Every finding on record at Rose City Nursing and Rehabilitation

Based on observation, interview and record review it was determined the facility failed to ensure food and beverages were labeled and stored in a manner to minimize spoilage and cross contamination for 4 of 4 kitchen refrigerators and 1 of 1 unit refrigerator reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: Review of the US FDA 2022 Food Code indicated the following: -Food prepared and held cold must be clearly marked with date prepared or by day which the food shall be consumed or discarded. -Food must be labeled with a use-by-date if stored for at least 24 hours. -Food could be stored up to seven days. The facility's Food Receiving and Storage Policy, last revised 10/2017, revealed the following: -Foods shall be received and stored in a manner that complies with safe food handling practices. -All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). -All food belonging to residents must be labeled with the resident's name, the item and the use by date. -Beverages must be dated when opened and discarded after 24 hours. 1. On 2/23/25 at 9:02 AM, a brief kitchen tour was completed and revealed the following: -In refrigerator number one, a block of cheese slices was unlabeled and undated and a plastic to-go container with a white grated substance was unlabeled and undated. -In refrigerator number two, two pitchers of red liquid were unlabeled and undated. -In refrigerator number four, 24 one pound cubes of butter were undated and three five pound blocks of cheese were unlabeled and undated. On 2/23/25 at 9:02 AM, Staff 5 (Cook) confirmed the items identified in refrigerator one, refrigerator two and refrigerator four were not properly labeled or dated. On 2/26/25 at 9:45 AM, Staff 4 (Dietary Manager) stated she expected all food and beverage items to be labeled and dated. 2. On 2/25/25 at 10:00 AM and 10:09 AM, Staff 6 (Cook) and Staff 13 (CNA) reviewed the residents' refrigerator which contained numerous food and beverage items. The following food and beverages were observed to be stored as follows: -a previously opened, one liter bottle of soda pop was unlabeled and undated. -a previously opened 12 ounce bottle of cola was unlabeled and undated. -a previously opened 12 ounce bottle of tea was unlabeled and undated. -a dirty and stained cloth bag containing a bottle of liquid and various food items was unlabeled and undated. On 2/25/25 at 10:09 AM, Staff 6 and Staff 13 confirmed the above mentioned food and beverage items located in the residents' refrigerator were not properly labeled or dated and a dirty cloth bag of beverages and food should not be stored in the refrigerator due to concerns with cross contamination. On 2/26/25 at 9:45 AM, Staff 4 (Dietary Manager) stated she expected all food and beverage items in the residents' refrigerator should be labeled and dated. 3. On 2/26/25 at 9:45 AM, a follow-up kitchen visit was completed with Staff 4 (Dietary Manager) which revealed the following: -In refrigerator number one, seven individual servings of brown sauce in plastic to-go cups were unlabeled and undated and four, one pound cubes of butter were undated. -In refrigerator number three, a plastic to-go container of pasta was unlabeled and undated. -In refrigerator number four, 22 one pound cubes of butter were undated and three five pound blocks of cheese were unlabeled and undated. On 2/26/25 at 9:45 AM, Staff 4 (Dietary Manager) stated she expected all food and beverage items to be labeled and dated.

Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours per day, seven days per week for 33 of 61 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care. Findings include: The facility's Staffing, Sufficient and Competent Nursing Policy, last revised 8/2022, indicated the following: -A registered nurse provided services at least eight consecutive hours every 24 hours, seven days a week. A review of the facility's DCSDRs (Direct Care Staff Daily Reports) revealed the following: In 7/2024, nine days were reviewed and revealed four days without appropriate RN coverage on 7/16/24, 7/20/24, 7/22/24 and 7/23/24. In 8/2024, 22 days were reviewed and revealed 12 days without appropriate RN coverage on 8/4/24, 8/5/24, 8/6/24, 8/10/24, 8/11/24, 8/12/24, 8/13/24, 8/17/24, 8/18/24, 8/19/24, 8/20/24 and 8/24/24. In 9/2024, 30 days were reviewed and revealed 17 days without appropriate RN coverage on 9/1/24, 9/3/24, 9/8/24, 9/9/24, 9/10/24, 9/11/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/21/24, 9/23/24, 9/24/24, 9/26/24, 9/28/24, 9/29/24 and 9/30/24. On 2/25/25 at 4:01 PM and 2/26/25 at 12:04 PM, Staff 1 (Administrator) and Staff 2 (Administrator-In-Training) reported RN coverage for the facility had been challenging for several months. Staff 1 and Staff 2 reviewed the DCSDRs for 7/2024, 8/2024 and 9/2024 and staff payroll records, and acknowledged the lack of RN coverage on the days identified.

Based on observation, interview and record review it was determined the facility failed to properly dispose of expired medications for 1 of 1 resident medication storage refrigerators and 1 of 1 medical storage rooms reviewed for medication storage. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications. Findings include: The facility's Storage of Medications policy with revision date 11/2020 did not address vials of medications but indicated outdated medications were to be destroyed by the facility. The manufacturer insert indicated an open and in use multi-dose vial of Tuberculin should be thrown away after 30 days to avoid oxidation and degradation. During a review of the resident medication storage refrigerator on 2/24/25 at 11:33 AM Staff 12 (LPN) verified the following expired medication was found: - one open and used multi-dose vial of Tuberculin (solution used in testing for Tuberculosis) with an open date of 1/22/25. On 2/24/25 at 11:36 AM Staff 12 stated the facility policy was to throw away open vials after 30 days. During a review of the medication storage room on 2/24/25 at 1:22 PM Staff 2 (Administrator-In-Training) verified the following expired medications were found: - two bottles of [NAME] lotion (lotion for relief of itching) with 9/2022 expiration dates. - three bottles of [NAME] lotion with 3/2023 expiration dates. On 2/24/25 at 1:25 PM Staff 2 stated the facility policy for expired medications was to throw away the expired medications and order replacements if needed.

Based on interview and record review it was determined the facility failed to provide a qualified professional to direct the activities program for 1 of 1 facility reviewed for activities. This placed residents at risk for unmet physical, mental and psychosocial needs. Findings include: On 2/25/25 at 10:17 AM Staff 11 (Activity Director/Social Services Director) stated one of his roles at the facility was to organize and lead activities. Staff 11 stated he was told a certification was not necessary to performed the duties of an Activity Director and confirmed he had not started or completed the necessary training required. On 2/26/25 at 1:11 PM Staff 1 (Administrator) confirmed Staff 11 did not have the necessary Activity Director certification.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activity program for 3 of 3 sampled residents (#s 5,10 and 20) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's Activity Programs-Staffing Policy, revised 6/2018, indicated the following: The activity director/coordinator's responsibilities included the following: -completing or delegating the completion of the activities component of the comprehensive assessment; -ensuring activity goals and approaches reflected in the residents' care plans were individualized to match the skills, abilities and interests/preferences of each resident; -monitoring and evaluating the residents' responses to activities and revising the approaches as appropriate; -developing, implementing, supervising and evaluating activity programs at least quarterly; -sufficient activity personnel were on duty to meet the needs of the residents and the functions of the activities program. 1. Resident 10 was admitted to the facility in 12/2020 with diagnoses included non-traumatic subarachnoid hemorrhage (bleeding in the brain not due to any head trauma), mild cognitive impairment and failure to thrive. Resident 10's 12/3/20 Admission Activities Assessment indicated the resident was very social and enjoyed being around people, loved to watch old TV shows such as I Love [NAME] and The [NAME] Bunch, and liked to play dominos and bingo. The resident's identified preferences included arts and crafts, music and watching TV. Resident 10's Activity Care Plan, last revised 5/9/24, included one-to-one visits, pet visits, sensory one-to-one activities including hand massages, watching old TV shows including cartoons and animal shows, coloring, painting, visiting with others, going on walks and being outside. Resident 10's 9/30/24 Annual MDS revealed the resident had no cognitive impairments. Resident 10 reported it was somewhat to very important to use the phone in private, have books/newspapers/magazines to read, listen to music, be around animals, keep up with the news, do things in groups of people, do favorite activities, go outside when the weather was nice and participate in religious services or practices. Resident 10's 12/20/24 Activity Quarterly Review indicated the resident participated in group activities, enjoyed one-to-one activities and walks outside. The 12/18/24 Resident Council Meeting Minutes indicated residents wanted more bingo and a gaming system. The facility's Activity Calendar revealed the following scheduled activities: -2/24/25 10:00 AM: 1:1 Visits 1:00 PM: Bingo -2/25/25 11:00 AM: Games and Music 1:00 PM: Bingo 3:00 PM: Smoothie Day -2/26/25 10:00 AM: 1:1 Visits 1:00 PM: Bingo 3:00 PM: Birthday Party Resident 10's Activity Participation Logs for 1/2025 and 2/2025 indicated Resident 10 participated in a reminiscing activity on 1/2/25. Random observations of Resident 10 conducted from 2/23/25 through 2/25/25 between the hours of 8:00 AM and 4:30 PM revealed Resident 10 resided in the only upstairs bedroom of a two story house, with one roommate and no other residents around. Resident 10 was not observed out of her/his room, at anytime. The resident was observed watching shows on her/his tablet, lying in bed with the lights off, sleeping or sitting at the edge of the bed. Resident 10 was not observed in any group or one-to-one activities and no books, newspapers, magazines or music was observed in the resident's room. On 2/24/25 bingo was scheduled but did not occur and on 2/25/25 games, music and bingo were scheduled but did not occur. On 2/23/25 at 11:01 AM, Resident 10 stated she/he liked to socialize and play bingo but was unable to participate because she/he could no longer walk, therefore, could not go downstairs where the majority of residents resided and group activities occurred. Resident 10 stated she/he was no longer able to socialize with other seniors because she/he could no longer go downstairs. On 2/25/25 at 8:24 AM, Staff 9 (CNA) stated Resident 10 liked to be downstairs to watch television and play bingo. Staff 9 stated Resident 10 was unable to walk, and was unable to go downstairs for approximately the last month and a-half. Staff 9 stated there were no activities occurring in the facility except maybe bingo once a month, there were no real activities here and there was nothing going on in Resident 10's room except for the resident watching her/his tablet. On 2/13/25 at 10:13 AM, Staff 11 (Activity Director/Social Service Director) stated he was new to the position and served as the activity director for approximately three months. Staff 11 stated he received two weeks of training which occurred concurrently with his medical records training and he had no previous experience running an activities program in a long-term care setting. Staff 11 stated it was his responsibility to complete the activities section on the MDS, complete an admission/annual activity assessment, develop the residents' activity care plans, complete quarterly activity reviews and document all activities in residents' electronic health records. Staff 11 stated Resident 10 enjoyed coming downstairs for bingo and playing games such as Uno, checkers or chess. Staff 11 reported Resident 10 had been one of his most active residents who regularly participated in group activities but the resident was no longer able to walk downstairs, so was unable to participate in activities. Staff 11 stated his job also included social service director and working in medical records and, because of his schedule, he usually missed two to three scheduled activities a week. On 2/26/25 at 12:52 PM Staff 2 (Administrator-In-Training) and at 1:11 PM Staff 1 (Administrator) were present for an interview. Staff 2 stated he was aware activities were an issue but did not realize the extent of the problem. Staff 2 acknowledged scheduled activities were being missed. Staff 1 stated he expected activities to be planned based on residents' requests, preferences, physical and mental abilities, and activities occurred every day and at various times of the day. 2. Resident 20 was admitted to the facility in 8/2024 with diagnoses including end-stage renal disease, major depressive disorder and anxiety disorder. Resident 20's 8/12/24 Admission Activities Assessment indicated the resident enjoyed relaxing, being outdoors, music, nature, long-boarding and reading. The resident had a list of preferred activities and was open to trying new activities at the facility. Resident 20's 8/18/24 Annual MDS revealed the resident had no cognitive impairments. The resident's activity preferences and interests were not assessed. Resident 20's Activities Care Plan, last revised 11/27/24, indicated to identify at least two activities the resident liked to participate in, Resident 20 would participate in two preferred activities per week, arrange 1:1 visits with the resident and remind Resident 20 when an activity was to occur. Resident 20's 11/29/24 Admission Activities Assessment indicated the resident enjoyed music, board games and watching television. The 12/18/24 Resident Council Meeting Minutes indicated residents wanted more bingo and a gaming system. The facility's Activity Calendar revealed the following scheduled activities: -2/24/25 10:00 AM: 1:1 Visits 1:00 PM: Bingo -2/25/25 11:00 AM: Games and Music 1:00 PM: Bingo 3:00 PM: Smoothie Day -2/26/25 10:00 AM: 1:1 Visits 1:00 PM: Bingo 3:00 PM: Birthday Party Resident 20's 1/2025 and 2/2025 Activity Participation Logs indicated the resident played video games on 1/2/25 and 1/6/25. Random observations of Resident 20 conducted from 2/23/25 through 2/25/25 between the hours of 8:00 AM and 4:30 PM revealed the resident was often in her/his room with ear phones on, sleeping or sitting at the edge of the bed. The resident was observed walking in the hallways of the facility, at times. The resident left the facility for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys stop working properly). On 2/24/25 bingo was scheduled but did not occur and on 2/25/25 games, music and bingo were scheduled but did not occur. On 2/23/25 at 10:01 AM and 2/24/25 at 1:04 PM, Resident 20 stated there were no activities in the facility and she/he was stuck staring at the walls in her/his room or watching television. Resident 20 reported she/he was an artist but there were no art supplies except color crayons and coloring pages designed for kids and there were no enrichment activities like arts/crafts, exercising or chair yoga. Resident 20 stated Staff 11 (Activity Director/Social Service Director) was so busy he was unable to walk with the resident when it was nice outside. Resident 20 reported she/he spoke-up at Resident Council and tried to offer ideas and solutions for the lack of activities. On 2/25/25 at 8:24 AM, Staff 9 (CNA) stated Resident 20 liked bingo and hanging-out with people. Staff 9 stated there were no activities occurring in the facility except maybe bingo once a month, there were no real activities here and there was nothing going on in Resident 20's room that he was aware of. On 2/25/25 at 10:13 AM, Staff 11 stated he was new to the position of activity director and had been in this role for approximately three months. Staff 11 stated he received two weeks of training which occurred concurrently with his medical records training and he had no previous experience running an activities program in a long-term care setting. Staff 11 stated it was his responsibility to complete the activities section on the MDS, complete an admission/annual activity assessment, develop the residents' activity care plans, complete quarterly activity reviews and document all activities in residents' electronic health records. Staff 11 stated Resident 20 liked to watch anime and play bingo and Uno with the group. Staff 11 stated his job also included social service director and working in medical records and, because of his schedule, he usually missed two to three scheduled activities a week. On 2/26/25 at 12:52 PM Staff 2 (Administrator-In-Training) and at 1:11 PM Staff 1 (Administrator) were present for an interview. Staff 2 stated he was aware activities were an issue but did not realize the extent of the problem. Staff 2 acknowledged scheduled activities were being missed. Staff 1 stated he expected activities to be planned based on residents' requests, preferences, physical and mental abilities, and activities occurred every day and at various times of the day. 43691 3. Resident 5 was admitted to the facility in 8/2024 with diagnoses including heart failure. An 8/27/24 Activity Admission Assessment revealed Resident 5 was interested in participating in activities. A 9/3/24 Annual MDS indicated Resident 5 had no cognitive impairments and was interested in participating in group activities. Resident 5's Care Plan revised on 12/9/24 included goals of increased participation in activities with interventions including giving Resident 5 verbal reminders of activities before the start of activities. A review of Resident 5's activity Task Records from 1/25/25 through 2/24/25 revealed Resident 5 did not participate in any activities. On 2/23/25 at 9:33 AM Resident 5 stated she/he was rarely invited to activities and activities rarely occurred as scheduled. Review of the 2/2025 Activity Calendar revealed the following activities were scheduled on 2/24/25: - Games and Music at 11:00 AM - Bingo at 1:00 PM Random observations on 2/24/25 from 8:00 AM through 4:00 PM revealed no scheduled games, music or bingo occurred. On 2/25/25 at 8:24 AM Staff 9 (CNA) stated the only activity he ever observed occurring was bingo which only happened once a month. On 2/25/25 at 10:17 AM Staff 11 (Activity Director/Social Services Director) stated Resident 5's activity participation was documented in the activity logs, but he had not completed any documentation specifically regarding Resident 5's participation. Staff 11 acknowledged activities did not occur as scheduled due to the challenges of fulfilling responsibilities as both the Activity Director and the Social Service Director.

