Every finding on record at Silver City Care Center

Based on record review, and interview, the facility failed to notify the provider when insulin was not administered as ordered for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for insulin (injectable medication used to help lower blood glucose levels) administration. This deficient practice could likely lead to uncontrolled blood glucose levels (BGL), result in residents not receiving necessary care, or worsening of medical conditions. The findings are: A. Record review of R #1's Face Sheet, no date, revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had a diagnosis of diabetes mellitus (DM a condition defined by persistently high levels of sugar [glucose] in the blood) B. Record review of R #1's physicians' orders revealed the following: 1. an order dated 12/30/25: Novolin 70/30 (a man-made insulin designed to help manage blood glucose levels by combining 70% longer acting insulin with 30% regular insulin which acts quickly to reduce blood sugar, the combination allows for both immediate and sustained blood glucose control) FlexPen (a compact, pre-filled insulin delivery device) inject 44 units subcutaneously (given just under the skin) in the morning for diabetes mellitus. 2. An order dated 12/08/25: NovoLog injection solution inject as per sliding scale (a method used to adjust insulin doses based on blood glucose levels) subcutaneously before meals and at bedtime for DM: if BGL is 0 - 110 = give 0 units; if 111 - 150 = give 0 units; if 151 - 200 = give 2 units; if 201 - 250 = give 4 units; if 251 - 300 = give 6 units; if 301 - 350 = give 8 units; if 351 - 400 = give 10 units; if 401 - 450 = give 12 units, contact provider if BGL is greater than 451. C. Record review of R #1's MAR dated January 2026, revealed the following: 1. 01/03/26 R #1's BGL was 112 and a partial dose (PD) of Novolin 70/30 was given. 2. 01/04/26 R #1's BGL was 144 and a PD of Novolin 70/30 was given. 3. 01/09/26 at 6:30 AM R #1's BGL was 278, R #1 refused her NovoLog sliding scale insulin. D. Record review of R #1's MAR dated February 2026, revealed the following: 1. 02/19/26 R #1's BGL was 177 and Novolin 70/30 was held (HD: not given). 2. 02/22/26 R #1's BGL was 86 staff documented within range (WR=blood sugar within range and no insulin given). 3. 02/25/26 R #1's BGL was 74 and Novolin 70/30 was held. 4. 02/26/26 R #1's BGL was 150 and Novolin 70/30 was not given (NG=Parameters [preset range of blood glucose values used to determine action to be taken] out of range-med not given). E. Record review of R #1's MAR dated March 2026, revealed the following: 1. 03/01/26 R #1's BGL was 86 staff documented WR. 2. 03/03/26 R #1's BGL was 79 and Novolin 70/30 was held. 3. 03/04/26 R #1's BGL was 68 and Novolin 70/30 was not given. 4. 03/10/26 at 8:00 AM R #1's BGL was 153, staff documented WR blood sugar within range and no insulin given. F. On 06/10/26 at 12:02 PM, during an interview, Nurse Practitioner #1 stated the following: 1. Nursing staff should contact the facility provider or the on-call provider when residents are requesting partial doses of their insulin to determine the course of action and nursing staff should not take it upon themselves to give a partial dose of insulin. 2. Nursing staff should administer the insulin if there are no hold parameters included in the order. 3. Nursing staff should communicate with the facility providers or on-call providers when residents refuse their insulin. 4. Nursing staff should administer sliding scale insulin as ordered.

Based on record review and interview, the facility failed to meet professional standards of practice for 1 (R #1) of 3 (R #1, R #2 and R #3) residents reviewed for insulin (injectable medication used to help lower blood glucose levels) administration, when staff failed to administer insulin as ordered by the provider. This deficient practice could likely lead to uncontrolled blood glucose levels (BGL) or worsening of medical conditions. The findings are: A. Record review of R #1's Face Sheet, no date, revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had a diagnosis of diabetes mellitus (a condition defined by persistently high levels of sugar [glucose] in the blood) B. Record review of R #1's physicians' orders revealed an order dated 12/30/25: Novolin 70/30 (a man-made insulin designed to help manage blood glucose levels by combining 70% longer acting insulin with 30% regular insulin which acts quickly to reduce blood sugar, the combination allows for both immediate and sustained blood glucose control) FlexPen (a compact, pre-filled insulin delivery device) inject 44 units subcutaneously (given just under the skin) in the morning for diabetes mellitus. C. Record review of R #1's MAR dated January 2026, revealed the following: 1. 01/03/26 R #1's BGL was 112 and a partial dose (PD) of Novolin 70/30 was given. 2. 01/04/26 R #1's BGL was 144 and a PD of Novolin 70/30 was given. D. Record review of R #1's MAR dated February 2026, revealed the following: 1. 02/19/26 R #1's BGL was 177 and Novolin 70/30 was held (HD: not given). 2. 02/22/26 R #1's BGL was 86 staff documented within range (WR=blood sugar within range and no insulin given). 3. 02/25/26 R #1's BGL was 74 and Novolin 70/30 was held. 4. 02/26/26 R #1's BGL was 150 and Novolin 70/30 was not given (NG=Parameters [preset range of blood glucose values used to determine action to be taken] out of range-med not given). E. Record review of R #1's MAR dated March 2026, revealed the following: 1. 03/01/26 R #1's BGL was 86 staff documented WR. 2. 03/03/26 R #1's BGL was 79 and Novolin 70/30 was held. 3. 03/04/26 R #1's BGL was 68 and Novolin 70/30 was not given. F. On 06/10/26 at 12:02 PM, during an interview, Nurse Practitioner #1 stated the following: 1. Nursing staff should administer the insulin if there are no hold parameters included in the order. 2. Partial doses of insulin should not be given without discussing with the facility or on-call provider. 3. Nursing staff should contact the provider, either at the facility or the on-call provider that is available 24 hours a day, 7 days a week if there is a concern regarding a residents' BGL and insulin order.

