Every finding on record at Santa Rosa Center for Rehabilitation and Healing

Based on a record review, interviews, and review of facility policy, the facility failed to prevent new skin breakdown from occurring for 1 of 3 residents reviewed for pressure ulcers (Resident #3).The findings include:Review of Resident #3's medical record revealed he had been admitted to the facility on [DATE] for respite services. Resident #3 had a medical history significant for Alzheimer's, dementia, and a stroke in 2024 which caused him to have left sided weakness. Review of Resident #3's Baseline Care Plan revealed the section for skin breakdown was left blank. A Skin Risk Assessment performed on 04/24/26 identified that Resident #3 was at moderate risk for skin breakdown. Further review of the medical record showed that an admission Skin Assessment form completed on 04/25/26 documented no evidence of skin breakdown upon admission. A subsequent Skin Assessment form, documented on 04/29/26 (the date of discharge) at 10:02 AM revealed the presence of redness and a small blister on the right side of Resident #3's body. Review of a Progress Note dated 04/29/26 at 11:25 AM revealed that Resident #3 was discharged home accompanied by his wife. However, no documentation was found regarding the noted skin breakdown that had been documented on the Skin Assessment form earlier that morning. An interview was conducted with Resident #3's spouse on 06/01/26 at approximately 4:02 PM. She stated that Resident #3 had acquired new skin break down during the 5-day respite stay at the facility. The spouse stated she had informed the Assistant Director of Nursing (ADON) of the skin breakdown prior to Resident #3's discharge and that the ADON had documented a Skin Assessment form on 04/29/26 at 10:02 AM prior to Resident #3's discharge from the facility. An interview was conducted with the facility's Wound Care nurse on 06/02/26 at approximately 1:47 PM. The Wound Care nurse stated that staff completed full skin assessments on every resident upon admission. She explained that if a resident developed any skin breakdown during their stay, she would notify the resident's family and the physician for wound care orders. She stated she was unaware of Resident #3 having skin breakdown during his stay at the facility. Given the time to independently review Resident #3's Skin Assessments, the Wound Care nurse confirmed that the admission Skin Assessment done on 04/24/26 showed no skin breakdown. She further confirmed that the discharge Skin Assessment done on 04/29/26 documented new areas of skin breakdown. After reviewing the chart, she noted that there was no documentation of the physician or family being notified of this change in condition. An interview was conducted with Staff H, Unit Manager on 06/02/26 at approximately 2:15 PM. Staff H explained that any skin conditions acquired during a resident's stay were promptly reported to both the resident's family and physician. Staff H further stated these notifications, along with any resulting new physician orders, would be documented in the resident's medical record. Given the time to independently review Resident #3's admission and discharge Skin Assessments, Staff H confirmed that Resident #3 developed new skin breakdown during his respite stay and found no additional documentation indicating any follow up actions made by the ADON. A review of the facility's policy titled Skin and Wound Management (undated) revealed nurses were required to conduct and document regular skin inspections using the Skin Sweep form at admission and weekly. The policy also required obtaining a physician's order when skin impairment was identified and notifying the resident's representative to discuss interventions that supported wound healing.

Based on observation, resident interview, staff interviews, record review, and policy review, the facility failed to ensure the interdisciplinary team assessed and determined residents were capable of self-administration of medications prior to allowing 1 of 20 sampled residents to self-administer medications. (Resident #2) The findings include: An observation of Resident #2 was conducted on 12/1/25 at 11:41 AM. The resident was in bed and a green, round pill was observed in a medication cup on top of the overbed table. The resident stated the medication was a Tums (a medication used for upset stomach and nausea) and that the nurse brought it in a while ago. (Photographic evidence was obtained.) A review of Resident #2's electronic medical record revealed the resident had a current physician order dated 10/26/23 for Tums oral tablet chewable 500 mg give one tablet two times a day for gastroesophageal reflux disease. A review of the quarterly minimum data set with an assessment reference date of 11/13/25 revealed Resident #2 had a brief interview of mental status score of 15, indicating the resident was cognitively intact. The record revealed no assessment or care plan for Resident #2 to self-administer medications. A telephone interview was conducted with Employee A (Licensed Practical Nurse), who worked on 12/1/25 and would have administered this medication. She stated she gave Resident #2 her 9:00 AM medications on 12/1/25. She stated she did not observe the resident ingest her Tums, but acknowledged she was supposed to observe the resident take the medication. An interview was conducted with the Director of Nursing (DON) on 12/3/25 at 11:10 AM. The DON stated the nurse is expected to observe the resident ingest the medications. An additional interview was conducted with the DON on 12/4/25 at 9:20 AM. The DON confirmed Resident #2 was not assessed or care planned to self-administer medications. Review of the undated facility policy for Administration of Drugs revealed self-administration of drugs is permitted when approved by the interdisciplinary team, including the physician, and documented.

Based on observations, record review, staff interview, and policy review, the facility failed to implement the plan of care for 1 of 1 sampled resident reviewed for edema. (Resident #103)The findings include:Observations of Resident #103 were conducted on 12/2/25 at 12:05 PM and 12/3/25 at 11:35 AM. During both observations, the resident was sitting in his wheelchair with no compression stockings on his lower extremities. A review of Resident #103's electronic medical record revealed the resident had a current diagnosis of edema and a current physician order dated 11/13/25 for compression stockings to bilateral lower extremities when out of bed as tolerated. A review of the current medication and treatment records revealed no indication of the use of compression stockings. A review of the resident's current plan of care for risk of complications related to Cerebrovascular Accident revealed an intervention dated 11/14/25 for compression stockings to bilateral lower extremities when out of bed as tolerated. An interview was conducted with Employee B (Licensed Practical Nurse) on 12/3/25 at 12:16 PM. Employee B stated Resident #103 did not wear compression stockings and she did not believe he had a physician order for compression stockings. On 12/3/25 at 12:18 PM, Employee B reviewed Resident #103's medical record and confirmed the physician order for compression stockings was not placed in the electronic system correctly and did not populate the treatment record to implement the order. An interview was conducted with the Director of Nursing (DON) on 12/3/25 at 12:23 PM. The DON confirmed the physician's order for compression stockings was not populated to the medication or treatment record. Review of the facility policy for Resident Assessment Instrument Comprehensive Care Plan effective September 2024 revealed: The facility will utilize the Resident Assessment Instrument process to assess residents' needs, develop individualized care plans, and ensure the delivery of quality care. This process will involve interdisciplinary team members and be revised to reflect resident condition changes.

Based on observation, record review, staff interviews, and policy review, the facility failed to ensure Certified Nursing Assistants demonstrated competency during care to ensure resident safety for 1 of 4 sampled residents reviewed for accidents. (Resident #50) The findings include: An observation of Resident #50 was conducted on 12/2/25 at 10:12 AM. During the resident's interview, the resident initiated her call light and stated her neck was itching. Employee C (Certified Nursing Assistant) answered the resident's call light. Resident #50 asked Employee C to obtain a tube of cream from her bedside nightstand drawer and apply the cream to her neck. Employee C obtained the tube of Clotrimazole-Betamethasone Dipropionate cream 1- 0.05% and applied the cream to the resident's neck. Clotrimazole-Betamethasone Dipropionate cream is a prescription topical cream used to treat fungal skin infections. A review of Resident #50's current physician ordered medications revealed an order dated 11/25/25 for Clotrimazole-Betamethasone External Cream 1-0.05 % (Clotrimazole w/ Betamethasone) - apply to rash topically every day and evening shift. Apply to neck, back, arms, and upper chest. An interview was conducted with Employee C on 12/2/25 at 2:35 PM. Employee C stated the nurses in the facility allow her to apply prescription creams to residents. She stated she knew she was not supposed to do so. An interview was conducted with the Director of Nursing (DON) on 12/2/25 at 2:38 PM. The DON stated she expects the nurses to apply prescription creams to residents and keep them in the treatment cart. Review of the undated facility policy for Administration of Drugs revealed: Drugs and biologicals may be administered only by licensed physicians, licensed registered or practical nursing personnel, or by other personnel who are duly authorized to perform such services under state law.

Based upon observations, interviews and policy and record review, the facility failed to ensure accommodation of needs in 6 out of 20 residents rooms related to call lights being in reach of the residents. (Rooms 416, 502, 412, 505, 513, and 515)The findings include:On 9/24/25 at 10:15 AM, a tour of the facility was conducted, and the following observations were made on the 400-500 nursing care units concerning call lights being out of reach of the residents while in their rooms: In room [ROOM NUMBER], a resident was lying in their bed and the call light was positioned hanging on the wall above his bed, out of his reach.In room [ROOM NUMBER], the resident call light was hanging on the wall in between the A and B beds while the residents were in their room laying in their beds, out of reach.In room [ROOM NUMBER], the call light was positioned at the head of bed and tucked under the resident's pillow, out of reach of the resident laying on her right side facing the window.In room [ROOM NUMBER], the call light for the resident residing in the B-bed was observed hanging on the wall out of reach of the resident lying in their bed.In room [ROOM NUMBER], the A-bed call light was observed clipped to a call light box on the wall in between the A and B beds, out of reach of the resident while lying in his bed.In room [ROOM NUMBER], a call light was observed at the top of the bed hanging on the bedrail, out of the resident's reach while the resident was lying in bed. An observation was made at 2:00 pm on the same unit and the same rooms. In every case, the call lights were still placed out of the residents' reach. An interview was conducted with Staff Member A (Social Services Assistant) on 9/24/25 at approximately 2:00 pm, who revealed all the managers do a call light audit at least once a month. That is something the Administrator put in place a while back to ensure the lights are being monitored and answered timely and appropriately. An interview was performed with the Social Services Director on 9/24/25 at around 2:30 pm. She stated that there have been concerns voiced in regard to call lights not being answered in a timely manner and all the department head managers are asked to complete call light audits monthly at random periods of time to ensure they are being answered and promptly and to ensure call bells are placed within the reach of residents. An interview was conducted with the Administrator on 9/24/25 at 3:00 pm, who states call light audits were implemented due to concerns voiced by residents and family representatives. The department head managers are asked to perform call light checks on a weekly and monthly basis to ensure call lights are being answered timely.A follow up interview was conducted with the Director of Nursing on 9/24/25. She revealed that education in-services are completed with staff on call lights and answering call lights in a timely manner. When she has conducted her audits, she has not visually seen call lights deliberately placed out of reach of residents but voiced the only ones that she has seen has been clipped to privacy curtains when housekeeping has been in the room cleaning. A review of the facility call light policy was conducted and revealed under section key procedural points include when the resident is in bed or confined to a chair be sure the call lights is within easy reach of the resident.

Based on observation, interview, record review, and policy review, the facility failed to ensure accuracy of Preadmission Screening and Resident Review (PASRR) forms for 1 of 1 residents sampled for PASRR review. (Resident #1) The findings included: On 7/29/24, a review of the PASRR from dated 1/13/23 for Resident #1 was conducted. Section A of the form indicated that Resident #1 had a history of Bipolar Disorder and Schizophrenia. The form had no additional information regarding functional criteria, services, or basis for findings. The PASRR form indicated that Resident#1's admission was not a provisional admission. Section IV of the form indicated that Resident #1 had no diagnosis or suspicion of serious mental illness or mental disability and a level II PASRR was not required. The form was signed by a hospital staff member and dated 1/13/23. On 7/30/24, a review of Resident #1's records was conducted. The diagnosis list of Resident #1 revealed that she was admitted on [DATE] with an admitting diagnosis of paranoid schizophrenia. Bipolar Disorder was also added to the diagnosis list on 1/17/2023. A review of the psychiatric evaluation of Resident #1, dated 7/25/24, indicated that the resident had an ongoing history of paranoid schizophrenia and bipolar disorder with a depressed mood. Resident #1 had been prescribed psychotropic medications for the management of paranoid schizophrenia and bipolar disorder. A review of the Care Plan revealed that Resident #1 had a diagnosis of paranoid schizophrenia with periods of agitation and yelling out. The care plan indicated that Resident #1 can become combative and refuse care at times. The goal listed on the care plan was that she would have no behaviors that prevent the delivery of care through the next review date. The review of the Social Service Quarterly Assessment note dated 7/10/24 indicated that the resident experienced delirium in the forms of inattention and disorganized thinking. The entry indicated that Resident #1 often had difficulty tracking conversations and derailment was evidenced, many questions were answered tangentially as she provided irrelevant responses to questions. Her speech is sometimes presented as gibberish. The note indicated that Resident #1's legal guardian was contacted. Current psychotropic medications and results of recent screenings for depression were reviewed with the guardian. On 08/01/24 at approximately 9:29 AM, an interview was conducted with the Director of Admissions and Marketing (DOAM). She was asked to review the PASRR form, diagnosis list, and record Resident #1. The DOAM verified that Resident #1 was admitted as a long-term admission and the PASRR dated 1/13/23 was that the most recent. The DOAM explained that she relies on the admitting hospital to let her know her if a PASRR level II is indicated. She was asked to describe the process for review of PASRR forms received from the hospital for accuracy. The DOAM explained that she would consult the Director of Nursing (DON) for any questions regarding PASRR screenings for newly admitted residents. She indicated that she has not had to request a resident review/evaluation request for any resident since starting in the position in August 2023. A copy of the facility policy for PASRR forms was requested. On 8/1/24 at approximately 9:58 AM, an interview was conducted with the Regional Nurse Consultant (RNC) regarding the PASRR for Resident #1. She explained that PASRR forms should be corrected if an error is identified. New admissions are reviewed in a clinical meeting. If a PASRR level II is indicated, the DON would complete and submit a PASRR review request. The RNC was asked if Resident #1 should have had a PASRR level II requested. She indicated that the PASRR form would be corrected.