Based on observation, interview and record review it was determined the facility failed to ensure dialysis services were in place including monitoring and communication with the dialysis provider for 1 of 1 sampled resident (# 20) reviewed for dialysis. This placed residents at risk for dialysis complications and delayed treatment. Findings include: Resident 20 was admitted to the facility in 8/2024 with diagnoses including diabetes, end-stage renal disease and dependence on dialysis (a medical treatment that removes waste products from the blood when the kidneys are not working properly). Resident 20's 8/18/24 Admission MDS indicated the resident had no cognitive impairments and received dialysis. Resident 20's 1/26/25 Dialysis Care Plan indicated the resident received dialysis on Tuesday, Thursday and Saturday. From 2/1/25 through 2/25/25, Resident 20 had 10 dialysis treatments. A review of Resident 20's Dialysis Communication Forms from 2/1/25 through 2/25/25 revealed the following days when the facility did not have pre-dialysis and post-dialysis information: -2/4/25, 2/6/25 and 2/15/25. A review of Resident 20's health record revealed no evidence nursing staff contacted the dialysis center to obtain a verbal or electronic report on 2/4/25, 2/6/25 or 2/15/25. On 2/25/25 at 1:36 PM, Resident 20 was out of the facility for dialysis and at 2:01 PM, she/he was observed returning to the facility from her/his scheduled dialysis appointment. On 2/23/25 at 10:01 AM, Resident 20 stated she/he went to dialysis three times a week; on Tuesday, Thursday and Saturday. Resident 20 stated the facility did not consistently complete the Dialysis Communication Form and nursing did not always assess her/him upon returning back to the facility from the dialysis center for several hours after she/he returned. On 2/26/25 at 8:09 AM and 12:16 PM Staff 3 (DNS/RNCM) stated the top portion of the Dialysis Communication Form was to be completed by the nurse and sent with the resident to dialysis. She stated upon the resident's return, the dialysis center should have completed the mid-portion of the Dialysis Communication Form, the nurse assessed the resident and then completed the last section of the report. Staff 3 confirmed the facility did not have pre-dialysis and post-dialysis information for Resident 20 on 2/4/25, 2/6/25 and 2/15/25 and there was no evidence nursing staff contacted the dialysis center to obtain a verbal or electronic report. Staff 3 stated she expected communication between the facility and dialysis center via the Dialysis Communication Form for each dialysis visit and, if information was missing, she expected staff to contact the dialysis center to obtain the information.

Based on observation, interview and records review it was determined the facility failed to assess safety with smoking for 1 of 1 resident (#19) reviewed for smoking. This placed residents at risk for unsafe smoking. Findings include: The facilities 8/2022 Smoking Policy for Residents states resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: - current level of tobacco consumption; - method of tobacco consumption; - desire to quit smoking; and - ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). Resident 19 was admitted to the facility in 1/2025 which diagnoses including congestive heart failure. A review of Resident 19's clinical record revealed no indication a smoking assessment was completed or if the resident was an independent smoker. On 2/23/25 at 10:07 AM a list of residents who smoke was received from Staff 1 (Administrator) and Resident 19 was not included on the list. On 2/25/25 at 12:15 PM Resident 19 was observed independently entering the smoking area with smoking supplies. On 2/25/25 at 12:20 PM Staff 1 was observed entering the smoking area. At 12:25 PM Staff 1 reentered the facility holding Resident 19's cigarettes and lighter. Staff 1 stated I'm going to be back to do a smoking assessment on [her/him]. On 2/25/25 at 12:42 PM Staff 9 (CNA) stated Resident 19 kept her/his own smoking supplies and went out on her/his own to smoke since the resident was admitted to the facility. On 2/25/25 at 1:29 PM Staff 3 (DNS/RNCM) acknowledged Resident 19 was not assessed for smoking safety and should have been prior to being allowed to smoke independently for Resident 19's safety.

Based on observation, interview and record review it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents and the public at risk for incomplete and inaccurate staffing information. Findings include: The facility's Staffing, Sufficient and Competent Nursing Policy, last revised 8/2022, indicated the following: -Direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) were posted in the facility for every shift. A review of the facility's DCSDRs (Direct Care Staff Daily Reports) revealed the following: From 1/21/25 through 2/22/25, 32 days were reviewed and revealed 11 days when portions of the DCSDRs were incomplete or inaccurate on 1/23/25, 1/24/25, 1/29/25, 1/30/25, 1/31/25, 2/12/25, 2/13/25, 2/14/25, 2/20/25, 2/21/25 and 2/20/25. On 2/25/25 at 4:01 PM, Staff 1 (Administrator) and Staff 2 (Administrator-In-Training) reviewed the 1/21/25 through 2/22/25 DCSDRs and verified the reports were incomplete or inaccurate on the days identified. Staff 1 and Staff 2 stated they expected the DCSDRs to be completed accurately and with all information included.

Based on interview and record review it was determined the facility failed to ensure a transfer notice with appeal rights was provided in writing to the resident or their representative, and the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified of the resident's hospitalization for 1 of 1 sampled resident (#3) reviewed for hospitalization s. This placed residents at risk for lack of access to an advocate to inform them of their options and rights, and lack of information regarding discharge. Findings include: The facility's Bed Hold Policy: Bed-Holds and Returns with revision date 10/2022 stated all residents of the facility were to be provided with written notice at least twice; once in the admission packet, and again at the time of transfer or if the transfer was an emergency within 24 hours. Resident 3 admitted to the facility in 1/2025 with diagnoses including hypothermia (body temperature too low) and sepsis (severe infection). A 1/29/25 Admission MDS indicated Resident 3 was cognitively intact. A review of Resident 3's health record revealed she/he was transferred to the hospital on 2/15/25. No evidence was found in Resident 3's health record to indicate a transfer notice with appeals rights was provided to the resident or their representative upon transfer. Resident 3's health record also had no indication the Office of the State Long-Term Care Ombudsman was notified of the resident's hospitalization . On 2/26/25 8:45 AM Staff 3 (DNS/RNCM) stated a transfer notice was to be sent with a resident at time of transfer by the facility nurse and the RNCM was to follow up to ensure the notice was given to the resident. She stated she was not aware the Office of the State Long-Term Care Ombudsman was to be notified at time of transfer. She verified a transfer notice was not given to Resident 3 or her/his representative, and the Office of the State Long-Term Care Ombudsman was not notified of the resident's hospitalization . She stated the expectation was for the facility bed hold policy to be followed with every transfer out of the facility.

Based on interview and record review it was determined the facility failed to ensure bowel status was assessed and a bowel care medication regimen was administered as ordered for 1 of 3 sampled residents (#1) reviewed for bowel care. Resident 1 developed abdominal pain, was admitted to the hospital and required surgery to remove part of the large intestine due to impaction (hardened stool stuck in the rectum or lower colon due to chronic constipation-occurs when constipated for a long time) and a colostomy (surgical procedure used to bring the healthy end of the large intestine through the abdominal wall for feces to leave the body) was placed. Findings include: Resident 1 was admitted to the facility 10/4/23 with diagnoses including developmental delay and stroke. An 10/3/23 hospital physician Progress Note revealed Resident 1 had a diagnosis of severe constipation, chronic-improved and had a history of chronic constipation with past frequent admissions. The resident was to continue senna (laxative) and Miralax (Miralax) at a high frequency in the hopes of getting more doses in her/him as the resident often refused the medication. The goal was for the resident to have one bowel movement per day. The note also indicated the resident's family reported Miralax was an effective medication regimen at home. An 10/4/23 hospital Discharge Order included glycolax (generic for Miralax) administered four times a day. Review of the 10/2023 MAR revealed Resident 1's physician order for glycolax four times a day was not initiated. Progress Notes for 10/2023 revealed no staff communication with Resident 1's physician requesting to discontinue the glycolax four times a day. A care plan initiated 10/4/23 did not address the resident's history of constipation. An 10/11/23 admission MDS and associated CAAs did not address Resident 1's history of constipation, past hospitalization s for constipation or goals identified in the resident's hospital records for the resident to have one bowel movement a day. Resident 1's 1/2024 bowel record revealed she/he had up to three bowel movements a day except on 1/2/24 when the resident did not have a bowel movement. 11 of 63 bowel movements were documented as small. A 2/2024 bowel record revealed the following: -2/1/24 no bowel movement -2/2/24 small soft bowel movement on the night shift -2/3/24 and 2/4/24 no bowel movement -2/5/24 medium soft bowel movement on the day shift -2/6/24 through 2/11/24 no bowel moment -2/12/24 small soft bowel movement on night shift -2/13/24 large formed bowel movement on the evening shift -2/14/24 and 2/15/24 no bowel movement -2/16/24 small soft bowel movement on the evening shift and a large soft bowel movement on the night shift -2/17/24 small soft bowel movements on day and night shifts -2/18/24-2/20/24 no bowel movement (Resident 1 had nine bowel movements in 20 days. Resident 1 was discharged on [DATE] at approximately 1:00 AM). On 3/6/24 at 2:18 PM Staff 5 (CNA) stated when Resident 1 had a bowel movement on 2/17/21 it was the size of a small plastic spoon and was the consistency of peanut butter. On 3/7/24 at 1:03 PM Staff 4 (CNA) stated when Resident 1 had a bowel movement on 2/17/24 it was the size of a golf ball. Staff 4 stated on 2/20/24 when the resident went to the hospital her/his stomach was very big and it was not like that on 2/17/24. If it was big, she would have reported it to the nurse. Resident 1's 2/2024 MAR from 2/1/24 through 2/20/24 revealed the following: -Sennosides (treats constipation) BID was refused 9 of 40 opportunities. -Bisacodyl rectal suppository was to be administered if the resident did not have a bowel movement for greater than 48 hours. -there were no documented refusals when the resident did not have a bowel movement from 2/6/24-2/11/24 -Resident one refused bisacodyl on 2/13/24 (Lactulose/laxative was administered; see below) -One dose was administered on 2/20/24 at 12:03 AM prior to the resident's discharge to the hospital -Lactulose BID if bisocodyl was refused. -Lactulose was administered on 2/5/25 but no indication a bisocodyl suppository was refused -Lactulose was administered on 2/9/24 but no indication a bisacodyl suppository was refused (documented as ineffective but not readministered) -Lactulose was administered on 2/13/24 after the suppository was refused -Lactulose was administered on 2/20/24 prior to the resident's hospitalization Glycolax every four hours PRN: -a dose was administered on 2/3/24,was documented as ineffective, the resident was not administered another dose and the resident did not have a bowel movement on 2/3/24 -a dose was administered 2/10/24 at 10:03 PM and documented as ineffective and another dose was not given until 2/12/24 at 7:08 AM -a dose was administered on 2/13/24 at 9:34 PM and effectiveness was documented as unknown. No dose was re-administered when the resident did not have a bowel movement on 2/14/24. Progress notes revealed on 2/13/23 Resident 1 did not have a bowel moment for three days, had hypoactive bowel sounds (reduced regularity of sound indicating slowed bowel activity), her/his abdomen was distended and non-tender. Resident 1 stated she/he passed gas, refused a suppository and was administered Lactulose. On 2/21/24 the note indicated Resident 1 screamed in pain, her/his abdomen was slighted distended and reported something was not right. The resident was administered a suppository at approximately 12:00 AM, the physician was notified and the resident was sent to the hospital. Resident 1's record did not include additional assessments when the resident did not have a bowel movement from 2/6/24 through 2/11/24 or an assessment related to the change in the resident's bowel pattern from 1/2024 to 2/2024. A 2/15/24 Managed Risk Agreement indicated Resident 1 refused ADL care, dietary recommendations, physician visits, CBGs, insulin, therapy, mental health services and interactions with staff. The form did not address bowel care refusals. A 2/21/24 at 1:29 AM Emergency Department Provider Note indicated Resident 1 vomited upon arrival to the hospital and had a firm, distended, tender abdomen. The resident had imaging which showed a very large colon with very large stool burden. Resident 1's diagnosis was fecal impaction and stercoral colitis (chronic constipation leads to fecal impaction, colon distention and masses of dehydrated fecal material). Aggressive bowel care was provided. A 2/24/24 Operative Report revealed Resident 1 had stercoral colitis and a large bowel obstruction. Findings included an immensely dilated rectum and immense stool burden with no possibility of cleaning out the colon resulting in a colostomy. On 3/7/24 at 9:12 AM Staff 1 (DNS) stated the initial screening of documents for new admissions to the facility was usually completed by the DNS or the RNCM. The DNS or RNCM reviewed the documents provided by the hospital including the history and the orders. Staff 1 acknowledged the facility had the information related to the resident's history of constipation, the resident's frequent hospitalization s related to constipation, and the facility did not assess and implement a care plan specific to the resident's bowel care needs. Staff 1 stated the orders were initially entered into the computer by the RNCM and the floor nurses reviewed the hospital orders prior to the first medication administration. A request was made to Staff 1 to provide documentation at the time of the resident's admission to the facility the staff clarified with the physician the glycolax was not to be administered four times a day and only PRN. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure a resident representative was provided written notice of the facility bed hold policy for 1 of 3 sampled residents (#1) reviewed for bowel care. This placed residents and responsible parties at risk for lack of knowledge related to rights to return to the facility. Findings include: Resident 1 was admitted to the facility in 2023 with a diagnosis of a stroke. Resident 1's record revealed she/he had an appointed guardian. A Bed-Holds and Returns policy last revised 3/2022 revealed residents were to receive written information in the admission packet about the bed-hold policy and within 24 hours of an emergency transfer. Progress Notes revealed Resident 1 was sent to the emergency department on 2/21/24. The notes indicated the guardian was contacted on 2/27/24, the guardian reported she/he wanted the facility to hold the resident's bed and was then was notified by the facility she/he would be financially responsible to place a hold for the resident's bed. The 2/28/24 note indicated the guardian deliberated the cost of the bed-hold, did not want to hold Resident 1's bed and the facility notified the guardian the resident's belongings would be stored at the facility until they were able to pick up the items. On 3/7/24 at 2:13 PM Witness 1 (Hospital Case Manager) stated when she spoke to Resident 1's guardian she/he indicated she/he did not receive written information about the bed-hold policy and was told by phone she/he had to pay in order to allow Resident 1 to be readmitted to the facility. Resident 1's guardian could not afford to hold the bed and did not understand the resident could go back to the facility. On 3/7/24 and 3/8/24 via e-mail Staff 6 (Administrator In Training) indicated Resident 1's guardian was notified by phone and not in writing of the facility's bed-hold policy after the resident was discharged from the facility. On 3/8/24 Staff 6 also stated the resident's guardian was not provided an admission agreement which contained a bed-hold policy when the resident was initially admitted to the facility.