Based on observation and interview, the facility failed to store food under sanitary conditions for all 64 residents who eat food from the kitchen (residents were identified by the resident matrix provided by the administrator on (01/05/26) when staff failed to label and date all items in the kitchen refrigerator. Failure to store food under safe and sanitary conditions could likely lead to foodborne illnesses in residents. The findings are: A. On 01/05/26 at 12:10 PM, an observation of the kitchen revealed the following: 1. The walk-in refrigerator had: a. Two butter blocks with no dates, b. Jello in large container no date, no cover, c. Chorizo dated 12/20/25, 4. Pears no date in container, 5. Peanut Butter bar dessert in container no date, 6. Ham sliced in a ziplock bag was open dated 01/01/25, 7. Baked crispy pineapple cake in the pantry storage area with no date. 2. The walk-in freezer had: a. Salsbury streak opened with no date, b. Chicken patties opened with no date, c. Lemon meringue pie with no date, d. Pie crusts opened with no date e. Corn tortillas were opened loosely and not tightly sealed with a date of 12/11/25. B. On 01/05/26 at 12:29 PM, during an interview with the Dietary Manager (DM), she stated she checks dates of food every day. The staff who unload the food truck are to date the boxes as soon as they come in before storing them. The staff are to date the food when opened. She confirmed that there was food in the refrigerator and freezer that had no dates, no covers on food containers, food was not tightly sealed and outdated dates on food. The DM stated that her expectation is that the staff date and mark foods and throw them away if outdated.

