Every finding on record at Ridgmar Medical Lodge

Based on interview and record review, the facility failed to complete a thorough and accurate discharge summary for one of two residents (Resident #1) reviewed for discharge process. -The facility failed to initiate a formal discharge with appropriate documentation when Resident #1 went on therapeutic leave without medications or personal belongings from 06/14/26-06/24/26, which extended beyond Medicaid's bed-hold limit of 3 days. Resident #1 was readmitted to the facility on [DATE] after a hospital stay. This failure could place residents at risk of not receiving ongoing person-centered care, which could lead to worsening conditions or serious harm.Findings included:Record review of Resident #1's Discharge MDS Assessment, dated 06/14/26, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and discharged on 06/14/26. The MDS Assessment under Section C-Cognitive Patterns reflected Resident #1's BIMS score was not documented. The MDS Assessment under Section E-Behavior reflected Resident #1 did not hallucinate or have delusions. The MDS Assessment under Section GG-Functional Abilities reflected Resident #1 required setup assistance with most ADLs. Resident #1 used a motorized wheelchair and was independent with mobility. The MDS Assessment under Section I-Active Diagnoses reflected Resident #1's active diagnoses included: chronic atrial fibrillation (heart disorder that causes a rapid and irregular heartbeat), chronic respiratory failure, morbid obesity (body mass index of 40 or higher), diabetes mellitus (the body's inability to regulate blood sugar levels), unspecified dementia (brain disorder that causes loss of memory and thinking), schizophrenia (mental health condition characterized by delusions), and bipolar disorder (mental health condition that causes extreme shifts in mood). Record review of Resident #1's NT/ST MDS Assessment, dated 06/24/26, reflected the resident readmitted to the facility from a short-term general hospital on [DATE] Record review of Resident #1's EHR, under assessments reflected the resident had a BIMS score of 15 which indicated her cognition was intact. Record review of Resident #1's care plan, revised 05/28/26, reflected the resident was able to sign herself out on therapeutic pass. Interventions included: educating the resident on safety precautions while out on pass. The care plan also reflected that Resident #1 frequently left the facility in her electric wheelchair with a history of buying things for other residents with her money when she went out. The resident notified staff when she was leaving. Interventions included: administering medications as ordered and monitoring and documenting effectiveness, anticipating and meeting the resident's needs, providing opportunity for positive interactions, encouraging the resident to allow the facility to purchase needed or wanted items for other residents, and explaining and reinforcing to the resident why behavior was inappropriate. Record review of Resident #1's progress notes, dated 06/14/26 at 8:43 p.m. by RN B, reflected the following: [Resident #1] left the facility with family without signing out. [Resident #1] sitting in W/C awake and alert, no distress or discomfort noted no complain [sic] of pain, [Resident #1] alert and oriented to time and place and self, skin clear no excoriation noted BLE edema nnoted [sic]. Record review of Resident #1's progress notes, dated 06/14/26 at 8:45 p.m. by RN B, reflected the following: [Resident #1] is not back on facility yet, [RN B] called [Resident #1] several time [sic] but no answer, unable to get family on the phone, no phone number listed. Record review of Resident #1's progress notes, dated 06/14/26 at 8:48 p.m. by RN B, reflected the following: [Resident #1] still OOP, [Resident #1] did not returned [sic] call, [RN B] also called [Resident #1] and friends listed on face sheet, no answer, [RN B] also called [local hospitals], [Resident #1] did not sign self into those facility [sic]. DON notify about [Resident #1] status. Record review of Resident #1's progress notes, dated 06/15/26 at 8:15 a.m. by MA C, reflected the following: [Resident #1] oop. Record review of Resident #1's progress notes, dated 06/17/26 at 7:25 a.m. by MA C, reflected the following: [Resident #1] oop. Record review of Resident #1's progress notes, dated 06/24/26 at 9:33 p.m. by LVN D, reflected the following: [Resident #1] arrived via [transportation company] at [3:30 p.m.] in her electric wheelchair from [local hospital] with diagnosis of CHF exacerbation. Upon arrival, vital signs were within normal limits. [Resident #1] was AAO X4 (fully awake and aware or person, place, time, and situation). Skin assessment completed with no skin issues noted. Record review of Resident #1's EHR reflected there was no AMA document or discharge summary completed with details of the resident's recapitulation of stay, current health status, or post-discharge plan. In an interview on 07/23/26 at 2:00 p.m., Resident #1 stated she left the facility last month because she was upset about the facility not helping her get a housing voucher for her own place. Resident #1 stated she chose to leave because she no longer wanted to be at the nursing facility. Resident #1 stated that she left the facility with a family member and did not tell the facility her plans because she was unsure about what she was going to do; however, she ended up getting on a train and going to [NAME], TX. Resident #1 stated she did not take any of her medications or belongings and was homeless in the community for approximately one week before she started swelling with fluid and had to be admitted to the hospital. Resident #1 stated she was able to return to the nursing facility after being discharged from the hospital. In an interview on 07/23/26 at 2:24 p.m. with the Administrator and DON, the DON stated Resident #1 left the facility with family in her electric wheelchair. The DON stated Resident #1's family was recently released from jail and was trying to convince the resident to be on the street with him. The Administrator stated Resident #1 was her own RP and was competent enough to make the decision to leave the facility, and they could not force her to stay. The DON stated when a resident left the faciity on therapeutic leave the protocol was for the resident to sign out with medication and provide information for destination and length of time away. The DON stated Resident #1 left the facility without her medication and was at risk due to co-morbidities. The DON stated she notified the MD and he suggested discharging the resident AMA. There was no documented evidence of this notification provided. The DON stated she contacted the local police department to alert them to be in the lookout and called Resident #1's friends and the local hospitals checking for her with no updates initially. The DON stated the facility was later informed that Resident #1 was somewhere in another city and after about a week they found that the resident was in the hospital. The DON stated she had a good rapport with Resident #1 and she wanted the resident to know that she could always return to the nursing facility, and she never thought to start the discharge process. The Administrator stated the facility's discharge policy did not specify at what point an AMA discharge should be initiated. In an interview on 07/23/26 at 3:42 p.m., MA A stated she worked at the facility for about 3 months. MA A stated she worked with Resident #1 and described the resident as independent with most care needs and often out on pass. MA A stated she did not work on the day Resident #1 left the facility, but she was informed during a standup meeting that the resident was missing. MA A stated Resident #1 was away from the facility for about a week, and she had never been away that long. MA A stated she administered Resident #1 her medications and they remained in the mediation cart while the resident was away from the facility. In an interview on 07/23/26 at 4:10 p.m., the MD stated Resident #1 left the facility approximately 5-6 times, but she always returned. The MD stated Resident #1 was competent and had the right to leave the facility if she wanted to. However, he stated from a clinical standpoint, it was dangerous for Resident #1 to be in the community without her medication due to her co-morbidities. The MD stated an AMA discharge should have been completed to provide documentation in the clinical records of the risks involved with the resident leaving and limit the facility's liability. Record review of the facility's policy titled Discharging a Resident Without a Physician's Approval, revised 01/21/24, reflected in part the following: Policy Statement:A physician's order should be obtained for all discharges, unless a resident or representative is discharging himself or herself against medical advice. Policy Interpretation and Implementation:Should a resident, or his or her representative (sponsor), request an immediate discharge, the resident's Attending Physician, Administrator and Director of Nurses will be notified.The order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record in a timely manner after the discharge.If the resident or representative (sponsor) insists upon being discharged without the approval of the Attending Physician, the resident and/or representative (sponsor) must sign a Discharge AMA Release of Responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting. The facility failed to report injuries of unknown source to HHSC when Resident #1 went to the hospital on [DATE] and was found to have multiple fractures, which included her right 4th, 5th and 6th ribs, her right humeral head (the rounded end of the upper arm bone that forms the ball of the shoulder joint), her right glenoid/scapula, and both of her coracoids (a small hook-like structure on the lateral edge of the scapula). This failure could place residents at risk of not having injuries of unknown origins reported.Findings included: Record review of Resident #1's Discharge MDS Assessment, dated 04/03/26, reflected a [AGE] year-old female, who was admitted to the facility on [DATE] and discharged on 04/03/26 to the hospital. There was not a BIMS calculated for her. Her functional abilities for chair/bed-to-chair transfer and sit-to-stand transfers required the helper to do all of the effort to complete the activity or required two or more helpers to complete the activity as the resident was dependent on staff. She had active diagnoses of age-related osteoporosis (a condition characterized by weakened bones due to the natural aging process, leading to an increased risk of fractures and breaks) and muscle wasting and atrophy (the loss or thinning of muscle tissue, leading to decreased muscle mass and strength). Her MDS indicated she did not have any falls since admission/entry or reentry or the prior assessment. Record review of Resident #1's electronic health record which included her progress notes, orders, care plan, and assessments reflected no mention of a fall or any incident during her stay from 01/22/26 to 04/03/26. Record review of Resident #1's hospital records, dated 04/03/26 to 04/10/26, reflected the following: Hospital Course/Summary: .Patient and [Resident #1's POA] report a history of multiple falls approximately 10 months ago.She has been bedbound since early January, requiring Hoyer lift and maximal assistance for mobility. Patient denies any falls in the past 4 months.In the ED, imaging revealed multiple right-sided rib fractures.#1 multiple traumatic fractures: -Right ribs (4-6), right humeral head, right glenoid/scapula, bilateral coracoid. Further review reflected: Clinical Notes.Intervention: .Pt was not very clear on how she received all the fractures other than to say, 'I the [sic] sling they had on the Hoyer lift, split and fell out of it. I hit my whole body on the bed and floor.' When SW called the facility to obtain an explanation on what they knew about the pts [sic] having multiple fracture [sic], [the Marketing Director] [the Marketing Director's phone number], in admission states, 'I checked with my director of nursing and no one knows anything about the pt falling or having any issues.' Record review of the facility's incidents/accidents log from January 2026 to April 2026 did not reflect any incidents that involved a Hoyer lift transfer and Resident #1. An attempted phone interview on 04/14/26 at 9:59 AM was made to Resident #1, but she did not answer and did not call back prior to exit. A voicemail message was left for her to call the state surveyor back. In a phone interview on 04/14/26 at 9:28 AM, a Concerned Party revealed Resident #1 was sent to the hospital where it was found she had multiple fractures. The Concerned Party said she talked to the facility's Marketing Director to see if anything happened at the facility that would have caused the injuries she sustained. The Concerned Party said she was told by the Marketing Director the facility was not aware of anything that could have caused Resident #1's injuries. In a phone interview on 04/14/26 at 8:43 AM, Resident #1's POA said Resident #1 went to the hospital on [DATE], and the hospital found that the resident had fractured shoulder blades and ribs. Resident #1's POA said Resident #1 was bedbound, and she was never made aware of any incidents that would have caused these injuries to the resident. Resident #1's POA said Resident #1 told her and the hospital that she fell during a Hoyer lift transfer at the facility, but she did not have any other details. In a phone interview on 04/14/26 at 12:08 PM, LVN A said she cared for Resident #1 mostly at night. LVN A said she never heard of Resident #1 having a fall from a Hoyer lift, never saw her have any unexplained bruising, and never noticed her being in any pain. LVN A said Resident #1 never presented as if she had fractures of any kind. LVN A said she never heard that Resident #1 had any falls or incidents that would cause any fractures or injuries while at the facility. In an interview on 04/14/26 at 12:13 PM, RN B said she cared for Resident #1 often. RN B said Resident #1 never presented with any pain, did not have any falls while at the facility, and never presented as if she had any fractures. RN B said she had never heard of Resident #1 falling from a Hoyer lift transfer. RN B said Resident #1 was on a blood thinner medication but did not have any unexplained bruising to her body. In a phone interview on 04/14/26 at 12:30 PM, RN D said she cared for Resident #1 for a few days but never noticed any bruising on her body. RN D said Resident #1 never complained of pain and had no falls that she was aware of. RN D said she never heard that Resident #1 fell from a Hoyer lift transfer.In an interview on 04/14/26 at 12:32 PM, CNA I said she cared for Resident #1. CNA I said she never noticed any bruising to Resident #1's body, she never complained of pain, and she never had a fall or a fall from a Hoyer lift that she knew of. CNA I said Resident #1 never presented like she had any fractures. In a phone interview on 04/14/26 at 12:36 PM, CNA F said she cared for Resident #1. CNA F said she never noticed any bruising on Resident #1's body, Resident #1 never complained of pain, and as far as she knew Resident #1 never had a fall or fell during a Hoyer lift transfer. CNA F said she never noticed Resident #1 acting as if she had fractures to her body. In an interview on 04/14/26 at 12:46 PM, the WCN said she saw Resident #1 to treat her wounds. The WCN said she never saw Resident #1 have any unexplained bruising, she never complained of pain, she never had a fall that she was aware of, and never had fall from a Hoyer lift. The WCN said Resident #1 never presented as if she had fractures to her body. In an interview on 04/14/26 at 12:50 PM, the ADON said Resident #1 never complained of pain, did not present as if she had any fractures, never had any falls or falls from a Hoyer lift transfer that she was aware of. In an interview on 04/14/26 at 12:57 PM, the Marketing Director said she had only been working at the facility for 7 days. The Marketing Director said she did speak with the case worker from the hospital who informed her Resident #1 had a broken clavicle, scapula, finger, collar bone, and bruising when she was admitted to the hospital on [DATE]. The Marketing Director said she told the case worker from the hospital she would look into what happened because she was not aware of any incidents at the facility that would cause those injuries to Resident #1. The Marketing Director said she talked to the DON about what she was told and explained to the hospital they were not aware of how Resident #1 could have become injured since nothing happened at the facility. In an interview on 04/14/26 at 1:21 PM, Central Supply said she was informed Hoyer lift slings needed to be replaced every 6 months. Central Supply said she had replaced all Hoyer lift slings in the facility as of February 2026 because they were 6 months old. Central Supply said she had not been informed of any Hoyer lift sling that was broken, frayed, or in disrepair that needed to be replaced since February 2026. Observation on 04/14/26 at 1:23 PM, with Central Supply and the DON in the laundry area of the facility, the Hoyer lift slings that were recently laundered were in good condition and did not show any signs of wear or tear. In a phone interview on 04/15/26 at 8:57 AM, LVN J said Resident #1 never complained of any pain, never had any falls, never presented as if she had any fractures, and never had a fall from a Hoyer lift transfer that she was aware of. In a phone interview on 04/15/26 at 9:02 AM, RN E said she cared for Resident #1. RN E said Resident #1 never complained of pain, never presented as if she had fractures, and never had any falls while at the facility. RN E said she was never made aware Resident #1 had a fall from a Hoyer lift transfer. In a phone interview on 04/15/26 at 9:08 AM, Resident #1's Dialysis Clinic's Supervisor said Resident #1 went to the dialysis clinic 3 times per week. Resident #1's Dialysis Clinic Supervisor said Resident #1 never had any falls at the clinic. Resident #1's Dialysis Clinic's Supervisor said the clinic used the Hoyer lift sling that was from the facility. Resident #1's Dialysis Clinic's Supervisor said she never noticed the sling in disrepair or ripped or appeared as if it should not be used. Resident #1's Dialysis Clinic's Supervisor said Resident #1 never presented as if she had fractures, never complained of pain, and never had any unexplained bruises to her body. In a phone interview on 04/15/26 at 9:27 AM, LVN C said she cared for Resident #1 on the weekends. LVN C said she never noticed any bruising to Resident #1's body, Resident #1 never complained of pain, and never presented as if she had fractures. LVN C said she was never made aware Resident #1 had a fall or a fall from a Hoyer lift transfer while at the facility. In a phone interview on 04/15/26 at 9:29 AM, CNA G said he cared for Resident #1. CNA G said he never noticed any bruising to Resident #1, she never complained of pain, and she never presented like she had fractures. CNA G said he was not aware of any falls that Resident #1 had or that she fell during a Hoyer lift transfer. In a phone interview on 04/10/26 at 10:10 AM, the NP said as far as she was aware, Resident #1 only had one complaint of generalized left shoulder pain so a lidocaine patch was ordered and administered for her. The NP said a chest x-ray was also completed on 02/17/26 which did not show any fractures. The NP said no falls were ever reported for Resident #1 or any incidents that would have caused the fractures identified at the hospital. In an interview on 04/15/26 at 10:21 AM, the PTA said she saw Resident #1 three times per week for therapy services. The PTA said she never saw Resident #1 complaining of pain, never knew her to have had a fall, and never heard she had a fall during a Hoyer lift transfer. The PTA said Resident #1 had arthritis in her shoulders and would have generalized pain in that area, but it did not seem to affect the resident. In an interview on 04/15/26 at 10:38 AM, the Van Driver said he took Resident #1 to her dialysis clinic 3 times per week and never saw her in any pain. The Van Driver said he never heard about Resident #1 having a fall, never saw any bruising on the resident's body, and the Hoyer lift sling she sat on appeared in good condition each time he saw it. In a phone interview on 04/15/26 at 10:45 AM, CNA H said he cared for Resident #1. CNA H said he never saw any bruises on Resident #1, she never complained of pain, and never presented like she had any fractures. CNA H said as far as he knew, Resident #1 never had a fall and never fell from a Hoyer lift transfer. In a phone interview on 04/15/26 at 11:54 AM, the Physician said when he saw Resident #1 she never complained of any pain and had no reported falls or incidents that would have caused the identified fractures by the hospital. The Physician said he did not believe the injuries occurred at the facility and thought something could have happened during her transport from the facility to the hospital to cause the injuries. In an interview on 04/15/26 at 1:55 PM, the Administrator said he would be the one responsible for reporting this situation to HHSC. The Administrator said he did not report Resident #1's fractures that were found at the hospital when she went on 04/03/26. The Administrator said the hospital initially reached out to the Marketing Director, but he was not sure what day that was. The Administrator said he was not aware of any incident that could have occurred at the facility to cause Resident #1 to have these injuries that were reported (the fractures). The Administrator said since the facility was not aware of how the injuries occurred, they would be considered injuries of unknown origin. The Administrator said after the facility was informed of the injuries they did start talking to staff who cared for Resident #1, completed in-services with staff, and did not find that anything occurred during Resident #1's stay that would cause these injuries. The Administrator said he was confused on whether or not he should report the situation with Resident #1 because he was not sure when the injuries happened or how they could have happened. The Administrator said if injuries of unknown origin were not reported to HHSC it could hurt the individual involved. The Administrator said this should have been reported to HHSC within 2 hours because it was the regulation and to keep residents safe. In an interview on 04/15/26 at 2:32 PM, the DON said Resident #1 went to the hospital on Friday, 04/03/26. The DON said she called Resident #1's POA on either Saturday or Sunday (she was not sure which day it was) after she went to the hospital to check on Resident #1. The DON said Resident #1's POA mentioned to her that she had rib fractures but they were not sure how it happened. The DON said she began to interview staff who cared for Resident #1 and in-serviced them as well. The DON said no staff were aware of any incident that could have caused Resident #1's injuries. The DON said she believed the Marketing Director spoke with the case manager from the hospital the following Monday or Tuesday of the next week where it was confirmed the resident had multiple fractures. The DON said the Administrator was the one responsible for reporting this to HHSC and was aware of what the family member told her over the weekend. Record review of the facility's Abuse Investigation and Reporting policy, revised November 2024, reflected: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management.Reporting: 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury.

Based on observations, interviews, 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 ensure the stand-by freezer food items were dated, labeled, and secured. 2. The facility failed to ensure the stand-by refrigerator food items were dated with the date opened or expiration date, labeled with the contents in the clear package or box, and secured and tightly sealed according to the facility policy. 3. The grease in the deep fryer was dirty with blackened grease and food particles around edges. These failures could place residents at risk for foodborne illness and foodborne intoxication.Findings included: Observation on 02/18/2026 at 9:30 AM of the walk-in refrigerator revealed:- Open carton of 30 eggs located on bottom shelf not in dated box.- 1 cup of labeled prune juice on shelf with no date that had turned clear. Cup was leaking.- 2 bags of chicken that were not labeled and dated.- Box of lemons not labeled and dated. 1 rotten lemon in box. Observation of 02/18/2026 at 9:40 AM the walk-in freezer revealed:- 6 bags of frozen mini pizzas not labeled and dated. In an interview with the RD revealed that the DM was out on leave and the RD had been making visits to the facility to monitor the dietary department. The RD will follow up with the dietary staff to make sure food is properly labeled and dated. Observation on 02/18/2026 at 9:50 AM, revealed the deep fryer had a thick build-up of brown and black grease with food particles around the inside edges. There was grease that had run off the edges and down the sides and front of the deep fryer. The deep fryer was stationed beside the stove in the kitchen. In an interview on 02/18/2026 at 9:55 AM, the Dietary cook C acknowledged the deep fryer had old grease in it. Dietary cook C revealed the deep fryer should be cleaned once a week. The dietary cook stated that the kitchen had been short staffed, and the grease had not been changed for two weeks. Dietary staff is responsible for cleaning the deep fryer every week. In an interview on 02/18/2026 at 10:00 AM, with RD revealed she acknowledged the deep fryer needed to be cleaned. The RD stated that the dietary aide is assigned to clean the deep fryer. [NAME] D is working as the dietary aide today in the kitchen and will clean the fryer today. The RD will monitor this when she makes her visits to the facility. The RD revealed she has not been the RD at the facility very long. The DM has been out on leave and had been making more visits to the facility to monitor the dietary department. In an interview on 02/20/2026 at 4:00 PM with Administrator revealed that he was not aware of the deep fryer was not being cleaned by dietary staff. The Administrator's expectation is that there will be a cleaning schedule implemented, and the deep fryer will be cleaned on a regular basis. Administrator's expectations are for all food to be labeled and dated in the walk-in refrigerator and freezer. Review of the facility's Food Storage policy, revised 06/01/19, reflected, To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Policy Interpretation and Implementation.- Date, label and tightly seal all refrigerated foods using clean, non-absorbent, covered containers that are approved for food storage. - Store all frozen meats, poultry, seafood, fruits and vegetables, and some dairy products, such as ice cream, in the freezer at a temperature that maintains the frozen state of the foods. Policy did not reveal dating, labeling, sealing all freezer foods. Review of the facility's General Kitchen Sanitation, dated 10/01/18, reflected: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes to minimize the risk of infection and food borne illness. Clean food-contact surfaces of grills, griddles and similar cooking devices and the cavities and door seals of microwave ovens at least once a day; except for hot oil cooking equipment and hot oil filtering systems Record review of facility policy Cleaning Services dated 10/01/18, reflected: The facility will maintain a cleaning schedule prepared by the Nutrition & Foodservice Manager and followed by employees as assigned in order to ensure that the kitchen is clean and free of hazards. The Nutrition & Foodservice Manager will develop a cleaning schedule for daily, weekly and monthly cleaning. Sample forms for daily cleaning, weekly cleaning and monthly cleaning follow this policy. Record review of the U.S. FDA Food Code 2022 reflected: 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.17 . Commercial processed food: Open and hold cold . B . 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3 . Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above. (2) At 5 C (41 F) or less .4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, cleanable, properly designed, constructed, and used:47. Proper installation and location of equipment in the food establishment are important factors to consider for ease of cleaning in preventing accumulating of debris and attractants for insects and rodents.

Based on observation and interview, the facility failed to dispose of garbage and refuse properly for 1 of 2 (Dumpster #1) dumpster sites. The facility failed to ensure the doors were completely shut on Dumpster #1. This failure could place residents at risk of an unsanitary environment and could attract pests, rodents and other animals.Findings included: Observation on 02/18/2026 at 10:15 AM near the facility's dumpsters, revealed the lid was closed and one door was open on dumpster #1, exposing trash. Dumpster D the lid was closed and doors were closed. Interview on 02/18/2026 at 10:15 AM, the Dietary [NAME] D stated kitchen staff took out the trash from the kitchen. He stated the dumpster doors and lids were supposed to be closed, and the area should be clean. He stated if not, it could look bad, be unsanitary and could bring pests. Interview on 02/20/2026 at 4:00 PM, the Administrator stated staff were responsible for taking trash outside to the dumpsters. The Administrator stated his expectations are the dumpster doors should be closed all the way and trash should be picked up. With the doors being open, it would bring in rodents. Record review of the facility's Garbage Receptacles policy, revised 06/01/19, reflected: The facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk of food hazards. It shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insects and rodents with doors/lids kept closed and no waste outside of the receptacle.

Based on observation, interview and record review the facility failed to provide written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for 1 of 5 (Resident #23) residents reviewed for room changes.The facility failed to notify Resident #23's RP of room changes on 11/25/25. This failure could place residents at risk for decreased quality of life being in a new environment.Findings included:Record review of Resident #23's annual MDS assessment, dated 12/24/25, reflected Resident #23 was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses included neurological conditions (any disorder of the nervous system), cerebral palsy (a group of disorders that affect movement and muscle tone or posture), and seizure disorder or epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures). Resident #23's BIMS score was not completed due to the resident being rarely/never understood. Record review of Resident #23's progress notes dated 11/25/25 10:27 AM completed by LVN A revealed Resident adjusting to the room change, no changes in sleep or behavior.Observation and an attempted interview on 02/18/25 at 1:40 PM revealed Resident #23 was in his room lying in bed. An interview was attempted with Resident #23, but the resident did not respond. The resident did not exhibit any signs of distress.Interview on 02/20/26 at 10:52 AM, Resident #23's RP revealed she had visited Resident #23 in January 2026. RP stated she went to Resident #23's room, but the resident was not in the room. The RP stated she had to look around and had to ask staff where Resident #23 was moved too. The RP stated she was never notified via phone or received a notice that resident was moved to a different room. The RP stated when staff were asked why Resident #23 was moved, staff only stated it was due to safety concerns but no actual answer.Interview on 02/20/26 at 12:04 PM, LVN A revealed Resident #23 had been in her previous room for a while. She stated Resident #23 was moved closer to the nurses' station due to safety concerns, resident tends to have behaviors like messing with his g-tube or putting himself on the floor. LVN A stated she did not notify the family of Resident #23 room change, she stated it would had been the Social Worker's responsibility. Interview on 02/20/26 at 12:26 PM, the Social Worker revealed it was her and the ADON's responsibility to notify the family of resident's room change. She stated she could not recall or was not aware of Resident #23 room change. The Social Worker stated she had not contacted Resident #23's RP to notify them of any room change. She stated maybe the nursing staff contacted the RP when Resident #23 was moved. She stated family should be notified prior to a resident moving to another room and document that family was made aware. She stated family should be made aware so that when they visit, they know where the resident was located. Interview on 02/20/26 at 1:52 PM, ADON B revealed Resident #23's room change happened months ago. She stated she could not recall the exact month. ADON B stated the resident's family should be notified when a resident moved to another room and it was the responsibility of the Social Worker to notify family. She stated she was not sure if Resident #23's RP was notified of his room change. She stated family or RP should be notified so that family is okay with the room change. Interview on 02/20/26 at 2:46 PM, the DON revealed it was the responsibility of the Social Worker to notify family when a room change occurs. She stated Resident #23 was moved due to room temperature problems, and they wanted the resident closer to the nurses' station. The DON stated she was not sure if Resident #23's RP was made aware of the room change. She stated family should be notified because they had to give consent to the move. Interview on 02/20/26 at 4:20 PM, the Administrator revealed his expectations were for the resident, the resident's family/RP to be notified prior to a room change. Record review of facility Admissions - Room Assignments/Room Changes policy, revised March 2017, reflected the following: A resident will be admitted to the first available room that meets his/her medical needs. Room assignments are made without regard to race, color, creed, national origin, or payment source.9. Room changes are made for the following reasons: a. Change in level of care; b. Incompatibility with roommates; c. Resident or Resident Representative request; and d. Medicare eligibility (if applicable)10. All needs and requests for room changes will be handled by Social Services and/or the DON and supporting documentation will be maintained in the resident's medical record to include the reason for the room change.11. The resident or resident's representative when applicable, will receive notice to include the reason for the change before the resident's room or roommate in the facility is changed or a new admission by using the ROOM CHANGE/NOTIFICATION FORM AD-166. A note will be provided in the medical record when a notice has been given as to who was given the notice and the reason for the change in resident's room or roommate.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 25 residents (Resident #23) reviewed for quality of care.The facility failed to complete a swallow study referral for Resident #23 when it was requested during a care plan meeting on 01/29/26. This failure could place all residents at risk of not being provided adequate care and treatment.Findings included:Record review of Resident #23's quarterly MDS assessment, dated 12/24/25, reflected Resident #23 was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses included neurological conditions (any disorder of the nervous system), cerebral palsy (a group of disorders that affect movement and muscle tone or posture), and seizure disorder or epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures). Resident #23's BIMS score was not completed due to the resident being rarely/never understood. The MDS Section K - Swallowing/Nutritional Status indicated the resident's nutritional approach was a feeding tube. Record review of Resident #23's care plan, revised date 02/02/26 reflected, Focus: [Resident #23] has a swallowing problem r/t Cerebral Palsy. NPO, tube feeding status. Mild protein calorie malnutrition. Goal: The resident will maintain weight and nutritional balance through the review date. The resident will have clear lungs, no signs and symptoms of aspiration through the review date. Interventions: Diet to be followed as prescribed. NPO, Tube feeding status.Record review of Resident #23's progress notes dated 01/29/26 10:27 AM completed by Social Worker revealed A care plan meeting and PASRR meeting was held for [Resident #23] today with MDS Nurses, PASRR Habilitation and ILS Coordinators, DOR and SW in attendance as well as [Resident #23] guardian [name] via telephone. [Resident #23] remains in long term care under Medicaid coverage. [Guardian Name] provided an updated copy of [Resident #23] Guardianship papers. [Resident #23] will continue monthly Hab services and weekly ILS services as well as therapy services including PT, OT and ST. [Resident #23] was seen by Podiatry on 1/15/26. [Guardian Name] requested a new MBSS study on [Resident #23] through Speech Therapy services. She had no other concerns.Observation and an attempted interview on 02/18/26 at 1:40 PM revealed Resident #23 was in his room laying in bed. Resident #23 was not able to answer questions due to his condition. The resident did not appear to be in distress or discomfort.Interview on 02/20/26 at 10:52 AM, Resident #23's RP revealed a care plan meeting was held on 01/29/26 and requested for a swallowing study to be completed for Resident #23. RP stated she would like to know if Resident #23 was able to eat and if so maybe Resident #23's g-tube could be removed. RP stated she had not heard back from the facility and would like the swallow study to be completed. Interview on 02/20/26 at 12:04 PM, LVN A revealed she was the nurse assigned to Resident #23. She stated Resident #23 had a g-tube. LVN A stated she was not aware of any swallow study request. Interview on 02/20/26 at 12:18 PM, the DOR revealed Resident #23 was receiving PT and OT services. He stated he was not aware of any swallowing study being requested. The DOR stated he attended the care plan that was held for Resident #23 on 01/29/26. He stated he does not recall a swallowing study being requested during the care plan meeting. The DOR stated he reached out to Speech Therapist and confirmed that no request for a swallow study had been made. The DOR stated if a swallow study had been requested it would usually take about a week for the referral to be completed. Interview on 02/20/26 at 12:26 PM, the Social Worker revealed she attended Resident #23's care plan meeting that was held on 01/29/26. She stated a swallow study was requested by Resident #23's RP. She stated that since the DOR attended the meeting, she assumed the DOR would had followed up on the request. She stated each department attends the care plan meetings and was aware of what needed to be done. The Social worker stated each department was responsible for each service request. She stated request for services should be completed prior to the next care plan meeting and it was not acceptable if not done.Interview on 02/20/26 at 1:52 PM, ADON B revealed she does not attend care plan meetings unless asked too. She stated she was not aware of any swallow study request for Resident #23. She stated therapy attends care plan meeting and they would had been responsible for putting in a referral or if she was made aware she could had done the referral. ADON B stated a referral time frame would be completed within a week of request. She stated there was no potential risk to the resident; however, if family request a service it should be followed on and completed. Interview on 02/20/26 at 2:46 PM, the DON revealed she sometimes attends care plan meeting if needed but usually the MDS Coordinator attends. She stated she did not attend the care plan meeting for Resident #23 on 01/29/26. She stated she was not aware Resident #23's RP requested a swallow study. She stated usually the nurses would be notified of the request, they would put in a referral and provide it to therapy. The DON stated if a service was requested during a care plan meeting it would be the responsibility of the team to notify the department. She stated her expectation was for someone to notify the department of the request of service and to follow up on it. She stated there was no potential risk; however, it should had been completed or followed up on the request. Interview on 02/20/2026 at 3:32 PM, Speech Therapist revealed Resident #23 was not receiving speech therapy services. She stated she was not aware of any swallow study request for Resident #23. She stated usually the nursing staff would notify her, and a referral would be completed. Speech Therapist stated the DOR did not mention any swallow study request during a care plan meeting to her. Interview on 02/20/26 at 4:20 PM, the Administrator revealed when a family requested a swallow study his expectations were for the facility staff to follow up, notify the DOR and complete the referral. Record review of facility Resident rights policy, received October 4, 2022, reflected the following: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: z. perform services for the facility if he or she chooses, or refuse to perform services for the facilityRecord review of facility Speech Therapy policy, revised 2013, reflected the following: The purpose of this procedure is to identify, assess and treat speech and language problems including swallowing disorders.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1, who had a history of wandering for which he wore a WanderGuard device, was provided with adequate supervision to prevent him from exiting the building on 07/23/25. The resident was observed outside the facility by a staff member, and he was found on the sidewalk near a street sign outside the facility.The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 07/23/25 and ended on 07/24/25. The facility had corrected the noncompliance before the survey began.This failure placed residents at risk of harm and/or serious injury. Findings included:Record review of Resident #1's annual MDS assessment, dated 06/16/25, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's diagnoses included senile degeneration of brain (progressive deterioration of brain tissue and function), unspecified dementia (a condition where the specific type of dementia cannot be identified despite the presence of cognitive decline and memory loss), Type 2 diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle weakness (a condition where your muscles cannot work with the expected amount of force), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations). The MDS reflected Resident #1 had severe cognitive impairment with a BIMS score of 1. The MDS further reflected Resident #1 did not exhibit wandering behaviors. Record review of Resident #1's care plan, dated 06/24/25, reflected Focus: [Resident #1] is an elopement risk/wanderer r/t Impaired safety awareness. Risk for Wandering/Elopement Identified Wanderguard (bracelet detected near a sensor, the system triggers an alert) to right leg. Goal: The resident will not leave facility unattended. Interventions: Identify if there are triggers for wandering / eloping. Identify wandering / elopement de-escalation behaviors. One on one with resident. Wanderguard to right leg-check placement Q shift. Focus: [Resident #1] is an elopement risk/wanderer r/t Impaired safety awareness 7/23/25. Goal: The resident's safety will be maintained through the review date. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. WANDER Guard to right ankle and check placement Q shift. Record review of Resident #1's Elopement Risk Evaluation, dated 06/20/25, reflected Resident #1 was at risk for elopement. The evaluation indicated Resident #1 had a history of attempting to leave the facility without informing staff, resident verbally expressed the desire to go home, packed belongings to go home, stayed near an exit door, and resident had wandering behavior. Record review of Resident #1's progress notes dated 07/23/25 at 14:01 [2:01 PM] by LVN C reflected: Writer was in room with a resident when loud voices were heard in the hallway. Writer waked out and saw [CNA D] in the hallway. Writer asked [CNA D] what was wrong? [CNA D] stated [Resident #1] is outside [CNA D] and I went out the back door on 200 hall and observed resident sitting in his wheelchair on the sidewalk smiling and giggling. Resident chair was facing south. Resident was brought back in the building and a head-to-toe assessment was performed which revealed no injuries. Resident was not hot or sweaty, respirations were even and unlabored, temperature was normal and vs stable. DON notified of elopement as well as Dr [Name], NP [Name] and Resident RP [Name]. Record review of Resident #1's Incident Report, dated 07/23/25 at 07:10 AM, reflected Incident location: Outside Incident Description: Nursing Description: Writer was in room with a resident when loud voices were heard in the hallway. Writer waked out and saw [CNA D] in the hallway. Writer asked [CNA D] what was wrong? [CNA D] stated [Resident #1] is outside [CNA D] and I went out the back door on 200 hall and observed resident sitting in his wheelchair on the sidewalk smiling and giggling. Resident chair was facing south. Resident was brought back in the building and a head-to-toe assessment was performed which revealed no injuries. Resident was not hot or sweaty, respirations were even and unlabored, temperature was normal and vs stable. DON notified of elopement as well as Dr [Name], NP [Name] and Resident RP [Name]. Resident Description: I'm going to my wedding. Immediate Action Taken: Description: Resident brought inside facility, full head to toe assessment completed, resident started on 1 on 1 supervision, DON [Name] notified of elopement as well as Dr [Name], NP [Name] and Resident RP [Name]. Injury Type: No injuries observed at time of incident. Level of Pain: 0 Level of Consciousness: AlertMobility: Wheelchair bound Mental Status: Oriented Person; Oriented to SituationNotes: Resident is able to tell staff what he was doing. Predisposing Physiological Factors: Impaired Memory Predisposing Situation Factors: Wanderer Other Info: Resident was a hx of wandering around the facility, resident propels self in his wc and has a wander guard in place. Record review of the facility's Provider Investigation Report, completed by the Administrator on 07/31/25, reflected the following: Incident date: 07/23/2025, Time of Incident: 07:45 AMWhile a CNA was walking down 200 Hall she saw the resident outside on the sidewalk. She got the nurse and they brought the resident back in the facility. Assessment Date 07/23/25; Time: 7:10 AM; Resident was brought back inside the facility, and completed a full head to toe assessment was completed and skin was intact. Investigation Summary: To the best of my knowledge here is the sequence of events on 7/23 for the allegation of the incident. 7:00 am resident was seen at the end of 300 hall 7:05 am resident was seen outside at the end of 200 hall still on facility property and staff went to get resident from outside. It has been learned by the resident that he was able to go out the end of 300 hall exit door and wheel himself toward the new apartment on the sidewalk until he was seen by CNA on 200 Hall. The employees on the 300 Hall stated that they never heard a door alarm sound at the end of 300 hall. The resident has had head to toe done and no injuries noted. Things facility has done: Resident placed on 1:1Started in servicing employees on elopement and wondering All residents are being wander guard assessment completedOrdered additional door alarmsDoing door checks every shift until [Door Alarm company] comes look at the doors.Spoke to family about looking for alternate placement for resident Started Elopement Drills. Provider Action Taken Post-Investigation: Resident remained on 1:1 supervision until he discharged from the facility on 7/24/25. [Door Alarm company] checked all exit door to ensure they are in working as order and alarming as intended. In-services and drills for staff training will continued. Interview on 08/13/25 at 12:25 PM, with CNA D revealed she was not the CNA assigned to Resident #1; however, at around 7:00 AM she was rounding up residents for breakfast. She stated she was coming out of 300 Hall and entering the 200 Hall when she observed Resident #1 going down the 300 Hall towards the dining area. She stated she could not recall the exact time she last observed Resident #1, but she observed Resident #1 in the dining area for breakfast. CNA D stated within 5 minutes she was in the middle of 200 Hall, outside room [ROOM NUMBER] when she looked outside the window located at the end of the hall, and she saw Resident #1 outside on the sidewalk. She stated Resident #1 was on the sidewalk on facility grounds near the street pole sign. She stated she called for help and LVN C assisted her with bringing Resident #1 immediately inside. CNA D stated when they went outside Resident #1 was laughing the entire time. She stated they asked Resident #1 how he got out, and Resident #1 stated I got out of that door. CNA D stated Resident #1 pointed at the 300 Hall exit door, which also had a ramp. She stated she did not hear the door alarm. She stated Resident #1 was fast in his wheelchair. She stated Resident #1 had a history of wandering the halls but was not sure about exit seeking. CNA D stated Resident #1 had a WanderGuard due to the resident wandering the halls, always packing his belongings, and saying he wanted to go home. She stated Resident #1 would always say I am making a plan to get out of here. She stated Resident #1 was assessed, and he had no injuries. She stated Resident #1 was wearing the WanderGuard when he eloped. CNA D stated she was in-serviced on abuse and neglect, elopement/code pink, and what to do when a resident eloped. She stated the staff had also completed elopement drills, extra alarms had been added to the doors, and elopement binders could be located at the nurse's station. Interview on 08/13/25 at 1:05 PM, with LVN C revealed she was the nurse assigned to Resident #1 on 07/23/25. She stated she could not recall the last time she observed Resident #1; however, according to staff the resident was last observed by the dining room located down the 300 Hall. She stated she was doing her morning rounds; other staff were rounding residents for breakfast. She stated she was in a resident room in the 200 Hall when she heard yelling coming out of the hallway He is outside. She stated CNA D and herself went outside and got Resident #1. LVN C stated Resident #1 was found on the sidewalk of the back of the 200 Hall. LVN C stated Resident #1 was laughing the entire time. She stated one of the CNAs took Resident #1 back to the dining room and Resident #1 pointed at the exit door at the end of the 300 Hall when asked which door he exited. LVN C stated no alarms were heard. She stated Resident #1 was assessed and no injuries were noted, and he was placed on 1:1 for elopement behaviors. She stated Resident #1 had a WanderGuard on and the WanderGuard was working because it was flashing red when she assessed him. She stated prior to Resident #1's elopement, the resident had a history of wandering the halls. LVN C stated she personally never observed Resident #1 exit seek but the resident would always say he wanted to leave. She stated Resident #1 would always pack his belongings, hold on to them, go down the 200 Hall and sit there looking outside. LVN C stated all facility staff were in-serviced on abuse and neglect, elopement/code pink, and what to do when a resident eloped. She stated the staff had also completed elopement drills, extra alarms were added to the doors, elopement assessments had been reviewed and updated. She stated the elopement binders were also reviewed and could be located at the nurse's station. LVN C stated she conducted a census head count before the start of her shift. Interview on 08/13/25 at 1:26 PM, with Resident #1's POA revealed she was made aware of Resident #1 exiting the facility. She stated Resident #1 had a WanderGuard on and when she was told by the Administrator that the resident exited the facility the Administrator told her that the WanderGuard sometimes don't work. Resident #1's POA stated she did not know how Resident #1 was able to exit the facility. Resident #1's POA stated Resident #1 was discharged home and then admitted to a secure unit at another facility. Interview on 08/13/25 at 1:36 PM, with MA E revealed she was working when Resident #1 eloped from the facility. She stated it was between 7:00 AM - 7:30 AM when she observed Resident #1 ambulating through the dining room. She stated Resident #1 did not stay in the dining room, he continued to ambulate in his wheelchair to the 300 Hall. She stated she could not recall what time Resident #1 was found. MA E stated no alarms were heard. She stated when she asked Resident #1 which door he exited Resident #1 stated right over there and pointed at the door located at the end of 300 Hall. She stated Resident #1 was known for wandering the halls but never exit seeking. She stated everyday Resident #1 would mention he wanted to go home and would pack his items. MA E stated she was in-serviced on abuse, neglect, and elopement. She stated extra alarms were added on the exit doors, staff must check exit doors on every shift, elopement assessments were completed, and the elopement book was updated. She stated staff were also in-serviced on checking WanderGuards and ensuring they were working properly. She stated if the WanderGuards were not flashing they were no good. Interview on 08/13/25 at 2:33 PM, with the Maintenance Director revealed he was notified of the elopement after Resident #1 was found. He stated he could not recall the exact time. He stated he checked all the facility exit doors to ensure the alarms were working properly. He stated the 200 Hall and 300 Hall exit doors were not equipped with the WanderGuard alarm. The Maintenance Director stated when he checked the 300 Hall exit door the alarm was not working properly. He stated the PCO of the alarm was low and only buzzing. The Maintenance Director stated he had an extra PCO in his office and he changed it. He stated the PCO was like the battery of the alarm. He stated he completed door safety and alarm checks monthly and the last time he checked the facility doors was on 07/02/25. The Maintenance Director stated they had [Door Alarm company] come out and check on all the doors to ensure the alarms were working properly. He stated after the elopement the facility added extra alarms on the 200 and 300 Hall exit doors. He stated the entrance door and the exit door on 400 Hall had the WanderGuard alarms. He stated the door codes were also changed. The Maintenance Director stated all doors were checked throughout the shift and must be documented/signed off on Shift Exit Door Check. He stated after all the staff were in-serviced on elopement/code pink, he had completed elopement drills with all three shifts. Interview on 08/13/25 at 3:06 PM, with the DON revealed she received a call in the morning regarding Resident #1. She stated the nurse informed her that a staff member was on the 200 Hall and observed Resident #1 through the window sitting outside the 200 Hall. She stated Resident #1 exited through the 300 Hall door and stated he was going to a wedding. The DON stated according to the staff Resident #1 was last seen in the dining room for breakfast. She stated based on the timeline it all happened within 5 minutes, from the time the resident was seen in the dining room and then seen outside. The DON stated no alarms were heard. She stated Resident #1 was assessed, no injuries were noted and he was placed on 1:1 supervision until the resident discharged home with family. She stated they in-serviced all the staff on abuse, neglect, and elopement. She stated they also added new alarms on the doors, they completed assessments on all residents with WanderGuards, risk assessments were completed, reviewed, and they updated the elopement binders. She stated elopement drills had been completed on all shifts. Interview on 08/13/25 at 3:26 PM, with the Administrator revealed he was notified around 7:10 AM - 7:15 AM regarding Resident #1 being outside. He stated from what he gathered, Resident #1 was last seen in the 300 Hall around 7 AM, and at 7:05 AM he was noticed outside the window from the 200 Hall. The Administrator stated Resident #1 was a pretty fast mover and he could have been outside within 5 minutes. He stated according to staff no alarms were heard. He stated Resident #1 had a WanderGuard but the door he went out was not equipped with a WanderGuard alarm. The Administrator stated the two main entrance doors were the doors equipped with the WanderGuard alarms. He stated the door on the 300 Hall was not an exit door. He stated when Resident #1 was brought back inside the resident stated he was going to a wedding. He stated Resident #1 was confused, had dementia, was an active wanderer and would wheel himself around the facility. He stated Resident #1 never tried to open any exit door. The Administrator stated Resident #1 was placed on 1:1 until they could find an appropriate placement. He stated all staff were in-serviced on elopement, they had completed elopement drills and code pink drills with staff. He stated a second alarm was placed for the 200 and 300 Hall doors, they added stop signs on the doors and door codes were changed. The Administrator stated the elopement binder was updated, and assessments were also reviewed and updated. Record review of facility Wandering and Elopements policy, revised November 15, 2023, reflected the following: The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measure to help guard against a resident wandering from the facility. The facility strives to prevent harm while maintaining the least restrictive environment for residents. This was determined to be a Past Non-Compliance Immediate Jeopardy on 08/13/25 at 4:25 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 08/13/25 at 4:38 PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of Elopement assessment/Evaluations reflected they were reviewed and completed on Resident #4, Resident #5, Resident #6, and Resident #7 on 07/23/25 and 07/24/25. Record review of facility invoice from [Door Alarm company] dated 07/24/25 reflected all door alarms were checked. Record review of facility Elopement binders located on both nurse's stations and reception reflected pictures of residents who were at elopement risk and contained information regarding the residents. Record review of the facility Elopement Drill/Code Pink Drills reflected drills were completed on the following dates: 07/24/25 - 5:30AM - 5:40AM, 2:45PM 3:05PM 07/30/25 - 6:00AM - 2:00PM, 2:00 PM - 10:00PM, and 10PM - 6:00AM (Facility continued to complete random code pink drills). Record review of facility Shift Exit Door Check forms for all exit doors from July 24 - August 8 reflected door checks were being completed for all three shifts (6AM-2PM, 2PM-10PM, 10PM-6AM). Record review of facility Door Safety and Alarm Check forms from January 2025 - August 2025 reflected they were completed monthly. Record review of Resident #4, Resident #5, Resident #6, and Resident #7 July and August 2025 MARs revealed Wanderguards were being monitored/checked placement and documenting behaviors. Observation on 08/13/25 from 11:00AM through 11:20 AM of Resident #4, Resident #5, Resident #6, and Resident #7 revealed WanderGuards were flashing a red light which indicated the WanderGuards were working properly. Observation on 08/13/25 from 2:36 PM through 2:50 PM revealed the doors on 200 and 300 Halls had two alarms. Alarms were loud enough to be heard from the nurse's station. Wander Guard doors were also checked, and no concerns noted. Record review of in-services dated 07/23/25 reflected all facility staff were in-serviced on Door Alarms, Wander guard, Wandering and Elopement, and Code pink. Objectives of the In-service: Elopement - Identified changes in behaviors of all resident's - notify management of wandering/risk of elopement behaviors. Be watchful of residents at risk and listen for door alarms. Elopement binders for at risk residents can be found at each nurses' station. Elopement Binders include current list of Residents high Risk for wandering. Wander guard - what your orders mean. Check skin around WanderGuard- Means just to make sure band or monitor is not causing pressure or injury. Check placement means to make sure band is not too loose or too tight and make sure is on the body part that the order says it is. Ex. R leg. Check Function - If red light is blinking - Battery is good condition. If the light is SOLID RED, GREEN, half red - cut WG off and replace with new WanderGuard spare will be locked in Medication carts. CALL DON, Code PINK - Missing Resident. The in-services were conducted and signed by all facility staff.Interviews on 08/13/25 from 12:25 PM through 08/14/25 at 1:49PM with CNA D, LVN C, ADON A, ADON B, MA E, CNA F, LVN G, MA H, MA I, MA J, CNA K, Treatment Nurse, Therapy L, Therapy M, Therapy N, CNA O, Dietary Aide, Kitchen Supervisor, Central Supply, LVN P, CNA Q, LVN R, CNA S, MA T, Social Worker, LVN U, CNA V, CNA W, Housekeeping Supervisor, and Housekeeping who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00AM revealed the facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize the elopement/code pink in-service, abuse, and neglect, completing head counts before shift change, elopement assessment were reviewed/competed (an evaluation to determine any resident at risk of elopement) , where to locate elopement binders, nurses ensure WanderGuards were checked daily to ensure they were working properly and document on the MAR, alarms added to the 200 and 300 Hall doors, door codes changed and door checks completed on all three shifts.