Based on interview and record review it was determined the facility failed to ensure an RN worked eight consecutive hours per day seven days per week for 46 of 97 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including resident assessment, care and services. Findings include: Review of the Direct Care Staff Daily Reports from 1/1/23 through 1/25/23, 2/19/23 through 2/28/23, 3/1/23 through 3/31/23 and 9/16/23 through 10/16/23 revealed the following days in 2023 with no RN coverage for eight consecutive hours: -January: 1, 2, 9, 10, 12, 13, 16, 17, 22, 23 and 24. -February: 19, 20, 21, 22, 24, 25, 26, 27 and 28. -March: 3, 4, 5, 6, 7, 12, 13, 14, 16, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31. -September: 17. -October: 1, 8 and 15. On 10/18/23 at 1:10 PM Staff 1 (Administrator) and Staff 5 (HR/Hiring Specialist) confirmed the facility lacked RN coverage on the identified dates.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 2 of 5 randomly selected staff members (#s 13 and 14) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: On 10/19/23 at 12:29 PM Staff 10 (Business Office Manager) provided a list of training hours for the sampled staff and confirmed the following: -Staff 13 (CNA): 0 annual training hours; -Staff 14 (CNA): 3 annual training hours. On 10/20/23 at 10:30 AM Staff 1 (Administrator) was notified of the findings of this investigation and acknowledged Staff 13 and Staff 14 lacked the required 12 hours of annual training.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from medication error rates of five percent or greater for 4 of 6 sampled residents (#s 2, 4, 10 and 15) reviewed for medication administration. The facility's medication error rate was 18.5 percent. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 10 was admitted to the facility in 2022 with diagnoses including rib fractures. Resident 10's 10/2023 MAR included a physician's order for morphine sulphate (narcotic pain medication) 5 mg TID at 8:00 AM, 2:00 PM and 8:00 PM. On 10/18/23 at 10:15 AM Staff 8 (CMA) administered 5 mg of morphine sulphate to Resident 10. On 10/18/23 at 1:10 PM Staff 8 acknowledged the morphine sulphate was administered late. On 10/18/23 at 1:15 PM Staff 2 (DNS) stated the expectation was for medications to be administered within one hour before or after the scheduled administration times. 2. Resident 2 was readmitted to the facility 2023 with diagnoses including hip pain and palliative care. Resident 2's 10/2023 MAR included a physician's order for acetaminophen 650 mg (pain medication) TID at 8:00 AM, 2:00 PM and 8:00 PM. a. On 10/18/23 at 10:31 AM Staff 8 (CMA) administered acetaminophen 650 mg to Resident 2. On 10/18/23 at 1:10 PM Staff 8 acknowledged the acetaminophen was administered late. b. On 10/20/23 at 9:42 AM Staff 8 (CMA) administered acetaminophen 650 mg to Resident 2. On 10/20/23 at 9:42 AM Staff 8 acknowledged the acetaminophen was administered late. On 10/18/23 at 1:15 PM Staff 2 (DNS) stated the expectation was for medications to be administered within one hour before or after the scheduled administration times. 3. Resident 15 was admitted to the facility in 2022 with diagnoses including diabetes. Resident 15's 10/2023 MAR included a physician's order for insulin glargine (treats high blood sugar) 50 unit injection. On 10/18/23 at 11:46 AM Staff 9 (LPN) prepared Resident 8's insulin glargine injector pen. Staff 9 did not prime the pen by activating a 2 unit test dose to remove air from the needle. Staff 9 was stopped before she administered the insulin to the resident. Staff 9 then activated a test dose. On 10/18/23 at 1:15 PM Staff 2 (DNS) verified insulin pens were supposed to be primed before use. 4. Resident 4 was readmitted to the facility in 2023 with diagnoses including chronic pain. Resident 4's 10/2023 MAR included a physician's order for acetaminophen 650 mg (pain medication) BID at 7:00 AM and 7:00 PM. On 10/20/23 at 9:21 AM Staff 8 (CMA) administered acetaminophen 650 mg to Resident 4. On 10/20/23 at 9:36 AM Staff 8 acknowledged the acetaminophen was administered late. On 10/18/23 at 1:15 PM Staff 2 (DNS) stated the expectation was for medications to be administered within one hour before or after the scheduled administration times.

Based on interview and record review it was determined the facility failed to comprehensively assess a resident for dementia for 1 of 1 sampled resident (#8) reviewed for dementia. This placed residents at risk for unmet care needs. Findings include: Resident 8 was admitted to the facility in 2022 with diagnoses including stroke and dementia. Resident 8's 8/28/23 CAA for Cognitive Loss/Dementia failed to indicate specifically how dementia was a problem for the resident, how the resident's dementia manifested, the impact on the resident or a rationale for the care planning decision. On 10/19/23 at 9:48 AM the CAA was reviewed with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional RN Consultant) who acknowledged the assessment was not comprehensive.

Based on interview and record review it was determined the facility failed to notify the physician of a worsening wound and weight loss for 2 of 2 sampled residents (#18 and #72) reviewed for wounds and nutrition. This placed residents at risk for inappropriate treatment, delayed healing and weight loss. Findings include: 1. Resident 72 was admitted to the facility in 2003 with diagnoses including stroke. Resident 72's Progress Notes from 9/21/22 through 10/7/22 revealed the following: - On 9/22/22 the resident's right big toenail was loose and bleeding after the resident's sock was removed. The provider gave treatment orders to apply a band-aid to secure the nail and change the band-aid daily. - On 9/27/22 the resident's toenail was coming off while in the shower with a moderate amount of bleeding. Pressure was applied, cleaned with wound cleanser and wrapped with gauze bandage wrap. A referral was received for the resident to be seen by a podiatrist. No notification to the physician or request for new treatment orders was found in the resident's clinical record. - On 9/30/22 no signs of infection were noted to the resident's right big toe and second toe. The note did not indicate what the issue was with the second toe or why it was monitored for infection. - On 10/7/22 the resident's right big toe and second right toenails came off, there were no signs or symptoms of infection and they both appeared healed. On 10/18/23 at 10:45 AM, 11:38 AM and 12:27 PM Staff 2 (DNS) acknowledged there was no indication the physician was notified when the condition worsened. Refer to F684 43691 2. Resident 18 was admitted to the facility in 2023 with diagnoses including brain damage. Review of weight records from 8/2023 through 10/2023 revealed Resident 18 weighed 127.4 on 8/9/23. On 10/15/23 Resident 18 weighed 113.1 pounds which was an 11.22% loss. Review of Resident 18's 8/2023 through 10/2023 records revealed no physician notification was made regarding Resident 18's unplanned weight loss. On 10/19/23 at 10:48 AM Staff 2 (DNS) confirmed Resident 18's physician should have been notified of Resident 18's unplanned weight loss.

Based on interview and record review it was determined the facility failed to timely assess a resident for a significant change in condition for 1 of 1 sampled resident (#8) reviewed for dementia, hospice and unnecessary medications. This placed residents at risk for unmet care needs. Findings include: Resident 8 was admitted to the facility in 2022 with diagnoses including stroke and dementia. A physician's order dated 8/11/23 indicated Resident 8 was admitted to hospice on 8/11/23. Resident 8's significant change in status MDS was dated 8/28/23. On 10/19/23 at 9:48 AM the MDS assessment date was reviewed with Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional RN Consultant) who acknowledged the assessment was completed late.

Based on interview and record review it was determined the facility failed to provide wound care and obtain physician's orders for wound care for 1 of 1 sampled resident (#72) reviewed for wounds. This placed residents at risk for infection and delayed healing. Findings include: Resident 72 was admitted to the facility in 2003 with diagnoses including stroke. Resident 72's Progress Notes from 9/21/22 through 10/7/22 revealed the following: - On 9/22/22 the resident's right big toenail was loose and bleeding after the resident's sock was removed. The provider gave treatment orders to apply a band-aid to secure the nail and change the band-aid daily. - On 9/27/22 the resident's toenail was coming off while in the shower with a moderate amount of bleeding. Pressure was applied, cleaned with wound cleanser and wrapped with gauze bandage wrap. A referral was received for the resident to be seen by a podiatrist. No notification to the physician or request for new treatment orders was found in the resident's clinical record. - On 9/30/22 no signs of infection were noted to the resident's right big toe and second toe. The note did not indicate what the issue was with the second toe or why it was monitored for infection. - On 10/2/22 no signs of infection were noted to the right big toe and second toe. Cleaned with wound cleaner and [left] open to air (no bandage was applied). No physician's order for this treatment was found in the resident's clinical record. - On 10/4/22 No bleeding from the right foot. Cleaned with wound cleaner and left open to air. - On 10/7/22 the resident's right big toe and second right toenails came off, there were no signs or symptoms of infection and they both appeared healed. Resident 72's 9/2022 and 10/2022 TARs revealed no indication treatment was provided to the resident's right big toe. On 10/18/23 at 10:45 AM, 11:38 AM and 12:27 PM Staff 2 (DNS) acknowledged there was no indication daily treatment was provided as ordered on 9/22/22, no indication the physician was notified when the condition worsened or updated treatment orders were provided.

Based on observations and interviews it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 10/17/23 through 10/20/23 identified the following issues: -rooms [ROOM NUMBERS] had missing light covers on their walls. -rooms [ROOM NUMBERS] had missing portions of blinds on the windows. -room [ROOM NUMBER]'s sink had pulled away from the wall approximately 1 inch leaving a gap between the sink and wall. -The wood frame of the awning covering the outdoor smoking area had a broken [NAME] and rotten wood. -The wooden threshold between a door and the smoking area had a two inch gap where the wood was missing. The remaining wood of the threshold contained divots and was missing paint. On 10/19/23 at 11:20 AM a facility walk through was completed with Staff 1 (Administrator) and Staff 6 (Maintenance Director). Staff 1 and Staff 6 both acknowledged the identified rooms were not homelike and the identified maintenance concerns needed to be repaired.

Based on interview and record review it was determined the facility failed to accurately assess a resident for behaviors for 1 of 1 sampled resident (#8) reviewed for dementia. This placed residents at risk for unmet care needs. Findings include: Resident 8 was admitted to the facility in 2022 with diagnoses including stroke and dementia. Resident 8's 8/28/23 MDS indicated the resident had no indicators for psychosis or behavioral symptoms. Resident 8's 10/19/23 Care Plan indicated the resident's behavior was monitored due to the resident's tendency to yell aggressively, curse, engage in inappropriate behavior toward female staff and argue with her/his roommate. On 10/19/23 at 9:48 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 3 (Regional RN Consultant) verified Resident 8's care plan was accurate, the resident was on behavior monitoring and the MDS assessment was not correct.

