator approximately two weeks ago to see if anyone had talked with her about the maintenance supervisor going to the memory unit frequently to visit the resident. She stated the administrator told her she had been made aware of her concerns. The CNA was asked if the administrator had her answer any questions regarding her concerns, or write out a statement regarding her concerns. She stated, No. At 3:10 p.m., the administrator and DON were asked if all the staff who worked on the memory unit had been interviewed as part of their investigation for the incident on 08/28/18 of alleged inappropriate sexual behavior. The DON stated, No just those who were working at the time of the alleged abuse. At 3:40 p.m., the DON was asked if it was appropriate behavior for the maintenance supervisor to be hugging and kissing residents. She stated, No. On 09/06/18 at 3:28 p.m.,the ADON was asked if she had received any reports from staff regarding the inappropriate sexual behavior of the maintenance supervisor going to the memory unit frequently to see resident #2. She stated, I know that he goes down there frequently to check wander guards. Staff have told me that he goes there frequently, but they didn't say they felt it was odd. She was asked what the maintenance supervisor's work schedule consisted of. She stated she didn't know because she was over nursing, not the other facility staff. She was asked if it was normal for the maintenance supervisor to go to see the resident on the memory unit at 10:00 p.m., after he had already gone home for the night. She stated, No. 2. Three abuse investigations from 10/12/17 to 03/14/18 were reviewed. The investigation conducted on 10/12/17 for resident #9 was an allegation of abuse. The investigation conducted on 12/07/17 for resident #10 was an allegation of neglect. The investigation conducted on 03/14/18 for resident #11 was an allegation of verbal abuse. Staff and residents were not asked specific questions related to the incidents, and residents and staff from all parts of the facility had not been interviewed. On 09/05/18 at 11:10 a.m., the administrator and DON were asked if there were any allegations of abuse currently under investigation. The administrator stated, No. On 09/06/18 at 3:15 p.m., the DON was asked if thorough investigations had been completed for the abuse investigations dated 10/12/17, 12/07/17, and 03/14/18. She stated, No. She was asked why she had not completed a thorough investigation for each of the abuse investigations. She stated, When we found that some of the allegations were true, we stopped the investigation. She was asked if a thorough investigation hasn't been conducted, how can you know that it's not a widespread problem. She stated, You can't.

On 06/22/16, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure hazardous chemicals were stored/secured from resident access. The IJ situation was verified with the Oklahoma State Department of Health. At 12:26 p.m., the administrator and DON were notified of the IJ situation related to the facility's failure to secure hazardous chemicals. On 06/22/16 at 3:55 p.m., an acceptable plan of removal was provided from the facility. The plan of removal documented: .Plan of Removal Unattended and/or Unlocked carts with Chemicals. The Administrator, (name withheld) immediately did a walk through facility to check H.K. carts, linen carts, bathrooms for any hazard chemicals. Insured all chemicals were secured. Immediately following this I called Housekeepers, supervisors, and shower team for an In-service beginning at 12:25 (p.m.). I went into detail regarding safety for all residents. H.K. carts, linen carts, shampoo, razors, cleaning supplies, anything a resident could possibly drink is a hazard. I expressed to staff what a serious offense this was and immediate termination would be the result of violation. In-service continued through 2:30 (p.m.) for all staff who came in for our scheduled Inservice. Any employee who did not attend will not be able to work until In-service is provided. For those staff members who were not present for In-service phone calls will be made to those. If we are unable to reach any employee who works here, they will not be allowed to work. (Name withheld), Director of Nursing, provided In-service for all employees who came in to attend our regular scheduled In-service. Again any chemical, shampoo, shaving cream, body wash cannot be left unattended on carts, linen carts, shower rooms, bathrooms, Resident room. When you are not giving a shower, shave (sic) these must be locked in between baths. H.K. carts must be locked if you take a break. H.K. carts must be locked if you enter a room to clean. All staff in general will be monitoring All departments. (Name withheld), maintenance when making repairs will monitor. (Name withheld), administrator will monitor on a daily basis when making rounds. (Name withheld), DON, (Name withheld), ADON, will monitor daily when making rounds. Nurses on all shifts daily will check bathrooms, linen carts, H.K. carts. Weekend RN (Name withheld) will monitor on the weekend. (Name withheld) weekend charge nurse will monitor on days and evening. (Name withheld) and (Name withheld) 10 (p.m.)-6 (a.m.) nurses will monitor. QA will monitor monthly for continued compliance. Daily documentation will be done q shift for secured chemicals. Dayshift will document & monitor 3 X q shift. Evening shift document & monitor 3 X q shift. Night shift document & monitor 3 X q shift. Staff members who did not attend In-service will be notified via phone by six (p.m.) tonight 6-22-16 . An inservice record, dated 06/22/16 and titled, Chemicals & locking cabinets & carts, documented 90 staff members attended an inservice designated for all staff. A facility inservice, dated 06/22/16, documented, .Topic: Cleaning Supplies/Hazardous Materials .A major problem that needs addressed immediately is our resident's safety regarding cleaning agents or hazardous materials that are not safely secured .All carts must be locked at all times if you are not with it .If you are not facing your cart or your eyes are not on your cart, it must be locked .If your back is turned, it must be locked .This includes housekeeping, nurses, cma's, etc .If you go on break your cart should be locked up .Housekeepers-if you are cleaning a resident's room, then (sic) minute you walk away from cart, it has to be locked .There should be no cleaning supplies left unlocked in shower rooms .This also goes for hazardous materials such as shaving creams, body sprays, razors, hand sanitizer, etc .All cleaning supplies/hazardous materials have to keep secured with a lock in shower room .If you leave shower room to go get another resident, or assist back to their room, the cabinet must be locked and nothing can be left out .This also applies to the unit .Housekeepers do not leave any cleaning supplies in the unit, ever .All hazardous materials should be locked up as well such as hairspray, razors, shaving cream, glue, anything that may be hazardous if ingested must be locked in cabinet in TV room .The child proof locks in the kitchen on cabinets, is not considered a lock, and will not keep them out .Has to be lock and key .All staff be aware of surroundings to keep resident's safe .Check shower rooms and bathrooms frequently .Unit staff-at the beginning of your shift check for anything that may have been left out and can be harmful to your residents .Nursing make periodic checks in bathrooms and shower rooms during your shift .If any employee is found to have left your cart unlocked and unattended or cabinet unlocked and unattended, or chemical left out and unattended, will be terminated effective immediately . A sign in sheet documented when staff was inserviced on cleaning supplies and hazardous materials. All staff were inserviced by 06/22/16 at 3:55 p.m. The immediate jeopardy was removed on 06/22/16 at 3:55 p.m., after all components of the plan of removal were carried out. The deficient practice remained at a pattern level of no actual harm with a potential for more than minimal harm. Based on observation, interview, and record review it was determined the facility failed to: ~ Ensure hazardous chemicals were not accessible to residents in an unsecured cabinet in the dining room of the dementia unit; in an unsecured cabinet in one (The shower room between Dogwood Hall and Elm Hall) of two shower rooms; and on three of three housekeeping carts. The facility identified 11 residents who utilized the dining room of the dementia unit and six resident's who had wandering behaviors outside of the dementia unit. Resident #24 wandered in and out of resident rooms and other rooms in the facility and went through items found in those rooms. The resident was observed in the unlocked shower room where chemicals were unsecured and was wandering on the halls where the chemicals were in the unlocked housekeeping carts. ~ Ensure smoking materials were secured for one (#6 ) of two residents reviewed for smoking hazards. The facility identified 13 residents who smoked. ~ Assess wandering behaviors and elopement risks, identify causes, interventions and need for supervison and monitoring for two (#18 and #19) of seven sampled residents with wandering behaviors. The DON identified six residents who exhibited wandering behaviors. Findings: A facility policy, revised October 2015 and titled Wandering/Elopement Policy, documented, .ALL RESIDENTS WILL BE ASSESSED UPON ADMIT FOR SAFETY AND RISK FACTORS THAT MIGHT PLACE THEM IN DANGER. ANY RESIDENT THAT IS IDENTIFIED AS BEING A FLIGHT RISK WILL HAVE A WANDER GUARD MONITOR PLACED . A facility policy, dated 04/15/16 and titled Smoking Policy, documented, .Residents will not be allowed to have cigarettes or paraphernalia such as: matches or lighters in their possession or in their rooms unless approved by the facility . 