Every finding on record at Renaissance Rehabilitation and Healthcare Center

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards reviewed for food service safety in the reviewed 1 of 1 kitchen. The facility failed to ensure food safety by not consistently monitoring, discarding expired food, maintaining unsanitary kitchen equipment, and storage areas. These failures can place residents at risk for foodborne illness. Findings included:Observation in the kitchen on 9/08/2025 at 9:15 AM of the one refrigerator in the kitchen reflected the following: - Dannon Creamy Yogurt with an expiration date of 9-03-2025.Observation in the kitchen on 9/08/2025 at 9:23 AM of the one pantry reflected the following: - Marshmallows with an expiration date of 8-18-2025. - Wonder Hamburger buns with an expiration date of 8-18-2025.- Wonder Hot Dog buns with an expiration date of 8-28-2025.- Observation in the kitchen on 9/08/2025 at 9:30 AM of the one pantry reflected the following: - The ice machine scoop container had standing water in it with a brown dirt-looking substance in the water that was touching the scoop.- The bin containing serving utensils was dirty and had debris in it.An interview on 9/10/2025 at 1:23 PM with the DA revealed it was everyone's responsibility to check for out-of-date products in the kitchen. The DA said some items went out of date faster, and those items were checked more often. The DA said when a truck came in, they would put the old items in the front and the new items in the back. The DA said that it was everyone's responsibility to clean the kitchen. The DA said they signed off on the log when something was complete. The DA said the bin that kitchen utensils were in should be cleaned daily. The DA said they get in-service training on food safety and cleanliness. The DA said that residents could get sick if they were served outdated food. Interview on 9/10/2025 at 1:29 PM the CK said that it is everyone's responsibility to check for out-of-date food and clean the kitchen. The CK said if she sees a food item that is out-of-date, she tells the DM and throws the item away. The CK said that she puts the old items in front and the new items in the back. The CK said they sign in the log when they do a kitchen cleaning task. The CK said the bins that hold the utensils should be cleaned daily. The CK said the ice machine ice scoop container should be cleaned regularly. The CK said that residents could get sick if out-of-date food is served or if food is served with dirty utensils. Interview on 9/10/2025 at 1:37 PM the DM said that it is everyone's responsibility to clean the kitchen and check dates of food daily. The DM stated that new food goes in the back and old food in the front. The DM said that staff initial the log when a cleaning task is done. The DM stated that the bins that hold utensils and the ice scoop should be cleaned twice daily. In-service was completed 30 days ago on food safety and cleaning . The DM said that residents could get sick from outdated food or dirty kitchen utensils. Interview on 9/10/2025 at 2:15 PM the ADM stated that kitchen staff are expected to clean the kitchen daily and regularly check for out-of-date items. The ADM said that residents could get sick if they were to eat outdated food or food served with dirty utensils. Record review of the facility's food storage policy that was updated on 6-25-2025.Policy Interpretation and ImplementationFood Services, or other designated staff, will maintain clean food storage areas at all times.Areas for cleaning dishes and utensils are located in a separate area from the food service line to ensure that a sanitary environment is maintained.Other opened containers must be dated and sealed or covered during storage.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 5 residents reviewed for wound care (Resident #4).LVN B failed to wash or sanitize her hands while going from a dirty to clean surface while performing wound care on 09/09/25 at 11:10 AM for Resident #4.This deficient practice placed residents at risk for cross contamination and the spread of infection.Record review of Resident #4's face sheet dated 09/09/25 reflected Resident #4 was a [AGE] year-old male with an admission date of 01/22/24. Resident #4's diagnoses included stage 4 pressure ulcer to coccyx ((tailbone) a triangular bone at the base of the spinal column), or stage 4 bedsore, (a severe wound that extends through all layers of skin into the underlying tissues, exposing muscle, bone, or tendon), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), diabetes (a group of diseases that result in too much sugar in the blood), and peripheral vascular disease, also known as peripheral artery disease, is a condition that occurs when blood vessels narrow or become blocked, reducing blood flow to the body. Peripheral vascular disease can affect any blood vessel outside of the heart, but it most commonly affects the legs and feet). Record Review of Resident #4's Quarterly MDS assessment dated [DATE] reflected Resident #4 was dependent on staff for toileting and personal hygiene, required set-up or clean up assist with eating, and required substantial/maximal assistance with showering. The MDS reflected Resident #4 had a BIMS score of 13 which indicated Resident #4 was cognitively intact. Record review of Resident #4's care plan dated 06/09/25 and revised 08/18/25 reflected Focus: Wound #1 Stage 4 pressure ulcer to coccyx/sacrum area (tailbone) - admitted with, secondary to immobility/refusal of care. Goal: Resident was his own responsible party and would be educated and demonstrate understanding the importance of my compliance to individualized interventions for wound healing, and pressure injury/ulcer will show signs of healing and remain free from infection by/through review date. Interventions included: Administer treatments as ordered and monitor for effectiveness. Record review of Resident #4's care plan dated 06/09/25 and revised 08/18/25 reflected Focus: Stage 4 pressure injury/ulcer to right lower buttocks r/t Immobility, Refusal of Care - admitted with. Goal: Resident was his own responsible party and would be educated and demonstrate understanding the importance of my compliance to individualized interventions for wound healing, and pressure injury/ulcer will show signs of healing and remain free from infection by/through review date. Interventions included: Administer treatments as ordered and monitor for effectiveness. Record review of Resident #4's care plan dated 06/09/25 and revised 08/18/25 reflected Focus: Wound #1 Stage 4 pressure injury/ulcer to left heel r/t Immobility, Refusal of Care - admitted with. Goal: Resident was his own responsible party and would be educated and demonstrate understanding the importance of my compliance to individualized interventions for wound healing, and pressure injury/ulcer will show signs of healing and remain free from infection by/through review date. Interventions included: Administer treatments as ordered and monitor for effectiveness. Record review of Resident #4's clinical physician orders dated 08/25/25 reflected an order for Clean wound to sacrum with Dakin's 0.125% solution and apply Santyl and calcium alginate cut to fit wound bed and cover with dry dressing daily and prn soiled/loose dressing every evening shift. Record review of Resident #4's clinical physician orders dated 08/25/25 reflected an order for Clean wound to right ischium (lower buttock) with Dakin's 0.125% solution and apply Santyl and calcium alginate cut to fit wound bed and cover with dry dressing daily and prn soiled/loose dressing every evening shift. Record review of Resident #4's clinical physician orders dated 08/25/25 reflected an order for Clean wound to left heel with wc/ns and apply Santyl and calcium alginate cut to fit wound bed and cover with dry dressing daily and prn soiled/loose dressing every evening shift. In and observation on 09/09/25 at 11:10 AM, revealed LVN B performed wound care on Resident #4. LVN B washed her hands and gathered her supplies. LVN B began wound care and removed the resident's dressing from the sacrum area. LVN B cleansed the area and then removed her dirty gloves. LVN B replaced her gloves without washing or sanitizing her hands. LVN B applied ointment and a new dressing to Resident #4's wound. LVN B then changed her gloves again without washing or sanitizing her hands and began wound care to resident right ischium. LVN B removed the dressing and cleansed the wound and removed her gloves. LVN B replaced her gloves, without washing or sanitizing her hands, and applied ointment and a new dressing to resident's wound. LVN B then changed her gloves without washing or sanitizing her hands and removed the dressing from Resident #4's left heel. LVN B cleaned the wound on resident's left heel and changed her gloves without washing or sanitizing her hands. LVN B applied ointment and a new dressing to the wound on the resident's left heel. LVN B removed her gloves and washed her hands. In an interview on 09/09/25 at 11:30 AM, LVN B stated she had not washed or sanitized her hands during the entire time she performed wound care for Resident #4. She stated she usually sanitized her hands when going from a dirty to clean surface and in between removing a dirty dressing and applying a new one, and she did not know why she had not because her sanitizer was in her pocket. She stated she had been in-serviced and trained on handwashing and infection control. She stated if hands were not washed or sanitized when going from a dirty to clean surface or during wound care when removing a dressing and applying and new one, it could have caused the infection to be re-introduced or the infection to spread onto the new dressing which was being applied to another wound. In an interview on 9/10/25 at 12:41 PM, the DON stated when performing wound care and changing gloves between the dirty and clean step, the staff should sanitize or wash their hands. She stated failure to sanitize could cause infections to spread and the nurses were responsible for doing that step. She stated the negative outcome to a resident if hands were not sanitized could be infections. In an interview on 9/10/25 at 1:11 PM, RN A stated hand hygiene should be done when changing gloves during wound care. She stated hand hygiene between the dirty and clean step was important to prevent the resident from getting infections. In an interview on 9/10/25 at 1:29 PM, the ADM stated he was not familiar with wound care steps, and he deferred to his DON for those types of questions. A record review of the facility policy titled, Handwashing-Hand Hygiene Policy and Procedure dated 3-2020 with a last revision date of 10-2020 reflected the following:Facility considers hand hygiene the primary means to prevent the spread of infections.Use an alcohol-based hand rub.for the following situations:1. Before and after contact with residents.2. Before handling clean or soiled dressings, gauze pads, etc.3. Before moving from a contaminated body site to a clean body site during resident care.4. After handling used dressings.

Based on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 5 residents (Resident #37) reviewed for resident rights. The facility failed to ensure Resident's #37's call light was within reach on 09/08/25. This failure could place residents at risk of needs not being met. Findings included: Record Review of Resident #37's face sheet dated 09/08/25 reflected the resident was a [AGE] year-old female admitted on [DATE]. Her diagnoses included ataxia (a neurological condition characterized by a lack of coordination and control of movements), chronic obstructive pulmonary disease (COPD) (a lung disease characterized by chronic respiratory symptoms and airflow limitation), atherosclerotic heart disease of native coronary artery (coronary artery disease) (heart disease involving the reduction of blood flow to the cardiac muscle due to a buildup of atheromatous plaque in the arteries of the heart), and dysphagia (difficulty in swallowing). Record Review of Resident #37's Quarterly MDS assessment dated [DATE] reflected Resident #37 was dependent on staff for eating, showering, and personal hygiene. The MDS reflected Resident #37 had a BIMS score of 03 which indicated Resident #37 was severely cognitively impaired. Record review of Resident #37's care plan dated 01/10/25 and revised on 02/11/25 reflected: Resident had an ADL self-care performance deficit. Goal: Resident #37 would maintain current level of function through the review date. [Resident #37] would improve current level of function through the review date.Interventions included: The resident was totally dependent on staff for repositioning and turning in bed as necessary. Record review of Resident #37's care plan dated 01/06/25 and revised on 01/10/25 reflected: Resident was a high risk for falls r/t imbalance, medications.Goal: Resident would not sustain serious injury through the review date.Interventions included: Maintain call light within reach. In an observation and interview on 09/08/25 at 11:01 AM, Resident #37 stated she was doing pretty good, and all staff treated her good. She stated she could not reach her call light where it was at that time. She stated she did not call anyone if she needed help, and she did not need any help. Observed Resident #37's call light cord which was running under Resident #37's fall mat and the call light was under the bed. In an interview on 09/08/25 at 11:08 AM, CNA C stated Resident #37 could use her call light, but she never did. She stated she always placed it by Resident #37 and told her to use it. She stated Resident #37 could not have reached the call light in the position it was in under the bed at that time. She stated she had been in-serviced on call light placement. She stated if a resident's call light was not within their reach, they may not have been able to tell staff what they needed or wanted, and they may have tried to get up to get what they needed or wanted and fell or hurt themselves. In an interview on 09/10/25 at 10:23 AM, the DON stated it was her expectation that all residents' call lights be within reach at all times. She stated staff had been trained on call light placement and ensuring residents had their call light within reach at all times. She stated if a resident's call light was out of their reach, it could have caused residents to not be able to get help if they required assistance. In an interview on 09/10/25 at 10:29 AM, the ADM stated it was his expectation that all residents' call lights be within reach at all times. He stated staff had been trained on call light placement and ensuring residents had their call light within reach at all times. He stated if a resident's call light was out of their reach, a resident may not have been able to get assisted in a timely manner or they may have had to resort to calling out. Record review of facility policy titled Resident Call System and dated October 2022 (reviewed 03/28/2023) reflected Policy: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 6. Calls for assistance are answered as soon as possible. Urgent requests for assistance are addressed immediately.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 1 medication storage rooms reviewed.The facility failed to ensure that expired medication administration supplies were removed from 1 of 1 medication storage rooms.This failure could place residents at risk for ineffective treatments and unnecessary invasive procedures. Use of these expired supplies could cause a central line medication catheter to dislodge, become infected, or need surgical replacement. Findings include: Observation on [DATE] at 3:00 PM of the medication storage room revealed the following medication administration supplies were expired: 1 Intravenous Administration Kit Expired [DATE] 1 Central line medication catheter Stabilizer Device Expired [DATE] 1 Central line medication catheter Stabilizer Device Expired [DATE] 4 Central line medication catheter Protection Disc (For Insertion Cite) Expired [DATE] 8 Central line medication catheter Dressing Kits Expired on the following dates: 1 on [DATE] 1 on [DATE] 1 on [DATE] 1 on [DATE] 1 on [DATE] 3 on [DATE] In an interview with LVN-B on [DATE] at 12:28 PM she stated her expectation regarding expired medical supplies was that they should be discarded and given to the DON. She stated normally the nurses, and the medication aides were responsible for checking the supplies in the medication rooms, but they currently didn't have a medication aide, so it's just the nurses now. She stated the negative outcome to residents if expired supplies were used, the care could be non-therapeutic or make treatments non-effective, and the resident might not get better. In an interview with the DON on [DATE] at 12:41 PM she stated her expectation on expired medical supplies was that they be tossed in the trash. She stated that all the staff who have access to the medication room were responsible for checking for expired supplies. She stated the negative outcome to residents if expired supplies were used, was the integrity of the supplies could be compromised, and they could be non-effective for the resident's treatment. In an interview with RN-A on [DATE] at 01:11 PM she stated her expectation on expired medical supplies was that they should have been thrown into the trash. She stated that the nurses were responsible for checking for expired supplies in the medication room. She stated the negative outcome to residents if expired supplies were used was, the supplies may not work properly. She stated an example of this was using an expired central line dressing kit that may not be sterile any longer, so it could create a risk of infection for the resident. In an interview with the ADM on [DATE] at 1:29 PM, he stated his expectation on expired medical supplies was that they should be disposed of. He stated that central supply staff or nurses were responsible for checking the medication room for expired supplies. He stated the negative outcome to residents if expired supplies were used, was the supplies may not perform as they were intended to. He stated that if an expired sterile dressing was used, it could malfunction and cause an infection for a resident. A record review of facility policy titled, Storage of Medications, dated [DATE] with a review date of [DATE], reflected the following: The nursing staff is responsible for maintaining medication storage areas in a clean, safe, and sanitary manner. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on interviews and records review, the facility failed to ensure that medical records were accurately documented for four (4) of thirteen (13) residents (Resident #6, Resident #8, Resident #12, Resident #13) reviewed for accurate clinical records, in that: The facility failed to ensure Resident #6, Resident #8, Resident #12, and Resident #13's EMARs were accurately reflecting narcotic medications administered. This deficient practice could result in errors in care and treatment. Findings included: Resident #6 Review of Resident #6's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Cirrhosis of the Liver (scarring of the liver), Muscle Weakness, Pain in unspecified joint, Femur fracture (large upper leg bone), unsteadiness on feet and repeated falls. Review of Resident #6's MDS assessment, dated 07/11/2023, reflected a BIMS of 5, indicating severe cognitive impairment. Review of Resident #6's EMAR reflected on 7/15/2023 and 7/16/2023 the 4:00 PM a dose of Tramadol HCL 50 mg tablet was checked off by medo and AMP respectively. Review of Resident #6's July Narcotic count sheet reflected no entries on 7/15/2023 and 7/16/2023 at 4:00 PM for the Tramadol HCL 50 mg tablet. Resident #8 Review of Resident #8's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Dementia (progressive memory impairment), Glaucoma (eye diseases that can cause vision loss), Type 2 Diabetes Mellitus, Malignant Neoplasm of Colon (cancer of the Colon), repeated falls, lack of coordination and muscle weakness. Review of Resident #8's MDS assessment, dated 05/18/2023, reflected a BIMS of 8, indicating moderate cognitive impairment. Review of Resident #8's EMAR reflected on 6/6/2023 the 10:00 PM dose of Tramadol HCL 50 mg tablet was checked off by VNR. Review of Resident #8's June narcotic count sheet reflected no entries on 6/6/2023 at 10:00 for the Tramadol HCL 50 mg tablet. Resident #12 Review of Resident #12's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Dementia, Major Depressive Disorder, Insomnia, and Disorientation. Review of Resident #12's MDS assessment, dated 05/5/2023, reflected a BIMS of 5 indicating severe cognitive impairment. Review of Resident #12's EMAR reflected on 5/22/2023 the 8:00 PM dose of Lorazepam 0.5 mg tablet was checked off by VNR. Review of Resident #12's May Narcotic count sheet reflected no entries on 5/22/2023 at 8:00 pm for the Lorazepam 0.5 mg tablet. Resident #13 Review of Resident #13's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Dementia (progressive memory impairment), Type 2 Diabetes Mellitus, Major Depressive Disorder, Pain in left shoulder, Pain in right knee, Pain in left ankle, unsteadiness on feet, hear Failure, Pulmonary Hypertension (high blood pressure affecting the lungs) and chronic kidney disease. Review of Resident #13's MDS assessment, dated 06/16/2023, reflected a BIMS of 3 indicating severe cognitive impairment. Review of Resident #13's EMAR reflected on 5/5/2023 and 5/14/2023, the HS dose of Tramadol HCL 50 mg tablet was checked off by tr and ML respectively. Review of Resident #13's May narcotic count sheet reflected no entries for 5/5/2023 or 5/14/2023 at HS for the Tramadol HCL 50 mg tablet. During an interview on 8/3/2023 at 1:05 PM, Resident #6 stated she did not remember missing any doses of medication in July of 2023 She states she was in pain all the time and did not remember if she had more pain on those days or not. During an interview on 8/3/2023 at 1:12 PM, Resident #8 stated she did not remember missing and medications in June of 2023, but she had no idea what medications they give her anyway, so she would not know if one was missing. She stated she was in pain all the time but did not recall if it was worse back in June. During an interview on 8/3/2023 at 1:25 PM, Resident #12 stated she did not remember any issues with her medications back in May of 2023 and does not remember if she felt more anxious that usual at that time, as it was several months back. During an interview on 8/3/2023, 1:30 PM, Resident #13 stated she did not recall any issues with medications back in Ma y of 2023 but that was too long to remember. She stated she would not know if they left out her pain medication anyway, because she could not identify it. She did not recall whether she was in pain back in May, it was too long ago. During an interview with the DON on 8/3/2023 at 11:30 am, she provided a list of names and phone numbers of the staff that had EMAR discrepancies. She identified AMP as LVN #1, medo as LVN #2, VNR as LVN#3, tr as agency nurse #1 and ML as agency nurse #2. During an interview on 8/3/2023 at 12:20 PM, LVN #1 stated her initials in the EMAR were AMP. When shown the EMAR check off on Resident #6 for the 4:00 PM dose of Tramadol HCL 50 mg tablet on 7/16/2023 and the July narcotic count book, she stated There is no entry there referring to the narcotic count book. She stated, I have no idea what happened; I guess I was in a hurry. She stated she had been working a double shift that day and she may have clicked it off in the EMAR before she gave the medication. She stated the resident could have been sleeping and that is why she had not given it. When asked if she followed the facility policy on documentation for medication administration she stated, Of course not. She stated they are not supposed to click it off on the EMAR until they give the medication She stated if residents did not get their pain medication they could be in severe pain. During an interview on 8/3/2023 at 12:25 PM, LVN #2 stated her initials in the EMAR were medo. When shown the EMAR check off on Resident #6 for the 4:00 PM dose of Tramadol HCL 50 mg tablet on 7/15/2023 and the July narcotic count book, she stated I clicked it off, but didn't give it. I made a mistake. She stated, I don't normally pass meds and she did not have a definite answer as to why there was a discrepancy. She stated she would normally click it off in the EMAR after she had given it, but stated she probably had not given it, ifit if it was not signed out on the narcotic count sheet. She also stated she did not follow facility policy for medication administration, and she really did not remember what happened that day, but she probably had not given it. When asked what could happen if residents did not get their pain medications she stated, the resident could be in pain. During an interview on 8/3/2023 at 1:45 PM, Agency Nurse #1 stated her initials in the EMAR were tr. When shown the EMAR check off on Resident #13 for the HS dose of Tramadol HCL 50 mg tablet on 5/5/2023 and the May narcotic count sheet, she stated that she did not remember what happened that day but if I clicked it in the EMAR, I probably gave it; maybe I put it on the wrong count sheet. She stated, I can't defend myself, but I'm pretty sure I gave it. She stated if residents did nott get their pain medication they could be in pain, and their blood pressure could go up if their pain wasn't alleviated. During an interview on 8/3/2023 at 2:15 PM, LVN #3 stated her initials in the EMAR are VNR. When shown the EMAR check off on Resident #8 on 6/6/2023 for the 10:00 PM dose of Tramadol HCL 50 mg tablet and Resident #12 on 5/22/2023 for the 8:00 PM dose of Lorazepam 0.5 mg tablet and the May and June narcotic count sheets, she stated she thought she had given it but did not remember. She stated she did not know if there was another count sheet but if she had given it she would have signed out for it on the narcotic count sheet where the others were. She said there was a possibility that she did not give the medications, but she did not know where else it would be documented. She stated she was supposed to give the medications then click it off in the EMAR and sign it out on the narcotic count sheets. She stated if residents did not get their pain meds they could have pain and if they do nott get their anti-anxiety meds (Lorazepam) they could get anxious. Agency Nurse #2,ML was contacted by phone three times on 8/3/2023 but had never returned any calls prior to exit on 8/3/2023. During an interview with the DON and the AD on 8/3/2023 at 10:21 am regarding the discrepancies between the EMAR and the narcotic count sheets, the DON stated, I'm thinking they just signed off on it and didn't give it. She further stated a checkmark on the EMAR indicated a medication was given, but if there was no entry on the narcotic count sheets, it had not been given. The DON stated her expectation was staff would give meds as ordered. The AD stated she didn't know too much about EMARs and narcotic count sheets. She stated her and the DON had previously conducted an audit of the narcotic count sheets after a staff expressed a concern and had not found any discrepancies. During an interview on 8/3/2023 at 4:15 PM, the MD stated he was not aware of any discrepancies between EMARS and narcotic count sheets at the facility. He stated they would have discussed discrepancies during their QAPI meetings, and these had not been previously discussed. He started his expectations were that staff would follow orders as given and if they do not it is a med error and should be reported. He stated he had not been notified of any med errors or meds not given. He stated if a resident did not get their prescribed Lorazepam they could have withdrawal symptoms, could have jitters, increased anxiety, or other side effects. He further stated if residents did not get their pain medications as ordered they could have increased pain and possible withdrawal symptoms if they take it on a regular basis. Review of facility policy Administering Medications revised April 2019 reflected 4. Medications are administered in a safe and timely manner, and as prescribed. Also reflected, 22. The individual administering the medication initials the residents MAR on the appropriate line after giving each medication and before administering the next ones.

Based on observations, interviews, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen for 2 of 2 (Freezer #1 and #2) reviewed for kitchen sanitation. The facility failed to ensure items in Freezer #1 and #2 were sealed properly. This failure could place residents at risk for food contamination and food-borne illness. Findings included: Observations on 06/27/23 for Freezer #1 revealed: - at 11:16 AM revealed a box of bacon was open, not sealed about 2 inches with bacon not sealed. - at 11:18 AM revealed a box of biscuits was open, not sealed about 1.5 inches. Interview on 06/27/23 at 11:19 AM, with Dietary Aide F revealed she did not use the biscuits today so she was not sure how long they had been unsealed. She stated she used the bacon this morning. She stated the items should be sealed. Observation on 06/27/23 at 11:26 AM, for Freezer #2 revealed a box of pork patties, dated 05/12/23 open about 2 inches not sealed. Interview on 06/27/23 at 11:27 AM, with Dietary Manager revealed the freezer items should be sealed right after being used. He stated they had limited space in the freezer so when they are moving items around the boxes could have opened more. He stated they had a small amount of dietary staff in the kitchen and was working in the kitchen as staff so he had not had an opportunity to look to see if freezer items were sealed properly. Review of facility's policy Food Receiving and Storage revised October 2022 reflected foods shall be received and stored in a manner that complies with safe food handling practices.