Based on observation, interview and record review it was determined the facility failed to provide supervision for safety for 1 of 3 sampled residents (#1) reviewed for accidents. As a result, Resident 1 sustained a second degree burn to her/his inner thigh. Findings include: The facility's Accidents and Incidents Policy revised 7/2017 revealed all accidents or incidents involving residents occurring on the premises were to be investigated and reported to the Adminsitrator. Documentation was to include when the accident or incident occuured, the nature of the injury, the circumstances surrounding the injury and the condition of the injured resident. Resident 1 was admitted to the facility in 2019 with diagnoses including dementia. Resident 1's current care plan initiated on 3/2019 revealed Resident 1 was on aspiration precautions and was 1:1 assistance with feeding with constant supervision. The care plan revealed the resident was unable to to perform ADL's due to dementia. The 1/12/20 MDS Comprehensive Assessment indicated Resident 1 had a BIMS score of 7 (indicating severe cognitive impairment). On 7/2/20, the facility submitted a Facility Reported Incident Form which indicated on 7/2/20 at 12:30 PM, Resident 1 was found to have chili on her/his lap which resulted in a first degree burn to Resident 1's right inner thigh. The facility determined Staff 5 (CNA) took Resident 1's food tray to her/his room, placed the tray on the bedside table and left the room. Resident 1 then grabbed the bowl of chili and it spilled onto her/his lap. Staff 10 (former CNA) discovered the resident in bed with the chili on her/his lap. A follow up investigative report by the facility dated 7/3/20 revealed the following: -On 7/2/20 at 12:20 PM Staff 10 asked Staff 9 (Former DNS) and Staff 3 (RCM) to go into Resident 1's room with her. Resident 1 was observed to have chili spilled on the bed and over her/his right upper thigh. -Staff 9 confirmed Staff 5 left the bowl of chili on the tray table beside Resident 1`s bed. -Resident 1 complained of pain in the burn area, which was measured at 5 X 5cm and the skin was observed to be peeling. -Staff 5 was interviewed and admitted he had left the tray with Resident 1, then left the room. Staff 5 stated he knew the care plan required 1:1 supervision, but he was not the assigned CNA and was just delivering the tray. -Staff 5 was given a disciplinary action and an in service training was provided to staff to hold resident meal trays for assisted diners. No observations were conducted of Resident 1 due to her/him discharging from the facility. Observations were made of Resident 2 and Resident 3 from 5/4/21 to 5/5/21. Both residents were observed to be assisted by staff with eating breakfast and lunch. Facility progress notes reviewed from 7/2/20 through 11/6/20 indicated Resident 1 received wound care from 7/3/20 through 10/27/20. There were several notes indicating Resident 1 experienced pain during wound care. Kaiser Permanente wound care documents reviewed from 7/3/20 through 8/3/20 indicated Resident 1 was diagnosed with a full thickness second degree burn of the right inner thigh. Photos taken on 7/6/20 revealed the second degree burn wound covered the majority of Resident 1's upper thigh, extending from the outer thigh, across the mid thigh and ending in the inner thigh area. Although no measurements were taken, the second degree burn wound's size appeared to be much larger than 5 X 5 cm. The second degree burn wound photo appeared raw with no scabbing, drainage and borders free of slough. A telephone encounter note dated 7/3/20 at 10:25 PM revealed call from facility stating they had not received Tylenol PO order yet and patient is having some pain from burn. On 5/4/21 at 2:13 PM, Staff 3 (RCM) stated she was present on 7/2/20 during the incident. She recalled she was asked by Staff 10 to go to Resident 1's room. Staff 10 told Staff 3 Resident 1 had chili on her/his front leg and the resident was cleaned. Staff 3 indicated she learned Staff 5 left the resident's meal tray in the room. Staff 3 could not recall low long the injury was present on the resident but stated it took quite a while to heal. On 5/4/21 at 2:20 PM, Staff 1 (Administrator) stated she was the Administrator in Training (AIT) at the time of the accident. Staff 1 confirmed Staff 5 did not follow the care plan for assistance with feeding Resident 1. On 5/4/21 at 4:52 PM, Staff 9 (Former DNS) stated, on 7/2/20 she was alerted by Staff 10 Resident 1 had a wound. Staff 9 indicated she observed extreme excoriation (raw, abraded skin) on Resident 1's groin/thigh area. Staff 9 stated it was a significant wound, painful and required dressing changes daily. Staff 9 indicated the chili was stuck to Resident 1's leg, the burn almost went down to muscle and was a second degree burn, possibly heading to a third degree burn. Staff 9 stated the chili immediately blistered Resident 1's skin and staff had to pop the blisters to get the chili off. Staff 9 spoke to Staff 5 who confirmed he delivered the tray and left the resident's room. Staff 9 stated this was the worse burn she had seen on any resident in the 25 plus years she had been a nurse. On 5/5/21 at 8:23 AM, Staff 4 (Dietary Manager) stated food temperatures are checked in the cooking pan, then the food was held on the steam well and temps were checked again. If food was too hot, an ice bath would be used to cool the food. Staff 4 recalled the incident and stated dietary staff received in service training regarding food temperatures. On 5/5/21 at 8:51 AM, Staff 5 (CNA) stated he delivered the food tray to Resident 1's room on 7/2/20. Staff 5 stated Resident 1 required a lot of care and was a 1:1 assist with meals. Staff 5 was passing trays to residents and brought the tray into Resident 1's room. Staff 5 indicated he was not the assigned CNA for Resident 1 and left the tray assuming the assigned CNA would be in shortly. Staff 5 was notified by another staff member Resident 1 had spilled the chili on her/his lap, went back to the room and observed Resident 1's thigh to be red and burned. Staff 5 acknowledged he was aware Resident 1 required 1:1 supervised assistance with eating and he made a big mistake. On 5/5/21 at 9:04 AM, Witness 1 (Relative) stated she was notified Resident 1 dropped a bowl of chili into her/his lap and it took a long time to heal. Witness 1 indicated at the time of the accident, Resident 1 required assistance with eating due to being unable to feed her/himself. On 5/5/21 at 1:43 PM, Staff 10 (Former CNA) stated she was the assigned CNA to Resident 1 on 7/2/20. Staff 10 recalled Resident 1's care plan included getting her/him up for meals, preparing the food and feeding the resident 1:1. Staff 10 stated she was supposed to take Resident 1's food tray to her/him but Staff 5 took the tray instead. Staff 10 went to Resident 1's room and observed the chili on her/his groin area. Staff 10 stated Resident 1 was in pain, saying oh, it hurts, ow, ow upon her entrance into the room. Staff 10 went into the hallway, yelled for help and Staff 9 came into the room to assist cleaning Resident 1. Staff 10 stated the staff initially didn't realize how bad the burn was and were trying to wipe the chili off. Staff 10 stated the burn was really bad, was red and the skin peeled off. On 5/6/21 at 10:51 AM, Staff 11 (LPN) stated she worked Sunday, 7/5/20 and changed Resident 1's dressing. Staff 11 recalled the wound appeared raw, open and burned with the skin peeled off. Staff 11 recalled Resident 1 experienced discomfort when the wound was cleaned and a narcotic PRN was ordered. Staff 11 indicated as the days went by, Resident 1 experienced more discomfort and pain, she/he would flinch during wound care or attempt to push staff's hands away from the second degree burn wound area. Staff 11 stated she used the term first degree burn in her progress notes because it was on the alert note and she was following the description in the incident report.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were free from physical abuse for 2 of 3 sampled residents (#2 and #3) reviewed for abuse. Resident 2 and Resident 3 sustained injuries and required hospital evaluation. This placed residents at risk for continued abuse. Findings include: 1. Resident 2 was admitted in 9/2016 with [DIAGNOSES REDACTED]. Resident 2 had a BIMS (Brief Interview for Mental Status) score of 10 and was reported to be moderately cognitively impaired but was able to make her/his needs known and used an assistive device for ambulation. On 11/23/19 A physical altercation occurred involving Resident 1 and Resident 2. Resident 1 was transported to the local ER by law enforcement for a psychiatric hold. Resident 2 was hospitalized and required medical treatment due to a [MEDICAL CONDITION]. On 12/5 at 5:47 PM Resident 2 stated she/he was in the dining room helping a resident when Resident 1 hit me. Resident 2 explained Resident 1 used a coffee cup to hit her/him. Resident 2 stated since returning from the hospital, she/he has been out of my room but had not seen Resident 1 and wanted to stay clear of her/him. Observations were made from 12/5/19 through 12/13/19 between the hours of 8:00 AM and 5:00 PM. At no time during observations did Resident 1 interact with Resident 2. On 12/10/19 and 12/13/19 at 10:30 AM Staff 3 (SSD) stated with all the occurrences, it seemed Resident 1 was always on edge, looking for that fight. Staff 3 stated we didn't think of the incidents then, but they all seemed to occur in the dining room. Cascadia Behavior health came in and evaluated Resident 1 and recommended we do 1 on 1 with Resident 1, but we missed that recommendation. Staff acknowledged she/he did not notify Resident 1's case manager of all of Resident 1's behavioral and plan of care changes. 2.Resident 3 was admitted in 2/2018 with [DIAGNOSES REDACTED]. Resident 3 had a BIMS (Brief Interview for Mental Status) score of 15 and was reported to be cognitively intact, able to make her/his needs known and used a wheelchair for locomotion. A FRI intake was reported on 6/11/19 regarding a resident to resident altercation which took place on 6/8/19. The FRI revealed the facility reported Resident 1 and Resident 3 were watching television in the dining room. Resident 1 stated Resident 3 was making derogatory comments towards him/her. Staff 13 reported Resident 1 would not calm down during this time and hit Resident 3 at least three times. Resident 3 reported headache and dizziness with a 10/10 pain level following the incident. On 12/13/19 at 12:00 PM Staff 2 (DNS) stated her/his understanding of types of reportable incidents involved resident to resident, serious injury and suspected abuse. Staff 2 (DNS) stated that many incidences weren't getting done or reported. The previous DNS did not complete them correctly. All incidents were reviewed with the DNS regarding physical altercations on the part of Resident 1 and did not contradict or deny any findings.

Based on observation, interview and record review it was determined the facility failed to protect a resident from sexual abuse for 1 of 5 sampled residents (#12) reviewed for abuse. As a result, Resident 12 was exposed to multiple incidents of sexual abuse. The facility was found to be in an Immediate Jeopardy situation in the area of CFR 483.12 Freedom from Abuse, Neglect, and Exploitation. Findings include: The facility's 8/2/17 Abuse Prevention, Intervention, Reporting and Investigation Policy and Procedure indicated the following: -Residents will be free from verbal, sexual, physical emotional/mental abuse, neglect, medical neglect misappropriation of resident property, corporal punishment and involuntary seclusion at all times. -The facility would develop and implement a system for identifying, investigating, preventing and reporting an incident, or suspected incident, of abuse as defined above. -It is the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family, or visitors including injuries of unknown source and theft or misappropriation of resident property. -Staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. -All reports of resident verbal, sexual, physical and mental abuse, corporal punishment; involuntary seclusion; neglect, or misappropriation of resident property shall be promptly and thoroughly investigated by facility management. -Sexual abuse was defined as, but not limited to, sexual harassment, sexual coercion or sexual assault. Resident 12 was admitted in 1/2014 with [DIAGNOSES REDACTED]. Resident 12 had a BIMS (Brief Interview for Mental Status) score of 1 and was reported to be severely cognitively impaired. Resident 18 was admitted in 10/2017 with [DIAGNOSES REDACTED]. Resident 18 had a BIMS (Brief Interview for Mental Status) score of 11 and was reported to be moderately cognitively impaired, but was able to make her/his needs know and direct her/his own care. Observations of Resident 12 and Resident 18 were made from 7/30/18 through 8/3/18 between the hours of 8:30 AM and 3:30 PM. Resident 12 was observed sitting either in the dining room or in a wheelchair in the hallway near the dining room across from the Nurses Station. Resident 12 appeared to be pleasantly confused and was cognitively impaired. Resident 12 was also observed walking around the hallway at times, receiving staff redirection to sit in her/his wheelchair. Resident 18 was observed to be either in her/his room, dining room or in the hallways of the facility. Resident 18 was either walking independently or with the assistance of a walker. On 7/31/18 at approximately 11:55 AM and 8/1/18 at approximately 10:30 AM, Resident 18 was observed walking near Resident 12 in the hallway near the Nurses Station with no staff present. Resident 18's record revealed a 12/31/17 incident in which Resident 18 exposed her/his private body part and grabbed Resident 12's hand to make her/him hold it. Staff described Resident 18 forced Resident 12's hand to hold Resident 18's private body part. The incident was investigated and reported to Adult Protective Services (APS). A safety agreement was made which included a 15 foot distance between the two residents and for Resident 12 to not be left alone with Resident 18. A 5/3/18 Progress Note indicated Resident 18 was observed in the dining room with her/his private body part exposed in front of a resident's face (later identified as Resident 12). The resident was touching Resident 18's private body part and was about to put it in her/his mouth when staff walked into the room and stopped the behavior. Staff spoke to Resident 18 about her/his inappropriate behavior. A 6/2/18 Progress Note indicated Resident 18 was observed to expose her/his private body part towards another resident (later identified as Resident 12). Staff explained to Resident 18 that her/his behavior was inappropriate and the resident was assisted to her/his room. Further investigation of Resident 18's Progress Notes revealed the facility was aware of Resident 18's inappropriate sexual behaviors in 11/2017. Progress Notes between 11/11/17 to 11/28/17 described 16 incidents of Resident 18 either exposing her/his private body part to other residents (not identified) or touching/rubbing other residents (either described as the hair/shoulder/leg or not identified as to where). Some of these incidents were documented to have occurred on the same dates. -11/11/17: Exposed self to a female resident. -11/18/17: Separate incidents of touching a female resident in the back hallway and in the dining room (area touched not identified). -11/19/17: Separate incidents of touching a female resident two times (no details as to the touching) and exposing her/his private body part to a resident in the dining room. -11/20/17: Rubbing the legs of a resident sitting close to her/him. -11/21/17: Separate incidents of rubbing the shoulders of a resident and touching the hair of a resident. -11/22/17: Separate incidents of touching hair and exposing private body part. -11/23/17: Touching another resident (no details as to the touching). -11/27/17: Caressing the hair of a resident. -11/28/17: Stroking the hair of a female resident (two times) and rubbing the back and shoulders of a female resident. Progress notes revealed there was no follow up on any of the incidents except for the 12/31/17 incident. Resident 18's care plan (last revised 1/5/18) identified she/he had inappropriate sexual behavior exhibited by exposing her/his private body part, grabbing other residents hand to massage her/his private body part, cuddling or fondling other residents, touching other residents and/or staff inappropriately. Interventions included intermittent/constant supervision during activities. The 12/31/17 Safety Agreement for Resident 18 was not included in Resident 18's current care plan. On 8/2/18 at 9:25 AM, Staff 11 (CNA) stated she had worked at the facility for three years. Staff 11 was not aware of any incidents between Resident 12 and Resident 18. Staff 11 stated Resident 18 was verbally inappropriate at times and showed her/his private parts. Staff 11 further stated that Resident 18 was to be supervised, but was not sure of the level of supervision required. On 8/2/18 at 9:34 AM, Staff 12 (CNA) stated she was not aware of any inappropriate behaviors for Resident 18. Staff 12 further stated she was not aware of any monitoring in regards to Resident 18. On 8/2/18 at 9:39 AM, Staff 1 (DNS) stated Resident 18 was alert and oriented most of the time. Staff 1 stated a one to one supervision as well as a 15 foot space between Resident 18 and female residents was added to Resident 18's care plan in response to the 12/31/17 incident. Resident 18's care plan also included Resident 18 was not to be left unsupervised. Staff 1 was not aware Resident 18's care plan did not include the above interventions. On 8/2/18 at 10:10 AM, Staff 2 (Social Services/Activities) stated Resident 18 had a history of [REDACTED]. Staff 2 stated this information was discovered approximately a few weeks after the resident was admitted . Staff 2 stated she was not aware of any incidents since the 5/3/18 incident and that most of the incidents involved Resident 12. Staff 2 further stated Resident 18 was to be kept away from female residents and required close supervision. Staff 2 stated Resident 18 acted like she/he did not understand why her/his behaviors were inappropriate and replied she/he and Resident 12 were consenting adults. On 8/2/18 at 9:17 AM, Staff 6 (CNA) stated Resident 18 had fondled Resident 12 sometime ago, but was not aware of the actual incident. Staff 6 further stated staff have to keep Resident 12 and Resident 18 apart, but was not aware of any other interventions. On 8/2/18 at 10:09 AM, Staff 3 (RN) stated she was aware of Resident 18's behaviors and had witnessed the resident exposing her/his private body part in front of Resident 12 in (MONTH) (YEAR). Staff 3 further stated staff kept a close eye on Resident 18 and tried to keep her/him separated from female residents. Staff 3 added CNAs were to monitor Resident 18's sexual behavior, but the behavior monitoring did not reflect specifically what Resident 18's sexual behaviors consisted of. On 8/2/18 at 11:46 AM, Staff 1 (DNS) and Staff 4 (Administrator) were asked about the multiple documented incidents involving Resident 12 and Resident 18. Staff 1 stated she was aware of the 5/3/18 incident, but not the 6/2/18 incident. Staff 4 state he was not aware of either the 5/3/18 or 6/2/18 incidents. Staff 1 acknowledged Resident 12 was cognitively impaired and unable to given consent. On 8/2/18 at 11:55 AM, Staff 1 and Staff 4 were informed of the failure of current measures used by the facility to ensure abuse prevention interventions were followed which constituted a situation of immediate jeopardy to the health and welfare of residents. Surveyors requested an immediate plan of correction to protect the residents from harm be developed and implemented. On 8/2/18 at 6:15 PM, a final immediate plan of correction was accepted from the facility and the plan was verified as implemented removing the immediate risk to residents health and welfare. The immediate plan of correction included: -The purpose of the plan of correction was to ensure that all female residents were safe. -A staff member will be assigned to Resident 18 during waking hours approximately 7:00 AM to 9:00 PM. When sleeping, CNA and Charge Nurse will monitor resident. -The staff member will assist Resident 18 to group activities of choice and monitor any behaviors and document any behaviors Resident 18 may display in the behavior log. Staff will be trained on 8/3/18. -A sexual behavior log will be implemented by the DNS and all staff will be trained on how to document. -The behaviors will be listed and data complied to help determine threat and understand trends and stimulating activity. -One on one training for staff by the Administrator/DNS or designee for training on dementia and sexual abuse. Facility will continue to use CMS Publication Hand in Hand module 2 -The above monitoring will be continued for four weeks and the QAPI committee will evaluate progress of plan and decide if further action is needed. -Resident 18 will be one-to-one tonight. -The schedule will be working to be able to provide one-to-one staff. -Staff 2 (Social Services/Activities) will train staff on what to monitor. -A memo will be posted in the 24 Hour report and it will be signed by staff to assure they know the procedure on 8/2/18.