Based on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 2 of 4 residents reviewed (Residents #2 and #3) for PASRR assessments.The facility failed to submit a Nursing Facility Specialized Services (NFSS) form by the specific deadline for Resident #2 and Resident #3.The failure placed residents at risk of not receiving specialized services and equipment which could decrease their quality of life.Findings included:Record review of Resident #2's annual MDS assessment, dated 06/26/25, reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses included neurological conditions (any disorder of the nervous system), cerebral palsy (a group of disorders that affect movement and muscle tone or posture), and seizure disorder or epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures). Resident #2's BIMS score not completed due to the resident was rarely/never understood. Resident #2 was noted to have impairment to both sides of his upper and lower extremities, and he did not use any of the mobility devices listed. Resident #2 was dependent (meaning helper did all of the effort and the resident did none of the effort to complete the activity) for chair/bed-to-chair transfers.Record review of Resident #2's care plan, revised 04/16/25, reflected Focus: PASRR positive R/T pt identified as having PASRR positive status related to an intellectual disability. (The following meetings completed, and services reviewed) PCSP 7/25/24. Habilitation coordination, ILS, PT and CMWC. PCSP 10/24/24. Habilitation coordination, ILS, PT, pcsp: 1/22/25 hc/pt/mcwc/ ILST. pscp: 4/16/2025 hc/pt/cmwc, ilst/ot. Goal: will maintain highest level of practice wellbeing for the next 90days. Interventions: provide service coordination with representative from LIDDA. report any need to evaluate for services and/or durable medical equip to maintain currently level of function. Record review of Resident #2's HSP dated 07/15/25 reflected the following: .Section 6, NF Specialized Services to be Monitored by the SPT .Name of Service: Customized Manual Wheelchair . Outcome/Goal: Pending assessment. Section 7, Preference Regarding Transitioning. Barrier identified by the SPT: [Resident #2] is waiting for a CMWC . signed by the Habilitation Coordinator.Record review of Resident #2's PCSP Form, dated 07/15/25, reflected under the section Nursing Facility Specialized Services, a number 3 was marked next to Customized Manual Wheelchair (CMWC) which indicated it was ongoing. Under the comments section next to LA-IDD Specialized Services Comments reflected: CLO Barriers - [Resident #2] needs a safe wheelchair to be in the community. Record review of emails provided by the Director of Rehab, dated 08/23/24, 11/13/24, and 05/30/25 reflected the Director of Rehab had emailed the previous MDS Coordinator the documents needed to submit for Resident #2's customized wheelchair. Observation and an attempted interview on 08/13/25 at 10:43 AM revealed Resident #2 was in his geri-chair (medical recliner designed to provide support and comfort for individuals who require extended sitting periods or have difficulty with mobility) in the common area. Resident #2 was not able to answer questions due to his condition. The resident did not appear to be in distress or discomfort.Record review of Resident #3's quarterly MDS assessment, dated 06/25/25, reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses included progressive neurological conditions (any disorder of the nervous system), cerebral palsy (a group of disorders that affect movement and muscle tone or posture), cerebrovascular accident (sudden loss of blood flow to the brain, causing brain tissue damage) and seizure disorder or epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures). Resident #3's BIMS score of 09 indicated moderate cognitive impairment. Resident #3 had no impairment to his upper and lower extremities and did not use any of the mobility devices listed. Resident #3 was independent (meaning resident completes the activity by themself with no assistance from a helper). Record review of Resident #3's care plan, revised 04/16/25, reflected Focus: PASRR positive R/T pt identified as having PASRR positive status related to an intellectual disability, Cerebral Palsy. (The following meetings completed, and services reviewed) PCSP update 8/15/24. Services pending MCD eligibility. meeting 120/24/24. PCSP: 1/22/25 PT/OT/ST/ILST/HC. 4/16/2025 New pscp pt/ot/st/ilst/hc. Goal: will maintain highest level of practice wellbeing for the next 90 days. Interventions: /invite LIDDA representative and RP to attend careplan meeting. Report any need to evaluate for services and/or durable medical equip to maintain currently level of function. Record review of Resident #3's HSP dated 07/15/25 reflected the following: NF Specialized Services to be Monitored by the SPT .Name of Service: Physical Therapy. Occupational Therapy. Speech Therapy Outcome/Goal: Pending assessment. signed by the Habilitation Coordinator.Record review of Resident #3's PCSP Form, dated 07/15/25, reflected under the section Nursing Facility Specialized Services, a number 3 was marked next to Specialized Assessment Occupational Therapy (OT), Specialized Assessment Physical Therapy (PT), Specialized Assessment Speech Therapy (ST) which indicated it was ongoing. Under the comments section next to LA-IDD Specialized Services Comments reflected: On 4/15/2025, PE recommended services included CMWC, DME, PT, OT, ST, ILST, HC, BS, and DH. LAR and [Resident #3] would like ongoing HC, ILST, PT, OT, ST with assessments. [Resident #3] wants to focus on therapy.Observation and interview on 08/13/25 at 10:46 AM, revealed Resident #3 was sitting in the common area with other residents. Resident #3 stated he was doing well; however, when asked further questions resident would respond with I do not know. Interview by phone on 08/13/25 at 10:14 AM with Resident #2 and Resident #3's Habilitation Coordinator revealed Resident #2 and Resident #3 last PASRR meeting was on 07/15/25. The HC stated Resident #2's CMWC assessment was completed and approved but was still missing a portion of the NFSS form to be completed. She stated Resident #2's CMWC had been an ongoing concern. She stated Resident #3 had not had any therapy services provided. The HC stated NFSS forms needed to be submitted 20 days after the PASRR meeting on 07/15/25.Interview on 08/14/25 at 9:50 AM, with the MDS Coordinator revealed she had been employed since June 23rd, 2025. She stated Resident #2's NFSS CMWC/DME Assessment was completed and approved on 06/03/25; however, the application was not fully completed and was still pending submission. She stated on 07/15/25 a PCSP meeting was completed, and the facility had 20 days from the meeting to complete another assessment, but it had not been done yet. She stated Therapy had to complete another evaluation because the evaluation in the system was too old. The MDS Coordinator stated it was in the process of being completed. The MDS Coordinator stated the Treatment Nurse used to be the MDS Coordinator prior to her being employed. She stated she was not sure why there was a delay on Resident #2's NFSS CMWC assessment. The MDS Coordinator stated Resident #3 was PASRR positive, and the PCSP meeting was completed on 07/15/25 and the prior meeting was on 04/16/25. She stated the NFSS form should have been submitted 20 days after the meeting but was not. She stated the NFSS form was for rehab therapy. She stated she did not know why it had not been submitted. The MDS Coordinator stated it was her responsibility to ensure all forms were submitted in a timely manner. She stated the potential risk if PASRR paperwork was not submitted through the database timely could be a delay in therapy services.Interview on 08/14/25 at 10:36 AM, with the Director of Rehab revealed Resident #2 was evaluated for a custom wheelchair based on a referral that was made. The Director of Rehab stated from there he sent over the forms to the previous MDS Coordinator to be uploaded in the database and sent to the PASSR unit for approval. The Director of Rehab stated the CMWC was signed 08/23/24 and the vendor came out a few days before that. The Director of Rehab stated he never received any follow-up or heard anything more about Resident #2's wheelchair. The Director of Rehab stated once the CMWC was signed it would usually take about a month or two to receive the wheelchair. He stated waiting a year for a wheelchair was too long. Interview on 08/14/25 at 11:21 AM, with the Treatment Nurse revealed she was the MDS Coordinator from October 2024 to June 2025. She stated she was involved in the PCSP meetings of Resident #2 and Resident #3. She stated she had submitted the NFSS forms for Resident #2 and Resident #3 back in April 2025 but could not recall the exact dates. However, there was a miscommunication with the residents' Habilitation Coordinator. She stated she had a conversation with the Habilitation Coordinator, and she was made aware that she needed to resubmit the NFSS forms and evaluation needed to be completed to prove that services were being covered. She stated sometime in May 2025 she was made aware that the facility was out of compliance with the NFSS forms, and they were given the opportunity to correct the issue. She stated the corporate MDS Coordinator was assisting at the time and informed her that the NFSS needed to be submitted but by that time she was already out of that position. She stated after she changed positions, she never followed up to ensure the NFSS were submitted. The Treatment Nurse stated there was no potential risk to the resident if the NFSS forms were not submitted timely, residents would still be seen by therapy, and it was more of a payment issue. Interview on 08/14/25 at 1:58 PM, with the Administrator revealed he was not aware Resident #2 and Resident #3's NFSS forms were still pending. He stated he was aware of the request for Resident #2's customized wheelchair, but he stated he was under the impression the forms and assessments were all completed. He stated the previous MDS Coordinator moved positions to be the Treatment Nurse, and they had a corporate MDS Coordinator assisting until the position was filled. He stated he was under the impression all the forms had been submitted for all residents. Record review of the facility's Preadmission and Screening Resident Record review (PASRR) Rules policy, dated 03/15/23, reflected the following: It is the intent of [Management Group] to meet and abide by all State and Federal regulations that pertain to resident Preadmission and Screening Resident Record review (PASRR) Rules .Post IDT Meeting Responsibilities .2. The facility will initiate the request for specialized services within 20 business day of the IDT/PCSP meeting, implement Specialized Services therapy within 3 business days after receiving approval from HHSC in the online portal and order CMWC and/or DME within 5 business days of receiving approval from HHSC in the online portal.

Based on interview and record review, the facility failed to provide behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of four residents reviewed for behavioral health services. The facility failed to follow-up to ensure Resident #1 received a psychiatric consultation after a verbal order was received from the NP on 02/12/25. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life. Findings included: Record review of Resident #1's face sheet, dated 03/14/25, reflected the resident was a [AGE] year-old female, with an admitted [DATE] and a discharge date of [DATE]. It noted Resident #1 was discharged to the hospital. Resident #1 had a diagnosis of Parkinson's Disease with Dyskinesia (a progressive neurodegenerative disorder that affects movement, balance, and coordination), Cognitive Communication Deficit (communication difficulty), and Dysarthria (difficulty in speaking due to damage or dysfunction in the muscle or nerves that control speech). Record review of Resident #1's quarterly MDS assessment dated [DATE], reflected Resident #1 had a BIMS score of 12, which indicted she had moderate cognitive impairment. There were no hallucinations, signs of delusion, or rejection of care noted on the assessment. The Resident Mood Interview in Section D of the MDS assessment noted Resident #1's Total Severity Score was 11, which could indicate moderate anxiety, depression, or other conditions which required further assessment. Record review of the PASRR Level 1 Screening for Resident #1, dated 01/30/25, reflected Resident #1 did not have a primary diagnosis for dementia, that the resident did not have mental illness, the resident did not have an itellectual disability or developmental disability. The screening was completed by the case manager at the hospital. Record review of Resident #1's care plan, dated 02/01/25, reflected the following: Focus The resident has a psychosocial well-being problem, mood problem, and little interest in doing things, actual r/t ineffective coping Goal The resident will have no indication of psychosocial well-being problem, mood problems, more interest in doing things Record review of a progress note dated 02/12/25 at 10:36 AM, documented by LPN Nurse A, reflected the following: Resident seen by NP, complain of depression, new orders for psych consult Record review of a Progress document from the NP, dated 02/13/25, reflected the following: Staff concerns regarding depression. Nursing staff request evaluation of patient due to (Family Member) request Plan: Pending psych consult Record review of a progress note submitted by LPN Nurse A on Resident #1's electronic record, dated 02/12/25 at 10:36 AM, reflected the following: Resident seen by NP, complain of depression, new orders for psych consult Record review of Resident #1's electronic record did not reflect any psychiatric consultation, any scheduled consultation, or any follow-up regarding the psych consult order. Record review of the physician's note dated 02/03/25 on Resident #1's electronic record, reflected the following: Resident is alert and oriented x3. Oriented to person. Oriented to time. Oriented to place. Level of cognitive impairment: Alert. Resident is coherent. Speech is clear. Resident makes self understood. Resident understands others. Mood is pleasant, no unwanted behaviors witnessed. Resident sleeps through the night. Resident's psycho-spiritual needs are met. Record review of the physician's note dated 02/13/25 on Resident #1's electronic record, reflected the following: Resident is alert and oriented x3. Oriented to place. Oriented to person. Oriented to time. Resident is coherent. Record review of the physician's note dated 02/16/25 on Resident #1's electronic record, reflected the following: Resident is alert and oriented x3. Oriented to person. Oriented to place. In an emailed interview on 03/13/25, Resident #1's Family Member stated the following: 2/3 (02/03/25), 9:24 AM Concerns start with (Resident #1's) mental health. In our text string (Resident #1) was talking about no one being at the table, am thinking she meant back at Grandview. Noticing a delirium mental state later in the day and at night. In the family chat she mentioned being at a place (that was brand new, so could not have been) and having keys for it. 2/5 (02/05/25), 4:28 PM Called the social worker and he could not answer any of our questions and referred me to the nurse. He said he met with (Resident #1) a couple times and she seems in good spirits and nothing has been brought to his attention. 2/11 (02/11/25), 1:15 PM They are doing a doctor on site consult as (Resident #1) is depressed and I confirmed that too. I explained my concerns with her mental state and bouts of delirium and confusion. (Family Friend) said (Resident #1) is hallucinating because she thinks there is something in her room next to her bed. (Resident #1) also had some emotional moments tonight and said she was depressed. I wondered if (Resident #1) should be back in the hospital? I sent (DON) a text and picture of her food and (Family Friend's) text about (Resident #1's) delirium following our concerns. 2/12 (02/12/25) (Resident #1) is texting more delirium. Said They are waiting and I'm scared 2/13 (02/13/25) She (LPN Nurse A) said (Resident #1) had the psych consult and are waiting to see what meds may be prescribed. Record review of the hospital document dated 02/21/25 reflected Resident #1 arrived at the hospital on 02/20/25, with a chief complaint of possible infection of a wound. It noted Resident #1's behavior was normal but withdrawn. In an interview on 03/14/25 at 9:50 AM, the Administrator stated Resident #1 arrived to the facility from an assisted living facility and was in bad shape. He stated it was almost like Resident #1 was depressed. The Administrator stated she did not want to get out of bed. He stated he never heard of Resident #1 having hallucinations. In an interview on 3/14/25 at 2:50 PM, Caregiver B stated Resident #1 appeared to be depressed. She stated Resident #1 never wanted to get out of bed and liked to lay on one side facing the window. Caregiver B stated Resident #1 was never observed having hallucinations. In an interview on 03/14/25 at 3:03 PM, the Social Worker stated he did not receive any complaints regarding Resident #1's mental state. He stated he only spoke with Resident #1's family members about physical therapy and preparing the resident to return to the assisted living facility. He stated he was not aware that Resident #1 was depressed. In a follow-up interview on 03/14/25 at 3:16 PM, the Social worker stated he would review the resident's electronic file and suggest psych services, or the NP would suggest or order psych services. He stated he was not aware Resident #1 needed psych services. He stated he did not recall anyone one, family, friends, or staff stating Resident #1 needed psych services or was possibly depressed. The Social Worker stated a resident's need for psych services is important and would have been processed immediately. In a telephone interview on 03/14/25 at 4:39 PM, LPN Nurse A stated she received a verbal order from the NP for psych services for Resident #1 on 02/12/25. LPN Nurse A stated Resident #1 did not like to leave her room, but she never saw her hallucinate. She stated she informed the Social Worker about the psych services order at the staff meeting the following day. LPN Nurse A stated she documented the psych services order in the progress notes, but she stated she failed to put the order in the system. LPN Nurse A stated usually when she received a verbal order, she would document in the progress notes, put the order in, print it, then would verbally tell the Social Worker. LPN Nurse A stated the risk of not putting the order in the system was Resident #1 did not receive the service. In an interview on 03/14/25 at 5:00 PM, the DON stated the facility had a standing order for psych services. She stated the facility staff had clinical meetings daily, and she stated she did not recall that verbal order for Resident #1 to get psych services. The DON stated she believed LPN Nurse A failed to put the order in the system. The DON stated the family voiced concern about Resident #1's hallucinations and delusion. She stated they had the pain managment team visit Resident #1 to ensure she was not overmedicated with the pain medications. The DON stated, after that it seemed there were not as many hallucinations. In a telephone interview on 03/14/25 at 5:08 PM, the NP stated she did recall that she gave a verbal order to a nurse for Resident #1 to receive psych services. She stated usually she did not work on the skilled hall but LPN Nurse A pulled her into Resident #1's room to assess the resident. She stated she gave the nurse a verbal order to have Resident #1 assessed for depression or anxiety on 02/13/25. In an follow-up interview on 03/14/25 at 5:12 PM, the DON stated she was not present at the facility the day the verbal order was given and she was not sure if the order got exchanged. She stated if a nurse received a verbal order, the nurse would document it, write the order, and discuss any referrals in the stand up meeting. The DON stated that was how verbal orders were usually discussed. The DON stated once the order was submitted, the Social Worker would go in and process the request for psych services. The DON stated during the morning meetings they would usually pull the progress notes and review, so she still was not sure how that verbal order was missed. The DON stated the bottom line was the verbal order was missed. The DON stated the risk was the referral was not processed, so the resident did not receive the services. In an interview on 03/14/25 at 5:20 PM, the Administrator stated the Social Worker dropped the ball on following up on psych services for Resident #1. He stated the order should have been put in and signed off. The Administrator stated it was a possible communication issue. The Administrator stated the risk of the verbal order not put in was Resident #1 did not receive psych services. Record review of the facility's policy titled, Referrals, Social Services, dated 2001 with a revision date of December 2008, reflected the following: Policy Interpretation and Implementation 1. Referrals for medical services must be based on physician evaluation of resident need and a related physician order. 2. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. 3. Social services will document the referral in the resident's medical record.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 2 of 6 halls (500 and 600) reviewed for pest control. The facility failed to prevent pests from entering the facility. On 10/21/24, Resident #162 was found in bed with fire ants on his body and he had been bit multiple times his torso, arms, and legs. This failure places residents at risk of serious physical harm from ant or other pest bites. Findings included: 1. Record review of Resident #162's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), aphasia (a language disorder that makes it difficult to understand and express written and spoken language), stroke, hemiplegia (total or partial paralysis of one side of the body), nontraumatic subarachnoid hemorrhage (intracranial bleeding), and difficulty in walking. Resident #162 had a BIMS of 7 which mean his cognition was severely impaired. The MDS further reflected the resident had impairment to one side of his upper and lower extremities. Resident #162 was dependent upon staff for all ADLs. Record review of Resident #162's care plan revised on 09/18/24 reflected the resident had an ADL self-care performance deficit related to immobility. Interventions included needing assistance from staff for all ADLs. The care plan further reflected the resident had a communication problem related to the diagnosis of aphasia. Interventions included to allow adequate time to respond, repeat as necessary, do not rush and request clarification from the resident to ensure understanding. Record review of Resident #162's weekly body audit dated 10/21/24 reflected he had ant bites to the right and left side of his abdomen. Record review of Resident #162's progress notes dated 10/22/24 reflected the following: Benadryl Allergy Oral Capsule 25MG Give 1 tablet by mouth every 6 hours as needed for itching Observation and interview with Resident #162 on 11/12/24 at 1:23 PM revealed he was in his room sitting in a gerichair. The resident was opening and closing his eyes and when asked how he was doing, he quietly whispered he was ok. The resident was asked if he recalled being bitten by ants and the resident was attempting to speak but closed his eyes and did not respond. Interview on 11/12/24 at 5:15 PM with LVN H revealed CNA BB alerted her that Resident #162 had been found in bed with ants that had been bitten, 10/21/24. LVN H said when she went in the resident's room, she did not see any ants but said Resident #162 was not able to call for help or use his call light due to his condition. She called the doctor and Benadryl was ordered for any discomfort. Interview on 11/13/24 at 1:48 PM with CNA BB revealed she had gone to check on Resident #162 around 7AM and as she pulled the cover back off the resident, she noticed there were a lot of little red ants on the bed and on the resident, 10/21/24. The Wound Care Nurse was in the room at the time the ants were found. CNA BB said as they were trying to strip the bed of the covers, the ants were crawling on her hands as well. Once they got all the ants off the resident and the bed, she noticed Resident #162 had bites on the sides of his abdomen, and his back and also noticed there were food crumbs in his bed. She said Resident #162 did not appear to be in any distress or pain at the time, and was just laying there. CNA BB stated she did not think the resident was able to register what had happened. The resident was taken to the shower right after to make sure all the ants had gotten off him. CNA BB said she worked with Resident #162 again about two days later and during his shower, she had noticed the ant bites had turned in to small pustules. CNA BB further stated that was the first time she had seen any ants in any room or that anyone had been bit. She did not look to see where the ants had come in from because everything happened so fast. Interview on 11/13/24 at 3:29 PM with the Wound Care Nurse revealed she had gone into Resident #162's room for wound care, 10/21/24 and noticed there were ants on his foot and the wound dressing. She immediately took the covers off Resident #162 and noticed he had been bit on his torso, his stomach and possibly his legs. The resident did not appear to be in any distress at the time and was just laying there. Resident #162 was cleaned up and taken to the shower by the aide. The Wound Care Nurse said she noticed a banana peel on the floor and saw ants around that but did not notice where they had come in from. The Wound Care Nurse further stated she was not aware of any other resident being bit and had never seen any ants in other rooms. Observation and interview on 11/12/24 at 3:32 PM with Pest Control revealed he was onsite at the facility treating/spraying one of patios. He said he regularly serviced the facility and had been called after the incident, 10/21/24, because ants had been found in the interior of the facility in the 500 rooms. Once he arrived on 10/23/24, he did not see any active ants inside the rooms and when he treated the outside, he found 3 mounds of fire ants and they had been up against the wall of the 500 hall, where Resident #162 had resided at the time he was bitten. Observation and interview on 11/12/24 at 3:38 PM revealed there was large ant mound next to a room where the 600 hall, Resident The ant mound had some white powder sprinkled on it and there were active ants crawling on the wall under the PTAC unit (a self-contained, ductless unit that can heat and cool a sing room or space) and on and around the ant mound. Pest Control identified the ants as being fire ants and stated the facility was good about calling him when they had issues. Record review of Resident 107's progress noted dated 11/11/24 documented by LVN H reflected the following: residents advise that there are ants in his room writer run in room and there were about 10 ants on the floor by bedside, head to toe assessment done no ant bites, writer advise resident to be moved to another room until room clean and spray tomorrow resident stated that no I am fine I just wanted you to know that there are ants in my room. I will be just fine I just wanted you to know that there are ants in my room, I will be just fine I don't need to [sic] moved. management is notified I am just fine Observation and interview on 11/12/24 at 3:38 PM revealed there was large ant mound next to a room where on the 600 hall, where Resident #107 resided. The ant mound had some white powder sprinkled on it and there were active ants crawling on the wall under the PTAC unit (a self-contained, ductless unit that can heat and cool a sing room or space) and on and around the ant mound. Pest Control identified the ants as being fire ants and stated the facility was good about calling him when they had issues. Observation and interview on 11/12/24 at 3:48 PM with Resident #107 revealed he was lying in bed looking at his phone. The resident was asked about having ants in his room and he said he had been at the facility for about two weeks and had never seen any ants in his room. Resident #107 did not recall telling anyone he had seen any ants. Further observation of the resident's room revealed there were no ants in his room or around his window or PTAC. Interview on 11/12/24 at 5:15 PM with LVN H revealed she was told by Resident #107 there were ants in his room and when she went to see, she did not see any but she let the Maintenance Director know so he could treat the room. Observation on 11/12/ 24 at 5:18 PM during a walk around the facility with the Maintenance Director revealed there were 7 active ant mounds. The Maintenance Director stepped on the ant piles and confirmed the ants were active. The ant beds were located along the 100 hall, 200 hall, and the 300 hall against the facility walls and in between resident rooms. Interview on 11/12/24 at 5:25 PM with the Maintenance Director revealed he checked his phone and said the last time he had completed a walk around of the facility was on 11/04/24 and the ant beds were not there. He said Pest Control was on site today, 11/12/24, treating the facility. The Maintenance Director said he was told Resident #162 had been bit by ants but by the time he went the room he did not see any active ants. Resident #162 was moved to another room and Pest Control was called so they could treat all the rooms on the 500 hall, where Resident #162 resided at the time he was bit. The Maintenance Director also said LVN H had told him there were ants in Resident #107's room yesterday, 11/11/24 and when he went to the room, he did not see any ants after inspecting the room. He went ahead and treated the room just in case. The Maintenance Director then went and did a walk through of patio and he noticed an ant bed outside of the 600 hall and he had treated the ant bed, that is was why it was covered in a white powder. He said it was his responsibility to ensure there were no pest in the facility and ensure Pest Control completed their rounds during their visits. Record review of the Pest Control log book on 11/14/24 reflected the facility had been treated on the following dates: 10/08/24 - preventative maintenance treatment throughout the exterior perimeter and service rodent bait stations. No reported activity by [Maintenance Director] 10/23/24 - serviced rooms 501, 502, 504, 506, 507, 508, 509, for ants and treated kitchen. 11/13/24 - treated the exterior perimeter and ant [NAME] against the building and the surrounding areas of the exterior of building perimeter where they found active [NAME] against the sidewalk close to the fire hydrant and also treated both courtyards. Record review of the facility's Pest Control policy, revised 09/22/23, reflected the following: Policy Statement Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation .1. This facility maintains an on-going pest control program for insects and rodents .3. Windows are screened to assist with insect and rodent entry .6. Maintenance services assist, when appropriate and necessary, in providing pest control services

Based on interview and record review, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #80) reviewed for unnecessary medications, psychotropic medications, and medication regimen review. The facility's Pharmacist Consultant recommended a dose reduction for Resident #80's Olanzapine 10mg. The physician agreed to be reduced to 5 mg, but the medication continued to be administered at 10 mg to the resident. This failure could place residents on psychoactive medications at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings included: Record review of Resident #80's face sheet dated 11/14/24 reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #80's Quarterly MDS Assessment, dated 10/14/24, revealed a BIMS score of 14, which indicated his cognition was intact. The MDS further revealed he had an active diagnoses of heart failure, hypertension, unspecified dementia, schizophrenia disorder and bipolar disorder. Record review of Resident #80's undated Care Plan reflected Focus: The resident uses psychotropic medications r/t Bipolar, mood disorder, Schizoaffective. Interventions: Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Record review of Resident #80's physician order dated 10/03/23 revealed OLANZapine Oral Tablet 10 MG (Olanzapine) Give 1 tablet by mouth one time a day related to BIPOLAR DISORDER, CURRENT EPISODE MANIC WITHOUT PSYCHOTIC FEATURES, UNSPECIFIED D/C date 10/08/24. Record review of Resident #80's Pharmaceutical Consultant Report Psychoactive Gradual Dose Reduction dated 01/18/24 revealed the following: According to Long-term care Drug Monitoring Regulations, our review of the above patient's chart identifies the following as requiring [your] attention. Please evaluate the routine use of the following psychoactive medication and consider a dose reduction. If a reduction is not desired, please indicate below a rationale for the continued use. This resident is prescribed the following psychoactive medications: - Olanzapine 10mg QHS - Trazodone 50mg QHS Physician Response to Record review: A dose reduction is appropriate: Yes - if yes, new order - Olanzapine to 5mg QHS. Signed by Physician on 01/25/24. Record review of Resident #80's Medication Administration Record reflected he was taking Olanzapine 10 mg by mouth one time a day for bipolar disorder. The MAR further reflected Resident #80 was administered the medication from 01/25/24 through 07/05/24. Interview on 11/12/24 at 12:03 PM of Resident #80s revealed he was doing well. Resident #80 stated he believed he received all his medications. He stated he could not recall what medications he was on. Interview on 11/14/24 at 3:34 PM with the DON revealed she was responsible for reviewing pharmacy recommendations. She stated she could confirm she had completed all pharmacy recommendations. She stated she was trying to locate why Resident #80's pharmacist recommendation was not completed. She stated the resident psychiatrist might had not agreed to the dose reduction; however, there was no documentation. She stated she was waiting on the resident psychiatrist to return her call. The DON stated in this case there was no risk to the resident for adverse reaction. Follow-up interview on 11/14/24 at 4:43 PM with the DON revealed she could not locate any documentation on to why Resident #80's Olazapine medication was not reduced. She stated the Psychiatrist contacted her and stated she was unaware of the pharmacist and physician recommendation. She stated it was a mistake on her part. She stated another GDR was completed in July 2024 for Resident #80 Olanzapine 10mg medication and dosage did not change. The DON stated it was important to follow pharmacy recommendations; however, if psych had any concerns regarding the medication psych would have had changed it. Record review of the facility's Tapering Medications and Gradual Drug Dose Reduction: policy, revised April 2007, reflected the following: Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Based on interview and record review, the facility failed to incorporate the recommendations from the PASARR Level II determination and the PASARR evaluation report for 2 of 5 residents reviewed (Residents #15 and #80) for PASARR assessments. 1. The facility failed to submit a Nursing Facility Specialized Services (NFSS) form requested by the specific deadline for Resident #15. 2. The facility did not refer Resident #80 to the appropriate state-designated mental health authority for review when he received a new diagnosis of schizoaffective disorder. This failure could affect residents with psychiatric diagnoses who may not be evaluated and receive needed PASRR services. Findings included: 1. Record review of Resident #15's Quarterly MDS Assessment, dated 09/13/24, reflected a BIMS score was not completed. Resident #15 was noted to have impairment to both sides of his upper and lower extremities but did not use any of the mobility devices listed. Resident #15 was dependent (meaning helper does all of the effort and the resident does none of the effort to complete the activity) for chair/bed-to-chair transfers. Resident #15's diagnoses included other neurological conditions (any disorder of the nervous system), cerebral palsy (a group of disorders that affect movement and muscle tone or posture), and seizure disorder or epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures). Record review of Resident #15's care plan reflected the following: Focus: PASRR positive R/T pt identified as having PASRR positive status related to an intellectual disability .MHMR of [County Name]. PCSP 7/25/24. Habilitation Coordination, ILS, PT and CMWC .Goal: will maintain highest level of practice wellbeing for the next 90days .Interventions: provide service coordination with representative from LIDDA .[sic]. Record review of Resident #15's Care Plan Conference document, dated 07/25/24, reflected under Additional Comments was the following: .starting pt assessment and get new w/c. Record review of Resident #15's Habilitative Service Plan (HSP) dated 07/25/24 reflected the following: Section 6, NF Specialized Services to be Monitored by the SPT .Name of Service: Customized Manual Wheelchair . signed by the Habilitation Coordinator. Record review of Resident #15's PCSP Form, dated 07/25/24, reflected under the section Nursing Facility Specialized Services, a number 2 was marked next to Customized Manual Wheelchair (CMWC) which indicated it was new. Under the comments section next to Nursing Facility Comments reflected: Accepted services of customized wheelchair, ILS, Hab coordination and PT with assessment. [sic]. Record review of an email provided by the DOR, dated 08/23/24, reflected it was an email to the previous MDS Coordinator from the DOR providing the documents needed to submit for Resident #15's customized wheelchair. The email included attachments including a quote, dated 08/21/24, from a DME company for Resident #15's customized wheelchair and a signed CMWC Supplier Acknowledgement and Signature Page dated 08/23/24. Telephone interview on 11/08/24 at 2:43 PM with Resident #15's HC revealed Resident #15 had his annual PASRR meeting on 07/25/24 when a manual wheelchair was added to his treatment plan. Resident #15's HC said she came back a month later and the facility had not made any progress on it. Resident #15's HC said the facility had 20 business days or 30 calendar days to initiate the service that was added from the 07/25/24 meeting. Resident #15's HC said she knew the facility had lots of staff changes recently so it was hard to stay in contact and get a status update. Observation and an attempted interview on 11/13/24 at 9:25 AM of Resident #15 revealed he was in his bed in his room, his bed was very low to the ground and a fall mat was at his bedside. Resident #15's geri-chair was across the room. Resident #15 was not able to answer questions due to his condition although he appeared to be okay. Interview on 11/13/24 at 12:10 PM with MDS Coordinator QQ revealed she just started at the facility a month ago and had not had the opportunity to work on Resident #15's PASRR services yet. MDS Coordinator QQ said she was in attendance for Resident #15's recent annual PASSR meeting and the wheelchair was marked as ongoing on the PCSP. MDS Coordinator QQ said she looked in the database and saw that that DME (the wheelchair) was initially started on 07/25/24. MDS Coordinator QQ said once something like DME was initiated, the therapy department was responsible for ensuring it was carried out. MDS Coordinator QQ said she was only responsible for uploading the receipts in the database. Interview on 11/13/24 at 12:25 PM with the DOR revealed he remembered bringing in a vendor to get Resident #15 evaluated for a wheelchair based on a referral that was made. The DOR said from there he sent over the quote and forms to the previous MDS Coordinator to be uploaded in the database and sent to the PASSR unit for approval. The DOR said the CMWC was signed 08/23/24 and the vendor came out a few days before that. The DOR said he never received any follow-up or heard anything more about Resident #15's wheelchair. Follow-up interview on 11/14/24 at 5:11 PM with MDS Coordinator QQ revealed she was responsible for ensuring all PASSR paperwork was submitted through the database in a timely manner. MDS Coordinator QQ said if PASRR paperwork was not submitted through the database timely, residents could miss out on services. 2. Record review of Resident #80's face sheet, dated 11/14/24 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #80 was diagnosed with schizoaffective disorder, unspecified on 03/06/24. Record review of Resident #80's Quarterly MDS Assessment, dated 10/14/24, revealed a BIMS score of 14, which indicated his cognition was intact. MDS further revealed resident had an active diagnosis of schizophrenia disorder. Record review of Resident #80's undated Care Plan reflected The resident uses psychotropic medications r/t Bipolar, mood disorder, Schizoaffective. Record review of Resident #80's PASRR Level 1 Screening, dated 01/18/22, reflected he did not have a mental illness. Interview on 11/13/24 at 3:06 PM with the MDS Coordinator QQ revealed Resident #80 was given a diagnosis of schizoaffective disorder on 03/06/24. She stated the only PASRR they have on file was for 01/18/22. She stated due to the new diagnosis Resident #80 required a new PASRR evaluation. She stated it was the responsibility of MDS Coordinators for submitting PASSR's whether for newly admitted residents or related to updates for new diagnoses for residents. She stated she had been employed since 10/07/24, and was not employed when Resident #80 was given the diagnosis. She stated she was not sure why it was not done. She stated upon employment she completed a general audit on resident clinical records but did not complete an audit on PASRRs. The MDS Coordinator QQ stated by not reviewing resident PASRR screenings along with diagnoses, placed residents at risk of not receiving needed services. Interview on 11/14/24 at 4:01 PM with the Administrator revealed the MDS Coordinators were responsible for updating the PASSR assessments and submitting them timely but had no information regarding Resident #80 PASRR. He stated MDS Coordinators kept track of all PASRRs, and the [NAME] Nurse would ensure PASRR were completed and submitted. He stated PASRR audits were completed prior to him being employed in July 2024. Record review of the facility's Preadmission and Screening Resident Record review (PASRR) Rules policy, dated 03/15/23, reflected the following: It is the intent of Priority Management Group to meet and abide by all State and Federal regulations that pertain to resident Preadmission and Screening Resident Record review (PASRR) Rules . When it is determined that an individual's diagnosis was changed and /or a state surveyor determines the PL1 was incorrect, the social worker or designee will complete and submit a form 1012 (MI) or new PL1 (ID/DD). A subsequent positive PL1 will be entered according to 1012 findings. 44140

Based on interview and record review, the facility failed to ensure a final summary of the resident's status at the time of the discharge was available for release to authorized persons and agencies, with consent of the resident or resident's representative for 1 of 3 residents (Resident #110) reviewed for discharge summary. The facility failed to complete a discharge summary after Resident #110 discharged from the facility on 08/24/24. This failure could place residents at risk for a lack of continued care and services. Findings included: Record review of Resident #110's face sheet, dated 11/13/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on [DATE]. Record review of Resident #110's Admission MDS Assessment, dated 08/24/24, reflected he had a BIMS score of 12, indicating moderate cognitive impairment. His diagnoses included other orthopedic conditions (refers to ailments, injuries, or diseases that cause pain or dysfunction in the musculoskeletal system), cancer (a disease resulting from uncontrolled growth and division of abnormal cells), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Record review of Resident #110's progress notes reflected on 08/23/24 at 2:00 PM Physician PP wrote: Contacted by staff patient is wanting to go home with home health. Patient discharged home to work with physical therapy at home. All other treatments to be handled by home health nurse and staff. Record review of Resident #110's chart reflected a Discharge Instruction Form under the Assessments section that was incomplete and blank; it had an effective date of 08/24/24. Interview on 11/14/24 at 4:54 PM with the DON revealed the discharge summary was typically completed by the discharging nurse after a resident discharged from the facility. The DON said the purpose of the discharge summary was to give directions for what to do when the resident went home. The DON said she expected staff to complete the discharge summary for residents after they left the facility. The DON said if the discharge summary was not completed the resident might miss a follow-up appointment or not understand something that needs to be done going forward after they get home. Record review of the facility's Discharge Summary and Plan policy, revised 11/14/23, reflected the following: 1. When the facility anticipates aa resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/IID, etc.), a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment.