42971 Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #20, Resident #213 and Resident #42) of 15 residents reviewed for ADLs. The facility failed to ensure: -Resident#20 had her fingernails cleaned and trimmed. -Resident#213 had her fingernails cleaned and trimmed. -Resident #42 had his facial hair and fingernails trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1. A record review of Resident #20's Quarterly MDS assessment dated [DATE] reflected Resident #20 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus and dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Resident #20 was unable to complete the cognition assessment. Resident #20 required total dependence of one-person physical assistance with transfer, dressing, and personal hygiene. A record review of Resident #20's Comprehensive Care Plan, revised 01/12/23, reflected Focus: I have an ADL self-care performance deficit related to dementia, impaired physical mobility related to weakness. Goal: I will receive necessary assistance to maintain clean and neat appearance. Interventions: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. An observation on 06/28/23 at 11:15 AM revealed Resident #20 was laying in her bed. The nails on both hands were approximately 0.3 centimeter in length extending from the tip of her fingers. Resident # 20 was unable to answer questions. 2. A record review of Resident #213's Comprehensive MDS assessment, dated 06/20/2023, reflected Resident #213 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, lack of coordination and legal blindness. Resident #213 had a BIMS of 09 which indicated Resident #213's cognition was moderately impaired. Resident#213 required extensive assistance of one-person physical assistance with dressing and personal hygiene. A record review of Resident #213's Comprehensive Care Plan dated 06/13/23 did not indicate personal hygiene and grooming. Observation and interview on 06/28/23 at 11:35 AM, revealed Resident #213 was sitting in her wheelchair. The nails on both hands were discolored tan and chipped. Resident #213 stated she could not clean and trim her nails. Resident #213 stated the chipped nails bothered her when they hanged to things. Interview on 06/28/23 at 12:35 AM, CNA B stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA B stated she would talk to the nurse about Resident #20 and Resident #213 long nails because they were both diabetic. CNA B stated fingernail care was provided for the residents during daily care. CNA B stated she did not notice long nails on Resident #20 and chipped nails on Resident #213. Interview on 06/28/23 at 12:45 PM, LVN D stated CNAs were responsible to clean and trim residents' nails as needed. LVN D stated only nurses cut residents' nails if they were diabetic. LVN D stated no one notified her Resident #20 and Resident #213's nails were long and chipped, and she had not noticed the nails herself. LVN D stated Resident #20 and Resident #213 were diabetic, she would clean and trim their nails. Interview on 06/28/23 at 2:31 PM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and chipped nails could be a skin break down and infection control issue. The DON stated she was responsible to do routine rounds for monitoring. The DON stated she had not noticed the nails herself. 3. A record review of Resident #42's Quarterly MDS assessment dated [DATE] reflected Resident #42 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Leukemia (cancer), hypertension, generalized muscle weakness, unsteadiness on feet, abnormalities of gait and mobility and lack of coordination. Resident #42 had a BIMS of 11 indicating he was moderately cognitively impaired. Resident #42 required limited assistance with hygiene and dressing. He required extensive assistance with bathing. A record review of Resident #42's Comprehensive Care Plan last revised 03/19/23 reflected Resident #42 had limited physical mobility related to weakness, decreased functional mobility, leukemia, cataracts and history of falls. Invention included to provide supportive care, assistance with mobility as needed. Document assistance as needed. Observation and interview on 06/27/23 at 12:05 PM, with Resident # 42 revealed he was lying in bed with an unkempt beard hair of about an inch length covering both cheeks below the mouth and under his chin and mustache about 1/2 inch length of facial hair. Resident #42 revealed his shower schedule was on the 2 pm to 10 pm shift. He stated he sometimes would get his shower, but he had not gotten his facial hair trimmed in 2 weeks. He stated he had been asking to get his facial hair trimmed for 2 weeks and CNAs make promises they will later come to trim it but do not. He stated sometimes he did refuse his showers when offered to him during an inconvenient time like meals, med pass time or too late on evening shift. Resident #42 stated he was not provided facial trimming for 2 weeks and preferred to have no facial hair including the beard and mustache. Observation on 06/28/23 at 2:00 PM, with Resident #42 revealed he was lying in bed with a beard hair of about a inch length below the mouth and under his chin and mustache about 1/2 inch of hair. Interview with Resident #42 revealed yesterday was his shower day and he did not get a shower or shaved. He stated his fingernails needed to be trimmed. Observation revealed fingernails on right hand were about 1/4 inch on each of his finger nails on right hand. He trimmed his own on one hand left hand because he was tired of waiting for them to be trimmed. He stated he felt like the CNAs did not want to be bothered and just wanted him to sign the shower sheet for refusal. Interview on 06/28/23 at 2:03 PM, Hospitality Aide H revealed she worked with Resident #42 along with another CNA who had not arrived yet on the 2 pm to 10 pm shift. She stated Resident #42 did refuse a shower one time for her because he had lost his belt to his pants. She stated she did not ask residents if they wanted their facial hair trimmed unless it was one of the two residents on 200 hall who she knew wanted their facial hair trimmed. She stated she was not aware Resident #42 wanted his facial hair of his beard and mustache trimmed. She did not ask Resident #42 if he would like his fingernails trimmed. Interview on 06/28/23 at 2:28 PM, Resident #42 revealed he told LVN G he had trimmed his left-hand fingernails himself and still needed his right hand fingernails trimmed. He told LVN G he was tired of waiting for staff to trim them. Resident #42 told LVN G he would like to have a shower or bed bath whichever he could get and would like his facial hair trimmed. Interview on 06/28/23 at 2:28 PM, LVN G revealed Resident #42 had refused showers before. She stated the CNAs should be trimming fingernails for Resident #42 on shower dates and trim his facial hair if resident wanted it trimmed. She stated CNAs should have been offering to Resident #42 facial trimming of his beard and mustache along with fingernail trimming. Interview on 06/28/23 at 2:35 PM, the DON revealed Resident #42 should be offered shower or a bed bath. The DON stated the CNAs should offer to Resident #42 facial trimming and fingernail trimming on shower days at least. Review of the facility's policy titled, Fingernails/Toenails, Care, revised February 2018, reflected, . The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed . 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting revised March 2018 reflected Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain .grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming and oral care) .

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for the facility's only kitchen, dining room and one of three halls (Hall 200) reviewed for pest control. The facility failed to keep an effective pest control program to ensure kitchen, dining room and residents' rooms on Hall 200 were free of flies. This failure could place residents at risk for reduced quality of life. Findings included: Observation on 06/27/23 at 11:04 AM revealed four flies were in the dish area of kitchen while Dietary Aide F wash using the dish machine. Observations on 06/27/23 at 11:10 AM and 11:15 AM revealed fly light had no light on it and was not plugged in the kitchen. Interview on 06/27/23 at 11:20 AM with Dietary Aide F and the Dietary Manager revealed the electronic fly light did not work to their knowledge. Observation on 06/27/23 at 11:23 AM revealed three flies in food prep area of kitchen while two dietary staff were doing food prep for lunch. Observation on 06/27/23 at 11:02 AM and 11:29 AM revealed an open full trash can with vegetables, food snack packages, cups and used condiment containers with no lid in dining room about 3 feet away from closed kitchen door. Interview on 06/27/23 at 11:30 AM with Maintenance Supervisor revealed the electronic bug light in the kitchen in the dish area should be plugged in so it kept the flies and gnats down. He stated he did have issues with dietary staff unplugging it so they can plug in something else. He stated the trash can in the dining room should be covered to keep the flies and gnats out of it. Observation and interview on 06/27/23 at 11:45 AM revealed three flies were in his room (resident room [ROOM NUMBER]). Resident #21 stated the flies were bad in the facility and saw the flies in his room constantly. Observation on 06/27/23 at 12:18 PM revealed there were four flies in resident's room (resident room [ROOM NUMBER]). Interview with Resident # 10 revealed the flies bothered her all the time and used the fly swatter in her hand to try to get rid of them. She stated there were some flies in her room now and had a lot of flies in her room on a daily basis. Observation on 06/27/23 at 12:28 PM revealed Resident #41 had two flies landing on her dining table during lunch. Observation on 06/27/23 at 12:30 PM with Resident #34 revealed she shooed two flies away from her lunch plate. Interview on 06/27/23 at 12:33 PM with Resident # 34 revealed the facility did have flies in dining room especially during meals. She stated the flies bothered her a lot when she is eating. Observation on 06/27/23 at 2:32 PM in resident room [ROOM NUMBER] revealed Resident #43's walker had two flies landing on his walker. Observation on 06/28/23 at 2:17 PM revealed fly light had no light on it and was not plugged in the kitchen. Interview on 06/28/23 at 2:19 PM with Maintenance Supervisor revealed he was not aware of the kitchen electronic fly light not working in the kitchen and should have been plugged in so it can help with flies. He stated he had new electronic fly lights which needed to be put up but was waiting for pest control to put them up. He stated the electronic fly light on 200 hall was not working well, was older and needed to be replaced with a new one. He stated he had put up one new electronic bug light on 100 hall so far. Observation on 06/28/23 at 2:21 PM revealed fly light on 200 hall had light on and about 4 flies were stuck to glue board. Interview on 06/29/23 at 9:50 AM with Administrator revealed pest control came out regularly at least once a month to service the facility for pests. She stated she was not aware of the fly light in the kitchen being unplugged or if it was not working properly. Review of email communication between the facility and pest control reflected the following: - dated 04/28/23 reflected Facility had 4 fly lights broken and needed to be replaced. Facility requested to order 4 bug lights sent to Pest Control company. - dated 04/28/23 reflected Pest Control company would order them and have them shipped. - dated 05/11/23 Maintenance emailed Pest Control company reflected .The bug lights that we received, 2 do not work. When we took them out of the box and plugged them in, they did not come on. What do we need to do to get them replaced? - dated 05/11/23 Pest Control company emailed Maintenance Supervisor back reflected Go ahead and set them those to the side. I'll have the tech check the starters and bulbs when he comes and if he can't get them working then he will take them and I will have new ones sent. It looks like we are scheduled for 5/23. - Dated 06/14/23 from Maintenance Supervisor to Pest Control company reflected We still have two of the new bug/fly lights that we ordered from you that do not work. I thought .was going to look at them on the 23rd of May but he did not. This month they have already come and serviced us. Can we please see about getting these lights replaced or repaired? We are in need of them at this time of year. - Dated 06/14/23 from Pest Control to Maintenance Supervisor reflected pest control reached out to vendor and will be shipping out two replacement lights today. Review of pest control visits for April to June 2023 reflected the following about flies: - dated 05/23/23 fly lights inspected and 3 glueboard (3 each) were replaced. - dated 06/08/23 fly lights glueboard (7 each) - dated 06/16/23 facility requested additional service on-site for emergency service regarding flies. Staff reported flies throughout the facility mainly the 200 hallway and resident room [ROOM NUMBER]. Upon inspection several flies were observed I applied a liquid resident fly bait to the tops (6 ft) of hallways 99-108, 200, 300 and dining area to help reduce fly pressure. Fly lights were inspected and insect monitors replaced as necessary. Resident room [ROOM NUMBER] was treated as well with liquid residual product by applying product to Swiffer head in the hallway, then wiping it to the top perimeter of the room. The exterior entrances and exits were treated with a repellant liquid residual product to deter flies from doorways. The dumpster area was treated with a liquid residual fly bait also. During the inspection of the exterior I found a hole in the wall outside of the kitchen door. I patched it temporarily with duct tape. This area is most likely how some flies are getting into the facility and needs proper repairs. This is a fly hot spot as it is close to dumpsters. Review of facility's pest control log for March to June 2023 reflected no documentation of flies. Review of facility's policy Pest Control revised May 2008 reflected this facility maintains an on-going pest control program to ensure that the building is free of insects and rodents.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 5 (Resident #22, Resident #27, Resident #31, Resident #40, and Resident #45) of 6 residents reviewed for infection control. The facility failed to ensure MA A disinfected the blood pressure cuff in between blood pressure checks for Residents #22, #27, #31, #40, and #45. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #22's Quarterly MDS assessment, dated 05/12/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses included elevated blood pressure, and hyperlipidemia (high levels of fat in the blood). He had a BIMS of 03 indicating his cognition was severely impaired. Record review of Resident #22's physician orders dated 06/28/23 reflected, carvedilol tablet 3.125 mg, give 1 tablet by mouth two times a day - Special instruction: Hold for systolic blood pressure less than 100, diastolic blood pressure less than 60 or heart rate less than 60. Cozaar tablet 25 mg, give 1 tablet by mouth one time a day - Special instruction: Hold for systolic blood pressure less than 100, diastolic blood pressure less than 60, or heart rate less than 60. Record review of Resident #27's Quarterly MDS, dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included history of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hyperlipidemia (an abnormal high concentration of fats or lipids in the blood), and shortness of breath. He had a BIMS of 12 indicating he was moderately impaired. Record review of Resident #27's physician orders dated 06/28/23 reflected, metoprolol tartrate 50 mg, give 1 tablet by mouth, two times a day - Special instruction: Hold for systolic blood pressure less than 110, diastolic blood pressure less than 60, or when the heart rate is less than 60. Record review of Resident #31's Comprehensive MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hyperlipidemia (an abnormal high concentration of fats or lipids in the blood), and dementia. She had a BIMS of 08 indicating her cognition was moderately impaired. Record review of Resident #31's physician orders dated 06/28/23 reflected, amlodipine tablet; 10 mg, give 1 tablet by mouth, one time per day - Special instruction: Hold for systolic blood pressure less than 110 and or diastolic blood pressure less than 60. Carvedilol tablet 25 mg, give 1 tablet by mouth two times a day - Special instruction: Hold for systolic blood pressure less than 110 and or diastolic blood pressure less than 60. Record review of Resident #40's Quarterly MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), and hyperlipidemia (an abnormal high concentration of fats or lipids in the blood). She had a BIMS of 03 indicating her cognition was severely impaired. Record review of Resident #40's physician orders dated 06/28/23 reflected, carvedilol tablet; 3.125 mg, give 1 tablet by mouth, two times per day - Special instruction: Hold for systolic blood pressure less than 110 and or heart rate less than 60. Enalapril maleate tablet 5 mg, give 1 tablet by mouth two times a day - Special instruction: Hold for systolic blood pressure less than 100 or diastolic blood pressure less than 60. Record review of Resident #45's Quarterly MDS assessment dated [DATE], revealed Resident #45 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included elevated blood pressure, pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot), and hyperlipidemia (an abnormal high concentration of fats or lipids in the blood). Resident #45 had a BIMS of 08 which indicated Resident #45's cognition was moderately impaired. Record review of Resident #45's physician orders dated 06/28/23 reflected, amlodipine tablet; 2.5 mg, give 1 tablet by mouth, two times per day - Special instruction: Hold for systolic blood pressure less than 110 and or diastolic blood pressure less than 60. Observation on 06/28/23 at 7:30 AM, revealed MA A performing morning medication pass, during which time she checked the blood pressures on Resident #40. MA A did not sanitize the blood pressure cuff before or after using it on Resident #40. MA A put the blood pressure cuff on top of the medication cart after use. Observation on 06/28/23 at 7:47 AM, revealed MA A performing morning medication pass, during which time she checked the blood pressure on Resident #45. MA A used the same blood pressure cuff right after using it on Resident #40. MA A did not sanitize the blood pressure cuff before or after using it on Resident #45. She left the blood pressure cuff on top of the medication cart. Observation on 06/28/23 at 7:57 AM, revealed MA A performing morning medication pass, during which time she checked the blood pressure on Resident #31. MA A used the same blood pressure cuff right after using it on Resident #45. MA A did not sanitize the blood pressure cuff before or after using it on Resident #31. Observation on 06/28/23 at 8:09 AM, revealed MA A performing morning medication pass, during which time she checked the blood pressure on Resident #22. MA A used the same blood pressure cuff right after using it on Resident #31. MA A did not sanitize the blood pressure cuff before or after using it on Resident #22. Observation on 06/28/23 at 8:15 AM, revealed MA A performing morning medication pass, during which time she checked the blood pressure on Resident #27. MA A used the same blood pressure cuff right after using it on Resident #22. MA A did not sanitize the blood pressure cuff before or after using it on Resident #27. Interview on 06/28/23 at 12:33 PM, MA A stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use (before and after use on each resident) in order to prevent transmitting an infection from one resident to another. She stated she forgot to wipe the cuff this time. Interview on 06/28/23 at 2:33 PM, the DON stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. She said she was responsible for training staff on infection control. She said that she did routine rounds in the floor to ensure the nurses and med aids were following proper infection control procedures. Record review of facility's policy Cleaning and Disinfection of Resident-Care Items and Equipment, reviewed March 2023, reflected . 6. Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions. 9. Durable medical equipment is cleaned and disinfected before reuse by another resident.

Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 (200 hall medication aide cart) of 2 medication carts reviewed for pharmacy services in that: The facility failed to ensure medications in unsecured containers were immediately removed from the 200 hall MA cart. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: An observation on 06/27/2023 at 12:20 PM of the MA Cart for Hall 200 revealed the blister pack for Resident #43's tramadol 50 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill was still inside the broken blister and taped over. In an observation and interview on 06/27/23 at 12:20 PM, MA A stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blister. She stated the risk of a damaged blister would be a potential for drug diversion. She stated the nurses and medication aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated the count was done at shift change and the count was correct. She stated she did not see the broken blisters during the count. She stated when a broken seal was observed, tow nurses should discard the medication. At this time the surveyor checked the medication; the count was compared to the blister packs and the count was correct. Interview on 06/28/23 at 2:31 PM, the DON stated if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be losing the medication because the seal was broken. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated she supposed to check the carts randomly. Review of the facility's policy Storage of Medications, revised April 2019 reflected the following: . 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5%. There were 2 errors out of 27 opportunities, resulting in a facility had a 7.4 percent (%) medication error rate for one (Resident #45) of 6 residents reviewed for medication administration. The facility failed to ensure MA A administered medications per the physician orders for Resident #45. MA A administered the wrong dose of Eliquis (anticoagulant medication used to treat and prevent blood clots) and ropinirole HCl (used to treat restless leg syndrome). This failure could place residents at risk for not receiving therapeutic effects of their medications. The findings included: A record review of Resident #45's Quarterly MDS assessment dated [DATE], revealed Resident #45 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot), restless legs syndrome, and dementia. Resident #45 had a BIMS of 08 which indicated Resident #45 was cognitively moderately impaired. A record review of Resident #45's physician's orders dated 6/28/23 revealed Resident #45 was to receive Eliquis tablet 2.5 milligrams (Apixaban), give 5 milligrams by mouth two times a day related to pulmonary embolism. Give 2 of 2.5 milligrams. And to receive ropinirole HCl tablet 1 milligram, give 1 tablet by mouth two times a day related to restless legs syndrome. Take total of 1.5 milligram (1tablet of 1 milligram and 1 tablet of 0.5 milligram) A record review of Resident #45's medication administration record dated 6/28/23 revealed Resident #45 was to receive Eliquis tablet 2.5 milligrams (Apixaban), give 5 milligrams by mouth two times a day related to pulmonary embolism. Give 2 of 2.5 milligrams. And to receive ropinirole HCl tablet 1 milligram, give 1 tablet by mouth two times a day related to restless legs syndrome. Take total of 1.5 milligram (1tablet of 1 milligram and 1 tablet of 0.5 milligram). During an observation of the medication pass on 6/28/23 at 7:47 AM, revealed MA A administered to Resident #45 the following medications: Eliquis tablet 2.5 milligrams and ropinirole HCl tablet 1 milligram. In an interview of on 6/28/23 at 12:33 PM, MA A stated she overlooked the two orders. MA A stated she did not administer the right dose. MA A stated she gave less than the ordered dose, the risk would be ineffective medication. MA A stated she was to follow the five rights of medications: right patient, right order, right time, right dose, and right route. In an interview on 6/28/23 at 02:31 PM, the DON stated she expected the medications to be administered per the physician orders and for the staff to follow the five rights of medication administration, which included the right dose. The DON stated by giving a dose less than the order, the risk would be failure to give a therapeutic dose. The DON stated nursing staff were to complete in-service regarding the 5 rights of medication administration. On 3/28/23 at 02:40 PM, this surveyor attempted to call the physician, a message was left. Record review of the facility policy revised April 2019, titled Administering Medications reflected, . Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 10. The individual administering the medication checks the label 3 times to verify the right resident, right medication, right dosage, right time and right method (route of administration before giving the medication.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to remove cans with dents around the seals, approximately two inches, from storage area can rack. 2. The facility failed to properly store a scooping receptacle inside a bulk food bin. 3. The facility failed to ensure staff disposed of cigarette butts properly. These failures could place residents at risk for cross contamination and food borne illnesses. The findings included: Observations of the kitchen on 08/28/19 at 9:30 a.m. revealed a resident drinking cup inside the bulk bin of flour. Observation of the dry storage room on 08/28/19 at 9:45 a.m. revealed one can of sliced peaches and one can of enchilada sauce that were dented around the seal of both cans. The dented cans were on the rack full of cans that were not dented. Observation of the resident tray line on 08/28/19 at 9:55 a.m. revealed a smoked cigarette butt on the top shelf above the resident tray line. An interview on 08/28/19 at 9:35 a.m. with Dietary Manager confirmed the resident drinking cup should not be inside the bulk bin. An interview on 08/29/19 at 3:42 p.m. with Cook A revealed she knew the cup should not be in the bulk bin of flour. She stated the cup was already inside the flour when she used it. She stated she did not remove the cup after she used it as a scoop. An interview on 08/28/19 at 9:50 a.m. with the Dietary Manager revealed she was responsible for putting up the food supplies and checking for dented cans. She stated there was a separate area for dented cans that needed to be returned to the vendor, and she must have overlooked the two dented cans on the shelf. An interview on 08/28/19 at 10:00 a.m. with the Dietary Manager revealed she had gone out to smoke and came back in a rush and set the cigarette butt on the shelf above the resident tray line. Review of facility policy, Food Storage, revised date (MONTH) (YEAR) reflected: .8. Do not store scoops in ready to eat food . .11. Dented or otherwise damaged cans will not be used. Once, identified, dented cans should be stored in a separate area to be returned to vendor or discarded. Review of U.S. Department of Health and Human Services Food Code (YEAR) reflected: Section 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: (A) Except as specified under (B) of this section, in the food with their handles above the top of the food and the container; (B) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon. Section 3-202.15 Package Integrity. Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. Section 2-401.11 Food Contamination Prevention Eating, Drinking, or Using Tobacco. Proper hygienic practices must be followed by food employees in performing assigned duties to ensure the safety of the food, prevent the introduction of foreign objects into the food, and minimize the possibility of transmitting disease through food. Personal care items' means items or substances that may be poisonous, toxic, or a source of contamination.