Based on record review, observation, and interview, the facility failed to ensure medical records were complete and accurate for 4 (R #5, R #10, R #11, and R #16) of 4 (R #5, R #10, R #11, and R #16) residents reviewed accuracy of documentation when staff failed to: 1. Accurately document R #5's dental assessment. 2. Accurately document activity participation for R #10 and R #11. 3. Accurately document R #16's skin assessment. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records. The findings are: R #5 A. Record review of R #5's admission documents, no date, revealed R #5 was admitted to the facility on [DATE]. B. On 01/06/26 at 9:42 AM, during an observation and interview with R #5, the following was revealed: 1. R #5 stated that she had several broken teeth that needed to be pulled. 2. R #5 had several of her teeth broken with discoloration on the top and bottom of her mouth. C. Record review of R #5's admission assessment, dated 11/17/25, revealed staff documented R #5 had no natural teeth or tooth fragments and was edentulous (lacking teeth). D. On 01/07/26 at 2:50 PM, during an interview, LPN # 16 observed R #5 in her room and confirmed that R #5 was not edentulous. E. On 01/08/26 at 3:10 PM, during an interview, the DON confirmed the following: Staff documented on R #5's admission assessment that she was edentulous. R #5's admission assessment was inaccurate. Staff were expected to ensure resident dental status was assessed and documented accurately. R #10 F. Record review of R #10's admission document, no date, revealed that R #10 was admitted to the facility on [DATE]. G. On 01/05/26 at 3:06 PM, during an interview with family member (FM), she stated R #10 wants to go to Christian Church service and it is not offered. FM stated the manager in secure unit, said there is Catholic services offered here with activities, and they can't take him out due to his wandering. FM further stated that she doesn't know if activities are offered at the facility because, when FM visits R #10 she does not see activities going on in the secure unit. H. Record review of the facility's activities participation record for October 2025-December 2025 revealed no documentation for attending church services for R #10. I. On 01/07/26 at 1:35 PM, during an interview with the Unit Manager (UM), he stated R #10 likes to hear music and reads his bible. He stated R #10 goes off unit with activities staff for church service. UM stated he couldn't provide documentation of residents going to church services to check with activities staff. J. On 01/07/26 at 1:46 PM, during an interview, Activities Director (AD) stated activities aide goes to the secure unit on Thursdays at 10:00 AM to take R #10 to church services. AD stated activities staff does not document activity participation for the secure unit, and the manager of the secured unit should be documenting R #10's activity attendance. K. On 01/07/26 at 2:09 PM during an interview with the Administrator, she stated she is the supervisor for the UM and AD. Administrator stated that the UM oversees the secure unit. The Administrator stated her expectation is that the UM documents the activities that residents attend on and off the secure unit. R #11 L. Record review of R #11's admission document, no date, revealed that R #11 was admitted to the facility on [DATE]. M. Record review of R #11's care plan dated 06/12/25 revealed a goal that staff will encourage resident to participate in facility activities and provide one to one, programs as needed through next review date. N. Record review of the facility's activities participation record for October 2025-December 2025 revealed no documentation for one-to-one activities for R #11. O. On 01/07/26 at 1:32 PM, during an interview with the UM, he stated R #11 does receive one-to-one activities at least once a day. The staff read her books and magazines, she enjoys a slinky object on her arm, and staff take R #11 outside weather permitting. His expectation is that staff complete the activity participation record when activities occur. R #16 P. Record review of R #16's admission documents, no date, revealed R # #16 was admitted to the facility on [DATE]. Q. On 01/05/26 at 2:45 PM, during an observation of R #16 by the nurses' station, the following was revealed the following: 1. R #16 had blood on his right elbow. 2. LPN #17 cleansed R #16's right elbow and placed a bandage over the wound. R. On 01/08/26 at 9:46 AM, during an observation and interview of R #16 in the hallway, the following was revealed: 1. R #16 had a dressing that was falling off his right elbow that appeared to have dried blood on it. 2. R #16 stated that staff had not changed the bandage since he got the wound on 01/05/26. S. Record review of R #16's skin assessment, dated 01/08/26, revealed staff documented that R #16 had no skin issues. T. On 01/08/26 at 9:57 AM, during an interview, the wound care nurse stated the following: 1. She was not aware R #16 had a wound on his right elbow. 2. She observed R #16's elbow and confirmed he had a wound on his right elbow. 3. She confirmed that on 01/08/26, staff documented that R #16 had no skin issues 4. She confirmed that R #16's skin assessment was inaccurate. T. On 01/08/26 at 3:04 PM, during an interview, the DON confirmed that staff were expected to assess resident skin condition at least weekly and were expected to document accurately on the skin assessment form.

Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation in the residents' medical record for 4 (R #8, R #10, R #32 and R #63) of 5 (R #7, R #8, R #10, R #32 and R #63) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: R #8 A. Record review of R #8's admission document, no date, revealed the following: 1. R #8 was admitted to the facility on [DATE], 2. R #8 was diagnosed with the following diagnoses: a. Vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. b. Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (cognitive decline affecting daily life but lacks specific neuropsychiatric symptoms like agitation, hallucinations, depression, or severe worry, with severity mild, moderate, severe also not yet specified). c. Anxiety Disorder (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), unspecified. d. Insomnia, unspecified (is a common sleep condition that involves consistent difficulty falling asleep, staying asleep, or achieving restorative, quality sleep despite having adequate opportunity and environment for sleep). B. Record review of R #8's physician's orders revealed an order dated 09/25/25 for Quetiapine Fumarate tablet 200 mg (is used to treat schizophrenia in adults and children who are at least [AGE] years old. It is also used alone or with divalproex or lithium to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods) give 1 tablet by mouth at bedtime for Dementia with psychotic disturbance. C. Record review of R #8's pharmacy recommendation summary report dated 10/28/25, revealed the following: 1. R #8 is currently receiving Quetiapine 200 mg by mouth once daily for dementia with psychotic disturbance. 2. Patients with dementia-related psychosis (involves hallucinations (seeing/hearing things not there) and delusions (false, unshakable beliefs) occurring) treated with atypical antipsychotics (second-generation antipsychotics) are newer medications for mental health conditions like schizophrenia, bipolar disorder, and severe depression) are at an increased risk of death compared to placebo (a medicine or procedure prescribed for the psychological benefit to the patient rather than for any physiological effect). An increased incidence of cerebrovascular accident (is the medical term for a stroke) and adverse events (including fatalities) has been reported in elderly patients with dementia-related psychosis. 3. A benefit/risk analysis of current therapy warrants a continuation at the present dose. 4. R #8's physician did not provide a benefit/risk analysis with patient specific information as to why R #8 needed to remain on medication. R #10 D. Record review of R #10's admission document, no date, revealed the following: 1. R #10 was admitted to the facility on [DATE], 2. R #10 was diagnosed with the following diagnoses: a. Alzheimer's Disease (is the biological process that begins with the appearance of a buildup of proteins in the form of amyloid plaques and neurofibrillary tangles in the brain). b. Dementia, unspecified severity, with other behavioral disturbance, (cognitive decline affecting daily life but lacks specific neuropsychiatric symptoms like agitation, hallucinations, depression, or severe worry, with severity mild, moderate, severe also not yet specified). E. Record review of R #10's physician's orders revealed an order dated 07/01/25 for Quetiapine 25 mg, oral tablet (is used to treat schizophrenia in adults and children who are at least [AGE] years old. It is also used alone or with divalproex or lithium to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods) give 1 tablet by mouth 25 mg, two times a day for Dementia with psychotic disturbance. F. Record review of R #10's pharmacy recommendation summary report dated 10/28/25, revealed the following: 1. R #10 is currently receiving Quetiapine 25 mg by mouth twice daily for dementia with psychotic disturbance. 2. Patients with dementia-related psychosis (involves hallucinations (seeing/hearing things not there) and delusions (false, unshakable beliefs) occurring) treated with atypical antipsychotics (second-generation antipsychotics) are newer medications for mental health conditions like schizophrenia, bipolar disorder, and severe depression) are at an increased risk of death compared to placebo. An increased incidence of cerebrovascular adverse events (including fatalities) has been reported in elderly patients with dementia-related psychosis. 3. A benefit/risk analysis of current therapy warrants a continuation at the present dose. 4. R #10's physician did not provide a benefit/risk analysis with patient specific information as to why R #10 needed to remain on medication. R #32 G. Record review of R #32's admission document, no date, revealed the following: 1. R #32 was admitted to the facility on [DATE], 2. R #32 was diagnosed Dementia, unspecified severity, with Agitation, (is used specifically for documenting cases of unspecified dementia, a condition characterized by a decline in cognitive function without a clearly identified cause. It includes varying severities and can be recorded with or without accompanying behavioral, psychotic, mood, or anxiety disturbances). H. Record review of R #32's physician's orders revealed an order dated 12/17/25 for Rexulti oral tablet 1.5 mg (as an adjunctive therapy to antidepressants for the treatment of major depressive disorder (MDD) in adults, treatment of schizophrenia in adults and pediatric patients ages 13 years and older, treatment of agitation associated with dementia due to Alzheimer's disease) give 1 tablet by mouth one time a day. I. Record review of R #32's pharmacy recommendation summary report dated 12/27/25, revealed the following: 1. R #32 is currently receiving the atypical antipsychotic Rexulti 2 mg by mouth once daily by mouth in the evening for Dementia with Behavioral disturbance and agitation. 2. Patients with dementia-related psychosis (involves hallucinations (seeing/hearing things not there) and delusions (false, unshakable beliefs) occurring) treated with atypical antipsychotics (second-generation antipsychotics) are newer medications for mental health conditions like schizophrenia, bipolar disorder, and severe depression) are at an increased risk of death compared to placebo. An increased incidence of cerebrovascular adverse events (including fatalities) has been reported in elderly patients with dementia-related psychosis. 3. A benefit/risk analysis of current therapy warrants a continuation at the present dose. 4. R #32's physician did not provide a benefit/risk analysis with patient specific information as to why R #32 needed to remain on medication. J. On 01/09/2026 at 12:33 PM, during an interview with the DON regarding the resident benefit risk analysis for medication for R #8, R #10, and R #32. DON stated she does see in the chart where it is documented specifically benefit risk analysis for the medications. DON's expectation is that the physician document in the chart the benefit risk analysis. R #63 K. Record review of R #63's admission document, no date, revealed the following: 1. R #63 was admitted to the facility on [DATE], 2. R # 63 was diagnosed with the following diagnoses: a. Depression (a mood disorder that causes persistent feelings of sadness and a loss of interest in activities, affecting how a person thinks, feels, and acts), unspecified. b. Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (cognitive decline affecting daily life but lacks specific neuropsychiatric symptoms like agitation, hallucinations, depression, or severe worry, with severity mild, moderate, severe also not yet specified). c. Anxiety disorder (Feelings of fear, dread, and uneasiness that may occur as a reaction to stress), unspecified. L. Record review of R #63's physician's orders revealed the following orders: 1. An order dated 08/11/25 for Escitalopram Oxalate (major depressive disorder and generalized anxiety disorder) give 15 mg by mouth one time a day for depression. 2. An order dated 10/02/25 for Zyprexa (to treat certain mental health conditions) give 1 tablet by mouth one time a day for dementia with psychotic disturbances. M. Record review of R #63's pharmacy recommendation summary report dated 10/26/25, revealed the following: 1. R #63 is currently receiving Zyprexa 5 mg by mouth once daily at bedtime for dementia with psychotic disturbance, consider gradual dose reduction (GDR). 2. Patients with dementia-related psychosis (involves hallucinations (seeing/hearing things not there) and delusions (false, unshakable beliefs) occurring) treated with atypical antipsychotics (second-generation antipsychotics) are newer medications for mental health conditions like schizophrenia, bipolar disorder, and severe depression) are at an increased risk of death compared to placebo. An increased incidence of cerebrovascular adverse events (including fatalities) has been reported in elderly patients with dementia-related psychosis. 3. A benefit/risk analysis of current therapy warrants a continuation at the present dose. 4. R #63's physician did not provide a benefit/risk analysis with patient specific information as to why R #63 needed to remain on medication. N. Record review of R #63's pharmacy recommendation summary report dated 12/26/25, revealed the following: 1. R R #63's is currently receiving Escitalopram (a prescription antidepressant medication ) 15 mg by mouth once daily, consider gradual dose reduction (GDR). 2. R #63's physician did not provide rationale with patient specific information as to why a GRD was not done. O. On 01/09/26 at 11:27 AM, during an interview, the DON confirmed that a rationale and benefit/risk analysis is not documented in R #63's medical record. The DON stated that her expectation is that a rationale should be provided and that an analysis should be completed.