1. On 06/21/16 at 4:25 p.m., the door of the cabinet below the sink in the dining area of the dementia unit was opened and a non working child safety latch was observed attached to the inside of the door. Just inside the cabinet and within easy reach was a bottle of Consume BioBowl Natural Acid Toilet Cleaner. Activity supplies were observed around the chemical bottle such as construction paper, molding clay, syrup for shaved ice, foam holiday themed cut-outs, and flexible drinking straws. An MSDS for Consume Bio-Bowl, documented, .Warning .Causes serious eye irritation .May be harmful if swallowed .May cause skin irritation .This product contains living bacterial spores .Avoid contact with open wounds, broken skin or mucous membranes .Keep out of reach of children . On 06/21/16 at 4:25 p.m., CNA #5 observed the chemical bottle and stated the maintenance department had stored the chemical under the sink after using it to remove an odor from the sink and plumbing. She was asked if residents in the dementia unit could open the cabinet. She stated, Yes, they can open it. She was asked how long the chemical had been under the sink. She stated she was not sure but knew it had been there for months. She was asked if staff were always present in the dining room. She stated staff were not always present in the dining room when one staff member went on break, the other walked the hall. She was asked if there was any restrictions on where residents went within the dementia unit. She stated, No. She was asked if residents were allowed in the dining room without staff supervision. She stated, Yes. The chemical was removed from the cabinet. On 06/22/16 at 7:50 a.m., seven residents of the dementia unit were observed in the dining room without staff supervision. On 06/22/16 at 7:52 a.m., CNA #6 was asked if residents were ever in the dining room unsupervised. She stated, No. I may go next door to get a wheelchair but that's it. On 06/22/16 at 8:15 a.m., CNA #7 was asked if staff were assigned to always stay in the dining room. She stated staff were where the residents were gathered. On 06/22/16 at 9:20 a.m., maintenance man #2 was asked when he had last worked on the kitchen sink in the dining room of the dementia unit. He stated, It's been six to eight months. I went through the plumbing to make sure there was no excessive build-up, then bleached and deodorized the sink and pipes. On 06/22/16 at 9:45 a.m., three residents of the dementia unit were observed in their day room preparing to watch a movie with staff. Resident #10 was observed wandering from resident rooms, to the hallway, and into the dining room in a repeated circuit. There were no staff present in the dining room. On 06/22/16 at 10:15 a.m., LPN #2 was observed providing treatment on the dementia unit. She was asked where chemicals were stored in the dementia unit. She stated chemicals were not to be stored under the sink but instead with housekeeping. She stated if chemicals were stored on the dementia unit, they would be locked in a cabinet. She was asked if there were wandering residents on the dementia unit. She stated, Oh yes. She was asked if it was possible for a wandering resident on the dementia unit to be in the dining room unsupervised. She stated, Definitely, yes. On 06/22/16 at 10:25 a.m., the DON was asked where chemicals were stored in the dementia unit. She stated she did not think there were any chemicals stored on the dementia unit but if there were, they would be secured in the locked closet. She was asked if there were wandering residents who resided on the secured unit. She stated, Yes. She was asked if a wandering resident could be in the dining room of the secured unit unsupervised. She stated, Yes. The DON was informed of the chemical stored under the sink in an unsecured cabinet with a non working child safety latch. She was shown the MSDS for the chemical and asked if the unsecured storage of the chemical would be considered an accident hazard. She stated, Yes. 2. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An undated care plan, documented, .has a dx of dementia .She at times wanders into offices & other's rooms .Wander guard in place as needed . An admission assessment, dated 05/06/16, documented the resident required limited assistance with ADLs and used a walker during ambulation. A nurse's note, dated 06/10/16 at 6:00 a.m., documented, .res attempting to open med room doors & tx carts .res hitting at locked doors to unit . A nurse's note, dated 06/17/16 at 3:30 p.m., documented, .Res confused and wandering in (/) out of her room & up & down halls . A nurse's note, dated 06/19/16 at 11:15 a.m., documented, .Res going into break room et going through staff's belongings .Explained to res that those belong to staff .Res stated I thought there might be candy there . On 06/22/16 at 11:39 a.m., the shower room between Dogwood hall and Elm hall was observed with both entrances open. The door of a floor mounted free standing cabinet was observed to be open approximately three inches. The cabinet contained a bottle of acid based foaming cleanser. The shower room cabinet was unattended and the foaming cleanser was within easy reach of a resident. An MSDS for foaming acid restroom cleaner, documented, .EMERGENCY OVERVIEW .DANGER .CORROSIVE TO EYES .CAUSES EYE BURNS .CAUSES SKIN IRRITATION .HARMFUL OR FATAL IF SWALLOWED .Eye contact Corrosive Causes permanent eye damage, including blindness .Skin contact .Severe skin irritation .Ingestion .Causes burns to mouth, throat and stomach . On 06/22/16 at 11:41 a.m., resident #24 was observed ambulating with a walker from the Dogwood hall entrance through the shower room and exiting out the Elm hall door. She stated she was looking for the person who had provided her a shower earlier in the day. The open cabinet containing the bottle of acid based foaming cleanser was unsecured in the unattended shower room. On 06/22/16 at 11:45 a.m., a housekeeping cart was observed to be parked outside of a soiled utility room and was unattended on Elm Hall. The top of the cart was open with the following chemicals visible and within easy reach of residents. ~one spray bottle of Odor control ~one spray bottle of Virex ~one bottle of Consume Bio-bowl cleaner An MSDS for Odor Zyme, documented, .Potential Health Effects .Inhalation .Prolonged overexposure to vapors and spray mist in poorly ventilated areas may cause nose and throat irritation .Eye Contact .Direct contact with product may cause irritation .Skin Contact .Repeated or prolonged exposure may cause skin irritation .Ingestion .May cause mouth, throat, esophagus and stomach irritation, nausea, vomiting and diarrhea . An MSDS for Virex II 256, documented, .EMERGENCY OVERVIEW .DANGER .CORROSIVE .CAUSES SKIN AND EYE BURNS .HARMFUL OR FATAL IF SWALLOWED .COMBUSTIBLE LIQUID AND VAPOR . On 06/22/16 at 11:47 a.m., housekeeper #1 came out of the closed soiled utility room and was asked what the facility policy was regarding the storage and security of chemicals. She stated the housekeeping carts were to be kept closed when in the hall or unattended. She locked the cart and stated she left the top of the cart open because her hours had been recently cut and she was in a hurry. On 06/22/16 at 11:53 a.m., a housekeeping cart was observed to be parked on Apple Tree hall with the top part unlocked and unattended. The cart contained the following chemicals: ~one spray bottle of disinfectant, ~one spray bottle of Virex II 256, and ~one bottle of Comet Cleaner with Bleach. An MSDS for disinfectant spray, documented, .Store locked up .Avoid contact with skin, eyes or clothing .Inhalation .Inhalation of vapors in high concentration may cause irritation of respiratory system .Eye Contact .May cause slight irritation .Ingestion .Ingestion may cause irritation to mucous membranes . An MSDS for Comet Deodorizing Cleanser with Chlorinol, documented, .Ingestion .Ingestion may cause gastrointestinal irritation, nausea, vomiting and diarrhea . Housekeeper #2 was observed to exit a residents bathroom and was asked what the facility policy was regarding the storage/securing of chemicals. She stated they were to keep the cart lids closed and locked when they left the cart unattended. She was asked if she had left the unlocked housekeeping cart unattended. She stated she was in the residents bathroom. She stated they do not always lock the carts when they leave them unattended. On 06/22/16 at 11:56 a.m., a housekeeping cart was observed on Dogwood Drive hall to be unlocked and unattended. The cart was observed to contain the following. ~one spray bottle of Virex II 256, and ~one spray bottle of disinfectant. Housekeeper #3 was observed to come out of the residents bathroom and was asked what the facility policy was for the storage/securing of chemicals. She stated they were to keep the housekeeping cart locked when unattended but when she would go from room to room she would keep it unlocked so she could easily access the cleaning agents. A nurse's note, dated 06/23/16 at 12:10 a.m., documented, .Res (up) in w/c, trying to get inside nurses station .Res redirected .Res also attempting to go in other rooms/unit .Indep with transfers .self propels in w/c, also able to ambulate (with) wheeled walker . A nurse's note, dated 06/23/16 at 9:30 p.m., documented, .resident going in and out of residents rooms, going through their belongings, resident re-directed, resident observed