Based on interview and record review, the facility failed to maintain a quality assessment and assurance (QAA) committee consisting of the DON, a medical director, and at least three other members, of the facility's staff that met at least quarterly to identify issues with respect to which quality assessment and assurance activities were necessary for two of four quarters of the annual time period reviewed. The facility failed to ensure the Medical Director attended the QAA committee meetings from January 2017 through August 2017 (two quarters). This failure could affect 47 residents by placing them at risk for not having the medical director current on issues being addressed in the facility for quality monitoring and improvement. Findings included: In an interview with the Administrator on 09/15/17 at 1:06 p.m., she stated that the expectation was to have the Director of Nursing, Administrator and Medical Director present at QAA meetings. When asked about the Medical Director, she stated he had not been present at the quality assurance meetings. She stated that there was not a reason why he was not present. On 09/15/17, an attempt was made to call and interview the Medical Director at 3:15 p.m. The medical director did not respond. A voice message was left. Review of the Quality Assurance & Assessment Meeting for January 2017 revealed no signature to show the medical director was present. Review of the Quality Assurance & Assessment Meeting for February 2017 revealed no signature to show the medical director was present. Review of the Quality Assurance & Assessment Meeting for March 2017 revealed no signature to show the medical director was present. Review of the Quality Assurance & Assessment Meeting for April 2017 revealed no signature to show the medical director was present. Review of the Quality Assurance & Assessment Meeting for May 2017 revealed no signature to show the medical director was present. Review of the Quality Assurance & Assessment Meeting for June 2017 revealed no signature to show the medical director was present. Review of the Quality Assurance & Assessment Meeting for July 2017 revealed no signature to show the medical director was present. Review of the Quality Assurance & Assessment Meeting for August 2017 revealed no signature to show the medical director was present. Review of the Quality Assurance & Assessment Meeting for September 2017 revealed no signature to show the medical director was present. Review of the quality assurance policy and procedure dated January 2015 revealed the home would have a system of quality assurance and performance improvement to promote the highest practical level of care for the resident. The home would have regular quality insurance and performance improvement meetings to review and determine the effectiveness of the home care and function. .Procedure The home will have a quality assurance and performance improvement team which consist of at least the following: a. Administrator b. Director of nursing c. Medical director d. A minimum of three other members of the home staff Review of the CMS 672, signed and dated by the ADON, revealed the census for the facility was 47 residents.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents, for one (Resident #1) of seven residents reviewed for accidents. The facility failed to transfer Resident #1 appropriately, with the assistance of two staff members. As a result, she sustained a non-displaced tibial plateau fracture of the left knee. This failure could affect 24 residents who required two-person assistance with transfers (including residents who required two-person assistance with a Hoyer lift) by jeopardizing their safety when being transferred. Findings include: Review of Resident #1's Face Sheet, dated 04/13/17, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Plan of Care, dated 08/02/16, reflected she required two staff members to assist with transfers. On 03/28/17, the Comprehensive Plan of Care was updated to reflect that she required a mechanical lift for transfers. Review of Resident #1's MDS assessment, dated 03/13/17, reflected Resident #1 had moderately impaired cognition. She was identified as requiring the assistance of at least two staff members for transfers. Review of the facility's Provider Investigation Report, dated 03/24/17, reflected that CNA A admitted to assisting Resident #1 from the bed to the wheelchair without the assistance of an additional staff member. The need for Resident #1 to be assisted with transfers by two staff members was indicated in her Care Plan and available for all staff members to review. As a result of this failure, Resident #1 sustained a nondisplaced tibial plateau fracture of the left knee. CNA was given a written warning and provided with 1:1 in-servicing. All other direct care staff members were in-serviced, as well. Interview with Resident #1 on 04/13/17 at 8:35 a.m. revealed there was an isolated incident in which CNA A transferred her from the bed to the wheelchair without assistance from another staff member. Resident #1 stated she heard a pop when her leg hit the wheelchair and got caught under a metal bar on the wheelchair. She stated she initially refused an x-ray due to not believing there was anything wrong with her knee. However, she later agreed to an x-ray and it was determined she had a fracture. Resident #1 stated typically, two staff members assisted her with transfers. Review of x-ray results completed on Resident #1, dated 03/18/17, reflected she sustained a non-displaced tibial plateau fracture. Interview with CNA A on 04/13/17 at 11:29 a.m. revealed on 03/18/17, she transferred Resident #1 from the bed to the wheelchair without the assistance of another staff member. CNA A stated she assisted Resident #1 in sitting on the side of the bed, and she then assisted Resident #1 in standing up. Resident #1 stated she heard a pop, so she was assisted back into a sitting position on the bed. Resident #1 requested to stand up again, and at that point CNA B walked into the room due to the call light being on. CNA B was in the room when CNA A completed the remainder of the transfer. CNA A stated she assisted Resident #1 in standing up again, and Resident #1 denied any complaints of pain. She was transferred into her wheelchair. CNA A stated she had been previously in-serviced regarding safe transfers, as well as how to identify what type of transfer each resident required. She stated she was aware that Resident #1 required more than one staff member to assist in transfers, but she failed to ensure the proper transfer was conducted. CNA A revealed she received additional training following the incident. Interview with CNA B on 04/13/17 at 11:57 a.m. revealed on 03/18/17, she witnessed CNA A transfer Resident #1 without the assistance of another staff member. She explained that she went into Resident #1's room due to the call light being on. When she walked into the room, Resident #1 was sitting on the side of the bed. CNA B moved the wheelchair to make it more accessible, and CNA A transferred Resident #1 into the wheelchair. CNA B stated Resident #1 did not complain of pain, and she reported she did not know anything about Resident #1 hearing her knee pop until after the investigation was initiated. CNA B further stated she did not care for Resident #1 on a normal basis, so at the time of the incident she did not know CNA A was conducting an improper transfer. CNA B stated she typically found out how a resident should be transferred by reviewing the resident's Care Plan. Interview with the DON on 04/13/17 at 1:00 p.m. revealed on 03/18/17, she was notified that Resident #1 reported hearing her knee pop during a transfer completed by CNA A. Resident #1 initially refused an x-ray, although she later agreed due to pain. It was determined that Resident #1 sustained a fracture. She was sent to the hospital for further treatment and evaluation, and she returned to the facility with a knee immobilizer and orders for an orthopedic follow-up. Resident #1 completed orthopedic services, and she remained non-compliant in using the knee immobilizer. The DON stated CNA A should have followed Resident #1's Care Plan and ensured two staff members were assisting with the transfer to avoid injury. Interview with the Administrator on 04/13/17 at 1:26 p.m. revealed on 03/18/17, CNA A neglected to ensure Resident #1's safety when she conducted an improper transfer. She stated CNA A had access to Resident #1's Care Plan, which noted what type of transfer Resident #1 required. She further stated it was CNA A's fault that Resident #1 sustained the fracture, as she admitted to not following proper protocol. The Administrator said CNA A received in-services regarding safe transfers prior to and following the incident. Review of a Gait Belt Transfer Skills Check List and Mechanical Lift Transfer Skills Check List, dated 12/02/16, reflected CNA A demonstrated competency when conducting these types of transfers. Review of in-service records reflected the following: CNA A was most recently in-serviced on the transferring of residents on 07/12/16, 02/14/17, and 03/21/17. Review of a Notice of Disciplinary Action, dated 03/19/17, reflected CNA A was suspended pending an investigation of abuse/neglect. A subsequent Notice of Disciplinary Action, dated 03/27/17, reflected CNA A received a written notice due to a policy violation involving an improper transfer. Review of the facility's Abuse - Reportable Events Policy and Procedure, dated 08/2016, reflected, .Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Interview with the ADON on 04/14/17 at 10:39 a.m. revealed a total of 24 residents required the assistance of two staff members for transfers (including residents who required two-person assistance with a Hoyer lift).

Based on observation, interview and record review, the facility failed to ensure grievances voiced by the residents were promptly resolved for one (Resident #4) of thirteen residents reviewed for grievances. Resident #4 complained Resident #14's television was too loud for over two months, with staffs' knowledge, but no resolution. This failure could affect all 48 residents in the facility and result in decreased self-worth, dignity, and unresolved concerns. Findings included: Review of Resident #4's Face Sheet dated 07/20/16 revealed that he was a [AGE] year-old male who was admitted to the facility 05/11/16. Review of Resident #14's undated Face Sheet revealed that he was a [AGE] year-old male who was admitted to the facility 05/25/13. Interview with Resident #4 on 09/06/16 at 11:20 AM revealed he complained about issues going on with Resident #14 to staff. He stated Resident #14 was partially deaf and turned his television all the way up to hear it. When he made a complaint about it to staff, they just came and turned it down. However, after a while, he eventually turned it back up. Resident #4 stated he stopped complaining about it because nothing changed; he just dealt with it. He stated this issue had been on-going since he moved to his room. Review of the facility Room Change form, dated 06/22/16, reflected Resident #4 moved into the room with Resident #14 on 06/22/16. Observation of the noise level during Resident #4's interview in his room on 09/06/16 at 1:45 PM revealed Resident #14's television volume was turned up so loud that the resident and surveyor raised their voices and repeated statements to be heard and understood. Observation of the noise level in Resident #4's room on 09/07/16 at 2:03 PM revealed Resident #14's television volume was loud as he watched soccer. The television was heard outside of the room in the hall before surveyor entered to interview Resident #4. Review of Resident #4's Social Progress Notes dated 06/24/16 reflected, 6/24/16 Followup (sic) w/ wife to see if resident was ok w/ the move. She states the TV is too loud and he (sic) unable to hear his own TV or talk on the phone. I say I will talk w/ resident and see how we can accommodate him .6/24/16 I asked roommate to turn TV down a little for his resident (sic) to hear TV . . Review of the facility's concern log dated May to August revealed Resident #4's noise complaint was not documented or logged. Interview with the Social Worker on 09/08/16 at 11:20 AM revealed the facility purchased Resident #14 a pair of wireless headphones yesterday (09/07/16). She did not know whether or not the television was Bluetooth compatible, and stated that she would test them out later. The Social Worker stated she first heard about the noise complaint on 06/24/16, according to her notes. Staff tried to get Resident #14 to turn his television down, but it did not work out. Generally, with regard to handling of complaints, the Social Worker stated she kept her own grievance book and followed up on them until resolved. However, she did not write up a grievance for Resident #4. She stated this was an oversight on her part. She stated she wrote up the grievance today (09/08/16). Review of Grievance/Complaint Investigation Report, authored by the Social Worker and dated 09/08/16, revealed documentation of Resident #4's noise complaint and details. Interview with the IAdmin on 09/08/16 at 11:45 AM revealed that she had been the interim Administrator at the facility since 07/19/16. Staff made her aware of Resident #4's noise complaint yesterday (09/07/16). The facility purchased Resident #14 headphones last night, and staff would be advised to monitor that he wore them. If Resident #14 was not cooperative, they would move Resident #4 to another room. The IAdmin confirmed that Resident #4's situation/complaint qualified as one that should have been documented in the complaint log. Review of the facility's Grievance policy, revised March 2012 reflected, It is the policy of this home that staff promptly attempt to resolve grievances the resident may have including those, which involve the behavior of others .Procedure .The home will inform each resident upon admission and at least annually of their right to voice grievances .Grievance will be written on the home's (Grievance/Complaint Report Form) .The home will address each grievance in a reasonable time frame .home will upon resolution of grievance, follow-up in a timely manner to assure that resolution has been successful . Form CMS-672, Resident Census and Conditions of Residents, signed by MDS Coordinator and dated 09/06/16 reflected a total of 48 residents in the facility.

Based on observation, interview, and record review, the facility failed to provide for the maintenance of comfortable sound levels for one (Resident #4) of twelve residents reviewed for Quality of Life. Resident #4 complained Resident #14's television was too loud for over two months with no resolution. This failure could affect the 21 residents that resided on hall 300 and result in diminished quality of life. Findings included: Review of Resident #4's Face Sheet dated 07/20/16 revealed that he was a [AGE] year-old male who was admitted to the facility 05/11/16. Review of Resident #14's undated Face Sheet revealed that he was a [AGE] year-old male who was admitted to the facility 05/25/13. Interview with Resident #4 on 09/06/16 at 11:20 AM revealed he complained about issues going on with Resident #14 to staff. He stated Resident #14 was partially deaf and turned his television all the way up to hear it. When he made a complaint about it to staff, they just came and turned it down. However, after a while, he eventually turned it back up. Resident #4 stated he stopped complaining about it because nothing changed; he just dealt with it. He stated this issue had been on-going since he moved to his room. Review of the facility Room Change form, dated 06/22/16, reflected Resident #4 moved into the room with Resident #14 on 06/22/16. Observation of the noise level during Resident #4's interview in his room on 09/06/16 at 1:45 PM revealed Resident #14's television volume was turned up so loud that the resident and surveyor raised their voices and repeated statements to be heard and understood. Observation of the noise level in Resident #4's room on 09/07/16 at 2:03 PM revealed Resident #14's television volume was loud as he watched soccer. The television was heard outside of the room in the hall before surveyor entered to interview Resident #4. Review of Resident #4's Social Progress Notes dated 06/24/16 reflected, 6/24/16 Followup (sic) w/ wife to see if resident was ok w/ the move. She states the TV is too loud and he (sic) unable to hear his own TV or talk on the phone. I say I will talk w/ resident and see how we can accommodate him .6/24/16 I asked roommate to turn TV down a little for his resident (sic) to hear TV . . Review of the facility's concern log dated May to August revealed Resident #4's noise complaint was not documented or logged. Interview with the ADON on 09/07/16 at 12:10 PM revealed she was aware of Resident #4's complaint about the noise level in his room. The ADON stated the facility was buying Resident #14 headphones that reached to the television from his bed. She stated complaints normally went to the Administrator and Social Worker for resolution. Interview with the DON on 09/07/16 at 12:45 PM revealed she was aware of Resident 4's complaint of the noise level in his room. She stated in the beginning, there was an issue with the television being too loud. Resident #14's family was going to buy him headphones, and that was all she knew. Follow up interview with the ADON on 09/07/16 at 1:15 PM revealed Resident #14's family did not want to pay for the headphones. She believed the facility was going to purchase them so Resident #4 did not have to hear the noise anymore. Interview with CNA C on 09/07/16 at 2:02 PM revealed Resident #4 complained to her one to two times about Resident #14's television being too loud. She responded by asking Resident #14 to turn it down. Interview with the Social Worker on 09/08/16 at 11:20 AM revealed the facility purchased Resident #14 a pair of wireless headphones yesterday (09/07/16). She did not know whether or not the television was Bluetooth compatible, and stated that she would test them out later. The Social Worker stated she first heard about the noise complaint on 06/24/16, according to her notes. Staff tried to get Resident #14 to turn his television down, but it did not work out. Generally, with regard to handling of complaints, the Social Worker stated she kept her own grievance book and followed up on them until resolved. However, she did not write up a grievance for Resident #4. She stated this was an oversight on her part. She stated she wrote up the grievance today (09/08/16). Review of Grievance/Complaint Investigation Report, authored by the Social Worker and dated 09/08/16, revealed documentation of Resident #4's noise complaint and details. Interview with the IAdmin on 09/08/16 at 11:45 AM revealed that she had been the interim Administrator at the facility since 07/19/16. Staff made her aware of Resident #4's noise complaint yesterday (09/07/16). The facility purchased Resident #14 headphones last night, and staff would be advised to monitor that he wore them. If Resident #14 was not cooperative, they would move Resident #4 to another room. The IAdmin confirmed that Resident #4's situation/complaint qualified as one that should have been documented in the complaint log. Review of the facility's Grievance policy, revised March 2012 reflected, It is the policy of this home that staff promptly attempt to resolve grievances the resident may have including those, which involve the behavior of others .Procedure .The home will inform each resident upon admission and at least annually of their right to voice grievances .Grievance will be written on the home's (Grievance/Complaint Report Form) .The home will address each grievance in a reasonable time frame .home will upon resolution of grievance, follow-up in a timely manner to assure that resolution has been successful . The facility ' s Daily Census Report dated 09/06/16 reflected a total of 21 residents on hall 300.

Based on observation, interview and record review, it was determined the facility failed to promptly notify the physician of the findings for one of (Residents #5) of two residents reviewed for urinary tract infection [MEDICAL CONDITION] and whose laboratory results were reviewed. Resident #5's U/A (urinalysis) results dated 04/23/15 were not reported to the physician until 08/13/15. These failures could affect all 50 facility residents by not having their labs promptly reviewed by their physician placing them at risk for delay in treatment and worsening of a medical condition. Findings included: Review of Resident #5's most recent MDS assessment, dated 08/28/15, a significant change assessment revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Observation on 09/08/15 at 6:40 p.m. revealed Resident #5 was in her room, eating dinner. LVN A stated at that time Resident #5 required the assistance of two staff for transfer and she had been treated last month for a UTI. Review of physician telephone orders for Resident #5 revealed an order for [REDACTED].>Review of lab report (with C/S) for Resident #5, dated 04/23/15 at 9:00 p.m., reflected Escherichia coli (bacteria that is found in the rectal area) greater than 100,000 colony counts was isolated. The colony count for Proteus mirabilis was 50,000 to 99,000, less than 100,000 colony counts was isolated. The urinalysis report had a hand written note that it was sent PA on 08/12/15 at 22:30 (10:30 p.m.). Another hand written note on the sheet, per LVN A at 00:33 a.m. (12:33 a.m.) 08/13/15, reflected an order for [REDACTED]. Further review of physician telephone orders for Resident #5 revealed there were no treatment orders dated 04/23/15. Review of a physician telephone order for Resident #5, dated 08/13/15, revealed an order for [REDACTED]. A nurse's note, dated 08/12/15 at 11:00 p.m. regarding Resident #5 reflected, Sent labs UA with C/S to PA awaiting orders. 24 hour chart check. A nurse's note, dated 08/13/15 at 12:33 a.m. regarding Resident #5 reflected an order was received back. The new order was for [MEDICATION NAME] 500 mg one tablet by mouth twice a day for seven days for a UTI. Interview on 09/10/15 at 2:30 p.m. with the DON regarding the order for UAC/S for Resident #5, the DON stated she could not find lab orders for the UAC/S, 08/13/15. The DON was asked if any lab tests were obtained to determine the most recent organism to be treated. The DON stated she would check to find if there were labs done before the treatment started. Review of the lab report, dated 04/23/15 with the DON, revealed the report had been more than three months old and staff had faxed the report to the PA with a treatment order received based on the lab report. The DON revealed there were no current lab orders for the treatment and facility staff had faxed to the physician an old lab report. The facility PA was interviewed on 09/11/15 at 4:50 p.m. The interview revealed he normally ordered a UAC/S before orders for treatments were given to ensure the proper antibiotics were ordered. The C/S provides the orgasm to be treated and would not have treated the possible UTI without the UAC/S. The PA further stated facility staff faxed the report to the physician, called the PAs and read the report. The PA stated he never got the actual lab report copy (ies); staff called and read off the report to them, (the Pas). He stated that decision for treatment was based on the organism(s) that presented in the culture (C/S report). The PA also stated that if the preliminary report was positive for [MEDICATION NAME] he would normally start the resident on something [MEDICATION NAME] three days until the final culture report was available; then he would change the treatment to a drug like [MEDICATION NAME]. The PA further stated he would give [MEDICATION NAME] preventive measures. The PA stated facility staff could not send a urine specimen for a UAC/S without a physician's orders [REDACTED].>The PA stated the facility did not give him information that Resident #5 was confused, lethargic or any information regarding UTI other than the result on the lab report. He was not aware he was given results from an out dated lab report when he ordered the [MEDICATION NAME]. In a telephone interview on 09/14/15 at 1:15 p.m. with LVN A she stated the lab company faxed to the facility a bunch of lab reports which included Resident #5's report. On 08/13/15, She faxed the report to the PA and later received an order for [REDACTED]. She did not assess the resident for any signs and symptoms of UTI. LVN A stated during this time, around 08/12/15, Resident #5 had some confusion, altered mental status, which was reported in report. She did not personally assess the resident and/or document any signs and symptoms of UTI. In an interview on 09/11/15 at 4:45 p.m. with the DON she stated she expected labs to be completed by the next day and sent to the physician, and staff must ensure it was a current lab report. She stated once the facility received the lab results, the staff should promptly notify the physician and/or the PA of the results. Review of the facility's current P/P for Lab Orders revised March 2012, revealed: The attending physician will be notified promptly of lab results. Laboratory results will be maintained in the resident's clinical record. Review of the facility's Resident Census and Condition of Residents, Form CMS-672, completed and signed on 09/09/15 by the MDS Coordinator, revealed a total census of 50 residents.

Based on interview and record review, it was determined the facility failed to use the services of an RN for at least eight consecutive hours a day and seven days a week in the facility for eleven (07/18/15, 07/19/15, 07/25/15, 07/26/15, 08/01/15, 08/02/15, 08/16/15, 08/22/15, 08/23/15, 08/29/15 and 08/30/15) of 26 days reviewed from 06/11/15 through 09/11/15. There was no RN coverage on the weekends (Saturday and/or Sunday) on 07/18/15, 07/19/15, 07/25/15, 07/26/15, 08/01/15, 08/02/15, 08/16/15, 08/22/15, 08/23/15, 08/29/15 and 08/30/15. This failure placed all 50 residents receiving nursing services at risk for not having their nursing and medical needs met. Findings included: Review of the facility's daily staff assignment sheets and employee time cards from 06/11/15 through 09/11/15 revealed there was no RN coverage on the weekends for the following dates: 07/18/15, 07/19/15, 07/25/15, 07/26/15, 08/01/15, 08/02/15, 08/16/15, 08/22/15, 08/23/15, 08/29/15 and 08/30/15. Interview on 09/11/15 at 2:11 p.m. with the DON revealed she had tried to cover the weekends with diferrent RNs, but it had not worked out too well. The DON stated she had recently hired an RN on 08/25/15 to cover the weekends. Form CMS-672, Resident Census and Conditions of Residents, signed by the MDS Coordinator on 09/09/15, reflected a total census of 50 residents.