Based on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for 2 of 3 reviewed (Resident #44 and #84) for feeding tubes. 1. RN E failed to provide Resident #44 with two cartons of formula during bolus feeding as ordered by the physician. 2. The facility failed to follow physician's orders of providing Resident #84 with her 20 hours of feeding intake. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of g-tube care or weight loss. Findings included: 1. Record review of Resident #44's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke, non-Alzheimer's dementia, dysphagia (difficulty swallowing), and cognitive communication deficit. The MDS further reflected the resident required a feeding tube for nutrition. Record review of Resident #44's care plan revised on 09/23/24 reflected the resident had a potential/actual nutritional problem related to gastrostomy status - use a parenteral feeding as nutritional approach. Interventions included to provide and serve diet as ordered. Record review of Resident #44's order summary report for November 2024 reflected the following : Enteral Feed Order three times a day for nutritional enteral: Enteral Nutrition via Bolus: Isosource 1.5, 2 Cartons (500mL) TID. Provides 1500 mL, 2250 kcal, 102 g protein Observation on 11/14/24 at 11:29 AM revealed that during the bolus feeding RN E performed hand hygiene and donned the appropriate PPE and only administered 1 carton of formula instead of 2 to Resident #44. Interview on 11/14/24 at 12:35 PM with RN E revealed she had just started working at the facility two weeks prior and began caring for Resident #44 on Monday, 11/11/24. She said she misread the resident's orders and had only been given him 1 carton of formula for the past 3 days for breakfast and lunch. RN E said risk of not giving Resident #44 the correct amount of bolus formula could cause the resident not to get all of his nutrition. Interview on 11/14/24 at 3:43 PM with the DON revealed she was not aware RN E had only been giving Resident #44 1 carton of formula instead of 2. The DON said the resident had a recent weight loss but it was related to him being in the hospital for 18 days of the prior month because he was having issues with this gtube placement. The DON further stated Resident #44 ran the risk of not getting his entire nutrition and less calories if he was not given 2 cartons of formula. Interview on 11/14/24 with the Dietitian revealed Resident #44's recent weight loss was related to his extended stay in the hospital. She said Resident #44 had recently has an 8 ounce weight gain since he returned from the hospital on 11/01/24 and that was a normal amount of gain for his body weight. The Dietitian further stated Resident #44 ran the risk of not getting all of his required nutrition if he was only getting 1 carton instead of 2 cartons of formula during his bolus feedings. Record review of Resident #84 's quarterly MDS assessment, dated 10/11/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing). The MDS assessment reflected the staff assessment for mental status was completed and indicated there was severe impairment cognitively. Record review of Resident #84's physician's orders reflected: Enteral Feed every shift Enteral: Enteral Nutrition Glucerna 1.2 at 85 ml per hour for 20 hours via pump. Start infusion at 11 AM and continue until 7 AM. with a start date of 10/07/24. Record review of Resident #84's care plan, dated 07/13/24, reflected: Focus: [Resident #84] requires the use of a feeding tube rule out dysphagia;Goal: Resident will maintain adequate nutritional and hydration status as evidenced by weight being stable, no signs or symptoms of malnutrition, or dehydration through review date; Interventions: Administer tube feeding and water flushes as ordered. 2. Observation on 11/12/24 at 12:57 PM of Resident #84 revealed her tube feeding machine was not on. The tube and the pole were splashed with feeding residues, and she was not able to answer any questions. Observation on 11/13/24 at 12:16 PM of Resident #84 revealed her tube feeding machine was not on and she was not able to answer any questions. Observation and interview on 11/13/24 at 12:51 PM with LVN O revealed she was Resident #84's nurse. She stated she took over the hall at 11:00 AM and she stated she does not know who put on the pump. She stated she knows the machine get turned off in the morning at 7:00 AM. LVN O said she knew Resident #=84's tube feeding machine was supposed to be turned back on at 11:00 AM but she thought the other nurse turned it on before she left. She stated the same thing happened on 11/12/24 and the machine was put on the same time as today. LVN O said Resident #84's order stated she was supposed to receive 20 hours of nutrition and the machine should only be off for four hours. LVN O said not turning the machine on when it was time would have caused Resident #84 not to get her full 20 hours of nutrition and it would put her at risk of losing weight. Observation and interview on 11/13/24 at 02:38 PM with LVN SS revealed she was Resident #84's nurse from 6:00 AM-11:00 AM. She stated she disconnected the pump machine at 07:00AM and Resident #84 was supposed to be connected back at 11:00 AM. She stated when she gave report the resident was not connected, the oncoming nurse was supposed to connect her back. Observation on 11/14/24 at 12:10 PM of Resident #84 revealed her tube feeding machine was not on and she was not able to answer any questions. Interview with the DON on 11/14/24 at 12:15 PM revealed her expectation was, staff should follow the doctors' orders a to any resident's down time for their tube feeding machine and nutrition. The DON said she need to figure out why it happened today again, and she had talked to nurses the previous day but she stated she had brand new nurses working on that hall form 11:00 AM.The DON said the purpose of following the order was to make sure the resident got the proper amount of calories for sustainability and if not, it put them at risk of losing weight. She stated the nurses were supposed to notify the doctor and get a new order to compensate for the hours missed. She stated she called the doctor, and they will adjust the time. She stated she does not think she has done training on g-tube feeding but facility had done competency skills with staffs. She stated she expected the nurses to keep the pole and the pump clean. Observation and interview on 11/14/24 at 12:33 PM with LVN P revealed she was Resident #84's nurse. She stated she took over the hall at 10:00 AM and she was falling behind. She stated she had just connected Resident #84 pump machine. She stated she called the nurse practitioner, and she got new orders to connect the pump at 12:30 PM because they were falling behind, and she did not want that to happen in future. She stated the potential risk wound resident getting hungry and no other risks. Record review of the facility's current Enteral Nutrition policy, revised November 2018, reflected: .11. The nurse confirms that orders for enteral nutrition are complete. Complete orders include: .f. The volume /rate goals and recommendations for advancement toward these: and g. Instructions for flushing (solution, volume, frequency, timing and 24-hour volume) . Record review of the facility's Enteral Tube Feeding via Syringe (Bolus) policy, revised July 2019, reflected the following: Purpose The purpose of this procedure is to provide nutritional support to residents unable to obtain nourishment orally .General Guidelines .2. Check the enteral nutrition label against the order before administration 42859

Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #42) reviewed for pressure ulcers. The facility failed to ensure Resident #42 received wound care treatment and services for newly identified wound to the sacral area. This failure could affect the residents, who received pressure ulcer care, by placing them at risk of infections and worsening of pressure ulcers. Findings included: Record review of Resident #42's face sheet dated 11/14/24 reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #42's Quarterly MDS Assessment, dated 11/02/24, revealed a BIMS score was not completed due to resident is rarely/never understood. Resident #42 had active diagnoses of malnutrition, muscle wasting and atrophy, abnormal posture, rheumatoid arthritis, hypertension, Dementia, and chronic kidney disease. MDS further indicated Section M - Skin Conditions revealed resident at risk of pressure ulcers/injuries. Resident #42 had no venous and arterial ulcers present. Record review of Resident #42's Care Plan, revised 10/11/24, reflected: Focus: The resident has pressure ulcer or potential for pressure ulcer development r/t Immobility. History of Stage 3 to Right Heel - resolved. History of Stage 3 to the rt buttock - resolved. Goal: The resident's will Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: Low air loss mattress in place. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Goal: Resident at risk for pressure sores r/t Hx of ulcers. Goal: The resident will have intact skin, free of redness, blisters, or discoloration by/through review date. Interventions: air mattress to help with not developing new sores. Inform the resident/family/caregivers of any new area of skin breakdown. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Record review of Resident #42's Weekly Body assessment completed on 11/06/24 reflected the resident had no skin issues. Record review of Resident #42's progress notes from 11/09/24 reflected: Cleansed wound to coccyx area with NS, pat dry, applied Maxsorb ll, covered with island dressing. Record review of Resident #42's physician orders reflected there were no treatment orders for wounds. Observation on 11/12/24 at 11:53 AM of Resident #42 revealed she was in bed sleeping, and the resident had an air mattress. Interview on 11/13/24 at 3:35 PM with the Wound Care Nurse revealed Resident #42 had no current wounds. She stated Resident #42 had a wound on the coccyx that had resolved in late August 2024. Interview on 11/14/24 at 1:37 PM with CNA W revealed she was the CNA assigned for Resident #42. She stated Resident #42 had a wound on her sacral area. She stated the resident had a dressing on with a date of 11/10/24. She stated either Saturday 11/09/24 or Sunday 11/10/24 it was noted Resident #42 had some redness to her sacral area. She stated the wound was reported to LVN TT. CNA W stated the dressing was cleaned and intact. She stated since it was reported to LVN TT, she thought everyone else knew about the wound. She stated she had not followed-up with anyone after 11/10/24 because she thought everyone knew about it. Interview on 11/14/24 at 1:41 PM with LVN TT revealed she was the weekend nurse for Resident #42 for the weekend of 11/09/24 and 11/10/24. She stated she could not recall if it was Saturday or Sunday, but the CNA on the hall reported to her that Resident #42 had redness to her sacral area. She stated she notified the Nurse Practitioner and was provided with an order to cleanse with normal saline and cover with a dressing. She stated Resident #42 had a history of ulcers. She stated she did not take any measurements; however, by her observation it was small and appeared to be less than 2 cm. She stated there was no drainage, no bleeding, and no signs of infection. She stated it was beginning to open, more of shearing of the skin. She stated she documented in the resident progress notes, 24-hour report and notified the Wound Care Nurse. She stated believed she generated the orders in the resident's clinical record. Observation on 11/14/24 at 2:30 PM with the Wound Care Nurse revealed Resident #42 was lying in bed sleeping. The Wound Care Nurse completed a skin assessment, and Resident #42's heels and other parts the body were intact. Resident #42 was observed to have a dressing on her sacral area dated 11/10/24. The dressing was clean and intact. The Wound Care Nurse removed the dressing, and the resident had a wound on the sacral area that was opening and had a scab. The measurements were 1 cm x 1.5 cm and 2x1 cm. There was scanty drainage with no redness or signs of infection noted. Interview on 11/14/24 at 2:40 PM with the Wound Care Nurse revealed she was unaware of the wound. She stated it had not been reported to her. She stated she was made aware of the wound today (11/14/24) when the skin assessment was completed. The Wound Care Nurse stated she would follow-up with the doctor and obtain orders. She stated she did not receive any information from the weekend nurse. She stated she reviewed the 24-hour report and did not see anything on Resident #42. The Wound Care Nurse stated she could not locate any treatment orders in the resident's chart. Interview on 11/14/24 at 2:58 PM with the NP revealed she was notified of Resident #42's sacral wound. She stated she visited the resident on Sunday 11/10/24 and observed the wound. She stated she staged the pressure ulcer on Resident #42's coccyx at a Stage 2. She stated she provided an order to apply Maxsorb. She stated her expectations were for the nursing staff to notify her immediately when they noticed a wound. She stated if treatment was delayed it could lead to worsening of the wound and infection. Interview on 11/24/24 at 3:11 PM with CNA UU by phone revealed she was the assigned CNA to Resident #42 for Saturday 11/09/24 from 2:00 PM-10:00 PM. She stated while providing incontinent care she noticed redness to resident sacral area; she stated it was not open and no drainage was noted. She stated it was only red, and it was less than a dime size. She stated she reported to LVN TT who was the assigned nurse on the hall and a dressing was placed. Record review of the facility's 24 Hour Report/Change of Condition Report dated 11/09/24 reflected: Resident #42 - Shearing (loose) wound to coccyx dressed. Record review of facility 24 Hour Report/Change of Condition Report dated 11/10/24 reflected: [Resident #42] -wound to coccyx - dressing intact - wound care department aware. Follow-up interview on 11/14/24 at 4:33 PM with the Wound Care Nurse revealed she did not review the 24-hour report in paper form. She stated she reviewed the 24-hour report in PCC, and it did not address Resident #42. She stated she normally did review both forms of communication, but she just forgot to review the 24-hour report paper form. She stated she contacted LVN TT. and it was reported that LVN TT had notified the NP and obtained orders. She stated LVN TT told her that she documented in the progress notes; however, LVN TT did not generate the order in the system. She stated all nurses could generate orders in the system. She stated the risk of not providing treatment to the resident was that it could lead to an infection. Interview on 11/14/24 at 4:45 PM with the DON revealed when a new wound was noted on a resident her expectations were for the charge nurse to contact the doctor, get orders, and start the treatment. She stated LVN TT did the correct thing by contacting the NP, obtaining orders, and documenting in the notes in PCC. She stated LVN TT documented in the 24-hour report and noted she had notified the Wound Care Nurse. However, the Wound Care Nurse stated she was not made aware of the wound. The DON stated the orders should be generated in PCC, if not, it would not be communicated within the nurses. She stated 24-hour reports were reviewed every morning during morning meeting. She stated Resident #42 report note was not picked up on. She stated the potential risk to the resident if treatment was not provided could lead to a decline of the wound. She stated she was glad LVN TT notified the NP and obtained order. She stated LVN TT was certain she generated the orders in PCC. Record review of Resident #42's Weekly Body Assessment completed on 11/14/24 reflected the following: New Skin Concern - Right buttock 2cm x 1cm treatment stated - Left buttock 1.5cm x 1cm treatment started. Record review of the facility's current Wound Care policy, revised November 2017, reflected: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure . .12.Dress wound. Pick up sponge and apply directly to area. [NAME] tape with initial, time and date and apply to dressing . The following information should be recorded in the resident's medical records: 1. The type of wound care given. 44140

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Resident #84) reviewed for pharmaceutical services. LVN O failed to follow physician orders for administering a Scopolamine Transdermal Patch, which was used to prevent nausea and vomiting, to Resident #84 on 11/12/24. This failure could put residents at risk of not receiving their medications as ordered. Findings included: Record review of Resident #84 's quarterly MDS assessment, dated 10/11/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included Myopathy (general term referring to any disease that affects the muscles that control voluntary movement in the body)and Dementia (general term for a decline in mental abilities that affects a person's daily life).The MDS indicated resident had severely impaired cognition. Record review of Resident #84's November 2024 Physician Orders dated 3/23/2024 reflected the following: Scopolamine Transdermal Patch 72 Hour (Scopolamine). Apply 1 patch transdermal every 72 hours. Observation on 11/14/24 at 10:00 AM with the DON, revealed Resident #84 was having 2 Scopolamine Transdermal patches on the right ear dated 11/9 /24 and 11/12/24.Resident skin was intact. Telephone interview with LVN O on 11/14/24 at 2:59 PM revealed she was the one that applied the patch dated 11/12/24 on Resident #84, she stated she did not see the patch dated 11/09/24. LVN O stated she was aware she was supposed to remove the old patch before administering the new one. She stated the risk of not removing the old patch was over medication and skin irritation. LVN O stated she had done in services on medication administration. Interview with the DON on 11/14/24 at 4:24 PM revealed her expectation was that nurses should remove the old patch before applying the new patch. She stated failure to remove the old patch would lead to overdose. She stated facility had done in-service on medication administration on but not on patches removal. No dated training was provided. Record review of the facility trainings revealed LVN O had skill checks but no date on the training. Record review of the facility's current Pharmacy Services policy, dated April 2007, reflected the policy did not address patch administration and removal. The DON stated they did not have a policy that addressed patch removal.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 of 5 residents (Resident #55 and Resident #10) reviewed for quality of care. 1. The facility failed to ensure LA Z did not pick Resident #55 up and place her in her wheelchair before a nurse was able to complete an assessment after she fell out of her wheelchair onto the hard-wood floor in the dining room on 11/12/24. Resident #55 was seen on the floor with a pool of blood around her head and was moaning in pain after she fell . The facility failed to ensure CNA Y did not remove Resident #55 from the dining room area after she had a fall from her wheelchair, before she could be assessed by a nurse, and while she was actively bleeding from her head. 2. The facility failed to ensure Resident #10's dressings on her left heel, leg, and right hip were dated as per the facility policy. These failures could place residents at risk of not receiving necessary medical care, harm, and death. Findings included: 1. Record review of Resident #55's Admission Record, dated 11/12/24, reflected the resident was an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #55's Quarterly MDS Assessment, dated 08/26/24, reflected she had a BIMS score of 00 indicating severe cognitive impairment. Resident #55 was noted to use a wheelchair and required substantial/maximal assistance (meaning helper did more than half of the effort) for sit to stand transfers. Resident #55's active diagnoses included non-traumatic brain dysfunction (brain injuries not caused by external force), non-alzheimer's dementia (the loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform their usual daily activities), and senile degeneration of the brain (a decline in cognitive function, memory, and behavioral abilities). Resident #55 was also noted to have had falls since the prior assessment was completed that resulted in two or more falls with and without injuries. Record review of Resident #55's Physician's Orders reflected the following: Clean abrasion to right forehead with wound cleaner then pat dry leaving open to air daily every day shift for abrasion with a start date of 11/12/24. Record review of Resident #55's Care Plan reflected the following: Focus: The resident has had an actual fall .Goal: The resident will resume usual activities without further incident through the review date . Record review of Resident #55's Fall Risk Screening, dated 11/12/24, reflected a score 15, indicating a high fall risk. Record review of Resident #55's Progress notes reflected the following: - the Wound Care Nurse on 11/12/24 at 11:00 AM wrote: Res was found on the floor in the dining room attempting to stand without assistance losing balance falling to the floor. Facility staff observed blood coming from face and resident continued attempting to stand unassisted. Facility staff alerted nursing staff of situation. Facility staff assisted resident to wheelchair then to nurse's station. Res is transferred by this nurse writer from wheelchair to bed for full assessment including pain, skin, rom. Abrasion cleaned with normal saline then bandage applied. Neuros started Doctor, DON notified, hospice and [family member] notified as well. Observation and interview on 11/12/24 at 10:00 AM of the 600-hallway revealed LA Z asking for a nurse because a resident had fallen on the hard-wood floor in the dining room. This surveyor walked down the 600-hall to find a nurse and went to the dining room to check on the resident. LA Z was kneeled next to Resident #55 who was laying on the floor on her stomach with a pool of blood coming from her head. Resident #55 was observed to be moaning. This surveyor went to another nurse's station and then back down the 600-hall trying to find the nurse when LA Z was seen transferring Resident #55 to her wheelchair while pressing linen to her head where she was bleeding from. This surveyor found CNA Y in a resident's room and explained to her that LA Z had just picked up Resident #55 and placed her in her wheelchair after she had fallen and hit her head and was bleeding. The surveyor asked CNA Y where the nurse was and to check on Resident #55 in the meantime. The surveyor went to the front to have a nurse paged to the dining room as a resident had fallen and the nurse could not be located. The surveyor began walking down the 600-hall again and saw CNA Y wheeling Resident #55 down the hall away from the dining room while pressing linen to her head where she was bleeding from. CNA Y brought Resident #55 to the nurse's station where a nurse met them with a treatment cart. Resident #55 was grimacing and moaning. Observation and interview on 11/12/24 at 10:25 AM of Resident #55 revealed she was sitting in her wheelchair in a common area of the facility. Resident #55 had a large knot on the right side of her forehead with a laceration in the middle of it. Resident #55 said she fell down and hurt herself really bad, but someone picked her up from the floor and put her in her wheelchair. Resident #55 said her head was hurting but she did not have pain anywhere else. Observation on 11/12/24 at 10:30 AM of the dining room revealed it was hard-wood floor and had a yellow wet floor cone that was covering a recently mopped area where Resident #55 had just fallen earlier. Interview on 11/12/24 at 10:56 AM with LA Z revealed he had been employed at the facility for three months. LA Z said he saw a resident had fallen out of their wheelchair in the dining room and as he got closer he realized it was Resident #55. LA Z said he looked down the 600-hall to see if a CNA or nurse was there and could not find anyone but saw a female walk out of a room pushing desk and a clipboard. LA Z asked that person if a nurse was nearby and saw them take off assuming they were looking for a nurse. LA Z said he looked back at Resident #55 and saw blood dripping from her head so he grabbed a pillow case to put on her head. LA Z said he then picked Resident #55 up to put her in her wheelchair to get help at the nurse's station. LA Z said he picked Resident #55 up because he saw her trying to get up on her own and saw the blood coming from her head. LA Z said when he finished putting Resident #55 in her wheelchair he saw a female and a CNA coming out of one of the rooms behind him. LA Z said then the CNA ended up pushing Resident #55 in her wheelchair to the nurse's station. LA Z said he then took off to get a housekeeper to clean and mop up the blood from the dining room floor. LA Z said the CNA told him he was supposed to leave Resident #55 on the floor until a nurse could assess her before moving her. LA Z said the CNA also told him to go wash his hands because he had blood on them and did not use any gloves when he put the pillowcase to her head to stop the bleeding. LA Z said he was not trained before today (11/12/24) on what to do if a resident had a fall. Interview on 11/12/24 at 11:14 AM with CNA Y revealed she came out of a room on the 600-hall when the surveyor came to get her. CNA Y said she walked down the dining room with the surveyor while she explained that Resident #55 had fallen and was bleeding from her head. CNA Y said when she got to the scene LA Z had pick Resident #55 up and placed her in her wheelchair. CNA Y said she saw Resident #55's head was bleeding and there was a pillowcase on her head. CNA Y said the surveyor had explained that someone was coming to the dining room but there was so much going through her mind at the time. CNA Y said her first thought was to stop and make sure Resident #55 was okay and normally people would come to the location to care for the resident where they fell . CNA Y said the fact that LA Z had already picked Resident #55 up from the floor and no one was around, she decided to wheel her to find a nurse. CNA Y said she should have stayed in the dining room area with Resident #55 while the surveyor went to look for the nurse. CNA Y said it could have caused further harm to the resident by moving her and she should not have wheeled her away from the area to the nurse's station. CNA Y said she had been trained before today (11/12/24) to leave the resident where they were and to not move them before the nurse could assess her. Interview on 11/12/24 at 11:20 AM with HK X revealed she knew to not move or pick up a resident if they had a fall but she had not been trained by the facility. Interview on 11/12/24 at 11:27 AM with CNA W revealed she would move a resident from the scene of a fall if they were picked up by someone else before the nurse was able to assess them. CNA W said she had not been trained on what to do when a resident has had a fall before today (11/12/24). Interview on 11/12/24 at 12:25 PM with the Wound Care Nurse revealed she was told Resident #55 had fall on the floor and was transferred from the floor to the wheelchair. The Wound Care Nurse said she did a full assessment on Resident #55 after taking her to her room. The Wound Care Nurse said a full skin assessment was completed and neuro checks were started. The Wound Care Nurse said during the assessment she noted Resident #55 had a skin tear to her forehead that was red with granulated tissue and swollen. The Wound Care Nurse said Resident #55 told her that she was picking things up off the floor and then boom and that guy picked her up like a baby and put her in the chair and then [the Wound Care Nurse] came. The Wound Care Nurse said Resident #55 was on routine pain medicine and she did not have any pain anywhere else. The Wound Care Nurse said staff were not allowed to move a resident after they've had a fall because the nurse needed to complete an assessment. The Wound Care Nurse said LA Z should not have picked Resident #55 up and CNA Y should not have wheeled her away from the area. Interview on 11/12/24 at 1:00 PM with the ADON revealed she heard the page overhead for a nurse to come down to the dining room. The ADON said she later saw Resident #55 at lunch eating and saw she had an abrasion to her forehead. The ADON said if a resident had a fall, the staff who found her should get a nurse immediately. The ADON said the resident had to be assessed by a licensed nurse before being moved in anyway. The ADON said LA Z told her he did pick up Resident #55 before she was assessed by a nurse. The ADON said she also saw CNA Y wheeling Resident #55 down the hallway before she was assessed by a nurse. Interview on 11/12/24 at 1:23 PM with the DON revealed LA Z saw Resident #55 on the floor and hollered out for a nurse. The DON said LA Z picked up Resident #55 from the floor and put her in her wheelchair. The DON said CNA Y then walked around the corner and saw Resident #55 in her wheelchair and did not see a nurse so rolled the resident to the nurse's station. The DON said Resident #55 was assessed by a nurse and was noted to have a head injury. The DON said Resident #55 must have hit her head on the floor because she had a round bruised area to the right side on her forehead. The DON said Resident #55's family, doctor, and hospice company were contacted about the incident. The DON said all staff should know that if they were not a nurse they leave them there and get a nurse. The DON said the nurse has to complete an assessment before being moved because it could cause further harm. The DON said LA Z told her that he did not know to do that at the time. The DON said CNA Y's train of thought was that since Resident #55 was already up in her wheelchair she needed to get her to the nurse. The DON said she did tell CNA Y that she should have left Resident #55 in the area of where she fell and not moved her. The DON said staff were trained on what to do when a resident had a fall but she was not sure if the training was provided to non-direct care staff. The DON said she saw the importance from what happened today to change that because non-direct care staff do not need to be picking up residents from the floor after a fall. The DON said each department head was responsible for ensuring their employees were trained on different topics. The DON said she expected staff to wait for a nurse to come and assess the resident and not move them at all or from the area. The DON said if the resident was moved prior to a nurse's assessment that could cause further injury. The DON said she was ultimately responsible for ensuring residents were not moved prior to being assessed by a nurse after a fall. Interview on 11/12/24 at 2:05 PM with the HK Supervisor revealed LA Z told him he saw Resident #55 on the floor and since she was bleeding so he picked her up. The HK Supervisor told LA Z he was not supposed to do that and instead was supposed to wait for a nurse. The HK Supervisor said he was responsible for providing trainings to his staff on different topics. The HK Supervisor said he thought he had trained LA Z on what to do when a resident fell but he was not sure. Interview on 11/12/24 at 2:15 PM with the Administrator revealed he found out that LA Z assisted Resident #55 in getting back to her wheelchair after she fell . The Administrator said CNA Y took Resident #55 in her wheelchair from the area where she fell to the nurse's station. The Administrator said Resident #55 had some bruising and a laceration to her forehead, but she was stable and acting as herself. The Administrator said LA Z should not have picked Resident #55 up from the ground, that it was not right to do that if he was not certified or licensed to do so. The Administrator said he was unsure if LA Z had been trained on what to do when a resident had a fall. The Administrator said all staff should know to never pick up a resident before a nurse completes an assessment. The Administrator said he ideally hoped what staff would do even if they were not trained was to notify a certified person like a nurse before moving them in anyway. Interview on 11/12/24 at 2:29 PM with HR revealed she was only responsible for orientation trainings that covered fall prevention when someone was newly hired. HR explained that department heads or the nursing department was responsible for any additional trainings for their staff. Interview on the phone on 11/12/24 at 5:16 PM with Resident #55's family member revealed there was a language barrier, but they were aware she had a fall and that she was okay. Interview on the phone on 11/12/24 at 5:18 PM with Physician V revealed he was unsure if the facility had communicated with him about Resident #55's fall and would have to confirm with his NP and office staff first. The surveyor never received any follow-up phone calls. Interview on the phone on 11/12/24 at 5:28 PM with Resident #55's Hospice company revealed a message was left for the Case Manager to call back at a later time with the information being requested. Record review of LA Z's personnel file reflected he was trained regarding fall prevention on 08/02/24, which did not include information on what to do after a resident has already fallen. Record review of the facility's Falls and Fall Risk, Managing policy, revised 11/14/23, reflected the following: According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Record review of the facility's undated policy titled Falls- Clinical Protocol reflected the following: .2. In addition, the nurse shall assess and document/report the following as needed 2. Record review of Resident #10 's quarterly MDS assessment, dated 10/17/24, reflected the resident was a [AGE] year-old female admitted to the facility initially on 05/01/20 and readmitted on [DATE], with diagnoses that included pressure ulcers/injuries, had a BIMS score of 11 indicating the resident's cognition was moderately impaired. It also reflected the resident had pressure ulcers/injuries, and she was at risk of developing pressure. Record review of Resident #10's care plan, dated 10/11/24, reflected Resident #10 had a pressure ulcer to the left buttocks, left ischium, and arterial wounds to the right heel, left leg and left heel and abrasion to right leg and hip. Goals: The resident's Pressure ulcer will show signs of healing and remain free from infection. interventions were to administer treatments as ordered and monitor for effectiveness. Record review of Resident #10's physician's orders, dated 10/17/24, reflected the resident had an Arterial Wound to left heel and left leg, clean wound with wound cleanser or Normal saline, then pat dry, lightly pack with dakin soaked gauze to wound, then cover with dry dressing daily and as needed. Resident #10 had other orders dated 10/17/24 Cleanse right ischium abrasion with wound cleanser, pat dry, paint with betadine then calcium alginate, cover bordered gauze daily and as needed. Record review of Resident #10's November MAR on 11/14/24 reflected the last time wound care was performed was on 11/13/24 for his left heel, left leg and right ischium. Observation and interview with Resident# 10 on 11/12/24 at 03:29 PM revealed she had arterial wounds on her bilateral heels and on her bottom. Resident #10 stated she received wound care every day. Observation on 11/14/24 at 12:59 PM with the Wound Care Nurse revealed Resident#10 had a dressing on the right ischium, left heel and left leg that was clean and was not dated. Interview on 11/14/24 at 1:01 PM with the Wound Care Nurse revealed she was the one who had performed wound care on Resident #10 on 11/13/24 and she dated the sacrum and the left ischium. She stated for the other dressings on the resident's left heels, left leg and right ischium she did not know what happened; she forgot to put the date and initials on 11/13/24. She stated failure to put the date could cause the resident to miss the dressing change. Interview on 11/14/24 at 4:18 PM with the DON revealed her expectation was that nurses put dates on wound dressings for monitoring and ensuring the dressing changes were being done. The DON stated failure to date the dressing would hinder staff from ensuring dressing changes were done timely leading to wounds worsening. The DON stated the Wound Care Nurse was new in that position, but she had received training by a nurse from another facility. She stated she had not done an in-service on wound care with staff. Record review of the facility's current Wound Care policy, revised November 2017, reflected: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure . .12.Dress wound. Pick up sponge and apply directly to area. [NAME] tape with initial, time and date and apply to dressing .

Based on observation, interview, and record review, the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the Stat Survey Agency in accordance with State law through established procedured for two of two incidents (Resident #162 and Resident #300) reviewed abuse, neglect, and misappropriation. 1. The facility failed to report to the State Survey Agency when Resident #162 was found in bed and had been bitten by fire ants. 2. The Administrator, who was the Abuse Prevention Coordinator, failed to report to the State Survey Agency and initiate an investigation after being informed of a written allegation of misappropriation made by Resident #300's family member. This failure could place the residents in the facility at risk of continued abuse and neglect. Findings included: 1. Record review of Resident #162's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), aphasia (a language disorder that makes it difficult to understand and express written and spoken language), stroke, hemiplegia (total or partial paralysis of one side of the body), nontraumatic subarachnoid hemorrhage (intracranial bleeding), and difficulty in walking. Resident #162 had a BIMS of 7 which mean his cognition was severely impaired. The MDS further reflected the resident had impairment to one side of his upper and lower extremities. Resident #162 was dependent upon staff for all ADLs. Record review of Resident #162's care plan revised on 09/18/24 reflected the resident had an ADL self-care performance deficit related to immobility. Interventions included needing assistance from staff for all ADLs. The care plan further reflected the resident had a communication problem related to the diagnosis of aphasia. Interventions included to allow adequate time to respond, repeat as necessary, do not rush and request clarification from the resident to ensure understanding. Record review of Resident #162's weekly body audit dated 10/21/24 reflected he had ant bites to the right and left side of his abdomen. Record review of Resident #162's progress notes dated 10/22/24 reflected the following: Benadryl Allergy Oral Capsule 25MG Give 1 tablet by mouth every 6 hours as needed for itching Observation and interview with Resident #162 on 11/12/24 at 1:23 PM revealed he was in his room sitting in a gerichair. The resident was opening and closing his eyes and when asked how he was doing, he quietly whispered he was ok. The resident was asked if he recalled being bitten by ants and the resident was attempting to speak but closed his eyes and did not respond. Interview on 11/12/24 at 5:15 PM with LVN H revealed CNA BB alerted her that Resident #162 had been found in bed with ants that had been bitten, 10/21/24. LVN H said when she went in the resident's room, she did not see any ants but said Resident #162 was not able to call for help or use his call light due to his condition. She called the doctor and Benadryl was ordered for any discomfort. Interview on 11/13/24 at 1:48 PM with CNA BB revealed she had gone to check on Resident #162 around 7AM and as she pulled the cover back off the resident, she noticed there were a lot of little red ants on the bed and on the resident, 10/21/24. The Wound Care Nurse was in the room at the time the ants were found. CNA BB said as they were trying to strip the bed of the covers, the ants were crawling on her hands as well. Once they got all the ants off the resident and the bed, she noticed Resident #162 had bites on the sides of his abdomen, and his back and also noticed there were food crumbs in his bed. She said Resident #162 did not appear to be in any distress or pain at the time, and was just laying there. CNA BB stated she did not think the resident was able to register what had happened. The resident was taken to the shower right after to make sure all the ants had gotten off him. CNA BB said she worked with Resident #162 again about two days later and during his shower, she had noticed the ant bites had turned in to small pustules. CNA BB further stated that was the first time she had seen any ants in any room or that anyone had been bit. She did not look to see where the ants had come in from because everything happened so fast. Interview on 11/13/24 at 3:29 PM with the Wound Care Nurse revealed she had gone into Resident #162's room for wound care, 10/21/24 and noticed there were ants on his foot and the wound dressing. She immediately took the covers off Resident #162 and noticed he had been bit on his torso, his stomach and possibly his legs. The resident did not appear to be in any distress at the time and was just laying there. Resident #162 was cleaned up and taken to the shower by the aide. The Wound Care Nurse said she noticed a banana peel on the floor and saw ants around that but did not notice where they had come in from. The Wound Care Nurse further stated she was not aware of any other resident being bit and had never seen any ants in other rooms. Observation and interview on 11/12/24 at 3:32 PM with Pest Control revealed he was onsite at the facility treating/spraying one of patios. He said he regularly serviced the facility and had been called after the incident, 10/21/24, because ants had been found in the interior of the facility in the 500 rooms. Once he arrived on 10/23/24, he did not see any active ants inside the rooms and when he treated the outside, he found 3 mounds of fire ants and they had been up against the wall of the 500 hall, where Resident #162 had resided at the time he was bitten. Record review of the Pest Control log book on 11/14/24 reflected the facility had been treated on the following dates: 10/08/24 - preventative maintenance treatment throughout the exterior perimeter and service rodent bait stations. No reported activity by [Maintenance Director] 10/23/24 - serviced rooms 501, 502, 504, 506, 507, 508, 509, for ants and treated kitchen. 11/13/24 - treated the exterior perimeter and ant [NAME] against the building and the surrounding areas of the exterior of building perimeter where they found active [NAME] against the sidewalk close to the fire hydrant and also treated both courtyards. 2. Record review of Resident #300's MDS reflected the resident was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #300 discharged on [DATE]. His diagnoses included renal insufficiency, anemia, liver transplant status, and septicemia. Resident #300 had a BIMS of 8 suggesting the resident has moderate cognitive impairment. Interviews were attempted with complainant on 11/12/24 at 10:10 AM, 11/13/24 at 2:22 PM, and 11/14/24 at 1:46 PM. Interview with Administrator on 11/14/24 at 2:01 PM revealed that Administrator had been employed at the facility for four months. Administrator stated that Resident #300's family came to the facility on [DATE] and picked up the resident's personal belongings. Administrator said that the family called about a week later and stated that the resident's phone and wallet were missing. Administrator stated that he went and checked the nurses' carts, rooms, etc. but could not located the missing items. Administrator revealed that he interviewed the staff the following day and determined that a CNA observed the emergency transport company place the resident's wallet and phone on the resident before they wheeled him out of the facility. Administrator stated that he phoned the family and suggested that they call the ambulance/transport company or hospital to determine if they had seen the wallet and phone. Administrator said that the family filed a police report, and the police came and interviewed him about the missing wallet and phone. Administrator was unable to provide documentation about the police interview/investigation. Administrator revealed that he did not file a report with State Survey Agency because he did not believe the wallet and phone were stolen. Administrator stated that he did not know the facility policy of an allegation of misappropriation of resident property. Administrator revealed that what he normally does when he has an allegation of misappropriation of property was first search for the missing item. If the item was not found, he reported it to State Survey Agency, resident's physician, ombudsman, responsible part, APS, and law enforcement. Record Record review of October 2024 grievances reflected no grievances regarding the resident's missing items. Record Record review of the facility's policy titled Abuse and Reporting Policy revised July 2017, reflected the following: Policy: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Reporting 1. All alleged violations including abuse, neglect, exploitation, or mistreatment, including injuries of an unknow source, and misappropriation of property will be reported by the facility administrator, or his or her designee, to the following persons or agencies; a. The State licensing/certification agency responsible for surveying/licensing the facility. 48236

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect and misappropriation for two of two incidents (Resident #162 and Resident #300) reviewed for reporting. 1. The facility failed to follow their policy to report to the State Survey Agency when Resident #162 was found in bed and had been bitten by fire ants. 2. The Administrator, who was the Abuse Prevention Coordinator, failed to follow their policy to report to the State Agency and initiate an investigation after being informed of a written allegation of misappropriation made by Resident #300's family member. This failure could place the residents in the facility at risk of continued abuse and neglect. Findings included: Record Review of the facility's policy titled Abuse and Reporting Policy revised July 2017, reflected the following: Policy: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Reporting 1. All alleged violations including abuse, neglect, exploitation, or mistreatment, including injuries of an unknow source, and misappropriation of property will be reported by the facility administrator, or his or her designee, to the following persons or agencies; a. The State licensing/certification agency responsible for surveying/licensing the facility. 1. Review of Resident #162's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), aphasia (a language disorder that makes it difficult to understand and express written and spoken language), stroke, hemiplegia (total or partial paralysis of one side of the body), nontraumatic subarachnoid hemorrhage (intracranial bleeding), and difficulty in walking. Resident #162 had a BIMS of 7 which mean his cognition was severely impaired. The MDS further reflected the resident had impairment to one side of his upper and lower extremities. Resident #162 was dependent upon staff for all ADLs. Review of Resident #162's care plan revised on 09/18/24 reflected the resident had an ADL self-care performance deficit related to immobility. Interventions included needing assistance from staff for all ADLs. The care plan further reflected the resident had a communication problem related to the diagnosis of aphasia. Interventions included to allow adequate time to respond, repeat as necessary, do not rush and request clarification from the resident to ensure understanding. Review of Resident #162's weekly body audit dated 10/21/24 reflected he had ant bites to the right and left side of his abdomen. Review of Resident #162's progress notes dated 10/22/24 reflected the following: Benadryl Allergy Oral Capsule 25MG Give 1 tablet by mouth every 6 hours as needed for itching Observation and interview with Resident #162 on 11/12/24 at 1:23 PM revealed he was in his room sitting in a gerichair. The resident was opening and closing his eyes and when asked how he was doing, he quietly whispered he was ok. The resident was asked if he recalled being bitten by ants and the resident was attempting to speak but closed his eyes and did not respond. Interview on 11/12/24 at 5:15 PM with LVN H revealed CNA BB alerted her that Resident #162 had been found in bed with ants that had been bitten, 10/21/24. LVN H said when she went in the resident's room, she did not see any ants but said Resident #162 was not able to call for help or use his call light due to his condition. She called the doctor and Benadryl was ordered for any discomfort. Interview on 11/13/24 at 1:48 PM with CNA BB revealed she had gone to check on Resident #162 around 7AM and as she pulled the cover back off the resident, she noticed there were a lot of little red ants on the bed and on the resident, 10/21/24. The Wound Care Nurse was in the room at the time the ants were found. CNA BB said as they were trying to strip the bed of the covers, the ants were crawling on her hands as well. Once they got all the ants off the resident and the bed, she noticed Resident #162 had bites on the sides of his abdomen, and his back and also noticed there were food crumbs in his bed. She said Resident #162 did not appear to be in any distress or pain at the time, and was just laying there. CNA BB stated she did not think the resident was able to register what had happened. The resident was taken to the shower right after to make sure all the ants had gotten off him. CNA BB said she worked with Resident #162 again about two days later and during his shower, she had noticed the ant bites had turned in to small pustules. CNA BB further stated that was the first time she had seen any ants in any room or that anyone had been bit. She did not look to see where the ants had come in from because everything happened so fast. Interview on 11/13/24 at 3:29 PM with the Wound Care Nurse revealed she had gone into Resident #162's room for wound care, 10/21/24 and noticed there were ants on his foot and the wound dressing. She immediately took the covers off Resident #162 and noticed he had been bit on his torso, his stomach and possibly his legs. The resident did not appear to be in any distress at the time and was just laying there. Resident #162 was cleaned up and taken to the shower by the aide. The Wound Care Nurse said she noticed a banana peel on the floor and saw ants around that but did not notice where they had come in from. The Wound Care Nurse further stated she was not aware of any other resident being bit and had never seen any ants in other rooms. Observation and interview on 11/12/24 at 3:32 PM with Pest Control revealed he was onsite at the facility treating/spraying one of patios. He said he regularly serviced the facility and had been called after the incident, 10/21/24, because ants had been found in the interior of the facility in the 500 rooms. Once he arrived on 10/23/24, he did not see any active ants inside the rooms and when he treated the outside, he found 3 mounds of fire ants and they had been up against the wall of the 500 hall, where Resident #162 had resided at the time he was bitten. Review of the Pest Control log book on 11/14/24 reflected the facility had been treated on the following dates: 10/08/24 - preventative maintenance treatment throughout the exterior perimeter and service rodent bait stations. No reported activity by [Maintenance Director] 10/23/24 - serviced rooms 501, 502, 504, 506, 507, 508, 509, for ants and treated kitchen. 11/13/24 - treated the exterior perimeter and ant [NAME] against the building and the surrounding areas of the exterior of building perimeter where they found active [NAME] against the sidewalk close to the fire hydrant and also treated both courtyards. 2. Record review of Resident #300's MDS reflected the resident was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #300 discharged on [DATE]. His diagnoses included renal insufficiency, anemia, liver transplant status, and septicemia. Resident #300 had a BIMS of 8 suggesting the resident has moderate cognitive impairment. Interviews were attempted with complainant on 11/12/24 at 10:10 AM, 11/13/24 at 2:22 PM, and 11/14/24 at 1:46 PM. Interview with Administrator on 11/14/24 at 2:01 PM revealed that Administrator had been employed at the facility for four months. Administrator stated that Resident #300's family came to the facility on [DATE] and picked up the resident's personal belongings. Administrator said that the family called about a week later and stated that the resident's phone and wallet were missing. Administrator stated that he went and checked the nurses' carts, rooms, etc. but could not located the missing items. Administrator revealed that he interviewed the staff the following day and determined that a CNA observed the emergency transport company place the resident's wallet and phone on the resident before they wheeled him out of the facility. Administrator stated that he phoned the family and suggested that they call the ambulance/transport company or hospital to determine if they had seen the wallet and phone. Administrator said that the family filed a police report, and the police came and interviewed him about the missing wallet and phone. Administrator was unable to provide documentation about the police interview/investigation. Administrator revealed that he did not file a report with State Survey Agency because he did not believe the wallet and phone were stolen. Administrator stated that he did not know the facility policy of an allegation of misappropriation of resident property. Administrator revealed that what he normally does when he has an allegation of misappropriation of property was first search for the missing item. If the item was not found, he reported it to State Survey Agency, resident's physician, ombudsman, responsible part, APS, and law enforcement. Record review of October 2024 grievances reflected no grievances regarding the resident's missing items. 48236