with break room key, laundry room key and (one) other key . On 6/27/16 at 2:26 p.m., the housekeeping supervisor was asked what the facility policy was regarding the storing and securing of chemicals. She stated chemicals were to be locked at all times. She was asked who was responsible to ensure chemicals were safely secured and/or stored. She stated all employees. She was asked how chemicals were to be stored and/or secured safely. She stated they were to be locked up at all times. The housekeeping supervisor was asked how the storage of chemicals was monitored by the facility. She stated she periodically monitored the housekeeping carts. She was asked where the monitoring of chemicals was documented. She stated it was not documented. On 06/27/16 at 4:15 p.m., the DON was asked how chemicals were stored in the facility. She stated, They should be locked and secured. She was asked who was responsible for ensuring chemicals were locked and secured. She stated, The person using them. The DON was asked how the facility monitored the safe storage of chemicals. She stated, Housekeeping should monitor. They (chemicals) never should have been in the shower room or the unit. On 06/27/16 at 4:57 p.m., the administrator was asked what the facility policy was regarding the storage of chemicals. She stated chemicals were to be locked up at all times. She was asked who was responsible to ensure chemicals were safely stored in the facility. She stated maintenance and housekeeping. The administrator was asked how the facility monitored the storage of chemicals. She stated the storage of chemicals was something she monitored during her daily walk through of the facility. She stated she felt she had not completed a thorough walk through of the facility because she had been in the shower room three times the morning the chemicals were observed unsecured and unattended in the open shower room cabinet. 3. Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. A safe smoking evaluation, dated 04/22/16, had the following items documented with a check mark, .Resident may smoke independently or with set up .Resident may smoke unsupervised in designated smoking areas .Resident must request smoking materials from staff . A handwritten entry, in the comments section of the safe smoking evaluation, documented, .spoke (with) res & talked about smoking only while sitting. He agrees and stated he will follow all smoking rules . An annual assessment, dated 06/08/16, documented the resident was independent in cognitive skills for daily decision making, was independent with transfers and ambulation, had limited range of motion on one side for upper and lower extremities, and was a smoker. The current care plan documented, .(Resident) is a smoker .supervise him as needed .provide a smoking apron as needed for safety .smoking in bed is strictly prohibited .a smoking assessment will be per facility protocol . On 06/21/16 at 10:28 a.m., three packages of cigarettes and two lighters were observed laying on top of the overbed table in the resident's room. The resident was not observed in the room. On 06/22/16 at 3:00 p.m., three package of cigarettes and two lighters were observed laying on top of the overbed table in the resident's room. The resident was not observed in the room. On 06/23/16 at 5:00 p.m., two closed packages of cigarettes, one open package of cigarettes, and a lighter were observed laying on top of the overbed table. The resident was not observed in the room. On 06/27/16 at 8:50 a.m., resident #6 was observed laying in bed with two packages of cigarettes and a lighter laying on the overbed table. He was asked if he was permitted to keep smoking materials in his room. He stated, Yes. On 06/27/16 at 1:35 p.m., resident #6 was asked how often he smoked. He stated every two to three hours. He was asked if staff were present when he smoked. He stated staff were present in the designated smoking area when he smoked. On 06/27/16 at 1:45 p.m., CNA #4 was asked if residents were allowed to keep cigarettes and lighters at their bedside. She stated the independent residents could keep smoking materials at bedside, but the dependent residents smoking materials were secured in the medication room. The CNA was asked if resident #6 required supervision when he smoked. The CNA stated, Yes. On 06/27/16 at 1:58 p.m., LPN #3 was asked if residents were allowed to keep cigarettes and lighters at their bedside. She stated, cigarettes and lighters were kept in the medication room. The LPN was asked if resident #6 required supervision when he smoked. She stated the resident was independent with smoking. On 06/27/16 at 4:30 p.m., the DON was asked who was responsible for completing the smoking evaluation. She stated the charge nurses were responsible for completing the smoking assessment at admission and quarterly. She was asked if resident #6 was independent with smoking. She stated after the recent policy change, he was found to be independent with smoking. The DON was asked if the resident was allowed to keep cigarettes and lighters in his room. She stated, No. She was asked if she was aware resident #6 had cigarettes and lighters on his overbed table. She stated, No, he is not suppose to have them in his room. On 06/27/16 at 5:15 p.m., the administrator was asked if residents were allowed to keep cigarettes and lighters at bedside. She stated if they are independent with smoking they are allowed to keep cigarettes and lighters in their possession. She was asked if having cigarettes and lighters in a resident's room would present a potential safety hazard for wandering residents. She stated she did not believe it would present a hazard because the facility encouraged residents to keep lighters in their purses. She was asked if resident #6 was independent with smoking. She stated Yes. The administrator was asked to review the safe smoking evaluation, dated 04/22/16, for resident #6. She was asked if the evaluation documented the resident was to request his smoking materials from the staff. She stated, Yes. She stated after the smoking policy had been reviewed and revised, she had discussed revising the smoking evaluation form with the DON. She stated it had been her mistake the section requesting smoking materials be maintained by staff had not been removed from the evaluation. The administrator was informed of the observations viewed from the hallway of smoking materials left unattended and unsecured on a resident's overbed table. She was asked if smoking materials left unattended and unsecured on a resident's overbed table would be considered a hazard. She stated, Apparently, it is. 4. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 02/22/16, documented the resident was severely impaired in cognition, required extensive assistance with most ADLs, and had not exhibited any wandering behaviors for seven days during the seven day look back period. A quarterly assessment, dated 05/23/16, documented the resident was severely impaired cognition, required extensive assistance with most ADLs, and had not exhibited any wandering behaviors for seven days during the seven day look back period. A care plan, revised on 05/26/16, documented, .wanders throughout the facility in her w/c at X's .Document behavior and confer with MD as needed .She has a wander guard in place . On 06/23/16 at 11:30 a.m., the resident was observed in the hallway in her wheelchair. A wander guard monitor was observed on her wheelchair. On 06/23/16 at 3:30 p.m., the resident's clinical record was reviewed. There was no documented wandering/elopement assessment found in the clinical record. On 06/27/16 at 4:13 p.m., the DON was asked if resident #18 had a wandering/elopement assessment and if so where could the assessment be found. She stated the facility did not do a formal elopement assessment, but there should be documentation in the nurse's notes. She was asked if the resident had any documentation in her nurse's notes regarding her wandering behavior. The DON stated she did not know. 5. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual assessment, dated 08/24/15, documented the resident was severely impaired in cognition and had not exhibited any episodes of wandering for seven days during the seven day look back period. A quarterly assessment, dated 05/23/16, documented the resident was severely impaired in cognition and had not exhibited any episodes of wandering for seven days during the seven day look back period. On 06/22/16, resident #19 was documented on a list of residents who had been identified by the facility as exhibiting wandering behaviors. On 06/23/16 at 10:35 a.m., the resident was observed in his wheelchair, by the front door of the facility, as his family exited the building. A wander guard was observed on his wheel chair and sounded as he approached the front door with his family. Review of the resident's clinical record did not reveal an assessment for the use of the wander guard. On 06/23/16 at 10:50 a.m., the DON was asked if resident #19 exhibited wandering behavior. She stated, Yes. The DON was asked what assessment the facility completed for the use of a wander guard. She stated, We don't do a formal assessment. She was asked what criteria was met for a wander guard to be placed on resident #19. She stated the resident had a history of [REDACTED]. She stated the resident was not aware of his surroundings or the temperature outside. She was asked where the rationale was documented for the use of the wander guard. She reviewed the resident's clinical record including the care plan. She stated she could not find any documentation for the use of the wander guard.