Based on observation, interview, and record review, it was determined the facility failed to maintain an Infection Control Program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for three(Residents #14, #15, and #16) of four residents observed during blood glucose monitoring. 1) RN B obtained blood samples from Resident #14, #15 and #16 for glucose monitoring without disinfecting the glucose meter before or after use. 2) RN B placed the glucose meter in the general use treatment cart . These failures could affect the six residents identified by the ADON who were diabetics on Hall 200 who required blood sugar monitoring, which placed them at risk for cross-contamination and possible infections. Findings included: RN B was observed obtaining blood samples for glucose monitoring on 09/09/15 using the facility's multi-use Assure Platinum glucose meter. The RN entered each resident's room to obtain their blood samples. Observations on 09/09/15 revealed the following: 1) At 11:35 a.m., RN B retrieved the glucose meter from the top of the medication cart. RN B did not disinfect the glucose meter before or after obtaining a blood sample from Resident #14. After testing the sample and without disinfecting the meter, the nurse placed the glucometer meter inside the medication cart and moved on to the next room. 2) At 11:45 a.m., RN B retrieved the meter from inside the top drawer of the medication cart. RN B did not disinfect the glucose meter before or after obtaining a blood sample from Resident #15. After testing the blood sample, RN B placed the glucose meter on the top drawer of the medication cart and moved to the next room. 3) At 11:55 a.m., RN B retrieved the meter from inside the top drawer of the medication cart. RN B did not disinfect the glucose meter before or after obtaining a blood sample from Resident #16. After testing the blood sample, RN B placed the glucose meter on the top drawer of the medication cart. During an interview with RN B on 09/09/15 at 2:00 p.m. revealed she forgot to use the PPI Sani Cloth wipes provided for the cleaning of the glucometer machine. She only realized after the surveyor completed the observation. She further stated she did not know the facility's policy/procedure for disinfecting the glucose meter, but was supposed to use the wipes for the meter and the top of the medication cart. The DON was interviewed on 09/10/15 at 2:30 p.m. about the facility's P/P and her expectations for disinfecting the glucose meters. The DON stated the P/P provided was the only one available and she expected staff to disinfect the meters between resident- use. She further stated she had provided in-service training on 09/09/15 related to Glucometer sampling and monitoring process. Review of the in-service record provided to the surveyor upon request on 09/21/15 for the facility nurses, revealed the in-service training was a review of the P/P and proper steps for obtaining blood samples and infection control. The facility's policy/procedure (P/P) related to disinfecting a glucose meter was requested from the DON on 09/11/15. A list provided by the ADON on 09/11/15 reflected RN B was responsible for providing finger sticks for blood glucose monitoring for six. A one page document titled Finger Stick Blood Sampling was provided by the DON on 09/11/15 and identified as the facility's current glucose meter disinfecting P/P. The document was dated revised March 2012. The P/P reflected: Clean the Glucometer with germicidal wipes/or bleach/h2O (water) solution with a 1 to 9 ratio before initial use, after final use and between each resident following manufacturer recommendations. Review of the Centers for Disease Control (CDC) website www.cdc.gov viewed on 09/21/15 reflected, Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. The website further reflected unsafe practices during assisted blood glucose monitoring that had contributed to transmission of HBV (Hepatitis B Virus), or had put persons at risk for infection included using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses. The website reflected disinfection solvent used should be effective against Human Immunodeficiency Virus (HIV), Hepatitis C, and Hepatitis B virus. Please note that 70% [MEDICATION NAME] solutions are not effective against viral blood-borne pathogens. On 09/11/15, the ADON identified 8 residents residing in the facility who had their blood glucose monitored using the multi-use Assure Platinum glucose meter.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care, for one (Resident #5) of two residents reviewed for urinary tract infection [MEDICAL CONDITION] and one (Resident #7) of three residents reviewed for indwelling urinary catheters. 1) The facility failed to ensure Resident #5 was assessed for a urinary tract infection. 2) The facility failed to ensure Resident #5 ' s signs and symptoms of a UTI were communicated to the nurses, documented, and followed up to ensure the resident received treatment. 3) LVN A failed to fax the physician a current lab report for Resident # 5. The physician's current treatment orders were based on an old lab report which was ordered on [DATE]. 4) The facility failed to ensure Resident #7's indwelling urinary catheter tube was anchored at all times. The failure to obtain a current UA, and C&S report, assess Resident #5 for signs and symptoms of a UTI, and obtain appropriate treatment orders placed her at risk [MEDICAL CONDITION], and placed the other 27 residents on Hall 200, where LVN A was the charge nurse, at risk for not receiving labs as ordered by their physicians. The failure to secure indwelling urinary catheter tubing placed the four residents with catheters at risk for trauma to the urethra, and possible urinary tract infections. Findings included: 1) Review of Resident #5's recent Significant Change in Status MDS assessment dated [DATE] revealed she was a [AGE] year-old female. The MDS assessment reflected Resident #5 had [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #5 required extensive assistance with locomotion, dressing and bathing. She also required limited assistance with transfer, and personal hygiene. Review of Resident #5's care plan dated 01/02/15, last reviewed and revised 07/15/15, revealed a plan for stress urinary incontinence. The goal reflected, resident will maintain current level/regain previous level of bladder continence. The approaches identified for this problem included: .Obtain labs as ordered Provide incontinence care after each incontinent episode Report signs/symptoms of UTI. (Acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine, blood in urine) Review of the care plan dated 08/13/15 reflected Resident #5 was on antibiotics and was at risk for adverse reactions. The care plan reflected Resident #5 was on [MEDICATION NAME] 500 mg BID (twice daily) for UTI. The goals were: Infection will be resolved or resolving at the end of the antibiotic therapy and resident will not have any adverse reactions to the antibiotic therapy. The interventions were: Give meds per order-monitor labs, cultures- report abnormals to MD Monitor resident for adverse reactions specific to the medication Follow universal/standard precaution to prevent cross contamination and spread of infection. Encourage fluids as ordered. Review of the telephone orders dated 04/23/15 revealed an order for [REDACTED].>Review of the urinalysis lab reports dated 04/23/15 at 9:00 p.m. revealed the following results: Reference Range Color __Yellow Yellow Clarity __Cloudy Clear Blood__Trace-Intact Negative [MEDICATION NAME] Positive Negative Leuko__Moderate Negative UWBC__10-25 None seen UBACT__ Moderate None seen Mucous __ Few None seen The report also had a C/S report which reflected a final report with Escherichia coli (commonly found in feces) greater than 100,000 colony counts isolated. The colony count for Proteus mirabilis was 50,000 to 99,000, less than 100,000 colony counts. The urinalysis report had a hand written note that it was sent PA on 08/12/15 at 22:30 (10:30) p.m. A hand written order on the lab sheet by LVN A at 00:33 a.m. 08/13/15 reflected an order for [REDACTED]. Further review of the telephone orders reflected there was no treatment orders dated 04/23/15. A telephone order dated 08/13/15 was reviewed. The telephone order reflected an order for [REDACTED]. Review of the nurses' notes from 07/27/15 at 03:55 a.m. to 08/13/15 at 11:00 p.m. revealed no documentation of Resident #5 experiencing any signs and symptoms of a UTI. The nurse's note on 08/12/15 at 11:00 p.m. revealed Sent labs ' UA with C/S to PA awaiting orders. 24 hour chart check. At 12:33 a.m. on 08/13/15 the nurse's note reflected an order was received back. New order were received for [MEDICATION NAME] 500 mg one tablet by mouth twice a day for seven days for a UTI. The nurse's note at 11:30 p.m. on 08/13/15 reflected the following: (Resident #5) continues on [MEDICATION NAME] 500 mg one tablet for UTI. Up as tolerated in wheelchair, alert and oriented times two to three with confusion. No complaints of dysuria/oliguria. Fluids encouraged. There were no current lab results in connection for the treatment. Review of Resident #5's medication administration flow sheet for August 2015 reflected Resident #5 was started with [MEDICATION NAME] 500 mg one table twice a day on 08/13/15 for seven days. Review of the 24 hour report worksheet for 08/10/15, 08/11/15, 08/12/15, and 08/13/15 revealed no documentation that Resident #5 had any signs and symptoms of a UTI. The surveyor observed Resident #5 on 09/08/15 at 6:40 p.m. in her room eating dinner. LVN A on rounds stated Resident #5 was ambulatory with a wheelchair, she was incontinent of bowel and bladder, alert and oriented to person and place with some confusion. LVN A stated Resident #5 required the assistance of two staff for transfer, and she was treated for [REDACTED]. Resident #5 was observed on 09/09/15 at 9:15 a.m. with RN B during the medication administration pass. Resident #5 received 30 ml of UTI _ STAT. RN B stated it was Resident #5's first dose and supplement/medication was to treat her frequent UTIs. (Resident #5) asked the nurse if that was what I had? RN B stated to the resident, yes, you have been having a lot of UTIs. The surveyor requested from RN B on 09/10/15 at1:20 p.m. the lab report for the [MEDICATION NAME] order on 08/13/15. RN B stated the lab reports and telephone orders were sent to the physician's office for them to be signed, and were not readily available in the facility. The DON was interviewed at 2:30 p.m. on 09/10/15 regarding the order for UAC/S for Resident #5. The DON was asked for the orders for the UAC/S for the treatment order for the [MEDICATION NAME]. The DON stated she could not find an order for [REDACTED]. The DON stated she would check to find out if there were labs done before the treatment. The surveyor reviewed the lab report dated 04/23/15 with the DON. She was informed the report had been more than three months old, and staff had faxed the report to the PA with treatment order received based on the lab report. At 2:50 p.m., the DON presented her individual Infection control log and pointed to an area dated 08/13/15 UTI-symptoms burning, odor. Further review of the log reflected Resident #5 was treated for [REDACTED]. The log had no information if the C/S was ordered or done and evidence of the organism treated. At 4:45 p.m., on 09/10/15 the DON stated she was not able to locate current lab reports for August 2015 relating to the organism being treated. On 09/11/15 at 12:10 p.m. the DON stated she spoke to LVN A, who received the telephone order for the [MEDICATION NAME], and she stated there was no lab report in the chart, on 08/13/15, so she called the lab and they faxed over the available lab (lab dated 04/23/15), and she sent it to the PA. The DON stated she was not sure what was going on with the resident at that time, 08/13/15. However, the PA did not observe or notice the wrong date, but sent an order for [REDACTED]. In an interview with Resident #5 on 09/11/15 at 2:30 p.m., she stated her urine was dark yellow, there was a time it burnt to urinate, but currently the burning came off and on. Resident #5 stated staff gave her cranberry juice for the bladder, but she preferred to drink water, as the cranberry juice was very tart and she did not like to drink it. Interview with LVN C on 09/11/15 at 2:20 p.m. revealed she was informed by a night shift nurse during report at that time, around 08/13/15, that Resident #5 was lethargic and would not get out of bed which was unlike her. LVN C stated Resident #5 was usually very active, out-going and liked to come out to activities, but was not doing that, she wanted to sleep all the time. LVN C further stated the UAC/S was obtained, and the result came out positive for a UTI. When LVN C was asked for the documentation of her assessment after report of the resident and/or her acknowledgement of the lab report, LVN C stated she did not perform an assessment and/or review the lab report. The facility PA was interviewed on 09/11/15 at 4:50 p.m. The interview revealed he normally ordered a UAC/S before orders for treatments were given to ensure the proper antibiotics were ordered. The C/S provides the orgasm to be treated and would not have treated the possible UTI without the UAC/S. The PA further stated facility staff faxed the report to the physician, called the PAs and read the report. The PA stated he never got the actual lab report copy (ies); staff called and read off the report to them, (the Pas). He stated that decision for treatment was based on the organism(s) that presented in the culture (C/S report). The PA also stated that if the preliminary report was positive for [MEDICATION NAME] he would normally start the resident on something [MEDICATION NAME] three days until the final culture report was available; then he would change the treatment to a drug like [MEDICATION NAME]. The PA further stated he would give [MEDICATION NAME] preventive measures. The PA stated facility staff could not send a urine specimen for a UAC/S without a physician's order. The PA stated the facility did not give him information that Resident #5 was confused, lethargic or any information regarding UTI other than the result on the lab report. He was not aware he was given results from an out dated lab report when he ordered the [MEDICATION NAME]. LVN A returned the surveyors call on 09/14/15 at 1:15 p.m. During the interview LVN A stated the lab company faxed to the facility a bunch of lab reports which included Resident #5's report. On 08/13/15, She faxed the report to the PA and later received an order for [REDACTED]. She did not assess the resident for any signs and symptoms of UTI. LVN A stated during this time, around 08/12/15, Resident #5 had some confusion, altered mental status, which was reported in report. She did not personally assess the resident and/or document any signs and symptoms of UTI. Review of the facility policy on Antibiotic Documentation presented to the surveyor by the facility DON on 09/11/15 at 12:10 p.m. as the facility ' s current policy on when to administer antibiotics, revised and dated 03/2012, revealed: POLICY: It is the policy of this home to assure that the resident receiving antibiotic therapy will be assessed routinely. PROCEDURE: 1. Licensed Nurse will document initial dose of antibiotic in the nurses ' note, as well as MAR. Documentation will include, but not limited to: Reason for Antibiotic 2. Licensed Nurse will document final dose in the nurses ' note, as well as MAR. Documentation will include, but not limited to: Assessment of Resident in relation to reason for antibiotic (i.e., color of urine, fever, odor of urine, lung sounds, etc.) 3. Licensed Nurse will document assessment of resident in the nurses ' notes every shift, for at least three (3) days after final dose of antibiotic. This documentation will include, but not limited to: Assessment of Resident in relation to reason for antibiotic (i.e, color of urine, fever, odor of urine, lung sounds, etc.) 2) Review of Resident #7 's MDS assessment, dated 08/18/15, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #7 had an indwelling catheter. Resident #7 was initially observed during rounds on 09/08/15 at 7:07 p.m. with LVN E. The resident was in his room lying in bed asleep. LVN E described the resident as alert only and stated that he utilized an indwelling urinary catheter. Observation on 09/10/15 at 9:39 a.m. revealed Resident #7 was transferred via mechanical lift from his wheelchair to his bed. During the transfer, CNA D asked Resident #7 not to pull on his catheter when the resident began to fidget with it. Interview on 09/10/15 at 9:50 a.m. with CNA D revealed Resident #7's indwelling urinary catheter was not anchored. Observation on 09/10/15 at 9:53 a.m. revealed Resident #7's indwelling urinary catheter was not anchored. Observation on 09/10/15 at 10:50 a.m. revealed Resident 7's indwelling urinary catheter was not anchored. At that time, LVN F stated Resident #7 did not have an anchor for his indwelling urinary catheter, and that she had never seen one used at the facility. The surveyor had observed Resident #7 during incontinent care at that time and the catheter was being tugged and pulled on during care. Interview on 09/10/15 at 5:56 p.m. with the DON revealed Resident #7's catheter tubing was now anchored. The DON stated staff had informed her that Resident #7's catheter tubing had not been anchored and she had provided staff with an anchor to place on the resident. Review of the facility's current Catheter (s) - Insertion and Care - Indwelling, Straight, Suprapubic and External p/p, dated June 2015, revealed . It is the policy of this home that the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risk of urinary tract complications Procedure - Indwelling Catheter - Insertion . RN (Registered Nurse)/LVN (Licensed Vocational Nurse) to insert catheter using following procedure . 7. Attach catheter strap to leg to assist in securing tubing Review of Resident #7's indwelling catheter care plan, dated 08/26/15, revealed . Resident will have catheter care managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma Provide catheter care Q (every) shift and as needed Review of Resident #7's September 2015 Treatment Administration Record regarding his catheter revealed . Catheter Care Q (every) shift and PRN (as needed) Every Shift . Foley catheter: Indwelling Catheter 16FR (French scale) assess Q shift Every Shift . Review of the facility's Resident Census and Condition of Residents, Form CMS-672, completed and signed on 09/09/15 by the MDS Coordinator, revealed a total census of 50 residents. In additon, the Form CMS-672 reflected four residents had indwelling or external catheters.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for two (Residents #1 and #2) of eight residents reviewed for pain management. 1) Resident #2 fell and exhibited signs and symptoms of pain including crying, moaning, guarding, and facial grimacing. LVN G, RN H, LVN I, and the ADON did not effectively manage the resident's continued pain by failing to adequately inform the physician of the symptoms. An X-ray was ordered two days after the fall and the resident had a right distal femur fracture. Three days later, Resident #2 had orders for [MEDICATION NAME] for pain. However, staff rarely administered the pain medication. After surveyor intervention, seven days after the resident's fall, an order for [REDACTED]. 2) Resident #1 complained of jaw pain and was ordered the [MEDICATION NAME] 50 mg orally two times a day as needed for pain on 10/24/11. The resident continued to experience pain and was provided with Tylenol instead of the [MEDICATION NAME] ordered by the physician. These failures resulted in Residents #1 and #2 experiencing unrelieved pain. These failures could affect the facility's 44 residents, who were on a pain management program, by placing them at risk for additional pain, untreated pain, hopelessness, fear and in-effective pain management. Findings included: 1) Review of an accident/incident report dated 10/21/11 revealed Resident #2 was observed on the floor on her knees on 10/21/11 at 4:15 p.m. According to the report, the resident fell out of the wheelchair and no pain or discomfort was noted. Resident #2's Nurse's Notes dated 10/21/11 and timed 4:15 p.m. revealed Resident #2 was assessed with [REDACTED]. Resident #2's Nurse's Notes dated 10/21/11 and timed 4:30 p.m. revealed the resident's physician was notified of the fall and no new orders were received. Resident #2's Nurse's Notes dated 10/22/11 and timed at 10:00 a.m. reflected there was no documented assessment of Resident #2 for pain, discomfort or injury. Resident #2's Nurse's Note dated 10/22/11 and timed at 10:00 p.m. reflected Resident #2 was crying out with pain in the right leg and the right knee was moderately swollen. This note reflected the RN charge nurse had notified the physician "earlier" in the day of the swelling in Resident #2's right knee and no new orders were received. There was no documentation of the physician being notified of this assessment. Nurse's Notes dated 10/22/11 and timed at 11:45 p.m. reflected Resident #2 was guarding her right leg and the right knee was noted with purple, yellow and green discoloration. The resident's right foot was noted with "slight" swelling on top and purple bruising to the sole of the foot. Resident #2 was "calling out in pain" with any movement of her leg. This note further reflected an ice pack was applied to the resident's knee. There was no documentation the physician was notified of this assessment. The 5:00 a.m. 10/23/11 Nurse's Note reflected there was no change in the swelling of Resident #2's right knee/foot. However, the resident continued to guard and cry out in pain during repositioning and incontinent care. There was no documentation the physician was notified. Resident #2's Nurse's Notes dated 10/23/11 and timed at 3:30 p.m. reflected an order had been received to obtain x-rays of the resident's right hip, femur/tibia, knee ankle and foot due to increasing bruising and pain. According to this note, the resident's right knee and thigh were positive for swelling, redness and warmth was noted to the knee and the skin surrounding the knee. Bruising and [MEDICAL CONDITION] were noted to the top of the resident's right ankle and right top foot. The note further reflected bruises remained on the sole of Resident #2's foot, the resident continued to "call" out with any movement to the right leg, very guarding, flinches and "draws up" towards chest. According to this note, the resident's pain intensity could not be assessed and 650 mg of Tylenol was administered. Nurse's Notes dated 10/23/11 and timed at 5:15 p.m. reflected the mobile x-ray company had arrived. The Nurse's Note dated 10/23/11 and timed at 6:00 p.m. reflected the results of the x-ray were received and Resident #2's right femur was positive for an acute fracture. An X-ray report dated 10/23/11 for Resident #2 reflected, " ...Acute Right Distal Femoral (Femur) Fracture.... " Nurse's Notes dated 10/23/11 and timed at 6:45 p.m. reflected nursing staff was informed by the ADON of the physician's orders [REDACTED]. The note further reflected no orders had been received for pain management. This note reflected a request was made of the ADON by LVN I to notify Resident #2's physician again and request pain management orders. According to the nurse's notes dated 10/23/11, the ADON notified nursing staff at 8:00 p.m. there were no additional orders received from the physician to address Resident #2's pain. The October 2011 MAR and physician's orders [REDACTED]. The [MEDICATION NAME] Tylenol one 325 mg tablet orally was ordered to be administered every four hours as needed. According to the MAR the Tylenol was administered on 10/22/11 and 10/23/11 at 3:30 p.m. and on 10/24/11 at 4:00 a.m. There was no documented assessment of Resident #2's pain at the time the Tylenol was administered. There was no documented assessment after the Tylenol was administered in an effort to determine effectiveness and/or if there was a need to notify the physician. A Telephone physician's orders [REDACTED].#2. Review of the Nursing 2012 Drug Handbook 32nd Edition, page 950 reflected: [MEDICATION NAME]-used for the management of mild to moderate pain. A Telephone physician's orders [REDACTED]. Review of the Nursing 2012 Drug Handbook 32nd Edition, page 1352 reflected: [MEDICATION NAME]- used for the management of moderate to moderately severe chronic pain. Resident #2's October 2011 MARs reflected the [MEDICATION NAME] was never administered and the [MEDICATION NAME] was administered once on 10/24/11,10/25/11 and 10/26/11. The MARs further reflected the [MEDICATION NAME] was administered twice on 10/27/11 and once on 10/28/11. The only documentation related to the resident's pain and the administration of the [MEDICATION NAME], was on 10/26/11 at 12:00 p.m. The cognitively impaired pain management flow sheet (PAINAD) for Resident #2 dated 10/26/11, reflected the resident was heard moaning and received [MEDICATION NAME]. (PAINAD scale- a pain behavior tool used to assess pain in older adults who have dementia or other cognitive impairment and are unable to reliably communicate their pain). Resident #2 was initially observed during rounds conducted on 10/25/11 at 9:40 a.m. The resident was observed asleep in bed with fading, blue and purple colored bruises to the face. During rounds, CNA A stated the resident was totally dependent on staff for all ADLs and had recently sustained a fall. An interview with the DON on 10/25/11 at 12:45 p.m. revealed Resident #2 had fallen on Friday 10/21/11 and sustained a [MEDICAL CONDITION] femur. Prior to surveyor intervention, Resident #2's only care plan related to pain reflected a review date of 08/25/11. The care plan addressed bilateral knee pain related to the [DIAGNOSES REDACTED]. Resident #2's "Pain Interviews" for the MDS assessment were reviewed. The interviews for the quarterly assessment dated [DATE], the annual assessment dated [DATE] and the significant change assessment dated [DATE] reflected the resident did not have pain. An interview with the DON on 10/27/11 at 4:43 p.m. revealed she had phoned the physician on Monday 10/24/11 related to Resident #2's pain. The DON stated [MEDICATION NAME] was ordered at that time. When queried if she thought the [MEDICATION NAME] was effective in managing Resident #2's pain, she stated, "No" nor was the [MEDICATION NAME] effective if the resident was exhibiting pain when she was moved. According to the DON, on Monday, 10/24/11, she had informed the resident's physician of the pain with movement. However, she stated there was no documentation of her notifying the physician of the resident's continued pain. The DON stated, "It's not documented anywhere." An interview was conducted on 10/28/11 at 2:00 p.m. with LVN G, the author of the 10/22/11 nurse's note. LVN G stated during the day shift on Saturday 10/22/11 Resident #2's right knee was positive for swelling. During this interview, the nurse confirmed she had not documented an assessment of the resident to determine if there was any injury or pain. She stated, "I should have" documented the swelling she observed during the day shift on 10/22/11. According to LVN G she reported the resident's swollen right knee to the weekend supervisor, RN H but she did not notify the physician. An interview was conducted on 10/29/11 at 10:15 a.m. with LVN I, the author of the nurse's notes dated/timed 10/22/11 at 10:00 p.m., 10/22/11 at 11:45 p.m. and 10/23/11 at 5:00 a.m. During this interview, LVN I stated she worked weekend doubles from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. According to LVN I, she received report from the off-going nurse (LVN G) on Saturday evening 10/22/11. She stated LVN G informed her of Resident #2's fall, of notifying the physician and there being no orders received for an x-ray. LVN I was unable to recall if she and LVN G had a discussion about Resident #2 being in pain. However, she was able to recall the resident experiencing pain during her shifts. During this interview, LVN I stated during the weekend (10/22-10/23/11) Resident #2 was miserable, clinging to staff, grabbing her right leg, grimacing and crying out in pain. She further stated, it was obvious the resident was experiencing pain and she and other staff were worried about it. During this interview with LVN I she stated, the weekend RN (RN H) and the DON were at the facility on Saturday 10/22/11. LVN I further stated RN H phoned the physician and she (LVN I) had assumed the call was to notify the physician of Resident #2's pain. Additionally, LVN I stated she did not call the physician herself, but instead continued with her work and let the weekend RN "take care of it." LVN I was unable to confirm what or if RN H had communicated with the physician on Saturday 10/22/11. She stated, no additional orders were provided to her on Saturday 10/22/11 related to Resident #2. When queried about what occurred on Sunday 10/24/11, LVN I stated, when she arrived on duty she "got ugly" and informed the facility's only ADON that something had to be done about Resident #2's continued pain. LVN I stated she phoned the physician and left a message but did not receive a return call. She further stated the ADON phoned the physician several times and left messages but received no return calls. According to LVN I, the ADON "finally had to text" the physician and an order was received for an x-ray. LVN I stated she specifically asked the ADON if the physician "say we could have pain med." The ADON responded "No." An interview with the facility's only ADON on 10/28/11 at 1:35 p.m. revealed on Sunday 10/23/11, nurse's informed her they had faxed a request to Resident #2's physician for x-rays and pain management orders. The ADON stated she phoned the physician on Sunday 10/23/11. According to the ADON when she did not receive a call back, she texted the physician and requested an x-ray for the resident's right leg. The physician responded with questions about the resident having any contusions, limited range of motion, screaming if the right lower extremity was moved or the inability to bear weight. The ADON stated her response to the physician was "yes" to the physician's questions and his text back to her was he wished he had been aware of it. As a result of communicating with the physician on 10/23/11 the ADON received an order for [REDACTED]. There was no assessment using the PAINDAD scale, nurses notes or the MAR to reflect the intensity of the resident's pain, or an assessment after the [MEDICATION NAME] was administered in an effort to determine if the medication was effective and/or if there was a need to notify the physician. According to the directions on the PAINAD flow sheet a symptoms score should have been totaled prior to providing pain relief methods and again after pain relief methods were implemented. A quarterly pain assessment dated [DATE] reflected Resident #2 experienced pain by facial grimacing when the right lower extremity was moved. However, the pain assessment in advanced dementia scale (PAINAD) dated 10/25/11 reflected the resident experienced no facial grimacing and therefore the PAINAD scale was incorrectly scored at 3. An observation of Resident #2 on 10/28/11 at 3:15 p.m. revealed CNA J and CNA K were providing the resident with incontinent care. The resident's right knee was swollen and discolored with fading purple, red, and green bruises. The resident was observed with signs and symptoms of pain while repositioned for cleansing during the incontinent care. During this time Resident #2 was observed blowing through pursed lips and frowning. When queried by the surveyor about being in pain, the resident was verbally unresponsive. Both CNA J and CNA K stated the resident appeared to experience pain whenever care was provided. They were unsure if the resident received pain medication. During this time CNA J stated Resident #2 would at times "moan out" during care. CNA J further stated "I know it hurts to move her." On 10/28/11 at 4:15 p.m. the surveyor informed LVN G of Resident #2's behaviors during incontinent care earlier at 3:15 p.m. LVN G stated she had not been informed, by CNA J or CNA K of Resident #2's symptoms of pain during incontinent care. The nurse further stated if the resident was experiencing pain routine pain medication might be required instead of prn (as needed) medication. LVN G stated she would assess the resident immediately and speak with the CNAs to determine their observations. On 10/28/11 at 4:30 p.m. LVN G informed the surveyor she had received an order to administer the narcotic [MEDICATION NAME] 7.5/325 mg orally to Resident #2 routinely every eight hours. An interview with LVN G on 10/28/11 at 4:43 p.m. revealed she had communicated with the CNAs providing care for Resident #2. She stated she spoke with the CNAs very strongly because if they did not communicate with her about the resident's pain, then she could not treat the pain properly. LVN G further stated she informed the CNAS that by not sharing information concerning Resident #2, it meant the resident stayed in pain even longer since she did not know the pain was that, "bad." Interview on 10/28/11 at 6:50 p.m. with the ADON revealed she had spoken to the Administrator concerning the physician not responding to nursing staff over the weekend regarding pain management for Resident #2. The ADON said she did not know if the Administrator spoke to the physician. The ADON further stated if the Administrator thought there was a real problem he would speak with the physician. On 10/28/11 at 7:18 p.m. the DON stated, she did not have as good of a working relationship with Resident #2's physician as the ADON did. Additionally, the DON stated she had been informed about the events during the weekend of 10/22/11 through 10/23/11. However, she had not been notified during the time attempts were made to contact the physician. The DON said she spoke with the physician later, but I did not know if the Administrator knew anything about "any of this." An interview conducted with Resident #2's primary physician on 10/31/11 at 11:00 a.m. revealed he was not provided with enough information when the nurses communicated with him about Resident #2. He stated he had initially been informed the resident slid from the wheelchair. According to the physician he asked "all the right questions" but had not been informed Resident #2 was experiencing pain. He further stated he received a call one and a half days after the residents fall related to the need for an x-ray. Additionally, the physician stated, "I asked, must depend on their judgment." 2) Resident #1 was initially observed during rounds conducted on 10/25/11 at 9:40 a.m. during this observation the resident was observed with her hands cupping her left jaw. Resident #1 stated she was experiencing jaw pain and had been complaining of the pain for two months. During this time, Resident #1 stated she had been receiving pain medication but did not know what the medication was. She further stated the medication was not effective and the pain was "killing" her. Review of Resident #1's physician's orders [REDACTED]. [DIAGNOSES REDACTED]. Resident #1's care plan review date was 10/06/11. A care plan related to pain addressed the problem/need of the resident's do not resuscitate status. Goals were to honor the resident's advanced directive and Resident #1 would have effective pain relief as evidenced by statements, a PAINAD scale of less than three every shift and with pain measures if needed. Interventions included medication as ordered. Another care plan addressed the risk for moderate pain related to a history of falls. Interventions included administering Tylenol as needed, assessing pain quarterly and observing for non-verbal signs/symptoms. Review of the website http://www.tylenol.com on 11/01/11, revealed Tylenol was used for the relief of fever, temporary relief of occasional headaches, minor aches and pains. Resident #1's most recent MDS assessment dated [DATE]. The assessment reflected the resident's cognitive skills for daily decision making were severely impaired. The assessment further reflected Resident #1 had no presence of pain within the last five days of the assessment. A Telephone physician's orders [REDACTED]. An observation of Resident #1 on 10/27/11 at 10:15 a.m. revealed the resident was experiencing pain. The resident stated the pain extended from her left jaw to her left ear. Resident # 1 further stated she had received pain medication earlier but did not know what the medication was. Additionally, the resident stated the medication was not working as she continued to have pain. An interview with LVN E on 10/27/11 at 10:15 a.m. revealed she had medicated Resident #1 with two 325 mg tablets of Tylenol for jaw pain. When queried why she had not administered the [MEDICATION NAME], LVN E stated, the medication was not available in the facility and there was no [MEDICATION NAME] in the emergency medication kit. LVN E further stated she was not sure if the [MEDICATION NAME] had been ordered. An interview with LVN E on 10/25/11 at 10:30 a.m. revealed she had phoned the pharmacy and discovered the original fax for the [MEDICATION NAME] had not been received. LVN E stated she re-faxed the order "a few minutes ago" and that fax was not received by the pharmacy. During this time, the DON stated there was [MEDICATION NAME] available in the emergency kit. An interview with LVN E on 10/25/11 at 10:45 a.m. revealed she obtained [MEDICATION NAME] from the facility's emergency kit and administered the medication to Resident #1. LVN E stated when she administered the [MEDICATION NAME], the resident had described the intensity of her pain as an eight on a 0 to 10 pain scale. LVN E stated Resident #1 then said the pain was so bad she was not sure what number it was. An observation of Resident #1 on 10/27/11 at 11:30 a.m. revealed she was napping in bed. Review of Resident #1's MAR dated October 2011 revealed Tylenol 650 mg had been administered twice on 10/11/11, once on 10/23/11, and once on 10/25/11 (a total of four times). Prior to 10/27/11 the [MEDICATION NAME] had not been administered (initially ordered 10/24/11). Further review of Resident #1's MARS, nurse's notes and pain manage flow sheets revealed there was no assessment of the resident's pain prior to the administration of the Tylenol. The pain management flow sheet dated 10/27/11 reflected Resident #1's pain rating prior to receiving the Tylenol was an eight on a 0 to 10 pain scale. According to the pain intensity scale located on the flow sheet, eight represented very severe pain and 10 represented excruciating pain. 3) The facility's policy and procedure (P/P) related to pain management reflected a revision date of September 2008. The P/P was provided by the Regional Vice President on 10/28/11 and identified as current. According to the P/P appropriate pain management helped the resident avoid periods of pain and established a treatment plan for episodes of acute pain and/or chronic pain. Intervening to treat pain before the pain became moderate or severe was a prime goal of the facility. The P/P reflected the facility's expectations for pain management included: "1. Identifying and intervening to treat pain aggressively, which can prevent negative consequences. Unrecognized and thus untreated (or under treated) pain can have serious consequences on the quality of life of our elderly residents. 2. The first principle of highly effective pain management is assessment. The process of assessment is aimed at controlling pain, identifying it immediately and then monitoring it as interventions are selected and implemented. Documenting pain assessments, interventions, and evaluation activities in a clear concise manner will assist the healthcare team in determining treatment effectiveness... [MEDICATION NAME] doses should be adjusted in each resident to achieve pain relief with an acceptable level of adverse side effects. Treat persistent pain persistently. Administer [MEDICATION NAME] regularly (around the clock, not PRN/as needed)... ...The procedure portion of the P/P reflected in part: 1. Pain intensity should be measured with the appropriate measurement tool. a. A pain scale of 0-10 (0=no pain, 10 = worst pain) should be utilized for the adult resident. b. If a resident cannot understand, is cognitively impaired or is unwilling/unable to communicate the 0-10 scale, the Pain Assessment in Advance Dementia (PAINAD) will be scored and totaled. A score of four or more may indicate the need for intervention... ...Nurses should routinely observe the residents for signs and symptoms of pain. [MEDICATION NAME] and treatments should be administered as prescribed... ...Acute/chronic pain should be reassessed 30 minutes to one hour after medications and/or alternative treatments are administered... ...The MDS nurse or the Unit Manager should monitor the resident over several days for pain management effectiveness...." The Policy and Procedure also reflected a care plan should be initiated and the physician should be notified when any type of prescribed pain management regimen is not effective in relieving the resident's pain. The CMS form 672, Resident Census and Conditions of Residents signed by the ADON on 10/25/11 reflected 44 residents were on a pain management program.