Based on interview and record review, the facility failed to ensure that orders for as needed (PRN) psychotropic medications (other than antipsychotics) indicated a duration for order for 6 of 8 residents reviewed for psychiatric medications. (Residents #398, #399, #56, #68, #73, and #66) The findings include: Resident #389 A review of Resident #389's physician orders revealed an order for Lorazepam (a psychotropic mediation used to treat anxiety) 0.5 milligrams (mg) every two hours as needed for anxiety, with no end date. A review of recommendations from the consulting Pharmacist revealed a recommendation dated 4/6/2023 stating, Centers for Medicare and Medicaid Services (CMS) regulatory limit of 1 days on PRN psychotropic drugs - Lorazepam 0.5mg every two hours prn for anxiety, without a stop date. Use beyond 14 days will require additional documentation establishing a continued need for the drug order. PRN psychotropics documentation allowing for extension of the order beyond 14 days if the attending physician or prescribing practitioner: 1) Believes it is appropriate to extend the order -and 2) Documents clinical rationale for the extension -and 3) provides a specific duration of use. The recommendation had not been reviewed at the time of the survey. Resident #399 A review of physician orders revealed an order with no end date for Xanax, a psychotropic mediation used to treat anxiety, 0.5 mg every 6 hours as needed for anxiety. A review of recommendations from the consulting Pharmacist revealed a recommendation dated 4/10/2023, which stated, RE: CMS regulatory limit of 14 days on PRN psychotropic drugs - Xanax 0.5mg every 6 hours as needed for anxiety, without a stop date. Use beyond 14 days will require additional documentation establishing a continued need for the drug order. PRN psychotropics documentation allowing for extension of the order beyond 1 days if the attending physician or prescribing practitioner: 1) Believes it is appropriate to extend the order -and 2) Documents clinical rationale for the extension -and 3) provides a specific duration of use. The physician's response documented on the form was,Continue Xanax due to continued severe anxiety, but still did not address the specific duration of use. Resident #56 A review of physician orders revealed an order dated 3/4/2023, for Lorazepam 1 MG by mouth every 6 hours as needed for anxiety, with no end date. A review of recommendations from the consulting Pharmacist revealed a recommendation from 2/10/2023, which stated, CMS regulatory limit of 1 days on PRN psychotropic drugs - Ativan (the name brand of the drug Lorazepam) 1 mg every 6 hours PRN without a stop date. Use beyond 14 days will require additional documentation establishing a continued need for the drug order. PRN psychotropics documentation allowing for extension of the order beyond 1 days if the attending physician or prescribing practitioner: 1) Believes it is appropriate to extend the order -and 2) Documents clinical rationale for the extension -and 3) provides a specific duration of use. At the time the physician's response was to discontinue the medication. However, the medication was then ordered again on 3/4/2023 with no end date. Resident #68 A review of physician orders revealed an order, dated 1/9/2023, for Lorazepam 1 mg by mouth every 12 hours as needed for anxiety, with no end date. A review of recommendations from the consulting Pharmacist revealed a recommendation from 2/10/2023, which stated, CMS REGULATORY LIMIT OF 14 DAYS ON PRN PSYCHOTROPIC DRUGS (NON-ANTIPSYCHOTIC) - Lorazepam 1 mg by mouth every 12 hours as needed for anxiety, without a stop date. Use beyond 14 days, will require documentation establishing a continued need for the drug order. PRN psychotropics (excluding antipsychotics) documentation allowing for extension of the order beyond 14 days if the attending physician or prescribing practitioner: 1) believes it is appropriate to extend the order -and 2) documents clinical rationale for the extension -and 3) provides a specific duration of use Please address this order for continued use or consider discontinuing based on recent use. With non-antipsychotic PRN drugs, it only has to be documented once. The physician response was documented as, Patient to continue medication as ordered. It is effective at preventing symptoms. Re-evaluate in 3 months. On 4/20/23 at 10:14 AM, an interview was conducted with the Director of Nursing (DON). She was asked to verify the orders for Residents #398, #399, #56, #68, #73, and #66. At that time she confirmed that all of these residents had orders for as needed psychotropic (other than antipsychotics) medications with no stop dates. A review was conducted of the facility's policy titled, Psychopharmacologic Drugs, with no effective or review dates noted on the form. Under the section titled, Procedural Guidelines, item number 9 the policy states, PRN (as needed) orders for psychotropic drugs are limited to 14 days. Excluding antipsychotic medications, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. 41185 On 04/20/2023, during the record review for Resident #66, medication orders revealed Lorazepam give 0.5mg two tablets every 6 hours as needed for agitation and prior to showers for 30 days was ordered by the Psychiatric Advance Registered Nurse Practitioner (APRN) on 01/20/2023. No end date was noted. 47847 A review of the handwritten physician's orders revealed an order dated 08/10/2022 for Ativan 2mg Intramuscular Twice a day as needed (PRN) #10. No end date is specified. A review of the active orders in the electronic medical record reveals a physician order on 08/10/2022 for Ativan Solution 2mg/ml (LORazepam) Inject 2mg Intramuscularly every 12 hours as needed for anxiety/agitation- Administer BID PRN, with no end date and marked indefinite. A review of Resident #73's Medication Administration Record (MAR) reveals behavior monitoring for restlessness, agitation, and anxiety. During April 2023, no problematic behaviors were documented being observed. A review of the most recent Consultant Pharmacist Communication to Physician signed and dated 01/25/2023 reveals a recommendation for a Gradual Dose Reduction (GDR) attempt including the medication Ativan 2mg IM q12h PRN. The Physician documented response is, an attempted GDR is likely to result in impairment of function or increased distressed behavior. No further documentation was found to support continuing this PRN order without an end date.

Based on observation, interviews, and record reviews, the facility failed to implement the comprehensive plan of care for 2 of 2 residents reviewed for care plans. (Residents #4 and #74) The findings include: A review of Resident #4's plan of care related to nutritional problems revealed the intervention: Sip cup with meals, Assist with meals. A review of the record for Nutrition Screening & Data Collection for Skilled Nursing Facilities, dated 07/20/2020 and signed by the Certified Dietary Manager and the Registered Dietician, revealed documentation under Nutrition Summary recommending sip cup with lid ordered as adaptive equipment. A review of Occupational Therapy (OT) Notes revealed an encounter from 2/2/23 stating, feeding retraining on snack food for pleasure foods with monitored or moderate assistance for utensils and cup handling. Follow-up documentation on 03/07/23 revealed, that upon discharge from therapy services, Resident #4's eating improved to supervision or touching assistance. Mealtime observations of Resident #4 noted no assistive or adaptive cups being used. On 04/20/23 at 11:50 am, interviews were conducted with Staff G CNA, Staff H CNA, Staff I CNA, and Staff J LPN. They were asked about the intervention of an assistive or adaptive cup in Resident #4's plan of care. All denied that this intervention is being implemented and agreed that, based upon documentation, adaptive cups should be in use. A review of resident #74's plan of care for Risk for Complications Related to Diagnoses revealed the intervention: Monitor for and document any edema. Notify MD. On 04/19/23 at 9:40 am, an observation was made of Staff K, RN assessing Resident #74 in which 3+ pitting edema was noted to bilateral lower extremities. When Staff K RN was asked how she would proceed with care or notification to provider after assessment findings, Employee K RN stated, Nothing, I mean I'll keep watching her. When Staff K RN was asked directly if she would report the new findings and reports of edema by the resident to the doctor or provider, Staff K RN stated, No and proceeded to walk away from the conversation. On 04/19/2023 at 5:10 pm, an interview was conducted with the Director of Nursing (DON). When asked about the concerns with the intervention in Resident #74's plan of care, she reported that her expectation is the doctor should be notified and the assessment should be documented. The DON agreed with surveyor findings.

Based on observations, interviews, and record reviews, the facility failed to provide appropriate services, equipment, and assistance to a resident admitted with limited range of motion (ROM) for 1 of 1 persons reviewed for mobility. (Resident #29) The findings were: On 04/17/2023 at 2:51 pm, an observation was made of Resident #29 with contracture to left hand and wrist. An interview was conducted with Resident #29 which verified the contracture was present since being admitted into the facility. Resident #29 stated no therapy assessment, treatment, or splinting for this diagnosis has been performed since admission. Resident #29 stated he requested therapy services to the physician. A review of Resident #29's record reveals the resident was admitted into the facility on [DATE] with a diagnosis of Left Wrist Contracture, Left Hand Contracture, and Hemiplegia/Hemiparesis following Cerebral Infarction affecting left non-dominant side. On 04/19/2023 at 11:00 am, an interview was conducted with the Rehabiliation Director. She was asked to review all evaluations and notes from physical therapy (PT), occupational therapy (OT) and restorative therapy. She confirmed no documentation existed of recent restorative therapy. She also confirmed PT & OT assessments and evaluations did not address residents limited ROM to left hand/wrist contracture. A review of the resident's active orders reveals an order placed on 03/27/2023 for Restorative Nursing Program- LE active ROM exercise in seated of laying-marching/knee binds, straight leg raises, ankle pumps. Ambulate with hemi-walker 30 feet x2 CGA-stand on left side, 3 x per week for 6 weeks. A review of the hard chart orders reveal a physician's interim/telephone order for Restorative Eval for Services dated 03/23/2023. On 04/19/2023 at 10:30 am, a review of the residents Treatment Administration Record (TAR) for the month of April shows no documentation of restorative nursing services. On 04/20/2023 at 12:15 pm, an interview was conducted with the Director of Nursing in which the Policy for Restorative Nursing Program was reviewed. She was asked about the physician orders, lack of documentation in the TAR, and the restorative nurse's ability for assessing someone with a contracture. She confirmed that treatment should be provided for a resident with these diagnoses to prevent a decline in ROM/mobility. She was unable to find proper documentation that the order was carried out prior to being notified of this surveyor's concerns by management on 04/19/2023 and agreed with the surveyor's findings.

Based on interview and clinical record review, the facility failed ensure the residents received a physician's visit every 60 days for 1 of 25 residents reviewed. (Resident #70) The findings include: A record review of Resident #70 on 4/19/23 noted that that resident had not received a visit from a physician since 10/26/22. In an interview with the Director of Nursing (DON) on 04/19/23 at 04:06 PM, the DON was asked if Resident #70 had received a physician's visit between November 2022 and present. The DON could not find any documented provider visits. It appeared that Resident #70 was mistakenly discharged from the computer documentation system the providers utilize. The DON validated that there had been no documented physician visits since 10/26/22. The DON stated she spoke with the lead provider at the practice, and he showed Resident #70 as discharged in his system. The DON stated there was some sort of glitch in the computer system they are trying to figure out. The DON stated that they believe that when the nurse practitioner discontinued her service with the patient when Resident #70 was enrolled in hospice, it also inadvertently deleted out of the lead provider's system. Based on their evaluation of Resident #70, the resident did not miss any medications or have any significant change in her status during this time period. On 04/20/23 10:06 AM, a policy that outlines the required frequency of visits from the provider was requested. The DON stated they did not have a policy; they just follow the regulation.