Based on observation, interview, and record review, it was determined the facility failed to assess, monitor, and intervene in a timely manner for complaints of pain for one (#6) of six sampled residents whose records were reviewed for pain management. The facility identified 50 residents who received pain management. Findings: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital discharge summary, dated 05/02/15, documented, .Diagnosis: [REDACTED].SPECIAL INSTRUCTIONS .NOTIFY PHYSICIAN .Chest pain . A chest x-ray, dated 05/06/15, documented, .IMPRESSION .Mild left basilar atelectasis . A physician order, dated 05/06/15, documented, .[MEDICATION NAME] 2.5mg/3ml 0.083% (one) vial updraft Q6 (hours) routine .[MEDICATION NAME] 500mg (one) P.O. Q Day X 5 days .[MEDICATION NAME] 20mg (one) P.O. TID X 3 days .DIAGNOSIS .L basilar atelectasis . A chest x-ray, dated 05/12/15, documented, .The study was compared to 05/06/15 .Cardiomegaly is present .There is no infiltrate, effusion or mass .IMPRESSION .Cardiomegaly . A quarterly assessment, dated 05/20/15, documented the resident was cognitively intact for daily decision making, and received oxygen therapy. A physician order, dated 05/26/15, documented .DC [MEDICATION NAME] 2.5mg/3ml 0.083% (one) vial Q 6 (hours) routine .(Change) to [MEDICATION NAME] 2.5mg/3ml 0.083% (one) vial BID per HHN @ 0600 & 2200 .DIAGNOSIS .SOB . A chest x-ray, dated 06/09/15, documented, .IMPRESSION .Right base infiltrate . A physician order, dated 06/09/15 at 8:00 a.m., documented, .Z-Pack P.O. as directed .[MEDICATION NAME] dose pack P.O. as directed .DIAGNOSIS .cough/wheezing . A physician order, dated 06/09/15 at 5:00 p.m., documented, .[MEDICATION NAME] 1 gram IM X 2 days . A physician progress notes [REDACTED].Pt reports he is having congestion .Lungs .Scattered rhonchi . A physician order, dated 06/16/15, documented, .[MEDICATION NAME] 1 gram IM X 3 days . A facility policy titled, Pain Policy, dated 07/31/15, documented, .The goal is to alleviate or minimize pain while assisting the resident to maintain as high a level of functioning as possible . A quarterly assessment, dated 08/19/15, documented the resident was cognitively intact for daily decision making, and received oxygen therapy. The resident's care plan, dated 08/20/15, documented, .(Resident #6) HAS RECURRENT [MEDICAL CONDITION] WITH CONGESTION AND COUGH and @ times, pneumonia .RESIDENT WILL BE HELPED TO FEEL BETTER AND BREATH (sic) EASY .MONITOR RESIDENT'S LUNG SOUNDS AND SP02 .RESIDENT TAKES [MEDICATION NAME] D 1 P.O. BID PER ORDERS .RESIDENT HAS [MEDICATION NAME] TX PER MD ORDERS AS NEEDED FOR SOB .[MEDICATION NAME] DOSE PACK AND/OR ANTIBIOTICS PER MD ORDERS AS NEEDED .CONFER WITH MD AS NEEDED . A pain assessment, dated 08/26/15, documented, .MEDICATIONS: Tylenol 325mg q day .RELATED Diagnosis: [REDACTED].RELATED DIAGNOSIS .Chest Pain . A monthly physician order, dated September 2015, documented, .[MEDICATION NAME] Tab(s) 0.4 MG 1 TAB SL Q 5MINUTES UP TO 3 DOSES PRN IF NO RELIEF CALL DOCTOR CHEST PAIN ST: 05/02/2015 .[MEDICATION NAME] SULFATE ml (2.5 MG/3 ML) 0.083%-1VIAL VIA HHN BID @ 0600 AND 2200 .DX: SHORTNESS OF BREATH .ST: 05/26/15 .[MEDICATION NAME] Tab(s) 325 MG 2 TABS (650MG) PO BID .NTE 4 GM IN 24HRS FROM ALL SOURCES .DX: PAIN .ST: 05/02/15 .[MEDICATION NAME] SULFATE ml (2.5MG/3ML) 0.083%-1 VIAL VIA HHN Q 4HRS PRN SHORTNESS OF BREATH/COUGH .ST: 05/02/15 . The resident's MAR, dated September 2015, documented on 09/14/15 resident #6 received Tylenol 325mg (two tablets) at 9:00 a.m. as per routine order, and Tylenol 325mg (two tablets) at 1:50 p.m. as per prn order. The reason the medication was administered and the effectiveness was not documented on the MAR. A physician visit summary, dated 09/04/15, documented, .HISTORY .CC .Cough .Some congestion .No problems reported by staff .Noted yesterday to have elevated BP and extra [MEDICATION NAME] ordered .Respiratory .Rhoncii (sic) . scattered .ASSESSMENT/PLAN .URI continue current treatment . On 09/14/15 at 8:34 a.m., resident #6 was observed sitting in the lobby area with a nasal cannula in place attached to an oxygen concentrator. CNA #1 approached resident #6 and asked, (Name withheld) you okay? The resident stated, No. CNA #1 asked resident #6, What's wrong? Are you hurting? He nodded yes. CNA #1 asked resident #6, Where do you hurt? He stated his chest. The CNA informed the resident she would report this to the nurse. On 09/14/15 at 8:38 a.m., LPN #1 stated to resident #6, She's getting you something for pain, ok? He nodded yes. At 8:40 a.m., CMA #1 approached the resident and gave him a small medication cup and assisted him with a drink of water. At 8:50 a.m., LPN #1 approached the resident and stated, Did that help? He nodded no. LPN #1 asked, Not at all? He nodded no. LPN #1 asked, Did it make your tummy upset? He nodded yes. LPN #1 asked, Ok so it's not hurting but it made your tummy upset? He nodded yes. LPN #1 stated, Ok let me see what we can do. On 09/14/15 at 9:08 a.m., LPN #1 informed the resident she had paged the physician and was waiting for a return call. At 9:47 a.m., LPN #1 stated to CMA #1, He should have [MEDICATION NAME], I found it in the chart finally. At 9:51 a.m., CMA #1 approached the resident and stated, Here's your medicine and there's a nausea pill for your stomach. She assisted him with the medication and a drink of water. The resident adjusted his hat and closed his eyes. At 10:09 a.m., medical records staff #1 approached the resident and asked, You doing okay today. He nodded no. She asked, You hurt or just feel yucky? He nodded yes. At 10:32 a.m., the resident remained seated in the lobby area with a nasal cannula in place attached to an oxygen concentrator. No assessments had been completed by the nursing staff. A nurses note signed by LPN #1, dated 09/14/15 at 10:55 a.m., documented, .This morning res c/o stomach being upset PRN [MEDICATION NAME] given this res c/o pain in stomach PRN Tylenol given Now res c/o (nausea without vomiting) PRN given for this and left message with Dr . On 09/14/15 at 11:26 a.m., CNA #1 was asked what her knowledge was of the resident. She stated he liked to be in the lobby, liked Pepsi, was talkative, liked to dance with her, was continent of urine, and she thought he didn't feel well that day. CNA #1 was asked how often resident #6 complained of pain. She stated he did not complain very often. She was asked when she had last heard the resident complain of pain. She stated it had been earlier in the morning. CNA #1 was asked if the resident had specified where he was experiencing pain. She stated, He said his chest was hurting him, so I told his nurse and med aide. CNA #1 was asked which nurse and medication aide she had reported his complaint to. She identified CMA #1 and LPN #1 by name. CNA #1 was asked what she reported to LPN #1 and CMA #1. She stated, I just said he wasn't feeling good, his chest was hurting and he wanted something for pain. At 11:30 a.m., CNA #1 approached the resident who was seated in the lobby area. She asked, Are you still hurting? He nodded yes and pointed to his right and left chest area and his mid upper abdomen. At 11:50 a.m., the surveyor asked the resident if he was not feeling well. He nodded no. He was asked where he hurt. He placed his left hand on the right chest area. He was asked if it hurt to breathe. He nodded yes. On 09/14/15 at 1:30 p.m., CMA #1 was asked about the resident's medical history. She stated she did not know. She was asked what medication she had administered to resident #6. She stated she had administered Milk of Magnesia, a nausea medication, [MEDICATION NAME], and Tylenol. She was asked why Tylenol had been administered. She stated, He complained of pain in his chest. She was asked who had reported to her the resident was experiencing chest pain. She stated the nurse aide and the nurse had asked her to give him Tylenol. CMA #1 was asked who she had reported his complaint of chest pain to. She stated the nurse. She was asked what the facility's protocol was for pain assessment. She stated when a pain medication was administered, vital signs and the residents' pain level was obtained. CMA #1 was asked how she assessed the resident's pain. She stated, I didn't. She was asked what had been done as a follow up after receiving pain medication. She stated she had not made it back to the resident but she was informed he was still experiencing pain, and was going to see if he could receive any additional medications. She was asked how long it had been since she had been informed of the resident still experiencing pain. She stated, About 40 minutes now. CMA #1 was asked who was responsible to assess the resident's pain after pain medication had been administered. She stated, I am. CMA #1 was asked in her professional opinion if she had adequately assessed resident #6's pain. She stated, No. On 09/14/15 at 1:48 p.m., LPN #1 was asked her knowledge of the resident's medical history. She stated he had a history of [REDACTED]. LPN #1 was asked what medications resident #6 had received during her shift. She stated he received [MEDICATION NAME] and Tylenol between 8:00 a.m. and 9:00 a.m. He later complained of nausea after he received Tylenol, and [MEDICATION NAME] was administered. She stated she attempted to notify the physician who was out of town and was awaiting a return call. LPN #1 was asked why resident #6 had received Tylenol. She stated for stomach pain. She was asked who assessed his pain. She stated one of the staff asked her to give him something for pain. LPN #1 was asked if she had asked resident #6 where his pain was located. She stated, Yes, I asked is your