Based on interview and record review, the facility failed to develop and implement detailed, facility-specific A/N/M written policies and procedures, which prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property when six (Residents #1, #2, #3, #4, #5 and #6) of six residents reviewed were involved in allegations of abuse and mistreatment. The facility's A/N/M p/p did not reflect detailed, facility-specific policies and procedures to be followed as part of their A/N/M prevention program. The facility's brief, two-page A/N/M policies and procedures reflected the same language as the language found in the regulatory requirement. The facility failed to ensure all alleged violations involving mistreatment or abuse were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures and there was evidence all alleged violations were thoroughly investigated and prevented further potential abuse while the investigations were in progress for six (Residents #1, #2, #3, #4, #5, and #6) of six residents reviewed. 1) On 11/16/10 Dietary Aide B yelled at Resident #2 to "get out of the dining room," then shoved the resident in her wheelchair and let go, allowing the resident to collide into a large easel, which was holding a framed picture measuring seven and one-half feet by six and one-fourth feet. This incident was not investigated or reported to the State agency and Dietary Aide B continued to have direct access to the facility residents. 2) Residents #5 and #6 alleged CNA A told Resident #4 to "shut up" on 11/13/10 and informed LVN C on 11/15/10. LVN C did not report the allegation of abuse to the Administrator and/or DON until 11/16/10. The allegation was not thoroughly investigated or reported to the State agency. Resident #5 said she was afraid of retaliation from CNA A. 3) Resident #1 made an allegation of physical, mental and verbal abuse by CNA A on 10/22/10, stating the CNA "popped her, flicked her face and talked down to her." The allegation was not reported to the State agency until 10/25/10 (3 days after the allegation). The allegation was not thoroughly investigated by conducting interviews with other residents, visitors, potential witnesses and staff. 4) On 09/06/10 Resident #3 alleged CNA A was loud and rough. The allegation of abuse was not investigated or reported to the State agency. The DON interviewed Resident #3 and her roommate Resident #5. CNA A continued to have access to Resident #3 and the other facility residents. Resident #3 said she was afraid of retaliation from CNA A. An Immediate Jeopardy (IJ) was identified on 11/30/10. While the IJ was lowered on 12/03/10, the facility remained out of compliance at a severity level of "No actual harm with potential for more than minimal harm, that is not Immediate Jeopardy" and a scope of "Widespread." The facility continued to in-service and monitor staff to ensure allegations of abuse/neglect were being investigated and residents were being protected. These failures created an environment in which abuse could flourish and could affect the facility's 65 residents, including Residents #1, #2, #3, #4, #5 and #6 at risk for further abuse, neglect, mistreatment, and/or misappropriation of personal property, which could result in serious mental health complications, physical injuries and have a negative impact on the residents' quality of life. Findings included: On 11/30/10 at 10:50 a.m., the Administrator provided a document entitled Procedure for Abuse and Neglect. The document reflected detailed procedures for two of the seven components, Screening and Training. The third component, Prevention reflected the same information contained in the facility's brief, two-page A/N/M policy and procedure, Freedom From Abuse or Neglect. The Administrator stated the facility's corporate personnel were "trying to write a policy." When asked on 11/30/10 at 10:50 a.m. what policy was followed by the facility to protect residents, investigate and report allegations of abuse, neglect or mistreatment , the Administrator said she utilized the facility's Accident and Incident policy. Review of the facility's current, undated Freedom From Abuse or Neglect policy and procedure revealed the extent of the facility's brief, two-page A/N/M policy and procedure was: (a) a list of the definitions of the different types of abuse and (b) the required seven components that only reflected the same language as the language found in the regulatory requirement. Each component was addressed in one to three sentences. This document did not address each of the required seven components with detailed, facility-specific policies and procedures to be followed as part of their A/N/M prevention program. The facility's current A/N/M policy and procedure reflected the following for each of the required seven components: "...The facility shall: 1. Screen potential employees for a history of abuse, neglect or mistreating residents, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. 2. Train employees, through orientation, annually, and on-going sessions on issues relating to abuse, prohibition practices, including prevention, identification and reporting of potential abuse or neglect. 3. Provide on-going in-service training on dealing with aggressive catastrophic reaction of residents and how to recognize signs of burnout, frustration and stress that may lead to abuse. 4. Provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. 5. Identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse; and to determine the direction of the investigation. 6. Investigate different types of incidents and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. 7. Protect residents from harm during an investigation. In cases of resident abuse, this should include separating the residents and provide monitoring as needed. If abuse is suspected by an employee, the employee will be suspended pending outcome of an investigation. 8. Report all alleged violations and all substantiated incidents to the State agency and all other agencies as required, and take all necessary corrective actions depending on the results of the investigation; report to the State nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service; and analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences." Information not addressed in the facility's A/N/M policies and procedures included, but was not limited to, the following: a) Prevention: staff member(s) responsible for providing and/or monitoring the provision of information about the facility's A/N/M prevention program to residents, staff, and visitors; content of information to be provided to residents, staff, and visitors; procedures for providing A/N/M policies and procedures to residents, staff, and visitors; procedures for residents, staff, and visitors to follow for reporting concerns, incidents, and complaints; and procedures for identifying and intervening in situations in which A/N/M could occur. b) Identification: staff member(s) responsible for conducting and/or monitoring the review of incidents; procedures for identifying the type of incidents that may be considered A/N/M; procedures for the review of incidents, including suspicious injuries, for residents involved and for occurrences/patterns/trends to determine how to proceed with an investigation; and procedures for documenting the information. c) Investigation: staff member(s) responsible for conducting and/or monitoring investigations; types of incidents to be investigated; timeframe's for conducting investigations; procedures for conducting investigations - staff member(s) responsible for conducting interviews, individuals to be interviewed, questions to be asked in the interviews; and procedures for documenting investigations. d) Protection: for resident-to-resident incidents, procedures for intervening and/or separating residents, staff member(s) responsible for monitoring residents; for staff-to-resident incidents, timeframe's/procedures for suspending an employee, staff member(s) responsible for deciding whether or not to suspend an employee; procedures to follow based on the outcome of the investigation; and procedures for documenting the information. e) Reporting/Response: staff member(s) responsible for conducting and/or monitoring facility's response to and reporting of incidents and for reviewing/making any necessary revisions to the A/N/M policies and procedures to prevent recurrences; timeframe's for reporting incidents; what types of incidents required to be reported; specific agencies and individuals to whom incidents should be reported; and procedures for documenting agencies/individuals contacted and any changes to policies and procedures. 1) Review of Resident #2's clinical record revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE], per the face sheet dated 12/01/10. Review of the November 2010 consolidated physician's orders [REDACTED]. Review of a Monthly Nursing Review dated 11/09/10 revealed Resident #2 communicated only basic needs and had not exhibited any verbal aggression or other disruptive acts. Review of the quarterly MDS assessment dated [DATE] revealed Resident #2 was impaired in both short-term and long-term cognition. She usually understood others but was only sometimes understood by others. According to the MDS assessment, Resident #2 was moderately impaired with decision-making. There were no indicators of depression, anxiety and sad mood and no behavioral symptoms reflected on the MDS assessment. The MDS assessment further reflected Resident #2 required extensive assistance of one person with bed mobility, transfers and dressing. Resident #2 was totally dependent on one person for ADLs. Observation on 12/02/10 at 2:35 p.m. of Resident #2 revealed she was lying in her bed, dressed appropriately. The resident smiled as the surveyor spoke to her and was able to answer simple questions. Resident #2 could not recall being yelled at or shoved in her wheelchair by Dietary B. Resident #2 stated not being able to remember things was very embarrassing to her. Review of a Record of Concern form dated 11/17/10, signed by the ADON on 11/17/10 and by the Administrator on 11/19/10, revealed a complaint filed by LVNs F, G and H. "On 11/16/10, ____ (Dietary Aide B) from dietary was observed yelling (at) ____ (Resident #2), telling her to stay out of the dining room. He then pushed her in her wheelchair, hard, let the chair go and walked away. ____ (Resident #2) could not stop the w/c (wheelchair) and ran into the picture that was sitting on an easel by the Adm (Administrator's) office...Resident was visibly shaken." The documentation reflected Dietary B's immediate supervisor was notified. The ADON documented, "The three nurses noted above, all believe that this was an act of abuse toward the resident. If it had been an aid (sic) or nurse, they would have been suspended or terminated. The nurses want to know why "he is still here." Documentation from the Administrator on the Record of Concern form dated 11/17/10 reflected, "Talked to ____ (Dietary Aide B) - verbal warning - He is to notify nursing if Res (residents) are moving stems on table after it is set. Also not to set tables for dinner too early." Interview on 11/30/10 at 2:40 p.m., with LVN F revealed on 11/16/10 she was standing at the medication cart in the center of the facility, outside the dining room. LVN F stated she heard Dietary B raise his voice and in a sharp, loud tone he told Resident #2 "Get out of the dining room!" He then pushed Resident #2 in her wheelchair out of the dining room and into the center area of the facility, near where LVN F was standing. LVN F stated Dietary Aide B shoved Resident #2's wheelchair with enough force that the resident sped by LVN F. LVN F stated she yelled out, "Oh no!" LVN F was unable to reach Resident #2 before the resident hit a large easel holding a big, heavy picture. The picture on the easel teetered, according to LVN F, but did not fall on the resident. LVN F revealed Resident #2 was "scared to death." When asked how she knew Resident #2 was "scared to death," LVN F stated the expression on the resident's face was fear. She stated the resident's mouth was open and her eyes were wide. LVN F asked Resident #2 if she was okay and the resident stated, "I don't know." LVN F stated she immediately informed the DON of what she had witnessed, and the DON called the Dietary Manager. LVN F stated the incident "rattled" Resident #2, and because the resident had Dementia she was not able to understand what happened or why it happened. LVN F stated Dietary Aide B told her (LVN F) he was sorry after the incident and wanted to go to Resident #2's room and tell her he was sorry. LVN F stated she instructed Dietary Aide B to stay away from Resident #2. Interview on 12/01/10 at 2:20 p.m. with LVN G revealed on 11/16/10 she was seated at the nurse's station located in the center of the facility. She stated she heard LVN F yell out, "Oh!" and when she looked up she saw Resident #2 "fly by in her wheelchair," and LVN F running toward the resident, who was headed toward the lobby area. "____ (LVN F) caught ____ (Resident #2) just as she (the resident) crashed into the easel." LVN G stated Dietary Aide B was walking away. LVN G stated Resident #2 was "visibly shaken up." She added Resident #2 was "startled and trembling." LVN G stated LVN F attempted to comfort Resident #2 and brought the resident to the nurse's station. LVN G said she told LVN F she heard her (LVN F) yell, and it caused her to look up. LVN G stated LVN F said, "It wasn't me yelling. It was her (Resident #2)." LVN G was asked if she was interviewed as part of the facility's investigation following the incident with Dietary Aide B and Resident #2 on 11/16/10. LVN G stated she had not been interviewed about the incident. Interview on 12/01/10 at 2:40 p.m. with LVN H revealed on 11/16/10 she was standing at a medication cart located in the center of the facility. LVN H stated she heard LVN F yell "Oh my gosh!" LVN H stated she looked up in time to see Resident #2 "rolling fast in her wheelchair toward the easel and glass." LVN H stated the resident struck the easel and Dietary Aide B walked off. LVN H stated she was not asked to complete a statement following the incident involving Resident #2 and Dietary Aide B on 11/16/10. LVN H stated Resident #2 resided on her hall and when she asked the ADON if she was supposed to complete an incident report following the incident on 11/16/10, she was told no. Observation on 12/01/10 at 1:05 p.m. of the easel and the large, framed, glass-covered picture, identified by LVN F on 11/30/10 at 2:40 p.m. as the easel Resident #2 was pushed into, measured seven and one-half feet by six and one-fourth feet. During an interview on 11/30/10 at 1:40 p.m. with the Administrator, the surveyor requested any additional documentation of the incident involving Dietary B and Resident #2 on 11/16/10. The Administrator stated she would check with the DON. The surveyor asked if the allegation was reported to the State agency, and she replied it was not. Interview on 11/30/10 at 1:45 p.m. with the DON revealed the Administrator handled the allegation of verbal and physical abuse involving Dietary Aide B and Resident #2. The DON stated the facility's corporate office decided what was to be reported to the State agency. During an interview on 11/30/10 at 2:35 p.m., with the DON, she stated Dietary Aide B did not intentionally push Resident #2, therefore it was not reported to the State agency, and Dietary Aide B was not removed from direct contact with the residents. Interview on 12/01/10 at 1:40 p.m. with the Dietary Manager revealed Dietary Aide B was "a little slow, but came to work everyday." She stated on 11/16/10, Dietary Aide B was setting the tables for dinner, and Resident #2 was wheeling around the dining room in her wheelchair picking things up. The Dietary Manager stated after the DON told her what happened she, the Dietary Manager talked to Dietary Aide B and told him to be careful with the residents. The Dietary Manager stated she immediately went to talk to the Administrator, and the Administrator instructed her to bring Dietary Aide B to her office when he was finished doing what he was doing so the three of them could talk about the incident. The Dietary Manager stated the Administrator told Dietary B the incident could be considered abuse. The Dietary Manager stated she and the Administrator did not consider the incident to be abuse, because Dietary Aide B did not intentionally try to hurt the resident. The Dietary Manager stated the Administrator was the facility's Abuse Prohibition Coordinator, and she decided what to investigate and how to go about investigating allegations of abuse, neglect and mistreatment. Telephone interview on 12/01/10 at 2:00 p.m. with Dietary Aide B revealed on 11/16/10, he was setting the dining room tables for dinner. He stated Resident #2 was picking items up from the tables, including stemware. Dietary Aide B stated he wheeled the resident's wheelchair to the front of the facility. "I didn't know if the wheelchair was rolling fast or slow." Dietary Aide B denied telling Resident #2 to leave the dining room. He stated he told Resident #2 to not pick things up from the tables. Dietary Aide B stated Resident #2 almost ran into the easel, but LVN F stopped the resident from hitting the easel. 2) Review of Resident #4's clinical record revealed she was an [AGE] year-old female, who was admitted to the facility on [DATE] and re-admitted on [DATE], per the face sheet dated 12/01/10. Review of the December 2010 consolidated physician's orders [REDACTED]. Review of a Monthly Nursing Review dated 11/07/10 revealed Resident #4 communicated only basic needs, and she required daily intervention from staff with orientation and memory. The Monthly Nursing Summary Review reflected Resident #4 had not exhibited any verbal aggression or other disruptive acts. It was reflected on the Summary Resident #4 required maximum assistance with all ADLs and transfers. Review of the quarterly MDS assessment dated [DATE] revealed Resident #4's speech clarity was unclear, she was usually understood and sometimes understood others. Signs and symptoms of [MEDICAL CONDITION] included disorganized thinking, which fluctuated. The interview reflected in the MDS assessment to establish Resident #4's mental status revealed the resident was unable to complete the following sections: Repetition of Three Words, Temporal Orientation and Recall. The Resident Mood Interview portion of the MDS assessment reflected Resident #4 did not respond to any of the questions. The MDS assessment further reflected Resident #4 required extensive assistance of one person for bed mobility and limited assistance of two persons for transfers. The resident required limited assistance of one person for dressing and extensive assistance of two persons for personal hygiene. Observation on 11/30/10 at 1:00 p.m. of Resident #4 revealed she was lying in bed. Resident #4 was confused and could not answer simple questions. Review of Resident #5's clinical record revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE] and re-admitted on [DATE], per the face sheet dated 12/01/10. Review of the November 2010 consolidated physician's orders [REDACTED]. Review of a Monthly Nursing Review dated 11/04/10 revealed Resident #5 communicated without difficulty. The Monthly Nursing Summary Review reflected Resident #5 had not exhibited any verbal aggression or other disruptive acts. Resident #5 was alert and oriented to person, place and time and received assistance with ADLs. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had short-term cognitive impairment, but the resident's long-term memory was intact. She was able to recall the location of her room, staff names/faces and that she resided in a nursing facility. Resident #5's decision-making capacity was moderately impaired. According to the MDS assessment, Resident #5 usually understand others and was usually understood. There were no indicators of [MEDICAL CONDITION]-periodic disordered thinking/awareness reflected on the MDS assessment. The MDS assessment further reflected Resident #5 did not have indicators of depression, anxiety or sad mood and had not experienced any behavioral symptoms. Resident #5 required limited assistance of one person for bed mobility and extensive assistance of one person for transfers. The resident required the extensive assistance of one person for dressing and limited assistance of one person for personal hygiene. Interview on 11/30/10 at 1:10 p.m., with Resident #5, who was identified as interviewable by the facility, per a listing of interviewable residents dated 11/30/10, revealed she heard CNA A yelling at Resident #4 to shut up. Resident #5's room was located next door to Resident #4's room. When asked where she was when she heard CNA A, Resident #5 stated she was in her room, but she knew CNA A's voice. As the surveyor was leaving the room, both Resident #5 and Resident #3 asked the surveyor not to tell CNA A about the allegations they had made because, "She (CNA A) will get back at us." Review of Resident #6's clinical record revealed she was an [AGE] year-old female, who was admitted to the facility on [DATE] and re-admitted on [DATE], per the face sheet dated 12/01/10. Review of the November 2010 consolidated physician's orders [REDACTED]. Review of a Monthly Nursing Review dated 10/09/10 revealed Resident #6 communicated without difficulty and had not exhibited any verbal aggression or other disruptive acts. Resident #6 was alert and oriented to person, place and time and able to voice her needs. Review of the MDS assessment dated [DATE] revealed Resident #6 had clear speech clarity, made herself understood and was understood by others. Resident #6 scored 14 out of 15 on the section of the MDS assessment for cognitive impairment, including repetition of words, temporal orientation, and recall. According to the MDS assessment, Resident #6 did not have signs or symptoms of [MEDICAL CONDITION]. The interview reflected in the MDS assessment reflected the resident's mood was stable with no adverse indicators. The MDS assessment further reflected Resident #6 was independent with set-up assistance only for bed mobility and transfers. Resident #6 required limited assistance of one person for dressing and personal hygiene. Interview on 11/30/10 at 1:05 p.m., with Resident #6, who was identified as interviewable by the facility, per a listing of interviewable residents dated 11/30/10, revealed "a couple of weeks ago," she was in her room with her door open when she heard CNA A across the hall yell "shut up" at Resident #4. Resident #6 stated she could not see who CNA A was yelling at, but it was from the direction of Resident #4's room. "Her tone of voice is hateful. She talks down to the residents, like you're lesser than her. She's rude." Resident #6 stated CNA A lined the residents up in their wheelchairs against the wall and told them, "Now you just sit there! Like you don't dare move." During an interview on 11/30/10 at 12:45 p.m., LVN C stated approximately three weeks ago, he received a complaint about CNA A from Residents #5 and #6. He stated Residents #5 and #6 reported they heard CNA A telling Resident #4 to shut up. When asked what action he took following the allegation of verbal abuse, LVN C stated he told the DON the following day. LVN C stated the DON asked him to obtain statements from Residents #5 and #6. A typed statement, signed by LVN C and dated 11/16/10 reflected, "____ (Resident #5) reported she heard a CNA yelling "SHUT UP!" at ____ (Resident #4) on what she remembered to be Saturday the 13th of November. I asked ____ (Resident #5) who she believed it was that yelled at ____ (Resident #4). ____ (Resident #5) explained 'it was ____ (CNA A) that had yelled shut up at ____ (Resident #4).' I asked ____ (Resident #5) who else may have heard ____ (CNA A) yelling at ____ (Resident #4). ____ (Resident #5) states '____ (Resident #6) said she heard ____ (CNA A) being mean too." This nurse went to ____ (Resident #6) and asked what if anything exciting/abnormal happen (sic) this weekend. ____ (Resident #6) answered 'an aid (sic) was yelling shut up to (Resident #4) across the hall.' I asked if ____ (Resident #6) knew who had yelled at ____ (Resident #4). ____ (Resident #6) replied 'it was ____ (CNA A), I recognized her voice.' I asked both ____ and ____ (Resident #5 and Resident #6) if either of them had concerns about ____ (CNA A) providing care for them. ____ (Resident #5) replied 'I better not, cause she better not be mean to me!' " Interview on 11/30/10 at 1:30 p.m., with the DON revealed on 11/15/10 or 11/16/10, Residents #5 and #6 alleged CNA A told Resident #4 to shut up. The DON stated LVN C took their statements and she, the DON interviewed the residents. She stated each time she interviewed the residents who made the allegations, they denied it and would not provide specifics. The DON speculated there was a group of women, who did not like CNA A. During an interview on 11/30/10 at 1:40 p.m. with the Administrator, the surveyor requested any additional documentation of investigations for allegations of mistreatment made by Residents #5 and #6 on 11/16/10. The Administrator stated she would check with the DON. The surveyor asked if the allegations were reported to the State agency, and she replied they were not. Interview on 11/30/10 at 1:45 p.m. with the DON revealed she did not have any additional documentation for the allegations made against CNA A on 11/16/10. The DON stated the facility's corporate office decided what was to be reported to the State agency. During an interview on 11/30/10 at 2:35 p.m., with the DON, she stated following the allegation of verbal abuse on 11/16/10 by Residents #5 and #6, CNA A was counseled and reassigned to PRN status. The DON stated she interviewed another CNA (CNA I) who was working with CNA A at the time the allegation was made when CNA A told Resident #4 to shut up. The DON stated CNA I had responded, "Why would ____ (CNA A) say shut up to ____ (Resident #4) when ____ (Resident #4) doesn't even talk?" The DON stated, "Then I forgot about it." Review of CNA A's personnel records revealed a Personnel Action form dated 11/16/10 and signed by CNA A and the DON. The space for the Administrator's signature was blank. The form reflected, "Continued reports from residents about her loud and 'rough' care she provides. She has been asked on more than one occasion to become aware of how she says things to residents. Assured by CNA that in [AGE] years of service she has never had any complaints made against her." The form reflected CNA A was to have a partner when providing care to Residents #1, #3 and #5. Attached to the Personnel Action form was another Personnel Action form dated 11/16/10 reflecting, "Two residents (complained of) ____ (CNA A) yelling "shut up" to ____ (Resident #4). The res (residents) (complained of) this CNA being mean & yelling (at) another res. Numerous complaints had been brought to DON and ADON's attention regarding the same improper conduct." The form reflected CNA A was demoted to PRN status. Telephone interview on 12/01/10 at 3:30 p.m. with CNA A revealed she was aware an allegation had been made she told Resident #4 to shut up. CNA A stated the weekend of 11/13/10, she came to work sick. She stated, "I was sick. I was aching and had fever. That weekend I wasn't even talking to my co-workers or anybody. I was just trying to get through my eight hour shift." CNA A denied the allegation stating, "If these residents don't speak to me, I am not speaking to them." CNA A then stated the DON never told her she had to work with a partner, but CNA A insisted she not work alone. She stated following the incident on 10/22/10 she was moved to Hall 300 (where Residents #3, #4, #5 and #6 resided). CNA A stated she was allowed to provide care to any resident on Hall 300 without a partner. 3) Review of Resident #1's clinical record revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE], per the face sheet dated 10/21/10. Review of the significant change MDS assessment with an assessment reference date of 10/02/10 revealed the resident's ability to express ideas and wants was not impaired. The MDS assessment reflected Resident #1 was oriented to the year and had no signs and symptoms of [MEDICAL CONDITION]. The resident interview reflected on the MDS assessment evaluating mood revealed Resident #1 had little interest or pleasure in doing things, felt down, depressed or hopeless, felt bad about herself, experienced trouble concentrating and moving or speaking so slowly that other people could have noticed or being fidgety and restless. All of these symptom indicators occurred nearly every day, per the MDS assessment. Review of the behavior section on the MDS assessment revealed the resident did not have any behavioral symptoms, included [MEDICAL CONDITION]. Further review of the MDS assessment revealed Resident #1 was totally dependent for bed mobility, transfers, dressing, toilet use, bathing and personal hygiene. The [DIAGNOSES REDACTED]. Review of the history and physical progress note dated 09/28/10 revealed Resident #1 was alert and oriented to person, place and time. The resident's judgement and insight were intact and and her thought content was logical. Review of the consolidated physician's orders [REDACTED]. Observation of Resident #1 on 11/30/10 at 10:00 a.m. revealed she was lying in bed resting. Interview with Resident #1 at the time of the observation on 11/30/10 at 10:00 a.m. revealed CNA A was "not the most gentle person." Resident #1 stated CNA A was rough with her while providing care. The resident stated she thought CNA A was immature, because she did not like to "fool with" Resident #1. The resident stated CNA A did not like her and talked down to her. According to Resident #1, CNA A "popped her." The resident stated she told her family member about the mistreatment, but could not recall when the mistreatment occurred. Resident #1 stated CNA A was not permitted to provide care to her anymore, and she was relieved. During the facility's Entrance Con