Based on interview and record review, the facility failed to complete performance reviews at least every 12 months for 2 (CNA #16 and CNA #17) of 2 (CNA #16 and CNA #17) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care. The findings are: A. Record review of the employee files revealed the following: 1. CNA #16's hire date was 11/18/24. 2. The file did not contain any performance evaluations for CNA #16. 3. CNA #17's hire date was 09/20/24. 4. The file did not contain any performance evaluations for CNA #17. B. On 01/13/26 at 9:27 AM, during an interview, the administrator confirmed the following: 1. There were not any performance evaluations for CNA #16 and CNA #17. 2. Performance evaluations were expected to be completed at least annually on CNAs.

Based on observation, record review, and interview, the facility failed to ensure care plan revisions occurred for 4 (R #7, R #11, R #47, and R #71) of 4 (R #7, R #11, R #47, and R #71) residents when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #7 A. Record review of R #7's physician order, dated 12/31/25, revealed enteral feeding (delivering nutrients directly into the gastrointestinal tract (stomach or small intestine) using a soft tube, bypassing the mouth for inadequate oral intake at meals). Give 250 ml (milliliters) Jevity (name brand of fiber-fortified, complete nutritional liquid formula) 1.2 when resident eats less than 25% of meals. B. Record review of R #7's care plan, dated 04/22/25, revealed staff did not document R #7's enteral feed order and interventions for her enteral feed in her care plan. C. On 01/07/25 at 2:12 PM, during an interview, the DON confirmed that staff did not document R #7's enteral feeds or the interventions for the enteral feeds in the care plan. R #11 D. Record review of R #11's admission document, no date, revealed R #11 was admitted to the facility on [DATE]. E. On 01/06/26 at 11:03 AM, during an observation of R #11's toenails revealed her toenail were thick layered. F. Record review of R #11's physician orders revealed an order dated 11/14/25, to check fingernails and toenails. Trim and file as resident will allow as per guidelines every Tuesday and Friday and document resident refusals. G. Record review of R #11's care plan, dated 12/28/25, revealed staff did not document the following: 1. R #11's fingernail and toenail trimming. 2. Staff did not document how they manage care when R #11 refuses nail care and becomes combative. H. On 01/07/26 at 1:21 PM, during an interview with CNA #24, she stated R #11 toenails were thick layered. CNA #24 stated R #11 does not let staff file or trim her nails, she becomes combative. I. On 01/07/26 at 1:27 PM, during an interview with Unit Manager (UM), he stated that his expectation is that R #11 should be care planned for nail care and her behaviors. R #47 K. Record review of R #47's physicians order, dated 12/29/25, revealed oxygen therapy as needed at 1-2 liters per minute via nasal canula (lightweight, flexible medical device used to deliver supplemental oxygen) for low oxygen. L. Record review of R #47's care plan, dated 09/08/25, revealed that R #47's oxygen and interventions for the oxygen were not care planned. M. On 01/08/26 at 2:46 PM, during an interview, the Administrator confirmed R #47's oxygen and interventions were not documented on his care plan. The Administrator stated that the oxygen should be documented on R #47's care plan.