Based on interview and record review, it was determined the facility failed to implement written policies and procedures which prevented sexual abuse of residents for 1 of 5 sampled residents (#12) reviewed for abuse. The facility's failure led to prolonged sexually inappropriate behaviors and sexual abuse by Resident 18 toward Resident 12 and other residents. The facility was found to be in an Immediate Jeopardy situation in the area of CFR 483.12 Freedom from Abuse, Neglect, and Exploitation. Findings include: The facility's 8/2/17 Abuse Prevention, Intervention, Reporting and Investigation Policy and Procedure indicated the following: -Residents will be free from verbal, sexual, physical emotional/mental abuse, neglect, medical neglect misappropriation of resident property, corporal punishment and involuntary seclusion at all times. -It is the responsibility of employees to promptly report to facility management any incident or suspected incident of neglect or resident abuse from other residents, staff, family, or visitors including injuries of unknown source and theft or misappropriation of resident property. -Staff are mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse. -All reports of resident verbal, sexual, physical and mental abuse, corporal punishment; involuntary seclusion; neglect, or misappropriation of resident property shall be promptly and thoroughly investigated by facility management. -Sexual abuse was defined as, but not limited to, sexual harassment, sexual coercion or sexual assault. Resident 12 was admitted in 1/2014 with [DIAGNOSES REDACTED]. Resident 12 had a BIMS (Brief Interview for Mental Status) score of 1 and was reported to be severely cognitively impaired. Resident 18 was admitted in 10/2017 with [DIAGNOSES REDACTED]. Resident 18 had a BIMS (Brief Interview for Mental Status) score of 11 and was reported to be moderately cognitively impaired, but was able to make his needs know and direct his own care. Record record revealed two sexual incidents involving Resident 12 and Resident 18. On 5/3/18, Resident 18 placed her/his private body part in front of a resident's face (later identified as Resident 12). Resident 12 was touching Resident 18's private body part and was about to put it in her/his mouth when staff walked into the room and stopped the behavior. On 6/2/18, Resident 18 was observed exhibiting his private body part towards another resident (later identified as Resident 12). Further review of Resident 18's record revealed 16 incidents between 11/11/17 to 12/31/17, which described other incidents where Resident 18 was observed touching female residents, exposing her/his private body part to a female resident or displaying sexual aggression toward another resident. There was no facility investigations or follow up for the 5/3/18 or 6/2/18 incidents and no evidence the facility investigated any of the incidents between 11/11/17 to 12/31/17 or obtained further information to rule out sexual abuse. Resident 18 continued to exhibit sexually inappropriate behaviors towards other residents, mostly towards Resident 12 that were not reported or investigated. On 8/2/18 at 9:39 AM, Staff 1 (DNS) stated Resident 18 was alert and oriented most of the time and Staff 12 was very confused. When asked about any other documentation or investigations for the other inappropriate sexual incidents, Staff 1 was unaware if the 5/3/18 and 6/2/18 incidents had been investigated or if there had been further follow up on the other documented sexual incidents. On 8/2/18 at 10:09 AM, Staff 3 (RN) stated she was aware of Resident 18's behaviors and had witnessed the resident exposing her/his private body part in front of Resident 12 in (MONTH) (YEAR). Staff 3 stated she had reported this to Staff 1 (DNS) and Staff 4 (Administrator) but was not aware of any follow up. On 8/2/18 at 11:46 AM, Staff 1 (DNS) and Staff 4 (Administrator) were asked about the multiple documented incidents involving Resident 18. Staff 1 stated she was aware of the 5/3/18 incident, but not the 6/2/18 incident. Staff 4 stated he was not aware of either the 5/3/18 or 6/2/18 incident. Both confirmed the incidents were not investigated and the facility policy and procedure for Abuse Prevention and Reporting was not followed for any of the documented incidents. On 8/3/18 at 2:29 PM, Staff 1 (DNS) and Staff 4 (Administrator) were informed of the failure of current measures used by the facility to ensure prevention of sexual abuse for resident was followed which constituted a situation of immediate jeopardy to the health and welfare of residents. Surveyors requested a plan of correction to immediately protect the residents from harm be developed and implemented. On 8/3/18 at 3:35 PM, a final immediate plan of correction was accepted from the facility. The plan was verified as implemented removing the immediate risk to residents health and welfare. The immediate plan of correction included: -A training will be done with all staff on recognizing and reporting abuse. If an incidents occurs the Administrator and DNS will be notified within the hour via text or phone. The training will provide the policy and procedure for Abuse Prevention, Intervention, Reporting and Investigation. -One on one training for staff by the Administrator/DNS or designee for training on dementia and sexual abuse. Facility will continue to use CMS Publication Hand in Hand module 2 -The above monitoring will be continued for four weeks and the QAPI committee will evaluate progress of plan and decide if further action is needed.

Based on observation, interview and record review, it was determined the facility failed to provide care and services to prevent an avoidable decline in ambulation for 1 of 3 sampled residents (#3) reviewed for activities of daily living. As a result, Resident 3 no longer ambulated. Findings include: Resident 3 was admitted to the facility in 12/2003, with [DIAGNOSES REDACTED]. Resident 3 was observed on 7/30/18 at 2:27 PM and 3:39 PM, and on 7/31/18 at 9:10 AM and 3:10 PM, lying in bed watching TV or sitting on the edge of her/his bed eating. The resident was alert, friendly but presented with cognitive impairment. Resident 3's 7/11/17 ADL Functional/Rehabilitation Potential CAA assessed she/he was able to ambulate but needed assistance due to her/his [MEDICAL CONDITION]. Resident 3's Quarterly MDS with an assessment reference date (ARD) of 10/10/17, assessed she/he was able to walk in her/his room with limited assistance of one person. Resident 3's previous care plan dated 2/12/17, identified she/he was able to ambulate safely needing contact guard assistance of one person. Resident 3's most recent Quarterly MDS' with 1/31/18 and 5/3/18 ARDs, assessed she/he did not walk at all during the resident's assessment periods. Resident 3's physician visits on 3/28/18 and 5/3/18, did not address or provide clinical rationale as to why the resident could no longer ambulate. Resident 3's previous care plan dated 5/25/18, identified she/he was on a restorative nursing program to maintain/improve functional status. Resident 3 was on an ambulation program Tuesday, Thursday day shift and Wednesday and Friday evening shift, and was to stand with a walker for one minute. The RCM was to review the resident's restorative program once every month. Resident 3's current care plan revised on 7/19/18, identified she/he was no longer able to ambulate and was chair and bed bound. There was no evidence the facility conducted a comprehensive assessment to determine if the resident's decline in ambulation was due to circumstances of the resident's clinical condition which demonstrated the resident's decline was unavoidable. In addition, there was no evidence Resident 3 had received a consistent ambulation restorative program as care planned. In interviews on 7/31/18 at 12:41 PM and at 3:00 PM, Staff 9 (Agency CNA) and Staff 5 (CNA) stated Resident 3 had not walked for the last nine months. Staff 9 stated the resident was assisted to walk by standing and pivoting but this has stopped and was unaware as to why. Staff 5 stated she stood with the resident using a FWW for 20 seconds, but the resident was not on a restorative nursing program. In an interview on 8/1/18 at 3:39 PM, Staff 10 (RN) stated the resident was able to walk with a walker until 10/2017. Staff 10 stated she did not know why Resident 3 had decline and had not seen staff walking the resident. In interviews on 8/2/18 at 9:17 AM and at 6:07 PM, Staff 6 (CNA) stated Resident 3 was able to walk about eight months ago, but she/he had stopped walking and was not sure why. On 8/3/18 at 9:35 AM, Staff 1 (DNS) stated Resident 3 was on a restorative nursing program which started in (MONTH) (YEAR). Staff 1 stated the resident started with an ambulation program to get her/him to stand using a walker, but the resident was scared and only able to stand for 30 seconds. Staff 1 was unable to provide a clinical rationale as to why the resident was no longer able to ambulate.

Based on observation, interview and record review it was determined the facility failed to ensure a resident did not receive medications that were not prescribed for her/him and failed to ensure a resident did not receive a medication listed as an allergy for 1 of 5 sampled residents (#1) reviewed for medication errors and observed during medication administration observation. Resident 1 was administered Resident 2's medications including an antipsychotic medication, [MEDICAL CONDITION] medications and a medication to prevent low blood pressure. Resident 1 became lethargic and was admitted to the hospital. Findings include: Resident 1 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The resident's 9/25/16 Quarterly MDS indicated Resident 1 did not have issues related to swallowing and was cognitively intact. a. The 10/24/16 at 8:45 am Nurse's Note by Staff 3 (LPN) indicted Resident 1 was administered Resident 2's medications. Resident 1's physician was notified and the staff were to monitor the resident for over sedation. On 12/30/16 Staff 1 (Administrator) indicated Resident 1 received Resident 2's 8:00 am medications. Resident 2's 10/2016 Routine Medications for 8:00 am included the following medications: [REDACTED]. The 10/24/16 at 1:30 pm Nurse's Note by Staff 3 (LPN) indicated the resident was still sleeping, was over sedated and was monitored every 30 minutes. The 10/25/16 Incident Report indicated Staff 3 (LPN) prepared to give Resident 2 her/his medications. Resident 2 refused the medications and Staff 3 placed the prepared medications in the medication cart. Resident 1 approached Staff 3 at the medication cart and engaged in conversation. Staff 3 started to prepare Resident 1's medications but left the medication cart to assist another resident. Staff 3 returned to the medication cart and administered Resident 2's morning medications to Resident 1. On 12/30/16 at 2:10 pm and on 1/4/17 at 8:57 am a telephone call was placed to Staff 3 (LPN). A message was not able to be recorded. On 1/4/17 at 8:59 am Staff 5 (DNS) indicated Staff 3 was out of the country and may not be able to be contacted by phone. The 10/24/16 at 7:50 pm Nurse's Note by Staff 4 (RN) indicated Resident 1 rested with her/his eyes closed since early morning, did not respond to verbal or manual stimuli including a sternal rub to the chest and was noted to cough one time. The resident was assessed to have shallow respirations with an oxygen level of 89 percent. The resident's physician was notified and Resident 1 was sent to the hospital for evaluation and treatment. On 1/4/17 at 10:19 am Staff 4 (RN) indicated Resident 1 was in bed since approximately 9:00 am on 10/24/16. She monitored the resident at least every 30 minutes. At first the resident's head of the bed was elevated less than 45 degrees, but she instructed staff to increase the elevation of the head of bed to greater than 45 degrees. At one time the resident started to wake up and requested coffee from Staff 6 (CNA). Staff 4 instructed Staff 6 to not provide fluids to the resident because the resident was at risk for aspiration. Staff 4 was concerned of the resident's health status, called the resident's physician and obtained orders to transport the resident to the hospital for evaluation. On 1/4/17 at 1:20 pm Staff 6 (CNA) indicated she worked the day and the evening shift on 10/24/16. At approximately 9:00 am Resident 1 was in her/his wheel chair. The resident leaned to one side and Staff 3 (LPN) instructed Staff 6 to assist the resident to bed. The staff monitored the resident at least every 30 minutes and ensured the resident's incontinent brief was clean and changed at least every two hours. At one time the resident coughed once, opened her/his eyes and requested coffee. Staff 6 reported to Staff 4 the resident wanted coffee but Staff 4 instructed her to not provide Resident 1 with coffee because the resident was to be sent to the hospital for evaluation. The 10/24/16 hospital Emergency Department report indicated Resident 1 presented to the emergency department with an accidental overdose. The morning of 10/24/16 the facility staff administered Resident 1 the wrong medications including [MEDICATION NAME] and [MEDICATION NAME]. The resident became somnolent (very sleepy/drowsy). Staff reported this was not normal behavior for Resident 1. In the emergency department the resident was assessed to have a persistent severe fast heart rate and had an altered level of alertness. The notes indicated poison control was contacted and concerns were identified for a potential for acute toxicity in relation to the [MEDICATION NAME] and [MEDICATION NAME]. There was also a concern for a possible [MEDICATION NAME] toxidrome (condition caused by ingestion of multiple medications at one time. Symptoms can include altered mental status, fever, flushing, [MEDICAL CONDITION], increased heart rate, high blood pressure and muscle jerking) related to the [MEDICATION NAME]. The resident was admitted to the critical care unit to closely monitor the resident's heart and to administer fluids through the resident's veins. The 10/24/16 hospital History and Physical indicated the resident was admitted to the intensive care unit due to an elevated heart rate and altered mental status. The resident was identified to be largely incoherant. During the night the resident developed a fever, cough and low blood pressure. The note indicated a review of chest x-ray results indicated there was concern related to an aspiration event during somnolence. The 10/28/16 hospital Discharge Summary indicated the chest x-ray on 10/25/16 was reported to have left lung findings with concerns of pneumonia. On 12/30/16 at 9:35 a, Staff 2 (CNA) indicated he did not recall the specific day Resident 1 was administered the wrong medications. Staff 2 indicated Resident 1 did not have difficulty swallowing/eating and did not cough with food intake. 12/30/16 at 8:20 am Staff 7 (RN) indicated Resident 1 did not have a history of aspiration prior to 10/24/16 and was able to verbalize needs. On 1/4/17 at 8:59 am Staff 5 (DNS) acknowledged Resident 1 was administered significant doses of medications that were not prescribed to the resident. The resident became lethargic, oxygen levels were less than 90 percent on room air and the resident was sent to the hospital for monitoring. The resident's hospital stay was lengthened due to factors including a low grade fever. b. The 10/2016 Routine Medications indicated the resident was allergic to medications including [MEDICATION NAME] (prevents [MEDICAL CONDITION]). The 10/24/16 at 8:45 am Nurse's Note by Staff 3 (LPN) indicted Resident 1 was administered Resident 2's medications. Resident 1's physician was notified and the staff were to monitor the resident for over sedation. On 12/30/16 Staff 1 (Administrator) indicated Resident 1 received Resident 2's 8:00 am medications. Resident 2's 10/2016 Routine Medications to be administered at 8:00 am included [MEDICATION NAME] (prevents [MEDICAL CONDITION]). On 1/4/17 at 8:59 am Staff 5 (DNS) acknowledged Resident 1 was administered [MEDICATION NAME] in error. Staff 5 acknowledged [MEDICATION NAME] was listed as an allergy for Resident 1 and staff administered the resident [MEDICATION NAME] on 10/24/16. Staff 5 indicated he was not clear from the resident's record if [MEDICATION NAME] was a true allergy or a medication identified to not be an effective treatment for [REDACTED].

Based on interview and record review it was determined Staff 3 failed to follow standards of practice for the administration of medications for 1 of 2 staff (#3) reviewed for medication errors and medication administration observation. Resident 1 was administered Resident 2's medications including an antipsychotic medication, [MEDICAL CONDITION] medications and a medication to prevent low blood pressure. Resident 1 became lethargic and was admitted to the hospital. Findings include: Standards of Practice for the Licensed Practical Nurse and Registered Nurse rule [PHONE NUMBER] Scope of Practice Standards for Licensed Practical Nurses (2)(d)(A) Implementing treatments and therapy, appropriate to the context of care, including, but not limited to, medication administration . Conduct Derogatory to the Standards of Nursing Defined 851-045-0070 (1)(a)(b)(3)(h) Failing to dispense or administer medications . in a manner consistent with state and federal law . Resident 1 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The resident's 9/25/16 Quarterly MDS indicated Resident 1 was cognitively intact. The 10/24/16 at 8:45 am Nurse's Note by Staff 3 (LPN) indicted Resident 1 was administered Resident 2's medications. Resident 1's physician was notified and the staff were to monitor the resident for over sedation. On 12/30/16 Staff 1 (Administrator) indicated Resident 1 received Resident 2's 8:00 am medications. Resident 2's 10/2016 Routine Medications for 8:00 am included the following medications: [REDACTED]. The 10/25/16 Incident Report indicated Staff 3 (LPN) prepared to give Resident 2 her/his medications. Resident 2 refused the medications and Staff 3 placed the prepared medications in the medication cart. Resident 1 approached Staff 3 at the medication cart and engaged in conversation. Staff 3 started to prepare Resident 1's medications but left the medication cart to assist another resident. Staff 3 returned to the medication cart and administered Resident 2's morning medications to Resident 1. On 12/30/16 at 2:10 pm and on 1/4/17 at 8:57 am a telephone call was placed to Staff 3 (LPN). A message was not able to be recorded. On 1/4/17 at 8:59 am Staff 5 (DNS) indicated Staff 3 was out of the country and may not be able to be contacted by phone. The 10/24/16 hospital Emergency Department report indicated Resident 1 presented to the emergency department with an accidental overdose. The morning of 10/24/16 the facility staff administered Resident 1 the wrong medications including [MEDICATION NAME] and [MEDICATION NAME]. The resident became somnolent (very sleepy/drowsy). Staff reported this was not normal behavior for Resident 1. In the emergency department the resident was assessed to have a persistent severe fast heart rate and had an altered level of alertness. The notes indicated poison control was contacted and concerns were identified for a potential for acute toxicity in relation to the [MEDICATION NAME] and [MEDICATION NAME]. There was also a concern for a possible [MEDICATION NAME] toxidrome (condition caused by ingestion of multiple medications at one time. Symptoms can include altered mental status, fever, flushing, [MEDICAL CONDITION], increased heart rate, high blood pressure and muscle jerking) related to the [MEDICATION NAME]. The resident was admitted to the critical care unit to closely monitor the resident's heart and to administer fluids through the resident's veins. The hospital records indicated Resident 1 was discharged from the hospital on [DATE]. On 1/4/16 at 8:59 am Staff 5 (DNS) acknowledged Staff 3 (LPN) administered Resident 2's medications to Resident 1. Staff 5 indicated the staff were to focus on the medication administration task and not to engage in additional tasks to ensure medication errors did not occur. Refer to F-333 for additional information.