Based on record review and staff interview the facility failed to provide respiratory care in accordance with the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident #137 Review of Resident #137's record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] = Clear; 2= Rales; 3= Rhonchi; 4= Wheeze; 5= Rub; 6= Diminished. Document Location: A= Anterior; P= Posterior, R= Right; L=Lower; B= Bilateral. Review of the Medication Administration Record (MAR) for November 2021 revealed the area for documenting lung sounds (LS) was blank from 11/11/2021 through 11/16/2021. On 11/17/2021 at approximately 10:06 AM, an interview was conducted with Staff A, Registered Nurse (RN). RN A observed the November 2021 MAR and stated no lung sounds were documented as ordered in the space for them on the MAR. Resident #78 On 11/17/2021 at approximately 9:39 AM, an observation was made of Resident #78 during which the resident was observed sitting up in a chair wearing oxygen (O2) via nasal cannula, the O2 was set at 2 liters. Upon observation of nasal cannula tubing, a date of 10/23/2021 was written on the tubing. A review of the resident's care plan initiated 3/19/2021 revealed at risk for complications related to altered mental status, urinary tract infection, diabetes mellitus 2, [CONDITION(S)], [CONDITION(S)], chronic kidney disease stage 3, hypertension, [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. Further review revealed interventions revised on 6/1/2021 included O2 - check saturation every shift as ordered and change O2 tubing/humidifier every week as ordered. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Treatment Administration Record (TAR) for October 2021 and November 2021 demonstrated that the nasal cannula tubing had been changed weekly on 10/8/2021, 10/15/2021, 10/22/2021, 10/29/2021, 11/5/2021 and 11/12/2021. On 11/17/2021 at approximately 1:10 PM, an interview was conducted with Staff F, a Registered Nurse (RN), during which she was shown the date written on the oxygen tubing in Resident #78's room. RN F stated that it did not appear as though the tubing had been changed in a few weeks. When asked if she agreed that the tubing had not been changed RN F stated, Yes. On 11/17/2021 at approximately 1:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she had heard about the concern with a resident's oxygen tubing not being changed. She said the standard practice is that it is changed out weekly, and the date it is changed is written on the tubing. This surveyor stated the date on the tubing for Resident #78 was 10/23/2021 and it is now 11/17/2021. She stated that the tubing should have been changed and it was not. When asked if she was aware that the documentation in the TAR stated that it had been changed weekly, she stated she was aware. The surveyor asked if she could confirm that based on a tubing date of 10/23/2021 that the tubing had not been changed on the date documented on the TAR. She replied, Yes. A review of the policy titled, Departmental (Respiratory Therapy) - Prevention of Infection revised November 2011 revealed under Infection Control Considerations Related to Oxygen Administration, Change the oxygen cannulae and tubing every seven (7) days, or as needed. A review of the policy titled NURSING - Documentation, Clinical effective January 1999 and revised April 2019 revealed under Documentation Guidelines, 1. All entries in the medical record should be accurate, legible, dated, and timed.

Based on observations, record review, staff interview and policy review, the facility failed to document the medical symptoms that required the use of a physical restraint and failed to demonstrate attempts of less restrictive interventions prior to the initiation of a restraint for 1 of 1 sampled resident (#32) with restraints. The findings include: Resident #32 was first observed on 11/15/2021 at approximately 12:30 PM. Additional observations of Resident #32 were conducted on 11/16/2021 at 10:34 AM, 1:32 PM and 3:04 PM, and on 11/17/2021 at 12:19 PM and 1:07 PM. During each observation the resident was reclined in a geri-chair. An interview was conducted with Staff B, Certified Nursing Assistant (CNA) and Staff C, Registered Nurse (RN) on 11/15/2021 at 2:10 PM. RN C stated the resident is kept in the reclined position because the resident would get up independently. CNA B stated the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . A subsequent interview with RN C was conducted on 11/17/2021 at 11:12 AM. RN C stated the resident is routinely reclined in the geri-chair after dressing. RN C confirmed the resident was capable of standing independently and the resident is repositioned by staff when the resident complains of pain or needs to use the bathroom. An interview with Staff D, Physical Therapist (PT), was conducted on 11/17/2021 at 11:26 AM. PT D stated the resident presented to physical therapy in a reclined geri-chair. PT D advised that the resident is, impulsive and may hurt herself if she gets up. A subsequent interview with PT D was conducted on 11/18/2021 at 10:30 AM. PT D stated she has observed the resident attempting to get up by pulling on the side hand rails of the geri-chair and confirmed reclining the chair makes it difficult for the resident to get up. An interview was conducted with the Director of Nursing (DON) on 11/18/2021 at 10:40 AM. The DON confirmed witnessing the resident attempt to get out of the geri-chair by scooting forward in the chair causing the footrest to lower and would also throw her legs over the side of the chair in attempts to exit the chair. She confirmed reclining the chair made it difficult for the resident to get out of the chair. Review of the resident's clinical record revealed the resident was admitted on [DATE] and was first evaluated by physical therapy on 9/1/2021 with no mention of the geri-chair. The record contained no documentation from physical therapy regarding the need for the resident to be reclined in the geri-chair nor interventions attempted prior to implementing the practice of reclined positioning. There was no documented evaluation for the use of the reclining geri-chair and no physician order authorizing the use of the reclining geri-chair. The facility's Restorative - Physical Restraint Program policy effective 10/2010 and revised 12/2013 stated the facility will not impose any use of physical restraint on any resident for discipline or convenience. The policy further stated devices meeting physical restraints (including chairs) that prevent a resident from rising may be used only after a thorough evaluation of functional and cognitive abilities and the attending physician will provide a complete order for the restraint.

Based on interview with the Wound Care Nurse and review of pressure ulcer assessments, the resident care plan and facility policy, the facility failed to implement the plan of care 1 of 1 resident (#25) reviewed for pressure ulcers. The findings include: On 11/15/2021 at 11:13 AM during initial sampling it was noted that Resident #25 had doctor's orders for wound care to the coccyx (tailbone) and heels. A review was conducted of Resident #25's plan of care, which revealed a care plan that was initiated on 4/27/2020 and last revised on 9/2/2021 with the focus statement, The resident has actual impairment to skin integrity related to decreased mobility, incontinence of bowel and bladder, [CONDITION(S)] (swelling) to both legs. Squamous cell cancer of the skin, a stage 2 pressure injury to coccyx and a right heel pressure injury. Interventions listed included, weekly skin assessment and documentation by licensed nurse, notify the doctor at earliest sign of skin breakdown. The date initiated was 4/27/2020 and last revision on 6/01/2021. Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review was conducted of wound/skin assessments, which revealed the following: For the wound to the coccyx, assessments were documented on 8/30/2021, 9/4/2021, 9/27/2021, 11/3/2021 and 11/11/2021. The assessment conducted on 9/4/2021 did not include the measurements of the wound. Twenty-three days passed until the next assessment was documented. For the wound to the heel, assessments were documented on 8/30/2021, 9/4/2021, 9/27/2021, 11/3/2021 and 11/11/2021. The assessment conducted on 9/4/2021 did not include the measurements of the wound. Twenty-three days passed until the next assessment was documented. The assessment documented on 11/11/2021 did not contain any assessment information as the form was blank. On 11/17/2021 at 2:33 PM an interview was conducted with the Wound Care Nurse. The surveyor asked if there were paper records for pressure ulcer assessments. She replied that all assessments were in the electronic medical record. When asked about gaps in the weekly assessments, she stated that due to staffing issues brought about by COVID-19 (Coronavirus Disease 2019), she was working on a medication cart 2-3 times per week at times. She further stated that all of the wound care is being provided, but she was not able to work a medication cart, do wound care and get the paperwork completed, so she prioritized providing care to the residents over the paperwork. A review was conducted of the Skin care and Wound Management - Manage Wound Care policy effective February 2007 which revealed The facility will manage wound care based upon current standards of practice. Item number eight (8), under Procedure stated, Pressure related wounds will be documented by the nurse using the 'Skin Grid - Pressure' form at the time of discovery and every week thereafter until healed.

Based on observation, staff interview, and review of FDA (Food and Drug Administration) standards of practice, the facility failed to ensure staff served food in a sanitary manner during 1 of 2 meal observations. (Lunch 11/15/2021) The findings include: An observation of the lunch meal on the front 20 hall was conducted on 11/15/2021 at approximately 11:58 AM. Staff E, Certified Nursing Assistant (CNA), was observed to serve Resident #138 her meal. CNA E used her bare, ungloved hands to pull the resident's roll apart to butter the roll. An interview was conducted with CNA E on 11/18/2021 at approximately 8:58 AM. She stated you must wash your hands prior to handling the resident's food. She confirmed she handles the food with her bare hands as long as she has washed her hands. An interview was conducted with the Director of Nursing (DON) on 11/18/2021 at approximately 9:01 AM. The DON stated the facility expects staff will not handle food with bare hands; they should use a fork and knife or gloves if they handle food. A record review of the FDA U.S. Food and Drug Administration Employee Health and Personal Hygiene Handbook current as of 10/26/2020 and accessed on 12/6/2021 via https://www.fda.gov/food/retail-food-industryregulatory-assistance-training/retail-food-protection-employee-health-and-personal-hygiene-handbook revealed under Employee Health and Highly Susceptible Populations that managers and food employees must take the needed precautions to prevent the spread of infectious pathogens and viruses to highly susceptible populations (HSP). The handbook stated that a population is highly susceptible to foodborne illness if it is in a health care or nursing home setting. Further review revealed employees can take the following steps to prevent the spread of disease in a food establishment that serves a HSP: Use single-use gloves for one task. Do not touch RTE (ready-to-eat) foods with bare hands, and minimize bare hand contact with exposed food that is not RTE.

Based on interviews, and record review, the facility failed to determine on admission whether residents had advance directives, and if not, determine whether the resident wished to formulate an advance directive for 1 of 1 sampled residents reviewed for advanced directive (Resident #58). The findings include: On 12/01/20 a record review was conducted for resident #58 which revealed the resident did not have documentation of an Advanced Directive (AD). On 12/01/20 at approximately 10:25 AM, an interview was conducted with Staff member C, a Registered Nurse (RN), who was asked if she could locate resident #58's AD within the record. After reviewing the record staff member C confirmed that she could not find a copy of the AD. She then stated that she would ask the Social Services Director. On 12/01/20 at approximately 10:30 AM, an interview was conducted with the Social Services Director who stated that this was her error and that normally admissions complete the paperwork but she had not followed up to ensure the documentation of the AD was complete and in the resident's record.

Based on interviews, observations, and record review, the facility failed to honor the Resident's right to receive food choices of preference for 1 of 2 (#76). The findings include: On 11/30/2020 at approximately 12:36 PM, an interview was conducted with Resident #76 who stated they have been receiving food items that were listed on the dislike food list. On 11/30/2020 at approximately 12:46 PM, Resident #76 was observed to receive broccoli, a food item listed under disliked food list. Broccoli was clearly written on the meal ticket, under Food dislikes column (Photographic evidence obtained). On 12/01/2020 at approximately 2:57 PM, an interview was conducted with the Food Services Director. The Director stated the facility had 4 (four) staff members checking trays prior to delivery to residents: a cook, two kitchen aids, and a Certified Nurse Assistant (CNA). On 12/2/2020 at approximately 2:14 PM, Facility's policy: Alternate Food Choices and Substitutions and Honoring Preferences dated 2016 was reviewed. This Policy stated: the facility also supports resident choice and allowing Residents to choose foods by honoring their food preferences. On 12/3/2020 at approximately 10:54 AM, a follow up interview was conducted with the Food Services Director. The Director stated that at least two staff members should have checked the tray's food items but they missed it. The resident should not have gotten the broccoli.

Based on staff and resident interview, clinical record review, and policy review the facility failed to properly document influenza vaccine education on the benefits and potential side effects of influenza vaccine in 5 of 5 residents selected for medical record review. The findings include: In record review was conducted for residents 3, 31, 40, 52, and 59, which revealed that there was no documentation of influenza vaccine education regarding the benefits and potential side effects of the immunization. On 12/3/2020 at approximately 10:08 AM, an interview was conducted with resident #52 during which the resident was asked if she recalled getting her flu immunization. She stated she received it last month (October). When asked if the facility had provided education on the benefits and risks of the vaccine. Resident #52 stated They just asked me if I wanted it and gave it to me. At this time Resident #52 was asked if she recalled receiving verbal or written education describing the vaccine to which she responded that no education was received. On 12/3/20 at approximately 10:45 AM, an interview was conducted with the Risk Manager, who was advised that there was no evidence of influenza vaccine education in the medical record of 5 of 5 selected residents. (3, 40, 31, 52, 59) as per the facility Influenza Vaccine policy statement. The Risk Manager advised that the best place would be in the progress notes or nursing notes, and if it wasn't there, it likely wasn't documented. A review of the facility policy titled Influenza Vaccine: Policy Statement, dated August 2016, outlined the following: 4. Prior to the vaccination, the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's/employee's medical record.

Based on observations and interviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 4 residents sampled for evnironment (#31). The findings include: On 11/30/2020 at approximately 11:30 AM, an observation was made of resident #31, during which the resident was resting in her room in a Geri-chair that had torn material on the arm rests that exposed the chair's wood frame. Also observed was the resident's tube feeding infusion pump that had exposed wires on the plug with surgical tape wrapped around them. On 12/1/2020 at approximately 07:35 AM, a follow up observation was made of resident #31 who was agian noted to be in her room in the torn Geri-chair, with the same tube feeding pump with the exposed cable wires wrapped with surgical tape. On 12/1/2020 at approximately 12:50 PM, an interview was conducted with the Director of Nursing (DON). Who as asked to observe resident #31's geri chair and infusion pump. After the observation she stated, that is not good and this chair needs to be removed, not acceptable. The DON immediately informed the Administrator of these concerns. The administrator walked with the surveyor and DON to resident #31's room and verified the chair was unacceptable and needed to be removed.