Based on observation, interview, and record review, it was determined the facility failed to ensure one (Resident #2) of four residents reviewed for abuse was free from verbal and physical abuse. On 11/16/10 Dietary Aide B yelled at Resident #2 to "get out of the dining room," then shoved the resident in her wheelchair and let go, allowing the resident to collide into a large easel, which was holding a framed picture measuring seven and one-half feet by six and one-fourth feet. This incident was not investigated or reported to the State agency and Dietary Aide B continued to have direct access to the facility residents. An Immediate Jeopardy (IJ) was identified on 11/30/10. While the IJ was lowered on 12/03/10, the facility remained out of compliance at a severity level of "No actual harm with potential for more than minimal harm, that is not Immediate Jeopardy" and a scope of "Widespread." The facility continued to in-service and monitor staff to ensure allegations of abuse/neglect were being investigated and residents were being protected. These failures created an environment in which abuse could flourish and could affect the facility's 65 residents, including Resident #2, at risk for further abuse, which could result in serious mental health complications and/or physical injuries. Findings included: 1) Review of Resident #2's clinical record revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE], per the face sheet dated 12/01/10. Review of the November 2010 consolidated physician's orders [REDACTED]. Review of a Monthly Nursing Review dated 11/09/10 revealed Resident #2 communicated only basic needs and had not exhibited any verbal aggression or other disruptive acts. Review of the quarterly MDS assessment dated [DATE] revealed Resident #2 was impaired in both short-term and long-term cognition. She usually understood others but was only sometimes understood by others. According to the MDS assessment, Resident #2 was moderately impaired with decision-making. There were no indicators of depression, anxiety and sad mood and no behavioral symptoms reflected on the MDS assessment. The MDS assessment further reflected Resident #2 required extensive assistance of one person with bed mobility, transfers and dressing. Resident #2 was totally dependent on one person for ADLs. Observation on 12/02/10 at 2:35 p.m. of Resident #2 revealed she was lying in her bed, dressed appropriately. The resident smiled as the surveyor spoke to her and was able to answer simple questions. Resident #2 could not recall being yelled at or shoved in her wheelchair by Dietary B. Resident #2 stated not being able to remember things was very embarrassing to her. Review of a Record of Concern form dated 11/17/10, signed by the ADON on 11/17/10 and by the Administrator on 11/19/10, revealed a complaint filed by LVNs F, G and H. "On 11/16/10, ____ (Dietary Aide B) from dietary was observed yelling (at) ____ (Resident #2), telling her to stay out of the dining room. He then pushed her in her wheelchair, hard, let the chair go and walked away. ____ (Resident #2) could not stop the w/c (wheelchair) and ran into the picture that was sitting on an easel by the Adm (Administrator's) office...Resident was visibly shaken." The documentation reflected Dietary B's immediate supervisor was notified. The ADON documented, "The three nurses noted above, all believe that this was an act of abuse toward the resident. If it had been an aid (sic) or nurse, they would have been suspended or terminated. The nurses want to know why "he is still here." Documentation from the Administrator on the Record of Concern form dated 11/17/10 reflected, "Talked to ____ (Dietary Aide B) - verbal warning - He is to notify nursing if Res (residents) are moving stems on table after it is set. Also not to set tables for dinner too early." Interview on 11/30/10 at 2:40 p.m., with LVN F revealed on 11/16/10 she was standing at the medication cart in the center of the facility, outside the dining room. LVN F stated she heard Dietary B raise his voice and in a sharp, loud tone he told Resident #2 "Get out of the dining room!" He then pushed Resident #2 in her wheelchair out of the dining room and into the center area of the facility, near where LVN F was standing. LVN F stated Dietary Aide B shoved Resident #2's wheelchair with enough force that the resident sped by LVN F. LVN F stated she yelled out, "Oh no!" LVN F was unable to reach Resident #2 before the resident hit a large easel holding a big, heavy picture. The picture on the easel teetered, according to LVN F, but did not fall on the resident. LVN F revealed Resident #2 was "scared to death." When asked how she knew Resident #2 was "scared to death," LVN F stated the expression on the resident's face was fear. She stated the resident's mouth was open and her eyes were wide. LVN F asked Resident #2 if she was okay and the resident stated, "I don't know." LVN F stated she immediately informed the DON of what she had witnessed, and the DON called the Dietary Manager. LVN F stated the incident "rattled" Resident #2, and because the resident had Dementia she was not able to understand what happened or why it happened. LVN F stated Dietary Aide B told her (LVN F) he was sorry after the incident and wanted to go to Resident #2's room and tell her he was sorry. LVN F stated she instructed Dietary Aide B to stay away from Resident #2. Interview on 12/01/10 at 2:20 p.m. with LVN G revealed on 11/16/10 she was seated at the nurse's station located in the center of the facility. She stated she heard LVN F yell out, "Oh!" and when she looked up she saw Resident #2 "fly by in her wheelchair," and LVN F running toward the resident, who was headed toward the lobby area. "____ (LVN F) caught ____ (Resident #2) just as she (the resident) crashed into the easel." LVN G stated Dietary Aide B was walking away. LVN G stated Resident #2 was "visibly shaken up." She added Resident #2 was "startled and trembling." LVN G stated LVN F attempted to comfort Resident #2 and brought the resident to the nurse's station. LVN G said she told LVN F she heard her (LVN F) yell, and it caused her to look up. LVN G stated LVN F said, "It wasn't me yelling. It was her (Resident #2)." LVN G was asked if she was interviewed as part of the facility's investigation following the incident with Dietary Aide B and Resident #2 on 11/16/10. LVN G stated she had not been interviewed about the incident. Interview on 12/01/10 at 2:40 p.m. with LVN H revealed on 11/16/10 she was standing at a medication cart located in the center of the facility. LVN H stated she heard LVN F yell "Oh my gosh!" LVN H stated she looked up in time to see Resident #2 "rolling fast in her wheelchair toward the easel and glass." LVN H stated the resident struck the easel and Dietary Aide B walked off. LVN H stated she was not asked to complete a statement following the incident involving Resident #2 and Dietary Aide B on 11/16/10. LVN H stated Resident #2 resided on her hall and when she asked the ADON if she was supposed to complete an incident report following the incident on 11/16/10, she was told no. Observation on 12/01/10 at 1:05 p.m. of the easel and the large, framed, glass-covered picture, identified by LVN F on 11/30/10 at 2:40 p.m. as the easel Resident #2 was pushed into, measured seven and one-half feet by six and one-fourth feet. During an interview on 11/30/10 at 1:40 p.m. with the Administrator, the surveyor requested any additional documentation of the incident involving Dietary B and Resident #2 on 11/16/10. The Administrator stated she would check with the DON. The surveyor asked if the allegation was reported to the State agency, and she replied it was not. Interview on 11/30/10 at 1:45 p.m. with the DON revealed the Administrator handled the allegation of verbal and physical abuse involving Dietary Aide B and Resident #2. The DON stated the facility's corporate office decided what was to be reported to the State agency. During an interview on 11/30/10 at 2:35 p.m., with the DON, she stated Dietary Aide B did not intentionally push Resident #2, therefore it was not reported to the State agency, and Dietary Aide B was not removed from direct contact with the residents. Review of Resident #2's clinical record, including flow sheets, MARs and nurse's notes for 11/16/10 did not reveal the resident's vital signs following the incident on 11/16/10. Interview on 12/01/10 at 1:40 p.m. with the Dietary Manager revealed Dietary Aide B was "a little slow, but came to work everyday." She stated on 11/16/10, Dietary Aide B was setting the tables for dinner, and Resident #2 was wheeling around the dining room in her wheelchair picking things up. The Dietary Manager stated after the DON told her what happened she, the Dietary Manager talked to Dietary Aide B and told him to be careful with the residents. The Dietary Manager stated she immediately went to talk to the Administrator, and the Administrator instructed her to bring Dietary Aide B to her office when he was finished doing what he was doing so the three of them could talk about the incident. The Dietary Manager stated the Administrator told Dietary B the incident could be considered abuse. The Dietary Manager stated she and the Administrator did not consider the incident to be abuse, because Dietary Aide B did not intentionally try to hurt the resident. The Dietary Manager stated the Administrator was the facility's Abuse Prohibition Coordinator, and she decided what to investigate and how to go about investigating allegations of abuse, neglect and mistreatment. Telephone interview on 12/01/10 at 2:00 p.m. with Dietary Aide B revealed on 11/16/10, he was setting the dining room tables for dinner. He stated Resident #2 was picking items up from the tables, including stemware. Dietary Aide B stated he wheeled the resident's wheelchair to the front of the facility. "I didn't know if the wheelchair was rolling fast or slow." Dietary Aide B denied telling Resident #2 to leave the dining room. He stated he told Resident #2 to not pick things up from the tables. Dietary Aide B stated Resident #2 almost ran into the easel, but LVN F stopped the resident from hitting the easel. During an interview on 12/01/10 at 2:20 p.m., LVN G was asked if she was interviewed as part of the facility's investigation following the incident with Dietary Aide B and Resident #2 on 11/16/10. LVN G stated she had not been interviewed about the incident. 2) On 11/30/10 at 10:50 a.m., the Administrator provided a document entitled Procedure for Abuse and Neglect. The document reflected detailed procedures for two of the seven components, Screening and Training. The third component, Prevention reflected the same information contained in the facility's brief, two-page A/N/M policy and procedure, Freedom From Abuse or Neglect. The Administrator stated the facility's corporate personnel were "trying to write a policy." When asked on 11/30/10 at 10:50 a.m. what policy was followed by the facility to protect residents, investigate and report allegations of abuse, neglect or mistreatment , the Administrator said she utilized the facility's Accident and Incident policy. Review of the facility's current, undated Freedom From Abuse or Neglect policy and procedure revealed the extent of the facility's brief, two-page A/N/M policy and procedure was: (a) a list of the definitions of the different types of abuse and (b) the required seven components that only reflected the same language as the language found in the regulatory requirement. Each component was addressed in one to three sentences. This document did not address each of the required seven components with detailed, facility-specific policies and procedures to be followed as part of their A/N/M prevention program. The facility's current A/N/M policy and procedure reflected the following for each of the required seven components: "...The facility shall: ...2. Train employees, through orientation, annually, and on-going sessions on issues relating to abuse, prohibition practices, including prevention, identification and reporting of potential abuse or neglect. 3. Provide on-going in-service training on dealing with aggressive catastrophic reaction of residents and how to recognize signs of burnout, frustration and stress that may lead to abuse. ...5. Identify events, such as... occurrences... that may constitute abuse; and to determine the direction of the investigation. 6. Investigate different types of incidents and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. 7. Protect residents from harm during an investigation. In cases of resident abuse, this should include separating the residents and provide monitoring as needed. If abuse is suspected by an employee, the employee will be suspended pending outcome of an investigation. 8. Report all alleged violations and all substantiated incidents to the State agency and all other agencies as required, and take all necessary corrective actions depending on the results of the investigation; report to the State nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service; and analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences." Information not addressed in the facility's A/N/M policies and procedures included, but was not limited to, the following: a) Prevention: procedures for staff to follow for reporting concerns, incidents, and complaints. b) Identification: procedures for identifying the type of incidents that may be considered A/N/M; procedures for the review of incidents and for occurrences to determine how to proceed with an investigation; and procedures for documenting the information. c) Investigation: staff member(s) responsible for conducting and/or monitoring investigations; types of incidents to be investigated; timeframe's for conducting investigations; procedures for conducting investigations - staff member(s) responsible for conducting interviews, individuals to be interviewed, questions to be asked in the interviews; and procedures for documenting investigations. d) Protection: for staff-to-resident incidents, timeframes/procedures for suspending an employee, staff member(s) responsible for deciding whether or not to suspend an employee; procedures to follow based on the outcome of the investigation; and procedures for documenting the information. e) Reporting/Response: staff member(s) responsible for conducting and/or monitoring facility's response to and reporting of incidents and for reviewing/making any necessary revisions to the A/N/M policies and procedures to prevent recurrences; timeframe's for reporting incidents; what types of incidents required to be reported; specific agencies and individuals to whom incidents should be reported; and procedures for documenting agencies/individuals contacted and any changes to policies and procedures. 3) An IJ was identified on 11/30/10. On 11/30/10 at 3:30 p.m., the surveyor informed the Administrator and the DON an IJ was identified in the area of Resident Behavior and Facility Practice with Substandard Quality of Care (SQC). The Administrator and the DON were requested to provide a Plan of Removal for the IJ. 4) On 12/03/10 at 10:30 a.m., the surveyor informed the Administrator and DON the facility's undated Plan of Removal was accepted. Review of the facility's undated Plan of Removal revealed the following: 1. Resident #2 was interviewed by the Director of Social Services and assessed for psychological harm; 2. Alert, oriented residents were interviewed to determine if abuse had occurred and were informed of facility policies to report abuse immediately to the facility's Abuse Prohibition Coordinator (Regional Vice President) or to a staff member who would in turn report the allegation to the facility's Abuse Prohibition Coordinator; 3. All incident reports for the previous 30 days were reviewed for over-looked allegations of abuse or mistreatment; 4. Incident reports lacking a complete investigation or follow through were to be addressed immediately; 5. On 11/30/10 the Regional Vice President provided in-service training to the DON and Administrator regarding incident reports, concern forms, identification, investigations and reporting procedures for allegations of abuse, neglect, injuries of unknown origin, mistreatment and misappropriation of property. The in-service training covered the accuracy and completion of incident reports, concern forms and how to handle allegations of abuse and mistreatment. The DON and Administrator were educated about the process by which the facility would address, investigate, report allegations of abuse, neglect, injury of unknown origin, mistreatment and misappropriation of property was covered. The methods by which the facility would follow to ensure residents were protected from alleged perpetrators during the investigation was discussed. Topics of training included, Employee Code of Conduct, Senior Crime [MEDICATION NAME] Employee Oath, Reporting/Identification Abuse and Neglect, Elder Abuse and Neglect and Beyond Compliance. Validation of learning and understanding the in-service material was evidenced by the completion of two tests administered to the DON and Administrator following the in-service; 6. In-services were initiated for all staff on 11/30/10 regarding reporting of abuse, neglect, injuries of unknown origin, mistreatment, misappropriation of property and reporting of unusual occurrences. The process by which the facility would address, investigate, report allegations of abuse, neglect, injury of unknown origin, mistreatment and misappropriation of property was covered. The methods by which the facility would follow to ensure residents were protected from alleged perpetrators during the investigation was discussed. Topics of training included, Employee Code of Conduct, Senior Crime [MEDICATION NAME] Employee Oath, Reporting/Identification Abuse and Neglect, Elder Abuse and Neglect and Beyond Compliance. Validation of learning and understanding the in-service material was evidenced by the completion of two tests administered to all staff following the in-service; and 7. The facility's Medical Director was notified by the facility to inform him about the IJ and the facility's Plan of Removal. The facility's Plan of Removal included a revised A/N/M policy and procedure that addressed each of the required seven components with detailed, facility-specific policies and procedures to be followed as part of their A/N/M prevention program. 5) Interview on 12/01/10 at 9:00 a.m., with the facility's Regional Vice President revealed the Administrator and Dietary Aide B had been suspended. The Regional Vice President revealed he reviewed the facility's incident reports and a total of four incidents had been reported to the State agency, including allegations made by Residents #3, #5 and #6. He stated the incident involving Resident #2 and Dietary Aide B was also reported. The Regional Vice President stated he arrived at the facility at 7:00 p.m. on 11/30/10 and in-services regarding abuse and neglect were initiated with all staff. He stated the Social Services Director interviewed Residents #1, #3, #5 and #6. The Regional Vice President provided the Provider Investigation Reports for review, which were initiated on 12/03/10 as part of the Plan of Removal of the IJ. Review of the Provider Investigation Report dated 12/03/10 revealed Resident #2 required extensive assistance, was not interviewable and lacked the capacity to make informed decisions. The Report reflected on 11/16/10 at 3:00 p.m. Dietary Aide B was setting the tables in the dining room. Resident #2 was moving objects around on the tables and Dietary Aide B was heard yelling the resident to get out of the dining room. Dietary Aide B pushed Resident #2's wheelchair out of the dining room , letting her go near the nurse's station. "One witness states that he was walking at a fast pace when he let her go. She (Resident #2) drifted in her w/c (wheelchair) apx (approximately) 20 feet where she struck an esal (sic) with a picture on it." The Provider Investigation Report reflected, "____ (Resident #2 ) was assessed by ____ (LVN F) right after the incident occurred. She also asked ____ (LVN G and ____ (the ADON) to conduct an assessment. They did not find any injury due to the incident." There was an undated, typed statement attached to the Provider Investigation Report signed by Dietary Aide B. The statement reflected, "On 11/16/10 I was setting up the dining room for supper, resident (Resident #2) was moving items on table and I said to her stop, and leave the dining room. _____,another resident was coming up by us and he asked me what was on the menu, I thought her chair had stopped and when I turned to (another resident) to answer his question. I didn't see her wheelchair was still moving. I went back to what I doing after I talked to (another resident)...." LVN F wrote and signed a statement regarding the incident on 11/16/10 involving Resident #2 and Dietary Aide B, which was attached to the Provider Investigation Report. The statement was undated. The statement reflected LVN F looked up from medication cart and saw Dietary Aide B "shove" Resident #2's wheelchair and "let go of it." LVN F wrote Resident #2 was scared. A statement authored and signed by the DON on 12/01/10 reflected, "____ (Resident #2) was brought into my office on 11/16/10 wide-eyed and wringing her hands. It was reported to me that she had been pushed by ____ (Dietary Aide B) and was unable to stop herself and ran into the easel, knocking down the picture. I asked an aide to go get her vitals and called ____, Dietary Dept. (Department) Head in to discuss matter (with) her. Conveyed information of incident to her & she told me she would 'take care of it.' " Interview on 12/01/10 at 2:10 p.m., with the Regional Vice President revealed Dietary Aide B was at the facility when the Regional Vice President arrived on 11/30/10 at 7:00 p.m. The Regional Vice President stated he immediately sent Dietary Aide B home pending the results of the investigation. 6) Interview on 12/01/10 at 10:15 a.m., with the DON revealed all staff with the exception of five staff members were in-serviced about abuse, neglect and mistreatment the evening of 11/30/10. She stated the Employee Code of Conduct, Senior Crime [MEDICATION NAME] Employee Oath, Reporting/Identification Abuse and Neglect, Elder Abuse and Neglect and Beyond Compliance were topics covered during the in-service. The DON revealed she and the Administrator received an in-service from the Regional Vice President about reporting abuse, neglect and mistreatment. During the interview, the DON stated on 11/16/10, after receiving the allegation CNA A told Resident #4 to shut up, she said she asked the Administrator what to do. The DON stated the Administrator instructed her (the DON) to talk to CNA A. 7) Observation on 12/02/10 at 2:20 p.m. revealed signs posted in common areas of the facility with the facility's Abuse Prohibition Coordinator (Regional Vice President) and contact information where he could be reached seven days a week, 24 hours a day. 8) Interviews conducted from 12/01/10 through 12/03/10 with the staff identified in the following paragraph and they revealed they had all attended the facility's in-service regarding abuse, neglect, injuries of unknown origin, mistreatment, misappropriation of property and reporting of unusual occurrences. All were able to verbalize the facility's revised A/N/M policies and procedures and their roles. Finally, all staff interviewed were able to correctly identify the facility's Abuse Prohibition Coordinator (Regional Vice President). Validation of training attendance was verified for each of the staff below by reviewing in-service sign-in sheets and completed posts tests. The following staff were interviewed: CNA L on 12/01/10 at 1:10 p.m., Dietary Manager on 12/01/10 at 1:40 p.m., Social Services Director on 12/01/10 at 9:45 a.m., LVN G on 12/01/10 at 2:20 p.m., LVN H on 12/01/10 at 2:40 p.m., CNA J on 12/01/10 at 3:00 p.m., CNA K on 12/01/10 at 3:40 p.m., CNA M on 12/02/10 at 6:00 p.m., CNA N on 12/02/10 at 6:15 p.m., the DON on 12/03/10 at 9:10 a.m., LVN O on 12/03/10 at 10:10 a.m., CNA P on 12/03/10 at 10:20 a.m., LVN Q on 12/03/10 at 10:40 a.m., Medical Records on 12/03/10 at 2:00 p.m., Wound Care Nurse on 12/03/10 at 2:10 p.m., Staff Development Coordinator on 12/03/10 at 2:15 p.m., the Marketing Director on 12/03/10 at 2:20 p.m. and the facility's only ADON on 12/03/10 at 2:23 p.m. 9) While the IJ was lowered on 12/03/10, the facility remained out of compliance at a severity level of "No actual harm with potential for more than minimal harm, that is not Immediate Jeopardy" and a scope of "Widespread." The facility continued to in-service and monitor staff to ensure implementation of the Plan of Removal. 10) On 11/30/10 at approximately 10:00 a.m., the Administrator stated the current census was 65 residents.