1. Based on observation, interview and record review it was determined the facility failed to contact the physician when a significant change in condition was observed for 1 of 5 sampled residents (#21) reviewed for unnecessary medications. This resulted in Resident 21 not receiving prompt medical intervention for two days after a change in condition. The resident required emergency medical attention and was admitted to the hospital in critical condition. Findings include: Resident 21 was admitted to the facility in 12/2015 with [DIAGNOSES REDACTED]. On 3/7/16 at 1:00 pm Resident 21 was observed with eyes closed and non responsive when staff notified her/him lunch was ready to eat. Staff 7(CNA) attempted to give the resident a cup which the resident could not hold. Staff 7 stated the resident was not her/his usual self and was usually talkative, responsive and walked around the facility independently. Staff 7 stated the resident was very shaky and reported the resident's condition to the charge nurse. On 3/7/16 at 1:04 pm Staff 2 (LPN) observed Resident 21 and stated the resident was lethargic due to a PRN dose of [MEDICATION NAME] (antipsychotic) given by the previous nurse on duty. Staff 2 did not assess the resident's vital signs and stated she held the routine dose of [MEDICATION NAME] because the resident appeared oversedated. On 3/8/16 at 2:17 pm Resident 21 was observed with eyes closed seated on a chair. Staff 3 (CNA) stated the resident seemed to be lethargic. Staff 3 further stated the resident was normally very active and walked around the facility independently. Staff 3 stated the resident was not her/his usual self. In an interview on 3/9/16 at 10:01 am Staff 2 stated the nurse from the 3/8/16 night shift informed her Resident 21 was not able to hold a cup. Staff 2 stated at 7:40 am the resident's vital were assessed and the resident had a fever of 103.4 f, a blood pressure of 86/58 and the blood sugar was too high for the glucometer (machine to check blood sugar level) to get a reading. Staff 2 stated the resident was transported by ambulance to the hospital and was admitted in critical condition. On 3/9/16 at 10:06 am Staff 2 acknowledged she observed the resident on 3/7/16 in a lethargic state and held the resident's [MEDICATION NAME] because she believed the resident was overmedicated. Staff 2 acknowledged she did not assess the resident's vital signs, did not document her observation and did not inform the physician of the resident's condition. In an interview on 3/9/16 at 4:08 pm Staff 12 (RN) stated she worked from 2:30 pm to 10:30 pm on 3/8/16 and noticed the resident was not up and around the facility as usual and seemed to be sleepy. Staff 12 acknowledged she did not assess the resident's vital signs or document her observations. In an interview on 3/10/16 at 5:40 am Staff 11 (LPN) stated he worked the morning of 3/8/16 and noticed the resident was lethargic which was usual. Staff 11 acknowledged he did not document the resident's symptoms or assess the resident's vital signs. Resident 21 was prescribed sliding scale insulin and oral medication to control blood sugar. On 12/29/15 the facility requested the resident's insulin be discontinued due to resident refusals, 14 days after admit to the facility. On 12/29/15 the physician discontinued Resident 21's insulin injections. The order did not discontinue CBG monitoring. The resident's medical record indicated the facility discontinued the CBG monitoring when the insulin was discontinued. Review of the resident's medical record indicated the last entry made by a nurse was dated 2/21/16 which noted the resident was in good spirits, active and not in pain. The record did not include documentation of vital signs or CBGs from 2/21/16 until 3/9/16 when the resident was sent to the hospital in critical condition. The 3/14/16 hospital record revealed Resident 21 was admitted to the hospital on [DATE] in critical condition with [MEDICAL CONDITION] (high blood sugar) [MEDICAL CONDITION] (serious infection). The physician's impression noted it was unclear if infectious pneumonia had precipitated the resident's decline or the severe lactic acidosis (kidney failure related to high blood sugar) due to missed medications was the first symptomology. On 3/14/16 at 11:08 am Staff 1 (DNS) acknowledged Resident 21 was observed by nursing staff to be lethargic, not active, less responsive, unable to hold a cup on 3/7/16 and 3/8/16. Staff 1 acknowledged the nursing staff had not assessed the resident's vital signs, documented any concerns or contacted the physician to report the change in condition. Staff 1 acknowledged the facility had requested the resident's insulin to be discontinued 14 days after admit and that the facility did not continue to monitor the resident's blood sugar. Staff 1 stated he was not notified by nursing staff of the resident's condition until 3/9/16. 2. Based on observation, interview and record review it was determined the facility failed to follow physician's orders for 1 of 1 sampled residents (#14) reviewed for hospice care. This placed residents at risk for unmet care needs. Findings include: Resident 14 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. Resident 14 was re-admitted to the facility on [DATE] with a referral for hospice services. The March 2016 MAR indicated [REDACTED] The hospital discharge order dated 3/2/16 included an order for [REDACTED]. On 3/9/16 at 11:18 am Resident 14 was observed in bed with the nasal cannula in nostrils, the oxygen was on and the concentrator level at 2.5 l/min. On 3/10/16 at 2:21 pm Resident 14 was observed in bed with the nasal cannula in nostrils, the oxygen was on and the concentrator set on 1.5 l/min. Staff 12 (RN) stated the resident's oxygen concentrator should be on 2 l/min and changed the level from 1.5 l/min to 2. Staff 12 stated the resident was on 2 l/min of continuous oxygen prior to her/his recent hospitalization . Staff 12 acknowledged the resident used oxygen throughout the day since she/he readmitted . Staff 12 acknowledged she could not find an order for [REDACTED].>On 3/11/16 at 2:30 pm Staff 2 (LPN) acknowledged the facility had not followed the hospital discharge order dated 3/2/16 to use supplemental oxygen when blood level saturation was below 88%. Staff 2 further acknowledged staff administered oxygen continuously to the resident and not PRN as ordered. On 3/14/16 at 1:59 pm Staff 1 (DNS) acknowledged the facility had not followed the physician order for [REDACTED].> 3. Based on observation, interview and record review, it was determined the facility failed to follow RD recommendations for 1 of 3 sampled residents (# 7) who were reviewed for nutrition and failed to obtain treatment orders, document and monitor a new skin event for 1 of 1 sampled resident (#13) who was reviewed for skin. This placed residents at risk for inappropriate treatments and unmet care needs. Findings include: a. Resident 7 was admitted to the facility in 12/2003 with [DIAGNOSES REDACTED]. On 3/9/16 at 8:05 am and 12:16 pm, the resident was observed to eat independently in her/his room. The resident's Nutritional Status CAA completed on 1/9/16 noted the resident was on [MEDICATION NAME] (a diuretic medication) which could affect her/his weight and she/he triggered due to her/his body mass index. The resident's RD Assessment completed on 1/27/16 noted the resident's weight was stabilizing, intake had improved and recommended to discontinue 90ml 2cal BID (a nutritional supplement) and NEMs (nutritional enhanced meals) and to continue to monitor for changes. The resident's 2/2016 and 3/2016 MAR indicated [REDACTED]. In an interview on 3/9/16 at 12:35 pm, Staff 2 (LPN) stated when the RD visits she makes a list of recommendations which go to the DNS and then to the doctor and then would go onto the resident's MAR. In an interview on 3/9/16 at 3:10 pm, Staff 1 (DNS) stated the facility did not have a system for RD recommendations. Staff 1 confirmed the resident's RD recommendations were not followed. b. Resident 13 was admitted to the facility in 9/2007 with [DIAGNOSES REDACTED]. According to the facility's policy and procedures for Skin Tears - Abrasions and Minor Breaks noted the purpose of this procedure is to guide the prevention and treatment of [REDACTED]. Preparation: 1) obtain physician's order as needed, review the resident's care plan, current orders and [DIAGNOSES REDACTED].Record the following information in the resident's medical record: 1) the site and description of the abrasion or wound, 2) the date and time the abrasion was discovered, 3) date and time the injury occurred, if known 6) all assessment data .9) any complications related to the abrasion .11) interventions implemented or modified to prevent additional abrasions . The resident's Pressure CAA completed on 8/10/15, identified the resident was at risk for pressure ulcers due to the resident's inability to reposition herself/himself, incontinent of bowel and bladder and was dependent on staff for all ADL care. In an interview on 3/9/16 at 9:44 am, Staff 5 (CNA) stated the resident had a new skin issue on her/his buttocks that she believed was open and had not reported it to the nurse, but was going to. In an interview on 3/9/16 at 1:32 pm, Staff 2 (LPN) stated she had not received any report on the resident having a skin issue or an open area on the resident's bottom. In an interview on 3/10/16 at 8:42 am, Staff 7 (CNA) stated the resident had a red dot and there was barrier cream on the area. Staff stated she had not reported the skin issue to the nurse because she assumed someone knew because there had been cream on the resident's bottom. In an interview on 3/10/16 at 9:23 am, Witness 1 (Agency LPN) stated the resident's skin issue was just reported to me and I will look at it today. Witness 1 stated the NOC nurse did not report any skin issues to me and the aide told me there was white cream on the resident, which I assumed is a zinc oxide ointment. On 3/10/16 at 1:11 pm, the RN Surveyor observed two small red cracks located on the resident's coccyx with a cream ointment covering the area. The last nursing note found in the resident's clinical record was dated 12/27/15. There was no documentation of resident's new skin issue. There was no physician order obtained for the use of ointment to be administered as a treatment intervention for the resident's new skin issue. The resident's 3/2016 MAR indicated [REDACTED]. In an interview on 3/10/16 at 3:50 pm, Staff 1 (DNS) stated his expectations for a new skin issue were for staff to begin a skin sheet and place on MAR, document size and location, and initiate treatment. Staff acknowledged the lack of documentation and obtaining treatment orders and stated he believed there were standing orders for the use of A&D or Zinc Oxide ointments. In a follow-up interview on 3/11/16 at 9:09 am, Staff 2 (LPN) stated she had learned about the resident's new skin issues on Wednesday, 3/9/16 and had observed it and had applied A & D ointment on the resident's skin. Staff 2 confirmed she did not document the resident's new skin issue, nor contact the resident's physician, nor document the treatment intervention(s).

Based on observation interview and record review it was determined the facility failed to maintain acceptable parameters of nutritional status for 1 of 3 resident's (#s 1 and 21) sampled residents reviewed for nutritional status. Failure to re-assess, provide interventions, offer supplements or contact the physician when a resident has severe weight loss puts residents at risk for medical complications [REDACTED]. 1. Resident 21 was admitted to the facility in 12/2015 with [DIAGNOSES REDACTED]. The Medical Nutrition assessment dated [DATE] noted Resident 14 weighed 129 lbs and indicated an ideal weight for the resident was 148 lbs. The Admission MDS dated [DATE] indicated Resident 21 had nutritional deficits. The Nutrition CAA noted Resident 21 was diabetic, frequently refused insulin and was non-compliant with dietary restrictions. Resident 21's current care plan indicated the goal for the resident was to eat at least 50% of all meals. The interventions on the care plan included snacks after breakfast, dinner and lunch. The care plan did not include the dietician's assessment to gain weight and the goal weight of 148 lbs. The Meal Monitors noted if residents did not eat 50% of a meal to offer an alternative caloric replacement. The Meal Monitor dated 1/2016 and 2/2016 indicated the resident was not offered a replacement when less than 50% of a meal was eaten. The Weight Report included weights for the resident as follows: 12/15/15 129 lbs 1/04/16 120 lbs 2/11/16 105 lbs The Quarterly Nutrition Note dated 2/23/16 noted Resident 21 had a significant weight loss and weighed 105 lbs, directed the facility to notify the physician and monitor for a change in condition. The dietician recommended the resident receive health shakes tid. The March 2016 MAR indicated [REDACTED]. The hospital record dated 3/14.16 noted Resident 21 was admitted in critical condition with blood sugar affecting kidney function, possible pneumonia and severe malnutrition. On 3/14/16 at 11:12 am Staff 1 (DNS) acknowledged Resident 21 lost 24 lbs since admit on 12/15/15. Staff 1 acknowledged the resident lost nine pounds in the first four weeks with no interventions or notification to the physician. Staff 1 acknowledged the resident's January and February 2016 Meal Monitors indicated the resident was not offered a caloric replacement when less than 50% of her/his meals were consumed. Staff 1 acknowledged the 2/23/16 dietician's recommendation to include health shakes tid was not implemented when asked by survey on 3/8/16 as well as the recommendation to monitor a change in condition. Staff 1 further acknowledged the resident's physician was not notified until 2/28/16 about the unintended weight loss. Staff 1 further acknowledged the resident was sent to the hospital on [DATE] in critical condition and one of the [DIAGNOSES REDACTED]. 1. Resident 1 was admitted to the facility in 7/2003, with [DIAGNOSES REDACTED]. On 3/8/16 at 12:41 pm and on 3/9/16 at 8:50 am, the resident was observed to stay in bed and not eat the breakfast or lunch meal. The resident's Annual MDS completed in 10/2015, assessed the resident as having had a weight loss of 5% or more in the last month. The resident's Quarterly MDS completed in 1/2016, assessed the resident as having had a weight loss of 10% or more in the last 6 months. The resident's Nutritional Status CAA dated 10/13/15, assessed the resident as sleeping late and refusing breakfast, eating late in afternoon and was offered NEMs (nutritionally enhanced meals) and 2.0 cal (nutritional drink) for food refusal. The resident's RD Assessment completed on 1/27/16, assessed the resident as having a weight of 163.6 pounds and had a weight gain of 14.6 pounds in one month, which was a significant noted weight fluctuation in last six months. Resident had been on 2 cal QID due to significant weight loss and recommended to discontinue 60ml 2cal QID due to weight increase and improved PO intake. The RD's Medical Nutritional Therapy Assessment Recommendations also completed on 1/27/16, recommended the MD to be notified of significant weight gain and for 60ml 2 cal QID to be discontinued. The resident's weight record located in the resident's clinical record documented the resident's weight in 1/2016 as 150lbs. The resident's 2/2016 and 3/2016 MAR indicated [REDACTED]. There was no documented evidence in the resident's clinical record the resident's physician was notified of the resident's weight gain. In an interview on 3/9/16 at 1:32 pm, Staff 2 (LPN) stated the resident was weighed by the hoyer scale and weights have been a concern due to a fluctuation in weights and the resident had weights that were exactly the same as prior months. Staff 2 stated staff were recently retrained on how to use the hoyer scale. In an interview on 3/9/16 at 2:12 pm, Staff 8 (RD) stated she received the 163.6 lb weight in January from the facility's Monthly Vital Signs Worksheet. When identified of the weight discrepancy, Staff 8 stated she had seen erroneous weights in past, but this was the weight she received from the facility. In an interview on 3/9/16 at 3:10 pm, Staff 1 (DNS) stated he was aware of inconsistent weights and staff not using the hoyer scale correctly and has been frustrated. Staff 1 also acknowledged RD recommendations were not followed and the facility did not have a system for RD recommendations. In an interview on 3/19/16 at 3:50 pm, Staff 6 (Administrator) stated he was aware of staff not weighing residents correctly and was re-training staff on how to use the hoyer scale.