Based on staff interviews, clinical record review, incident report review and policy review, the facility failed to immediately identify and report allegations of neglect to both the state survey agency and the state abuse agency for 2 of 4 sampled residents (#1 & #2). The facility failed to provide supervision for Resident #1 who had known wandering behaviors, impaired decision-making skills, short term and long-term memory impairment, was difficult to redirect and had known exit seeking behaviors. During the evening of 12/12/19, the facility staff were unaware the resident was missing from the facility until she was observed by staff knocking on the outside of the Therapy room exit door. The facility failed to timely report an allegation of neglect related to a significant injury of unknown source (a [MEDICAL CONDITION] leg bone near the hip) for resident #2. On [DATE], resident #2 was observed yelling out in pain. The resident's left hip area was swollen, and she was drawing her leg up. The resident was transferred to a local hospital where the upper leg fracture was identified. The facility did not report the incident until 1/17/2020, 2 weeks later. The facility's failure to identify and immediately report allegations of neglect could cause residents to suffer further abuse and neglect, and serious bodily injury. This situation resulted in findings of Immediate Jeopardy at a scope and severity of isolated (J). The facility Administrator, Risk Manager and Regional Director were notified of the findings of Immediate Jeopardy on [DATE] at 4:55 PM. The Immediate Jeopardy is ongoing. Cross reference F610, F689 and F[AGE]7. The findings include: Resident #1: According to the nurse's notes on 12/12/19 at 5:15 PM, nursing staff observed Resident #1 outside the building knocking on the exit door by therapy and waving at staff. Upon opening the door, Resident #1 came inside and the alarm immediately sounded due to resident's code alert bracelet. The resident was assisted to the dining room since it was supper time, and provided with a 1:1 staff member due to the unknown exit from the facility. The Administrator, Director of Nursing (DON), Risk Manager (RM), house supervisor, family, and the physician were all notified of the resident's elopement out of the facility. Both a 1:1 and every 15-minute checks were initiated and the code alert bracelet on the right ankle was changed even though it was functioning. The nurses notes continued to document 1:1 supervision through 12/13/19 at 3:00 PM. Prior to this elopement event, the nurses notes reflect that Resident #1 was having behaviors and agitation throughout that day and staff were having difficulty re-directing. At 3:30 PM, nursing documented that Resident #1 continues to pace in hallway.she is not agitated at this time, but unable to redirect by staff. The facility did not complete or submit a federal immediate report regarding the elopement to the state agency nor was the state abuse and neglect agency notified. The facility completed a state required adverse incident report on [DATE], 8 days after the event. The incident investigation documented, Resident observed knocking on outside of therapy hall door. When door was opened by staff, resident came in and alarm immediately sounded due to resident's code alert transmitter. No injuries were noted. The facility's analysis of the incident: Approximately five minutes before Resident #1 was knocking on the therapy window in the interior hallway and was escorted to the nurse's desk where she was standing with several staff members. She had not been noted approaching any exit. The incident investigation information did not indicate how the facility determined the missing timeframe of 5 minutes. The incident report did not mention the resident's cognitive status, the outdoor temperature, the weather, nor did it describe how the resident exited the building. Clinical record review revealed that Resident #1 was admitted to the facility 10/2/19. A review of the Minimum Data Set (MDS) quarterly report dated 1/2/2020 indicated the resident has a Brief Interview for Mental Status (BI[CONDITION]) score of 00 which indicated severe cognitive impairment. Section EO200, Behavioral Symptoms, indicated daily wandering behaviors. Section G, Functional Status, indicated Resident #1 walked without assistance. Pertinent active [DIAGNOSES REDACTED]. She took anti-anxiety and anti-depressant medications. Section PO200, Alarms, indicated a wander/elopement alarm was used daily. She had both a pre and post admission elopement assessment completed prior to admission on [DATE] and again on [DATE]. On both occasions, Resident #1 was determined to be at risk for elopement. A care plan was initiated on 10/11/19 regarding the risk for elopement, and included: wanders in facility daily at times into other resident's rooms with interventions; redirect resident when attempting to go outside facility or into other resident rooms; implement use of wander guard bracelet; check and change bracelet per policy; take resident for supervised walks and added intervention dated 1/13/20 1:1 staff during 3:00 PM - 11:00 PM shift. The facility's elopement policy, Risk Management-Missing Resident Elopement, dated April 2006 with revision date November 2013, was reviewed. The second sentence of the policy identified that elopement occurs when a resident who needs supervision leaves a safe area without supervision. The surveyor interviewed the Risk Manager on [DATE]20 at 4:58 PM. The surveyor asked her if she had any witness statements or a timeline for the events included in the elopement investigation. The Risk Manager replied, No, I just typed it up as I did it. The surveyor asked her why a Federal Immediate report of neglect was not filed and she responded, Resident #1 had been seen a few minutes before, I did not think there was enough time to be considered unsafe. The surveyor reminded the Risk Manager about the street in front of the building, and the river behind the building within 3/10 of a mile. The surveyor asked the Risk Manager, with those factors in mind, if she thought the resident was unsafe. The Risk Manager stated that she had not thought of that. On 2/20/2020 at approximately 9:00AM, both the Risk Manager (RM) and the Administrator asked the surveyor why neglect should have been reported. The surveyor explained the need to report neglect as well as abuse to AHCA on via a Federal Immediate report, and to the state abuse agency. The Director of Nursing (DON) was interviewed on 2/20/2020 at 11:17 AM about the timeline for the elopement events. The DON said she was in the building until about 5:00 or 5:05 PM and left about the same time as the Social Worker (SW) on 12/12/19. The DON said that she walked to her car and drove past the therapy door. Resident #1 was not outside the door at that time. An interview was conducted with the SW on 2/20/2020 at 11:22 AM. The SW stated she went outside just behind the DON. She said she observed Resident #1 outside with a nurse and a certified nursing assistant. The staff waved me on past (Resident #1) because they knew they would have a hard time getting her back in if I was there. The surveyor asked both the SW and DON if they made a formal statement to the RM and both said they had not. A follow-up interview was conducted with the Administrator at 11:27 AM on 2/20/2020. The Administrator stated, Do you now see why we do not think it was neglect and that she went out the therapy door? The RM may not have recorded the information accurately. Resident #2: The Nurse's Notes were review for Resident #2. On 12/26/19 at 5:30 AM, a nurse documented that the physician was notified that resident #2 was discovered sitting at the foot of the bed during the 3:00 PM - 11:00PM shift on 12/25/19. The resident sustained [REDACTED]. The physician ordered an X-ray of the spine at that time to rule out any fractures. The next nursing note regarding resident #2 was on 1/3/20 at 8:15 AM which documented that resident #2 was lying in bed on right side hollering out with severe pain. Resident #2 complained of pain when any attempt was made to move the left lower extremity (left leg). There was 3+ [MEDICAL CONDITION] noted to the upper leg (moderate to severe [MEDICAL CONDITION] where finger pressure leaves a 4-8 millimeter dent). The nurse documented, no recent reports of any falls or injuries since last documented incident of 12/25/19. The physician was notified and orders received to transfer the resident to the hospital for X-rays of the left hip and leg to rule out fracture. A review of a Nursing Home Federal Report filed on 1/17/2020, 14 days after the fracture of unknown source was found, indicated resident #2 was found on [DATE] at 8:15 AM to have swelling and pain of the lower left leg. The report stated an x-ray performed indicated an intertrochanteric fracture with a subtrochanteric fracture line extension (a [MEDICAL CONDITION] leg bone near the hip). In an interview with the Administrator and the Risk Manager on 1/21/2020 at approximately 3:05 PM, the Administrator stated that resident #2 had a fall on 12/25/19 with no pain upon assessment. On [DATE], the Certified Nursing Assistants (CNAs) went to get resident #2 up for the day and she complained of pain in hip, it was swollen, and she was drawing her leg up. Resident #2 had an x-ray and a fracture was identified. On [DATE], the Risk Manager began her investigation and spoke with the 2 shifts prior. The resident had not complained of pain on prior shifts. On 1/17/2020 we filed the state required adverse report for the fracture. In an overabundance of caution, we filed the immediate report which fell under injury of unknown origin, which in hindsight, maybe we shouldn't have. We believe we know the cause now according to the doctor's report. When asked to define an injury of unknown origin, the Risk Manager responded, one that we don't know the cause of. The Risk Manager stated it requires an immediate report and confirmed they did not know the cause of injury on [DATE]. The Administrator stated the timeframe for filing an immediate report is within 24 hours and added the report should have been filed within 24 hours. Neither the Administrator nor the Risk Manager acknowledged the requirement to report abuse or injuries of unknown origin within 2 hours after the allegation was made if serious bodily injury was involved. The facility's abuse and neglect policy, Administrator/Employment Administration/ Nursing Policies/Risk Management / Social Services/Staff Development - Abuse, Neglect, Exploitation, and Misappropriation, with effective date of February 2006 and revision date of December 2016, was reviewed. The policy stated, It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation, and misappropriation and the occurrence of an injury of an unknown source, and to ensure that all alleged violations of Federal and / or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director and the Director of Nursing. The abuse coordinator/designee shall immediately report any alleged violation of abuse, neglect, exploitation, misappropriation or injury of unknown source that meet the reporting criteria to the Agency for Health Care Administration (state survey agency), the Adult Protective Services (state abuse agency), and the local law enforcement if they feel a crime has occurred. Under the procedure, section 6, Reporting, states, All staff members are required to report suspected maltreatment. They may report to the Abuse Hotline; however, they are also obligated to report to a supervisor or department manager so that the resident may immediately be protected. Upon initial investigation, where there is suspicion that ANE (abuse, neglect, exploitation) may have occurred, the Abuse Coordinator/designee shall immediately report the alleged violation to the Agency for Health Care Administration (for the Federal report), Adult Protective Services, and local law enforcement when appropriate. the Risk manager/designee will file the Immediate Federal report with AHCA, and then submit the summary and findings of the investigation with the 5-Day Federal Report. On page 6, the procedure defines Neglect as, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, staff interviews, clinical record review, incident report review and policy review, the facility failed to thoroughly investigate allegations of neglect for 2 of 4 residents reviewed for neglect (#1 & #2). The facility failed to conduct a thorough investigation of an elopement incident to identify the root cause and contributory factors that led to the elopement of Resident #1. On 12/12/19 at approximately 5:15 PM, Resident #1 exited the facility unsupervised. Resident #1 had known wandering behaviors, impaired decision-making skills, short term and long-term memory impairment, was difficult to redirect and had known exit seeking behaviors. The investigation failed to determine how the resident exited the building, the length of time the resident was missing, or a timeline of events. The facility failed to conduct a thorough investigation to identify the root cause for a serious injury of unknown source (broken femur) for resident #2. On 1/3/20 resident #2 was complaining of severe left leg pain which was later determined to be caused by a displaced femur fracture (large leg bone, [MEDICAL CONDITION]). The facility's investigation failed to determine possible causes of this fracture of unknown source. The facility's failure to complete a thorough investigation to determine the root cause of neglect allegations (elopement and femur fracture) could put residents at risk for further abuse, neglect, and serious bodily injuries. This situation resulted in Immediate Jeopardy at a scope and severity of isolated (J). The facility Administrator, Risk Manager and Regional Director were notified of the findings of Immediate Jeopardy on [DATE] at 4:55 PM. The Immediate Jeopardy was ongoing. Cross reference F[AGE]9, F689 and F[AGE]7. The findings include: Resident #1: According to the nurse's notes on 12/12/19 at 5:15 PM, nursing staff observed Resident #1 outside the building knocking on the exit door by therapy and waving at staff. Upon opening the door, Resident #1 came inside and the alarm immediately sounded due to resident's code alert bracelet. The resident was assisted to the dining room since it was supper time, and provided with a 1:1 staff member due to the unknown exit from the facility. The Administrator, Director of Nursing (DON), Risk Manager (RM), house supervisor, family, and the physician were all notified of the resident's elopement out of the facility. Both 1:1 supervision and every 15-minute checks were initiated and the code alert bracelet on the right ankle was changed even though it was functioning. The nurse's notes continued to document 1:1 supervision through 12/13/19 at 3:00 PM. Prior to this elopement event, the nurses notes reflect that Resident #1 was having behaviors and agitation throughout that day and staff were having difficulty re-directing. At 3:30 PM, nursing documented that Resident #1 continues to pace in hallway.she is not agitated at this time, but unable to redirect by staff. Clinical record review revealed that Resident #1 was admitted to the facility 10/2/19. A review of the Minimum Data Set (MDS) quarterly report dated 1/2/2020 indicated the resident has a Brief Interview for Mental Status (BI[CONDITION]) score of 00 which indicated severe cognitive impairment. Section EO200, Behavioral Symptoms, indicated daily wandering behaviors. Section G, Functional Status, indicated Resident #1 walked without assistance. Pertinent active [DIAGNOSES REDACTED]. She took anti-anxiety and anti-depressant medications. Section PO200, Alarms, indicated a wander/elopement alarm was used daily. She has both a pre and post admission elopement assessment completed prior to admission on [DATE] and again on [DATE]. On both occasions, Resident #1 was determined to be at risk for elopement. A care plan was initiated on 10/11/19 regarding the risk for elopement, and included: wanders in facility daily at times into other resident's rooms with interventions; redirect resident when attempting to go outside facility or into other resident rooms; implement use of wander guard bracelet; check and change bracelet per policy; take resident for supervised walks and added intervention dated 1/13/20 1:1 staff during 3:00 PM - 11:00 PM shift. The Risk Manager completed a state required adverse incident report on [DATE], 8 days after the event. The incident investigation form documented, Resident observed knocking on outside of therapy hall door. When door was opened by staff, resident came in and alarm immediately sounded due to resident's code alert transmitter. No injuries were noted. The incident investigation information about the apparent cause documented by the Risk Manager included the following: Approximately 5 minutes before (Resident #1) was knocking on the therapy window in the interior hallway and was escorted to the nurse's desk where she was standing with several staff members. She had not been noted approaching any exit. The incident investigation information did not indicate how the facility determined the missing timeframe of 5 minutes. The incident report did not mention the resident's cognitive status, the outdoor temperature, the weather, nor did it describe how the resident exited the building. The surveyor interviewed the Risk Manager on [DATE]20 at 4:58 PM. The surveyor asked her if she had any written statements or a timeline for the investigation for the elopement. She said, No, I just typed it up as I did it. On [DATE] about 3:00 PM, the surveyor interviewed the Regional Director. The Regional Director stated, yes, there were witness statements regarding the elopement. The Risk Manager must have misunderstood what you were asking for when you were asking for witness statements. The Regional Director asked the Risk Manager for the file regarding the elopement, she checked but did not have a file. The Administrator brought a 4 page file which included 2 undated witness statements, one from the DON and the other by the Social Worker (SW) and a form titled Resident Incident/Accident, Risk Manager's Notes. On [DATE] about 3:20 PM the Risk Manager was shown the statements by the DON and SW regarding the incident. The surveyor asked the Risk Manager, Did you take these statements? and she replied no. The Risk Manager was asked, Have you seen them before? and she again replied no. The investigation documentation provided by the Administrator about the elopement incident of Resident #1 revealed that the investigation was completed by the Risk Manager, and consisted of 4 pages in total. The 1st page was titled, Resident Incident/Accident, Risk Manager's Notes. On this page, the Risk Manager reiterated the incident and listed some immediate interventions. Regarding the incident, the Risk Manager documented, Resident observed knocking on outside door of therapy hall and waving at staff. Upon opening door, she came inside and alarm sounded immediately. Code alert transmitter was on right ankle. The (name) Speech Therapist had taken resident to the nurse's desk approximately 5 minutes before when she was knocking on the interior hallway window to therapy. She stood at the desk with staff who talked about taking her to the supper meal. The 2nd page of the investigation consisted of 6 sentences written by the Risk Manager. The Risk Manager again reiterated the situation and what the Speech Therapist did, and then added additional information that staff Licensed Practical Nurse B (LPN B) reported that (Resident #1) was standing at the nurse's desk with several staff members at 5:10 PM that evening. (Resident #1) was not seen approaching any exit doors. There were no injuries to the resident. The 3rd page of the investigation was an undated witness statement from the SW. The SW documented that on 12/12/19 between approximately 5:00 PM and 5:05 PM she and the DON left the facility for the day. Upon walking out the door, we observed Resident #1 walking in the direction of the rehab hall. I walked directly to my car parked on the side of the building and within 2-3 minutes I drove past the rehab hall door exit where I observed Resident #1 standing outside the side rehab exit door. She had 2 staff members present helping her back into the building. The 4th and final page was an undated witness statement from the DON who concurred that she left with the SW between 5:00 PM and 5:05 PM and that she saw Resident #1 inside turning toward the rehab hall. The DON then wrote, I walked out the door and went to my care. It was raining that night, and I did not see any resident outside by the therapy door when I passed by. There were no further witness statements or indications that additional statements were obtained, nor additional potential witnesses interviewed. The investigation report failed to identify the 2 staff observed outside with Resident #1, as stated by the Social Worker. There were no certified nursing assistant (CNA) interviews included. The report did not determine who else may have been a potential witness. There was no indication that any other staff were interviewed, or that visiting family members or residents were interviewed. According to the weather report the sun set at 4:50 PM on 12/12/19. There was a light rain with thunder at 5:02 PM. The outside temperature was 52 degrees Fahrenheit. Both doors at the front of the building are close to a street which was observed to be busy at 5:30 PM on [DATE]. There was a river 3/10's of a mile away from the facility . An interview was conducted with Employee A Speech Therapist (ST) on [DATE]20 at 4:12 PM. She was asked to recall what happened on the night Resident #1 eloped. She said her peer had left around 5 PM. She said she was keeping Resident #1 busy and she had been with her about an hour before supper. She took her back to the nursing station, but she was back knocking on my window within a couple of minutes. She took the resident back a couple of times to the nurses station. They were getting ready to take her to supper the last time she was taken back. Next, the ST went to the bathroom and moved to the back area of the therapy room to get work done. She heard knocking and kept hearing it. She then saw Employee B LPN (licensed practical nurse) and a CNA letting Resident #1 back into the building. She said she did not hear any alarms and she had no idea how the resident had gotten out of the building. Employee B LPN was interviewed on [DATE] at 4:39 PM. She said it was almost supper time about 5 PM. I left Resident #1 at the nursing station with other staff do go down the therapy hall to answer a call light in room [ROOM NUMBER]. I helped them to the bathroom which took about 5-7 minutes. I came out and heard knocking. The ST and I met in the hallway. Employee B said she opened the door and found Resident #1 outside alone. The last time I had seen her was at the nursing station around 5 PM. She stated, I do not know if she went out the front door with someone. It was not raining or storming that I remember. Resident #1 was dry. Since she was outside alone, yes I would say she was unsafe. I walked to every exit in the building with her to try to figure out which door she went out. I talked to all the staff in the main dining room, and no one had seen her in the dining room. I think maybe a family member let her out the front door. I replaced the code alert on her ankle and put her on 1:1 supervision. The DON was interviewed on 2/20/2020 at 11:17 AM she said she was in the building until 5:00 to 5:05 PM and left about the same time as the SW on 12/12/19. She stated, I walked to my car and drove past the therapy door- Resident #1 was not outside the door. An interview was conducted with the SW, who is related to Resident #1, on 2/20/2020 at 11:22 AM. The SW said she went outside just behind the DON and got into her car. As she was driving past the therapy door, she said she observed (Resident #1) outside with the nurse and certified nursing assistant (CNA). They waved me on past her because they knew they would have a hard time getting her back in. The surveyor asked both the SW and DON if they made a formal statement to the RM and both said they did not. (There was no mention by LPN B either in interview or in her written statement that a CNA was present or that the SW or the DON was seen when she opened the door for Resident #1 to let her back in). The Administrator stated at 11:27 AM on 2/20/2020 and stated, Do you see now why we do not think it was neglect and that she went out the therapy door. The RM may not have recorded the information accurately. Resident #2 The Nurse's Notes were review for Resident #2. On 12/26/19 at 5:30 AM, a nurse documented that the physician was notified that resident #2 was discovered sitting at the foot of the bed during the 3:00 PM - 11:00 PM shift on 12/25/19. The resident sustained [REDACTED]. The physician ordered an X-ray of the spine at that time to rule out any fractures. The next nursing note regarding resident #2 was on 1/3/20 at 8:15 AM where a nurse documented that resident #2 was lying in bed on right side hollering out with severe pain. Resident #2 complained of pain when any attempt was made to move the left lower extremity (left leg). There was 3+ [MEDICAL CONDITION] noted to the upper leg (moderate to severe [MEDICAL CONDITION] where finger pressure leaves a 4-8 millimeter dent). The nurse documented, no recent reports of any falls or injuries since last documented incident of 12/25/19. The physician was notified, and orders received to transfer the resident to the hospital for X-rays of the left hip and leg to rule out fracture. A review of a Nursing Home Federal Report filed on 1/17/2020, 14 days after the fracture of unknown source was found, indicated resident #2 was found on [DATE] at 8:15 AM to have swelling and pain of the lower left leg. The report stated an x-ray performed indicated an intertrochanteric fracture with a subtrochanteric fracture line extension (a [MEDICAL CONDITION] leg bone near the hip). The facility investigation of this injury of unknown source was requested for review. A two page typed document signed by the Risk Manager with no date or time was provided as evidence of investigation of this incident. The document contained summaries of responses from staff member interviews regarding resident #2, and no separate or signed witness statements were provided. The investigation report contained a summary of the discovery of the injury of unknown source, a review of medical records showing past falls in September, October and December 2019, and interviews with 5 LPNs and 4 CNAs. The investigation did not show how the interviewed staff were chosen or when the interviewed staff had last worked with the resident. The report stated that on 1/3/20, Resident #2 was complaining of severe pain with any attempt to move her left lower extremity. The physician was notified and ordered X-rays of the left hip and left leg. Previously on 10/15/19, Resident #2 had pain to the left hip and knee and refused to stand while in therapy. X-rays were ordered at that time, but no acute fractures were seen. On 12/25/19, Resident #2 was found sitting on her floor with an abrasion to the upper mid back and no complaint of pain that that time. The Risk Manager documented, Staff interviews were conducted. (Name of LPN) stated that 1/3/20 was the first day that [MEDICAL CONDITION] was noted to the left lower extremity and that she had never complained of that kind of pain. (Names of 4 additional nurses with no dates of working, shifts or other information provided) all reported that they were not aware of any [MEDICAL CONDITION] to the left leg prior to the morning of 1/3/20. The final paragraph of the investigation contained CNA interviews. (CNA M) stated that (Resident #2) complained of pain to the left leg and swelling was present early in the 11PM - 7AM shift on 1/3/20 and (Resident #2) said 'Oh' when she tried to change her socks and that she told (the 11PM-7 AM nurse on duty, LPN I). When (Resident #2) refused to get up, (LPN I) gave her [MED]. (CNA M) took (CNA N) with her when she tried to get her up for the third time, but there was too much pain and they left her in bed. (CNA N) stated that she went with (CNA M) when she asked for help to get Resident #2 up, but that she complained of pain when they turned her to dress and they left her in bed. CNA O had (Resident #2) on 1/2/20 on the 7AM to 3PM shift and reported that (Resident #2) stood up to go to the bathroom with no complaint of pain. (CNA P) was assigned to (Resident #2) on 1/2/20 on 3PM-11PM shift and stated that she took (Resident #2) to the bathroom, there was no problem getting her on or off the toilet, no complaint of pain and no swelling noted. The facility incident log beginning November 2019 through present was requested on [DATE] for review. The incident log for January 2020 did not contain any entry regarding resident #2. The January incident log had been signed and dated by the Administrator on 2/11/2020. In an interview, the Risk Manager stated on [DATE] at 10:32 AM that the incident log provided to the surveyor on the first day of the survey ([DATE]) was up to date at that time. The Administrator reviewed the document on [DATE] at 3:05 PM and agreed the injury of unknown origin should have been noted on the incident log. In an interview with the Administrator and Risk Manager on 1/21/2020 at approximately 3:05 PM, the Administrator stated on [DATE], the Certified Nursing Assistants (CNAs) went to get resident #2 up for the day and she complained of pain in the hip, it was swollen, and she was drawing her leg up. Resident #2 had an x-ray and a fracture was identified. On [DATE], the Risk Manager began her investigation and spoke with the 2 shifts prior. The resident had not complained of pain on prior shifts. We believe we know the cause now according to the doctor's report which included a [DIAGNOSES REDACTED].#4. There was no documentation provided of an interview with a physician or other practitioner to substantiate the assumption. According to the job description of the Risk Manager, duties of the Risk Manager include, Prepared a weekly 'Risk Management Report' designed to identify risks and report on preventive action plans. Reviews with the Administrator and establishes goals. The report form has areas to document resident concerns such as falls, falls with significant injury, pressure ulcers, UTIs, federal reports filed, hospital discharges et cetera. A review of the weekly risk management report dated [DATE]-[DATE] and [DATE]-1/16/20 were reviewed. The reports did not indicate any significant resident injuries, or reports filed for investigations regarding injury of unknown origin. A risk management report dated 1/17/20-[DATE] identified an immediate report and a federal five-day report both submitted on 1/17/20 for a [MEDICAL CONDITION]. The form identified a representative from the state abuse agency preformed an onsite visit related to the [MEDICAL CONDITION]. The Administrator, director of nursing, and Risk Manager had signed each of the forms. The facility's abuse and neglect policy, Administrator/Employment Administration/ Nursing Policies/Risk Management / Social Services/Staff Development - Abuse, Neglect, Exploitation, and Misappropriation, with effective date of February 2006 and revision date of December 2016 was reviewed. The policy stated, It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation, and misappropriation and the occurrence of an injury of an unknown source, and to ensure that all alleged violations of Federal and / or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director and the Director of Nursing. The Investigation procedure is outlined on page 4, under part 7. Investigation: A thorough investigation will be conducted. The Abuse Coordinator designee will initiate procedures for conducting the investigation. The investigation will include the type of allegation, what occurred, when, where and to whom. Interview of witnesses separately, caregivers, roommates, obtaining statements, observing and documenting demeanor, document the cognitive status if the victim, resident witnesses, document if credible/believable. Obtain a signed statement from alleged perpetrator, if possible. If neglect is alleged, identify staff, length of time, and outcome to the resident. Review alleged perpetrator past performance and reputation, describe action taken to protect resident. Review nurse's notes and other records for information about the incident. Upon completion of the investigation, the facility should prepare a summary report of the findings and conclusions, including any actions taken by the facility. On page 5, part 8, the Corrective Action procedure states that the facility shall make all reasonable efforts to determine the cause of the suspected maltreatment and take corrective action consistent with the investigation findings to eliminate any ongoing danger to the resident or other residents. All corrective actions will be documented. Any incident will be reviewed at the quality assurance committee meeting. On page 6, the procedure defines Neglect as, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, staff interviews, medical record review, review of the facility policy entitled Missing Resident and Elopement dated November 2013 and review of manufacturer's instructions for the code alert bracelet (wander-monitoring bracelet, an electronic bracelet typically worn on a resident's wrist or ankle, which alarms if the resident wearing a transmitter is detected in the exit alarm zone or locks the door), the facility failed to prevent 1 of 4 cognitively impaired residents with known wandering behaviors, and at high risk for elopement from exiting the facility unsupervised and unwitnessed (Resident #1). On the evening of 12/12/19 at about 5:15 PM, Resident # 1 was observed by staff to be standing outside of the building, tapping on a door and waving at staff. The facility failure to ensure the safety of Resident #1 on the evening of 12/12/2019, when she was able to exit the facility unwitnessed, placed the resident at risk for serious harm. The resident could have fallen, gotten hit by a car, had exposure to cold, and/or gotten lost. This resulted in a finding of Immediate Jeopardy at a scope and severity of isolated (J). The facility Administrator, Risk Manager and Regional Director were notified of the findings of Immediate Jeopardy on [DATE] at 4:55 PM. The Immediate Jeopardy is ongoing. Four residents were identified as elopement risk in the facility. Cross reference F[AGE]9, F610 and F[AGE]7. The findings include: Several observations of Resident #1 were conducted during the survey on [DATE] at 9:50 AM, 11:20 AM, 1:30 PM and 2:30PM, on 2/20/20 at 9:10 AM and 12:15 PM and on [DATE] at 8:20 AM, 9:10 AM, 9:50 AM and 12:30 PM. During all observations, the resident was observed neatly groomed with long dark hair, dressed in slacks, shirts and shoes, and walking without assistance. Based on appearance and posture, Resident #1 could easily be mistaken as a visiting family member. On [DATE] about 9:51 AM Resident #1 was observed in her room coloring. The Social Worker, who is also a relative of Resident #1, asked her in the presence of the surveyor, if she knew her name and where she was. Resident #1 was able to state her first name but not her last name. She did not know the name of the facility and could not verbalize where she lived. Clinical record review revealed that Resident #1 was admitted to the facility 10/2/19. A review of the Minimum Data Set (MDS) quarterly report dated 1/2/2020 indicated the resident has a Brief Interview for Mental Status (BI[CONDITION]) score of 00 which indicated severe cognitive impairment. Section EO200, Behavioral Symptoms, indicated daily wandering behaviors. Section G, Functional Status, indicated Resident #1 walked without assistance. Pertinent active [DIAGNOSES REDACTED]. She took anti-anxiety and anti-depressant medications. Section PO200, Alarms, indicated a wander/elopement alarm was used daily. She had both a pre and post admission elopement assessment completed prior to admission on [DATE] and again on [DATE]. On both occasions, Resident #1 was determined to be at risk for elopement. A care plan was initiated on 10/11/19 regarding the risk for elopement, and included: wanders in facility daily at times into other resident's rooms with interventions; redirect resident when attempting to go outside facility or into other resident rooms; implement use of wander guard bracelet; check and change bracelet per policy; take resident for supervised walks and added intervention dated 1/13/20 1:1 staff during 3:00 PM - 11:00 PM shift. According to the nurse's notes for Resident #1 on 12/12/19 at 5:15 PM, nursing staff observed Resident #1 outside the building knocking on the exit door by therapy and waving at staff. Upon opening the door, Resident #1 came inside and the alarm immediately sounded due to resident's code alert bracelet. The resident was assisted to the dining room since it was supper time, and provided with a 1:1 staff member due to the unknown exit from the facility. The Administrator, Director of Nursing (DON), Risk Manager (RM), house supervisor, family, and the physician were all notified of the resident's elopement out of the facility. Both a 1:1 and every 15-minute checks were initiated and the code alert bracelet on the right ankle was changed even though it was functioning. There was no documentation that a resident head count was conducted to ensure all residents were accounted for. The nurse's notes continued to document 1:1 supervision through 12/13/19 at 3:00 PM. Prior to this elopement event, the nurses notes reflect that Resident #1 was having behaviors and agitation throughout that day and staff were having difficulty re-directing. On 12/12/19 at 3:30 PM, nursing documented that Resident #1 continues to pace in hallway.she is not agitated at this time, but unable to redirect by staff. The facility completed a state required adverse incident report on [DATE], 8 days after the event. The incident investigation documented, Resident observed knocking on outside of therapy hall door. When door was opened by staff, resident came in and alarm immediately sounded due to resident's code alert transmitter. No injuries were noted. The facility's analysis of the incident: Approximately five minutes before Resident #1 was knocking on the therapy window in the interior hallway and was escorted to the nurse's desk where she was standing with several staff members. She had not been noted approaching any exit. The incident investigation information did not indicate how the facility determined the missing timeframe of 5 minutes. The incident report did not mention the resident's cognitive status, the outdoor temperature, the weather, nor did it describe how the resident exited the building. According to the weather report the sun set at 4:50 PM on 12/12/19, and there was a light rain with thunder at 5:02 PM. The outside temperature was 52 degrees Fahrenheit. Both doors at the front of the building are close to a two lane street which was observed to be busy at 5:30 PM on [DATE]. There was a river 3/10's of a mile away from the facility. Further review of the incident investigation information showed the resident was immediately placed on 1:1 supervision while awake, and her code alert (wander-monitoring bracelet), although working, was changed for a new one. The information documented that Maintenance will check doors daily for proper functioning. A technician for the code alert system checked the therapy hall door 5 days later on 1[DATE] and a replacement part was scheduled to be replaced on 1/7/2020. The code alert system was also installed on the front door, but there was no documentation that the technician checked this door. On [DATE]20 from 4:20-4:55 PM, all exit doors were checked with the Risk Manager (RM) who wore a wander monitoring device on her ankle. The therapy door exit which staff stated that they assumed Resident #1 exited out of worked appropriately. The front door inconsistently alarmed when the RM walked up to it several times. One time it alarmed as she approached, the next time it did not; however, it locked each time. The Administrator and Regional Director who joined the observation, noted the inconsistency, and said they would have a technician come and check the door. They stated they will post someone at the front door to observe exits until it was repaired. The surveyor asked the Administrator, RM, Regional Director, and Maintenance what the door was expected to do, and they voiced various opinions, and were not sure. The side door by therapy is a locked door it does not alarm according to the RM because it is always locked. It does alarm when RM pushes on it and continues to alarm until the code is entered in at the door. The DON was interviewed on [DATE] about 1:30 PM regarding accounting supervision of residents. The DON stated that licensed staff check on residents when passing medications, Certified Nursing Assistants (CNAs) make rounds every 2 hours and they will check typically where the residents usually go such as activities or the TV room. Any resident with dementia or confusion is closely monitored and rounds are more often. If they find someone missing, they contact the nurse then initiate elopement protocol. The facility did not formally document their rounds. The surveyor asked the DON, When are the elopement risk residents checked? The DON responded, if they are having exit seeking behaviors we check more often. The surveyor asked the DON, How will you prevent future elopements? The DON replied that they have Resident #1 on 1:1 staffing in the evening hours until she goes to sleep. She normally sleeps through the night. We will increase supervision during the day if she is out of her room and seems more agitated. The corrective action documentation for daily door checks for proper functioning showed that checks for all the doors did not begin until 4 days after the elopement incident, starting on 1[DATE]. The documentation showed that daily door checks stopped on 1/14/20, with a note, back to weekly checks. Further review of the daily door checks revealed the door were not checked on 12/21/19, 12/22/19 (weekend days), 12/25/19, 1[DATE] (weekend days), and 12/29/19 (weekend days). The surveyor interviewed the Administrator at 10:00 AM on 2/20/2020. The Administrator was asked about the missing daily checks as noted above and why the facility waited 4 days to begin checking doors. The Administrator replied that maintenance was off on weekends. She also stated that an upgrade was made to the therapy hall door on 1/7/2020. The manufacturer's instructions for the code alert system were requested and reviewed. According to the Wander Management Transmitter Guide 0510-1122-B provided by the facility: if a transmitter is detected in an Exit Alarm Zone and the door is open, an alarm sounds at the exit. Depending upon which equipment you have installed, the Wander management Solution can automatically lock the door and deactivate elevators. The transmitters: both the adult and code watch transmitters send a signal to be received by Exit Alarm receivers which are low frequency (LF) antennas placed on or near a door frame or in an exit alarm zone. The exit alarm controller receives data form the exit alarm receivers and issues an alarm if a resident wearing a transmitter is detected in the exit alarm zone and the door is open. The Exit alarm controller contains a keypad that allows authorized staff to reset the system after an alarm. Warning: when the code watch is placed on a resident's ankle, be sure to adjust the antennae at each door to a 4-5 foot range to the ankle. Failure to do so may allow a resident to elope because they will be closer to the door when the door detects the transmitter. During an interview with the DON on 2/20/2020 around 1:00 PM, she said the code alert transmitters are checked for function every day on 11 PM -7 AM shift and placement is checked on every shift. This is documented in the treatment administration record. On [DATE], 11 PM - 7 AM licensed staff were interviewed regarding checks for the transmitters by the night nurses. An interview was conducted with Registered Nurse E (RN E) who worked the unit where Resident #1 resided during the night of 2/20/2020. RN E was interviewed at 7:30 AM on [DATE]. The surveyor asked her how the function of the transmitter was checked. RN E replied, They were sleeping, so I did not take them to the door to check function of the wander guard last night. She said she would record the function checks in the treatment book. She was not aware of any resident elopements in the past several months Additional nursing interviews were conducted regarding checking the functional status of the code alert bracelets on [DATE] from 7:30 AM to 8:18 AM. Licensed practical nurse I (LPN I), who also works 11 PM -7 AM and said that she is responsible for checking the code alerts. She stated correctly how to check the function. She stated she is not aware of any elopements in the last several months. LPN G also stated correctly how to test the function of the code alert. The night supervisor, RN F, explained the function of the code alert and said there had been one elopement in the past couple of months. It was Resident #1. On 2/20/2020 at 2:53 PM, the DON was asked about staff education regarding elopements. She said there had been no education regarding elopements since the elopement of Resident #1. The Administrator and Risk Manager returned at 3:00 PM to say there were elopement drills biannually. The Risk Manager said the last elopement drill was in November 2019. The facility's elopement policy, Risk Management-Missing Resident Elopement, dated April 2006 with revision date November 2013, was reviewed. The second sentence of the policy identified that elopement occurs when a resident who needs supervision leaves a safe area without supervision. The procedure states under #3: upon return of the resident to the facility, the DON or charge nurse should: a. examine the resident for injuries; b contact the attending physician and report what happened c. contact the resident's legal representative and inform them of the incident ; d. make appropriate notation in the resident's medical record.