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for the lunch meal on 11/13/24 for 1 of 2 reviewed (Resident #11) for food and nutrition services. The facility failed to ensure residents on a pureed diet were served pureed bread during the lunch meal on 11/13/24. This failure could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances. Findings included: Record review of Resident #11's face Sheet, dated 11/13/24, reflected the resident was a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Record review of Resident #11's undated consolidated physician's orders reflected the resident had an active order for a regular/enhanced diet, pureed texture, nectar thick consistency starting on 10/28/24. Record review of Resident #11's MDS, dated [DATE], reflected primary diagnoses of congestive heart failure, dysphagia, muscle wasting, malnutrition, and renal insufficiency. Resident also had a BIMS score of 11. Further review reflected Resident #11 required a mechanically altered therapeutic diet. Record review of Resident #11's undated care plan reflected, Focus: The resident has potential nutritional problem, pureed diet, NTL. Uses divider plate. Goal: The resident will maintain adequate nutritional status as evidenced by maintaining weight within 5% of her BASELINE, no s/sx of malnutrition, through review date. Interventions: Monitor/document/report PRN any s/sx of dysphagia: pocketing, chocking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concern during meals. Monitor/record report to MD PRN s/sx of malnutrition: Emaciation (Cachexia) muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7% in 3 months, >10 % in 6 months. Provide and serve diet as ordered. **PUREED****NECTAR LIQUIDS**. Provide, serve diet as ordered. Monitor intake and record q meal. RD to evaluate and make diet change recommendations PRN. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Administer medications as ordered. Monitor/Document for side effects and effectiveness. Record review of Order Listing Report dated 11/14/24 reflected the facility had eight total residents on a pureed diet. Record review of the facility's menu for the lunch meal on 11/13/24 revealed country fried steak with cream gravy, garlic mashed potatoes, buttered carrots, warm roll, chocolate Oreo pudding, and beverage. Observation on 11/13/24 at 11:10 AM revealed that [NAME] RR did not puree rolls for the facility's lunch meal. Observation on 11/13/24 at 12:45 PM revealed the pureed test tray provided to survey team did not have a pureed roll. The regular test provided to survey team did have a roll. Observation on 11/13/24 at 1:23 PM revealed that Resident #11 did not receive pureed bread on her lunch plate. Interview on 11/13/24 at 1:45 PM with [NAME] RR revealed that he forgot to puree the dinner roll. [NAME] RR was unable to answer further questions about pureed meals. Interview on 11/13/24 at 1:50 PM with the Dietary Manager, who had been employed at the facility for two days, revealed that the facility policy stated that regular, puree, and mechanical soft diets were all supposed to receive the same items on the menu but in different forms (textures). The Dietary manager stated that this was important so that residents on pureed and mechanical soft diets do not experience negative mental and effects from eating different foods from residents with regular diets. The Dietary Manager added that it was important also so that the residents did not experience any negative health effects due to a lack of nutrition. The Dietary Manager said that he would be in-servicing his staff on nutrition value as well as the risk of residents not receiving all items listed on the menu. The dietary manager stated that he would be putting systems in place to ensure this did not occur in the future. Interview on 11/13/24 at 1:54 PM with the Dietician revealed that the policy stated that dietary staff were to follow the diet menu spreadsheet provided by the food service products distributer. She stated that the importance was because it was nutritionally designed to meet residents' needs. If all the items were not prepared that were on the spreadsheet, then the resident can have a negative clinical outcome. The Dietician stated that she last in-serviced on 10/25/24 on following menus and diet textures. Record review of the facility's Menus policy, revised October 2008, reflected the follow: Menus shall a) meet the nutritional needs of residents; b) be prepared in advance; and c) be followed.

Based on interviews and record reviews the facility failed to ensure residents were free from abuse and exploitation for 1 (Resident #1) of 5 residents reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was protected from sexual abuse by Resident #2, who had a history of being inappropriate with female residents. Resident #1 reported that Resident #2 came into her room on 02/23/24 at 3:00 AM and removed her brief and attempted to have non-consensual intercourse with the resident. An IJ was identified on 03/13/24. The IJ template was provided to the facility on [DATE] at 10:45 AM. While the IJ was removed on 03/13/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on documenting inappropriate behavior. This failure could place residents at risk of sexually inappropriate behaviors from other residents. Findings included: Review of Resident #1's undated Admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, stroke, and fluid on the brain. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 7, indicating she was severely cognitively impaired. Her Functions Status indicted she required maximum assistance with toileting, and moderate assistance with bathing, hygiene, and dressing her lower body. Review of Resident #1's care plan, dated 12/22/23, revealed she was dependent on staff to meet her emotional, intellectual, physical and social needs related to cognitive deficits. Interventions included activities that do not involve demanding cognitive tasks. Resident #1 also had limited mobility related to Parkinson's. Family had requested no male residents in Resident #1's room and no sexual activity related to impaired cognition, with interventions including intervening as necessary to protect her rights and safety. Resident #1 also had impaired cognitive function related to her stroke. Resident #1 was being monitored for her psychosocial well-being related to alleged sexual contact. Review of Resident #2's undated Admission Record revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses that included heart failure, and diabetes. Review of Resident #2's admission MDS, dated [DATE], revealed a BIMS score of 15, indicating he was cognitively intact. His Behavioral Assessment indicated he had no changes in his behaviors. His Functional Status indicated he was independent in his ADLs except for bathing which required partial assistance. Review of Resident #2's care plan, dated 12/18/23, revealed he had not been placed at risk for inappropriate behaviors. Review of Resident #3's undated Admission Record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes, prostate cancer, and presence of genital implants. Review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating he was cognitively intact. His Behavioral Assessment revealed no changes in his behaviors. His Functional Status indicated he required a wheelchair for mobility and he required partial assistance with most of his ADLs except eating and hygiene. Review of Resident #3's care plan, dated 12/11/23, indicated he had a behavior occurrence, with interventions including intervening as necessary to protect the rights and safety of others and monitoring of behaviors episodes to identify the underlying cause. Review of the facility's Provider Investigation Report revealed on 02/23/24 about 3:00 AM Resident #2 was observed exiting Resident #1's room and returning to his room. The CNA that observed this notified the nurse who entered Resident #1's room to find her in bed with her private area exposed. Resident #1 stated he took it off when asked why her brief was pulled down. Notifications were made to the DON and the Administrator. The DON questioned Resident #1 and asked if Resident #2 had tried to have sex with her, Resident #1 stated he tried but it was too tight. Resident #2 was placed on 1:1 observation and the police were called. The police interviewed Resident #1 and she denied anything had happened, so they opted not to press charges against Resident #2. Resident #1 was sent to the hospital for a SANE exam. The exam was not done because the family declined it, and there was not a police agency to take possession of any evidence collected. The resident was returned to the facility. Resident #2 was emergently discharged that same day. Interview on 03/12/24 at 9:10 AM the Administrator revealed he interviewed Resident #2, and he stated Resident #2 knew there had to be consent before he could do anything with another resident. Resident #1's ability to consent was questionable because of her BIMS score, she did not call out for help, and her story changed when the police questioner her. Safe Surveys of all residents revealed no other victims. The Administrator stated talking to Resident #2 was like talking to a [AGE] year-old. Interview on 03/12/24 at 11:35 AM, Resident #1 was hesitant to answer questions, even with a female surveyor present to interview her. Resident #1 stated she woke up to see an unknown male in her room, when he pulled the sheets back he thought he was a staff member coming to do a procedure. She did not object until he penetrated her vagina, at which time she told him to stop and get out of her room. Resident #1 stated he left her room in a hurry. Resident #1 stated she did not know something was wrong until she was repeatedly interviewed by multiple people. Resident #1 stated she just tries to put it out of her mind and not think about it. Interview on 03/12/24 at 12:24 PM, the Social Worker stated there had been multiple incidences of Resident #2 engaging in possibly inappropriate behavior with other female residents. Twice he was noted to kiss two female residents. He spent a lot of time in female resident rooms, would hold the hand of female residents in the hallway, and one incident of a female resident getting into his bed, fully clothed, while Resident #2 was in the shower. The Social Worker stated there had been multiple conversations with Resident #2 about appropriate behavior and personal space. She stated none of the incidences were reported because they involved residents that could consent. The only incident that involved someone not able to consent was the incident with Resident #1. Interview on 03/12/24 at 12:50 PM, CNA A stated she had been walking down the 200 Hall around 3:00 AM on 02/23/24 to retrieve linen for a resident that had vomited in her bed when she observed Resident #2 leaving Resident #1's room in a hurry. When CNA A asked why he had been in Resident #1's room he seemed very nervous and stumbled over his words. Resident #2 finally stated his roommate needed to be changed. CNA A checked the roommate who denied needing to be changed. CNA A then went to Resident #1's room and observed Resident #1 exposed from the waist down, knees bent, and her brief around her ankles. CNA A notified the nurse and another CNA. After CNA A cleaned her resident up she was assigned to monitor Resident #2 1:1, which she did until the end of her shift. CNA A stated she had been told to keep an eye on Resident #2 when he was around female residents because he seemed to be too friendly with them. She stated she had never heard of Resident #2 being sexually inappropriate with anyone. Interview on 03/12/24 at 1:15 PM, LVN B stated she had been called to Resident #1's room on 02/23/24 about 3:00 AM. When she observed Resident #1 exposed she asked her what had happened. Resident #1 stated he did it, indicating the male who had just left her room. LVN B attempted to ask more questions but Resident #1 seemed to be in shock and did not want to talk about it. When she spoke to Resident #2, he seemed nervous but denied doing anything other than going into Resident #1's room. She notified the DON immediately. LVN B stated Resident #2 was known to go into female resident rooms and had been told not to do that, and their monitoring had never indicated anything inappropriate had occurred. Interview on 03/12/24 at 1:40 PM, RN C stated Resident #2 was known to kiss on female residents, hold their hands, spend a lot of time in female resident rooms. These actions had been reported to the DON when they occurred, but the DON stated as long as both residents were consenting, they couldn't stop them. Resident #2's behaviors were documented in the 24-hour logbook. RN C stated the staff knew Resident #2 needed to be monitored because he knew what he was doing, and he was moving from female to female trying to find one that would be receptive to his advances. Review of Resident #2's psychiatry note for 2/22/24 reflected the resident was being treated for depression, anxiety, and coping skills. No indication of inappropriate or sexual behaviors had been reported to the psychologist. Review of the 200 Hall 24-hour logbook for February 2024 indicated: 02/01/24 - [Resident #2]. Watch for kissing female residents 02/02/24 - [Resident #2] Watch for behaviors. Watch for physically being inappropriate with females 02/04/24 - [Resident #2] Watch from going closer to [Resident #4] 02/05/24 - [Resident #4] In [Resident #2's] bed fully dressed asked to return to room. [Resident #2] Monitor behaviors. Inviting [Resident #4] to bed 02/06/24 - [Resident #4] Monitor behaviors. [Resident #2] Monitor behaviors 02/07/24 - [Resident #4] Monitor behaviors [Resident #2] Monitor behaviors Interview on 03/12/24 at 2:15 PM, the DON stated when the police had questioned Resident #2 he admitted to touching Resident #1 in the private area after she had touched him in his private area. When the police questioned Resident #1 and she told them nothing had happened, the police informed the DON they would not press any charges against Resident #2. Resident #1 was sent to the hospital for an exam and was returned to the facility without the exam being done. Resident #2 had been placed on 1:1 monitoring in the facility's conference room while the investigation was done, and he was discharged that same afternoon. The DON stated when she asked Resident #2 why he had gone to Resident #1's room at 3:00 am he stated he went to check on his friend. Interview on 03/12/24 at 2:30 PM, the Administrator stated he thought he had done everything he could do to protect the residents. He stated there was a current resident (Resident #3) who exhibited the same behaviors as Resident #2, and he had tried to discharge him. Resident #3 appealed the discharge and won because nothing physical had occurred by Resident #3. The Administrator stated that made them hesitant to discharge Resident #2 when he was admitted and began to exhibit the same behaviors as Resident #3. Review of the facility's policy Abuse and Neglect dated 10/15/22, reflected: The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe environment and protect residents from abuse. Sexual abuse is defined as non-consensual sexual contact of any type with a resident On 03/13/24 at 10:45 AM, the Administrator was notified that an Immediate Jeopardy in the areas of Abuse, Neglect, and Exploitation. The facility submitted the following acceptable Plan of Removal on 03/13/24 at 1:48 PM: Survey (Complaint) - 03/13/2024 F 600 Freedom from Abuse and Neglect Plan 1. Resident #1 was assessed with no injuries noted from abuse on 2/23/24 by , [LVN B] 2. Safe Survey Checks - were conducted and completed on 2/23/2024 on all residents by Administration staff to assess, identify and prevent abuse. Re evaluated 3/13/24 on all res by Social service/Nursing to ensure inappropriate behaviors are being identified and initiate monitoring. 3. Medical Director notified. 4. Once identified behaviors monitoring sheets specific kissing, spending time in res room, hand holding will be immediately initiated 3/13/24. 5. Staff will be in-serviced on this process 3/13/24. a. Safe Survey Checks will be conducted by Administrative designees on random residents weekly for 30 days, then monthly thereafter. Any negative finding will be reported to the Administrator and acted on immediately. 6. The Safe Survey Checks were reviewed and checked by the Administrator for any abuse or mistreatment of residents on 3/13/24 a. Safe Survey Checks will be reviewed by Administrator weekly for 30 days then monthly thereafter. Any negative finding will be acted upon immediately. 7. The Director of Nursing and Administrator will in-service all scheduled employees on abuse and mistreatment starting immediate 3/13/24. a. All remaining employees will be in-serviced on abuse or mistreatment of residents prior to shift start, by Administrative or designee by 3/13/24. a. The Director of Nursing and Administrator will in-service all scheduled staff starting on 3/14/2024 on abuse prevention program/ behavior monitoring. 3/13/24 b. All remaining employees will be in-serviced on abuse prevention program prior to the shift start and behavior monitoring, by Administrative or designee by 3/14/2024. a. Administrator/Designee will do random Audits of with residents behaviors sheets to monitor for behaviors, Daily and PRN Starting 3/13/2024 8. Any negative findings from the behavior observation will be acted on by the Administrator immediately then report findings to the Q.A.P.I. weekly for 30 days, then monthly thereafter. 9. Estimated completion date 3/14/2024. 10. Should a resident of informed capacity be observed engaging in a behavior that might have the potential to be considered inappropriate with a resident of uninformed capacity: That resident's behavior will be care planed for a meeting with administration / designee discussing acceptable behavior and informed consent. Clinical monitoring documented thru behavioral sheets will occur per shift until experiences discharge or a clinical change of condition which would revaluate their plan of care. Resident RP, MD will be notified. Resident will be referred to social services for psycho social and psychological assessment for intervention. Administration / DON / Designee will review behavioral sheets in Morning QAPI each business day. Should similar behaviors continue the resident will be subject to immediate discharge. 11. The observed residents with uninformed consent Care Plan will be updated to reflect: The observed issues identified with a resident of informed consent. RP, and MD notification. Resident will be referred to social services for psycho social and psychological assessment for intervention. Administration / DON / Designee will review behavioral sheets in Morning QAPI each business day. Monitoring of the Plan of Removal continued and included interviews with staff on day and evening shifts. Interview on 03/13/24 at 2:00 PM, CNAD, dayshift, stated she had been in-serviced on abuse, neglect and exploitation. All touching that is not social was to be reported to the DON or the Administrator. She was to intervene by separating the residents. She was to observe residents that had entered other resident rooms, especially residents that were not cognitive. Interview on 03/13/24 at 2:13 PM, RN C, day shift, stated she had been in-serviced on behaviors, inappropriate behaviors such as kissing and hugging. She was to notify the DON or Administrator if she observed such behavior. She was to make sure the residents involved had their care plans updated to reflect the behaviors. If the behavior appeared not to be consensual, separate the residents and report it. Monitor resident that went into other resident rooms. Interview on 03/13/24 at 2:16 PM, CNA E, day shift, stated she had been in-serviced on sexual abuse and encounters, monitoring resident for inappropriate behavior. She was to make sure any interactions between residents was consensual and if not to notify the DON or the Administrator. Interview on 03/13/24 at 2:24 PM, CNA F, day shift, stated she had been in-serviced on sexual abuse and what to do if she observed any inappropriate behavior with residents that were not cognitively intact. Any inappropriate behavior was to be reported to the DON or the Administrator. Interview on 03/13/24 at 2:26 PM, CNA G, day shift, stated she had been in-serviced on abuse and inappropriate behaviors such as hugging and kissing. She was to separate the residents and report it to the DON or the Administrator. Interview on 03/13/24 at 2:50 PM, CNA H, evening shift, stated she had been in-serviced on sexual abuse and inappropriate behaviors such as kissing and hugging. Any such behaviors were to be reported to the DON or the Administrator. Interview on 03/13/24 at 4:14 PM, CNA I, evening shift, stated she had been in-serviced on abuse and inappropriate behavior such as inappropriate touching, kissing, etc. She was to separate the residents and notify the nurse, the DON, or the Administrator. Interview on 03/13/24 at 4:16 PM, CNA J, evening shift, stated she had been in-serviced on abuse and inappropriate behavior such as kissing or hugging between residents that appear non-consensual or inappropriate. She was to notify the DON or the Administrator. Interview on 03/13/24 at 4:20 PM, the Business Office Manager stated she had been in-serviced on abuse and inappropriate behaviors such as kissing or hugging between residents. If it seems inappropriate she was to notify the Administrator or the DON. Interview on 03/13/24 at 4:22 PM, the Business Office Assistant stated she had been in-serviced on abuse and inappropriate behavior such as hugging or kissing between residents. If it seemed inappropriate, she was to report it to the Administrator or the DON. Interview on 03/13/24 at 4:24 PM, the Admissions Director stated she had been in-serviced on abuse and inappropriate behaviors. She was to report any yelling, kissing, or touching between residents to the Administrator or the DON. Interview on 03/13/24 at 4:30 PM, the HR Director stated she had been in-serviced on abuse and inappropriate behavior. If she observed or suspected any abuse she was to report it to the Administrator or the DON. Interview on 03/13/24 at 4:38 PM, MA K, evening shift, stated she had been in-serviced on abuse and inappropriate behavior such as hugging and kissing between residents that did not appear to welcome the actions. Any suspected abuse was to be reported to the DON or the Administrator. Interview on 03/13/24 at 4:53 PM, RN L, evening shift, stated she had been in-serviced on abuse and inappropriate behavior such as touching, kissing, or hugging and she was to report any behavior to the DON or the Administrator. After the monitoring was completed, the Administrator was informed the Immediate Jeopardy was removed on 03/13/24 at 5:40 PM. The facility remained out of compliance at a severity level of Isolated and a scope of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #2) of 5 residents reviewed for care plans. The facility failed to ensure Resident #2's care plan included his behaviors and monitoring of his behaviors. An IJ was identified on 03/13/24. The IJ template was provided to the facility on [DATE] at 10:45 AM. While the IJ was removed on 3/13/24, the facility remained out of compliance at a scope of Isolated and a severity level of potential for more than minimal harm because all staff had not been trained on documenting inappropriate behavior. This failure could place residents at risk of inappropriate sexual behaviors from other residents. Findings included: Review of Resident #1's undated Admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, stroke, and fluid on the brain. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 7, indicating she was severely cognitively impaired. Her Functions Status indicted she require maximum assistance with toileting, and moderate assistance with bathing, hygiene, and dressing her lower body. Review of Resident #1's care plan, dated 12/22/23, revealed she was dependent on staff to meet her emotional, intellectual, physical and social needs related to cognitive deficits. Interventions included activities that do not involve demanding cognitive tasks. Resident #1 also had limited mobility related to Parkinson's. Family had requested no male residents in Resident #1's room and no sexual activity related to impaired cognition, with interventions including intervening as necessary to protect her rights and safety. Resident #1 also had impaired cognitive function related to her stroke. Resident #1 was being monitored for her psychosocial well-being related to alleged sexual contact. Review of Resident #2's undated Admission Record revealed the resident was a [AGE] year-old male admitted on [DATE] with diagnoses that included heart failure, and diabetes. Review of Resident #2's admission MDS, dated [DATE], revealed a BIMS score of 15, indicating he was cognitively intact. His Behavioral Assessment indicated he had no changes in his behaviors. His Functional Status indicated he was independent in his ADLs except for bathing which required partial assistance. Review of Resident #2's care plan, dated 12/18/23, revealed he had not been placed at risk for inappropriate behaviors. Review of Resident #3's undated Admission Record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes, prostate cancer, and presence of genital implants. Review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating he was cognitively intact. His Behavioral Assessment revealed no changes in his behaviors. His Functional Status indicated he required a wheelchair, for mobility and he required partial assistance with most of his ADLs except eating and hygiene. Review of Resident #3's care plan, dated 12/11/23, indicated he had a behavior occurrence, with interventions including intervening as necessary to protect the rights and safety of others and monitoring of behaviors episodes to identify the underlying cause. Interview on 03/12/24 at 12:24 PM, the Social Worker stated within a few weeks of Resident #2's admission staff began to report his behaviors of spending time with the female residents and holding their hands in the halls. The Social Worker stated there had been multiple conversations held with Resident #2 about appropriate behavior and personal space. Resident #2 indicted he understood each time but continued to have reports of inappropriate behavior with female residents of kissing, hugging, and spending time in their rooms. Staff observed Resident #2 but they never caught him doing anything with residents unable to consent. Interview on 03/12/24 at 1:40 PM, RN C stated reports of Resident #2 kissing other residents had been reported to the DON. The DON stated as long as both residents were consenting and able to consent, they had the right to have a relationship. Interview on 03/12/24 at 2:10 PM, the DON stated consenting cognizant residents had the right to develop relationships and Resident #2's actions had all been with consenting residents until the incident with Resident #1, so they had no reason to monitor his actions. The DON stated the MDS Coordinator was responsible for care plans and keeping them updated. Interview on 03/12/24 at 2:30 PM, the Administrator stated he was aware of Resident #2's penchant to hang around the female residents. The Administrator stated he had spoken with Resident #2 in the past about consent and who could consent, Resident #2 stated he understood. The Administrator stated he had no inclination that Resident #2 would escalate his behaviors like he had allegedly done with Resident #2. The Administrator stated he had another current resident (Resident #3) that had exhibited similar behaviors, but no physically inappropriate actions, and he had attempted to discharge that resident. The resident appealed the discharge and won, so the Administrator had no cause to discharge Resident #2 for the same behaviors until he crossed the line. Interview on 03/12/24 at 3:45 PM, the MDS Coordinator stated she was responsible for creating the comprehensive care plan based on the MDS assessment. Updates to the care plan were made when she was notified during morning meetings. The MDS Coordinator stated she was unaware of Resident #2's behaviors, only Resident #3's and that was why Resident #3's behaviors were added to his care plan. On 03/13/24, the Administrator was notified that an Immediate Jeopardy in the area of Comprehensive Resident Centered Care Plan. The facility submitted the following acceptable Plan of Removal on 03/13/24 at 1:48 PM: Survey (Complaint) - 03/13/2024 F 656 Comprehensive Care Plan Plan 1. Resident #1 was assessed with no injuries noted from abuse on 2/23/24 by, [LVN B] 2. Safe Survey Checks - were conducted and completed on 2/23/2024 on all residents by Administration staff to assess, identify and prevent abuse. Re evaluated 3/13/24 on all res by Social service/Nursing to ensure inappropriate behaviors are being identified and initiate monitoring. 3. Medical Director notified. 4. Once identified behaviors monitoring sheets specific kissing, spending time in res room, hand holding will be immediately initiated 3/13/24. 5. Staff will be in-serviced on this process 3/13/24. a. Safe Survey Checks will be conducted by Administrative designees on random residents weekly for 30 days, then monthly thereafter. Any negative finding will be reported to the Administrator and acted on immediately. 6. The Safe Survey Checks were reviewed and checked by the Administrator for any abuse or mistreatment of residents on 3/13/24 a. Safe Survey Checks will be reviewed by Administrator weekly for 30 days then monthly thereafter. Any negative finding will be acted upon immediately. 7. The Director of Nursing and Administrator will in-service all scheduled employees on abuse and mistreatment starting immediate 3/13/24. a. All remaining employees will be in-serviced on abuse or mistreatment of residents prior to shift start, by Administrative or designee by 3/13/24. a. The Director of Nursing and Administrator will in-service all scheduled staff starting on 3/14/2024 on abuse prevention program/ behavior monitoring. 3/13/24 b. All remaining employees will be in-serviced on abuse prevention program prior to the shift start and behavior monitoring, by Administrative or designee by 3/14/2024. a. Administrator/Designee will do random Audits of with residents behaviors sheets to monitor for behaviors, Daily and PRN Starting 3/13/2024 8. Any negative findings from the behavior observation will be acted on by the Administrator immediately then report findings to the Q.A.P.I. weekly for 30 days, then monthly thereafter. 9. Estimated completion date 3/14/2024. 10. Should a resident of informed capacity be observed engaging in a behavior that might have the potential to be considered inappropriate with a resident of uninformed capacity: That resident's behavior will be care planed for a meeting with administration / designee discussing acceptable behavior and informed consent. Clinical monitoring documented thru behavioral sheets will occur per shift until experiences discharge or a clinical change of condition which would reevaluate their plan of care. Resident RP, MD will be notified. Resident will be referred to social services for psycho social and psychological assessment for intervention. Administration / DON / Designee will review behavioral sheets in Morning QAPI each business day. Should similar behaviors continue the resident will be subject to immediate discharge. 11. The observed residents with uninformed consent Care Plan will be updated to reflect: The observed issues identified with a resident of informed consent. RP, and MD notification. Resident will be referred to social services for psycho social and psychological assessment for intervention. Administration / DON / Designee will review behavioral sheets in Morning QAPI each business day. Monitoring of the Plan of Removal continued and included interviews with the DON and the MDS Coordinator regarding monitoring of care plans. Interview on 03/13/24 at 3:00 PM, the DON stated she would complete the in-service on care plans with the MDS Coordinator as she was the only nurse to make changes to the care plans. Interview on 03/13/24 at 3:45 PM, the MDS Coordinator stated she had been updated by the DON about keeping care plans up to date as soon as she was made aware of changes in the morning meetings. Review of Resident #3's updated care plan revealed a focus of the resident significantly intruding on the privacy of others. Going into other residents rooms and attempts to touch/kiss female residents Interventions included Redirect, and monitor resident location and 30 day discharge if needed Review of the facility's policy Care Plans, Comprehensive Person-Centered, dated December 2016, reflected: .1. The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family develops and implements a comprehensive person-centered care plan for each resident. .8. g. Incorporate identified problem areas. 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. .14. The IDT must review and update the care plan: a. When there has been a significant change in the resident's condition. The Immediate Jeopardy was removed on 03/13/24. While the Immediate Jeopardy was removed on 03/13/24, the facility remained out of compliance at a scope of pattern and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems of the plan of removal.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #53) of eighteen residents reviewed for accidents. CNA F failed to transfer Resident #53 with the assistance of another staff person or the use of the Hoyer lift, which resulted in the resident sustaining a [MEDICAL CONDITION] leg. The failure placed the 18 residents, who were dependent upon staff for transfers, at risk for accidents and injuries. Findings included: Review of Resident #53's MDS assessment, dated 03/22/18, revealed the resident was a [AGE] year-old-male admitted to the facility 12/03/14. The resident's [DIAGNOSES REDACTED]. For surface-to-surface transfers, the resident was not steady and was only able to stabilize with staff assistance. The resident had functional limitation in range of motion in her upper and lower extremity on one side and required the use of a wheelchair for mobility. Review of Resident #53's care plan initiated 03/27/18 revealed he required the assistance of two staff members for transfers. Review of a Provider Investigation Report, signed and dated by the Administrator on 04/05/18, revealed CNA F used an improper transfer technique to transfer Resident #53 on 03/31/18 at 11:00 a.m., which resulted in the resident sustaining a right tibia fracture. The post-investigation provider action included educating all staff on proper and safe transfer techniques to include transfers using gait-belts, slide boards, and Hoyer lifts. Facility staff were also provided in-service training on the Importance of Using Kardex in Patient Room and Problem Solving Difficult Transfers. In addition, CNA F was written up and a Performance Improvement Plan was initiated with the employee. Review of Resident #53's Health Status Note, dated 03/31/18 at 4:27 p.m. entered by LVN E revealed the following: .Complaints of pain that the patient sustained this morning when the aide was getting him out of bed, this nurse assessed the knee earlier in the morning shift and didn't (sic) notice any signs of bruising or warmth to the site, until this time when he (Resident #53) voiced another concern of pain, hence [MEDICATION NAME] 1 po (by mouth) prn (as needed) administered respectively. resident requested for an xray to rule out any fracture, the Dr. on call For (Physician J) paged and the xray was approved, and placed with (x-ray company) pending to be carried out, will monitor. Review of Resident #53's x-ray dated 03/31/18 revealed the resident had an old [MEDICAL CONDITION] knee. Review of Resident #53's Health Status Note, dated 04/01/18 at 6:51 a.m. entered by LVN K revealed the following: X-ray results read out to NP (Nurse Practitioner) and was informed about Pt's (patient's) right lower foot noted swollen. Order received for X-ray to the affected area. Confirmation .received from (x-ray company) for an X-ray to be done this am. Pain management done x1 (one time) on this shift and staff continued to monitor. Review of Resident #53's Health Status Note, dated 04/01/18 at 3:13 p.m. entered by LVN E revealed the following: second X-ray carried out on this shift and came positive for a fracture, (Physician J) was on site, assessed the patient and referred him to (hospital) via (ambulance). ER (emergency room ). no further concerns noted, will monitor. Review of Resident #53's x-ray ordered on [DATE] and read at 12:05 p.m. revealed the resident had an acute distal tibial [MEDICAL CONDITION] leg, which is a [MEDICAL CONDITION] leg. Observation and interview on 04/17/18 at 1:30 p.m. revealed Resident #53 had a cast on his right leg, and his right arm was contracted. When asked about his right leg, Resident #53 revealed an aide was getting him out of bed one morning, and she sat him up on the side of his bed. During the transfer, his good leg got caught on his bad leg, and as the aide kept turning him he heard his leg pop twice. He stated he screamed out because he was in pain once he was in the wheelchair. Resident #53 stated he did not recall if he was assessed by the nurse or if he had let anyone know about the pain he was having, but he was sent out to the hospital the next day. He stated the way he was transferred by staff varied because sometimes he was transferred by one person or two people, and at times he was transferred using the Hoyer lift. Interview with CNA F on 04/19/18 at 9:39 a.m. revealed she began working at the facility (MONTH) (YEAR) and this had not been her first time transferring Resident #53 alone. She stated some staff preferred to use two people to transfer the resident, if they did not feel comfortable transferring him alone. On the day of the incident, she stated she transferred Resident #53 by placing the resident's left foot on his right foot and pivoting over to the wheelchair while she used the gait belt. She stated Resident #53 yelled very loudly during this transfer, and he asked her if she heard his knee pop twice, to which she said no. She reported the incident to the charge nurse, LVN E, and he went in and touched the resident's knee and told her it was not warm and made a hand motion to her, implying he was ok. CNA F stated she thought everything was fine until she saw the resident with a cast on the following day. CNA F stated she received in-service training, and she was told each resident had a Kardex in their closets that told them everything about a resident, including transfers. She stated she was not aware of that system until after the incident with Resident #53. Interview with LVN E on 04/19/18 at 10:36 p.m. revealed the day of the incident, CNA F called him into Resident #53's room because the resident was complaining of knee pain after she got him up for breakfast. He stated he assessed the resident and looked for signs of swelling and touched the resident's knee to see if it was warm to touch, but everything looked fine. The resident was then sent to breakfast and later when the resident was still complaining of pain he called the doctor to order an x-ray. He stated the doctor ordered another x-ray because the first one was inconclusive. LVN E stated he had not called the x-ray in stat because when had assessed the resident earlier that day he had not noticed anything abnormal. Interview with the Weekend Supervisor, RN G, on 04/19/18 at 12:38 p.m. revealed she had worked the weekend of the incident with Resident #53. She stated the resident had showed her his leg pointing to his knee and said someone had hurt his leg during a transfer. RN G stated she told the resident they would get an x-ray ordered because she noticed he had swelling around his knee. RN G did not recall the time but thought it was late afternoon or early evening. She stated she spoke with LVN E and told him to order an x-ray. Before she left her shift, she stated she made sure the x-ray had been ordered. RN G stated she had not been informed about the incident when it occurred that morning. Interview with OTA on 04/19/18 at 1:25 p.m. revealed Resident #53 had been discharged from therapy services on 03/27/18. During his therapy sessions they had been working on transfers and the resident was not able to tolerate the pivots due to his knees so he was discharged from services and determined to require transfers via Hoyer lift. She stated she had been told by staff that Resident #53 refused to use the Hoyer lift. The OTA therapy recommendations were written in the nurses' 24-hour report, and the nurses were notified of the discharge recommendations after a resident discharged from therapy services. Review of Resident #53's Physical Therapy Discharge Summary, signed and dated by PT L on 03/27/18, revealed the resident required maximum assistance with transfers. The recommendation was for the resident to be transferred by Hoyer lift. Review of the 24-Hour Report/Change of Condition Report, dated 03/27/18, revealed Resident #53 required Hoyer lift for transfers. Interview with PT L on 04/20/18 at 10:30 a.m. revealed she had written a recommendation on the 24-Hour Report for Resident #53 to be transferred via Hoyer lift so staff could see it on each shift. She stated she would not have given a verbal report of this recommendation to anyone. Interview with LVN H on 04/20/18 at 1:07 p.m. revealed the 24 hour report was checked before and during change of shift, and he did not recall seeing entry with a recommendation that Resident #53 be transferred by Hoyer lift. Interview with the DON on 04/20/18 at 2:28 p.m. revealed she was notified of the incident with Resident #53 on Sunday, 04/01/18, by RN G. She said she was told there had been two x-rays and a fracture had been identified so the resident was being sent out to the hospital. During her investigation, RN G told her about CNA F transferring the resident. She also told her Resident #53's Kardex posted in his closed showed the resident as being a one to two person transfer. RN G stated the Kardex did not show the resident as requiring a Hoyer lift transfer until she changed it following the incident. At that time, when therapy changes were made the charge nurse was responsible for changing the Kardex in the closet. The DON stated she got a statement from Resident #53 on Monday 04/02/18 revealing that his legs had gotten tangled with each other during his transfer, and that he later told the charge nurse he thought something was wrong and requested an x-ray. She also spoke with LVN E, who said he had assessed the resident, but she was not aware of the timeline and thought he had called to get an x-ray right away. Review of the facility's current Safe Lifting and Movement of Residents policy and procedure, dated (MONTH) (YEAR), revealed the following: .1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan Review of the Resident Census and Conditions of Residents Form CMS-672, signed and dated by MDS Coordinator I on 04/17/18, revealed eighteen residents were dependent upon staff for transfers.