stomach bothering you. LPN #1 was asked what the resident's response was. She stated he nodded yes. She was asked what assessment was completed for the resident's stomach pain. She stated, My assessment was, does your stomach hurt? She stated if Tylenol had not helped she would get him something else for pain. LPN #1 was asked who had reported resident #6 was having pain. She stated the administrator informed her and she had reported it to the medication aide. She was asked what assessment was completed after resident #6 received Tylenol. She stated she asked the resident if the pain medication was effective and he complained of nausea at that time. LPN #1 was asked what the facility's protocol was regarding pain assessment. She stated if the resident had more than one medication they used a pain scale. LPN #1 was asked what the resident had rated his pain prior to receiving Tylenol. She stated, I did not ask him. If it didn't work I was going to get him something else. LPN #1 was asked who was responsible for the assessment of pain before administering pain medication. She stated, I am. I get the medication he needs and get with the doctor if that is not adequate. LPN #1 was asked in her professional opinion if she had adequately assessed the resident's pain before administering pain medication. She stated the pain medication was effective. She stated, If he had more medication available I would have asked in more detail the pain rating. A nurses note signed by LPN #1, dated 09/14/15 at 2:00 p.m., documented, .Spoke with Dr (name withheld) d/t Dr (name withheld) out of clinic .New order for chest x-ray, CBC & BMP .CN was able to listen to res lungs .rubbing noted mostly to upper L lobe .CN asked res if his stomach hurt he shook his head yes .CN then asked res to show where & he placed his hand on his upper stomach . On 09/14/15 at 2:09 p.m., the DON was asked her knowledge of resident #6's medical history. She reviewed the resident's clinical record and stated in June he was on [MEDICATION NAME] for three days for pneumonia, and cough with wheezing. The DON was asked what assessment would be completed when a resident complained of chest pain and difficulty breathing. She stated vital signs, pain description, listen to lung sounds, do a full assessment, and call the doctor. She was asked who was responsible for completing an assessment when a resident complained of chest pain and difficulty breathing. She stated, Any LPN. She was asked in her professional opinion was resident #6's pain adequately assessed. She stated, No.

Based on observation, interview, and record review, it was determined the faclility failed to ensure paint medication was administered properly and low air loss pressure mattress functioned properly for one (#11) of three sampled residents who had pain. This had the potential to affect all 75 residents who resided at the facility. Findings: The instruction manual for the low air loss/alternating pressure mattress for resident #11 documented .Operations .The pressure adjustment knob controls the air pressure in the mattress. Turning the knob clockwise will increase the pressure; counter-clockwise decreases the pressure. Higher pressures will support heavier patients. The pressure should be adjusted according to individual comfort preferences .You can also check if the pressure is suitable for the patient by sliding one hand beneath the air cells at the level of the patient's buttocks. The air cells will alternately inflate and deflate. You should feel slight contact with the buttocks when the air cells beneath the buttocks deflate .The ALTERNATE/STATIC switch selects between Alternate Pressure mode and Static Pressure mode. With Alternate Pressure mode, alternating air cells are partially deflated and inflated, avoiding prolonged pressure on any single point beneath the patient; this is to prevent pressure ulcers. With Static Pressure mode, all of the air cells are equally inflated. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/12/15, the hospice care plan notes documented, .Facility nurse, (name omitted), states pt buttocks often painful and limiting sitting time and frequent turning helps . The hospice care plan, dated 06/22/15, documented, .Impaired Skin Integrity .Wound Location. Coccyx upper et lower .Interventions .Provide an alternating pressure pad for the bed . The significant change assessment, dated 06/24/15, documented the resident received hospice services and experienced occasional moderate pain. On 06/29/15, the hospice care plan notes documented, .Pt. C/O increased bottom pain where wounds are . On 07/06/15, the hospice care plan notes documented, .Increased pain d/t worsening coccyx wound noted. New pain med order changes noted . A hand written physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. On 07/29/15 at 1:25 p.m., LPN #1 was observed to administer the liquid [MEDICATION NAME] with a needleless syringe into the mouth of the resident and then provide the resident with a drink of water. The resident drank the water and swallowed. The resident was observed laying in bed. The resident did not appear to sink into the bed. The resident was asked if he had pain. The resident stated his buttocks hurt very badly all the time. The resident was asked if the pain medication was effective. The resident shrugged a shoulder slightly and stated the medicine helped but his buttocks always hurt. The resident was observed to lay on an air mattress with the dial setting at approximately 160 and the switch set to static air flow. On 07/29/15 at 5:26 p.m., LPN #6 was observed to administer the liquid [MEDICATION NAME] with a needleless syringe into the mouth of the resident and then provide the resident with a drink of water. The resident drank the water and swallowed. The resident was observed laying in bed. The resident did not appear to sink into the bed. The resident was asked if he was in pain. The resident stated his buttocks always hurt bad. The settings for the air mattress the resident lay on remained at approximately 160 on the dial and the switch set to static air flow. On 07/30/15 at 10:15 a.m., LPN #1 was asked how soon could the resident drink fluids when administered a liquid sublingual medication. The LPN stated, .As long as it is in their mouth and it is absorbing, they can drink what they want when they want. On 07/30/15 at 10:25 a.m., LPN #2 was asked how soon could the resident drink fluids when administered a sublingual liquid medication. The LPN stated she would tell the resident to wait a few minutes before drinking fluids to allow the medication to be absorbed. On 07/30/15 at 11:15 a.m., resident #11 was observed laying in bed and did not appear to sink into the bed. The bed felt very hard. The resident was observed to lay on an air mattress with the dial setting at approximately 160 and the switch set to static air flow. The resident was asked if he was in pain. The resident stated his rear hurt bad. He was asked what the pain was like. He stated the pain was sharp. The resident was asked if he received pain medication. He stated yes. The resident was asked if the pain medication was effective. He stated the medication helped but his buttocks always hurt. The resident was asked if it effected his quality of life. He raised his voice and stated, Yes. On 07/30/15 at 3:10 p.m., the DON was asked what the facility policy was for administering fluids with sublingual medications. She stated you do not provide fluids with sublingual medications because the medication would not stay under the tongue and wound not be absorbed as well in the stomach. At 4:00 p.m., LPN #6 was observed to perform a dressing change to the resident's coccyx. The resident was asked to roll onto his left side. The resident did not sink into the bed. The resident was observed to lay on an air mattress with the dial setting at approximately 160 and the switch set to static air flow. After the dressing, the resident was asked if he was in pain. He stated his buttocks hurt bad. On 07/30/15 at 4:40 p.m., the DON was asked what were the settings for the air mattress for resident #11. She stated she would have to look up the information. At 5:10 p.m., the DON returned and that she did not know the settings for the bed except that the bed should be set for alternating pressure. At 6:20 p.m., the DON stated she had changed the settings for the bed for resident #11. The bed was observed to be set with the dial at 125 and the switch set to alternating pressure. The DON asked the resident if the bed was still hard. The resident answered loudly, Yes. The DON asked the resident if the bed hurt the his buttocks. The resident answered loudly and with emphisis, Yes. The DON was asked what the ordered settings were for the bed. She stated she had only found documentation it was to be set for alternating pressure. The DON was asked how the instruction manual documented setting up the bed for resident use. She stated she did not have a copy of the instruction manual. On 07/30/15 at 6:35 p.m., resident #11 was asked if he felt comfortable in his bed. He stated his bed hurt. He was asked if he had informed anyone about his bed. He stated, he informed the staff the bed was hard. He was asked who he had told about his bed. He stated he could not remember their name. He was asked when he had informed someone about his bed. He stated he did not remember when but he had complained about the bed often. On 07/30/15 at 7:00 p.m., the DON was asked who was responsible to ensuring therapeutic air mattresses were set up properly for resident use. She stated nursing was responsible for ensuring the therapeutic air mattresses were set up properly.