Based on observation, interview, and record review, it was determined the facility failed to ensure all alleged violations involving mistreatment or abuse were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures and there was evidence all alleged violations were thoroughly investigated and prevented further potential abuse while the investigations were in progress for six (Residents #1, #2, #3, #4, #5, and #6) of six residents reviewed. 1) On 11/16/10 Dietary Aide B yelled at Resident #2 to "get out of the dining room," then shoved the resident in her wheelchair and let go, allowing the resident to collide into a large easel, which was holding a framed picture measuring seven and one-half feet by six and one-fourth feet. This incident was not investigated or reported to the State agency and Dietary Aide B continued to have direct access to the facility residents. 2) Residents #5 and #6 alleged CNA A told Resident #4 to "shut up" on 11/13/10 and informed LVN C on 11/15/10. LVN C did not report the allegation of abuse to the Administrator and/or DON until 11/16/10. The allegation was not thoroughly investigated or reported to the State agency. Resident #5 said she was afraid of retaliation from CNA A. 3) Resident #1 made an allegation of physical, mental and verbal abuse by CNA A on 10/22/10, stating the CNA "popped her, flicked her face and talked down to her." The allegation was not reported to the State agency until 10/25/10 (3 days after the allegation). The allegation was not thoroughly investigated by conducting interviews with other residents, visitors, potential witnesses and staff. 4) On 09/06/10 Resident #3 alleged CNA A was loud and rough. The allegation of abuse was not investigated or reported to the State agency. The DON interviewed Resident #3 and her roommate Resident #5. CNA A continued to have access to Resident #3 and the other facility residents. Resident #3 said she was afraid of retaliation from CNA A. An Immediate Jeopardy (IJ) was identified on 11/30/10. While the IJ was lowered on 12/03/10, the facility remained out of compliance at a severity level of "No actual harm with potential for more than minimal harm, that is not Immediate Jeopardy" and a scope of "Widespread." The facility continued to in-service and monitor staff to ensure allegations of abuse/neglect were being investigated and residents were being protected. These failures created an environment in which abuse could flourish and could affect the facility's 65 residents, including Residents #1, #2, #3, #4, #5 and #6 at risk for further abuse, which could result in serious mental health complications and/or physical injuries. Findings included: 1) Review of Resident #2's clinical record revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE], per the face sheet dated 12/01/10. Review of the November 2010 consolidated physician's orders [REDACTED]. Review of a Monthly Nursing Review dated 11/09/10 revealed Resident #2 communicated only basic needs and had not exhibited any verbal aggression or other disruptive acts. Review of the quarterly MDS assessment dated [DATE] revealed Resident #2 was impaired in both short-term and long-term cognition. She usually understood others but was only sometimes understood by others. According to the MDS assessment, Resident #2 was moderately impaired with decision-making. There were no indicators of depression, anxiety and sad mood and no behavioral symptoms reflected on the MDS assessment. The MDS assessment further reflected Resident #2 required extensive assistance of one person with bed mobility, transfers and dressing. Resident #2 was totally dependent on one person for ADLs. Observation on 12/02/10 at 2:35 p.m. of Resident #2 revealed she was lying in her bed, dressed appropriately. The resident smiled as the surveyor spoke to her and was able to answer simple questions. Resident #2 could not recall being yelled at or shoved in her wheelchair by Dietary B. Resident #2 stated not being able to remember things was very embarrassing to her. Review of a Record of Concern form dated 11/17/10, signed by the ADON on 11/17/10 and by the Administrator on 11/19/10, revealed a complaint filed by LVNs F, G and H. "On 11/16/10, ____ (Dietary Aide B) from dietary was observed yelling (at) ____ (Resident #2), telling her to stay out of the dining room. He then pushed her in her wheelchair, hard, let the chair go and walked away. ____ (Resident #2) could not stop the w/c (wheelchair) and ran into the picture that was sitting on an easel by the Adm (Administrator's) office...Resident was visibly shaken." The documentation reflected Dietary B's immediate supervisor was notified. The ADON documented, "The three nurses noted above, all believe that this was an act of abuse toward the resident. If it had been an aid (sic) or nurse, they would have been suspended or terminated. The nurses want to know why "he is still here." Documentation from the Administrator on the Record of Concern form dated 11/17/10 reflected, "Talked to ____ (Dietary Aide B) - verbal warning - He is to notify nursing if Res (residents) are moving stems on table after it is set. Also not to set tables for dinner too early." Interview on 11/30/10 at 2:40 p.m., with LVN F revealed on 11/16/10 she was standing at the medication cart in the center of the facility, outside the dining room. LVN F stated she heard Dietary B raise his voice and in a sharp, loud tone he told Resident #2 "Get out of the dining room!" He then pushed Resident #2 in her wheelchair out of the dining room and into the center area of the facility, near where LVN F was standing. LVN F stated Dietary Aide B shoved Resident #2's wheelchair with enough force that the resident sped by LVN F. LVN F stated she yelled out, "Oh no!" LVN F was unable to reach Resident #2 before the resident hit a large easel holding a big, heavy picture. The picture on the easel teetered, according to LVN F, but did not fall on the resident. LVN F revealed Resident #2 was "scared to death." When asked how she knew Resident #2 was "scared to death," LVN F stated the expression on the resident's face was fear. She stated the resident's mouth was open and her eyes were wide. LVN F asked Resident #2 if she was okay and the resident stated, "I don't know." LVN F stated she immediately informed the DON of what she had witnessed, and the DON called the Dietary Manager. LVN F stated the incident "rattled" Resident #2, and because the resident had Dementia she was not able to understand what happened or why it happened. LVN F stated Dietary Aide B told her (LVN F) he was sorry after the incident and wanted to go to Resident #2's room and tell her he was sorry. LVN F stated she instructed Dietary Aide B to stay away from Resident #2. Interview on 12/01/10 at 2:20 p.m. with LVN G revealed on 11/16/10 she was seated at the nurse's station located in the center of the facility. She stated she heard LVN F yell out, "Oh!" and when she looked up she saw Resident #2 "fly by in her wheelchair," and LVN F running toward the resident, who was headed toward the lobby area. "____ (LVN F) caught ____ (Resident #2) just as she (the resident) crashed into the easel." LVN G stated Dietary Aide B was walking away. LVN G stated Resident #2 was "visibly shaken up." She added Resident #2 was "startled and trembling." LVN G stated LVN F attempted to comfort Resident #2 and brought the resident to the nurse's station. LVN G said she told LVN F she heard her (LVN F) yell, and it caused her to look up. LVN G stated LVN F said, "It wasn't me yelling. It was her (Resident #2)." LVN G was asked if she was interviewed as part of the facility's investigation following the incident with Dietary Aide B and Resident #2 on 11/16/10. LVN G stated she had not been interviewed about the incident. Interview on 12/01/10 at 2:40 p.m. with LVN H revealed on 11/16/10 she was standing at a medication cart located in the center of the facility. LVN H stated she heard LVN F yell "Oh my gosh!" LVN H stated she looked up in time to see Resident #2 "rolling fast in her wheelchair toward the easel and glass." LVN H stated the resident struck the easel and Dietary Aide B walked off. LVN H stated she was not asked to complete a statement following the incident involving Resident #2 and Dietary Aide B on 11/16/10. LVN H stated Resident #2 resided on her hall and when she asked the ADON if she was supposed to complete an incident report following the incident on 11/16/10, she was told no. Observation on 12/01/10 at 1:05 p.m. of the easel and the large, framed, glass-covered picture, identified by LVN F on 11/30/10 at 2:40 p.m. as the easel Resident #2 was pushed into, measured seven and one-half feet by six and one-fourth feet. During an interview on 11/30/10 at 1:40 p.m. with the Administrator, the surveyor requested any additional documentation of the incident involving Dietary B and Resident #2 on 11/16/10. The Administrator stated she would check with the DON. The surveyor asked if the allegation was reported to the State agency, and she replied it was not. Interview on 11/30/10 at 1:45 p.m. with the DON revealed the Administrator handled the allegation of verbal and physical abuse involving Dietary Aide B and Resident #2. The DON stated the facility's corporate office decided what was to be reported to the State agency. During an interview on 11/30/10 at 2:35 p.m., with the DON, she stated Dietary Aide B did not intentionally push Resident #2, therefore it was not reported to the State agency, and Dietary Aide B was not removed from direct contact with the residents. Interview on 12/01/10 at 1:40 p.m. with the Dietary Manager revealed Dietary Aide B was "a little slow, but came to work everyday." She stated on 11/16/10, Dietary Aide B was setting the tables for dinner, and Resident #2 was wheeling around the dining room in her wheelchair picking things up. The Dietary Manager stated after the DON told her what happened she, the Dietary Manager talked to Dietary Aide B and told him to be careful with the residents. The Dietary Manager stated she immediately went to talk to the Administrator, and the Administrator instructed her to bring Dietary Aide B to her office when he was finished doing what he was doing so the three of them could talk about the incident. The Dietary Manager stated the Administrator told Dietary B the incident could be considered abuse. The Dietary Manager stated she and the Administrator did not consider the incident to be abuse, because Dietary Aide B did not intentionally try to hurt the resident. The Dietary Manager stated the Administrator was the facility's Abuse Prohibition Coordinator, and she decided what to investigate and how to go about investigating allegations of abuse, neglect and mistreatment. Telephone interview on 12/01/10 at 2:00 p.m. with Dietary Aide B revealed on 11/16/10, he was setting the dining room tables for dinner. He stated Resident #2 was picking items up from the tables, including stemware. Dietary Aide B stated he wheeled the resident's wheelchair to the front of the facility. "I didn't know if the wheelchair was rolling fast or slow." Dietary Aide B denied telling Resident #2 to leave the dining room. He stated he told Resident #2 to not pick things up from the tables. Dietary Aide B stated Resident #2 almost ran into the easel, but LVN F stopped the resident from hitting the easel. 2) Review of Resident #4's clinical record revealed she was an [AGE] year-old female, who was admitted to the facility on [DATE] and re-admitted on [DATE], per the face sheet dated 12/01/10. Review of the December 2010 consolidated physician's orders [REDACTED]. Review of a Monthly Nursing Review dated 11/07/10 revealed Resident #4 communicated only basic needs, and she required daily intervention from staff with orientation and memory. The Monthly Nursing Summary Review reflected Resident #4 had not exhibited any verbal aggression or other disruptive acts. It was reflected on the Summary Resident #4 required maximum assistance with all ADLs and transfers. Review of the quarterly MDS assessment dated [DATE] revealed Resident #4's speech clarity was unclear, she was usually understood and sometimes understood others. Signs and symptoms of [MEDICAL CONDITION] included disorganized thinking, which fluctuated. The interview reflected in the MDS assessment to establish Resident #4's mental status revealed the resident was unable to complete the following sections: Repetition of Three Words, Temporal Orientation and Recall. The Resident Mood Interview portion of the MDS assessment reflected Resident #4 did not respond to any of the questions. The MDS assessment further reflected Resident #4 required extensive assistance of one person for bed mobility and limited assistance of two persons for transfers. The resident required limited assistance of one person for dressing and extensive assistance of two persons for personal hygiene. Observation on 11/30/10 at 1:00 p.m. of Resident #4 revealed she was lying in bed. Resident #4 was confused and could not answer simple questions. Review of Resident #5's clinical record revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE] and re-admitted on [DATE], per the face sheet dated 12/01/10. Review of the November 2010 consolidated physician's orders [REDACTED]. Review of a Monthly Nursing Review dated 11/04/10 revealed Resident #5 communicated without difficulty. The Monthly Nursing Summary Review reflected Resident #5 had not exhibited any verbal aggression or other disruptive acts. Resident #5 was alert and oriented to person, place and time and received assistance with ADLs. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had short-term cognitive impairment, but the resident's long-term memory was intact. She was able to recall the location of her room, staff names/faces and that she resided in a nursing facility. Resident #5's decision-making capacity was moderately impaired. According to the MDS assessment, Resident #5 usually understand others and was usually understood. There were no indicators of [MEDICAL CONDITION]-periodic disordered thinking/awareness reflected on the MDS assessment. The MDS assessment further reflected Resident #5 did not have indicators of depression, anxiety or sad mood and had not experienced any behavioral symptoms. Resident #5 required limited assistance of one person for bed mobility and extensive assistance of one person for transfers. The resident required the extensive assistance of one person for dressing and limited assistance of one person for personal hygiene. Interview on 11/30/10 at 1:10 p.m., with Resident #5, who was identified as interviewable by the facility, per a listing of interviewable residents dated 11/30/10, revealed she heard CNA A yelling at Resident #4 to shut up. Resident #5's room was located next door to Resident #4's room. When asked where she was when she heard CNA A, Resident #5 stated she was in her room, but she knew CNA A's voice. As the surveyor was leaving the room, both Resident #5 and Resident #3 asked the surveyor not to tell CNA A about the allegations they had made because, "She (CNA A) will get back at us." Review of Resident #6's clinical record revealed she was an [AGE] year-old female, who was admitted to the facility on [DATE] and re-admitted on [DATE], per the face sheet dated 12/01/10. Review of the November 2010 consolidated physician's orders [REDACTED]. Review of a Monthly Nursing Review dated 10/09/10 revealed Resident #6 communicated without difficulty and had not exhibited any verbal aggression or other disruptive acts. Resident #6 was alert and oriented to person, place and time and able to voice her needs. Review of the MDS assessment dated [DATE] revealed Resident #6 had clear speech clarity, made herself understood and was understood by others. Resident #6 scored 14 out of 15 on the section of the MDS assessment for cognitive impairment, including repetition of words, temporal orientation, and recall. According to the MDS assessment, Resident #6 did not have signs or symptoms of [MEDICAL CONDITION]. The interview reflected in the MDS assessment reflected the resident's mood was stable with no adverse indicators. The MDS assessment further reflected Resident #6 was independent with set-up assistance only for bed mobility and transfers. Resident #6 required limited assistance of one person for dressing and personal hygiene. Interview on 11/30/10 at 1:05 p.m., with Resident #6, who was identified as interviewable by the facility, per a listing of interviewable residents dated 11/30/10, revealed "a couple of weeks ago," she was in her room with her door open when she heard CNA A across the hall yell "shut up" at Resident #4. Resident #6 stated she could not see who CNA A was yelling at, but it was from the direction of Resident #4's room. "Her tone of voice is hateful. She talks down to the residents, like you're lesser than her. She's rude." Resident #6 stated CNA A lined the residents up in their wheelchairs against the wall and told them, "Now you just sit there! Like you don't dare move." During an interview on 11/30/10 at 12:45 p.m., LVN C stated approximately three weeks ago, he received a complaint about CNA A from Residents #5 and #6. He stated Residents #5 and #6 reported they heard CNA A telling Resident #4 to shut up. When asked what action he took following the allegation of verbal abuse, LVN C stated he told the DON the following day. LVN C stated the DON asked him to obtain statements from Residents #5 and #6. A typed statement, signed by LVN C and dated 11/16/10 reflected, "____ (Resident #5) reported she heard a CNA yelling "SHUT UP!" at ____ (Resident #4) on what she remembered to be Saturday the 13th of November. I asked ____ (Resident #5) who she believed it was that yelled at ____ (Resident #4). ____ (Resident #5) explained 'it was ____ (CNA A) that had yelled shut up at ____ (Resident #4).' I asked ____ (Resident #5) who else may have heard ____ (CNA A) yelling at ____ (Resident #4). ____ (Resident #5) states '____ (Resident #6) said she heard ____ (CNA A) being mean too." This nurse went to ____ (Resident #6) and asked what if anything exciting/abnormal happen (sic) this weekend. ____ (Resident #6) answered 'an aid (sic) was yelling shut up to (Resident #4) across the hall.' I asked if ____ (Resident #6) knew who had yelled at ____ (Resident #4). ____ (Resident #6) replied 'it was ____ (CNA A), I recognized her voice.' I asked both ____ and ____ (Resident #5 and Resident #6) if either of them had concerns about ____ (CNA A) providing care for them. ____ (Resident #5) replied 'I better not, cause she better not be mean to me!' " Interview on 11/30/10 at 1:30 p.m., with the DON revealed on 11/15/10 or 11/16/10, Residents #5 and #6 alleged CNA A told Resident #4 to shut up. The DON stated LVN C took their statements and she, the DON interviewed the residents. She stated each time she interviewed the residents who made the allegations, they denied it and would not provide specifics. The DON speculated there was a group of women, who did not like CNA A. During an interview on 11/30/10 at 1:40 p.m. with the Administrator, the surveyor requested any additional documentation of investigations for allegations of mistreatment made by Residents #5 and #6 on 11/16/10. The Administrator stated she would check with the DON. The surveyor asked if the allegations were reported to the State agency, and she replied they were not. Interview on 11/30/10 at 1:45 p.m. with the DON revealed she did not have any additional documentation for the allegations made against CNA A on 11/16/10. The DON stated the facility's corporate office decided what was to be reported to the State agency. During an interview on 11/30/10 at 2:35 p.m., with the DON, she stated following the allegation of verbal abuse on 11/16/10 by Residents #5 and #6, CNA A was counseled and reassigned to PRN status. The DON stated she interviewed another CNA (CNA I) who was working with CNA A at the time the allegation was made when CNA A told Resident #4 to shut up. The DON stated CNA I had responded, "Why would ____ (CNA A) say shut up to ____ (Resident #4) when ____ (Resident #4) doesn't even talk?" The DON stated, "Then I forgot about it." Review of CNA A's personnel records revealed a Personnel Action form dated 11/16/10 and signed by CNA A and the DON. The space for the Administrator's signature was blank. The form reflected, "Continued reports from residents about her loud and 'rough' care she provides. She has been asked on more than one occasion to become aware of how she says things to residents. Assured by CNA that in [AGE] years of service she has never had any complaints made against her." The form reflected CNA A was to have a partner when providing care to Residents #1, #3 and #5. Attached to the Personnel Action form was another Personnel Action form dated 11/16/10 reflecting, "Two residents (complained of) ____ (CNA A) yelling "shut up" to ____ (Resident #4). The res (residents) (complained of) this CNA being mean & yelling (at) another res. Numerous complaints had been brought to DON and ADON's attention regarding the same improper conduct." The form reflected CNA A was demoted to PRN status. Telephone interview on 12/01/10 at 3:30 p.m. with CNA A revealed she was aware an allegation had been made she told Resident #4 to shut up. CNA A stated the weekend of 11/13/10, she came to work sick. She stated, "I was sick. I was aching and had fever. That weekend I wasn't even talking to my co-workers or anybody. I was just trying to get through my eight hour shift." CNA A denied the allegation stating, "If these residents don't speak to me, I am not speaking to them." CNA A then stated the DON never told her she had to work with a partner, but CNA A insisted she not work alone. She stated following the incident on 10/22/10 she was moved to Hall 300 (where Residents #3, #4, #5 and #6 resided). CNA A stated she was allowed to provide care to any resident on Hall 300 without a partner. 3) Review of Resident #1's clinical record revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE], per the face sheet dated 10/21/10. Review of the significant change MDS assessment with an assessment reference date of 10/02/10 revealed the resident's ability to express ideas and wants was not impaired. The MDS assessment reflected Resident #1 was oriented to the year and had no signs and symptoms of [MEDICAL CONDITION]. The resident interview reflected on the MDS assessment evaluating mood revealed Resident #1 had little interest or pleasure in doing things, felt down, depressed or hopeless, felt bad about herself, experienced trouble concentrating and moving or speaking so slowly that other people could have noticed or being fidgety and restless. All of these symptom indicators occurred nearly every day, per the MDS assessment. Review of the behavior section on the MDS assessment revealed the resident did not have any behavioral symptoms, included [MEDICAL CONDITION]. Further review of the MDS assessment revealed Resident #1 was totally dependent for bed mobility, transfers, dressing, toilet use, bathing and personal hygiene. The [DIAGNOSES REDACTED]. Review of the history and physical progress note dated 09/28/10 revealed Resident #1 was alert and oriented to person, place and time. The resident's judgement and insight were intact and and her thought content was logical. Review of the consolidated physician's orders [REDACTED]. Observation of Resident #1 on 11/30/10 at 10:00 a.m. revealed she was lying in bed resting. Interview with Resident #1 at the time of the observation on 11/30/10 at 10:00 a.m. revealed CNA A was "not the most gentle person." Resident #1 stated CNA A was rough with her while providing care. The resident stated she thought CNA A was immature, because she did not like to "fool with" Resident #1. The resident stated CNA A did not like her and talked down to her. According to Resident #1, CNA A "popped her." The resident stated she told her family member about the mistreatment, but could not recall when the mistreatment occurred. Resident #1 stated CNA A was not permitted to provide care to her anymore, and she was relieved. During the facility's Entrance Conference on 11/30/10 at 8:40 a.m. with the Administrator the surveyor requested for review the facility's current A/N/M policy and procedure, a copy of the Provider Investigation Report for Resident #1 and a resident roster identifying all interviewable residents. The Administrator stated during the Entrance Conference she was responsible for monitoring the facility's A/N/M prevention program. The Administrator revealed Resident #1 made an allegation of abuse on 10/22/10 (Friday). The Administrator stated Resident #1's family member was a disgruntled employee who no longer worked at the facility. The Administrator stated the family member arrived at the facility on the evening of 10/22/10 demanding to look at the resident's "entire body" from head to toe. LVN C accompanied the family member and an assessment of Resident #1's body was performed. LVN C's shift ended shortly after the assessment, and LVN D arrived at the facility. At 6:45 p.m., LVN D was summoned to Resident #1's room by the resident's family member. At that time, Resident #1 told LVN D CNA A had mistreated her. The Administrator stated LVN D immediately notified her and the DON. LVN D obtained a statement from Resident #1 at that time. The Administrator revealed she and the DON arrived at the facility on 10/22/10, after being notified of the allegation, to initiate an investigation. The Administrator revealed there was "history" between Resident #1's family member and CNA A. The Administrator stated CNA A had been employed at the facility for six months, and there had been no complaints filed against CNA A by residents or family members. The Administrator stated Resident #1 was interviewable and had never made allegations of abuse. The Administrator stated, it was decided after interviewing the resident, the resident's family member "put ____ (Resident #1) up to it" in an effort to get CNA A in trouble. The Administrator stated she, the DON, LVN D and the Wound Care Nurse interviewed Resident #1 on separate occasions, and the resident denied being mistreated. When asked if other residents were interviewed, as part of the investigation, the Administrator answered in the affirmative. The surveyor requested to review all documentation of the facility's investigation pertaining to Resident #1. During the interview with the Administrator on 11/30/10 at 8:40 a.m., the surveyor asked why the allegation of abuse was not reported to the State agency until 10/25/10 (three days after the allegation of abuse was made), per the DADS Investigation Intake Form. The Administrator stated when she contacted her corporate office, she was told to wait until Monday to make the report to DADS. According to the Administrator, the corporate representative told her reporting immediately did not include the days of the weekend. The Administrator stated the policy of the facility's corporate office was to collect witness statements and fax the investigation and witness statements to the corporate office. Determination on whether to report allegations was made by the facility's corporate office. Review of the Provider Investigation Report dated 10/29/10 revealed on 10/22/10 at 6:45 p.m., Resident #1 alleged CNA A abused her. The report reflected Resident #1 was capable of making informed decisions. The report further reflected a skin assessment was completed on 10/22/10 and a yellow, green bruise was noted on the resident's and two yellow, green bruises were observed on the resident's abdomen. The report reflected after multiple interviews with residents, staff and Resident #1, mistreatment by CNA A was denied. "____ (Resident #1) on initial interview following visit from ____ (resident's family member) had verbalized negative interaction. Resident was re-interviewed by different investigators and denied knowing or being hurt/mistreated by ____ (CNA A). No bodily injuries were noted on assessment by licensed staff." The Provider Investigation Report reflected CNA A was re-assigned and would no longer be providing care to Resident #1. It was concluded the bruises observed on Resident #1's body were a result of the sit-to-stand lift. The Administrator signed and dated the report 10/29/10. Review of an Incident Report dated 10/22/10 and signed by the Administrator, DON and LVN D revealed Resident #1 reported she was mistreated by CNA A. The Incident Report reflected the resident named CNA A as the alleged perpetrator. The Investigation of the Incident/Accident Report, attached to the Incident Report, signed by LVN D and dated 10/22/10, reflected the resident was observed to have two bruises on her abdomen and one bruise on her right knee, which were yellow, green in color. There were no measurements of the bruises included on the report. The report further reflected the bruises were suspected to be caused by the sit-to-stand lift. CNA A was sent home following the allegation made by Resident #1. The report reflected, "Statements were received from coworkers, upon 2nd & 3rd investigation Res (Resident #1) was unable to verbalize abuse, stating nobody has ever hurt her." A Concern/Complaint Investigation report, attached to the Provider Investigation Report, dated 10/22/10 and signed by the DON reflected, "____ (Resident #1) reported to her nurse mistreatment by her aide (CNA A) at approx. 1845 (6:45 p.m.) on Fri (Friday), 10/22/10. Assessment was done after interview with ____ (Resident #1) and no marks, red areas, or bruising (fresh) was noted. Yellow-green bruises on knee (right) were noted. Resident unable to tell nurse how bruise was acquired, or when she received it. She was asked if (CNA A) or anyone else had hurt her, and she denied knowing ____ (CNA A) or had been hurt today or any other time. She did state she was afraid but was unable to tell me what she was afraid of. She kept repeating, 'I'm so scared.' When asked if there was someone she was afraid of she answered, 'I'm scared ____ (Resident #1's family member) will say something.' ____ (the previous DON) asked about what, and she replied, 'the policy.' ____ (the previous DON) asked what policy? I'm confused. She (Resident #1) replied, 'So am I.' " The recommendations reflected on the Concern/Complaint Investigation included CNAs were not to go into Resident #1's room or provide care without a partner, CNA A would no longer provide care to Resident #1 and in-services were conducted on safe transfers with the sit-to-stand lift, abuse/neglect and skin assessments. "Statements from co-workers of ____ (CNA A) regarding her care of residents may be helpful." LVN D documented Resident #1's statement, and the resident, along with LVN D, signed it. The statement dated 10/22/10 and timed 6:45 p.m. reflected, "____ (CNA A), dark black, has her way with me, sh