Based on staff interview and record review, the facility quality assurance and performance improvement (QAPI) process failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to resident elopement that occurred on 12/12/19 and the reporting and investigation of allegations of neglect for 2 of 4 sampled residents, #1 and #2. The facility's failure to follow the QAPI process may prevent the facility from correcting and improving their systems to ensure resident safety and prevent serious harm. This situation resulted in Immediate Jeopardy at a scope and severity of isolated (J). The Immediate Jeopardy began on 12/12/19. The facility Administrator and Regional Director were notified of the findings of Immediate Jeopardy on [DATE] at 4:55 PM. The Immediate Jeopardy is ongoing. Cross reference F[AGE]9, F610 and F689. The findings included: Resident #1 was admitted to the facility on [DATE]. The resident had known wandering behaviors, impaired decision-making skills, short term and long-term memory impairment, was difficult to redirect and had known exit seeking behaviors. During the evening of 12/12/19, the facility staff were unaware the resident was missing from the facility until she was observed by staff knocking on the outside of the Therapy room exit door. A review of nursing notes from 12/12/19 was conducted for Resident #1. According to the nurse's notes on 12/12/19 at 5:15 PM, nursing staff observed Resident #1 outside the building knocking on the exit door by therapy and waving at staff. Upon opening the door, Resident #1 came inside and the alarm immediately sounded due to resident's code alert bracelet. A review of her Minimum Data Set (MDS) quarterly report dated 1/2/2020 indicated the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 00 which indicated severe cognitive impairment. Section EO200, Behavioral Symptoms, indicated daily wandering behaviors. The facility completed a state required adverse incident report 8 days after the event on [DATE]. The facility failed to complete or submit a federal immediate report regarding the elopement to the state agency, nor did they notify the state abuse and neglect agency. The investigation information failed to identify all staff who were witnesses or had the potential to be witnesses and failed to include any CNA interviews or other potential witnesses such as residents or visiting family members. The investigation did not mention the resident's cognitive status, the weather, nor did the it describe how the resident exited the building. In the facility's incident investigation information related to elopement of a resident (#1) on 12/12/2019, the facility identified the following corrective actions: Resident's code alert transmitter was replaced. Resident #1 was placed on 1:1 supervision while awake, which continues. Technology company was contacted and on evaluation found that the advance warning was not sounding prior to the door opening. Replacement of the door mechanism is scheduled for 1/7/20. The Maintenance Department is checking all doors daily for proper function. On [DATE]20 from 4:20 to 4:55 PM all exit doors were checked with the Risk Manager (RM) who wore a code alert bracelet (wandering monitoring device) on her right ankle (all residents identified as elopement risks wear a bracelet on or near the ankle). The therapy door exit which staff stated that they assumed Resident #1 exited out of worked appropriately. The front door inconsistently alarmed as the RM walked up to it, several times. One time it alarmed as she approached, the next time it did not; however, it locked each time. The Administrator and Regional Director who had joined the observation, noted the inconsistency, and said they would have a technician come and check the door. They stated they will post someone at the front door to observe exits until it was repaired. The surveyor asked the Administrator, RM, Regional Director, and Maintenance what the door was expected to do, and they voiced various opinions, and were not sure. The side door by therapy is a locked door it does not alarm according to the RM because it is always locked. It does alarm when RM pushes on it and continues to alarm until the code is entered in at the door. Evidence of the corrective action for daily door checks for proper functioning was requested and reviewed. the documentation showed that checks for all the doors did not begin until 4 days later, starting on 1[DATE]. The documentation showed that daily door checks stopped on 1/14/20, with a note, back to weekly checks. Further review of the daily door checks revealed the door were not checked on 12/21/19, 12/22/19 (weekend days), 12/25/19, 1[DATE] and 12/29/19 (weekend days). An interview was conducted with the Administrator at 10:00 AM on 2/20/2020. The Administrator was asked why the facility waited 4 days to begin checking doors. The surveyor asked the Administrator about the missing daily checks as noted above, and she stated it was because maintenance was off on weekends. She also stated that an upgrade was made to the therapy hall door on 1/7/2020. On 2/20/2020 at 2:53 PM, the DON said there had been no education regarding elopements since the elopement of Resident #1. The Administrator and Risk Manager stated at 3:00 PM there were elopement drills biannually. The Risk Manager said the last elopement drill was in November 2019. Resident #2: The facility failed to timely report an allegation of neglect related to a significant injury of unknown source (a [MEDICAL CONDITION] leg bone near the hip) for resident #2. On [DATE], resident #2 was observed yelling out in pain. The resident's left hip area was swollen, and she was drawing her leg up. The resident was transferred to a local hospital where the upper leg fracture was identified. A nursing note on 1/3/20 at 8:15 AM documented that resident #2 was lying in bed on right side hollering out with severe pain. Resident #2 complained of pain when any attempt was made to move the left lower extremity (left leg). There was 3+ [MEDICAL CONDITION] noted to the upper leg (moderate to severe [MEDICAL CONDITION] where finger pressure leaves a 4-8 millimeter dent). The nurse documented, no recent reports of any falls or injuries since last documented incident of 12/25/19. The physician was notified, and orders received to transfer the resident to the hospital for X-rays of the left hip and leg to rule out fracture. Review of the hospital records revealed an intertrochanteric fracture with a subtrochanteric fracture line extension (a [MEDICAL CONDITION] leg bone near the hip), which required surgical intervention. A Nursing Home Federal Report was filed on 1/17/2020, 14 days after the fracture of unknown source was found. The injury of unknown source was not documented in the incident log or the weekly Risk Management report. The investigation failed to determine the cause of the injury, and failed to identify all staff who were witnesses or had the potential to be witnesses. The weekly risk management report dated [DATE]-[DATE] did not indicate any significant resident injuries, nor did the report identify any reports filed for investigations regarding injury of unknown source. On [DATE] at 2:32 PM, an interview took place related to the facility QAPI program. The Administrator, Risk Manager, and DON met with the survey team to discuss the QAPI process. When asked for a QAPI plan and agendas, the Administrator provided a blank template. The Administrator refused to provide agendas or sign in rosters for meetings and stated they were combined with the minutes and could not be provided. The Administrator provided a QAPI plan dated 2018 and stated there was not a more current copy of a QAPI plan. The plan identified 5 goals: 1. Decrease percentage of residents who report moderate to severe pain. 2. Reduce the number of UTIs and put systems in place to educate nurses on prevention and alternate treatments. 3. Put processes in place to reduce the usage of catheters 4. Work to decrease the percentage of residents who lose too much weight from 9.4% to under 7%. 5. Reduce the long-term residents that have depressive symptoms from 7.5% to under the national average of 4.7. The Administrator stated the 2018 QAPI plan needed to be updated and it's been a while since she reviewed. The Administrator was asked to provide evidence that the plans were put into place. The Administrator offered one sheet of paper related to falls initiative titled Falls Committee, 12/30/19. The document listed the falls for the period and then in bullet format stated: no trends identified, and listed several interventions. When asked to provide documentation that the interventions were implemented and whether they were effective, how effectiveness was measured, the Administrator could not provide evidence. On [DATE] at 3:05 PM, surveyor interviewed the Administrator and Risk Manager, both members of the QAPI team regarding Resident #2's injury of unknown source. The Administrator reviewed the incident log for January 2020 and agreed the incident was not on the log and stated the review is part of the Quality Assurance (QA) process. The Administrator agreed she was made aware of the incident on 1/3/20. She reviewed the weekly risk management report dated [DATE] - [DATE] and agreed it did not include an incident report or any notation of the fracture and a federal immediate report was not identified on the form. The Administrator and Director of Nursing (DON) had signed the form. The surveyor asked about any continuing quality improvement plans related to previous citations at F[AGE]9, Failure to Report cited in September 2019 and F689, accidents cited in November 2019. The Administrator responded that the QAPI committee reviews the incident log. There was resident to resident aggression that was involved in the prior citation from previous survey so that was the focus of QAPI improvement plan. The Administrator confirmed the only action taken by the QAPI committee to address a deficiency, F[AGE]9, cited in September 2019 concerning investigations was reviewing the incident logs. The surveyor asked the Administrator to provide documentation of action plans from QAPI, and the Administrator continued to assert they were embedded within the minutes of the QAPI committee and not discoverable by the state agency. The Administrator did not provide any written action plans for QAPI activities related to investigations, or injuries of unknown origin. The Administrator continued to offer that she could make a copy of the plans of correction from those surveys, but when asked to provide evidence that those plans were implemented and ongoing monitoring occurred, she would not answer or provide any documentation.