Based on observation, interview and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect of residents for one (Resident #1) of eight residents reviewed for neglect. CNA A had worked with Resident #1 only one time prior to 08/23/14. CNA A had not read the plan of care for Resident #1 and thus was unaware Resident #1 could become resistant to care. On 08/23/14, CNA A assisted Resident #1 with incontinence care and putting on her pants. When she assisted the resident to sit up, the resident began cursing and swinging her arms. CNA A thought the resident was going to fall back and grabbed the resident by the arms resulting in bilateral avulsions (tearing away forcibly of a part or structure) from just below her elbows to just above her wrists. The resident was transferred to a local hospital's ER for evaluation and treatment. On 09/24/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/26/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope "isolated" because the facility was still evaluating the effectiveness of the Plan of Removal. This failure could affect the other 17 residents identified with a history of behaviors at risk of serious injuries due to failure of a nurse aide to know their assessed and care planned level of care and services. Findings included: Resident #1's Admission Record, dated 09/11/14, reflected she originally admitted to the facility on [DATE] and her most recent re-admission was 01/31/14. She was 94-years-old and her [DIAGNOSES REDACTED]. Resident #1's quarterly MDS assessment, dated 08/12/14, reflected she was oriented to year, month and day; exhibited no signs and symptoms of [MEDICAL CONDITION]; exhibited no behaviors; and required one person's extensive physical assistance with dressing and personal hygiene. Resident #1 was 65 inches tall and weighed 124 pounds and required staff assistance to stabilize her when she went from surface-to-surface, such as transfer from bed to chair. She was incontinent of bowel and bladder and had skin tears at that time. Resident #1's Care Plan, initiated 09/16/13 and revised 09/24/13, reflected she was "resistive to care r/t (related to) adjustment to nursing home, behaviors: refusing showers and care...." The interventions included if she resisted ADLs to reassure her and leave, then return 5 to 10 minutes later and try again. Resident #1's Progress Notes, reflected the following: -- Notes dated 08/23/14 at 10:52 PM and written by LVN B, reflected the resident was sent to the ER at 7:15 that morning. The Note reflected, "CNA came and reported that the resident got combative when she was trying to get her up. Resident was swinging her arms and the CNA was trying to prevent her from hitting. Resident got skin tears to both forearms, approximately 7 inches long by 3 inches wide. Nurse tried to apply first aid, skin tears were too severe. Notified doctor to send out, notified family, administrator was notified. Resident was sent to (local) hospital. Will continue to monitor." -- Notes dated 08/23/14 at 10:55 PM and written by LVN B, noted " (Resident #1) returned from the ER around 3 p.m. she was with her daughter. Resident has dry dressing and steri strips applied to her arms ." Review of Resident #1's local hospital closed record, dated 08/23/14, reflected the following: -- The ED Physician Note, dated 08/23/14 at 8:06 AM noted: " . . . (resident) presents to the ED c/o (complain of) avulsions, with daughter at bedside. Pt (Patient) reports via daughter that she was unruly this morning at her NH (nursing home) and when an aide restrained her manually, her skin ripped. Daughter reports her mother is frequently combative, and is suffering from a UTI. Pt has no other complaints at this time. " -- That same date at 10:29 AM, it noted Resident #1 was ready to discharge and her [DIAGNOSES REDACTED]. Observation of Resident #1 at the facility in her room and in bed, on 09/11/14 at approximately 4:10 PM, revealed both arms were bandaged from her elbows to her wrists with purple bruising extending from the bottom of the bandage to the top/middle part of her hands. An interview with Resident #1 at that time revealed she could recall the incident. Resident #1 stated "that black girl" scratched me. Interview on 09/14/14 at 11:00 AM with LVN B revealed she had worked at the facility for almost one year. She stated she always worked weekend doubles and was on duty on 08/23/14. LVN B revealed on 08/23/14 CNA A came to her regarding a skin tear Resident #1 sustained. LVN B went to Resident #1's room and found Resident #1 lying sideways on her bed kind of crooked on the bed and at the foot of the bed with her arms drawn to her body. Resident #1 was dressed from the waist down with her pants and shoes on. The resident's wheelchair was positioned parallel to the bed. LVN B revealed CNA A told her she was getting ready to put Resident #1's shirt on and the resident started fighting. LVN B said when she approached the resident, she had blood all over the front her body but there was none on the bed. LVN B asked Resident #1 what happened. She stated Resident #1 told her she did not want to get up and CNA A pulled her by her arms and hurt her. She stated the injuries were from the elbow down to the wrists. LVN B revealed the resident's skin was pulled down to her wrists. She stated she was "'horrified" at the injuries. LVN B revealed those were the worst injuries she had ever seen. LVN B continued by saying she had LVN C to come and assist her with pulling Resident #1's skin back up over the muscle on both arms. LVN B said Resident #1 had thin skin, and she saw the resident did not have any blood or skin under her nails and nothing on her hands which indicated to LVN B the resident did not make contact with CNA A. LVN B said she had RN D call 911 and contact the family and the doctor. LVN B revealed it was her opinion if things happened the way the aide told her, the resident's injuries would have been at the wrists and not the whole forearm. LVN B revealed the physician at the hospital called her to ask her what happened. The physician told LVN B Resident #1's injuries measured 10+ inches length on both arms. LVN B revealed she had provided care for Resident #1 over the past year and "...if you rush her she gets combative or if she is tired. So you step away and come back later." LVN B said she never had a problem with Resident #1 being combative with her and she knew staff had to give the resident time and go back later if necessary. LVN B thought the CNA A was pretty nonchalant about the incident and did not display any emotion, which she thought was unusual because the injuries were so severe. LVN B had completed a written statement for the facility, dated 08/23/14. The statement reflected, "(CNA A) came to me and stated that she was trying to get (Resident #1) up and she was getting aggressive. I went into the resident room and she was laying (sic) on her bed, both forearms had severe lacerations. I asked the CNA (CNA A) to please go get another nurse to assist me. Nurse (LVN C) came in to help apply pressure. Start first aide applied and there was a large amount of skin. Another nurse (LVN HH) went to notify the doctor & call the ambulance. (LVN HH) also notified (Resident #1's family member). I notified the (Administrator and DON). Had CNA write a statement and asked her to go home until she was notified. Resident stated she didn't want to get (up) and the CNA was pulling on her." An interview with the Paramedic, on 09/11/14 at 1:45 PM, revealed he responded to the 911 call from the facility. The Paramedic stated on 08/23/14 at 7:15 AM, his team had been picked to transport Resident #1 to the hospital for emergency medical services. The Paramedic stated a nurse met him at the door and she was crying because the resident's injuries were so bad. The Paramedic stated Resident #1 had large skin tears/shears to at least 50 to 60 % of both of her arms. He stated he had never seen injuries like that. An interview with LVN C on 09/14/14 at 11:25 AM confirmed LVN B came and got her to look at Resident #1's arms. She assisted LVN B with first aid. She stated the injuries were bad. The resident's skin was pulled down from her elbows to her wrists. LVN C revealed she had never seen injuries that bad and she had been a nurse for [AGE] years. She stated CNA A was nonchalant about Resident #1's injuries. LVN C revealed she had worked with CNA A for six months and she thought she was a good aide. She stated CNA A was different that day. LVN C revealed she read CNA A's statement and she did not think it was consistent with what happened. Review of LVN C's written statement obtained by the facility and dated 08/23/14, reflected, "I was called to (Resident #1's) room by (LVN B) to look at res (resident's) arms. Large amt (amount) of skin was hanging from res fore arms. First aid rendered & 911 called." Review on 09/12/14 of CNA A's written statement obtained by the facility and dated 08/22/14 (sic), reflected "I (CNA A) went to get (Resident #1) up about 6:30 AM in room (room number) and I went to set (sic) her up on the edge of the bed she started swinging end (sic) fighting and her arm hit the wheel chair that's when I notice her arms was (sic) bleeding so I laid her back in the bed and went and got the nurse (LVN B)." An interview with CNA A 09/12/14 at 12:00 PM, confirmed she was the nurse aide who had assisted Resident #1 at the time of the incident. At the time of the interview, CNA A was noted to have a dark complexion and stand approximately 5 feet tall. She stated she had worked for the facility for almost one year. She stated she worked as a floater and thus worked different halls. She stated she currently worked four days on and two days off working the 6:00 AM to 2:00 PM shift. She stated she had received training in managing behaviors in the past and in-services on Abuse and Neglect. CNA A revealed prior to the incident with Resident #1, she had not really worked that hall. When asked how she could learn about the residents' characteristics, CNA A replied there were mini care plans in the residents' rooms. CNA A said she could also reference the ADL (Activities of Daily Living) book at the Nurse's Station for information about the resident. CNA A revealed the first day she worked with Resident #1, the resident was fine. She stated the day of the incident was the second time she had provided care to Resident #1. She stated she had cleaned Resident #1 in her bed, put her slacks and shoes on and swung the resident's legs around to the floor. When she got the resident to the edge of the bed, Resident #1 started swinging and cussing at her. CNA A stated she put her hands up to protect her own face and protect herself from the resident. CNA A revealed she thought the resident was falling backwards and that was when she grabbed the resident's arms to keep her from falling backwards. CNA A stated she was putting Resident #1 back in bed and that was when she saw the blood on Resident #1's arms. She did not indicate Resident #1 hit her arms on a wheelchair. She notified LVN B of what had occurred. CNA A stated if she could have done anything differently, she should have stepped away and let Resident #1 calm down and go back later. When asked why she did not take that action, CNA A replied she was not sure why. On 09/12/14, CNA A completed a second statement at the request of the Investigator. She noted, "On the morning of Aug (August) 23 (2014) I went in to get (Resident #1) out of bed for breakfast. I got her dress (sic) in bed, she was fine, but once she sat up on the side of the bed she started to swing & pull back so for to keep her from hitting her head on the railing I grab (sic) her hands and she kept swinging so I put her legs back on the bed to lye (sic) her back down that's when I noticed her arms were bleeding so I went and got the nurse (LVN B) and they sent her out to the hospital and sent me home." Review of CNA A's personnel record reflected she was hired on 09/15/13. The record contained no evidence of prior counseling(s) for failing to implement a resident's assessed and care planned level of care or for causing physical injuries to a resident. Review of training records, reflected CNA A had received training on Abuse and Neglect four times, Resident Rights two times and Dementia care once during the year of 09/15/13 through 09/15/14. Review of CNA A's time punch records revealed on 08/24/14, 08/25/14, 08/26/14 she did not work. On 08/29/14, she returned to work and worked through 09/11/14. CNA A did not work any additional days. Interview on 09/11/14 at approximately 3:15 PM with the Administrator revealed she had conducted the investigation of the incident involving Resident #1 and suspended CNA A pending the outcome of the investigation. The Administrator stated CNA A was brought back to work because the CNA "didn't do anything wrong." The resident was combative and flailing her arms sitting on the side of her bed. The CNA grabbed the resident's arms to protect the resident and her skin tore. The resident had very thin skin and the aide was small in stature. The family requested CNA A not provide care to Resident #1, and the CNA was subsequently moved to another hall. An interview on 09/11/14 at approximately 4:00 PM with the Staff Development Coordinator revealed she read the Provider Investigation Report, dated 08/23/14, about Resident #1's avulsions and CNA A's witness statement. The Coordinator stated her concern was CNA A's witness statement indicated she was defending herself from the resident with crossed arms and open hands and "that did not add up." An interview with the Administrator on 09/12/14 at approximately 3:45 PM revealed CNA A was suspended due to the surveyor's findings. The Administrator stated a decision on CNA A's employment would be determined based on the surveyor's findings. Further interview with the Administrator on 09/15/14 at approximately 1:10 PM revealed CNA A was terminated for failure to follow policies by not coming in to the facility to speak with the surveyor and Administrator. Interview on 09/12/14 at 2:00 PM with CNA D revealed he had been employed with the facility for a period of 10 months. He stated he had provided care for Resident #1 during seven of those months. CNA D revealed he never had a problem with her being aggressive or combative with him. He stated it was all in the approach with her. CNA D said it was all about what Resident #1 wanted. He revealed Resident #1 told him she and CNA A started to argue. He stated Resident #1 was able to recall what happened that day. Interview on 09/12/14 at 2:30 PM with LVN I revealed she had provided care to Resident #1 and some days she was combative. She stated it was all in the approach with the resident. LVN I revealed if the resident did not know someone, she might be combative. She stated someone could not just go in her room and start flipping the lights on and being abrupt. Review on 09/11/14 of the facility's current Abuse policy, with a release date 04/14/14, revealed, "...physical and mental abuse...of the patient as well as mistreatment...are strictly prohibited....Patients have the right to be free of...physical, and mental abuse...of the patient as well mistreatment...1. Prohibitions on abuse apply to: a. Center staff...9. Identify patients most at risk of neglect and abuse, may include but is not limited to: a. Patients who have dementia...." The facility's current Resident Refusal of Care policy, revised 04/28/10, reflected occasional refusals or failure to follow physician's orders [REDACTED]. Some residents consistently refused to accept or failed to follow the ordered treatment, therapeutic diet or services. Every attempt was made to accommodate the resident's request and still provide the appropriate care and services to meet the residents' needs while following the physician's orders [REDACTED]. On 09/24/14 at 6:10 PM., the Administrator, DON, LVN H, and LVN L were notified of the IJ had been identified for failure to ensure nurse aides provided residents their care planned level of care and services to prevent residents from sustaining serious injuries. Interview on 09/25/14 at 9:40 AM with the DON revealed since the incident with Resident #1, all Unit Managers now had a tool they could use that addressed staff interactions with the residents, identified as having behaviors. She said they initiated the in-services on 09/24/14. The training provided to staff included: How to recognize burnout, Kardex/CNA for CNA use regarding a resident's care requirements including behavior interventions, resident rights and abuse and neglect. Skin assessments were initiated on 09/12/14 and residents with fragile skin were identified to be at high risk for skin tears and the information was added to their care plans. Training for management/staff was provided in the area of residents with fragile skin and skin tear prevention. Audit rounds would be conducted by Nurse Managers and they would utilize a tool developed to monitor CNAs' knowledge of residents resistive to care, where they locate information pertaining to the residents and refusal of care. The tool was to be utilized by managers daily. All staff would be trained and those who had not had the training would not be allowed to return to work until they had received the required in-services. On 09/25/14, the Administrator was notified their Plan of Removal was accepted. The Plan of Removal, dated 09/25/14, reflected the following: -- Upon return from the hospital the resident (Resident #1) was evaluated and seen by the facility's certified Wound Care Nurse...The resident's Wound Care Physician , evaluated the resident's skin condition upon on 8/29/14. Additional skin treatment orders were ordered by wound care physician 8/29/14...The resident's care plan was reviewed and updated on 8/23/14 to reflect current health status by the facility's Minimum Data Set (MDS) nurse,(sic). The patient's medical history provides documentation of behavioral changes related to infection [MEDICAL CONDITION]. The resident's care plan reflects this information...(CNA A) was suspended pending outcome of facility investigation 8/23/14 and ultimately terminated from facility employment. -- On 08/23/14, CAN A was suspended pending the outcome of the facility's investigation. -- On 8/29/14, CNA A was re-in serviced on abuse related to this incident, and how to effectively deal with combative residents; this training was provided by the Staff Development Coordinator (sic). -- A Safe Survey was conducted after (CNA A) return on several residents throughout the facility whom (CNA A) had provided care with no negative outcome. (CNA A) returned to duty on 08/29/14 after the facility had completed its initial investigation of the incident. -- On 09/11/14, as a result of a complaint survey initiated by DADS, further details emerged questioning (CNA A) original statement. The facility reopened its investigation on 09/11/14. She (CNA A) was suspended as a result the reopening of the investigation. As a result of the facilities (sic)reopened investigation she was terminated on 09/15/14 primarily for her inability to provide a consistent statement regarding the incident with (Resident #1) on 08/23/14. (CNA A) failed to meet the facility standards of providing the highest standard of care to its residents. The facility is vigilant in protecting our residents from perceived mistreatment...Residents with behaviors were identified by resident assessment report in Point Click Care, electronic charting program, on 9/23/14. - The behavioral care plans and Certified Nursing Assistant (CNA) Kardex, (Kardex are a resource for CNAs, like a mini care plan to give personalized care to individual residents). Fragile skin is skin that has very thin tissue do to the loss of subcutaneous tissue. -- All of the residents identified were reviewed, and updated to reflect resident's current behavioral status by Director of Nursing, Unit Managers, (LVN H) and Assistant Director of Nursing ,(LVN J). -- The following residents have been identified with the potential for behaviors: (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18)...Identified residents exhibit the following types of behaviors; resistance to care, verbal outburst, inappropriate language, disrobing. -- Additionally, to assist in identifying the residents at risk, the facility consultant pharmacist reviewed residents receiving [MEDICAL CONDITION] medication to assure that appropriate recommendations are reviewed by resident's physician and subsequent orders are implemented by the licensed nurse; this review is done monthly and was last completed on 9/15/14. This review assures that the resident receives the appropriate medication to assist with behavior management and prevent adverse side effects. The consultant pharmacist will provide a monthly report of his/her review to the Director of Nursing. The Director of Nursing, will present a summary of the report to the Facility's Performance Improvement Committee on a monthly basis; this will be an on-going measure/intervention. -- Ad lib referrals to psychology and psychiatric services are determined by resident review in the Interdisciplinary Clinical Rounds (nursing, dietician, Social Worker, MDS, and Activities, process that occurs at least 5 days weekly. The Clinical Rounds Process is retrospective review of clinical needs of residents identified by the center's 24- hour reporting system. This process was implemented in February 2014 and is an ongoing facility practice with no end date. -- Residents identified will be discussed to assure that proper measures/interventions are implemented to resolve clinical concerns, assure that the MD and families are notified of concerns along with any appropriate follow up measures, care plans reviewed and updated and or created as new condition warrants, and that interventions are monitored until the clinical concern is resolved... -- All Kardex have been updated and are located at the nursing station for added security and confidentiality...Kardex will also notate residents identified with behaviors for additional interventions and suggestions to assure care is optimally provided. -- CNAs have been educated and are required to check it frequently for changes, as well as adding appropriate/helpful information. CNAs were in-serviced on Assessing Risk of Challenging Behaviors, Resident Rights, and Resident's Rights to Refuse Care, Definition(s) of Abuse, Behavioral Management, and Skin Tears: Prevention and Management, the dates of the in-services were on 09/12/14 -09/15/14. As part of the training, CNAs were in-serviced on the expectation of reviewing the Kardex prior to the start of each shift to assure that the CNA has the most updated information regarding the president's plan of care. Competency was evaluated and determined by questionnaire given by the Director of Nursing...This quiz tested the employee's knowledge of the following: How to deal with combative residents, Resident Right to refuse Care, notification to nursing supervisor and understanding that resident care is primary function. If employee missed more than one (1) question, additional training was provided... -- Additionally nursing staff have been in-serviced on 'burnout' and sign and symptoms of, as well as prevention and what to do if detected... quiz tested the employee's knowledge of the following: How to deal with combative residents, Resident Right to refuse Care, notification to nursing supervisor and understanding that resident care is their primary priority...Education/in-servicing was initiated and provided by the Staff Development Coordinator, 9/12-9/15/14. This education included: Assessing Risk of Challenging Behaviors, Resident Rights, Resident's Rights to Refuse Care, Definition(s) of Abuse, Behavioral Management, Skin Tears: Prevention and Management. These in-services were for Licensed Nurses and CNAs. Staff education was initiated and conducted by the Staff Development Coordinator on 8/25/14 for licensed nurses and CNAs on abuse training and how to effectively care for the combative resident. Subsequent staff education concluded on 9/13/14. -- As of 9/13/14, current licensed nurses and CNAs received the above training/education, and will be on-going annually and as needed...Additionally CNAs were educated on resident's plan of care, understanding the resident is priority, and steps to take when resident is combative...The competency evaluation(s) associated with this training was determined through quiz/test. This quiz tested the employee's knowledge of the subject matter. If employee missed more than one (1) question, additional training was provided...The facility will incorporate a behavior management review daily in the clinical rounds meeting. The behavioral management review will utilize an interdisciplinary approach to identify and analyze root cause(s) of behaviors...." To verify the facility had implemented their Plan of Removal the following was conducted: -- Review of in-service training records for facility employees on all shifts confirmed training had been provided in the areas of : How do you identify burnout and what to do., fragile skin, Kardex (Resident information for the Certified Nurse Aides) and expected CNA use regarding a residents care, resident care requirements to include residents who had been identified with behaviors and expected staff interventions, resident rights and training in the area of abuse and neglect. Review of the sign in sheets revealed out of 128 employees all had received the in-service training except for 6 employees. - Review of the care plans for the identified 18 residents who were identified as exhibiting behaviors confirmed their care plans and Kardex records had been updated to reflect the identified behavior. -- Interview with the Administrator and the DON on 09/25/14 at 3:45 PM revealed they had already met on 09/23/14 with the Medical Director as part of the Quality Assurance Review related to the incident and addressed other quality concerns. - Interviews were conducted with staff, representing staff from each shift and working weekdays and/or weekends. The staff interviewed were three LVNs (LVNs L, R and U); 17 CNAs (CNAs M, N, O, P, Q, S, T, V, W, X, Y, Z, AA, CC, DD, EE and FF); Housekeeping Manager, Social Worker, Business Office Manager and Business Office Assistant. Each employee was able to articulate what constituted abuse and/or neglect, how they would determine the level of care a resident required, and what action they would take if they observed an employee continuing to provide care for a resident exhibiting a behavior of resistance to care. On 09/29/14 at 12:15 PM, the Administrator was informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's Plan of Removal, dated 09/25/14, reflected 18 residents were at risk for behaviors including Resident #1.