Based on interviews and record reviews it was determined the facility failed to ensure a resident was free of verbal and mental abuse for 1 of 5 sampled residents (#1). Resident 1 was told she/he was not sick while she/he struggled to breathe and Staff 4 (LPN) repeatedly told other staff while in common areas near the resident's room, that the resident was "faking and not sick." Findings include: Resident 1 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's quarterly MDS dated [DATE] indicated the resident could understand others and make self understood without difficulty. The resident had a brief interview for mental status score of 15 out of 15 which indicated the resident was not cognitively impaired. Review of physician orders [REDACTED]. A facility investigation indicated the resident complained of difficulty breathing throughout the day on 1/16/13. The resident asked repeatedly for her/his inhaler and was seen winded and gasping. The resident continued to decline and showed further signs of struggling for air in the afternoon at approximately 1:00 pm. The resident repeatedly stated she/he "could not breathe," "help me." The resident's condition was not communicated to the physician or addressed by the day shift charge nurse (Staff 4, LPN). The evening shift nurse (Staff 8, RN) came on duty at approximately 2:45 pm on 1/16/13 and addressed the resident's change of condition. NNs dated 1/16/13 at 3:00 pm indicated the resident was red faced and hot with oxygen on 2 liters. The resident's oxygen saturation level was 79% and the resident stated "can't breathe," was wheezing and upset. The physician was contacted and the resident was sent out to the hospital for evaluation. At 10:45 pm the resident returned with a new order for [MEDICATION NAME] (Steroid to open lungs) and oxygen 2 liters prn. In an interview on 1/29/13 at 11:05 am Resident 1 indicated she/he remembered the incident on 1/16/13 very well. The resident indicated she/he was scared and couldn't breathe. The resident asked for her/his inhaler repeatedly but the nurse refused many times to give it to her/him. The resident indicated she/he did finally get the inhaler but it provided no relief and she/he still could not breathe. The resident further indicated Staff 4 told the resident she/he was "faking it, nothing wrong that I was fine." The resident stated she/he had been sick with a cough for about a week so it was hard to breathe normally. The resident indicated her/his breathing got worse as the day progressed. Staff 4 eventually gave the resident oxygen later in the day but it did not help either, the resident stated she/he still could not breathe. The resident could not recall if Staff 4 checked her/his vitals because she/he was "so upset, doubts it, she would barely acknowledge me." Staff 8 (RN) came on duty, checked the resident's vitals and got her/him sent out to the hospital. The resident stated she/he finally had a bit of relief from the medications they gave her/him in the ambulance. The resident stated it was not the first time Staff 4 refused to give her/him the inhaler. The resident indicated she/he did not remember every detail of the incident, she was "panicked, when you can't breathe its terrible." Staff 4 came into the resident's room the next day and told her/him again she/he wasn't even sick, "didn't know what sick was, faking all along." The resident did not understand why Staff 4 wouldn't believe her/him and said she/he faked it when the resident just wanted help. In interviews on 1/29/13 at 10:25 am and 11:30 am Staff 5 (CNA) and Staff 9 (SS) indicated the resident expressed difficulty breathing throughout the day on 1/16/13. The resident repeatedly asked for help and stated she/he could not breathe. Staff 5 and Staff 9 told the charge nurse Staff 4 (LPN) multiple times throughout the shift the resident did not look good and could not breathe. In an interview conducted on 1/29/13 at 2:35 pm Staff 8 (RN) indicated the resident looked terrible, verbally stated she/he could not breathe and was visibly in distress. Staff 8 checked the resident's vital signs and called the physician to get the resident sent to the hospital for evaluation. The previous shifts charge nurse Staff 4 (LPN) did not contact the physician at any earlier point in the day. In an interview on 1/29/13 at 3:15 pm Staff 2 (DNS) indicated Staff 4 should have taken Resident 1's complaints seriously and addressed them promptly. The physician should have been notified of the resident's condition if medications were not providing the resident with relief and breathing did not improve. The resident should not have been told she/he was "faking illness," nor should comments have been made to other staff that the resident's complaints were "faked." In an interview on 1/30/13 at 1:20 pm Staff 4 (LPN) indicated the resident received the inhaler at 6:30 am from night shift for wheezing. The resident requested the inhaler multiple times and Staff 4 told her/him it could not be given again until 10:30 am. The resident refused activities and smoking that day. The resident "worked self up, very dramatic, hard to assess." Staff 4 stated the resident said she/he could not breathe but did not seem distressed. Towards the end of the shift Staff 4 the resident was yelling "I can't breathe" and was all worked up. Staff 4 put oxygen on the resident and she/he seemed to calm down. The resident calmed down so Staff 4 saw no need to contact the physician. Refer to F-224 and F-281

Based on interviews and record reviews it was determined the facility failed to ensure a resident was free from neglect for 1 of 5 sampled residents (#1). Resident 1 complained repeatedly of difficulty breathing that worsened throughout the shift. Staff 4 did not provide timely, appropriate care to address the resident's decline in condition and difficulty breathing. Findings include: Resident 1 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's quarterly MDS dated [DATE] indicated the resident could understand others and make self understood without difficulty. The resident had a brief interview for mental status score of 15 out of 15 which indicated the resident was not cognitively impaired. Review of physician orders [REDACTED]. A facility investigation indicated the resident complained of difficulty breathing throughout the day on 1/16/13. The resident asked repeatedly for her/his inhaler and was seen winded and gasping. The resident continued to decline and showed further signs of struggling for air in the afternoon at approximately 1:00 pm. The resident repeatedly stated she/he "could not breathe," "help me." The resident's condition was not communicated to the physician, addressed timely or appropriately by the day shift charge nurse (Staff 4, LPN). The evening shift nurse (Staff 8, RN) came on duty at approximately 2:45 pm on 1/16/13 and addressed the resident's change of condition. NNs dated 1/16/13 at 3:00 pm indicated the resident was red faced and hot with oxygen on 2 liters. The resident's oxygen saturation level was 79% and the resident stated "can't breathe," was wheezing and upset. The physician was contacted and the resident was sent out to the hospital for evaluation. At 10:45 pm the resident returned with a new order for [MEDICATION NAME] (Steroid to open lungs) and oxygen 2 liters prn. In an interview on 1/29/13 at 11:05 am Resident 1 indicated on 1/16/13 she/he was scared and couldn't breathe. The nurse, Staff 4, would not listen. The resident asked for her/his inhaler repeatedly but the nurse refused many times to give it to her/him. The resident indicated she/he did finally get the inhaler but it provided no relief and she/he still could not breathe. The resident further indicated Staff 4 told the resident she/he was "faking it, nothing wrong that I was fine." The resident stated she/he had been sick with a cough for about a week so it was hard to breathe normally. The resident indicated her/his breathing got worse as the day progressed. Staff 4 eventually gave the resident oxygen later in the day but it did not help either, the resident stated she/he still could not breathe. The resident could not recall if Staff 4 checked her/his vitals because she/he was "so upset, doubts it, she would barely acknowledge." Staff 8 came on duty, checked the resident's vitals and got her/him sent out to the hospital. The resident stated she/he finally had a bit of relief from the medication they gave her/him in the ambulance. The resident stated it was not the first time Staff 4 refused to give her/him the inhaler. The resident indicated she/he did not remember every detail of the incident, she was "panicked, when you can't breathe its terrible." Staff 4 came into the resident's room the next day and told her/him again she/he wasn't even sick, "didn't know what sick was, faking all along." The resident did not understand why Staff 4 wouldn't believe her/him and said she/he faked it when the resident just wanted help. In interviews on 1/29/13 at 10:25 am Staff 5 (CNA) indicated the resident did not look right at the start of the day shift on 1/16/13. The resident stated she/he could not breathe, did not feel well and needed her/his inhaler. The resident asked more than once Staff 5 stated the nurse, Staff 4, was unconcerned but did eventually provide the inhaler to the resident. The resident continued to complain of difficulty breathing, refused activities and smoke breaks. The resident did not normally complain of shortness of breath, skip activities or skip smoke breaks, it was very out of the ordinary. Staff 5 did not see if the resident received the inhaler again that morning. Staff 5 checked on the resident again after the activity was over and the resident was still having a hard time breathing; it was not alarming at that point but also not normal. The resident was begging for her/his inhaler but the nurse said it was too soon. Staff 5 indicated not long after she was in the dining room and could hear Staff 4 talking very loud to the resident but could not hear exactly what was said. The resident came out of her/his room distressed asking anybody and everybody nearby to please help her/him. Staff 5 again told the charge nurse the resident was not breathing well, asked for the inhaler and did not look good. Staff 5 stated she had never seen the resident act so anxious, worried and desperate. The resident was alert, oriented and made her/his needs known. Approximately 30 minutes before Staff 5 left for the afternoon Staff 4 checked the resident and agreed to put oxygen on the resident. The oxygen seemed to be on correctly and Staff 5 could hear the concentrator running but the resident did not get any relief. Staff 5 stated the resident continued to be short of breath and stated she/he could not breathe. Staff 5 heard Staff 4 repeatedly say the resident was faking and that nothing was wrong with the resident. Staff 5 indicated she did not witness any of Staff 4's conversations with the resident. Staff 5 further indicated Staff 4's comments were made in common resident areas not far from the resident's room. In an interview on 1/29/13 at 11:30 am Staff 9 (SS) indicated the resident was alert, oriented and made her/his needs known. The resident was not always motivated but also did not have a lot of complaints. Staff 9 stated it was not normal for the resident to act desperate or dramatic. The resident was begging for help because she/he could not breathe. The resident had been sick with a cold so she/he was not at her/his normal level to start. When Staff 9 came into work on 1/16/13 around 9:00 am the resident was disheveled, no makeup, hair not done and had refused smoke breaks in the morning. Staff 9 indicated the resident said she/he didn't feel well and attended a favorite activity for only a few minutes before going back to her/his room. Staff 9 further indicated the resident continued to ask for an inhaler and stated she/he could not breathe. Staff 9 informed Staff 4, charge nurse, of the resident's complaints and poor appearance but Staff 4 stated the resident was"faking." Staff 9 returned to check on the resident again just after 1:00 pm and the resident again said she/he could not breathe, was almost gasping for air and winded when she/he talked. Staff 4 was again told about the resident's condition and difficulty breathing. Staff 9 stated Staff 4 again said the resident was "faking," did not check the resident's vitals, reassure the resident, check the resident's positioning or try to make the resident more comfortable. Staff 9 stayed with the resident and attempted to adjust her/his position to encourage easier breathing but the resident did not improve. Staff 9 stated they tried to involve Staff 1 (Administrator) but he was tied up in a meeting. The resident tried to get up and walk to the office if Staff 9 left the room all while begging for help. Staff 9 indicated she again told Staff 4 that the resident could not breathe, her/his color was bad and resident was winded. Staff 9 stated she "demanded" Staff 4 do something "right now." Staff 4 finally agreed to put oxygen on the resident, but the resident still did not appear to get relief as she/he continued to struggle to breathe. When Staff 8 (RN), evening charge nurse, came on shift she came to see the resident. The resident's oxygen saturations were at 79%, blood pressure and respirations were elevated as well. Staff 8 called the physician and sent the resident to the hospital. In an interview conducted on 1/29/13 at 2:35 pm Staff 8 (RN) indicated when she arrived at the facility approximately 2:45 pm the resident looked terrible, verbally stated she/he could not breathe and was visibly in distress. Staff 8 checked the resident's vital signs and called the physician to get the resident sent to the hospital for evaluation. Staff 8 returned to the resident after contacting the physician to check the oxygen. The resident was not improved with the use of oxygen and it was the last thing Staff 8 could check to possibly help the resident. Staff 8 discovered the canister to the concentrator was not screwed in properly so the resident had not actually received any oxygen. Staff 8 secured the canister and the resident showed slight improvement with an increase in saturation levels into the 80's. Staff 8 further indicated Staff 4 tried to pull her to report rather than check on the resident. The resident's physician was not contacted until Staff 8 started her shift. Staff 8 further indicated Staff 4 tried to pull her to report rather than check on the resident. The resident's condition and behavior on 1/16/13 was not within her/his norm. In an interview on 1/29/13 at 3:15 pm Staff 2 (DNS) indicated Staff 4 should have taken Resident 1's complaints seriously and addressed them promptly. Staff 2 further indicated the resident's oxygen should have been rechecked when there was no change in the resident's condition. In an interview on 1/30/13 at 1:20 pm Staff 4 (LPN) indicated the resident received the inhaler at 6:30 am from night shift for wheezing. The resident requested the inhaler multiple times and Staff 4 told her/him it could not be given again until 10:30 am. The resident refused activities and smoking that day. The resident "worked self up, very dramatic, hard to assess." Staff 4 stated the resident said she/he could not breathe but did not seem distressed; towards the end of the shift the resident was yelling "I can't breathe" and was worked up. Staff 4 put oxygen on the resident and she/he seemed to calm down. The resident calmed down so Staff 4 saw no need to contact the physician and did not look again at the oxygen. Refer to F-281