Based on observation, interview, and record review, it was determined the facility failed to provide and implement interventions to aid in the healing of pressure ulcers for two (#1 and 11) of three sampled residents with pressure ulcers. This resulted in actual harm to resident #1 when the facility did not change treatments, notify the physician, or obtain treatment supplies in a timely manner for a non-healing pressure ulcer. The facility identified three residents with pressure ulcers. Findings: The facility's undated policy on pressure sore monitoring documented, .On a weekly basis, the charge nurse will .provide assurance that the primary physician has been alerted to the following: .Sores that do not appear to respond to treatment or do not improve .sores that worsen in condition nor increase in size . The directions for the use of PolyMem WIC Wound Filler documented, .PolyMem WIC wound filler products are dressings which may be paced into open wounds to eliminate dead space, absorb exudate, and help establish and maintain the appropriate moisture balance of exposed tissues. They provide fast wicking, gently expand (a out 1/3) to fill space, and help create an optimal healing environment .Precautions .Trim so the filler is about 1/3 smaller than the open cavity or tunnel width .Directions for use (-) Eliminate cavities by gently filling .Application (-) .Size - cavity filler and rope will gently expand about 1/3 when absorbing fluid. Therefore, they should be smaller and thinner than the wound by 1/3 .For tunneling wounds, rope should be narrower than the tunnel or wound .For open wounds, gently place one or more layers of Cavity Filler .For tunneling wounds .Do not overfill by forcing . The package documented the dressing material measured 1.2 x 0.4 x 14 cms. The instruction manual for the low air loss/alternating pressure mattress for resident #11 documented .Operations .The pressure adjustment knob controls the air pressure in the mattress. Turning the knob clockwise will increase the pressure; counter-clockwise decreases the pressure. Higher pressures will support heavier patients. The pressure should be adjusted according to individual comfort preferences .You can also check if the pressure is suitable for the patient by sliding one hand beneath the air cells at the level of the patient's buttocks. The air cells will alternately inflate and deflate. You should feel slight contact with the buttocks when the air cells beneath the buttocks deflate .The ALTERNATE/STATIC switch selects between Alternate Pressure mode and Static Pressure mode. With Alternate Pressure mode, alternating air cells are partially deflated and inflated, avoiding prolonged pressure on any single point beneath the patient; this is to prevent pressure ulcers. With Static Pressure mode, all of the air cells are equally inflated. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].cleanse area to (right) gluteal fold with NS, pat dry, apply Xenederm q shift and prn . The order documented there was shearing to the area. Wound care flow sheets, dated 11/24/14, documented the resident had two wounds on her right gluteal fold. It was documented the first wound was 3.0 x 2.0 cms and was caused by shearing. It was documented the second wound measured 2.5 x 2 cms and was caused by scratching. A physician's orders [REDACTED]. It was documented to treat the second wound with Santyl and collagen daily until resolved. A wound care flow sheet, dated 11/25/14, documented, .area #1 and #2 on (right) gluteal fold combined. res scratching wound bigger .continue c same tx: collagen, Santyl, (and) cover daily . It was documented the area was 7.5 x 5.0 cms; and the wound bed was beefy red with 30% slough. A physician's orders [REDACTED].#1 and #2. It was documented to treat the right gluteal fold wound with Santyl and collagen daily and as needed until resolved. Weekly wound sheets documented the following: ~ 12/02/14 - 9.0 x 6.5 cms. It was documented the wound bed was pink and 70% slough. It was documented the wound had deteriorated; ~ 12/09/14 - 8.0 x 6.0 cms. It was documented the wound bed was 20% beefy red and 80% eschar. It was documented the wound had improved; ~ 12/16/14 - 10.0 x 8 cms. It was documented the wound had purulent drainage; the wound bed was 10% slough and 90% eschar; and the peri wound was macerated. It was documented the wound had deteriorated; and ~ 12/23/14 - 8.0 x 7.5 cms with an undetermined depth. It was documented the wound bed was 20% pink and 80% slough. No eschar or drainage was documented. It was documented the wound had improved. A physician's orders [REDACTED]. A weekly wound sheet, dated 12/30/14, documented the wound was 8.0 x 9.0 with an undetermined depth. It was documented, .#1 (and) #2 . It was documented the wound bed had 90% yellow black slough; the odor was foul, and the peri wound was macerated. A physician's orders [REDACTED]. Review of the clinical record revealed no documentation the wound treatment had been changed from the time it was first identified on 11/25/14 until the resident was sent to the hospital on [DATE]. admission orders [REDACTED]. It was documented the services were to start on 01/26/15. A weekly wound sheet entry, dated 01/22/15, documented the resident had returned from the hospital. It was documented, .wound now consider (sic) stage IV . It was documented the pressure ulcer measured 4.5 x 6.5 x 3 cms and had a beefy red wound bed. It was documented the [DEVICE] was in use. A wound clinic visit note, with a fax date of 01/27/15, documented the resident had a stage IV pressure ulcer. It was documented the wound had infection; was non-healing; was at a vulnerable pressure point; and was in a difficult to dress location. The pressure ulcer measurements were 6.0 x 2.8 x 5 cms. It was documented there was no tunneling or undermining. It was documented there was 100% pink healthy tissue. A weekly wound sheet, dated 02/05/15, documented the pressure ulcer was 6.0 x 6.5 x 4.0 cms. It was documented the wound bed was beefy red with some yellow; foul odor was noted; and the pressure ulcer had deteriorated. A physician's orders [REDACTED]. Weekly wound sheets documented the following: ~ 02/10/15 - 6.5 x 6.5 x 5.0 cms. It was documented the wound bed was red and yellow, no odor was noted, and the ulcer had deteriorated. It was documented the dressing treatment had been changed to calcium alginate with silver; and ~ 02/17/15 - 6.5 x 6.0 x 3.0 cms. It was documented the wound bed was red, there was no odor, and the ulcer had improved. A physician's progress note, dated 02/21/15, documented, .patient has been going to wound care .now being turned over to (Quail Ridge Living Center) .wound down to 6 cm and improving . A weekly wound sheet, dated 02/24/15 documented the ulcer was 5.5 x 6.0 x 3.0 cms. It was documented the would bed was red, there was no odor, and the ulcer had improved. A physician's orders [REDACTED]. A quarterly assessment, dated 03/03/15, documented the resident was cognitively intact; required extensive assistance with bed mobility and personal hygiene; was totally dependent for transfers; was at risk for developing pressure ulcers; and had one stage II pressure ulcer. A weekly wound sheet, dated 03/03/15, documented the ulcer measured 6.0 x 7.0 x 4.5 cms. It was documented the wound bed was beefy red, no odor was noted, and the ulcer had deteriorated. Two physician's orders [REDACTED]. Weekly wound sheets documented the following: ~ 03/10/15 - 5.5 x 5.0 x 3.5 cms with tunneling of 5.0 cms at the 2 o'clock position; tunneling of 7.0 cms at the 6 o'clock position; and tunneling of 5.0 cms at the 8 o'clock position. It was documented the wound bed was beefy red, and no odor was noted. It was not marked if the ulcer had improved, deteriorated, or stayed the same. ~ 03/17/15 - 5.5 x 5.0 x 4.0 cms with tunneling of 5.0 cms at the 2 o'clock position, and tunneling of 6.0 cms at the 6 and 7 o'clock positions. It was documented there was no odor. It was not marked if the ulcer had improved, deteriorated, or stayed the same; and ~ - 03/24/15 - 5.0 x 3.5 x 4.0 cms with tunneling of 4.8 cms at the 2 o'clock position and tunneling of 6.0 cms at the 7 o'clock position. It was documented the ulcer had improved. A physician's progress note, dated 03/26/15, documented, .previous wound is healing well according to nurses . Weekly wound sheets documented the following: ~ 03/31/15 - 4.5 x 3.5 x 4 cms with tunneling of 6.0 cms at the 2 o'clock position and tunneling of 6.5 cms at the 7 o'clock position. It was documented the ulcer had improved; ~ 04/07/15 - 4.0 x 3.0 x 4.0 with tunneling of 5.0 cms at the 2 o'clock position and tunneling of 6.5 cms at the 7 o'clock position. It was documented the ulcer had improved; ~ 04/14/15 - 4.5 x 2.5 x 5.0 cms with tunneling of 8.0 cms at the 2 and 7 o'clock positions. It was documented the ulcer had improved; ~ 04/21/15 - 4.0 x 2.5 x 9.0 cms with tunneling of 9.0 cms at the 2 o'clock position and 8.0 cms at the 7 o'clock position. It was documented the ulcer had improved; and ~ 04/28/15 - 3.3 x 2.0 x 9.0 cms. There was no tunneling documented. It was documented the ulcer had improved. Review of the clinical record revealed no documentation to show any treatment changes had been made from 02/09/15 through 04/28/15. There was no documentation to show the physician had been made aware of the tunneling or other status of the ulcer. A wound