Based on observation, interview and record review, it was determined the facility failed to conduct a thorough investigation of one of one incident of neglect involving Resident 1. The facility failed to thoroughly investigate the circumstances of Resident #1's injuries in order to know CNA A had only worked with Resident #1 one time prior to 08/23/14, CNA A had not read the plan of care for Resident #1, and the injuries were not caused by a wheelchair. CNA A was unaware Resident #1 could become resistant to care; thus, when Resident #1 began cursing and swinging her arms, the CNA A responded inappropriately resulting in Resident #1 sustaining bilateral avulsions (tearing away forcibly of a part or structure) from just below her elbows to just above her wrists. The resident was transferred to a local hospital's ER for evaluation and treatment. On 09/24/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/26/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope "isolated" because the facility was still evaluating the effectiveness of the Plan of Removal. Failure to thoroughly investigate incidents of neglect, placed the other 17 residents identified as having a behaviors, at risk for serious injuries due to failure of staff to provide care according to their assessed and care planned level of care and services. Findings included: 1. Review of the Abuse policy, with a release date 04/14/14, revealed, "...physical and mental abuse...of the patient as well as mistreatment...are strictly prohibited....Patients have the right to be free of...physical, and mental abuse...of the patient as well mistreatment...1. Prohibitions on abuse apply to: a. Center staff...9. Identify patients most at risk of neglect and abuse, may include but is not limited to: a. Patients who have dementia...." 2. Resident #1's Admission Record, dated 09/11/14, reflected she originally admitted to the facility on [DATE] and her most recent re-admission was 01/31/14. She was 94-years-old and her [DIAGNOSES REDACTED]. Resident #1's quarterly MDS assessment, dated 08/12/14, reflected she was oriented to year, month and day; exhibited no signs and symptoms of [MEDICAL CONDITION]; exhibited no behaviors; and required one person's extensive physical assistance with dressing and personal hygiene. Resident #1 was 65 inches tall and weighed 124 pounds and required staff assistance to stabilize her when she went from surface-to-surface, such as transfer from bed to chair. She was incontinent of bowel and bladder and had skin tears at that time. Resident #1's Care Plan, initiated 09/16/13 and revised 09/24/13, reflected she was "resistive to care r/t (related to) adjustment to nursing home, behaviors: refusing showers and care...." The interventions included if she resisted ADLs to reassure her and leave, then return 5 to 10 minutes later and try again. Resident #1's Progress Notes, reflected the following: -- Notes dated 08/23/14 at 10:52 PM and written by LVN B, reflected the resident was sent to the ER at 7:15 that morning. The Note reflected, "CNA came and reported that the resident got combative when she was trying to get her up. Resident was swinging her arms and the CNA was trying to prevent her from hitting. Resident got skin tears to both forearms, approximately 7 inches long by 3 inches wide. Nurse tried to apply first aid, skin tears were too severe. Notified doctor to send out, notified family, administrator was notified. Resident was sent to (local) hospital. Will continue to monitor." -- Notes dated 08/23/14 at 10:55 PM and written by LVN B, noted " (Resident #1) returned from the ER around 3 p.m. she was with her daughter. Resident has dry dressing and steri strips applied to her arms " . Review of Resident #1 ' s local hospital closed record, dated 08/23/14, reflected the following: -- The ED Physician Note, dated 08/23/14 at 8:06 AM noted: " . . . (resident) presents to the ED c/o (complain of) avulsions, with daughter at bedside. Pt (Patient) reports via daughter that she was unruly this morning at her NH (nursing home) and when an aide restrained her manually, her skin ripped. Daughter reports her mother is frequently combative, and is suffering from a UTI. Pt has no other complaints at this time. " -- That same date at 10:29 AM, it noted Resident #1 was ready to discharge and her [DIAGNOSES REDACTED]. Observation of Resident #1 at the facility in her room and in bed, on 09/11/14 at approximately 4:10 PM, revealed both arms were bandaged from her elbows to her wrists with purple bruising extending from the bottom of the bandage to the top/middle part of her hands. An interview with Resident #1 at that time revealed she could recall the incident. Resident #1 stated "that black girl" scratched me. Interview on 09/14/14 at 11:00 AM with LVN B revealed she had worked at the facility for almost one year. She stated she always worked weekend doubles and was on duty on 08/23/14. LVN B revealed on 08/23/14 CNA A came to her regarding a skin tear Resident #1 sustained. LVN B went to Resident #1's room and found Resident #1 lying sideways on her bed kind of crooked on the bed and at the foot of the bed with her arms drawn to her body. Resident #1 was dressed from the waist down with her pants and shoes on. The resident's wheelchair was positioned parallel to the bed. LVN B revealed CNA A told her she was getting ready to put Resident #1's shirt on and the resident started fighting. LVN B said when she approached the resident, she had blood all over the front her body but there was none on the bed. LVN B asked Resident #1 what happened. She stated Resident #1 told her she did not want to get up and CNA A pulled her by her arms and hurt her. She stated the injuries were from the elbow down to the wrists. LVN B revealed the resident's skin was pulled down to her wrists. She stated she was "'horrified" at the injuries. LVN B revealed those were the worst injuries she had ever seen. LVN B continued by saying she had LVN C to come and assist her with pulling Resident #1's skin back up over the muscle on both arms. LVN B said Resident #1 had thin skin, and she saw the resident did not have any blood or skin under her nails and nothing on her hands which indicated to LVN B the resident did not make contact with CNA A. LVN B said she had RN D call 911 and contact the family and the doctor. LVN B revealed it was her opinion if things happened the way the aide told her, the resident's injuries would have been at the wrists and not the whole forearm. LVN B revealed the physician at the hospital called her to ask her what happened. The physician told LVN B Resident #1's injuries measured 10+ inches length on both arms. LVN B revealed she had provided care for Resident #1 over the past year and "...if you rush her she gets combative or if she is tired. So you step away and come back later." LVN B said she never had a problem with Resident #1 being combative with her and she knew staff had to give the resident time and go back later if necessary. LVN B thought the CNA A was pretty nonchalant about the incident and did not display any emotion, which she thought was unusual because the injuries were so severe. LVN B had completed a written statement for the facility, dated 08/23/14. The statement reflected, "(CNA A) came to me and stated that she was trying to get (Resident #1) up and she was getting aggressive. I went into the resident room and she was laying (sic) on her bed, both forearms had severe lacerations. I asked the CNA (CNA A) to please go get another nurse to assist me. Nurse (LVN C) came in to help apply pressure. Start first aide applied and there was a large amount of skin. Another nurse (LVN HH) went to notify the doctor & call the ambulance. (LVN HH) also notified (Resident #1's family member). I notified the (Administrator and DON). Had CNA write a statement and asked her to go home until she was notified. Resident stated she didn't want to get (up) and the CNA was pulling on her." An interview with the Paramedic, on 09/11/14 at 1:45 PM, revealed he responded to the 911 call from the facility. The Paramedic stated on 08/23/14 at 7:15 AM, his team had been picked to transport Resident #1 to the hospital for emergency medical services. The Paramedic stated a nurse met him at the door and she was crying because the resident's injuries were so bad. The Paramedic stated Resident #1 had large skin tears/shears to at least 50 to 60 % of both of her arms. He stated he had never seen injuries like that. An interview with LVN C on 09/14/14 at 11:25 AM confirmed LVN B came and got her to look at Resident #1's arms. She assisted LVN B with first aid. She stated the injuries were bad. The resident's skin was pulled down from her elbows to her wrists. LVN C revealed she had never seen injuries that bad and she had been a nurse for [AGE] years. She stated CNA A was nonchalant about Resident #1's injuries. LVN C revealed she had worked with CNA A for six months and she thought she was a good aide. She stated CNA A was different that day. LVN C revealed she read CNA A's statement and she did not think it was consistent with what happened. Review of LVN C's written statement obtained by the facility and dated 08/23/14, reflected, "I was called to (Resident #1's) room by (LVN B) to look at res (resident's) arms. Large amt (amount) of skin was hanging from res fore arms. First aid rendered & 911 called." Review on 09/12/14 of CNA A's written statement obtained by the facility and dated 08/22/14 (sic), reflected "I (CNA A) went to get (Resident #1) up about 6:30 AM in room (room number) and I went to set (sic) her up on the edge of the bed she started swinging end (sic) fighting and her arm hit the wheel chair that's when I notice her arms was (sic) bleeding so I laid her back in the bed and went and got the nurse (LVN B)." An interview with CNA A 09/12/14 at 12:00 PM, confirmed she was the nurse aide who had assisted Resident #1 at the time of the incident. At the time of the interview, CNA A was noted to have a dark complexion and stand approximately 5 feet tall. She stated she had worked for the facility for almost one year. She stated she worked as a floater and thus worked different halls. She stated she currently worked four days on and two days off working the 6:00 AM to 2:00 PM shift. She stated she had received training in managing behaviors in the past and in-services on Abuse and Neglect. CNA A revealed prior to the incident with Resident #1, she had not really worked that hall. When asked how she could learn about the residents' characteristics, CNA A replied there were mini care plans in the residents' rooms. CNA A said she could also reference the ADL (Activities of Daily Living) book at the Nurse's Station for information about the resident. CNA A revealed the first day she worked with Resident #1, the resident was fine. She stated the day of the incident was the second time she had provided care to Resident #1. She stated she had cleaned Resident #1 in her bed, put her slacks and shoes on and swung the resident's legs around to the floor. When she got the resident to the edge of the bed, Resident #1 started swinging and cussing at her. CNA A stated she put her hands up to protect her own face and protect herself from the resident. CNA A revealed she thought the resident was falling backwards and that was when she grabbed the resident's arms to keep her from falling backwards. CNA A stated she was putting Resident #1 back in bed and that was when she saw the blood on Resident #1's arms. She did not indicate Resident #1 hit her arms on a wheelchair. She notified LVN B of what had occurred. CNA A stated if she could have done anything differently, she should have stepped away and let Resident #1 calm down and go back later. When asked why she did not take that action, CNA A replied she was not sure why. On 09/12/14, CNA A completed a second statement at the request of the Investigator. She noted, "On the morning of Aug (August) 23 (2014) I went in to get (Resident #1) out of bed for breakfast. I got her dress (sic) in bed, she was fine, but once she sat up on the side of the bed she started to swing & pull back so for to keep her from hitting her head on the railing I grab (sic) her hands and she kept swinging so I put her legs back on the bed to lye (sic) her back down that's when I noticed her arms were bleeding so I went and got the nurse (LVN B) and they sent her out to the hospital and sent me home." Review of CNA A's personnel record reflected she was hired on 09/15/13. The record contained no evidence of prior counseling(s) for failing to implement a resident's assessed and care planned level of care or for causing physical injuries to a resident. Review of training records, reflected CNA A had received training on Abuse and Neglect four times, Resident Rights two times and Dementia care once during the year of 09/15/13 through 09/15/14. Review of CNA A's time punch records revealed on 08/24/14, 08/25/14, 08/26/14 she did not work. On 08/29/14, she returned to work and worked through 09/11/14. CNA A did not work any additional days. Interview on 09/11/14 at approximately 3:15 PM with the Administrator revealed she had conducted the investigation of the incident involving Resident #1 and suspended CNA A pending the outcome of the investigation. The Administrator stated CNA A was brought back to work because the CNA "didn't do anything wrong." The resident was combative and flailing her arms sitting on the side of her bed. The CNA grabbed the resident's arms to protect the resident and her skin tore. The resident had very thin skin and the aide was small in stature. The family requested CNA A not provide care to Resident #1, and the CNA was subsequently moved to another hall. An interview on 09/11/14 at approximately 4:00 PM with the Staff Development Coordinator revealed she read the Provider Investigation Report, dated 08/23/14, about Resident #1's avulsions and CNA A's witness statement. The Coordinator stated her concern was CNA A's witness statement indicated she was defending herself from the resident with crossed arms and open hands and "that did not add up." An interview with the Administrator on 09/12/14 at approximately 3:45 PM revealed CNA A was suspended due to the surveyor's findings. The Administrator stated a decision on CNA A's employment would be determined based on the surveyor's findings. Further interview with the Administrator on 09/15/14 at approximately 1:10 PM revealed CNA A was terminated for failure to follow policies by not coming in to the facility to speak with the surveyor and Administrator. Interview on 09/12/14 at 2:00 PM with CNA D revealed he had been employed with the facility for a period of 10 months. He stated he had provided care for Resident #1 during seven of those months. CNA D revealed he never had a problem with her being aggressive or combative with him. He stated it was all in the approach with her. CNA D said it was all about what Resident #1 wanted. He revealed Resident #1 told him she and CNA A started to argue. He stated Resident #1 was able to recall what happened that day. Interview on 09/12/14 at 2:30 PM with LVN I revealed she had provided care to Resident #1 and some days she was combative. She stated it was all in the approach with the resident. LVN I revealed if the resident did not know someone, she might be combative. She stated someone could not just go in her room and start flipping the lights on and being abrupt. The facility's current Resident Refusal of Care policy, revised 04/28/10, reflected occasional refusals or failure to follow physician's orders [REDACTED]. Some residents consistently refused to accept or failed to follow the ordered treatment, therapeutic diet or services. Every attempt was made to accommodate the resident's request and still provide the appropriate care and services to meet the residents' needs while following the physician's orders [REDACTED]. On 09/24/14 at 6:10 PM., the Administrator, DON, LVN H, and LVN L were notified of the IJ had been identified for failure to ensure nurse aides provided residents their care planned level of care and services to prevent residents from sustaining serious injuries. Interview on 09/25/14 at 9:40 AM with the DON revealed since the incident with Resident #1, all Unit Managers now had a tool they could use that addressed staff interactions with the residents, identified as having behaviors. She said they initiated the in-services on 09/24/14. The training provided to staff included: How to recognize burnout, Kardex/CNA for CNA use regarding a resident's care requirements including behavior interventions, resident rights and abuse and neglect. Skin assessments were initiated on 09/12/14 and residents with fragile skin were identified to be at high risk for skin tears and the information was added to their care plans. Training for management/staff was provided in the area of residents with fragile skin and skin tear prevention. Audit rounds would be conducted by Nurse Managers and they would utilize a tool developed to monitor CNAs' knowledge of residents resistive to care, where they locate information pertaining to the residents and refusal of care. The tool was to be utilized by managers daily. All staff would be trained and those who had not had the training would not be allowed to return to work until they had received the required in-services. On 09/25/14, the Administrator was notified their Plan of Removal was accepted. The Plan of Removal, dated 09/25/14, reflected the following: -- Upon return from the hospital the resident (Resident #1) was evaluated and seen by the facility's certified Wound Care Nurse...The resident's Wound Care Physician , evaluated the resident's skin condition upon on 8/29/14. Additional skin treatment orders were ordered by wound care physician 8/29/14...The resident's care plan was reviewed and updated on 8/23/14 to reflect current health status by the facility's Minimum Data Set (MDS) nurse,(sic). The patient's medical history provides documentation of behavioral changes related to infection [MEDICAL CONDITION]. The resident's care plan reflects this information...(CNA A) was suspended pending outcome of facility investigation 8/23/14 and ultimately terminated from facility employment. -- On 08/23/14, CAN A was suspended pending the outcome of the facility's investigation. -- On 8/29/14, CNA A was re-in serviced on abuse related to this incident, and how to effectively deal with combative residents; this training was provided by the Staff Development Coordinator (sic). -- A Safe Survey was conducted after (CNA A) return on several residents throughout the facility whom (CNA A) had provided care with no negative outcome. (CNA A) returned to duty on 08/29/14 after the facility had completed its initial investigation of the incident. -- On 09/11/14, as a result of a complaint survey initiated by DADS, further details emerged questioning (CNA A) original statement. The facility reopened its investigation on 09/11/14. She (CNA A) was suspended as a result the reopening of the investigation. As a result of the facilities (sic)reopened investigation she was terminated on 09/15/14 primarily for her inability to provide a consistent statement regarding the incident with (Resident #1) on 08/23/14. (CNA A) failed to meet the facility standards of providing the highest standard of care to its residents. The facility is vigilant in protecting our residents from perceived mistreatment...Residents with behaviors were identified by resident assessment report in Point Click Care, electronic charting program, on 9/23/14. - The behavioral care plans and Certified Nursing Assistant (CNA) Kardex, (Kardex are a resource for CNAs, like a mini care plan to give personalized care to individual residents). Fragile skin is skin that has very thin tissue do to the loss of subcutaneous tissue. -- All of the residents identified were reviewed, and updated to reflect resident's current behavioral status by Director of Nursing, Unit Managers, (LVN H) and Assistant Director of Nursing ,(LVN J). -- The following residents have been identified with the potential for behaviors: (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18)...Identified residents exhibit the following types of behaviors; resistance to care, verbal outburst, inappropriate language, disrobing. -- Additionally, to assist in identifying the residents at risk, the facility consultant pharmacist reviewed residents receiving [MEDICAL CONDITION] medication to assure that appropriate recommendations are reviewed by resident's physician and subsequent orders are implemented by the licensed nurse; this review is done monthly and was last completed on 9/15/14. This review assures that the resident receives the appropriate medication to assist with behavior management and prevent adverse side effects. The consultant pharmacist will provide a monthly report of his/her review to the Director of Nursing. The Director of Nursing, will present a summary of the report to the Facility's Performance Improvement Committee on a monthly basis; this will be an on-going measure/intervention. -- Ad lib referrals to psychology and psychiatric services are determined by resident review in the Interdisciplinary Clinical Rounds (nursing, dietician, Social Worker, MDS, and Activities, process that occurs at least 5 days weekly. The Clinical Rounds Process is retrospective review of clinical needs of residents identified by the center's 24- hour reporting system. This process was implemented in February 2014 and is an ongoing facility practice with no end date. -- Residents identified will be discussed to assure that proper measures/interventions are implemented to resolve clinical concerns, assure that the MD and families are notified of concerns along with any appropriate follow up measures, care plans reviewed and updated and or created as new condition warrants, and that interventions are monitored until the clinical concern is resolved... -- All Kardex have been updated and are located at the nursing station for added security and confidentiality...Kardex will also notate residents identified with behaviors for additional interventions and suggestions to assure care is optimally provided. -- CNAs have been educated and are required to check it frequently for changes, as well as adding appropriate/helpful information. CNAs were in-serviced on Assessing Risk of Challenging Behaviors, Resident Rights, and Resident's Rights to Refuse Care, Definition(s) of Abuse, Behavioral Management, and Skin Tears: Prevention and Management, the dates of the in-services were on 09/12/14 -09/15/14. As part of the training, CNAs were in-serviced on the expectation of reviewing the Kardex prior to the start of each shift to assure that the CNA has the most updated information regarding the president's plan of care. Competency was evaluated and determined by questionnaire given by the Director of Nursing...This quiz tested the employee's knowledge of the following: How to deal with combative residents, Resident Right to refuse Care, notification to nursing supervisor and understanding that resident care is primary function. If employee missed more than one (1) question, additional training was provided... -- Additionally nursing staff have been in-serviced on 'burnout' and sign and symptoms of, as well as prevention and what to do if detected... quiz tested the employee's knowledge of the following: How to deal with combative residents, Resident Right to refuse Care, notification to nursing supervisor and understanding that resident care is their primary priority...Education/in-servicing was initiated and provided by the Staff Development Coordinator, 9/12-9/15/14. This education included: Assessing Risk of Challenging Behaviors, Resident Rights, Resident's Rights to Refuse Care, Definition(s) of Abuse, Behavioral Management, Skin Tears: Prevention and Management. These in-services were for Licensed Nurses and CNAs. Staff education was initiated and conducted by the Staff Development Coordinator on 8/25/14 for licensed nurses and CNAs on abuse training and how to effectively care for the combative resident. Subsequent staff education concluded on 9/13/14. -- As of 9/13/14, current licensed nurses and CNAs received the above training/education, and will be on-going annually and as needed...Additionally CNAs were educated on resident's plan of care, understanding the resident is priority, and steps to take when resident is combative...The competency evaluation(s) associated with this training was determined through quiz/test. This quiz tested the employee's knowledge of the subject matter. If employee missed more than one (1) question, additional training was provided...The facility will incorporate a behavior management review daily in the clinical rounds meeting. The behavioral management review will utilize an interdisciplinary approach to identify and analyze root cause(s) of behaviors...." To verify the facility had implemented their Plan of Removal the following was conducted: -- Review of in-service training records for facility employees on all shifts confirmed training had been provided in the areas of : How do you identify burnout and what to do., fragile skin, Kardex (Resident information for the Certified Nurse Aides) and expected CNA use regarding a residents care, resident care requirements to include residents who had been identified with behaviors and expected staff interventions, resident rights and training in the area of abuse and neglect. Review of the sign in sheets revealed out of 128 employees all had received the in-service training except for 6 employees. - Review of the care plans for the identified 18 residents who were identified as exhibiting behaviors confirmed their care plans and Kardex records had been updated to reflect the identified behavior. -- Interview with the Administrator and the DON on 09/25/14 at 3:45 PM revealed they had already met on 09/23/14 with the Medical Director as part of the Quality Assurance Review related to the incident and addressed other quality concerns. - Interviews were conducted with staff, representing staff from each shift and working weekdays and/or weekends. The staff interviewed were three LVNs (LVNs L, R and U); 17 CNAs (CNAs M, N, O, P, Q, S, T, V, W, X, Y, Z, AA, CC, DD, EE and FF); Housekeeping Manager, Social Worker, Business Office Manager and Business Office Assistant. Each employee was able to articulate what constituted abuse and/or neglect, how they would determine the level of care a resident required, and what action they would take if they observed an employee continuing to provide care for a resident exhibiting a behavior of resistance to care. On 09/29/14 at 12:15 PM, the Administrator was informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's Plan of Removal, dated 09/25/14, reflected 18 residents were at risk for behaviors including Resident #1.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures for abuse and neglect prevention when they 1) Failed to prohibit neglect of residents for one (Resident #1) of eight residents reviewed for neglect. 2) Failed to ensure administrative staff conducted a thorough investigation of one of one incident involving Resident #1 sustaining serious injuries during care performed by CNA A. The facility failed to thoroughly investigate the circumstances of Resident #1's injuries in order to know CNA A had only worked with Resident #1 one time prior to 08/23/14, CNA A had not read the plan of care for Resident #1, and the injuries were not caused by a wheelchair. CNA A was unaware Resident #1 could become resistant to care; thus, when Resident #1 began cursing and swinging her arms, the CNA A responded inappropriately resulting in Resident #1 sustaining bilateral avulsions (tearing away forcibly of a part or structure) from just below her elbows to just above her wrists. The resident was transferred to a local hospital's ER for evaluation and treatment. On 09/24/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/26/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope "isolated" because the facility was still evaluating the effectiveness of the Plan of Removal. This failure could affect the other 17 residents identified with a history of behaviors at risk for injuries due to failure of a nurse aide to know their assessed and care planned level of care and services. Findings included: 1. Review of the Abuse policy, with a release date 04/14/14, revealed, "...physical and mental abuse...of the patient as well as mistreatment...are strictly prohibited....Patients have the right to be free of...physical, and mental abuse...of the patient as well mistreatment...1. Prohibitions on abuse apply to: a. Center staff...9. Identify patients most at risk of neglect and abuse, may include but is not limited to: a. Patients who have dementia...." 2. Resident #1's Admission Record, dated 09/11/14, reflected she originally admitted to the facility on [DATE] and her most recent re-admission was 01/31/14. She was 94-years-old and her [DIAGNOSES REDACTED]. Resident #1's quarterly MDS assessment, dated 08/12/14, reflected she was oriented to year, month and day; exhibited no signs and symptoms of [MEDICAL CONDITION]; exhibited no behaviors; and required one person's extensive physical assistance with dressing and personal hygiene. Resident #1 was 65 inches tall and weighed 124 pounds and required staff assistance to stabilize her when she went from surface-to-surface, such as transfer from bed to chair. She was incontinent of bowel and bladder and had skin tears at that time. Resident #1's Care Plan, initiated 09/16/13 and revised 09/24/13, reflected she was "resistive to care r/t (related to) adjustment to nursing home, behaviors: refusing showers and care...." The interventions included if she resisted ADLs to reassure her and leave, then return 5 to 10 minutes later and try again. Resident #1's Progress Notes, reflected the following: -- Notes dated 08/23/14 at 10:52 PM and written by LVN B, reflected the resident was sent to the ER at 7:15 that morning. The Note reflected, "CNA came and reported that the resident got combative when she was trying to get her up. Resident was swinging her arms and the CNA was trying to prevent her from hitting. Resident got skin tears to both forearms, approximately 7 inches long by 3 inches wide. Nurse tried to apply first aid, skin tears were too severe. Notified doctor to send out, notified family, administrator was notified. Resident was sent to (local) hospital. Will continue to monitor." -- Notes dated 08/23/14 at 10:55 PM and written by LVN B, noted " (Resident #1) returned from the ER around 3 p.m. she was with her daughter. Resident has dry dressing and steri strips applied to her arms " . Review of Resident #1 ' s local hospital closed record, dated 08/23/14, reflected the following: -- The ED Physician Note, dated 08/23/14 at 8:06 AM noted: " . . . (resident) presents to the ED c/o (complain of) avulsions, with daughter at bedside. Pt (Patient) reports via daughter that she was unruly this morning at her NH (nursing home) and when an aide restrained her manually, her skin ripped. Daughter reports her mother is frequently combative, and is suffering from a UTI. Pt has no other complaints at this time. " -- That same date at 10:29 AM, it noted Resident #1 was ready to discharge and her [DIAGNOSES REDACTED]. Observation of Resident #1 at the facility in her room and in bed, on 09/11/14 at approximately 4:10 PM, revealed both arms were bandaged from her elbows to her wrists with purple bruising extending from the bottom of the bandage to the top/middle part of her hands. An interview with Resident #1 at that time revealed she could recall the incident. Resident #1 stated "that black girl" scratched me. Interview on 09/14/14 at 11:00 AM with LVN B revealed she had worked at the facility for almost one year. She stated she always worked weekend doubles and was on duty on 08/23/14. LVN B revealed on 08/23/14 CNA A came to her regarding a skin tear Resident #1 sustained. LVN B went to Resident #1's room and found Resident #1 lying sideways on her bed kind of crooked on the bed and at the foot of the bed with her arms drawn to her body. Resident #1 was dressed from the waist down with her pants and shoes on. The resident's wheelchair was positioned parallel to the bed. LVN B revealed CNA A told her she was getting ready to put Resident #1's shirt on and the resident started fighting. LVN B said when she approached the resident, she had blood all over the front her body but there was none on the bed. LVN B asked Resident #1 what happened. She stated Resident #1 told her she did not want to get up and CNA A pulled her by her arms and hurt her. She stated the injuries were from the elbow down to the wrists. LVN B revealed the resident's skin was pulled down to her wrists. She stated she was "'horrified" at the injuries. LVN B revealed those were the worst injuries she had ever seen. LVN B continued by saying she had LVN C to come and assist her with pulling Resident #1's skin back up over the muscle on both arms. LVN B said Resident #1 had thin skin, and she saw the resident did not have any blood or skin under her nails and nothing on her hands which indicated to LVN B the resident did not make contact with CNA A. LVN B said she had RN D call 911 and contact the family and the doctor. LVN B revealed it was her opinion if things happened the way the aide told her, the resident's injuries would have been at the wrists and not the whole forearm. LVN B revealed the physician at the hospital called her to ask her what happened. The physician told LVN B Resident #1's injuries measured 10+ inches length on both arms. LVN B revealed she had provided care for Resident #1 over the past year and "...if you rush her she gets combative or if she is tired. So you step away and come back later." LVN B said she never had a problem with Resident #1 being combative with her and she knew staff had to give the resident time and go back later if necessary. LVN B thought the CNA A was pretty nonchalant about the incident and did not display any emotion, which she thought was unusual because the injuries were so severe. LVN B had completed a written statement for the facility, dated 08/23/14. The statement reflected, "(CNA A) came to me and stated that she was trying to get (Resident #1) up and she was getting aggressive. I went into the resident room and she was laying (sic) on her bed, both forearms had severe lacerations. I asked the CNA (CNA A) to please go get another nurse to assist me. Nurse (LVN C) came in to help apply pressure. Start first aide applied and there was a large amount of skin. Another nurse (LVN HH) went to notify the doctor & call the ambulance. (LVN HH) also notified (Resident #1's family member). I notified the (Administrator and DON). Had CNA write a statement and asked her to go home until she was notified. Resident stated she didn't want to get (up) and the CNA was pulling on her." An interview with the Paramedic, on 09/11/14 at 1:45 PM, revealed he responded to the 911 call from the facility. The Paramedic stated on 08/23/14 at 7:15 AM, his team had been picked to transport Resident #1 to the hospital for emergency medical services. The Paramedic stated a nurse met him at the door and she was crying because the resident's injuries were so bad. The Paramedic stated Resident #1 had large skin tears/shears to at least 50 to 60 % of both of her arms. He stated he had never seen injuries like that. An interview with LVN C on 09/14/14 at 11:25 AM confirmed LVN B came and got her to look at Resident #1's arms. She assisted LVN B with first aid. She stated the injuries were bad. The resident's skin was pulled down from her elbows to her wrists. LVN C revealed she had never seen injuries that bad and she had been a nurse for [AGE] years. She stated CNA A was nonchalant about Resident #1's injuries. LVN C revealed she had worked with CNA A for six months and she thought she was a good aide. She stated CNA A was different that day. LVN C revealed she read CNA A's statement and she did not think it was consistent with what happened. Review of LVN C's written statement obtained by the facility and dated 08/23/14, reflected, "I was called to (Resident #1's) room by (LVN B) to look at res (resident's) arms. Large amt (amount) of skin was hanging from res fore arms. First aid rendered & 911 called." Review on 09/12/14 of CNA A's written statement obtained by the facility and dated 08/22/14 (sic), reflected "I (CNA A) went to get (Resident #1) up about 6:30 AM in room (room number) and I went to set (sic) her up on the edge of the bed she started swinging end (sic) fighting and her arm hit the wheel chair that's when I notice her arms was (sic) bleeding so I laid her back in the bed and went and got the nurse (LVN B)." An interview with CNA A 09/12/14 at 12:00 PM, confirmed she was the nurse aide who had assisted Resident #1 at the time of the incident. At the time of the interview, CNA A was noted to have a dark complexion and stand approximately 5 feet tall. She stated she had worked for the facility for almost one year. She stated she worked as a floater and thus worked different halls. She stated she currently worked four days on and two days off working the 6:00 AM to 2:00 PM shift. She stated she had received training in managing behaviors in the past and in-services on Abuse and Neglect. CNA A revealed prior to the incident with Resident #1, she had not really worked that hall. When asked how she could learn about the residents' characteristics, CNA A replied there were mini care plans in the residents' rooms. CNA A said she could also reference the ADL (Activities of Daily Living) book at the Nurse's Station for information about the resident. CNA A revealed the first day she worked with Resident #1, the resident was fine. She stated the day of the incident was the second time she had provided care to Resident #1. She stated she had cleaned Resident #1 in her bed, put her slacks and shoes on and swung the resident's legs around to the floor. When she got the resident to the edge of the bed, Resident #1 started swinging and cussing at her. CNA A stated she put her hands up to protect her own face and protect herself from the resident. CNA A revealed she thought the resident was falling backwards and that was when she grabbed the resident's arms to keep her from falling backwards. CNA A stated she was putting Resident #1 back in bed and that was when she saw the blood on Resident #1's arms. She did not indicate Resident #1 hit her arms on a wheelchair. She notified LVN B of what had occurred. CNA A stated if she could have done anything differently, she should have stepped away and let Resident #1 calm down and go back later. When asked why she did not take that action, CNA A replied she was not sure why. On 09/12/14, CNA A completed a second statement at the request of the Investigator. She noted, "On the morning of Aug (August) 23 (2014) I went in to get (Resident #1) out of bed for breakfast. I got her dress (sic) in bed, she was fine, but once she sat up on the side of the bed she started to swing & pull back so for to keep her from hitting her head on the railing I grab (sic) her hands and she kept swinging so I put her legs back on the bed to lye (sic) her back down that's when I noticed her arms were bleeding so I went and got the nurse (LVN B) and they sent her out to the hospital and sent me home." Review of CNA A's personnel record reflected she was hired on 09/15/13. The record contained no evidence of prior counseling(s) for failing to implement a resident's assessed and care planned level of care or for causing physical injuries to a resident. Review of training records, reflected CNA A had received training on Abuse and Neglect four times, Resident Rights two times and Dementia care once during the year of 09/15/13 through 09/15/14. Review of CNA A's time punch records revealed on 08/24/14, 08/25/14, 08/26/14 she did not work. On 08/29/14, she returned to work and worked through 09/11/14. CNA A did not work any additional days. Interview on 09/11/14 at approximately 3:15 PM with the Administrator revealed she had conducted the investigation of the incident involving Resident #1 and suspended CNA A pending the outcome of the investigation. The Administrator stated CNA A was brought back to work because the CNA "didn't do anything wrong." The resident was combative and flailing her arms sitting on the side of her bed. The CNA grabbed the resident's arms to protect the resident and her skin tore. The resident had very thin skin and the aide was small in stature. The family requested CNA A not provide care to Resident #1, and the CNA was subsequently moved to another hall. An interview on 09/11/14 at approximately 4:00 PM with the Staff Development Coordinator revealed she read the Provider Investigation Report, dated 08/23/14, about Resident #1's avulsions and CNA A's witness statement. The Coordinator stated her concern was CNA A's witness statement indicated she was defending herself from the resident with crossed arms and open hands and "that did not add up." An interview with the Administrator on 09/12/14 at approximately 3:45 PM revealed CNA A was suspended due to the surveyor's findings. The Administrator stated a decision on CNA A's employment would be determined based on the surveyor's findings. Further interview with the Administrator on 09/15/14 at approximately 1:10 PM revealed CNA A was terminated for failure to follow policies by not coming in to the facility to speak with the surveyor and Administrator. Interview on 09/12/14 at 2:00 PM with CNA D revealed he had been employed with the facility for a period of 10 months. He stated he had provided care for Resident #1 during seven of those months. CNA D revealed he never had a problem with her being aggressive or combative with him. He stated it was all in the approach with her. CNA D said it was all about what Resident #1 wanted. He revealed Resident #1 told him she and CNA A started to argue. He stated Resident #1 was able to recall what happened that day. Interview on 09/12/14 at 2:30 PM with LVN I revealed she had provided care to Resident #1 and some days she was combative. She stated it was all in the approach with the resident. LVN I revealed if the resident did not know someone, she might be combative. She stated someone could not just go in her room and start flipping the lights on and being abrupt. The facility's current Resident Refusal of Care policy, revised 04/28/10, reflected occasional refusals or failure to follow physician's orders [REDACTED]. Some residents consistently refused to accept or failed to follow the ordered treatment, therapeutic diet or services. Every attempt was made to accommodate the resident's request and still provide the appropriate care and services to meet the residents' needs while following the physician's orders [REDACTED]. On 09/24/14, an IJ was identified. On 09/24/14 at 6:10 PM., the Administrator, DON, LVN H, and LVN L were notified of the IJ had been identified for failure to ensure nurse aides provided residents their care planned level of care and services to prevent residents from sustaining serious injuries. Interview on 09/25/14 at 9:40 AM with the DON revealed since the incident with Resident #1, all Unit Managers now had a tool they could use that addressed staff interactions with the residents, identified as having behaviors. She said they initiated the in-services on 09/24/14. The training provided to staff included: How to recognize burnout, Kardex/CNA for CNA use regarding a resident's care requirements including behavior interventions, resident rights and abuse and neglect. Skin assessments were initiated on 09/12/14 and residents with fragile skin were identified to be at high risk for skin tears and the information was added to their care plans. Training for management/staff was provided in the area of residents with fragile skin and skin tear prevention. Audit rounds would be conducted by Nurse Managers and they would utilize a tool developed to monitor CNAs' knowledge of residents resistive to care, where they locate information pertaining to the residents and refusal of care. The tool was to be utilized by managers daily. All staff would be trained and those who had not had the training would not be allowed to return to work until they had received the required in-services. On 09/25/14, the Administrator was notified their Plan of Removal was accepted. The Plan of Removal, dated 09/25/14, reflected the following: -- Upon return from the hospital the resident (Resident #1) was evaluated and seen by the facility's certified Wound Care Nurse...The resident's Wound Care Physician , evaluated the resident's skin condition upon on 8/29/14. Additional skin treatment orders were ordered by wound care physician 8/29/14...The resident's care plan was reviewed and updated on 8/23/14 to reflect current health status by the facility's Minimum Data Set (MDS) nurse,(sic). The patient's medical history provides documentation of behavioral changes related to infection [MEDICAL CONDITION]. The resident's care plan reflects this information...(CNA A) was suspended pending outcome of facility investigation 8/23/14 and ultimately terminated from facility employment. -- On 08/23/14, CAN A was suspended pending the outcome of the facility's investigation. -- On 8/29/14, CNA A was re-in serviced on abuse related to this incident, and how to effectively deal with combative residents; this training was provided by the Staff Development Coordinator (sic). -- A Safe Survey was conducted after (CNA A) return on several residents throughout the facility whom (CNA A) had provided care with no negative outcome. (CNA A) returned to duty on 08/29/14 after the facility had completed its initial investigation of the incident. -- On 09/11/14, as a result of a complaint survey initiated by DADS, further details emerged questioning (CNA A) original statement. The facility reopened its investigation on 09/11/14. She (CNA A) was suspended as a result the reopening of the investigation. As a result of the facilities (sic)reopened investigation she was terminated on 09/15/14 primarily for her inability to provide a consistent statement regarding the incident with (Resident #1) on 08/23/14. (CNA A) failed to meet the facility standards of providing the highest standard of care to its residents. The facility is vigilant in protecting our residents from perceived mistreatment...Residents with behaviors were identified by resident assessment report in Point Click Care, electronic charting program, on 9/23/14. - The behavioral care plans and Certified Nursing Assistant (CNA) Kardex, (Kardex are a resource for CNAs, like a mini care plan to give personalized care to individual residents). Fragile skin is skin that has very thin tissue do to the loss of subcutaneous tissue. -- All of the residents identified were reviewed, and updated to reflect resident's current behavioral status by Director of Nursing, Unit Managers, (LVN H) and Assistant Director of Nursing ,(LVN J). -- The following residents have been identified with the potential for behaviors: (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18)...Identified residents exhibit the following types of behaviors; resistance to care, verbal outburst, inappropriate language, disrobing. -- Additionally, to assist in identifying the residents at risk, the facility consultant pharmacist reviewed residents receiving [MEDICAL CONDITION] medication to assure that appropriate recommendations are reviewed by resident's physician and subsequent orders are implemented by the licensed nurse; this review is done monthly and was last completed on 9/15/14. This review assures that the resident receives the appropriate medication to assist with behavior management and prevent adverse side effects. The consultant pharmacist will provide a monthly report of his/her review to the Director of Nursing. The Director of Nursing, will present a summary of the report to the Facility's Performance Improvement Committee on a monthly basis; this will be an on-going measure/intervention. -- Ad lib referrals to psychology and psychiatric services are determined by resident review in the Interdisciplinary Clinical Rounds (nursing, dietician, Social Worker, MDS, and Activities, process that occurs at least 5 days weekly. The Clinical Rounds Process is retrospective review of clinical needs of residents identified by the center's 24- hour reporting system. This process was implemented in February 2014 and is an ongoing facility practice with no end date. -- Residents identified will be discussed to assure that proper measures/interventions are implemented to resolve clinical concerns, assure that the MD and families are notified of concerns along with any appropriate follow up measures, care plans reviewed and updated and or created as new condition warrants, and that interventions are monitored until the clinical concern is resolved... -- All Kardex have been updated and are located at the nursing station for added security and confidentiality...Kardex will also notate residents identified with behaviors for additional interventions and suggestions to assure care is optimally provided. -- CNAs have been educated and are required to check it frequently for changes, as well as adding appropriate/helpful information. CNAs were in-serviced on Assessing Risk of Challenging Behaviors, Resident Rights, and Resident's Rights to Refuse Care, Definition(s) of Abuse, Behavioral Management, and Skin Tears: Prevention and Management, the dates of the in-services were on 09/12/14 -09/15/14. As part of the training, CNAs were in-serviced on the expectation of reviewing the Kardex prior to the start of each shift to assure that the CNA has the most updated information regarding the president's plan of care. Competency was evaluated and determined by questionnaire given by the Director of Nursing...This quiz tested the employee's knowledge of the following: How to deal with combative residents, Resident Right to refuse Care, notification to nursing supervisor and understanding that resident care is primary function. If employee missed more than one (1) question, additional training was provided... -- Additionally nursing staff have been in-serviced on 'burnout' and sign and symptoms of, as well as prevention and what to do if detected... quiz tested the employee's knowledge of the following: How to deal with combative residents, Resident Right to refuse Care, notification to nursing supervisor and understanding that resident care is their primary priority...Education/in-servicing was initiated and provided by the Staff Development Coordinator, 9/12-9/15/14. This education included: Assessing Risk of Challenging Behaviors, Resident Rights, Resident's Rights to Refuse Care, Definition(s) of Abuse, Behavioral Management, Skin Tears: Prevention and Management. These in-services were for Licensed Nurses and CNAs. Staff education was initiated and conducted by the Staff Development Coordinator on 8/25/14 for licensed nurses and CNAs on abuse training and how to effectively care for the combative resident. Subsequent staff education concluded on 9/13/14. -- As of 9/13/14, current licensed nurses and CNAs received the above training/education, and will be on-going annually and as needed...Additionally CNAs were educated on resident's plan of care, understanding the resident is priority, and steps to take when resident is combative...The competency evaluation(s) associated with this training was determined through quiz/test. This quiz tested the employee's knowledge of the subject matter. If employee missed more than one (1) question, additional training was provided...The facility will incorporate a behavior management review daily in the clinical rounds meeting. The behavioral management review will utilize an interdisciplinary approach to identify and analyze root cause(s) of behaviors...." To verify the facility had implemented their Plan of Removal the following was conducted: -- Review of in-service training records for facility employees on all shifts confirmed training had been provided in the areas of : How do you identify burnout and what to do., fragile skin, Kardex (Resident information for the Certified Nurse Aides) and expected CNA use regarding a residents care, resident care requirements to include residents who had been identified with behaviors and expected staff interventions, resident rights and training in the area of abuse and neglect. Review of the sign in sheets revealed out of 128 employees all had received the in-service training except for 6 employees. - Review of the care plans for the identified 18 residents who were identified as exhibiting behaviors confirmed their care plans and Kardex records had been updated to reflect the identified behavior. -- Interview with the Administrator and the DON on 09/25/14 at 3:45 PM revealed they had already met on 09/23/14 with the Medical Director as part of the Quality Assurance Review related to the incident and addressed other quality concerns. - Interviews were conducted with staff, representing staff from each shift and working weekdays and/or weekends. The staff interviewed were three LVNs (LVNs L, R and U); 17 CNAs (CNAs M, N, O, P, Q, S, T, V, W, X, Y, Z, AA, CC, DD, EE and FF); Housekeeping Manager, Social Worker, Business Office Manager and Business Office Assistant. Each employee was able to articulate what constituted abuse and/or neglect, how they would determine the level of care a resident required, and what action they would take if they observed an employee continuing to provide care for a resident exhibiting a behavior of resistance to care. On 09/29/14 at 12:15 PM, the Administrator was informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's Plan of Removal, dated 09/25/14, reflected 18 residents were at risk for behaviors including Resident #1.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #1) of eight residents reviewed for prevention of accidents, received adequate supervision to prevent incidents. CNA A had worked with Resident #1 only one time prior to 08/23/14. CNA A had not read the plan of care for Resident #1 and thus was unaware Resident #1 could become resistant to care. On 08/23/14, CNA A assisted Resident #1 with incontinence care and putting on her pants. When she assisted the resident to sit up, the resident began cursing and swinging her arms. CNA A thought the resident was going to fall back and grabbed the resident by the arms resulting in bilateral avulsions (tearing away forcibly of a part or structure) from just below her elbows to just above her wrists. The resident was transferred to a local hospital's ER for evaluation and treatment. On 09/24/14 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/26/14, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope "isolated" because the facility was still evaluating the effectiveness of the Plan of Removal. This failure could affect the other 17 residents identified with a history of behaviors at risk of sericous injuries due to failure of a nurse aide to know their assessed and care planned level of care and services. Findings included: Resident #1's Admission Record, dated 09/11/14, reflected she originally admitted to the facility on [DATE] and her most recent re-admission was 01/31/14. She was 94-years-old and her [DIAGNOSES REDACTED]. Resident #1's quarterly MDS assessment, dated 08/12/14, reflected she was oriented to year, month and day; exhibited no signs and symptoms of delirium; exhibited no behaviors; and required one person's extensive physical assistance with dressing and personal hygiene. Resident #1 was 65 inches tall and weighed 124 pounds and required staff assistance to stabilize her when she went from surface-to-surface, such as transfer from bed to chair. She was incontinent of bowel and bladder and had skin tears at that time. Resident #1's Care Plan, initiated 09/16/13 and revised 09/24/13, reflected she was "resistive to care r/t (related to) adjustment to nursing home, behaviors: refusing showers and care...." The interventions included if she resisted ADLs to reassure her and leave, then return 5 to 10 minutes later and try again. Resident #1's Progress Notes, reflected the following: -- Notes dated 08/23/14 at 10:52 PM and written by LVN B, reflected the resident was sent to the ER at 7:15 that morning. The Note reflected, "CNA came and reported that the resident got combative when she was trying to get her up. Resident was swinging her arms and the CNA was trying to prevent her from hitting. Resident got skin tears to both forearms, approximately 7 inches long by 3 inches wide. Nurse tried to apply first aid, skin tears were too severe. Notified doctor to send out, notified family, administrator was notified. Resident was sent to (local) hospital. Will continue to monitor." -- Notes dated 08/23/14 at 10:55 PM and written by LVN B, noted " (Resident #1) returned from the ER around 3 p.m. she was with her daughter. Resident has dry dressing and steri strips applied to her arms " . Review of Resident #1 ' s local hospital closed record, dated 08/23/14, reflected the following: -- The ED Physician Note, dated 08/23/14 at 8:06 AM noted: " . . . (resident) presents to the ED c/o (complain of) avulsions, with daughter at bedside. Pt (Patient) reports via daughter that she was unruly this morning at her NH (nursing home) and when an aide restrained her manually, her skin ripped. Daughter reports her mother is frequently combative, and is suffering from a UTI. Pt has no other complaints at this time. " -- That same date at 10:29 AM, it noted Resident #1 was ready to discharge and her [DIAGNOSES REDACTED]. Observation of Resident #1 at the facility in her room and in bed, on 09/11/14 at approximately 4:10 PM, revealed both arms were bandaged from her elbows to her wrists with purple bruising extending from the bottom of the bandage to the top/middle part of her hands. An interview with Resident #1 at that time revealed she could recall the incident. Resident #1 stated "that black girl" scratched me. Interview on 09/14/14 at 11:00 AM with LVN B revealed she had worked at the facility for almost one year. She stated she always worked weekend doubles and was on duty on 08/23/14. LVN B revealed on 08/23/14 CNA A came to her regarding a skin tear Resident #1 sustained. LVN B went to Resident #1's room and found Resident #1 lying sideways on her bed kind of crooked on the bed and at the foot of the bed with her arms drawn to her body. Resident #1 was dressed from the waist down with her pants and shoes on. The resident's wheelchair was positioned parallel to the bed. LVN B revealed CNA A told her she was getting ready to put Resident #1's shirt on and the resident started fighting. LVN B said when she approached the resident, she had blood all over the front her body but there was none on the bed. LVN B asked Resident #1 what happened. She stated Resident #1 told her she did not want to get up and CNA A pulled her by her arms and hurt her. She stated the injuries were from the elbow down to the wrists. LVN B revealed the resident's skin was pulled down to her wrists. She stated she was "'horrified" at the injuries. LVN B revealed those were the worst injuries she had ever seen. LVN B continued by saying she had LVN C to come and assist her with pulling Resident #1's skin back up over the muscle on both arms. LVN B said Resident #1 had thin skin, and she saw the resident did not have any blood or skin under her nails and nothing on her hands which indicated to LVN B the resident did not make contact with CNA A. LVN B said she had RN D call 911 and contact the family and the doctor. LVN B revealed it was her opinion if things happened the way the aide told her, the resident's injuries would have been at the wrists and not the whole forearm. LVN B revealed the physician at the hospital called her to ask her what happened. The physician told LVN B Resident #1's injuries measured 10+ inches length on both arms. LVN B revealed she had provided care for Resident #1 over the past year and "...if you rush her she gets combative or if she is tired. So you step away and come back later." LVN B said she never had a problem with Resident #1 being combative with her and she knew staff had to give the resident time and go back later if necessary. LVN B thought the CNA A was pretty nonchalant about the incident and did not display any emotion, which she thought was unusual because the injuries were so severe. LVN B had completed a written statement for the facility, dated 08/23/14. The statement reflected, "(CNA A) came to me and stated that she was trying to get (Resident #1) up and she was getting aggressive. I went into the resident room and she was laying (sic) on her bed, both forearms had severe lacerations. I asked the CNA (CNA A) to please go get another nurse to assist me. Nurse (LVN C) came in to help apply pressure. Start first aide applied and there was a large amount of skin. Another nurse (LVN HH) went to notify the doctor & call the ambulance. (LVN HH) also notified (Resident #1's family member). I notified the (Administrator and DON). Had CNA write a statement and asked her to go home until she was notified. Resident stated she didn't want to get (up) and the CNA was pulling on her." An interview with the Paramedic, on 09/11/14 at 1:45 PM, revealed he responded to the 911 call from the facility. The Paramedic stated on 08/23/14 at 7:15 AM, his team had been picked to transport Resident #1 to the hospital for emergency medical services. The Paramedic stated a nurse met him at the door and she was crying because the resident's injuries were so bad. The Paramedic stated Resident #1 had large skin tears/shears to at least 50 to 60 % of both of her arms. He stated he had never seen injuries like that. An interview with LVN C on 09/14/14 at 11:25 AM confirmed LVN B came and got her to look at Resident #1's arms. She assisted LVN B with first aid. She stated the injuries were bad. The resident's skin was pulled down from her elbows to her wrists. LVN C revealed she had never seen injuries that bad and she had been a nurse for [AGE] years. She stated CNA A was nonchalant about Resident #1's injuries. LVN C revealed she had worked with CNA A for six months and she thought she was a good aide. She stated CNA A was different that day. LVN C revealed she read CNA A's statement and she did not think it was consistent with what happened. Review of LVN C's written statement obtained by the facility and dated 08/23/14, reflected, "I was called to (Resident #1's) room by (LVN B) to look at res (resident's) arms. Large amt (amount) of skin was hanging from res fore arms. First aid rendered & 911 called." Review on 09/12/14 of CNA A's written statement obtained by the facility and dated 08/22/14 (sic), reflected "I (CNA A) went to get (Resident #1) up about 6:30 AM in room (room number) and I went to set (sic) her up on the edge of the bed she started swinging end (sic) fighting and her arm hit the wheel chair that's when I notice her arms was (sic) bleeding so I laid her back in the bed and went and got the nurse (LVN B)." An interview with CNA A 09/12/14 at 12:00 PM, confirmed she was the nurse aide who had assisted Resident #1 at the time of the incident. At the time of the interview, CNA A was noted to have a dark complexion and stand approximately 5 feet tall. She stated she had worked for the facility for almost one year. She stated she worked as a floater and thus worked different halls. She stated she currently worked four days on and two days off working the 6:00 AM to 2:00 PM shift. She stated she had received training in managing behaviors in the past and in-services on Abuse and Neglect. CNA A revealed prior to the incident with Resident #1, she had not really worked that hall. When asked how she could learn about the residents' characteristics, CNA A replied there were mini care plans in the residents' rooms. CNA A said she could also reference the ADL (Activities of Daily Living) book at the Nurse's Station for information about the resident. CNA A revealed the first day she worked with Resident #1, the resident was fine. She stated the day of the incident was the second time she had provided care to Resident #1. She stated she had cleaned Resident #1 in her bed, put her slacks and shoes on and swung the resident's legs around to the floor. When she got the resident to the edge of the bed, Resident #1 started swinging and cussing at her. CNA A stated she put her hands up to protect her own face and protect herself from the resident. CNA A revealed she thought the resident was falling backwards and that was when she grabbed the resident's arms to keep her from falling backwards. CNA A stated she was putting Resident #1 back in bed and that was when she saw the blood on Resident #1's arms. She did not indicate Resident #1 hit her arms on a wheelchair. She notified LVN B of what had occurred. CNA A stated if she could have done anything differently, she should have stepped away and let Resident #1 calm down and go back later. When asked why she did not take that action, CNA A replied she was not sure why. On 09/12/14, CNA A completed a second statement at the request of the Investigator. She noted, "On the morning of Aug (August) 23 (2014) I went in to get (Resident #1) out of bed for breakfast. I got her dress (sic) in bed, she was fine, but once she sat up on the side of the bed she started to swing & pull back so for to keep her from hitting her head on the railing I grab (sic) her hands and she kept swinging so I put her legs back on the bed to lye (sic) her back down that's when I noticed her arms were bleeding so I went and got the nurse (LVN B) and they sent her out to the hospital and sent me home." Review of CNA A's personnel record reflected she was hired on 09/15/13. The record contained no evidence of prior counseling(s) for failing to implement a resident's assessed and care planned level of care or for causing physical injuries to a resident. Review of training records, reflected CNA A had received training on Abuse and Neglect four times, Resident Rights two times and Dementia care once during the year of 09/15/13 through 09/15/14. Review of CNA A's time punch records revealed on 08/24/14, 08/25/14, 08/26/14 she did not work. On 08/29/14, she returned to work and worked through 09/11/14. CNA A did not work any additional days. Interview on 09/11/14 at approximately 3:15 PM with the Administrator revealed she had conducted the investigation of the incident involving Resident #1 and suspended CNA A pending the outcome of the investigation. The Administrator stated CNA A was brought back to work because the CNA "didn't do anything wrong." The resident was combative and flailing her arms sitting on the side of her bed. The CNA grabbed the resident's arms to protect the resident and her skin tore. The resident had very thin skin and the aide was small in stature. The family requested CNA A not provide care to Resident #1, and the CNA was subsequently moved to another hall. An interview on 09/11/14 at approximately 4:00 PM with the Staff Development Coordinator revealed she read the Provider Investigation Report, dated 08/23/14, about Resident #1's avulsions and CNA A's witness statement. The Coordinator stated her concern was CNA A's witness statement indicated she was defending herself from the resident with crossed arms and open hands and "that did not add up." An interview with the Administrator on 09/12/14 at approximately 3:45 PM revealed CNA A was suspended due to the surveyor's findings. The Administrator stated a decision on CNA A's employment would be determined based on the surveyor's findings. Further interview with the Administrator on 09/15/14 at approximately 1:10 PM revealed CNA A was terminated for failure to follow policies by not coming in to the facility to speak with the surveyor and Administrator. Interview on 09/12/14 at 2:00 PM with CNA D revealed he had been employed with the facility for a period of 10 months. He stated he had provided care for Resident #1 during seven of those months. CNA D revealed he never had a problem with her being aggressive or combative with him. He stated it was all in the approach with her. CNA D said it was all about what Resident #1 wanted. He revealed Resident #1 told him she and CNA A started to argue. He stated Resident #1 was able to recall what happened that day. Interview on 09/12/14 at 2:30 PM with LVN I revealed she had provided care to Resident #1 and some days she was combative. She stated it was all in the approach with the resident. LVN I revealed if the resident did not know someone, she might be combative. She stated someone could not just go in her room and start flipping the lights on and being abrupt. Review on 09/11/14 of the facility's current Abuse policy, with a release date 04/14/14, revealed, "...physical and mental abuse...of the patient as well as mistreatment...are strictly prohibited....Patients have the right to be free of...physical, and mental abuse...of the patient as well mistreatment...1. Prohibitions on abuse apply to: a. Center staff...9. Identify patients most at risk of neglect and abuse, may include but is not limited to: a. Patients who have dementia...." The facility's current Resident Refusal of Care policy, revised 04/28/10, reflected occasional refusals or failure to follow physician's orders [REDACTED]. Some residents consistently refused to accept or failed to follow the ordered treatment, therapeutic diet or services. Every attempt was made to accommodate the resident's request and still provide the appropriate care and services to meet the residents' needs while following the physician's orders [REDACTED]. On 09/24/14 at 6:10 PM., the Administrator, DON, LVN H, and LVN L were notified of the IJ had been identified for failure to ensure nurse aides provided residents their care planned level of care and services to prevent residents from sustaining serious injuries. Interview on 09/25/14 at 9:40 AM with the DON revealed since the incident with Resident #1, all Unit Managers now had a tool they could use that addressed staff interactions with the residents, identified as having behaviors. She said they initiated the in-services on 09/24/14. The training provided to staff included: How to recognize burnout, Kardex/CNA for CNA use regarding a resident's care requirements including behavior interventions, resident rights and abuse and neglect. Skin assessments were initiated on 09/12/14 and residents with fragile skin were identified to be at high risk for skin tears and the information was added to their care plans. Training for management/staff was provided in the area of residents with fragile skin and skin tear prevention. Audit rounds would be conducted by Nurse Managers and they would utilize a tool developed to monitor CNAs' knowledge of residents resistive to care, where they locate information pertaining to the residents and refusal of care. The tool was to be utilized by managers daily. All staff would be trained and those who had not had the training would not be allowed to return to work until they had received the required in-services. On 09/25/14, the Administrator was notified their Plan of Removal was accepted. The Plan of Removal, dated 09/25/14, reflected the following: -- Upon return from the hospital the resident (Resident #1) was evaluated and seen by the facility's certified Wound Care Nurse...The resident's Wound Care Physician , evaluated the resident's skin condition upon on 8/29/14. Additional skin treatment orders were ordered by wound care physician 8/29/14...The resident's care plan was reviewed and updated on 8/23/14 to reflect current health status by the facility's Minimum Data Set (MDS) nurse,(sic). The patient's medical history provides documentation of behavioral changes related to infection (UTI). The resident's care plan reflects this information...(CNA A) was suspended pending outcome of facility investigation 8/23/14 and ultimately terminated from facility employment. -- On 08/23/14, CAN A was suspended pending the outcome of the facility's investigation. -- On 8/29/14, CNA A was re-in serviced on abuse related to this incident, and how to effectively deal with combative residents; this training was provided by the Staff Development Coordinator (sic). -- A Safe Survey was conducted after (CNA A) return on several residents throughout the facility whom (CNA A) had provided care with no negative outcome. (CNA A) returned to duty on 08/29/14 after the facility had completed its initial investigation of the incident. -- On 09/11/14, as a result of a complaint survey initiated by DADS, further details emerged questioning (CNA A) original statement. The facility reopened its investigation on 09/11/14. She (CNA A) was suspended as a result the reopening of the investigation. As a result of the facilities (sic)reopened investigation she was terminated on 09/15/14 primarily for her inability to provide a consistent statement regarding the incident with (Resident #1) on 08/23/14. (CNA A) failed to meet the facility standards of providing the highest standard of care to its residents. The facility is vigilant in protecting our residents from perceived mistreatment...Residents with behaviors were identified by resident assessment report in Point Click Care, electronic charting program, on 9/23/14. - The behavioral care plans and Certified Nursing Assistant (CNA) Kardex, (Kardex are a resource for CNAs, like a mini care plan to give personalized care to individual residents). Fragile skin is skin that has very thin tissue do to the loss of subcutaneous tissue. -- All of the residents identified were reviewed, and updated to reflect resident's current behavioral status by Director of Nursing, Unit Managers, (LVN H) and Assistant Director of Nursing ,(LVN J). -- The following residents have been identified with the potential for behaviors: (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18)...Identified residents exhibit the following types of behaviors; resistance to care, verbal outburst, inappropriate language, disrobing. -- Additionally, to assist in identifying the residents at risk, the facility consultant pharmacist reviewed residents receiving psychotropic medication to assure that appropriate recommendations are reviewed by resident's physician and subsequent orders are implemented by the licensed nurse; this review is done monthly and was last completed on 9/15/14. This review assures that the resident receives the appropriate medication to assist with behavior management and prevent adverse side effects. The consultant pharmacist will provide a monthly report of his/her review to the Director of Nursing. The Director of Nursing, will present a summary of the report to the Facility's Performance Improvement Committee on a monthly basis; this will be an on-going measure/intervention. -- Ad lib referrals to psychology and psychiatric services are determined by resident review in the Interdisciplinary Clinical Rounds (nursing, dietician, Social Worker, MDS, and Activities, process that occurs at least 5 days weekly. The Clinical Rounds Process is retrospective review of clinical needs of residents identified by the center's 24- hour reporting system. This process was implemented in February 2014 and is an ongoing facility practice with no end date. -- Residents identified will be discussed to assure that proper measures/interventions are implemented to resolve clinical concerns, assure that the MD and families are notified of concerns along with any appropriate follow up measures, care plans reviewed and updated and or created as new condition warrants, and that interventions are monitored until the clinical concern is resolved... -- All Kardex have been updated and are located at the nursing station for added security and confidentiality...Kardex will also notate residents identified with behaviors for additional interventions and suggestions to assure care is optimally provided. -- CNAs have been educated and are required to check it frequently for changes, as well as adding appropriate/helpful information. CNAs were in-serviced on Assessing Risk of Challenging Behaviors, Resident Rights, and Resident's Rights to Refuse Care, Definition(s) of Abuse, Behavioral Management, and Skin Tears: Prevention and Management, the dates of the in-services were on 09/12/14 -09/15/14. As part of the training, CNAs were in-serviced on the expectation of reviewing the Kardex prior to the start of each shift to assure that the CNA has the most updated information regarding the president's plan of care. Competency was evaluated and determined by questionnaire given by the Director of Nursing...This quiz tested the employee's knowledge of the following: How to deal with combative residents, Resident Right to refuse Care, notification to nursing supervisor and understanding that resident care is primary function. If employee missed more than one (1) question, additional training was provided... -- Additionally nursing staff have been in-serviced on 'burnout' and sign and symptoms of, as well as prevention and what to do if detected... quiz tested the employee's knowledge of the following: How to deal with combative residents, Resident Right to refuse Care, notification to nursing supervisor and understanding that resident care is their primary priority...Education/in-servicing was initiated and provided by the Staff Development Coordinator, 9/12-9/15/14. This education included: Assessing Risk of Challenging Behaviors, Resident Rights, Resident's Rights to Refuse Care, Definition(s) of Abuse, Behavioral Management, Skin Tears: Prevention and Management. These in-services were for Licensed Nurses and CNAs. Staff education was initiated and conducted by the Staff Development Coordinator on 8/25/14 for licensed nurses and CNAs on abuse training and how to effectively care for the combative resident. Subsequent staff education concluded on 9/13/14. -- As of 9/13/14, current licensed nurses and CNAs received the above training/education, and will be on-going annually and as needed...Additionally CNAs were educated on resident's plan of care, understanding the resident is priority, and steps to take when resident is combative...The competency evaluation(s) associated with this training was determined through quiz/test. This quiz tested the employee's knowledge of the subject matter. If employee missed more than one (1) question, additional training was provided...The facility will incorporate a behavior management review daily in the clinical rounds meeting. The behavioral management review will utilize an interdisciplinary approach to identify and analyze root cause(s) of behaviors...." To verify the facility had implemented their Plan of Removal the following was conducted: -- Review of in-service training records for facility employees on all shifts confirmed training had been provided in the areas of : How do you identify burnout and what to do., fragile skin, Kardex (Resident information for the Certified Nurse Aides) and expected CNA use regarding a residents care, resident care requirements to include residents who had been identified with behaviors and expected staff interventions, resident rights and training in the area of abuse and neglect. Review of the sign in sheets revealed out of 128 employees all had received the in-service training except for 6 employees. - Review of the care plans for the identified 18 residents who were identified as exhibiting behaviors confirmed their care plans and Kardex records had been updated to reflect the identified behavior. -- Interview with the Administrator and the DON on 09/25/14 at 3:45 PM revealed they had already met on 09/23/14 with the Medical Director as part of the Quality Assurance Review related to the incident and addressed other quality concerns. - Interviews were conducted with staff, representing staff from each shift and working weekdays and/or weekends. The staff interviewed were three LVNs (LVNs L, R and U); 17 CNAs (CNAs M, N, O, P, Q, S, T, V, W, X, Y, Z, AA, CC, DD, EE and FF); Housekeeping Manager, Social Worker, Business Office Manager and Business Office Assistant. Each employee was able to articulate what constituted abuse and/or neglect, how they would determine the level of care a resident required, and what action they would take if they observed an employee continuing to provide care for a resident exhibiting a behavior of resistance to care. On 09/29/14 at 12:15 PM, the Administrator was informed the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy," and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's Plan of Removal, dated 09/25/14, reflected 18 residents were at risk for behaviors including Resident #1.