Based on observation, record review and staff interview, the facility failed to use a dycem mat to prevent falls, as ordered by the physician, resulting in the resident falling to the floor and sustaining a fracture, bruising and swelling to the right hand for 1 of 3 residents sampled for falls (#1). The findings include: Review of an accident report filed by the facility described a fall that occurred on 10/26/2019 at 7:00 PM, in which resident #1 was observed by a nurse sliding from her chair to the floor. Swelling and bruising of resident #1's right hand was noted on 10/27/2019 and an x-ray of the right hand obtained on 10/28/2019 was positive for acute small fragment fracture at the 4th proximal phalanx (a broken ring finger). The report stated the resident had an order written [REDACTED].(CNA) care card. Per the facility investigation, the dycem was not in place at the time of the fall. The corrective action documented by the facility was the CNA (staff C, assigned to resident at time of fall) received education on the importance of reviewing the resident's Care Card and verifying that safety interventions are in place. This was dated on the report as 11/01/2019 at 8:02 AM. A review of resident #1's medical record included the physician order [REDACTED]. The care plan indicated risk for falls related to history of fall with right [MEDICAL CONDITION], dementia, confusion, forgetfulness and included a handwritten note dated 10/21/2019 indicating dycem was to be placed on the resident's chair. The CNA task/treatment log for resident #1 included the order for dycem to the chair and was to be initialed each shift, review of the log revealed that the documentation was incomplete for 3 PM -11 PM shift on 10/24, 10/28, 10/29 and for the 7 AM -3 PM shift on 10/28. Resident #1's record also included [DIAGNOSES REDACTED]. On 11/21/2019 at 11:48 AM, an observation of resident #1 in the restorative dining room revealed the Dycem was not placed under the resident. Staff A, a restorative CNA, was sitting next to resident #1 and confirmed there was no Dycem in the chair. On 11/21/2019 at 1:00 PM, in an interview staff B, the CNA assigned to resident #1 on 11/21/2019, stated she transferred resident #1 from her chair that morning, there was no Dycem in the chair, and staff B confirmed she was not aware that resident #1 required Dycem in the chair.