Based on observation, interview and record review, the Administrator and the DON failed to use the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psycho-social well-being for six (Residents #1, #2, #3, #4, #5 and #6) of six residents reviewed for allegations of abuse. The DON failed to ensure allegations of abuse and mistreatment were immediately reported to the Administrator. The Administrator and the DON failed to ensure for 1) allegations of abuse and mistreatment were reported to the State agency; 2) allegations of abuse and mistreatment were thoroughly investigated by interviewing possible witnesses including staff, residents and visitors; and 3) residents were protected following allegations of abuse and mistreatment from the potential of further abuse or mistreatment. The Administrator and the DON failed to develop and implement a facility p/p for A/N/M to provide specific procedures for the reporting, investigating and protection of residents when potential abuse, neglect, and mistreatment was identified as evidenced by: 1) On 11/16/10 Dietary Aide B yelled at Resident #2 to "get out of the dining room," then shoved the resident in her wheelchair and let go, allowing the resident to collide into a large easel, which was holding a framed picture measuring seven and one-half feet by six and one-fourth feet. This incident was not investigated or reported to the State agency and Dietary Aide B continued to have direct access to the facility residents. 2) Residents #5 and #6 alleged CNA A told Resident #4 to "shut up" on 11/13/10 and informed LVN C on 11/15/10. LVN C did not report the allegation of abuse to the Administrator and/or DON until 11/16/10. The allegation was not thoroughly investigated or reported to the State agency. Resident #5 said she was afraid of retaliation from CNA A. 3) Resident #1 made an allegation of physical, mental and verbal abuse by CNA A on 10/22/10, stating the CNA "popped her, flicked her face and talked down to her." The allegation was not reported to the State agency until 10/25/10 (3 days after the allegation). The allegation was not thoroughly investigated by conducting interviews with other residents, visitors, potential witnesses and staff. 4) On 09/06/10 Resident #3 alleged CNA A was loud and rough. The allegation of abuse was not investigated or reported to the State agency. The DON interviewed Resident #3 and her roommate Resident #5. CNA A continued to have access to Resident #3 and the other facility residents. Resident #3 said she was afraid of retaliation from CNA A. An Immediate Jeopardy (IJ) was identified on 11/30/10. While the IJ was lowered on 12/03/10, the facility remained out of compliance at a severity level of "No actual harm with potential for more than minimal harm, that is not Immediate Jeopardy" and a scope of "Widespread." The facility continued to in-service and monitor staff to ensure allegations of abuse/neglect were being investigated and residents were being protected. These failures created an environment in which abuse could flourish and could affect the facility's 65 residents, including Residents #1, #2, #3, #4, #5 and #6 at risk for further abuse, which could result in serious mental health complications and/or physical injuries. Findings included: 1) Review of Resident #2's clinical record revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE], per the face sheet dated 12/01/10. Review of the November 2010 consolidated physician's orders [REDACTED]. Review of a Monthly Nursing Review dated 11/09/10 revealed Resident #2 communicated only basic needs and had not exhibited any verbal aggression or other disruptive acts. Review of the quarterly MDS assessment dated [DATE] revealed Resident #2 was impaired in both short-term and long-term cognition. She usually understood others but was only sometimes understood by others. According to the MDS assessment, Resident #2 was moderately impaired with decision-making. There were no indicators of depression, anxiety and sad mood and no behavioral symptoms reflected on the MDS assessment. The MDS assessment further reflected Resident #2 required extensive assistance of one person with bed mobility, transfers and dressing. Resident #2 was totally dependent on one person for ADLs. Observation on 12/02/10 at 2:35 p.m. of Resident #2 revealed she was lying in her bed, dressed appropriately. The resident smiled as the surveyor spoke to her and was able to answer simple questions. Resident #2 could not recall being yelled at or shoved in her wheelchair by Dietary B. Resident #2 stated not being able to remember things was very embarrassing to her. Review of a Record of Concern form dated 11/17/10, signed by the ADON on 11/17/10 and by the Administrator on 11/19/10, revealed a complaint filed by LVNs F, G and H. "On 11/16/10, ____ (Dietary Aide B) from dietary was observed yelling (at) ____ (Resident #2), telling her to stay out of the dining room. He then pushed her in her wheelchair, hard, let the chair go and walked away. ____ (Resident #2) could not stop the w/c (wheelchair) and ran into the picture that was sitting on an easel by the Adm (Administrator's) office...Resident was visibly shaken." The documentation reflected Dietary B's immediate supervisor was notified. The ADON documented, "The three nurses noted above, all believe that this was an act of abuse toward the resident. If it had been an aid (sic) or nurse, they would have been suspended or terminated. The nurses want to know why "he is still here." Documentation from the Administrator on the Record of Concern form dated 11/17/10 reflected, "Talked to ____ (Dietary Aide B) - verbal warning - He is to notify nursing if Res (residents) are moving stems on table after it is set. Also not to set tables for dinner too early." Interview on 11/30/10 at 2:40 p.m., with LVN F revealed on 11/16/10 she was standing at the medication cart in the center of the facility, outside the dining room. LVN F stated she heard Dietary B raise his voice and in a sharp, loud tone he told Resident #2 "Get out of the dining room!" He then pushed Resident #2 in her wheelchair out of the dining room and into the center area of the facility, near where LVN F was standing. LVN F stated Dietary Aide B shoved Resident #2's wheelchair with enough force that the resident sped by LVN F. LVN F stated she yelled out, "Oh no!" LVN F was unable to reach Resident #2 before the resident hit a large easel holding a big, heavy picture. The picture on the easel teetered, according to LVN F, but did not fall on the resident. LVN F revealed Resident #2 was "scared to death." When asked how she knew Resident #2 was "scared to death," LVN F stated the expression on the resident's face was fear. She stated the resident's mouth was open and her eyes were wide. LVN F asked Resident #2 if she was okay and the resident stated, "I don't know." LVN F stated she immediately informed the DON of what she had witnessed, and the DON called the Dietary Manager. LVN F stated the incident "rattled" Resident #2, and because the resident had Dementia she was not able to understand what happened or why it happened. LVN F stated Dietary Aide B told her (LVN F) he was sorry after the incident and wanted to go to Resident #2's room and tell her he was sorry. LVN F stated she instructed Dietary Aide B to stay away from Resident #2. Interview on 12/01/10 at 2:20 p.m. with LVN G revealed on 11/16/10 she was seated at the nurse's station located in the center of the facility. She stated she heard LVN F yell out, "Oh!" and when she looked up she saw Resident #2 "fly by in her wheelchair," and LVN F running toward the resident, who was headed toward the lobby area. "____ (LVN F) caught ____ (Resident #2) just as she (the resident) crashed into the easel." LVN G stated Dietary Aide B was walking away. LVN G stated Resident #2 was "visibly shaken up." She added Resident #2 was "startled and trembling." LVN G stated LVN F attempted to comfort Resident #2 and brought the resident to the nurse's station. LVN G said she told LVN F she heard her (LVN F) yell, and it caused her to look up. LVN G stated LVN F said, "It wasn't me yelling. It was her (Resident #2)." LVN G was asked if she was interviewed as part of the facility's investigation following the incident with Dietary Aide B and Resident #2 on 11/16/10. LVN G stated she had not been interviewed about the incident. Interview on 12/01/10 at 2:40 p.m. with LVN H revealed on 11/16/10 she was standing at a medication cart located in the center of the facility. LVN H stated she heard LVN F yell "Oh my gosh!" LVN H stated she looked up in time to see Resident #2 "rolling fast in her wheelchair toward the easel and glass." LVN H stated the resident struck the easel and Dietary Aide B walked off. LVN H stated she was not asked to complete a statement following the incident involving Resident #2 and Dietary Aide B on 11/16/10. LVN H stated Resident #2 resided on her hall and when she asked the ADON if she was supposed to complete an incident report following the incident on 11/16/10, she was told no. Observation on 12/01/10 at 1:05 p.m. of the easel and the large, framed, glass-covered picture, identified by LVN F on 11/30/10 at 2:40 p.m. as the easel Resident #2 was pushed into, measured seven and one-half feet by six and one-fourth feet. During an interview on 11/30/10 at 1:40 p.m. with the Administrator, the surveyor requested any additional documentation of the incident involving Dietary B and Resident #2 on 11/16/10. The Administrator stated she would check with the DON. The surveyor asked if the allegation was reported to the State agency, and she replied it was not. Interview on 11/30/10 at 1:45 p.m. with the DON revealed the Administrator handled the allegation of verbal and physical abuse involving Dietary Aide B and Resident #2. The DON stated the facility's corporate office decided what was to be reported to the State agency. During an interview on 11/30/10 at 2:35 p.m., with the DON, she stated Dietary Aide B did not intentionally push Resident #2, therefore it was not reported to the State agency, and Dietary Aide B was not removed from direct contact with the residents. Interview on 12/01/10 at 1:40 p.m. with the Dietary Manager revealed Dietary Aide B was "a little slow, but came to work everyday." She stated on 11/16/10, Dietary Aide B was setting the tables for dinner, and Resident #2 was wheeling around the dining room in her wheelchair picking things up. The Dietary Manager stated after the DON told her what happened she, the Dietary Manager talked to Dietary Aide B and told him to be careful with the residents. The Dietary Manager stated she immediately went to talk to the Administrator, and the Administrator instructed her to bring Dietary Aide B to her office when he was finished doing what he was doing so the three of them could talk about the incident. The Dietary Manager stated the Administrator told Dietary B the incident could be considered abuse. The Dietary Manager stated she and the Administrator did not consider the incident to be abuse, because Dietary Aide B did not intentionally try to hurt the resident. The Dietary Manager stated the Administrator was the facility's Abuse Prohibition Coordinator, and she decided what to investigate and how to go about investigating allegations of abuse, neglect and mistreatment. Telephone interview on 12/01/10 at 2:00 p.m. with Dietary Aide B revealed on 11/16/10, he was setting the dining room tables for dinner. He stated Resident #2 was picking items up from the tables, including stemware. Dietary Aide B stated he wheeled the resident's wheelchair to the front of the facility. "I didn't know if the wheelchair was rolling fast or slow." Dietary Aide B denied telling Resident #2 to leave the dining room. He stated he told Resident #2 to not pick things up from the tables. Dietary Aide B stated Resident #2 almost ran into the easel, but LVN F stopped the resident from hitting the easel. 2) Review of Resident #4's clinical record revealed she was an [AGE] year-old female, who was admitted to the facility on [DATE] and re-admitted on [DATE], per the face sheet dated 12/01/10. Review of the December 2010 consolidated physician's orders [REDACTED]. Review of a Monthly Nursing Review dated 11/07/10 revealed Resident #4 communicated only basic needs, and she required daily intervention from staff with orientation and memory. The Monthly Nursing Summary Review reflected Resident #4 had not exhibited any verbal aggression or other disruptive acts. It was reflected on the Summary Resident #4 required maximum assistance with all ADLs and transfers. Review of the quarterly MDS assessment dated [DATE] revealed Resident #4's speech clarity was unclear, she was usually understood and sometimes understood others. Signs and symptoms of [MEDICAL CONDITION] included disorganized thinking, which fluctuated. The interview reflected in the MDS assessment to establish Resident #4's mental status revealed the resident was unable to complete the following sections: Repetition of Three Words, Temporal Orientation and Recall. The Resident Mood Interview portion of the MDS assessment reflected Resident #4 did not respond to any of the questions. The MDS assessment further reflected Resident #4 required extensive assistance of one person for bed mobility and limited assistance of two persons for transfers. The resident required limited assistance of one person for dressing and extensive assistance of two persons for personal hygiene. Observation on 11/30/10 at 1:00 p.m. of Resident #4 revealed she was lying in bed. Resident #4 was confused and could not answer simple questions. Review of Resident #5's clinical record revealed she was a [AGE] year-old female, who was admitted to the facility on [DATE] and re-admitted on [DATE], per the face sheet dated 12/01/10. Review of the November 2010 consolidated physician's orders [REDACTED]. Review of a Monthly Nursing Review dated 11/04/10 revealed Resident #5 communicated without difficulty. The Monthly Nursing Summary Review reflected Resident #5 had not exhibited any verbal aggression or other disruptive acts. Resident #5 was alert and oriented to person, place and time and received assistance with ADLs. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had short-term cognitive impairment, but the resident's long-term memory was intact. She was able to recall the location of her room, staff names/faces and that she resided in a nursing facility. Resident #5's decision-making capacity was moderately impaired. According to the MDS assessment, Resident #5 usually understand others and was usually understood. There were no indicators of [MEDICAL CONDITION]-periodic disordered thinking/awareness reflected on the MDS assessment. The MDS assessment further reflected Resident #5 did not have indicators of depression, anxiety or sad mood and had not experienced any behavioral symptoms. Resident #5 required limited assistance of one person for bed mobility and extensive assistance of one person for transfers. The resident required the extensive assistance of one person for dressing and limited assistance of one person for personal hygiene. Interview on 11/30/10 at 1:10 p.m., with Resident #5, who was identified as interviewable by the facility, per a listing of interviewable residents dated 11/30/10, revealed she heard CNA A yelling at Resident #4 to shut up. Resident #5's room was located next door to Resident #4's room. When asked where she was when she heard CNA A, Resident #5 stated she was in her room, but she knew CNA A's voice. As the surveyor was leaving the room, both Resident #5 and Resident #3 asked the surveyor not to tell CNA A about the allegations they had made because, "She (CNA A) will get back at us." Review of Resident #6's clinical record revealed she was an [AGE] year-old female, who was admitted to the facility on [DATE] and re-admitted on [DATE], per the face sheet dated 12/01/10. Review of the November 2010 consolidated physician's orders [REDACTED]. Review of a Monthly Nursing Review dated 10/09/10 revealed Resident #6 communicated without difficulty and had not exhibited any verbal aggression or other disruptive acts. Resident #6 was alert and oriented to person, place and time and able to voice her needs. Review of the MDS assessment dated [DATE] revealed Resident #6 had clear speech clarity, made herself understood and was understood by others. Resident #6 scored 14 out of 15 on the section of the MDS assessment for cognitive impairment, including repetition of words, temporal orientation, and recall. According to the MDS assessment, Resident #6 did not have signs or symptoms of [MEDICAL CONDITION]. The interview reflected in the MDS assessment reflected the resident's mood was stable with no adverse indicators. The MDS assessment further reflected Resident #6 was independent with set-up assistance only for bed mobility and transfers. Resident #6 required limited assistance of one person for dressing and personal hygiene. Interview on 11/30/10 at 1:05 p.m., with Resident #6, who was identified as interviewable by the facility, per a listing of interviewable residents dated 11/30/10, revealed "a couple of weeks ago," she was in her room with her door open when she heard CNA A across the hall yell "shut up" at Resident #4. Resident #6 stated she could not see who CNA A was yelling at, but it was from the direction of Resident #4's room. "Her tone of voice is hateful. She talks down to the residents, like you're lesser than her. She's rude." Resident #6 stated CNA A lined the residents up in their wheelchairs against the wall and told them, "Now you just sit there! Like you don't dare move." During an interview on 11/30/10 at 12:45 p.m., LVN C stated approximately three weeks ago, he received a complaint about CNA A from Residents #5 and #6. He stated Residents #5 and #6 reported they heard CNA A telling Resident #4 to shut up. When asked what action he took following the allegation of verbal abuse, LVN C stated he told the DON the following day. LVN C stated the DON asked him to obtain statements from Residents #5 and #6. A typed statement, signed by LVN C and dated 11/16/10 reflected, "____ (Resident #5) reported she heard a CNA yelling "SHUT UP!" at ____ (Resident #4) on what she remembered to be Saturday the 13th of November. I asked ____ (Resident #5) who she believed it was that yelled at ____ (Resident #4). ____ (Resident #5) explained 'it was ____ (CNA A) that had yelled shut up at ____ (Resident #4).' I asked ____ (Resident #5) who else may have heard ____ (CNA A) yelling at ____ (Resident #4). ____ (Resident #5) states '____ (Resident #6) said she heard ____ (CNA A) being mean too." This nurse went to ____ (Resident #6) and asked what if anything exciting/abnormal happen (sic) this weekend. ____ (Resident #6) answered 'an aid (sic) was yelling shut up to (Resident #4) across the hall.' I asked if ____ (Resident #6) knew who had yelled at ____ (Resident #4). ____ (Resident #6) replied 'it was ____ (CNA A), I recognized her voice.' I asked both ____ and ____ (Resident #5 and Resident #6) if either of them had concerns about ____ (CNA A) providing care for them. ____ (Resident #5) replied 'I better not, cause she better not be mean to me!' " Interview on 11/30/10 at 1:30 p.m., with the DON revealed on 11/15/10 or 11/16/10, Residents #5 and #6 alleged CNA A told Resident #4 to shut up. The DON stated LVN C took their statements and she, the DON interviewed the residents. She stated each time she interviewed the residents who made the allegations, they denied it and would not provide specifics. The DON speculated there was a group of women, who did not like CNA A. During an interview on 11/30/10 at 1:40 p.m. with the Administrator, the surveyor requested any additional documentation of investigations for allegations of mistreatment made by Residents #5 and #6 on 11/16/10. The Administrator stated she would check with the DON. The surveyor asked if the allegations were reported to the State agency, and she replied they were not. Interview on 11/30/10 at 1:45 p.m. with the DON revealed she did not have any additional documentation for the allegations made against CNA A on 11/16/10. The DON stated the facility's corporate office decided what was to be reported to the State agency. During an interview on 11/30/10 at 2:35 p.m., with the DON, she stated following the allegation of verbal abuse on 11/16/10 by Residents #5 and #6, CNA A was counseled and reassigned to PRN status. The DON stated she interviewed another CNA (CNA I) who was working with CNA A at the time the allegation was made when CNA A told Resident #4 to shut up. The DON stated CNA I had responded, "Why would ____ (CNA A) say shut up to ____ (Resident #4) when ____ (Resident #4) doesn't even talk?" The DON stated, "Then I forgot about it." Review of CNA A's personnel records revealed a Personnel Action form dated 11/16/10 and signed by CNA A and the DON. The space for the Administrator's signature was blank. The form reflected, "Continued reports from residents about her loud and 'rough' care she provides. She has been asked on more than one occasion to become aware of how she says things to residents. Assured by CNA that in [AGE] years of service she has never had any complaints made against her." The form reflected CNA A was to have a partner when providing care to Residents #1, #3 and #5. Attached to the Personnel Action form was another Personnel Action form dated 11/16/10 reflecting, "Two residents (complained of) ____ (CNA A) yelling "shut up" to ____ (Resident #4). The res (residents) (complained of) this CNA being mean & yelling (at) another res. Numerous complaints had been brought to DON and ADON's attention regarding the same improper conduct." The form reflected CNA A was demoted to PRN status. Telephone interview on 12/01/10 at 3:30 p.m. with CNA A revealed she was aware an allegation had been made she told Resident #4 to shut up. CNA A stated the weekend of 11/13/10, she came to work sick. She stated, "I was sick. I was aching and had fever. That weekend I wasn't even talking to my co-workers or anybody. I was just trying to get through my eight hour shift." CNA A denied the allegation stating, "If these residents don't speak to me, I am not speaking to them." CNA A then stated the DON never told her she had to work with a partner, but CNA A insisted she not work alone. She stated following the incident on 10/22/10 she was moved to Hall 300 (where Residents #3, #4, #5 and #6 resided). CNA A stated she was allowed to provide care to any resident on Hall 300 without a partner. 3) Review of Resident #1's clinical record revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE], per the face sheet dated 10/21/10. Review of the significant change MDS assessment with an assessment reference date of 10/02/10 revealed the resident's ability to express ideas and wants was not impaired. The MDS assessment reflected Resident #1 was oriented to the year and had no signs and symptoms of [MEDICAL CONDITION]. The resident interview reflected on the MDS assessment evaluating mood revealed Resident #1 had little interest or pleasure in doing things, felt down, depressed or hopeless, felt bad about herself, experienced trouble concentrating and moving or speaking so slowly that other people could have noticed or being fidgety and restless. All of these symptom indicators occurred nearly every day, per the MDS assessment. Review of the behavior section on the MDS assessment revealed the resident did not have any behavioral symptoms, included [MEDICAL CONDITION]. Further review of the MDS assessment revealed Resident #1 was totally dependent for bed mobility, transfers, dressing, toilet use, bathing and personal hygiene. The [DIAGNOSES REDACTED]. Review of the history and physical progress note dated 09/28/10 revealed Resident #1 was alert and oriented to person, place and time. The resident's judgement and insight were intact and and her thought content was logical. Review of the consolidated physician's orders [REDACTED]. Observation of Resident #1 on 11/30/10 at 10:00 a.m. revealed she was lying in bed resting. Interview with Resident #1 at the time of the observation on 11/30/10 at 10:00 a.m. revealed CNA A was "not the most gentle person." Resident #1 stated CNA A was rough with her while providing care. The resident stated she thought CNA A was immature, because she did not like to "fool with" Resident #1. The resident stated CNA A did not like her and talked down to her. According to Resident #1, CNA A "popped her." The resident stated she told her family member about the mistreatment, but could not recall when the mistreatment occurred. Resident #1 stated CNA A was not permitted to provide care to her anymore, and she was relieved. During the facility's Entrance Conference on 11/30/10 at 8:40 a.m. with the Administrator the surveyor requested for review the facility's current A/N/M policy and procedure, a copy of the Provider Investigation Report for Resident #1 and a resident roster identifying all interviewable residents. The Administrator stated during the Entrance Conference she was responsible for monitoring the facility's A/N/M prevention program. The Administrator revealed Resident #1 made an allegation of abuse on 10/22/10 (Friday). The Administrator stated Resident #1's family member was a disgruntled employee who no longer worked at the facility. The Administrator stated the family member arrived at the facility on the evening of 10/22/10 demanding to look at the resident's "entire body" from head to toe. LVN C accompanied the family member and an assessment of Resident #1's body was performed. LVN C's shift ended shortly after the assessment, and LVN D arrived at the facility. At 6:45 p.m., LVN D was summoned to Resident #1's room by the resident's family member. At that time, Resident #1 told LVN D CNA A had mistreated her. The Administrator stated LVN D immediately notified her and the DON. LVN D obtained a statement from Resident #1 at that time. The Administrator revealed she and the DON arrived at the facility on 10/22/10, after being notified of the allegation, to initiate an investigation. The Administrator revealed there was "history" between Resident #1's family member and CNA A. The Administrator stated CNA A had been employed at the facility for six months, and there had been no complaints filed against CNA A by residents or family members. The Administrator stated Resident #1 was interviewable and had never made allegations of abuse. The Administrator stated, it was decided after interviewing the resident, the resident's family member "put ____ (Resident #1) up to it" in an effort to get CNA A in trouble. The Administrator stated she, the DON, LVN D and the Wound Care Nurse interviewed Resident #1 on separate occasions, and the resident denied being mistreated. When asked if other residents were interviewed, as part of the investigation, the Administrator answered in the affirmative. The surveyor requested to review all documentation of the facility's investigation pertaining to Resident #1. During the interview with the Administrator on 11/30/10 at 8:40 a.m., the surveyor asked why the allegation of abuse was not reported to the State agency until 10/25/10 (three days after the allegation of abuse was made), per the DADS Investigation Intake Form. The Administrator stated when she contacted her corporate office, she was told to wait until Monday to make the report to DADS. According to the Administrator, the corporate representative told her reporting immediately did not include the days of the weekend. The Administrator stated the policy of the facility's corporate office was to collect witness statements and fax the investigation and witness statements to the corporate office. Determination on whether to report allegations was made by the facility's corporate office. Review of the Provider Investigation Report dated 10/29/10 revealed on 10/22/10 at 6:45 p.m., Resident #1 alleged CNA A abused her. The report reflected Resident #1 was capable of making informed decisions. The report further reflected a skin assessment was completed on 10/22/10 and a yellow, green bruise was noted on the resident's and two yellow, green bruises were observed on the resident's abdomen. The report reflected after multiple interviews with residents, staff and Resident #1, mistreatment by CNA A was denied. "____ (Resident #1) on initial interview following visit from ____ (resident's family member) had verbalized negative interaction. Resident was re-interviewed by different investigators and denied knowing or being hurt/mistreated by ____ (CNA A). No bodily injuries were noted on assessment by licensed staff." The Provider Investigation Report reflected CNA A was re-assigned and would no longer be providing care to Resident #1. It was concluded the bruises observed on Resident #1's body were a result of the sit-to-stand lift. The Administrator signed and dated the report 10/29/10. Review of an Incident Report dated 10/22/10 and signed by the Administrator, DON and LVN D revealed Resident #1 reported she was mistreated by CNA A. The Incident Report reflected the resident named CNA A as the alleged perpetrator. The Investigation of the Incident/Accident Report, attached to the Incident Report, signed by LVN D and dated 10/22/10, reflected the resident was observed to have two bruises on her abdomen and one bruise on her right knee, which were yellow, green in color. There were no measurements of the bruises included on the report. The report further reflected the bruises were suspected to be caused by the sit-to-stand lift. CNA A was sent home following the allegation made by Resident #1. The report reflected, "Statements were received from coworkers, upon 2nd & 3rd investigation Res (Resident #1) was unable to verbalize abuse, stating nobody has ever hurt her." A Concern/Complaint Investigation report, attached to the Provider Investigation Report, dated 10/22/10 and signed by the DON reflected, "____ (Resident #1) reported to her nurse mistreatment by her aide (CNA A) at approx. 1845 (6:45 p.m.) on Fri (Friday), 10/22/10. Assessment was done after interview with ____ (Resident #1) and no marks, red areas, or bruising (fresh) was noted. Yellow-green bruises on knee (right) were noted. Resident unable to tell nurse how bruise was acquired, or when she received it. She was asked if (CNA A) or anyone else had hurt her, and she denied knowing ____ (CNA A) or had been hurt today or any other time. She did state she was afraid but was unable to tell me what she was afraid of. She kept repeating, 'I'm so scared.' When asked if there was someone she was afraid of she answered, 'I'm scared ____ (Resident #1's family member) will say something.' ____ (the previous DON) asked about what, and she replied, 'the policy.' ____ (the previous DON) asked what policy? I'm confused. She (Resident #1) replied, 'So am I.' " The recommendation