Based on interview and record review, the facility failed to ensure each resident had the right to be free from verbal and/or mental abuse for four (Residents #1, #2, #3, and #5) of 14 residents reviewed for abuse. 1. The Administrator yelled at Resident #1 and demanded she go back inside the facility "right now." This resulted in Resident #1's fear of the Administrator and emotional distress. 2. The Administrator loudly asked Resident #2 "Where the hell are you going?" When the Transport Driver responded a doctor's appointment, the Administrator said, "Hell no." This resulted in Resident #2 crying, feeling sad and embarrassed. 3. The Administrator yelled at Resident #3 about an aerosol can of deodorizer in his room, grabbed the can, threw the can in a drawer and slammed the drawer closed. This resulted in Resident #3 crying and feeling bad. 4. The Administrator spoke rudely to Resident #5 while she was discussing the resident's bill. The Administrator did this in front of another resident. This resulted in Resident #5 feeling bullied, embarrassed, and fearful. An Immediate Jeopardy (IJ) was identified on 08/05/13. While the IJ was removed on 08/07/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the facility's other 118 residents by placing them at risk for abuse and/or mistreatment. Findings included: 1. Resident #1's Face Sheet, dated 08/01/13, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 05/17/13, reflected the resident was cognitively intact and did not have any behaviors. Resident #1's care plan, dated 05/27/13, reflected she attended activities of her choice and engaged in self-initiated leisure activities outside. Interview with the Division Director of Clinical Operations on 08/01/13 at 3:30 p.m. revealed the Administrator and DON were suspended pending an investigation. Interview with the Ombudsman on 08/01/13 at 4:15 p.m. revealed Resident #1 told her she went out to the courtyard every day for 20-45 minutes. The Administrator went out to the courtyard to tell the resident to come in and grabbed her arm on Monday, 07/29/13 between 3:34 and 4:00 p.m. Interview with Resident #1 on 08/02/13 at 3:15 p.m. revealed she was sitting outside in the sun one day when the Administrator and Social Worker approached her without identifying themselves. The resident said she knew the Social Worker, but she did not know the Administrator, and she was scared. The resident explained the Administrator yelled at her and demanded she go inside "right now." Resident #1 revealed she always sat in the sun, and she did not go in. The resident said when the ADON came and spoke with her, she returned to the building. She stated she reported the incident to CNA E. Resident #1 revealed the DON told her the Administrator was not arguing, and the incident would be her word against the Administrator's. The resident stated she knew the Administrator was gone, but she was afraid she would come back. Another interview with Resident #1 on 08/01/13 at 4:30 p.m. revealed the DON told her it was her word against the Administrator's when Resident #1 was giving her statement to the DON. A telephone interview with the Administrator on 08/05/13 at 3:39 p.m. revealed she noticed Resident #1 was asleep outside, and she was concerned about her. The Administrator and Social Worker A approached the resident, and Social Worker A reached and touched her arm lightly. She said Resident #1 jumped because she was startled. The Administrator revealed she told the resident she was concerned about her remaining outside because it was so hot. She stated she offered to help Resident #1 so she could cool down, and after she was cooled, the Administrator said she could return outside. Interview with Social Worker A, on 08/02/13 at 10:40 a.m. revealed she witnessed the interaction Resident #1 had with the Administrator in the courtyard on Monday, 07/29/13. The Social Worker said the Administrator saw someone on the patio in the courtyard, so she and the Administrator went out to check. The Social Worker explained the Administrator called the resident by her name, startling the resident, and told the resident to go back inside. According to Social Worker A, the resident asked the Administrator who she was, and the Administrator responded by giving her name and position. Social Worker A reported she was unsure of the demeanor of the resident when she came in with the ADON, but she described the Administrator as loud and pushy. The Administrator was adamant the resident come in. The Social Worker admitted if the Administrator had spoken to her in the same manner, she would have been hurt and probably cried. She added, "but I am sensitive." Interview with the facility's only ADON on 08/05/13 at 3:30 p.m. revealed on 07/30/13 another employee came to her office and told her the Administrator yelled at Resident #1. The ADON explained Resident #1 had fallen asleep while outside, and she woke up to someone yelling at her. The ADON stated Resident #1 reported she asked the Administrator three times who she was and the Administrator did not respond. Interview with Social Worker B on 08/05/13 at 1:25 p.m. revealed she first learned of the incident involving Resident #1 on 07/31/13. She said the ADON told her there was an issue and asked her to speak with Resident #1 and find out what was going on. Resident #1 told her she was out sunning and had fallen asleep, and the next thing the resident knew someone was tapping her arm and telling her to come in. Social Worker B stated the resident said the person kept tapping and pulling her arm to come in, and the resident kept asking the person to identify herself. Social Worker B revealed she spoke with Social Worker A and the ADON, and together they decided something needed to be done. The three staff members decided to call the Ombudsman and after sharing their report regarding the incident, the Ombudsman told them it was "reportable," so they decided to call corporate staff. Another interview with the ADON on 08/02/13 at 10:55 a.m. revealed the Administrator came to her office and told her Resident #1 was in the courtyard and needed to come in because she was going to get sunburned and dehydrated. The ADON described the Administrator as always being loud and easily frustrated. The ADON continued to explain the Administrator got tense and jittery when she was upset. The Administrator was frustrated because Resident #1 would not follow her instructions to come into the building. The ADON said an investigation was immediately started on Tuesday, 07/30/13, following the allegation made by Resident #1 regarding the incident in the courtyard the previous day Monday, 07/29/13. The ADON revealed when she came to work on Wednesday, 07/31/13, she was told by another staff member the DON called Resident #1 a liar. Another statement was taken from Resident #1, by Social Worker B on Wednesday, 07/31/13. Social Worker B called the Ombudsman, who said the incident was reportable. Social Worker B attempted to call corporate, leaving a message concerning the situation. The Corporate Director of Clinical Operations arrived at the facility on Wednesday afternoon 07/31/13. The Administrator and DON were suspended at that time. Interview with CNA E on 08/02/13 at 3:05 p.m. revealed the residents were treated well until recently. CNA E stated on 07/29/13 Resident #1 asked to speak to the employee, and at 9:30 p.m., she went to the resident's room to speak with her before the end of her shift. She stated Resident #1 reported the Administrator grabbed her arm and was "yanking" her and telling her to come in. CNA E revealed the resident said at the time of the incident, she did not know who the Administrator was. CNA E also stated the resident said she had reported the incident to the DON, but the DON explained to the resident it was her word against the facility's. CNA E confirmed she was the staff member who let Resident #1 go outside as the resident did daily. She said she would set a timer for 20 minutes and then bring her back inside. CNA E told Resident #1 that she (Resident #1) needed to report this incident. CNA E said she attempted to report the incident to the corporate office on 07/30/13, but she was unable to reach anyone. CNA E continued to explain she feared retaliation if she reported the incident. CNA E feared retaliation from the Administrator because she had always spoken rudely to her in morning staff meetings in front of everyone and she had removed herself from the position of staff development coordinator and returned to the floor. Interview with CNA F on 08/02/13 at 3:35 p.m. revealed she spoke to Resident #1 on 07/30/13 at 9:30 p.m. about the incident with the Administrator in the courtyard, and the employee told Resident #1 she (Resident #1) needed to report the incident. Resident #1 told the employee she had reported the incident to the DON and ADON. CNA F stated Resident #1 was upset and crying as she described the incident in the courtyard. Interview with CNA J on 08/02/13 at 4:20 p.m. revealed Resident #1 reported to her about the incident, and she reported it to the DON. CNA J stated Resident #1 said the DON called her a liar. Interview with LVN D on 08/06/13 at 10:24 a.m. revealed on Tuesday (07/30/13) at approximately 10:00 a.m. a CNA reported Resident #1 said a woman grabbed her and would not let go of her arm. The LVN did not state in her interview that she knew who the woman was that Resident #1 was talking about. LVN D went to the DON and reported the alleged abuse. LVN D also told Social Worker A. LVN D confirmed she spoke with the DON at 10:05 a.m., and the DON said "Okay, just let the Social Worker handle it." LVN D reported to Social Worker A at 10:15 a.m. and the ADON at 10:30 a.m. LVN D revealed the ADON said she would talk with Resident #1. LVN D stated the Administrator "was not very nice, and she spoke rudely to staff and residents." She revealed "she (Administrator) was not a people person." LVN D confirmed it was obvious Resident #1 had been crying, and she added Resident #1 did not cry a lot. She said the resident was nice, and she joked a lot with staff. The facility's Provider Investigation Report, dated 08/01/13, reflected, "(Resident #1) made an alleged (sic) allegation that (Administrator) grabbed her by the arm and insisted that she come into the building ...Provider Response (Administrator) suspended pending investigation (DON) suspended pending investigation Investigation Summary (Resident #1) was in the facility courtyard tanning. (Resident #1) made an alleged (sic) allegation that (Administrator) requested several times for her to come into building due to the concern of dehydration and sun burn. (Resident #1) stated that (Administrator) eventually grabbed her by the arm and insisted she come into building. According to (Resident #1) when she reported this to (DON), (DON) made the statement, 'it is your words versus the administrator.' Investigation Findings Inconclusive ...Provider Action Taken Post-Investigation 1. (Administrator) Suspended pending investigation and Statement taken 2. (DON) Suspended pending investigation and Statement taken ...10. In-services on abuse and neglect started ***Currently state investigators are investigating alleged (sic) allegation." 2. Resident #2's Face Sheet, dated 08/01/13,reflected the resident was a [AGE] year-old female, who was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2's MDS assessment, dated 06/21/13, reflected she was cognitively intact and did not exhibit any behaviors. The MDS assessment also reflected she sometimes felt down and hopeless. Interview with the Ombudsman on 08/01/13 at 4:15 p.m. revealed Resident #2 was going out via transportation to get her catheter changed, the resident was told the facility was not going to pay for her transport, and the Administrator told the resident she was not going to the appointment. Interview with Resident #2 on 08/02/13 at 3:05 p.m. revealed the resident was being taken to a doctor's appointment for a catheter change on 07/26/13 by a transport driver when the Administrator said loudly "Where the hell are you going?" The resident said the Transport Driver responded saying she was being taken to a doctor's appointment. Resident #2 revealed the Administrator then said, "Hell no." Resident #2 explained this incident made her feel both sad and embarrassed. She said she knew everyone present could hear the Administrator speaking to her in that manner. Interview with the Transport Driver, who worked for a transportation company, on 08/02/13 at 11:35 a.m. revealed on 07/26/13 he was at the facility to transport Resident #2 for a prearranged doctor's appointment. He stated he went to the resident's room and they went toward the front door together. He revealed the Administrator came out of an office and said, "Where the hell are you taking her? You are not taking her anywhere. This is bullshit." He said the Administrator demanded he come in her office. The Administrator called Resident #2's family member to determine who made the doctor's appointment and what it was for. The Transport Driver revealed the receptionist and other residents' family members were in the front area and heard what the Administrator said. He stated the resident was crying and asked him "Why is she talking to me that way?" The Transport Driver stated he was trying to comfort the resident as they left the building for the resident's appointment. A telephone interview with the Administrator on 08/05/13 at 3:39 p.m. revealed Resident #2's family member came in and asked the Administrator to go to the resident's room with him/her, so he/she could tell the resident to "cut her crap out." The Administrator stated she told the resident's family member he/she could not do that. The Administrator revealed Resident #2 had been making her own doctor's appointments when unnecessary. The Administrator stated she had never used profane language when speaking with a resident or in front of a resident. The Administrator was convinced this was a "witch hunt" because she had made changes when she came to the facility approximately six weeks prior to this incident. One of the changes the Administrator made was cutting out unauthorized overtime. The Administrator stated back in May overtime was $50,000 and $44,000 was from nursing. She implemented the policy that overtime could not be worked unless it was preauthorized by her. The Administrator revealed she was told by an employee she needed to be careful and watch her back because employees were planning to be mean and wanted to get her to quit. Interview with the Admissions Coordinator on 08/02/13 at 11:55 a.m. revealed she witnessed the incident involving Resident #2 and the Administrator. She stated she was coming from the restroom and saw the Transport Driver and the resident trying to leave. The Admissions Coordinator stated at that time, the Administrator went to the Transport Driver and said, "No, no. You aren't taking her anywhere." The Admissions Coordinator explained the Administrator was concerned about transportation costs. She said she did hear the Administrator say "bullshit" during this incident, and she witnessed the Transport Driver trying to console the resident, who the Admissions Coordinator said was sensitive. The Admissions Coordinator admitted she would have been offended if the Administrator had spoken to her in the same way the Administrator had spoken to the resident and Transport Driver. Interview with the BOA on 08/02/13 at 12:15 p.m. revealed she was sitting at her desk between the front door and the Administrator's office, when the Administrator who was in the MDS Coordinator's office, came out, saw the transport driver and Resident #2 and asked them where they were going and the resident told her they were going to an appointment. The BOA stated the Administrator told Resident #2 "No, no, no. You're not going anywhere." The BOA revealed the Administrator went to her (Administrator's) office, and she heard the Administrator say "bullshit." The BOA said the resident seemed upset, but she was not crying. The BOA revealed the resident made her own appointments to leave the facility and sometimes faked [MEDICAL CONDITION] to get attention. She stated she received calls from family members reporting the Administrator had treated them rudely while on the phone. The BOA admitted if the Administrator had spoken to her like she spoke to Resident #2 and the Transport Driver, she would have been very upset, and probably would have cried. Interview with the BOM on 08/05/13 at 12:45 p.m. revealed on 07/26/13 while sitting in her office, she heard the Administrator loudly say, "Where are you going, and where are you taking her?" She walked to the door and saw the Administrator talking to Resident #2 and the Transport Driver. She then returned to her desk. The BOM stated the Administrator did not sound angry, but she did sound frustrated. She revealed she did not take it personally the way the Administrator spoke to her, but she thought it was unprofessional. An interview with the Divisional Director of Clinical Operations on 08/02/13 at 12:50 PM revealed she was not aware of the incident with Resident #2 and the Administrator, which occurred on 07/26/13. The facility's Provider Investigation Report, signed 08/06/13, reflected, "...It was reported that (Administrator) used inappropriate language at (Resident #2)...Provider Response Suspension of employees ...Psychosocial assessment completed and monitored ...In-Serves (sic) conducted on Abuse and neglect Investigation Summary It was identified that (Administrator) did use inappropriate language with a resident (Resident #2) Investigation Findings Confirmed ...Provider Action Taken Post-Investigation ****Please see plan of removal to DADS ***Current state investigators, investigating incident as of 08-01-2013." 3. Resident #3's Face Sheet, dated 08/01/13, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3's MDS assessment, dated 06/21/13, reflected he was cognitively intact and did not exhibit any behaviors. The MDS assessment also reflected he sometimes felt down and hopeless. Interview with Resident #3 on 08/02/13 at 3:30 revealed the Administrator came in his room and yelled at him about an aerosol can of room deodorizer in his room, and his clothes hamper being in the corner of his room. The resident demonstrated the Administrator's tone of voice, and how she pointed her finger at his clothes hamper, while he explained the incident. He stated the Administrator grabbed the aerosol can and "threw" it in the drawer and "slammed" the drawer on his bedside table. Resident #3 revealed the way the Administrator treated him made him feel "bad." The resident said he cried after the Administrator left his room because of the way he was treated. 4. Resident #5's Face Sheet, dated 08/13/13, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's MDS assessment, dated 07/12/13, reflected she was cognitively intact, and did not exhibit any behaviors. Interview with Resident #5 on 08/06/13 at 10:50 a.m. revealed the Administrator entered her room with the resident's bill in her hands. The resident stated the Administrator was with another person, but she did not know who the other person was. Resident #5 revealed the Administrator spoke to her rudely and continued tapping the resident's billing statement as she spoke to her. Resident #5 revealed the Administrator explained her bill was past due. However, her bill was not past due. It was an error made by facility staff. Resident #5 stated she felt bullied, embarrassed and fearful when approached the way the Administrator approached her. She said the Administrator was loud and spoke to her about her statement in front of another resident. 5. An interview on 08/02/13 at approximately 9:30 AM with the Interim Administrator revealed he was the interim Administrator until a permanent Administrator was found. 6. The facility's current Abuse Policy, released on 08/31/12, reflected, "Verbal, sexual, physical, and mental abuse...as well as mistreatment...are strictly prohibited. All alleged violations involving mistreatment, neglect or abuse...are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures (including state survey and certification agency)...Retribution against patients, staff, or visitors who file reports of abuse is strictly prohibited...." According to the facility's abuse policy, abuse was "The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal Abuse The use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within hearing distance regardless of their age, ability to comprehend or disability...Mental Abuse Includes, but is not limited to, humiliation, harassment, threats of punishments or deprivation...." 7. The Administrator's personnel file reflected a hire date of 06/17/13. Background verifications were completed prior to her hire, including criminal history, license verification, and employee misconduct registry. 8. An IJ was identified on 08/05/13 at 9:30 a.m. and the Interim Administrator was notified. A Plan of Removal was requested at that time. 9. The facility's Plan of Removal, dated 08/05/13 and accepted on 08/07/13, reflected the following: 1) The following staff were suspended: Administrator on 07/31/13, the Interim DON on 07/31/13, Social Worker A on 08/05/13, the Admissions Coordinator on 08/06/13, the Receptionist on 08/0613, and the ADON on 08/06/13. Social Worker A was terminated on 08/06/13 and the Administrator was terminated on 08/07/13. 2) Clinical/Psychosocial assessments were conducted by Social Worker A and Social Worker B on involved residents as appropriate. No adverse effects clinically; facility would be providing ongoing support for demonstrated anxiety for Residents #1, #2, and #3. 3) Re-training and in-servicing (no employee would be allowed to work until they have received): a. Abuse (to include definitions); b. Respond/Recognize an Abuse Allegation; c. Conducting an investigation; d. Reporting. 4) Re-in-servicing for postings of available contact numbers for state regulatory agencies, Ombudsmen, corporate compliance line, and district team members. This was initiated on 08/01/13 and initial completion of all employees on 08/06/13 and then on-going with new employees. Inservices were conducted by Interim Administrator, Corporate Nurse, Interim ADON, and corporate personnel. 4) Identification of others at risk: a. Conducted interviews and safe surveys on all alert residents and reviewed documentation as well as observed non-interviewable residents to identify any other residents at risk. b) Conducted Resident Council to identify any grievances that could potentially be allegations. 5) Systemic changes: a. New hire orientation along with annual reviews would be enhanced to place emphasis on recognizing and reporting abuse (internally and externally). b. Postings of available contact numbers for state regulatory agencies, Ombudsman, corporate compliance line, district team members placed in work room, break room) time clock, both nurses' stations. c. Monthly abuse training for 90 days then quarterly. 6) Monitoring: a. Weekly visits/oversights with residents by the district team which consists of the Division Director Human Resources, the Regional Manager Financial Affairs, the District Director Clinical Operations, the Division Director Case Management, and the Division Vice President Operations for 90 days or until compliance was met. b. Random interviews with staff to ensure understanding of reeducation/in-service for 90 days or until compliance was met. Interviews would be kept on file. c. Any identified trends would be brought to the monthly performance improvement committee meeting and as needed. 7) ADDENDUM: The Medical Director was out of the country, but would be updated upon his return. His Nurse Practitioner was notified. 8) New key employees (to include Administrator and Director of Nursing) As above as well as weekly monitoring/evaluation of management style and compliance with state and federal definition/reporting of abuse, neglect, and misappropriation of resident property. Random residents, staff, and families would be interviewed for 60 days with interviews kept on file. 9) How to prevent this from happening in the future: a. Reference checks, b. criminal background check, c. nurse aide registry check, d. professional license check, e. New key employees (to include Administrator and Director of Nursing) As above as well as weekly monitoring/evaluation of management style and compliance with state and federal definition/reporting of abuse, neglect, and misappropriation of resident property. Random residents, staff, and families would be interviewed for 60 days with interviews kept on file. Interview with the Corporate Director of Clinical Operations on 08/06/13 10:30 a.m. revealed Social Worker A was terminated for her involvement with resident abuse at the facility. The interview also revealed the ADON, BOA, and Admissions Coordinator were suspended because of their failure to report abuse. Interview with the Corporate Director of Clinical Operations on 08/07/13 at 11:00 a.m. revealed the Administrator was terminated on 08/07/13. 10. Interviews conducted with CNA L, CNA M, CNA N, CNA O and CNA P on 08/07/13 from 10:30 a.m. through 11:30 a.m. revealed employees were inserviced on the different types of abuse and neglect, identifying abuse, reporting abuse and neglect and monitoring of residents. Employees interviewed verbalized understanding of the names and definitions of different types of abuse, how to recognize abuse and whom to contact/report abuse to especially in cases of allegations regarding the Administrator or upper level staff (corporate phone numbers were placed in the employee break room and by the time clock). Employees stated they felt comfortable reporting abuse or neglect and did not fear retaliation. 11. The IJ was removed on 08/07/13. The Interim Administrator was notified on 08/07/13 at 10:30 AM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" with a severity level of "actual harm that is not immediate jeopardy," due to the facility was still monitoring the Plan of Removal. 12. The facility-submitted 08/01/13 Resident Census and Conditions of Residents form reflected a census of 123 residents.

Based on interview and record review, it was determined the facility failed to ensure all alleged violations involving mistreatment and/or abuse were immediately reported to the State survey and certification agency and have evidence the alleged violations were thoroughly investigated for four (Residents #1, #2, #3, and #5) of 14 residents reviewed for abuse. 1. The BOA, Admissions Coordinator, and BOM failed to report the Administrator's mental and/or verbal abuse of Resident #2 on 07/26/13 to anyone, including the State survey and certification agency. Therefore, an investigation was not started until surveyor intervention on 08/01/13. If the BOA, Admissions Coordinator, or BOM had reported the abuse, then the Administrator's mental and/or verbal abuse of Resident #1 might have been prevented. 2. The ADON, Social Worker A, Social Worker B, and the DON failed to report the Administrator's mental and/or verbal abuse of Resident #1 on 07/29/13 to the State survey and certification agency. 3. The facility failed to have evidence of a thorough investigation into Resident #1's allegation of mental and/or verbal abuse by the Administrator on 07/29/13, until corporate staff entered the facility on 07/31/13 and completed an investigation on 08/06/13. An Immediate Jeopardy (IJ) was identified on 08/05/13. While the IJ was removed on 08/07/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the facility's other 118 residents by placing them at risk for abuse and/or mistreatment. Findings included: 1. Resident #2's Face Sheet, dated 08/01/13,reflected the resident was a [AGE] year-old female, who was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2's MDS assessment, dated 06/21/13, reflected she was cognitively intact and did not exhibit any behaviors. The MDS assessment also reflected she sometimes felt down and hopeless. Interview with the Ombudsman on 08/01/13 at 4:15 p.m. revealed Resident #2 was going out via transportation to get her catheter changed, the resident was told the facility was not going to pay for her transport, and the Administrator told the resident she was not going to the appointment. Interview with Resident #2 on 08/02/13 at 3:05 p.m. revealed the resident was being taken to a doctor's appointment for a catheter change on 07/26/13 by a transport driver when the Administrator said loudly "Where the hell are you going?" The resident said the Transport Driver responded saying she was being taken to a doctor's appointment. Resident #2 revealed the Administrator then said, "Hell no." Resident #2 explained this incident made her feel both sad and embarrassed. She said she knew everyone present could hear the Administrator speaking to her in that manner. Interview with the Transport Driver, who worked for a transportation company, on 08/02/13 at 11:35 a.m. revealed on 07/26/13 he was at the facility to transport Resident #2 for a prearranged doctor's appointment. He stated he went to the resident's room and they went toward the front door together. He revealed the Administrator came out of an office and said, "Where the hell are you taking her? You are not taking her anywhere. This is bullshit." He said the Administrator demanded he come in her office. The Administrator called Resident #2's family member to determine who made the doctor's appointment and what it was for. The Transport Driver revealed the receptionist and other residents' family members were in the front area and heard what the Administrator said. He stated the resident was crying and asked him "Why is she talking to me that way?" The Transport Driver stated he was trying to comfort the resident as they left the building for the appointment. A telephone interview with the Administrator on 08/05/13 at 3:39 p.m. revealed Resident #2's family member came in and asked the Administrator to go to the resident's room with him/her, so he/she could tell the resident to "cut her crap out." The Administrator stated she told the resident's family member he/she could not do that. The Administrator revealed Resident #2 had been making her own doctor's appointments when unnecessary. The Administrator stated she had never used profane language when speaking with a resident or in front of a resident. The Administrator was convinced this was a "witch hunt" because she had made changes when she came to the facility approximately six weeks prior to this incident. One of the changes the Administrator made was cutting out unauthorized overtime. The Administrator stated back in May overtime was $50,000 and $44,000 was from nursing. She implemented the policy that overtime could not be worked unless it was preauthorized by her. The Administrator revealed she was told by an employee she needed to be careful and watch her back because employees were planning to be mean and wanted to get her to quit. Interview with the Admissions Coordinator on 08/02/13 at 11:55 a.m. revealed she witnessed the incident involving Resident #2 and the Administrator. She stated she was coming from the restroom and saw the Transport Driver and the resident trying to leave. The Admissions Coordinator stated at that time, the Administrator went to the Transport Driver and said, "No, no. You aren't taking her anywhere." The Admissions Coordinator explained the Administrator was concerned about transportation costs. She said she did hear the Administrator say "bullshit" during this incident, and she witnessed the Transport Driver trying to console the resident, who the Admissions Coordinator said was sensitive. The Admissions Coordinator admitted she would have been offended if the Administrator had spoken to her in the same way the Administrator had spoken to the resident and Transport Driver. Interview with the BOA on 08/02/13 at 12:15 p.m. revealed she was sitting at her desk between the front door and the Administrator's office, when the Administrator who was in the MDS Coordinator's office, came out, saw the transport driver and Resident #2 and asked them where they were going and the resident told her they were going to an appointment. The BOA stated the Administrator told Resident #2 "No, no, no. You're not going anywhere." The BOA revealed the Administrator went to her (Administrator's) office, and she heard the Administrator say "bullshit." The BOA said the resident seemed upset, but she was not crying. The BOA revealed the resident made her own appointments to leave the facility and sometimes faked [MEDICAL CONDITION] to get attention. She stated she received calls from family members reporting the Administrator had treated them rudely while on the phone. The BOA admitted if the Administrator had spoken to her like she spoke to Resident #2 and the Transport Driver, she would have been very upset, and probably would have cried. Interview with the BOM on 08/05/13 at 12:45 p.m. revealed on 07/26/13 while sitting in her office, she heard the Administrator loudly say, "Where are you going, and where are you taking her?" She walked to the door and saw the Administrator talking to Resident #2 and the Transport Driver. She then returned to her desk. The BOM stated the Administrator did not sound angry, but she did sound frustrated. She revealed she did not take it personally the way the Administrator spoke to her, but she thought it was unprofessional. An interview with the Divisional Director of Clinical Operations on 08/02/13 at 12:50 PM revealed she was not aware of the incident with Resident #2 and the Administrator, which occurred on 07/26/13. The facility's Provider Investigation Report, signed on 08/06/13, reflected, "...It was reported that (Administrator) used inappropriate language at (Resident #2) ...Provider Response Suspension of employees ...Psychosocial assessment completed and monitored ...In-Serves (sic) conducted on Abuse and neglect Investigation Summary It was identified that (Administrator) did use inappropriate language with a resident (Resident #2) Investigation Findings Confirmed ...Provider Action Taken Post-Investigation ****Please see plan of removal to DADS ***Current state investigators, investigating incident as of 08-01-2013." 2. Resident #1's Face Sheet, dated 08/01/13, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 05/17/13, reflected the resident was cognitively intact and did not have any behaviors. Resident #1's care plan, dated 05/27/13, reflected she attended activities of her choice and engaged in self-initiated leisure activities outside. Interview with the Division Director of Clinical Operations on 08/01/13 at 3:30 p.m. revealed the Administrator and DON were suspended pending an investigation. Interview with the Ombudsman on 08/01/13 at 4:15 p.m. revealed Resident #1 told her she went out to the courtyard every day for 20-45 minutes. The Administrator went out to the courtyard to tell the resident to come in and grabbed her arm on Monday, 07/29/13 between 3:34 and 4:00 p.m. Interview with Resident #1 on 08/02/13 at 3:15 p.m. revealed she was sitting outside in the sun one day when the Administrator and Social Worker approached her without identifying themselves. The resident said she knew the Social Worker, but she did not know the Administrator, and she was scared. The resident explained the Administrator yelled at her and demanded she go inside "right now." Resident #1 revealed she always sat in the sun, and she did not go in. The resident said when the ADON came and spoke with her, she returned to the building. She stated she reported the incident to CNA E. Resident #1 revealed the DON told her the Administrator was not arguing, and the incident would be her word against the Administrator's. The resident stated she knew the Administrator was gone, but she was afraid she would come back. Another interview with Resident #1 on 08/01/13 at 4:30 p.m. revealed the DON told her it was her word against the Administrator's when Resident #1 was giving her statement to the DON. A telephone interview with the Administrator on 08/05/13 at 3:39 p.m. revealed she noticed Resident #1 was asleep outside, and she was concerned about her. The Administrator and Social Worker A approached the resident, and Social Worker A reached and touched her arm lightly. She said Resident #1 jumped because she was startled. The Administrator revealed she told the resident she was concerned about her remaining outside because it was so hot. She stated she offered to help Resident #1 so she could cool down, and after she was cooled, the Administrator said she could return outside. Interview with Social Worker A, on 08/02/13 at 10:40 a.m. revealed she witnessed the interaction Resident #1 had with the Administrator in the courtyard on Monday, 07/29/13. The Social Worker said the Administrator saw someone on the patio in the courtyard, so she and the Administrator went out to check. The Social Worker explained the Administrator called the resident by her name, startling the resident, and told the resident to go back inside. According to Social Worker A, the resident asked the Administrator who she was, and the Administrator responded by giving her name and position. Social Worker A reported she was unsure of the demeanor of the resident when she came in with the ADON, but she described the Administrator as loud and pushy. The Administrator was adamant the resident come in. The Social Worker admitted if the Administrator had spoken to her in the same manner, she would have been hurt and probably cried. She added, "but I am sensitive." Interview with the facility's only ADON on 08/05/13 at 3:30 p.m. revealed on 07/30/13 another employee came to her office and told her the Administrator yelled at Resident #1. The ADON explained Resident #1 had fallen asleep while outside, and she woke up to someone yelling at her. The ADON stated Resident #1 reported she asked the Administrator three times who she was, and the Administrator did not respond. Interview with Social Worker B on 08/05/13 at 1:25 p.m. revealed she first learned of the incident involving Resident #1 on 07/31/13. She said the ADON told her there was an issue and asked her to speak with Resident #1 and find out what was going on. Resident #1 told her she was out sunning and had fallen asleep, and the next thing the resident knew someone was tapping her arm and telling her to come in. Social Worker B stated the resident said the person kept tapping and pulling her arm to come in, and the resident kept asking the person to identify herself. Social Worker B revealed she spoke with Social Worker A and the ADON, and together they decided something needed to be done. The three staff members decided to call the Ombudsman and after sharing their report regarding the incident, the Ombudsman told them it was "reportable," so they decided to call corporate staff. Another interview with the ADON on 08/02/13 at 10:55 a.m. revealed the Administrator came to her office and told her Resident #1 was in the courtyard and needed to come in because she was going to get sunburned and dehydrated. The ADON described the Administrator as always being loud and easily frustrated. The ADON continued to explain the Administrator got tense and jittery when she was upset. The Administrator was frustrated because Resident #1 would not follow her instructions to come into the building. The ADON said an investigation was immediately started on Tuesday, 07/30/13, following the allegation made by Resident #1 regarding the incident in the courtyard the previous day Monday, 07/29/13. The ADON revealed when she came to work on Wednesday, 07/31/13, she was told by another staff member the DON called Resident #1 a liar. Another statement was taken from Resident #1, by Social Worker B on Wednesday, 07/31/13. Social Worker B called the Ombudsman, who said the incident was reportable. Social Worker B attempted to call corporate, leaving a message concerning the situation. The Corporate Director of Clinical Operations arrived at the facility on Wednesday afternoon 07/31/13. The Administrator and DON were suspended at that time. Interview with CNA E on 08/02/13 at 3:05 p.m. revealed the residents were treated well until recently. CNA E stated on 07/29/13 Resident #1 asked to speak to the employee, and at 9:30 p.m., she went to the resident's room to speak with her before the end of her shift. She stated Resident #1 reported the Administrator grabbed her arm and was "yanking" her and telling her to come in. CNA E revealed the resident said at the time of the incident, she did not know who the Administrator was. CNA E also stated the resident said she had reported the incident to the DON, but the DON explained to the resident it was her word against the facility's. CNA E confirmed she was the staff member who let Resident #1 go outside as the resident did daily. She said she would set a timer for 20 minutes and then bring her back inside. CNA E told Resident #1 that she (Resident #1) needed to report this incident. CNA E said she attempted to report the incident to the corporate office on 07/30/13, but she was unable to reach anyone. CNA E continued to explain she feared retaliation if she reported the incident. CNA E feared retaliation from the Administrator because she had always spoken rudely to her in morning staff meetings in front of everyone and she had removed herself from the position of staff development coordinator and returned to the floor. Interview with CNA F on 08/02/13 at 3:35 p.m. revealed she spoke to Resident #1 on 07/30/13 at 9:30 p.m. about the incident with the Administrator in the courtyard, and the employee told Resident #1 she (Resident #1) needed to report the incident. Resident #1 told the employee she had reported the incident to the DON and ADON. CNA F stated Resident #1 was upset and crying as she described the incident in the courtyard. Interview with CNA J on 08/02/13 at 4:20 p.m. revealed Resident #1 reported to her about the incident, and she reported it to the DON. CNA J stated Resident #1 said the DON called her a liar. Interview with LVN D on 08/06/13 at 10:24 a.m. revealed on Tuesday (07/30/13) at approximately 10:00 a.m. a CNA reported Resident #1 said a woman grabbed her and would not let go of her arm. The LVN did not state in her interview that she knew who the woman was that Resident #1 was talking about. LVN D went to the DON and reported the alleged abuse. LVN D also told Social Worker A. LVN D confirmed she spoke with the DON at 10:05 a.m., and the DON said "Okay, just let the Social Worker handle it." LVN D reported to Social Worker A at 10:15 a.m. and the ADON at 10:30 a.m. LVN D revealed the ADON said she would talk with Resident #1. LVN D stated the Administrator "was not very nice, and she spoke rudely to staff and residents." She revealed "she (Administrator) was not a people person." LVN D confirmed it was obvious Resident #1 had been crying, and she added Resident #1 did not cry a lot. She said the resident was nice, and she joked a lot with staff. The facility's Provider Investigation Report, signed on 08/06/13, reflected, "(Resident #1) made an alleged (sic) allegation that (Administrator) grabbed her by the arm and insisted that she come into the building ...Provider Response (Administrator) suspended pending investigation (DON) suspended pending investigation Investigation Summary (Resident #1) was in the facility courtyard tanning. (Resident #1) made an alleged (sic) allegation that (Administrator) requested several times for her to come into building due to the concern of dehydration and sun burn. (Resident #1) stated that (Administrator) eventually grabbed her by the arm and insisted she come into building. According to (Resident #1) when she reported this to (DON), (DON) made the statement, 'it is your words versus the administrator.' Investigation Findings Inconclusive ...Provider Action Taken Post-Investigation 1. (Administrator) Suspended pending investigation and Statement taken 2. (DON) Suspended pending investigation and Statement taken ...10. In-services on abuse and neglect started ***Currently state investigators are investigating alleged (sic) allegation." 3. Resident #3's Face Sheet, dated 08/01/13, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3's MDS assessment, dated 06/21/13, reflected he was cognitively intact and did not exhibit any behaviors. The MDS assessment also reflected he sometimes felt down and hopeless. Interview with Resident #3 on 08/02/13 at 3:30 revealed the Administrator came in his room and yelled at him about an aerosol can of room deodorizer in his room, and his clothes hamper being in the corner of his room. The resident demonstrated the Administrator's tone of voice, and how she pointed her finger at his clothes hamper, while he explained the incident. He stated the Administrator grabbed the aerosol can and "threw" it in the drawer and "slammed" the drawer on his bedside table. Resident #3 revealed the way the Administrator treated him made him feel "bad." The resident said he cried after the Administrator left his room because of the way he was treated. 4. Resident #5's Face Sheet, dated 08/13/13, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's MDS assessment, dated 07/12/13, reflected she was cognitively intact and did not exhibit any behaviors. Interview with Resident #5 on 08/06/13 at 10:50 a.m. revealed the Administrator entered her room with the resident's bill in her hands. The resident stated the Administrator was with another person, but she did not know who other person was. Resident #5 revealed the Administrator spoke to her rudely and continued tapping the resident's billing statement as she spoke to her. Resident #5 revealed the Administrator explained her bill was past due. However, her bill was not past due. It was an error made by facility staff. Resident #5 stated she felt bullied, embarrassed and fearful when approached the way the Administrator approached her. She said the Administrator was loud and spoke to her about her statement in front of another resident. 5. An interview on 08/02/13 at approximately 9:30 AM with the Interim Administrator revealed he was the interim Administrator until a permanent Administrator was found. 6. The facility's current Abuse Policy, released on 08/31/12, reflected, "Verbal... and mental abuse...are strictly prohibited. All alleged violations involving ...abuse...are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures (including state survey and certification agency)...Retribution against patients, staff, or visitors who file reports of abuse is strictly prohibited...." According to the facility's abuse policy, abuse was "The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal Abuse The use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within hearing distance regardless of their age, ability to comprehend or disability...Mental Abuse Includes, but is not limited to, humiliation, harassment, threats of punishments or deprivation... Procedure... For All Abuse Allegations 1. Begin an internal investigation...2. If allegation against staff, suspend pending allegation...4. Immediately report the allegations to the Director of Operations, DDCO, Regional Vice President, Human Resources, and legal counsel...6. Report the alleged abuse to the appropriate state agencies in accordance with state law...1. Post State Abuse Hotline telephone number at each nursing unit. 2. Educate residents, families, and staff on how and to whom they may report concerns, events, and complaints/concerns without fear of retribution...The Investigation 2. Document the details of the incident. 3. Evaluate the resident regarding emotional distress and identify impact on psychosocial functioning...9. Interview staff members...and/or residents who may have knowledge of alleged incident being investigated...15. Interview coworkers and/or residents to gain knowledge of their experiences with the accused person. 16. Describe any action(s) taken by the center to protect the resident(s) and to prevent a possible reoccurrence during the investigation (i.e...Suspension of the accused employee, pending investigation)...." 7. The Administrator's personnel file reflected a hire date of 06/17/13. Background verifications were completed prior to her hire, including criminal history, license verification, and employee misconduct registry. 8. An IJ was identified on 08/05/13 at 9:30 a.m. and the Interim Administrator was notified. A Plan of Removal was requested at that time. 9. The facility's Plan of Removal, dated 08/05/13 and accepted on 08/07/13, reflected the following: 1) The following staff were suspended: Administrator on 07/31/13, the Interim DON on 07/31/13, Social Worker A on 08/05/13, the Admissions Coordinator on 08/06/13, the Receptionist on 08/0613, and the ADON on 08/06/13. Social Worker A was terminated on 08/06/13, and the Administrator was terminated on 08/07/13. 2) Clinical/Psychosocial assessments were conducted by Social Worker A and Social Worker B on involved residents as appropriate. No adverse effects clinically; facility would be providing ongoing support for demonstrated anxiety for Residents #1, #2, and #3. 3) Re-training and in-servicing (no employee would be allowed to work until they have received): a. Abuse (to include definitions); b. Respond/Recognize an Abuse Allegation; c. Conducting an investigation; d. Reporting. 4) Re-in-servicing for postings of available contact numbers for state regulatory agencies, Ombudsmen, corporate compliance line, and district team members. This was initiated on 08/01/13 and initial completion of all employees on 08/06/13 and then on-going with new employees. Inservices were conducted by Interim Administrator, Corporate Nurse, Interim ADON, and corporate personnel. 4) Identification of others at risk: a. Conducted interviews and safe surveys on all alert residents and reviewed documentation as well as observed non-interviewable residents to identify any other residents at risk. b) Conducted Resident Council to identify any grievances that could potentially be allegations. 5) Systemic changes: a. New hire orientation along with annual reviews would be enhanced to place emphasis on recognizing and reporting abuse (internally and externally). b. Postings of available contact numbers for state regulatory agencies, Ombudsman, corporate compliance line, district team members placed in work room, break room) time clock, both nurses' stations. c. Monthly abuse training for 90 days then quarterly. 6) Monitoring: a. Weekly visits/oversights with residents by the district team which consists of the Division Director Human Resources, the Regional Manager Financial Affairs, the District Director Clinical Operations, the Division Director Case Management, and the Division Vice President Operations for 90 days or until compliance was met. b. Random interviews with staff to ensure understanding of reeducation/in-service for 90 days or until compliance was met. Interviews would be kept on file. c. Any identified trends would be brought to the monthly performance improvement committee meeting and as needed. 7) ADDENDUM: The Medical Director was out of the country, but would be updated upon his return. His Nurse Practitioner was notified. 8) New key employees (to include Administrator and Director of Nursing) As above as well as weekly monitoring/evaluation of management style and compliance with state and federal definition/reporting of abuse, neglect, and misappropriation of resident property. Random residents, staff, and families would be interviewed for 60 days with interviews kept on file. 9) How to prevent this from happening in the future: a. Reference checks, b. criminal background check, c. nurse aide registry check, d. professional license check, e. New key employees (to include Administrator and Director of Nursing) As above as well as weekly monitoring/evaluation of management style and compliance with state and federal definition/reporting of abuse, neglect, and misappropriation of resident property. Random residents, staff, and families would be interviewed for 60 days with interviews kept on file. Interview with the Corporate Director of Clinical Operations on 08/06/13 10:30 a.m. revealed Social Worker A was terminated for her involvement with resident abuse at the facility. The interview also revealed the ADON, BOA, and Admissions Coordinator were suspended because of their failure to report abuse. Interview with the Corporate Director of Clinical Operations on 08/07/13 at 11:00 a.m. revealed the Administrator was terminated on 08/07/13. 10. Interviews conducted with CNA L, CNA M, CNA N, CNA O and CNA P on 08/07/13 from 10:30 a.m. through 11:30 a.m. revealed employees were inserviced on the different types of abuse and neglect, identifying abuse, reporting abuse and neglect and monitoring of residents. Employees interviewed verbalized understanding of the names and definitions of different types of abuse, how to recognize abuse and whom to contact/report abuse to especially in cases of allegations regarding the Administrator or upper level staff (corporate phone numbers were placed in the employee break room and by the time clock). Employees stated they felt comfortable reporting abuse or neglect and did not fear retaliation. 11. The IJ was removed on 08/07/13. The Interim Administrator was notified on 08/07/13 at 10:30 AM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" with a severity level of "actual harm that is not immediate jeopardy," due to the facility was still monitoring the Plan of Removal. 12. The facility-submitted 08/01/13 Resident Census and Conditions of Residents form reflected a census of 123 residents.