care consultant form, with a fax date of 04/28/15, documented, .3.3 x 2.0 x 1.0 (sic) .tunneling .non .undermining .none .facility acquired .Physician plan for silver collagen. Silver Collagen indicated to continue to encourage deposition of an organization of newly formed collagen fibers and granulation tissue .Foam to conform to wound site, cushion against inadvertent trauma .Treatment intervention: Cleanse per facility protocol. Pack with silver collagen. Secure with transparent dressing. Change daily and PRN . A facsimile to the physician, dated 04/28/15, documented, .Area to (right) gluteal fold .is healing from outside in, wound nurse consultant in recommends changing tx to cleanse and flush wound c NS, pat dry, pack c silver collagen, cover c foam dressing secure c transparent dressing. Change daily (and) prn. May we change to this when supplies come in . The facsimile was signed by the physician and noted by the facility on 05/01/15. A physician's orders [REDACTED].DC wound care using [MEDICATION NAME] AG rope when supplies for new tx are in facility(.) Cleanse Irrigate wound bed c NS pat dry pack c silver collagen (and) cover c foam drsg. Secure with opsite q day (and) prn. Start when supplies are in .stage IV pressure ulcer . A weekly wound sheet, dated 05/05/15, documented the ulcer was 3.5 x 1.5 x 9.0 cms. It was documented there was no change in the ulcer. A physician's progress note, dated 05/08/15, documented, .right leg wound is healing and is half of the size previously .patient has a 2 cm open lesion right leg at the gluteal area. Apparently healing well . An entry on the weekly wound sheet, dated 05/10/15, documented, .order changed on 5-10-15 to collagen silver . The order was originally written on 05/01/15. Review of treatment sheets, dated 05/2015, revealed documentation the new treatment was not started until 05/11/15, ten days after the order was originally received. A physician's orders [REDACTED].clarification order DC irrigate wound bed c NS. Pat dry pack c [MEDICATION NAME] AG rope. Cover packing c [MEDICATION NAME] Extra cut to fit wound bed . Weekly wound sheets documented the following: ~ 05/12/15 - 3.0 x 1.5 x 8.5 cms. It was documented the ulcer had improved; ~ 05/18/15 - 3.0 x 1.5 x 8.5 cms. It was documented the ulcer had not changed; ~ 05/26/15 - 3.0 x 1.0 x 8.0 cms. It was documented the ulcer had improved; ~ 06/02/15 - 3.5 x 1.4 x 8 cms. It was documented the ulcer had deteriorated. A yearly assessment, dated 06/02/15, documented the resident was cognitively intact; required extensive assistance with bed mobility and personal hygiene; was totally dependent for transfers; and had one stage IV pressure ulcer. The resident's care plan, dated 06/04/15, documented a problem of an actual pressure ulcer. The goal was the resident would be free of ongoing skin breakdown. Interventions included to provide treatments and dressings per physician orders; confer with physician as needed; and to go to the wound clinic as needed. An entry on the weekly wound sheet, dated 06/05/15, documented, .wound tx changed back to calcium alginate with silver . A physician's orders [REDACTED].dc current tx .(change) to: cleanse wound c NS (and) irrigate wound bed c NS. Pat dry pack c calcium alginate c silver, cover c foam pad dressing (and) secure c opsite q day (and) PRN until resolved . It was documented the change in treatment was initiated on 06/05/15. A weekly wound sheet, dated 06/09/15, documented the ulcer was 3.5 x 1.5 x 7.0 cms. It was documented the ulcer had improved. A physician's progress note, dated 06/15/15, documented, .continues treatment with right gluteal fold . A weekly wound sheet, dated 06/16/15 documented the ulcer was 3.0 x 1.4 x 8.0 cms. It was documented the ulcer had improved. A facsimile to the physician, dated 06/16/15, documented, .May we change tx to (right) gluteal fold to cleanse c NS, pat dry, lightly pack wound bed with [MEDICATION NAME] (one) include packing strips, cover c foam dressing and opsite change q day (and) prn until resolved . The facsimile was signed by the physician on 06/17/15. It was documented the change in treatment was initiated on 06/17/15. Weekly wound sheets documented the following: ~ 06/23/15 - 3.0 x 1.4 x 8 cms. It was documented there was no change in the ulcer; ~ 06/30/15 - 2.8 x 1.5 x 7.5 cms. It was documented the ulcer was improved; ~ 07/07/15 - 3.0 x 1.2 x 8 cms. It was documented there was no change in the ulcer. A facsimile to the physician, dated 07/08/15, documented, .wound to (right) gluteal fold is not healing but not really changed in (two) wks. May we try to treat wound c antimicrobial silver wound packing strips (silverlon) cleanse (and) flush wound c NS, pat dry, loosely pack c silverlon, cover c foam dressing, rinse silverlon c tap water daily, change q 7 days. Change daily (and) prn . The facsimile was sent back to the facility with the physician response, .Unclear. changing daily, PRN or every 7 days? Please clarify order and initiate . The facility response was, .Silverlon is to be rinsed daily then reused then changed every 7 days, outer dressing changed daily (and) prn . A physician's telephone order was written on 07/09/15 with the above information. The order documented, .DC previous tx orders . Review of treatment sheets, dated 07/09 through 07/14/15, documented the treatment was provided as ordered by the physician. A weekly wound sheet, dated 07/14/15, documented the pressure ulcer was 3.0 x 1.5 x 8.5 cms. It was documented the ulcer had deteriorated. Treatment sheets, dated 07/15/15 and 07/16/15, documented initials with a circle drawn around the initials. Treatment sheets, dated 07/17/15, documented, .Hold . A physician's orders [REDACTED].Hold tx order .resume cleanse (and) irrigate (right) gluteal fold c NS (and) dry, lightly pack wound bed c [MEDICATION NAME] (one) inch packing strips, cover c foam drsg (and) opsite. (change) daily .stop when supplies in facility then resume silverlon order .stage IV pressure ulcer . A physician's progress note, dated 07/18/15, documented, .nurses and patient's concerns addressed .pressure sore stable . Treatment sheets, dated 07/18/15 through 07/21/15, documented the resident's pressure ulcer was treated with [MEDICATION NAME]. A weekly wound sheet, dated 07/21/15, documented the ulcer was 2.5 x 1.5 x 8.0 cms. It was documented the ulcer was improved. Treatment sheets, dated 07/22/15 through 07/26/15, documented the resident's pressure ulcer was treated with [MEDICATION NAME]. A physician's orders [REDACTED].dc current wound tx. (change) to cleanse wound to (right) gluteal fold c (water) pat dry pack c (unknown) silver rope, lightly cover wound (and) secure q 7 days and PRN . A weekly wound sheet, dated 07/28/15, documented the ulcer was 3.0 x 1.5 x 9.0 cms. It was documented the ulcer had deteriorated. On 07/29/15 at 9:30 a.m., the DON was asked who completed wound assessments. She stated the ADON did. On 07/29/15 at 1:52 p.m., LPN #1 and the ADON were interviewed. LPN #1 was asked if she completed the dressing changes for resident #1. She stated some, but not all. She was asked if the pressure ulcer ever had any tunneling. She stated yes, it did. LPN #1 stated the pressure ulcer was smaller than its' depth. The ADON was asked if she always completed the pressure ulcer measurements and assessments. She stated yes, except if she was off or in a meeting. She was asked how long she had been responsible for the pressure ulcer assessments. She stated she had been completing the assessments for about two years. The ADON was asked when the resident's pressure ulcer had been measured last. She stated it was done on the previous day. She was asked if the resident had been seen at a wound clinic. She stated yes, but it had been a little bit. The ADON was asked if the facility had a wound consultant. She stated, Yes. She stated, She doesn't see (resident #1). (resident #1) is Medicaid so she can't see her. The ADON was asked who determined the type of dressings and treatments the resident required. She stated the nursing staff brainstormed, and the wound consultant could be called. The ADON was asked if she had a difficult time getting the resident's pressure ulcer to heal. She stated, Oh, yes. She stated the pressure ulcer had been bouncing back and forth. She stated, We have tried different stuff. The ADON was asked if the resident would have benefited from being seen by the wound consultant. She stated the facility could and had talked with the wound consultant about the resident, and the wound consultant had given them some ideas for treatments. The ADON was asked if the resident had been receiving Medicare services, would she have been seen by the wound consultant. She stated, Yes. The ADON was asked what specialized training she had received related to pressure ulcers. She stated, Other than working on the floor, not much. LPN #1 stated the previous wound consultant would come to the facility and do brief inservices, but the current one did not. On 07/29/15, the ADON and LPN #1 were asked to show the surveyor the resident's pressure ulcer and obtain measurements. A straight piece of blackish-colored, and foam-like treatment material was observed in the cavity of the resident's pressure ulcer. The dressing material was approximately 1.0 cm wide and 0.25 cm thick. It could not be determined how long the material was. The treatment material did not fill