Based on record review and interview, the facility failed to ensure CNAs received the required in-service training of 12 hours per year for 2 (CNA #16 and CNA #17) of 2 (CNA #16 and CNA #17) CNAs reviewed for required in-service training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the residents. The findings are: A. Record review of the employee files revealed the following: 1. CNA #16's hire date was 11/18/24. 2. The file did not contain any documentation of in-service trainings for CNA #16. 3. CNA #17's hire date was 09/20/24. 4. The file did not contain any documentation of in-service trainings for CNA #17. B. On 01/13/26 at 9:27 AM, during an interview, the administrator confirmed the following: 1. There was no documentation of in-service trainings for CNA #16 and CNA #17. 2. CNAs were expected to have at least 12 hours of in-service training annually.

Based on interview and record review the facility failed to ensure residents obtained dental services for 1 (R #7) of 3 (R #5, R #7 and R #63) residents sampled for dental services, when they failed to ensure residents receive routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. The findings are: A. Record review of R #7's medical record revealed an admission date of 04/10/25. B. On 01/06/26 at 1:26 PM, during an interview with R #7's Family Member (FM) #1, he stated that R #7 had not been to see a dentist since she had been at the facility. R #7's FM #1 stated that R #7 does have missing teeth. C. On 01/09/26 at 11:55 AM, during an interview, R #7 stated that she had not been to the dentist. R #7 stated she would like to go to the dentist. D. On 01/09/26 at 12:02 PM, during an interview the Social Services confirmed that the resident has not been to the dentist since she was admitted to the facility.

Based on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #3) of 2 (R #3 and R #47) residents reviewed for respiratory care when staff failed to follow the physician's order for oxygen use. This deficient practice could likely result in residents receiving too much or not enough oxygen and can lead to worsening of their condition. The findings are: A. Record review of R #3's admission documents, no date, revealed the following: 1. R #3 was admitted to the facility on [DATE]. 2. R #3 had the following diagnoses: a. Chronic respiratory failure with hypoxia (a long-term condition where the lungs can't get enough oxygen into the blood, causing low blood oxygen). b. Chronic obstructive pulmonary disease (COPD, a progressive lung condition causing airflow obstruction, making breathing difficult). c. Tracheostomy (a surgical procedure that creates an opening (stoma) in the neck into the windpipe (trachea) to provide an airway). B. Record review of R #3's physician's order, dated 08/12/25, revealed an order for Oxygen concentrator to be set at 3 liters per minute (LPM, flow rate of oxygen) every day and night shift. C. On 01/06/26 at 4:32 PM, during an observation and interview with R #3, the following was revealed: 1. R #3's oxygen concentrator (a medical device that provides supplemental oxygen by taking in ambient air, filtering out nitrogen, and delivering concentrated, purified oxygen (typically 90-95% pure) to the user through a nasal cannula or mask) was set at 4 LPM. 2. R #3 stated his oxygen is usually set at 3 LPM. 3. R #3 stated a couple of days before the interview (was unsure of the date), his oxygen saturation (the percentage of hemoglobin (the iron-rich protein in red blood cells that carries oxygen from your lungs to the rest of your body) in your red blood cells that is carrying oxygen, indicating how well your body's tissues are receiving oxygen from the lungs) was at 72% and staff increased his oxygen concentrator to 4 LPM. D. Record review of R #3's medical record, no date, revealed staff did not document the following: 1. When R #3's oxygen concentrator was increased to 4 LPM. 2. A respiratory assessment (a systematic evaluation of the respiratory system using inspection, palpation, percussion, and auscultation to check breathing patterns, chest movement, lung sounds (like crackles, wheezes), oxygenation, and signs of distress to diagnose issues and monitor lung health) that indicated why R #3's oxygen concentrator was increased to 4 LPM. 3. Whether the provider was notified that R #3's oxygen concentrator was increased. E. On 01/07/26 at 9:05 AM, during an observation of R #3 in his room, revealed R #3's oxygen concentrator was set at 4 LPM. F. On 01/07/26 at 9:06 AM, during an interview, LPN #16 stated the following: 1. She confirmed R #3's oxygen concentrator was set at 4 LPM. 2. She confirmed R #3's physicians order was for R #3's oxygen concentrator to be set at 3 LPM. 3. She was not aware why R #3's oxygen concentrator had been increased to 4 LPM. 4. She confirmed R #3's medical record did not have any documentation regarding why R #3's oxygen was increased or that the provider was notified about increasing R #3's oxygen concentrator to 4 LPM. G. On 01/08/26 at 3:25 PM, during an interview, the DON confirmed the following: 1. If a resident had a change in their respiratory status that required a change in their oxygen concentration, staff were expected to: a. Document an assessment regarding the residents' change in condition. b. Notify the provider and resident's family regarding the change in the resident's condition. c. Enter new orders to increase the resident's oxygen concentrator level. staff did not document in R #3's medical record that R #3 had a change in condition that required his oxygen concentrator to be increased. 2. Staff did not document that a provider was notified about a change in R #3's respiratory status. 3. Staff did not use the communication application to communicate with on-call providers did not contain any messages regarding a change in R #3's respiratory status or the need to increase his oxygen concentration.