Based on interview and record review, it was determined the facility failed to follow the policies and procedures that prohibit abuse of residents for five (Residents #1, #2, #3, #4, and #5) 14 residents reviewed for abuse. 1. The Administrator yelled at Resident #1 and demanded she go back inside the facility "right now." This resulted in Resident #1's fear of the Administrator and emotional distress. 2. The Administrator loudly asked Resident #2 "Where the hell are you going?" When the Transport Driver responded a doctor's appointment, the Administrator said, "Hell no." This resulted in Resident #2 crying, feeling sad and embarrassed. 3. The Administrator yelled at Resident #3 about an aerosol can of deodorizer in his room, grabbed the can, threw the can in a drawer and slammed the drawer closed. This resulted in Resident #3 crying and feeling bad. 4. The Administrator spoke rudely to Resident #5 while she was discussing the resident's bill. The Administrator did this in front of another resident. This resulted in Resident #5 feeling bullied, embarrassed, and fearful. 5. The BOA, Admissions Coordinator, and BOM failed to report the Administrator's mental and/or verbal abuse of Resident #2 on 07/26/13 to anyone, including the State survey and certification agency. Therefore, an investigation was not started until surveyor intervention on 08/01/13. If the BOA, Admissions Coordinator, or BOM had reported the abuse, then the Administrator's mental and/or verbal abuse of Resident #1 might have been prevented. 6. The ADON, Social Worker A, Social Worker B, and the DON failed to report the Administrator's mental and/or verbal abuse of Resident #1 on 07/29/13 to the State survey and certification agency. 7. The facility failed to have evidence of a thorough investigation into Resident #1's allegation of mental and/or verbal abuse by the Administrator on 07/29/13, until corporate staff entered the facility on 07/31/13 and completed an investigation on 08/06/13. An Immediate Jeopardy (IJ) was identified on 08/05/13. While the IJ was removed on 08/07/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the facility's other 118 residents by placing them at risk for abuse and/or mistreatment. Findings included: 1. The facility's current Abuse Policy, released on 08/31/12, reflected, "Verbal... and mental abuse...are strictly prohibited. All alleged violations involving ...abuse...are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures (including state survey and certification agency)...Retribution against patients, staff, or visitors who file reports of abuse is strictly prohibited...." According to the facility's abuse policy, abuse was "The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal Abuse The use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within hearing distance regardless of their age, ability to comprehend or disability...Mental Abuse Includes, but is not limited to, humiliation, harassment, threats of punishments or deprivation... Procedure... For All Abuse Allegations 1. Begin an internal investigation...2. If allegation against staff, suspend pending allegation...4. Immediately report the allegations to the Director of Operations, DDCO, Regional Vice President, Human Resources, and legal counsel...6. Report the alleged abuse to the appropriate state agencies in accordance with state law...1. Post State Abuse Hotline telephone number at each nursing unit. 2. Educate residents, families, and staff on how and to whom they may report concerns, events, and complaints/concerns without fear of retribution...The Investigation 2. Document the details of the incident. 3. Evaluate the resident regarding emotional distress and identify impact on psychosocial functioning...9. Interview staff members...and/or residents who may have knowledge of alleged incident being investigated...15. Interview coworkers and/or residents to gain knowledge of their experiences with the accused person. 16. Describe any action(s) taken by the center to protect the resident(s) and to prevent a possible reoccurrence during the investigation (i.e...Suspension of the accused employee, pending investigation)...." 2. Resident #1's Face Sheet, dated 08/01/13, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 05/17/13, reflected the resident was cognitively intact and did not have any behaviors. Resident #1's care plan, dated 05/27/13, reflected she attended activities of her choice and engaged in self-initiated leisure activities outside. Interview with the Division Director of Clinical Operations on 08/01/13 at 3:30 p.m. revealed the Administrator and DON were suspended pending an investigation. Interview with the Ombudsman on 08/01/13 at 4:15 p.m. revealed Resident #1 told her she went out to the courtyard every day for 20-45 minutes. The Administrator went out to the courtyard to tell the resident to come in and grabbed her arm on Monday, 07/29/13 between 3:34 and 4:00 p.m. Interview with Resident #1 on 08/02/13 at 3:15 p.m. revealed she was sitting outside in the sun one day when the Administrator and Social Worker approached her without identifying themselves. The resident said she knew the Social Worker, but she did not know the Administrator, and she was scared. The resident explained the Administrator yelled at her and demanded she go inside "right now." Resident #1 revealed she always sat in the sun, and she did not go in. The resident said when the ADON came and spoke with her, she returned to the building. She stated she reported the incident to CNA E. Resident #1 revealed the DON told her the Administrator was not arguing, and the incident would be her word against the Administrator's. The resident stated she knew the Administrator was gone, but she was afraid she would come back. Another interview with Resident #1 on 08/01/13 at 4:30 p.m. revealed the DON told her it was her word against the Administrator's when Resident #1 was giving her statement to the DON. A telephone interview with the Administrator on 08/05/13 at 3:39 p.m. revealed she noticed Resident #1 was asleep outside, and she was concerned about her. The Administrator and Social Worker A approached the resident, and Social Worker A reached and touched her arm lightly. She said Resident #1 jumped because she was startled. The Administrator revealed she told the resident she was concerned about her remaining outside because it was so hot. She stated she offered to help Resident #1 so she could cool down, and after she was cooled, the Administrator said she could return outside. Interview with Social Worker A, on 08/02/13 at 10:40 a.m. revealed she witnessed the interaction Resident #1 had with the Administrator in the courtyard on Monday, 07/29/13. The Social Worker said the Administrator saw someone on the patio in the courtyard, so she and the Administrator went out to check. The Social Worker explained the Administrator called the resident by her name, startling the resident, and told the resident to go back inside. According to Social Worker A, the resident asked the Administrator who she was, and the Administrator responded by giving her name and position. Social Worker A reported she was unsure of the demeanor of the resident when she came in with the ADON, but she described the Administrator as loud and pushy. The Administrator was adamant the resident come in. The Social Worker admitted if the Administrator had spoken to her in the same manner, she would have been hurt and probably cried. She added, "but I am sensitive." Interview with the facility's only ADON on 08/05/13 at 3:30 p.m. revealed on 07/30/13 another employee came to her office and told her the Administrator yelled at Resident #1. The ADON explained Resident #1 had fallen asleep while outside, and she woke up to someone yelling at her. The ADON stated Resident #1 reported she asked the Administrator three times who she was, and the Administrator did not respond. Interview with Social Worker B on 08/05/13 at 1:25 p.m. revealed she first learned of the incident involving Resident #1 on 07/31/13. She said the ADON told her there was an issue and asked her to speak with Resident #1 and find out what was going on. Resident #1 told her she was out sunning and had fallen asleep, and the next thing the resident knew someone was tapping her arm and telling her to come in. Social Worker B stated the resident said the person kept tapping and pulling her arm to come in, and the resident kept asking the person to identify herself. Social Worker B revealed she spoke with Social Worker A and the ADON, and together they decided something needed to be done. The three staff members decided to call the Ombudsman and after sharing their report regarding the incident, the Ombudsman told them it was "reportable," so they decided to call corporate staff. Another interview with the ADON on 08/02/13 at 10:55 a.m. revealed the Administrator came to her office and told her Resident #1 was in the courtyard and needed to come in because she was going to get sunburned and dehydrated. The ADON described the Administrator as always being loud and easily frustrated. The ADON continued to explain the Administrator got tense and jittery when she was upset. The Administrator was frustrated because Resident #1 would not follow her instructions to come into the building. The ADON said an investigation was immediately started on Tuesday, 07/30/13, following the allegation made by Resident #1 regarding the incident in the courtyard the previous day Monday, 07/29/13. The ADON revealed when she came to work on Wednesday, 07/31/13, she was told by another staff member the DON called Resident #1 a liar. Another statement was taken from Resident #1, by Social Worker B on Wednesday, 07/31/13. Social Worker B called the Ombudsman, who said the incident was reportable. Social Worker B attempted to call corporate, leaving a message concerning the situation. The Corporate Director of Clinical Operations arrived at the facility on Wednesday afternoon 07/31/13. The Administrator and DON were suspended at that time. Interview with CNA E on 08/02/13 at 3:05 p.m. revealed the residents were treated well until recently. CNA E stated on 07/29/13 Resident #1 asked to speak to the employee, and at 9:30 p.m., she went to the resident's room to speak with her before the end of her shift. She stated Resident #1 reported the Administrator grabbed her arm and was "yanking" her and telling her to come in. CNA E revealed the resident said at the time of the incident, she did not know who the Administrator was. CNA E also stated the resident said she had reported the incident to the DON, but the DON explained to the resident it was her word against the facility's. CNA E confirmed she was the staff member who let Resident #1 go outside as the resident did daily. She said she would set a timer for 20 minutes and then bring her back inside. CNA E told Resident #1 that she (Resident #1) needed to report this incident. CNA E said she attempted to report the incident to the corporate office on 07/30/13, but she was unable to reach anyone. CNA E continued to explain she feared retaliation if she reported the incident. CNA E feared retaliation from the Administrator because she had always spoken rudely to her in morning staff meetings in front of everyone and she had removed herself from the position of staff development coordinator and returned to the floor. Interview with CNA F on 08/02/13 at 3:35 p.m. revealed she spoke to Resident #1 on 07/30/13 at 9:30 p.m. about the incident with the Administrator in the courtyard, and the employee told Resident #1 she (Resident #1) needed to report the incident. Resident #1 told the employee she had reported the incident to the DON and ADON. CNA F stated Resident #1 was upset and crying as she described the incident in the courtyard. Interview with CNA J on 08/02/13 at 4:20 p.m. revealed Resident #1 reported to her about the incident, and she reported it to the DON. CNA J stated Resident #1 said the DON called her a liar. Interview with LVN D on 08/06/13 at 10:24 a.m. revealed on Tuesday (07/30/13) at approximately 10:00 a.m. a CNA reported Resident #1 said a woman grabbed her and would not let go of her arm. The LVN did not state in her interview that she knew who the woman was that Resident #1 was talking about. LVN D went to the DON and reported the alleged abuse. LVN D also told Social Worker A. LVN D confirmed she spoke with the DON at 10:05 a.m., and the DON said "Okay, just let the Social Worker handle it." LVN D reported to Social Worker A at 10:15 a.m. and the ADON at 10:30 a.m. LVN D revealed the ADON said she would talk with Resident #1. LVN D stated the Administrator "was not very nice, and she spoke rudely to staff and residents." She revealed "she (Administrator) was not a people person." LVN D confirmed it was obvious Resident #1 had been crying, and she added Resident #1 did not cry a lot. She said the resident was nice, and she joked a lot with staff. The facility's Provider Investigation Report, dated 08/01/13, reflected, "(Resident #1) made an alleged (sic) allegation that (Administrator) grabbed her by the arm and insisted that she come into the building ...Provider Response (Administrator) suspended pending investigation (DON) suspended pending investigation Investigation Summary (Resident #1) was in the facility courtyard tanning. (Resident #1) made an alleged (sic) allegation that (Administrator) requested several times for her to come into building due to the concern of dehydration and sun burn. (Resident #1) stated that (Administrator) eventually grabbed her by the arm and insisted she come into building. According to (Resident #1) when she reported this to (DON), (DON) made the statement, 'it is your words versus the administrator.' Investigation Findings Inconclusive ...Provider Action Taken Post-Investigation 1. (Administrator) Suspended pending investigation and Statement taken 2. (DON) Suspended pending investigation and Statement taken ...10. In-services on abuse and neglect started ***Currently state investigators are investigating alleged (sic) allegation." 3. Resident #2's Face Sheet, dated 08/01/13,reflected the resident was a [AGE] year-old female, who was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2's MDS assessment, dated 06/21/13, reflected she was cognitively intact and did not exhibit any behaviors. The MDS assessment also reflected she sometimes felt down and hopeless. Interview with the Ombudsman on 08/01/13 at 4:15 p.m. revealed Resident #2 was going out via transportation to get her catheter changed, the resident was told the facility was not going to pay for her transport, and the Administrator told the resident she was not going to the appointment. Interview with Resident #2 on 08/02/13 at 3:05 p.m. revealed the resident was being taken to a doctor's appointment for a catheter change on 07/26/13 by a transport driver when the Administrator said loudly "Where the hell are you going?" The resident said the Transport Driver responded saying she was being taken to a doctor's appointment. Resident #2 revealed the Administrator then said, "Hell no." Resident #2 explained this incident made her feel both sad and embarrassed. She said she knew everyone present could hear the Administrator speaking to her in that manner. Interview with the Transport Driver, who worked for a transportation company, on 08/02/13 at 11:35 a.m. revealed on 07/26/13 he was at the facility to transport Resident #2 for a prearranged doctor's appointment. He stated he went to the resident's room and they went toward the front door together. He revealed the Administrator came out of an office and said, "Where the hell are you taking her? You are not taking her anywhere. This is bullshit." He said the Administrator demanded he come in her office. The Administrator called Resident #2's family member to determine who made the doctor's appointment and what it was for. The Transport Driver revealed the receptionist and other residents' family members were in the front area and heard what the Administrator said. He stated the resident was crying and asked him "Why is she talking to me that way?" The Transport Driver stated he was trying to comfort the resident as they left the building for the resident's appointment. A telephone interview with the Administrator on 08/05/13 at 3:39 p.m. revealed Resident #2's family member came in and asked the Administrator to go to the resident's room with him/her, so he/she could tell the resident to "cut her crap out." The Administrator stated she told the resident's family member he/she could not do that. The Administrator revealed Resident #2 had been making her own doctor's appointments when unnecessary. The Administrator stated she had never used profane language when speaking with a resident or in front of a resident. The Administrator was convinced this was a "witch hunt" because she had made changes when she came to the facility approximately six weeks prior to this incident. One of the changes the Administrator made was cutting out unauthorized overtime. The Administrator stated back in May overtime was $50,000 and $44,000 was from nursing. She implemented the policy that overtime could not be worked unless it was preauthorized by her. The Administrator revealed she was told by an employee she needed to be careful and watch her back because employees were planning to be mean and wanted to get her to quit. Interview with the Admissions Coordinator on 08/02/13 at 11:55 a.m. revealed she witnessed the incident involving Resident #2 and the Administrator. She stated she was coming from the restroom and saw the Transport Driver and the resident trying to leave. The Admissions Coordinator stated at that time, the Administrator went to the Transport Driver and said, "No, no. You aren't taking her anywhere." The Admissions Coordinator explained the Administrator was concerned about transportation costs. She said she did hear the Administrator say "bullshit" during this incident, and she witnessed the Transport Driver trying to console the resident, who the Admissions Coordinator said was sensitive. The Admissions Coordinator admitted she would have been offended if the Administrator had spoken to her in the same way the Administrator had spoken to the resident and Transport Driver. Interview with the BOA on 08/02/13 at 12:15 p.m. revealed she was sitting at her desk between the front door and the Administrator's office, when the Administrator who was in the MDS Coordinator's office, came out, saw the transport driver and Resident #2 and asked them where they were going and the resident told her they were going to an appointment. The BOA stated the Administrator told Resident #2 "No, no, no. You're not going anywhere." The BOA revealed the Administrator went to her (Administrator's) office, and she heard the Administrator say "bullshit." The BOA said the resident seemed upset, but she was not crying. The BOA revealed the resident made her own appointments to leave the facility and sometimes faked [MEDICAL CONDITION] to get attention. She stated she received calls from family members reporting the Administrator had treated them rudely while on the phone. The BOA admitted if the Administrator had spoken to her like she spoke to Resident #2 and the Transport Driver, she would have been very upset, and probably would have cried. Interview with the BOM on 08/05/13 at 12:45 p.m. revealed on 07/26/13 while sitting in her office, she heard the Administrator loudly say, "Where are you going, and where are you taking her?" She walked to the door and saw the Administrator talking to Resident #2 and the Transport Driver. She then returned to her desk. The BOM stated the Administrator did not sound angry, but she did sound frustrated. She revealed she did not take it personally the way the Administrator spoke to her, but she thought it was unprofessional. An interview with the Divisional Director of Clinical Operations on 08/02/13 at 12:50 PM revealed she was not aware of the incident with Resident #2 and the Administrator, which occurred on 07/26/13. The facility's Provider Investigation Report, signed on 08/06/13, reflected, "...It was reported that (Administrator) used inappropriate language at (Resident #2) ...Provider Response Suspension of employees ...Psychosocial assessment completed and monitored ...In-Serves (sic) conducted on Abuse and neglect Investigation Summary It was identified that (Administrator) did use inappropriate language with a resident (Resident #2) Investigation Findings Confirmed ...Provider Action Taken Post-Investigation ****Please see plan of removal to DADS ***Current state investigators, investigating incident as of 08-01-2013." 4. Resident #3's Face Sheet, dated 08/01/13, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3's MDS assessment, dated 06/21/13, reflected he was cognitively intact and did not exhibit any behaviors. The MDS assessment also reflected he sometimes felt down and hopeless. Interview with Resident #3 on 08/02/13 at 3:30 revealed the Administrator came in his room and yelled at him about an aerosol can of room deodorizer in his room, and his clothes hamper being in the corner of his room. The resident demonstrated the Administrator's tone of voice, and how she pointed her finger at his clothes hamper, while he explained the incident. He stated the Administrator grabbed the aerosol can and "threw" it in the drawer and "slammed" the drawer on his bedside table. Resident #3 revealed the way the Administrator treated him made him feel "bad." The resident said he cried after the Administrator left his room because of the way he was treated. 5. Resident #5's Face Sheet, dated 08/13/13, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's MDS assessment, dated 07/12/13, reflected she was cognitively intact and did not exhibit any behaviors. Interview with Resident #5 on 08/06/13 at 10:50 a.m. revealed the Administrator entered her room with the resident's bill in her hands. The resident stated the Administrator was with another person, but she did not know who the other person was. Resident #5 revealed the Administrator spoke to her rudely and continued tapping the resident's billing statement as she spoke to her. Resident #5 revealed the Administrator explained her bill was past. However, her bill was not past due. It was an error made by facility staff. Resident #5 stated she felt bullied, embarrassed and fearful when approached the way the Administrator approached her. She said the Administrator was loud and spoke to her about her statement in front of another resident. 6. An interview on 08/02/13 at approximately 9:30 AM with the Interim Administrator revealed he was the interim Administrator until a permanent Administrator was found. 7. The Administrator's personnel file reflected a hire date of 06/17/13. Background verifications were completed prior to her hire, including criminal history, license verification, and employee misconduct registry. 8. An IJ was identified on 08/05/13 at 9:30 a.m. and the Interim Administrator was notified. A Plan of Removal was requested at that time. 9. The facility's Plan of Removal, dated 08/05/13 and accepted on 08/07/13, reflected the following: 1) The following staff were suspended: Administrator on 07/31/13, the Interim DON on 07/31/13, Social Worker A on 08/05/13, the Admissions Coordinator on 08/06/13, the Receptionist on 08/0613, and the ADON on 08/06/13. Social Worker A was terminated on 08/06/13, and the Administrator was terminated on 08/07/13. 2) Clinical/Psychosocial assessments were conducted by Social Worker A and Social Worker B on involved residents as appropriate. No adverse effects clinically; facility would be providing ongoing support for demonstrated anxiety for Residents #1, #2, and #3. 3) Re-training and in-servicing (no employee would be allowed to work until they have received): a. Abuse (to include definitions); b. Respond/Recognize an Abuse Allegation; c. Conducting an investigation; d. Reporting. 4) Re-in-servicing for postings of available contact numbers for state regulatory agencies, Ombudsmen, corporate compliance line, and district team members. This was initiated on 08/01/13 and initial completion of all employees on 08/06/13 and then on-going with new employees. Inservices were conducted by Interim Administrator, Corporate Nurse, Interim ADON, and corporate personnel. 4) Identification of others at risk: a. Conducted interviews and safe surveys on all alert residents and reviewed documentation as well as observed non-interviewable residents to identify any other residents at risk. b) Conducted Resident Council to identify any grievances that could potentially be allegations. 5) Systemic changes: a. New hire orientation along with annual reviews would be enhanced to place emphasis on recognizing and reporting abuse (internally and externally). b. Postings of available contact numbers for state regulatory agencies, Ombudsman, corporate compliance line, district team members placed in work room, break room) time clock, both nurses' stations. c. Monthly abuse training for 90 days then quarterly. 6) Monitoring: a. Weekly visits/oversights with residents by the district team which consists of the Division Director Human Resources, the Regional Manager Financial Affairs, the District Director Clinical Operations, the Division Director Case Management, and the Division Vice President Operations for 90 days or until compliance was met. b. Random interviews with staff to ensure understanding of reeducation/in-service for 90 days or until compliance was met. Interviews would be kept on file. c. Any identified trends would be brought to the monthly performance improvement committee meeting and as needed. 7) ADDENDUM: The Medical Director was out of the country, but would be updated upon his return. His Nurse Practitioner was notified. 8) New key employees (to include Administrator and Director of Nursing) As above as well as weekly monitoring/evaluation of management style and compliance with state and federal definition/reporting of abuse, neglect, and misappropriation of resident property. Random residents, staff, and families would be interviewed for 60 days with interviews kept on file. 9) How to prevent this from happening in the future: a. Reference checks, b. criminal background check, c. nurse aide registry check, d. professional license check, e. New key employees (to include Administrator and Director of Nursing) As above as well as weekly monitoring/evaluation of management style and compliance with state and federal definition/reporting of abuse, neglect, and misappropriation of resident property. Random residents, staff, and families would be interviewed for 60 days with interviews kept on file. Interview with the Corporate Director of Clinical Operations on 08/06/13 10:30 a.m. revealed Social Worker A was terminated for her involvement with resident abuse at the facility. The interview also revealed the ADON, BOA, and Admissions Coordinator were suspended because of their failure to report abuse. Interview with the Corporate Director of Clinical Operations on 08/07/13 at 11:00 a.m. revealed the Administrator was terminated on 08/07/13. 10. Interviews conducted with CNA L, CNA M, CNA N, CNA O and CNA P on 08/07/13 from 10:30 a.m. through 11:30 a.m. revealed employees were inserviced on the different types of abuse and neglect, identifying abuse, reporting abuse and neglect and monitoring of residents. Employees interviewed verbalized understanding of the names and definitions of different types of abuse, how to recognize abuse and whom to contact/report abuse to especially in cases of allegations regarding the Administrator or upper level staff (corporate phone numbers were placed in the employee break room and by the time clock). Employees stated they felt comfortable reporting abuse or neglect and did not fear retaliation. 11. The IJ was removed on 08/07/13. The Interim Administrator was notified on 08/07/13 at 10:30 AM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" with a severity level of "actual harm that is not immediate jeopardy," due to the facility was still monitoring the Plan of Removal. 12. The facility-submitted 08/01/13 Resident Census and Conditions of Residents form reflected a census of 123 residents.

Based on interview and record review, it was determined the facility failed to implement its written policies and procedures that prohibit abuse of residents for four (Residents #1, #2, #3, and #5) of 14 residents reviewed for abuse. 1. The Administrator yelled at Resident #1 and demanded she go back inside the facility "right now." This resulted in Resident #1's fear of the Administrator and emotional distress. 2. The Administrator loudly asked Resident #2 "Where the hell are you going?" When the Transport Driver responded a doctor's appointment, the Administrator said, "Hell no." This resulted in Resident #2 crying, feeling sad and embarrassed. 3. The Administrator yelled at Resident #3 about an aerosol can of deodorizer in his room, grabbed the can, threw the can in a drawer and slammed the drawer closed. This resulted in Resident #3 crying and feeling bad. 4. The Administrator spoke rudely to Resident #5 while she was discussing the resident's bill. The Administrator did this in front of another resident. This resulted in Resident #5 feeling bullied, embarrassed, and fearful. An Immediate Jeopardy (IJ) was identified on 08/05/13. While the IJ was removed on 08/07/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect the facility's other 118 residents by placing them at risk for abuse and/or mistreatment. Findings included: 1. Resident #1's Face Sheet, dated 08/01/13, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 05/17/13, reflected the resident was cognitively intact and did not have any behaviors. Resident #1's care plan, dated 05/27/13, reflected she attended activities of her choice and engaged in self-initiated leisure activities outside. Interview with the Division Director of Clinical Operations on 08/01/13 at 3:30 p.m. revealed the Administrator and DON were suspended pending an investigation. Interview with the Ombudsman on 08/01/13 at 4:15 p.m. revealed Resident #1 told her she went out to the courtyard every day for 20-45 minutes. The Administrator went out to the courtyard to tell the resident to come in and grabbed her arm on Monday, 07/29/13 between 3:34 and 4:00 p.m. Interview with Resident #1 on 08/02/13 at 3:15 p.m. revealed she was sitting outside in the sun one day when the Administrator and Social Worker approached her without identifying themselves. The resident said she knew the Social Worker, but she did not know the Administrator, and she was scared. The resident explained the Administrator yelled at her and demanded she go inside "right now." Resident #1 revealed she always sat in the sun, and she did not go in. The resident said when the ADON came and spoke with her, she returned to the building. She stated she reported the incident to CNA E. Resident #1 revealed the DON told her the Administrator was not arguing, and the incident would be her word against the Administrator's. The resident stated she knew the Administrator was gone, but she was afraid she would come back. Another interview with Resident #1 on 08/01/13 at 4:30 p.m. revealed the DON told her it was her word against the Administrator's when Resident #1 was giving her statement to the DON. A telephone interview with the Administrator on 08/05/13 at 3:39 p.m. revealed she noticed Resident #1 was asleep outside, and she was concerned about her. The Administrator and Social Worker A approached the resident, and Social Worker A reached and touched her arm lightly. She said Resident #1 jumped because she was startled. The Administrator revealed she told the resident she was concerned about her remaining outside because it was so hot. She stated she offered to help Resident #1 so she could cool down, and after she was cooled, the Administrator said she could return outside. Interview with Social Worker A, on 08/02/13 at 10:40 a.m. revealed she witnessed the interaction Resident #1 had with the Administrator in the courtyard on Monday, 07/29/13. The Social Worker said the Administrator saw someone on the patio in the courtyard, so she and the Administrator went out to check. The Social Worker explained the Administrator called the resident by her name, startling the resident, and told the resident to go back inside. According to Social Worker A, the resident asked the Administrator who she was, and the Administrator responded by giving her name and position. Social Worker A reported she was unsure of the demeanor of the resident when she came in with the ADON, but she described the Administrator as loud and pushy. The Administrator was adamant the resident come in. The Social Worker admitted if the Administrator had spoken to her in the same manner, she would have been hurt and probably cried. She added, "but I am sensitive." Interview with the facility's only ADON on 08/05/13 at 3:30 p.m. revealed on 07/30/13 another employee came to her office and told her the Administrator yelled at Resident #1. The ADON explained Resident #1 had fallen asleep while outside, and she woke up to someone yelling at her. The ADON stated Resident #1 reported she asked the Administrator three times who she was and the Administrator did not respond. Interview with Social Worker B on 08/05/13 at 1:25 p.m. revealed she first learned of the incident involving Resident #1 on 07/31/13. She said the ADON told her there was an issue and asked her to speak with Resident #1 and find out what was going on. Resident #1 told her she was out sunning and had fallen asleep, and the next thing the resident knew someone was tapping her arm and telling her to come in. Social Worker B stated the resident said the person kept tapping and pulling her arm to come in, and the resident kept asking the person to identify herself. Social Worker B revealed she spoke with Social Worker A and the ADON, and together they decided something needed to be done. The three staff members decided to call the Ombudsman and after sharing their report regarding the incident, the Ombudsman told them it was "reportable," so they decided to call corporate staff. Another interview with the ADON on 08/02/13 at 10:55 a.m. revealed the Administrator came to her office and told her Resident #1 was in the courtyard and needed to come in because she was going to get sunburned and dehydrated. The ADON described the Administrator as always being loud and easily frustrated. The ADON continued to explain the Administrator got tense and jittery when she was upset. The Administrator was frustrated because Resident #1 would not follow her instructions to come into the building. The ADON said an investigation was immediately started on Tuesday, 07/30/13, following the allegation made by Resident #1 regarding the incident in the courtyard the previous day Monday, 07/29/13. The ADON revealed when she came to work on Wednesday, 07/31/13, she was told by another staff member the DON called Resident #1 a liar. Another statement was taken from Resident #1, by Social Worker B on Wednesday, 07/31/13. Social Worker B called the Ombudsman, who said the incident was reportable. Social Worker B attempted to call corporate, leaving a message concerning the situation. The Corporate Director of Clinical Operations arrived at the facility on Wednesday afternoon 07/31/13. The Administrator and DON were suspended at that time. Interview with CNA E on 08/02/13 at 3:05 p.m. revealed the residents were treated well until recently. CNA E stated on 07/29/13 Resident #1 asked to speak to the employee, and at 9:30 p.m., she went to the resident's room to speak with her before the end of her shift. She stated Resident #1 reported the Administrator grabbed her arm and was "yanking" her and telling her to come in. CNA E revealed the resident said at the time of the incident, she did not know who the Administrator was. CNA E also stated the resident said she had reported the incident to the DON, but the DON explained to the resident it was her word against the facility's. CNA E confirmed she was the staff member who let Resident #1 go outside as the resident did daily. She said she would set a timer for 20 minutes and then bring her back inside. CNA E told Resident #1 that she (Resident #1) needed to report this incident. CNA E said she attempted to report the incident to the corporate office on 07/30/13, but she was unable to reach anyone. CNA E continued to explain she feared retaliation if she reported the incident. CNA E feared retaliation from the Administrator because she had always spoken rudely to her in morning staff meetings in front of everyone and she had removed herself from the position of staff development coordinator and returned to the floor. Interview with CNA F on 08/02/13 at 3:35 p.m. revealed she spoke to Resident #1 on 07/30/13 at 9:30 p.m. about the incident with the Administrator in the courtyard, and the employee told Resident #1 she (Resident #1) needed to report the incident. Resident #1 told the employee she had reported the incident to the DON and ADON. CNA F stated Resident #1 was upset and crying as she described the incident in the courtyard. Interview with CNA J on 08/02/13 at 4:20 p.m. revealed Resident #1 reported to her about the incident, and she reported it to the DON. CNA J stated Resident #1 said the DON called her a liar. Interview with LVN D on 08/06/13 at 10:24 a.m. revealed on Tuesday (07/30/13) at approximately 10:00 a.m. a CNA reported Resident #1 said a woman grabbed her and would not let go of her arm. The LVN did not state in her interview that she knew who the woman was that Resident #1 was talking about. LVN D went to the DON and reported the alleged abuse. LVN D also told Social Worker A. LVN D confirmed she spoke with the DON at 10:05 a.m., and the DON said "Okay, just let the Social Worker handle it." LVN D reported to Social Worker A at 10:15 a.m. and the ADON at 10:30 a.m. LVN D revealed the ADON said she would talk with Resident #1. LVN D stated the Administrator "was not very nice, and she spoke rudely to staff and residents." She revealed "she (Administrator) was not a people person." LVN D confirmed it was obvious Resident #1 had been crying, and she added Resident #1 did not cry a lot. She said the resident was nice, and she joked a lot with staff. The facility's Provider Investigation Report, dated 08/01/13, reflected, "(Resident #1) made an alleged (sic) allegation that (Administrator) grabbed her by the arm and insisted that she come into the building ...Provider Response (Administrator) suspended pending investigation (DON) suspended pending investigation Investigation Summary (Resident #1) was in the facility courtyard tanning. (Resident #1) made an alleged (sic) allegation that (Administrator) requested several times for her to come into building due to the concern of dehydration and sun burn. (Resident #1) stated that (Administrator) eventually grabbed her by the arm and insisted she come into building. According to (Resident #1) when she reported this to (DON), (DON) made the statement, 'it is your words versus the administrator.' Investigation Findings Inconclusive ...Provider Action Taken Post-Investigation 1. (Administrator) Suspended pending investigation and Statement taken 2. (DON) Suspended pending investigation and Statement taken ...10. In-services on abuse and neglect started ***Currently state investigators are investigating alleged (sic) allegation." 2. Resident #2's Face Sheet, dated 08/01/13,reflected the resident was a [AGE] year-old female, who was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2's MDS assessment, dated 06/21/13, reflected she was cognitively intact and did not exhibit any behaviors. The MDS assessment also reflected she sometimes felt down and hopeless. Interview with the Ombudsman on 08/01/13 at 4:15 p.m. revealed Resident #2 was going out via transportation to get her catheter changed, the resident was told the facility was not going to pay for her transport, and the Administrator told the resident she was not going to the appointment. Interview with Resident #2 on 08/02/13 at 3:05 p.m. revealed the resident was being taken to a doctor's appointment for a catheter change on 07/26/13 by a transport driver when the Administrator said loudly "Where the hell are you going?" The resident said the Transport Driver responded saying she was being taken to a doctor's appointment. Resident #2 revealed the Administrator then said, "Hell no." Resident #2 explained this incident made her feel both sad and embarrassed. She said she knew everyone present could hear the Administrator speaking to her in that manner. Interview with the Transport Driver, who worked for a transportation company, on 08/02/13 at 11:35 a.m. revealed on 07/26/13 he was at the facility to transport Resident #2 for a prearranged doctor's appointment. He stated he went to the resident's room and they went toward the front door together. He revealed the Administrator came out of an office and said, "Where the hell are you taking her? You are not taking her anywhere. This is bullshit." He said the Administrator demanded he come in her office. The Administrator called Resident #2's family member to determine who made the doctor's appointment and what it was for. The Transport Driver revealed the receptionist and other residents' family members were in the front area and heard what the Administrator said. He stated the resident was crying and asked him "Why is she talking to me that way?" The Transport Driver stated he was trying to comfort the resident as they left the building for the resident's appointment. A telephone interview with the Administrator on 08/05/13 at 3:39 p.m. revealed Resident #2's family member came in and asked the Administrator to go to the resident's room with him/her, so he/she could tell the resident to "cut her crap out." The Administrator stated she told the resident's family member he/she could not do that. The Administrator revealed Resident #2 had been making her own doctor's appointments when unnecessary. The Administrator stated she had never used profane language when speaking with a resident or in front of a resident. The Administrator was convinced this was a "witch hunt" because she had made changes when she came to the facility approximately six weeks prior to this incident. One of the changes the Administrator made was cutting out unauthorized overtime. The Administrator stated back in May overtime was $50,000 and $44,000 was from nursing. She implemented the policy that overtime could not be worked unless it was preauthorized by her. The Administrator revealed she was told by an employee she needed to be careful and watch her back because employees were planning to be mean and wanted to get her to quit. Interview with the Admissions Coordinator on 08/02/13 at 11:55 a.m. revealed she witnessed the incident involving Resident #2 and the Administrator. She stated she was coming from the restroom and saw the Transport Driver and the resident trying to leave. The Admissions Coordinator stated at that time, the Administrator went to the Transport Driver and said, "No, no. You aren't taking her anywhere." The Admissions Coordinator explained the Administrator was concerned about transportation costs. She said she did hear the Administrator say "bullshit" during this incident, and she witnessed the Transport Driver trying to console the resident, who the Admissions Coordinator said was sensitive. The Admissions Coordinator admitted she would have been offended if the Administrator had spoken to her in the same way the Administrator had spoken to the resident and Transport Driver. Interview with the BOA on 08/02/13 at 12:15 p.m. revealed she was sitting at her desk between the front door and the Administrator's office, when the Administrator who was in the MDS Coordinator's office, came out, saw the transport driver and Resident #2 and asked them where they were going and the resident told her they were going to an appointment. The BOA stated the Administrator told Resident #2 "No, no, no. You're not going anywhere." The BOA revealed the Administrator went to her (Administrator's) office, and she heard the Administrator say "bullshit." The BOA said the resident seemed upset, but she was not crying. The BOA revealed the resident made her own appointments to leave the facility and sometimes faked [MEDICAL CONDITION] to get attention. She stated she received calls from family members reporting the Administrator had treated them rudely while on the phone. The BOA admitted if the Administrator had spoken to her like she spoke to Resident #2 and the Transport Driver, she would have been very upset, and probably would have cried. Interview with the BOM on 08/05/13 at 12:45 p.m. revealed on 07/26/13 while sitting in her office, she heard the Administrator loudly say, "Where are you going, and where are you taking her?" She walked to the door and saw the Administrator talking to Resident #2 and the Transport Driver. She then returned to her desk. The BOM stated the Administrator did not sound angry, but she did sound frustrated. She revealed she did not take it personally the way the Administrator spoke to her, but she thought it was unprofessional. An interview with the Divisional Director of Clinical Operations on 08/02/13 at 12:50 PM revealed she was not aware of the incident with Resident #2 and the Administrator, which occurred on 07/26/13. The facility's Provider Investigation Report, signed 08/06/13, reflected, "...It was reported that (Administrator) used inappropriate language at (Resident #2)...Provider Response Suspension of employees ...Psychosocial assessment completed and monitored ...In-Serves (sic) conducted on Abuse and neglect Investigation Summary It was identified that (Administrator) did use inappropriate language with a resident (Resident #2) Investigation Findings Confirmed ...Provider Action Taken Post-Investigation ****Please see plan of removal to DADS ***Current state investigators, investigating incident as of 08-01-2013." 3. Resident #3's Face Sheet, dated 08/01/13, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3's MDS assessment, dated 06/21/13, reflected he was cognitively intact and did not exhibit any behaviors. The MDS assessment also reflected he sometimes felt down and hopeless. Interview with Resident #3 on 08/02/13 at 3:30 revealed the Administrator came in his room and yelled at him about an aerosol can of room deodorizer in his room, and his clothes hamper being in the corner of his room. The resident demonstrated the Administrator's tone of voice, and how she pointed her finger at his clothes hamper, while he explained the incident. He stated the Administrator grabbed the aerosol can and "threw" it in the drawer and "slammed" the drawer on his bedside table. Resident #3 revealed the way the Administrator treated him made him feel "bad." The resident said he cried after the Administrator left his room because of the way he was treated. 4. Resident #5's Face Sheet, dated 08/13/13, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's MDS assessment, dated 07/12/13, reflected she was cognitively intact did not exhibit any behaviors. Interview with Resident #5 on 08/06/13 at 10:50 a.m. revealed the Administrator entered her room with the resident's bill in her hands. The resident stated the Administrator was with another person, but she did not know who the other person was. Resident #5 revealed the Administrator spoke to her rudely and continued tapping the resident's billing statement as she spoke to her. Resident #5 revealed the Administrator explained her bill was past due. However, her bill was not past due. It was an error made by facility staff. Resident #5 stated she felt bullied, embarrassed and fearful when approached the way the Administrator approached her. She said the Administrator was loud and spoke to her about her statement in front of another resident. 5. An interview on 08/02/13 at approximately 9:30 AM with the Interim Administrator revealed he was the interim Administrator until a permanent Administrator was found. 6. The facility's current Abuse Policy, released on 08/31/12, reflected, "Verbal... and mental abuse...are strictly prohibited. All alleged violations involving ...abuse...are reported immediately to the administrator of the facility and to other officials in accordance with state law through established procedures (including state survey and certification agency)...Retribution against patients, staff, or visitors who file reports of abuse is strictly prohibited...." According to the facility's abuse policy, abuse was "The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal Abuse The use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within hearing distance regardless of their age, ability to comprehend or disability...Mental Abuse Includes, but is not limited to, humiliation, harassment, threats of punishments or deprivation... Procedure... For All Abuse Allegations 1. Begin an internal investigation...2. If allegation against staff, suspend pending allegation...4. Immediately report the allegations to the Director of Operations, DDCO, Regional Vice President, Human Resources, and legal counsel...6. Report the alleged abuse to the appropriate state agencies in accordance with state law...1. Post State Abuse Hotline telephone number at each nursing unit. 2. Educate residents, families, and staff on how and to whom they may report concerns, events, and complaints/concerns without fear of retribution...The Investigation 2. Document the details of the incident. 3. Evaluate the resident regarding emotional distress and identify impact on psychosocial functioning...9. Interview staff members...and/or residents who may have knowledge of alleged incident being investigated...15. Interview coworkers and/or residents to gain knowledge of their experiences with the accused person. 16. Describe any action(s) taken by the center to protect the resident(s) and to prevent a possible reoccurrence during the investigation (i.e...Suspension of the accused employee, pending investigation)...." 7. The Administrator's personnel file reflected a hire date of 06/17/13. Background verifications were completed prior to her hire, including criminal history, license verification, and employee misconduct registry. 8. An IJ was identified on 08/05/13 at 9:30 a.m. and the Interim Administrator was notified. A Plan of Removal was requested at that time. 9. The facility's Plan of Removal, dated 08/05/13 and accepted on 08/07/13, reflected the following: 1) The following staff were suspended: Administrator on 07/31/13, the Interim DON on 07/31/13, Social Worker A on 08/05/13, the Admissions Coordinator on 08/06/13, the Receptionist on 08/0613, and the ADON on 08/06/13. Social Worker A was terminated on 08/06/13 and the Administrator was terminated on 08/07/13. 2) Clinical/Psychosocial assessments were conducted by Social Worker A and Social Worker B on involved residents as appropriate. No adverse effects clinically; facility would be providing ongoing support for demonstrated anxiety for Residents #1, #2, and #3. 3) Re-training and in-servicing (no employee would be allowed to work until they have received): a. Abuse (to include definitions); b. Respond/Recognize an Abuse Allegation; c. Conducting an investigation; d. Reporting. 4) Re-in-servicing for postings of available contact numbers for state regulatory agencies, Ombudsmen, corporate compliance line, and district team members. This was initiated on 08/01/13 and initial completion of all employees on 08/06/13 and then on-going with new employees. Inservices were conducted by Interim Administrator, Corporate Nurse, Interim ADON, and corporate personnel. 4) Identification of others at risk: a. Conducted interviews and safe surveys on all alert residents and reviewed documentation as well as observed non-interviewable residents to identify any other residents at risk. b) Conducted Resident Council to identify any grievances that could potentially be allegations. 5) Systemic changes: a. New hire orientation along with annual reviews would be enhanced to place emphasis on recognizing and reporting abuse (internally and externally). b. Postings of available contact numbers for state regulatory agencies, Ombudsman, corporate compliance line, district team members placed in work room, break room) time clock, both nurses' stations. c. Monthly abuse training for 90 days then quarterly. 6) Monitoring: a. Weekly visits/oversights with residents by the district team which consists of the Division Director Human Resources, the Regional Manager Financial Affairs, the District Director Clinical Operations, the Division Director Case Management, and the Division Vice President Operations for 90 days or until compliance was met. b. Random interviews with staff to ensure understanding of reeducation/in-service for 90 days or until compliance was met. Interviews would be kept on file. c. Any identified trends would be brought to the monthly performance improvement committee meeting and as needed. 7) ADDENDUM: The Medical Director was out of the country, but would be updated upon his return. His Nurse Practitioner was notified. 8) New key employees (to include Administrator and Director of Nursing) As above as well as weekly monitoring/evaluation of management style and compliance with state and federal definition/reporting of abuse, neglect, and misappropriation of resident property. Random residents, staff, and families would be interviewed for 60 days with interviews kept on file. 9) How to prevent this from happening in the future: a. Reference checks, b. criminal background check, c. nurse aide registry check, d. professional license check, e. New key employees (to include Administrator and Director of Nursing) As above as well as weekly monitoring/evaluation of management style and compliance with state and federal definition/reporting of abuse, neglect, and misappropriation of resident property. Random residents, staff, and families would be interviewed for 60 days with interviews kept on file. Interview with the Corporate Director of Clinical Operations on 08/06/13 10:30 a.m. revealed Social Worker A was terminated for her involvement with resident abuse at the facility. The interview also revealed the ADON, BOA, and Admissions Coordinator were suspended because of their failure to report abuse. Interview with the Corporate Director of Clinical Operations on 08/07/13 at 11:00 a.m. revealed the Administrator was terminated on 08/07/13. 10. Interviews conducted with CNA L, CNA M, CNA N, CNA O and CNA P on 08/07/13 from 10:30 a.m. through 11:30 a.m. revealed employees were inserviced on the different types of abuse and neglect, identifying abuse, reporting abuse and neglect and monitoring of residents. Employees interviewed verbalized understanding of the names and definitions of different types of abuse, how to recognize abuse and whom to contact/report abuse to especially in cases of allegations regarding the Administrator or upper level staff (corporate phone numbers were placed in the employee break room and by the time clock). Employees stated they felt comfortable reporting abuse or neglect and did not fear retaliation. 11. The IJ was removed on 08/07/13. The Interim Administrator was notified on 08/07/13 at 10:30 AM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" with a severity level of "actual harm that is not immediate jeopardy," due to the facility was still monitoring the Plan of Removal. 12. The facility-submitted 08/01/13 Resident Census and Conditions of Residents form reflected a census of 123 residents.