the pressure ulcer cavity. The ADON measured the ulcer and stated it was approximately 2.5 x 1.0 cms. She stated the material would expand to help fill the void of the pressure ulcer. The ADON stated the resident had dug a hole from scratching, but the wound clinic and hospital had classified it as a pressure ulcer. During the measurements, the treatment material fell out of the cavity. The ADON measured the depth of the ulcer and stated it was about 8.5 cms. She stated it was about 9 just yesterday. She stated the ulcer went in and angled down. On 07/29/15 at 3:47 p.m., the DON was asked who ordered supplies for wound care, including pressure ulcers. She stated the ADON did. At 3:50 p.m., the ADON was asked how long it took to received dressing change supplies. She stated, All depends. Some times a couple of days, some times a week. She was asked why it took so long to get supplies. she stated, I have to find it. I'm not sure why it takes so long. She stated she had used a new vendor with the last supplies for the resident. The ADON was asked why the order received on 05/01/15 for silver collagen was not implemented until 05/11/15. She stated the wound nurse consultant was not able to send the supplies. She stated the consultant called and informed her she could not send them, so the facility had to order them. The ADON was asked why the wound nurse consultant could not send the supplies. She stated, Because she (resident #1) was on Medicaid and not Medicare. The ADON was asked why she could not order the resident's dressing supplies from the facility's regular vendor. She stated, I'm not certain. We never have. The ADON was asked why the resident's treatment material was changed back to [MEDICATION NAME] on 07/17/15, after a new treatment order had been obtained on 07/08/15. She stated they had two pieces of the dressing, enough for two weeks. She stated the dressing had came out and had been thrown away, leaving only one week's supply. She stated the facility did not order any more treatment material until after the piece had been thrown away. The ADON was asked what happened between 04/21/15 and 04/28/15 with the tunneling that had been documented. She stated she could not find the tunneling. She stated, Maybe the 2 and 7 came together and made one. She was asked if the ulcer had tunneling now. She stated, I don't think there is tunneling. Her areas came together and made the depth. The ADON was asked why there was no change in treatment from 02/21/15 until 05/01/15 when the wound consultant had documented the resident needed silver collagen. She stated the ulcer was improving. The ADON was asked how the physician was involved in the care of the resident's pressure ulcer. She stated, He comes in and looks at it and changes it. She stated the physician made recommendations. The ADON was asked when a physician had last seen the resident's pressure ulcer. She stated, I can't tell you because I am not always here when he comes to visit. The ADON was asked how the current treatment material was supposed to fill the ulcer. She stated it expanded with exudate. She was asked if the ulcer cavity was eliminated with the treatment material. She stated, No On 07/29/15, the physician was asked how the facility kept him informed of the status of the resident's pressure ulcer. He stated, I'm responsible to see it's done right. He stated he had not looked at the pressure ulcer during his last couple of visits. He stated the facility frequently faxed suggestions for treatments to him. He stated the facility was better at wound management than he was. 2. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/12/15, the hospice care plan notes documented, .Facility nurse, (name omitted), states pt buttocks often painful and limiting sitting time and frequent turning helps . A wound care evaluation form, dated 06/19/15, documented, .Wound 1 .Coccyx .Date Onset .5/27/2015 .Exudate .Heavy .Thickness .Full Thickness .Etiology/ICD9 .Pressure Ulcer - Unstageable .Size (L x W cm.) .3.00 x 1.20 .Depth .UTD .Wound Bed: 80% yellow slough 20% red granulation .Intervention: Cleanse per facility protocol. Apply nickel thick layer santyl. Apply silver calcium alginate. Cover with adhesive foam dressing. Change daily and PRN . The hospice care plan, dated 06/22/15, documented, .Impaired Skin Integrity .Wound Location. Coccyx upper et lower .Interventions .Provide an alternating pressure pad for the bed . The significant change assessment, dated 06/24/15, documented the resident required extensive assistance with activities of daily living, required extensive two person assist with bed mobility, had an unstageable pressure ulcer with slough present, weighed 146 pounds, and was receiving hospice services. On 06/29/15, the hospice care plan notes documented, .Pt. C/O increased bottom pain where wounds are . On 07/06/15, the hospice care plan notes documented, .Increased pain d/t worsening coccyx wound noted. New pain med order changes noted . On 07/29/15 at 1:25 p.m., resident #11 was observed laying in bed. The resident did not appear to sink into the bed. The resident was asked if he had pain. The resident stated his buttocks hurt very badly all the time. The resident was observed to receive pain medication. The resident was asked if the pain medication was effective. The resident shrugged a shoulder slightly and stated the medicine helped but his buttocks always hurt. The resident was observed to lay on an air mattress with the dial setting at approximately 160 and the switch set to static air flow. At 5:26 p.m., resident #11 was observed laying in bed. The resident did not appear to sink into the bed. The settings for the air mattress the resident lay on remained at approximately 160 on the dial and the switch set to static air flow. On 07/30/15 at 11:15 a.m., resident #11 was observed laying in bed. The resident did not appear to sink into the bed. The bed felt very hard. The resident was observed to lay on an air mattress with the dial setting at approximately 160 and the switch set to static air flow. At 4:00 p.m., LPN #6 was observed to perform a dressing change to the resident's coccyx. The resident was asked to roll onto his left side. The resident turned to his left side and a bed pad was present under the resident. The resident did not sink into the bed. The air mattres dial setting was at approximately 160 and the switch set to static air flow. The old dressing was removed. A large pressure ulcer was observed. The wound bed appeared with a yellow escar center approximately one inch wide and two inches long with approximately one inch wide beefy red band encircling the yellow escar. Scattered around the wound bed were flakes of exposed bone. The LPN washed hands and changed gloves. She cleansed the wound with 4x4 gauze wet with Dakins solution. After cleansing the pressure ulcer, the LPN washed her hands. While away from the bed, the resident rolled toward his back and the pressure ulcer made contact with the bed pad. The LPN returned and asked the resident to turn again to his left side. The LPN applied Dakins soaked 4x4 gauze to the center of the pressure ulcer and waited three minutes before removing it. She again washed her hands and donned gloves. While away from the bed, the resident rolled toward his back and the pressure ulcer was again in contact with the bed pad. The LPN returned and asked the resident to again roll toward his left side. The LPN applied alginate to the wound bed. She then cut tape and applied one edge of the tape to the side of the overbed table. She applied a large ABD pad over the coccyx wound and secured it with the cut tape. On 07/30/15 at 4:40 p.m., the DON was asked what were the settings for the air mattress for resident #11. She stated she would have to look up the information. At 5:10 p.m., the DON returned and that she did not know the settings for the bed except that the bed should be set for alternating pressure. The DON was asked why there was an order for [REDACTED]. At 6:20 p.m., the DON stated she had changed the settings for the bed for resident #11. The bed was observed to be set with the dial at 125 and the switch set to alternating pressure. The DON asked the resident if the bed was still hard. The resident answered loudly, Yes. The DON asked the resident if the bed hurt the his buttocks. The resident answered loudly and with emphasis, Yes. The DON was asked what the ordered settings were for the bed. She stated she had only found documentation it was to be set for alternating pressure. The DON was asked how the instruction manual documented setting up the bed for resident use. She stated she did not have a copy of the instruction manual but thought you were to set the dial to the resident's weight. On 07/30/15 at 6:35 p.m., resident #11 was asked if he felt comfortable in his bed. He stated his bed hurt. He was asked if he had informed anyone about his bed. He stated, he informed the staff the bed was hard. He was asked who he had told about his bed. He stated he could not remember their name. He was asked when he had informed someone about his bed. He stated he did not remember when but he had complained about the bed often. On 07/30/15 at 7:00 p.m., the DON was asked who was responsible to ensuring therapeutic air mattresses were set up properly for resident use. She stated nursing was responsible for ensuring the therapeutic air mattresses were set up properly.