Based on interview, observation, and record review the facility failed to ensure the right to be free of verbal abuse for for 1 of 40 residents sampled for abuse (#84). The findings are: An interview with resident #84 on 4/18/11 at 12:05 PM revealed her statements that CNA #1 "will not do anything for me", "tries to get back at me", and "talks about me to other staff". She stated the CNA ridicules her for her disability (the resident is a quadriplegic and is totally dependent on staff for her care) which hurts her feelings and has brought her to tears on several occasions. Observations at this time revealed the resident to be visibly upset with tears in her eyes. The resident admitted an ongoing conflict with this CNA, acknowledging she (the resident) used to be very bitter and have a bad attitude and that she had often started trouble with this CNA in the past. She stated "I'm [AGE] years old and this is my life, I'm stuck in this chair and can't do anything for myself". She stated her attitude has improved, she accepts her situation better and doesn't treat people badly anymore, saying she still has a bad day now and then, "but I'm much better than I used to be". The resident stated she has requested this CNA not be assigned to her but she is still assigned to the 500 hall so does assist other CNA's in providing care to her sometimes, and they still interact in the hallway at times. The resident stated CNA #1 holds a great deal of influence on two other CNA's on her hall, CNA #2 and #3, and that she talks about the resident to them and gets them stirred up against her so none of them want to take care of her. The resident stated she has reported the problem to the Administrator, but nothing has been done and these CNA's still treat her badly and make snide remarks to her. Continued interview with this resident revealed denials of physical abuse by this CNA or any other facility staff, but statements that she has been verbally abused by CNA #1 stating she "makes fun of me because I am disabled or says this is why you are like you are". She stated she fears retaliation by staff and feel staff will not help her if she reports anything. She is also afraid the facility may try to discharge her if she complains, but stated "I've been here 3 years and I've never complained, but I can't take it anymore". She stated she does not fear physical retaliation, just continued verbal abuse and staff not wanting to care for her. Interview on 4/20/2011 at 9:12 AM with the Administrator revealed his statement that a couple of months ago he spoke with resident #84, who is also the Resident Council President, regarding grievances about CNAs tone of voice to residents. The Administrator reported that he talked one-on-one CNA #1 concerning being short with tone of voice and that she should not take resident #84's or any other residents comments personally. He stated that he had not heard of CNAs refusing to provide resident care. The Administrator reported that he conducted an inservice with staff concerning customer sensitivity training, he pointed out to staff that whether the accusation is false or true, the resident's perception is a reality and they should not react to resident's comments, but provide required care to the resident. The Administrator reported that he has not personally witnessed any negativity between resident #84 and CNA #1, but that his one-on-one with CNA #1 came as a result of resident grievances. The Administrator reported that he does not have any documentation of his talks with CNA #1. The Administrator reported that he has noticed the three CNAs (#1,2, and 3) hanging out together but has not noticed any improper behavior. The Administrator reported that the QA committee is monitoring these issues. On 2/1/11-2/3/11, the Administrator conducted an inservice concerning Customer Service with all staff in every dept. The Administrator was asked if he had considered reassigning any of these CNAs to another hall, he stated he was reluctant to do that because they do provide good resident care and since they have worked the back hall the residents are always very well kept, neat, clean, the hall is clean, beds made, the whole unit seems to look better to him. Interview with CNA #4 on 4/20/2011 at 10:02 AM revealed that she has been assigned on the back hallway for about a year or two. She states that she goes into resident #84's room and does her assignments, is very careful to keep personality out of it, doesn't encourage resident to get too familiar, has let resident know right up front she is there to care for her, not to be her friend. This CNA states in the past the socializing was so intense in the back hallway with this resident and CNAs #1, 2, and 3 that there was constant conflict. She agreed there has been a "click" among 3 CNAs on that hall, but it is much better lately. She states she thinks a big part of the problem between those 3 CNAs and resident #84 is that they are all young, their relationship got too personal and they started bickering. She doesn't believe the CNAs ever mistreated the resident. Interview on 4/20/2011 at 1:47 PM with LPN #1 revealed resident #84 has been in facility since [AGE] years old when she became a quadriplegic due to a motor vehicle accident. She has one child to raise, yet is totally helpless and has to rely on someone to put her to bed, to take her out, to do anything for her. She stated some CNAs act superior, some of their words can be construed as verbal abuse, its all in the approach. CNAs #1, 2 and 3 give good physical care, but their mouths will get out of hand. She has tried numerous times to tell them every action requires a reaction, but if they don't react, there cannot be any altercations. Since January 2010, resident #84 was real sarcastic, has given 100% turnabout, but still has her moments when she can yell, fly off the handle and be disruptive. The resident wants staff to stop doing what they are doing and attend to her and do what she wants, when she wants them to, but if these demands are handled right and you let her know why she may have to wait, she will wait. She states she sees both sides and both the resident and the CNAs are in the wrong at times, but their issues have not gotten better. She states she has informed the Administrator and requested that he separate the 3 CNAs, but he will not do it, she has complained to the Administrator numerous times about the problems on the back hall. She has had to reprimand the CNA's more than once about their loud mouths and the way they speak to the residents, but the behavior has not changed. She has been here since 10/2009 and has been to one Customer Service inservice and that was only due to the fact that Corporate conducted a mock survey and Corporate found issues on the back hall so the Administrator had to do the inservice. She stated the CNAs in question routinely hide out in resident rooms to socialize and talk on their cell phones while on duty. She personally witnessed the Administrator walk into a resident's room and catch them doing this and heard CNA #1 tell the Administrator that she knew he wasn't going to get on her about it since she had staffed the facility for him that weekend. On another occasion she saw the Administrator walk in on the CNAs again in a resident's room while they were doing the same thing and overheard him tell them he didn't care what they did, just don't get caught by the wrong people. She states some residents are reluctant to go to the shower room with these CNA's unless she goes with them because they speak so harshly to them and bark orders at them. She specifically mentioned that one resident has told her she doesn't like how these CNA's treat her and is afraid of them, but said she doubts the resident would speak with us about this. She stated she has also expressed her concerns to the DON (Director of Nursing) who just left the facility as well as the new DON. Interview on 4/21/11 at 10:20 AM with CNA #1 revealed she deals with resident #84 "in my own way", she ignores the resident's behaviors and provides care anyway; resident wants things done when she wants them done, is very impatient, does not accept that other residents need care and staff may be busy with them. Resident #84 and staff have a history of being playful with each other, teasing, etc. and it sometimes gets out of hand and then the resident wants to call and report the staff to retaliate against them; stressed she does not refuse the resident any care. Interview with the facility psychiatrist on 4/21/11 at 10:50 AM revealed him to say he had treated resident #84 for depression in the past but in recent conversation with staff it was his understanding the resident's depression was stable and he had not seen the resident professionally recently. He went on to say he was familiar with staff CNA #1. He stated when he sat at the nursing station on the back hall he heard CNA #1 talk gruffly to residents and staff and without manners on many occasions. Facility failure to intervene on resident #84's behalf when numerous staff were aware of a conflict between the resident and CNAs #1,2, and 3 resulted in the resident being subjected to continued ridicule and verbal and emotional abuse resulting in harm to her emotional well-being.