Based on interview and record review it was determined the facility failed to ensure a resident's change in condition was addressed by Staff 4 (LPN) and that multiple resident medications were given as ordered when signed out for 4 of 4 sampled residents (#s 1, 2, 3 and 4). Resident 1 had repeated complaints of difficulty breathing on 1/16/13, which were reported to Staff 4 (LPN). The resident's condition was not assessed and the physician was not notified until the evening shift nurse arrived for duty. The resident was later sent to the hospital for evaluation. Findings include: According to Oregon State Board of Nursing "Scope of Practice Standards for All Licensed Nurses [PHONE NUMBER] (1)(a) Advocates for the client's right to receive appropriate care ...considerate of the client's needs, choices and dignity and (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering." 1. Resident 1 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's quarterly MDS dated [DATE] indicated the resident could understand others and make self understood without difficulty. The resident had a brief interview for mental status score of 15 out of 15 which indicated the resident was not cognitively impaired. Review of physician orders [REDACTED]. A facility investigation indicated the resident complained of difficulty breathing throughout the day on 1/16/13. The resident asked repeatedly for her/his inhaler and was seen winded and gasping. The resident continued to decline and showed further signs of struggling for air in the afternoon at approximately 1:00 pm. The resident repeatedly stated she/he "could not breathe," "help me." The resident's condition was not communicated to the physician, addressed timely or appropriately by the day shift charge nurse (Staff 4, LPN). The evening shift nurse (Staff 8, RN) came on duty at approximately 2:45 pm on 1/16/13 and addressed the resident's change of condition. NNs dated 1/16/13 at 3:00 pm indicated the resident was red faced and hot with oxygen on 2 liters. The resident's oxygen saturation level was 79% and the resident stated "can't breathe," was wheezing and upset. The physician was contacted and the resident was sent out to the hospital for evaluation. At 10:45 pm the resident returned with a new order for [MEDICATION NAME] (Steroid to open lungs) and oxygen 2 liters prn. In an interview on 1/29/13 at 11:05 am Resident 1 indicated on 1/16/13 very well. The resident indicated she/he was scared and couldn't breathe. The nurse, Staff 4 (LPN), would not listen. The resident asked for her/his inhaler over and over but the nurse refused many times to give it to her/him. The resident indicated she/he did finally get the inhaler but it provided no relief and she/he still could not breathe. The resident further indicated Staff 4 told the resident she/he was "faking it, nothing wrong that I was fine." The resident stated she/he had been sick with a cough for about a week so it was hard to breathe normally. The resident indicated her/his breathing got worse as the day progressed. Staff 4 eventually gave the resident oxygen later in the day but it did not help either, the resident stated she/he still could not breathe. The resident could not recall if Staff 4 checked her/his vitals because she/he was "so upset, doubts it, she would barely acknowledge." Staff 8 came on duty, checked the resident's vitals and got her/him sent out to the hospital. The resident stated she/he finally had a bit of relief from the medication they gave her/him in the ambulance. The resident stated it was not the first time Staff 4 refused to give her/him the inhaler. The resident indicated she/he did not remember every detail of the incident, she was "panicked, when you can't breathe its terrible." Staff 4 came into the resident's room the next day and told her/him again she/he wasn't even sick, "didn't know what sick was, faking all along." The resident did not understand why Staff 4 wouldn't believe her/him and said she/he faked it when the resident just wanted help. In an interview on 1/29/13 at 10:25 am Staff 5 (CNA) indicated the resident did not look right at the start of the day shift on 1/16/13. The resident stated she/he could not breathe, did not feel well and needed her/his inhaler. The resident asked more than once Staff 5 stated the nurse, Staff 4 (LPN), was unconcerned but did eventually provide the inhaler to the resident. The resident continued to complain of difficulty breathing, refused activities and smoke breaks. Staff 5 did not see if the resident received the inhaler again that morning. Staff 5 checked on the resident again after the activity was over and the resident was still having a hard time breathing; it was not yet alarming at that point but also not normal for the resident. The resident was begging for her/his inhaler but the nurse said it was too soon. Staff 5 indicated not long after she was in the dining room and could hear Staff 4 talking very loud to the resident but could not hear exactly what was said. The resident came out of her/his room distressed asking anybody and everybody nearby to please help her/him. Staff 5 again told the charge nurse the resident was not breathing well, asked for the inhaler and did not look good. Staff 5 stated she had never seen the resident act so anxious, worried and desperate. Approximately 30 minutes before Staff 5 left for the afternoon Staff 4 checked the resident and agreed to put oxygen on the resident. The oxygen seemed to be on correctly and Staff 5 could hear the concentrator running but the resident did not get any relief. Staff 5 stated the resident continued to be short of breath and stated she/he could not breathe. Staff 5 heard Staff 4 repeatedly say the resident was faking and nothing was wrong with the resident. Staff 5 further indicated Staff 4's comments were made in common resident areas not far from the resident's room. In an interview on 1/29/13 at 11:30 am Staff 9 (SS) indicated the resident was alert, oriented and made her/his needs known. Staff 9 stated it was not normal for the resident to act desperate or dramatic. The resident was begging for help because she/he could not breathe. The resident had been sick with a cold so she/he was not at her/his normal level. When Staff 9 came into work on 1/16/13 around 9:00 am the resident was disheveled, no makeup on, hair was not done and had refused smoke breaks in the morning. Staff 9 indicated the resident said she/he didn't feel well and barely attended a favorite activity before the resident returned to her/his room. Staff 9 further indicated the resident continued to ask for an inhaler and stated she/he could not breathe. Staff 9 informed Staff 4, charge nurse, of the resident's complaints and poor appearance but Staff 4 stated the resident was faking. Staff 9 returned to check on the resident again just after 1:00 pm and the resident again said she/he could not breathe, was almost gasping for air and winded when she/he talked. Staff 4 was again told about the resident's condition and difficulty breathing. Staff 9 stated Staff 4 again said the resident was faking, did not check the resident's vitals, reassure the resident, check the resident's positioning or try to make the resident more comfortable. Staff 9 stayed with the resident and attempted to adjust her/his position to encourage easier breathing but the resident did not improve. Staff 9 stated they tried to involve Staff 1 (Administrator) but he was tied up in a meeting. The resident tried to get up and walk to the office if Staff 9 left the room all while begging for help. Staff 9 indicated she again told Staff 4 the resident could not breathe, color was bad and the resident was winded. Staff 9 further indicated she finally demanded Staff 4 do something "right now." Staff 4 finally agreed to put oxygen on the resident but the resident still continued to struggle to breathe. Staff 9 stated Staff 4 had no sense of urgency and repeatedly stated the resident was faking. When Staff 8 (RN), evening charge nurse, came on shift she came to see the resident. The resident's oxygen saturations were at 79%, blood pressure and respirations were elevated as well. Staff 8 called the physician and sent the resident to the hospital. In an interview conducted on 1/29/13 at 2:35 pm Staff 8 (RN) indicated when she arrived at the facility approximately 2:45 pm the resident looked terrible, verbally stated she/he could not breathe and was visibly in distress. Staff 8 checked the resident's vital signs and called the physician to get the resident sent to the hospital for evaluation. Staff 8 returned to the resident after contacting the physician to check the oxygen. The resident was not improved with the use of oxygen and it was the last thing Staff 8 could check to possibly help the resident. Staff 8 discovered the canister to the concentrator was not screwed in properly so the resident had not actually received any oxygen. Staff 8 secured the canister and the resident showed slight improvement with an increase in saturation levels into the 80's. Staff 8 further indicated Staff 4 tried to pull her to report rather than check on the resident. Staff 4 (LPN) was unconcerned with the resident's condition. The resident's physician was not contacted until Staff 8 started her shift. Staff 8 indicated she had never seen the resident look or act as she/he did on 1/16/13. The resident did not normally have complaints of profound shortness of breath nor did she/he beg for help. In an interview on 1/29/13 at 3:15 pm Staff 2 (DNS) indicated Staff 4 should have taken Resident 1's complaints seriously and addressed them promptly. The physician should have been notified of the resident's condition, if medications did not provide the resident with relief and improve her/his breathing. Staff 2 further indicated the resident's oxygen should have been rechecked when there was no change in the resident's condition. In an interview on 1/30/13 at 1:20 pm Staff 4 (LPN) indicated the resident received the inhaler at 6:30 am from night shift for wheezing. The resident "worked self up, very dramatic, hard to assess." Staff 4 stated the resident said she/he could not breathe but did not seem distressed; towards the end of the shift the resident was yelling "I can't breathe" and was worked up. Staff 4 put oxygen on the resident and she/he seemed to calm down. The resident calmed down so Staff 4 saw no need to contact the physician and did not look again at the oxygen. The resident received the inhaler twice during day shift on 1/16/13. 2. According to the Oregon State Board of Nursing "Conduct Derogatory to the Standards of Nursing Defined [PHONE NUMBER] (3)(a) Inaccurate recordkeeping in client or agency records,(b) Incomplete recordkeeping regarding client care; including, but not limited, failure to document care given or other information important to the client's care or documentation which is inconsistent with the care given. (c) Falsifying a client or agency record or records prepared for an accrediting or credentialing entity; including ...record care not given ..." a. Resident 1 was a long term resident of the facility. A facility investigation dated 1/9/13 indicated the resident's antibiotic was not received with no follow up, two doses were not given and were not signed for. A statement as to the cause noted "she (Staff 4) felt that (the resident) could just receive them longer." The physician was notified on 1/11/13 of the missed medications. The investigation indicated the missed medications were discovered by the evening shift. In an interview on 1/29/13 at 3:15 pm Staff 2 (DNS) indicated Staff 4 stated she would be more careful. Staff 2 further indicated this was not the first time Staff 4 had missed medications. b. Resident 2 was a long term resident of the facility. A facility investigation dated 12/29/12 indicated the resident missed three days of am medications. Staff 2 came in on 12/29/12 to pass medications and discovered the resident had not received her/his medications on 12/26/12, 12/27/12 and 12/28/12 but the medications were signed out on the MAR. Staff 4 (LPN) stated it was an oversight. In an interview on 1/29/13 at 3:15 pm Staff 2 (DNS) indicated Staff 4 stated she would be more careful. Staff 2 further indicated this was not the first time Staff 4 had missed medications. c. Resident 3 was a long term resident of the facility. A facility investigation dated 12/14/12 indicated the resident did not receive medications on 12/14/12. When Staff 2 came to work to pass medications on 12/15/12 it was discovered the medications had not been given but were signed out on the MAR. Staff 4 stated she had overlooked the medications. Copies of pill cards included with the investigation showed undispensed medications for 12/11/12 not 12/14/12. In an interview on 1/29/13 at 3:15 pm Staff 2 (DNS) indicated the medications were missed on 12/11/12. Staff 4 stated to Staff 2 she would be more careful. Staff 2 further indicated this was not the first time Staff 4 had missed medications. d. Resident 4 was a long term resident of the facility. A facility investigation dated 12/17/12 indicated Staff 4 did not give the 12/17/12 Certa Plus but signed it as given on the MAR. The staff responded that it was an oversight. The physician was notified of the missed medication on 12/18/12. Staff 4 stated it was an oversight, "everyone misses med every once in awhile." In an interview on 1/29/13 at 3:15 pm Staff 2 (DNS) indicated Staff 4 indicated she would be more careful. Staff 2 further indicated this was not the first time Staff 4 had missed medications. e. A facility investigation dated 8/9/12 indicated four [MEDICATION NAME] (narcotic pain medication) were found on top of the medication cart by the swing shift nurse, Staff 8 (RN). Staff 4 (LPN) was questioned and suspended. The investigation did not contain information about the resident's involved, why the incident occurred, training, future prevention or involved staff statements. The investigation was completed on 8/10/12. In an interview on 1/29/13 at 3;15 pm Staff 2 (DNS) indicated Staff 4 had signed out the medications on the MARs but had not given the medications to the residents. Staff 2 was unable to recall which resident's were involved as the incident occurred back in August 2012 and it was not documented on the incident investigation.

Based on staff interview and document review, it was determined that the facility failed to develop and operationalize abuse policy and procedures which comprehensively addressed training, prevention and reporting. Staff demonstrated a lack of knowledge of the policy with 8 of 10 staff (#s 1, 4, 6, 7, 8, 9, 10 and 11) interviewed unable to identify types of abuse without cues and 3 of 10 staff (#s 6, 8 and 9) interviewed indicating they would not consistently report potential verbal abuse. This placed all residents at risk for abuse resulting in immediate jeopardy and substandard quality of care. Findings include: 1. The facility's policy and procedure to address the prevention and reporting of abuse failed to address the following: - how staff were trained to provide appropriate interventions to deal with aggressive and/or catastrophic reactions in residents; - how to recognize signs of burnout, frustration and stress that could lead to abuse; - staff reporting of allegations without fear of reprisal; - how information was provided to residents and families on how and to whom they could report concerns without fear of retaliation; - features of the physical environment that may make abuse more likely to occur; - supervision of staff to identify inappropriate behavior; and - when reports to the State nurse aide registry would occur. Staff 1, Administrator, and Staff 2, DNS, were informed of the missing components of the facility's abuse policy and procedure on 1/13/2010 at 5:30 pm. 2. Inservice Records for 2010 identified that the last documented abuse prevention inservice had occurred on 3/25/10. There was no evidence that staff who missed the inservice had been provided further training opportunities. In addition, no system to reinforce the concepts that were taught during the training were identified. During a discussion on 1/11/11 at 9:24 am, Staff 8, Housekeeping Supervisor, was unable to recall the last training provided by the facility that addressed abuse. During an interview on 1/12/11 at 2:45 pm, Staff 9, CNA, shared that she could not remember receiving any training in abuse prevention, while working at the facility, and had received no training in working with resident's who had psychiatric disorders or was at risk for catastrophic reactions. Staff 6, Charge Nurse, indicated on 1/12/11 at 5:21 pm that she had received training at previous work situations and recalled "some inservices" while at the facility, but could not provide any additional information on the training content. In a 1/13/11 interview at 9:38 am, Staff 1, Administrator, stated that when staff were hired, they reviewed resident rights and abuse information. He shared that CNA's also received training as they were being certified and should come to the facility with knowledge regarding abuse. Staff then received annual inservice training regarding abuse prevention. In between the annual training's, Staff 1 stated that the facility was a community with incident reports filled out if staff heard or saw something. 3. The January 2011 Work Schedule indicated that staff were allowed to work multiple double shifts each week. In a 1/13/11 interview at 9:38, Staff 1 shared that three residents had voiced ongoing complaints regarding a staff member's behavior towards them. According to Staff 1, that staff member tended to raise his/her voice without knowing it. Although Staff 1 monitored the staff member informally, there was no documented evidence in her personnel file that she had been counseled regarding the resident complaints or a plan had been put in place to monitor that behavior. The staff member was regularly scheduled to work double shifts with management staff phoning her to see how the second shift was going. No onsite monitoring of the second shift had been planned. Staff 9 had been involved in a 9/1/10 substantiated complaint due to the use of profanity towards/around a resident. There was no documentation in Staff 9's personnel file that the staff had been counseled regarding the incident or a plan to monitor staff behavior had been put in place. Staff 9 was interviewed on 1/12/11 at 2:45 pm. She indicated that due to residents' behavior, she sometimes had to "catch" herself and control her reactions. She stated that she was tired and was currently working two jobs. Staff 9 shared that she could not "take it anymore...I'm out of here." In a 1/13/11 interview at 8:05 am, Staff 2, DNS, stated that she was not an expert and would not recognize staff burnout. In an effort to maintain consistent staffing, double shift scheduling was required and was an accepted practice in the facility. 4. During staff interviews from 1/12/11 to 1/13/11, eight of ten staff (#s 1, 4, 6, 7, 8, 9, 10 and 11) were unable to identify the types/categories of abuse without cues from the interviewer. All staff identified physical abuse, but many made qualifying statements regarding verbal abuse. Staff 6 indicated, on 1/12/11 at 5:21 pm, that she had a stern voice and it may have been considered abuse by some, but it was like being a mother - you needed to be politely stern. Staff 8, interviewed 1/11/11 at 9:24 am, stated that incident reports were not readily available and so, he would just intervene if he heard or saw potential abuse. Staff 9, interviewed 1/12/11 at 2:45 pm, and Staff 6, interviewed 1/12/11 at 5:21 pm, indicated that if they overheard staff in an abusive interaction with a resident, they would talk to the staff the first time and ask what was the problem. If that type of interaction happened a second time, they would report the abuse. Staff 1 and Staff 2 were informed of staff's lack of knowledge regarding the facility's abuse policy and procedure on 1/13/2010 at 5:30 pm. 5. On 1/13/11 at 5:30 pm, following consultation with Client Care Monitoring Unit (CCMU) supervisors, the surveyors informed Staff 1 and Staff 2 that the failure to develop and operationalize abuse policy and procedures constituted a situation of immediate jeopardy. At 8:00 pm, a plan of correction was provided to inservice all staff on abuse and reporting, revise their policy and procedures, and monitor staff knowledge of abuse prevention daily. The immediate jeopardy was abated at 8:00 pm on 1/13/11.