Based on observation, record review, and interview, the facility failed to ensure residents received quality treatment and care for 1 (R #16) of 4 (R #4, R #5, R #16, and R #80) residents reviewed for wound treatment when staff failed to: 1. Document R #16 had a wound on his right elbow. 2. Notify the provider and obtain orders for wound treatment for R #16 wound on his right elbow. 3. Provide wound care for R #16's wound on his right elbow. These deficient practices could likely lead to residents needs not being met and/or a worsening of their wounds. The findings are: A. Record review of R #16's admission documents, no date, revealed R #16 was admitted to the facility on [DATE]. B. On 01/05/26 at 2:45 PM, during an observation of R #16 by the nurses' station, revealed the following: 1. R #16 had blood on his right elbow. 2. LPN #17 cleansed R #16's right elbow and placed a bandage over the wound. C. On 01/05/26 at 2:46 PM, during an interview, LPN #17 stated she was placing a bandage on R #16 wound on his right elbow because R #16 had scraped his right elbow on the wheel of his wheelchair. D. On 01/08/26 at 9:46 AM, during an observation and interview of R #16 in the hallway, revealed the following: 1. R #16 had a dressing that was falling off his right elbow that appeared to have dried blood on it. 2. R #16 stated that staff had not changed the bandage since he got the wound on 01/05/26. E. On 01/08/26 at 9:57 AM, during an interview, the wound care nurse stated the following: 1. She was not aware that R #16 had a wound on his right elbow. 2. She observed R #16's elbow and confirmed he had a wound and a dressing that was falling off his right elbow. 3. When a new wound was identified, staff were expected to: a. Assess the wound. b. Notify the provider and resident family about the new wound. c. Document in the medical record regarding the new wound and who was notified regarding the wound. e. Enter orders to complete wound care on the wound. f. She confirmed there was no documentation in the medical record regarding R #16's wound on his right elbow or whether the provider was notified. g. She confirmed R #16's medical record did not have wound care orders for R #16's wound on his right elbow. h. She confirmed there was no documentation that R #16's dressing had been placed. F. On 01/08/26 at 3:04 PM, during an interview, the DON confirmed the following: 1. When a new wound was identified, staff were expected to evaluate and clean the wound, notify the provider and resident family, and enter wound care orders. 2. Staff did not document any information regarding R #16's wound on his right elbow. 3. Staff did not notify the provider or R #16's family that R #16 had a wound on his right elbow. 4. Staff did not enter any orders for wound care for R #16's wound on his right elbow.

Based on record review and interview, the facility failed to meet professional standards of practice for 1 (R #63) of 2 (R #7 and R #63) residents reviewed for physician's orders, when staff did not update an order for R #63's enteral feed. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication. The findings are: A. On 01/06/26 at 2:38 PM, during an interview, LPN #8 stated that R #63 only gets his Jevity (a brand of fiber-fortified, complete nutritional liquid formula) through his Percutaneous Endoscopic Gastrostomy (PEG- a flexible feeding tube placed through the abdominal wall directly into the stomach to deliver nutrition) tube when R #63 eats less than 50% of his meals by mouth. B. Record review of R #63's physician's orders revealed the following: 1. An order dated 11/08/25 for enteral feed (delivering liquid nutrition directly into the gastrointestinal tract (stomach or small intestine) via a soft tube when someone can't eat enough by mouth) four times a day Jevity 1.2 via PEG tube. 2. An order dated 12/01/25 for regular/liberalized diet puree texture, (a dietary modification consisting of foods that have been blended, strained, or pressed into a smooth, cohesive, pudding-like consistency that requires no chewing) thick liquids-Nectar consistency, allow sandwiches and soft snacks with supervision of intake. C. On 01/07/26 at 1:07 PM, during an interview, LPN #9 stated R #63 doesn't get the PEG tube feeding any more. LPN #9 stated that the resident is eating 100% by mouth of his meals. LPN #9 stated that R #63 had been eating on his own for a long time. D. On 01/07/26 at 1:12 PM, during an interview, the Nurse Practitioner (NP) stated R #63 is eating by mouth. The NP confirmed that the order for his PEG tube feeding 4 times a day was not updated to the current status of R #63 getting his PEG tube feeding only if R #63 eats less than 50% of his food by mouth. The NP stated that the order should be updated to document the most current treatment. E. On 01/07/26 at 1:25 PM, during an interview, the DON confirmed R #63's order was not updated. The DON stated that the order should be updated to clarify that R #63 should be fed via the PEG tube if he eats less than 50% of his meal by mouth.