Based on interview, observation, and record review the facility failed to operationalize their policy/procedure for prevention, identification, investigation, and reporting of abuse and mistreatment. The findings are: An interview with resident #84 on 4/18/11 at 12:05 PM revealed her statements that CNA #1 "will not do anything for me", "tries to get back at me", and "talks about me to other staff". She stated the CNA ridicules her for her disability (the resident is a quadriplegic and is totally dependent on staff for her care) which hurts her feelings and has brought her to tears on several occasions. Observations at this time revealed the resident to be visibly upset with tears in her eyes. The resident admitted an ongoing conflict with this CNA, acknowledging she (the resident) used to be very bitter and have a bad attitude and that she had often started trouble with this CNA in the past. She stated "I'm [AGE] years old and this is my life, I'm stuck in this chair and can't do anything for myself". She stated her attitude has improved, she accepts her situation better and doesn't treat people badly anymore, saying she still has a bad day now and then, "but I'm much better than I used to be". The resident stated she has requested this CNA not be assigned to her but she is still assigned to the 500 hall so does assist other CNA's in providing care to her sometimes, and they still interact in the hallway at times. The resident stated CNA #1 holds a great deal of influence on two other CNA's on her hall, CNA #2 and #3, and that she talks about the resident to them and gets them stirred up against her so none of them want to take care of her. The resident stated she has reported the problem to the Administrator, and the Director of Nursing (DON) but nothing has been done and these CNA's still treat her badly and make snide remarks to her. Continued interview with this resident revealed denials of physical abuse by this CNA or any other facility staff, but statements that she has been verbally abused by CNA #1 stating she "makes fun of me because I am disabled or says this is why you are like you are". She stated she fears retaliation by staff and feel staff will not help her if she reports anything. She is also afraid the facility may try to discharge her if she complains, but stated "I've been here 3 years and I've never complained, but I can't take it anymore". She stated she does not fear physical retaliation, just continued verbal abuse and staff not wanting to care for her. Interview on 4/20/2011 at 9:12 AM with the Administrator revealed his statement that a couple of months ago he spoke with resident #84, who is also the Resident Council President, regarding grievances about CNAs tone of voice to residents. The Administrator reported that he talked one-on-one CNA #1 concerning being short with tone of voice and that she should not take resident #84's or any other residents comments personally. He stated that he had not heard of CNAs refusing to provide resident care. The Administrator reported that he conducted an inservice with staff concerning customer sensitivity training, he pointed out to staff that whether the accusation is false or true, the resident's perception is a reality and they should not react to resident's comments, but provide required care to the resident. The Administrator reported that he has not personally witnessed any negativity between resident #84 and CNA #1, but that his one-on-one with CNA #1 came as a result of resident grievances. The Administrator reported that he does not have any documentation of his talks with CNA #1. The Administrator reported that he has noticed the three CNAs (#1,2, and 3) hanging out together but has not noticed any improper behavior. The Administrator reported that the QA committee is monitoring these issues. On 2/1/11-2/3/11, the Administrator conducted an inservice concerning Customer Service with all staff in every dept. The Administrator was asked if he had considered reassigning any of these CNAs to another hall, he stated he was reluctant to do that because they do provide good resident care and since they have worked the back hall the residents are always very well kept, neat, clean, the hall is clean, beds made, the whole unit seems to look better to him. Interview with CNA #4 on 4/20/2011 at 10:02 AM revealed that she has been assigned on the back hallway for about a year or two. She states that she goes into resident #84's room and does her assignments, is very careful to keep personality out of it, doesn't encourage resident to get too familiar, has let resident know right up front she is there to care for her, not to be her friend. This CNA states in the past the socializing was so intense in the back hallway with this resident and CNAs #1, 2, and 3 that there was constant conflict. She agreed there has been a "click" among 3 CNAs on that hall, but it is much better lately. She states she thinks a big part of the problem between those 3 CNAs and resident #84 is that they are all young, their relationship got too personal and they started bickering. She doesn't believe the CNAs ever mistreated the resident. Interview on 4/20/2011 at 1:47 PM with LPN #1 revealed resident #84 has been in facility since [AGE] years old when she became a quadriplegic due to a motor vehicle accident. She has one child to raise, yet is totally helpless and has to rely on someone to put her to bed, to take her out, to do anything for her. She stated some CNAs act superior, some of their words can be construed as verbal abuse, its all in the approach. CNAs #1, 2 and 3 give good physical care, but their mouths will get out of hand. She has tried numerous times to tell them every action requires a reaction, but if they don't react, there cannot be any altercations. Since January 2010, resident #84 was real sarcastic, has given 100% turnabout, but still has her moments when she can yell, fly off the handle and be disruptive. The resident wants staff to stop doing what they are doing and attend to her and do what she wants, when she wants them to, but if these demands are handled right and you let her know why she may have to wait, she will wait. She states she sees both sides and both the resident and the CNAs are in the wrong at times, but their issues have not gotten better. She states she has informed the Administrator and requested that he separate the 3 CNAs, but he will not do it, she has complained to the Administrator numerous times about the problems on the back hall. She has had to reprimand the CNA's more than once about their loud mouths and the way they speak to the residents, but the behavior has not changed. She has been here since 10/2009 and has been to one Customer Service inservice and that was only due to the fact that Corporate conducted a mock survey and Corporate found issues on the back hall so the Administrator had to do the inservice. She stated the CNAs in question routinely hide out in resident rooms to socialize and talk on their cell phones while on duty. She personally witnessed the Administrator walk into a resident's room and catch them doing this and heard CNA #1 tell the Administrator that she knew he wasn't going to get on her about it since she had staffed the facility for him that weekend. On another occasion she saw the Administrator walk in on the CNAs again in a resident's room while they were doing the same thing and overheard him tell them he didn't care what they did, just don't get caught by the wrong people. She states some residents are reluctant to go to the shower room with these CNA's unless she goes with them because they speak so harshly to them and bark orders at them. She specifically mentioned that one resident has told her she doesn't like how these CNA's treat her and is afraid of them, but said she doubts the resident would speak with us about this. She stated she has also expressed her concerns to the DON who just left the facility as well as the new DON. Interview on 4/20/11 at 2:30 PM with the DON revealed she has spoken to resident #84 several times, but denies knowledge of any conflict between her and any of the CNAs. She stated care on the 500 hall has improved with the three CNAs who are currently assigned back there. She states staff has not verbalized anything to her about these CNA's, but went on to say she thinks the interventions that have been put in place have helped issues on the back hall. Resident care is monitored through nurses and nurse supervisior. The last time resident #84 was in the office was Tuesday, 4/12/11 when the resident stated that she can not get anyone to do anything for her. She stated she has just assumed her duties as DON and the prior DON followed up with the staff on day shift in back hallway and did not have concerns with CNA #1 talking to residents in an abusive tone. Interview on 4/21/11 at 10:20 AM with CNA #1 revealed she deals with resident #84 "in my own way", she ignores the resident's behaviors and provides care anyway; resident wants things done when she wants them done, is very impatient, does not accept that other residents need care and staff may be busy with them. Resident #84 and staff have a history of being playful with each other, teasing, etc. and it sometimes gets out of hand and then the resident wants to call and report the staff to retaliate against them; stressed she does not refuse the resident any care. Interview with the facility psychiatrist on 4/21/11 at 10:50 AM revealed him to say he had treated resident #84 for depression in the past but in recent conversation with staff it was his understanding the resident's depression was stable and he had not seen the resident professionally recently. He went on to say he was familiar with staff CNA #1. He stated when he sat at the nursing station on the back hall he heard CNA #1 talk gruffly to residents and staff and without manners on many occasions. Interview on 4/21/11 at 2:40 PM with the facility Risk Manger/Social Worker revealed she has no specific knowledge of allegations of CNAs speaking rudely or treating residents roughly on the 500 hall. During interview on 4/21/11 at 3:15 PM with the facility Administrator he stated that during his past conversations with resident #84, she had commented that CNA #1 "laughs at her, is rude to her". When asked if he had considered initiating an abuse report, he stated "no, at the time I didn't feel it warranted that". He acknowledged he had not considered this as verbal or emotional abuse. Review of the facility Abuse, Neglect, Exploitation & Misappropriation policy/procedure states it is facility policy to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental) and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing. The Abuse/Coordinator/designee shall immediately report any alleged violation of abuse that meet the reporting criteria to the Agency for Health Care Administration, the Adult Protective services, and the local law enforcement if they feel a crime has occurred. The policy states the facility encourages residents and families, and requires staff to report concerns, incidents, and grievances without fear of retribution. the facility identifies, corrects, and intervenes in situations of alleged abuse. Reporting of suspected maltreatment is required of all staff. The policy provides for protection of any victims of abuse during the investigation. The facility failed to implement their own policy by failing to prevent verbal/emotional abuse, failing to investigate, and failing to report this abuse as evidenced by numerous staff acknowledging awareness of the behavior of CNA #1 towards resident #84. This failure resulted in emotional distress and harm to resident #84.