Based on record review, observation, and interview, the facility failed to ensure the MDS assessment was accurate for 2 (R #5 and R #9) of 8 (R #5, R #6, R #9, R #13, R #33, R #51, R #62 and R #80) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the resident's current health status and being unable to meet the resident's current needs. The findings are: R #5 A. Record review of R #5's admission documents, no date, revealed she was admitted to the facility on [DATE]. B. On 01/06/26 at 9:42 AM, during an observation and interview with R #5, revealed the following: 1. R #5 stated that she had several broken teeth that needed to be pulled. 2. R #5 had broken teeth, and her mouth was discolored on the top and bottom. C. Record review of R #5's admission MDS assessment dated [DATE], revealed staff documented R #5 was edentulous (lacking teeth). D. On 01/07/26 at 2:50 PM, during an interview, LPN #16 observed R #5 in her room and confirmed that R #5 was not edentulous. E. On 01/08/26 at 3:10 PM, during an interview, the DON confirmed the following: 1. Staff documented on R #5's admission MDS that she was edentulous. 2. R #5's admission MDS was inaccurate, and staff should not have documented that R #5 was edentulous. 3. Staff were expected to ensure that MDS assessments were accurate. R #9 F. Record review of R #9's admission record (no date) revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. Diagnosis included cerebral infarction unspecified (type of stroke caused by blockage of the vessels that affect blood flow to the brain that can lead to significant disability or death). G. Record review of R #9's medical record revealed the following: Computed tomography angiography (CTA) of the neck (specialized imaging that creates detailed images of the blood vessels in the neck and is used to evaluate conditions that can lead to serious complications like stroke) dated 02/13/25 results: a. Complete occlusion of the right common carotid (serious condition in which there is total blockage of the artery/major blood vessels which supply oxygen-rich blood to the brain, head and neck). b. Greater than 70 % stenosis of the left proximal internal carotid artery (significant narrowing of the artery/major blood vessels which supply oxygen-rich blood to the brain, head and neck). c. Recommend neurovascular evaluation (a specialized and comprehensive assessment with a doctor that specializes in diagnosing and treating conditions related to the blood vessels in the brain and spinal cord, particularly cerebrovascular [group of disorders that affect blood flow to the brain] diseases like stroke). H. Record review of R #9's provider progress note dated 02/14/25 revealed the following: Diagnosis, assessment and plan: a. Stenosis of the left internal carotid artery b. Occlusion of the right internal carotid artery. c. Plan: Discussed results of CTA of neck with resident. Discussed seriousness of findings. Answered all questions. Resident preferring not to go to the emergency department today but waiting for follow-up with vascular specialist. Verbalized understanding of seriousness of the findings and risks associated with waiting for follow-up care including death. I. Record review of R #9's Quarterly MDS assessment dated [DATE] revealed Section I, active diagnoses: Did not include the diagnoses from the CTA dated 02/13/25. J. On 01/08/26 at 3:31 PM an interview with the MDS coordinator revealed the following: 1. She was unaware of the diagnoses for R #9 after he had the CTA on 02/13/25. 2. The medical team liaison (MTL) will usually notify her of new diagnoses. 3. R #9's diagnoses from the CTA on 02/13/25 should have been added to R #9's MDS.

Based on observation, and interview, the facility failed to have reasonable accommodations for 1 (R #61) of 1 (R #61) resident sampled for environment, when they failed to put R #61's call light in a place he could reach it. This deficient practice could likely result in residents not being unable to notify staff when they are in need of assistance. The findings are: A. On 01/06/26 at 12:54 PM, during an observation of R #61's room revealed R #61's call light was hanging over the light above his bed. The light fixture is approximately 6 feet from the floor. B. On 01/06/25 at 12:56 PM, during an interview, CNA #8 confirmed that R #61's call light was hanging from the light fixture above his bed. CNA #8 confirmed that R #61 could not reach the call light. C. On 01/07/25 at 2:24 PM, during an interview, the Administrator confirmed that residents should be able to reach their call lights.

Based on observation and interview, the facility failed to ensure the griddle, essential equipment (vitally important; absolutely necessary) was in safe operating condition for 69 residents of 72 residents who eat food from the kitchen (residents were identified by the resident matrix provided by the Administrator on 11/05/25) when the facility failed to ensure the kitchen griddle had knobs to control the gas burners. If knobs are not in working order, then it could likely affect temperature range, making it difficult or impossible to adjust the heat. The findings are:A. On 11/05/25 at 1:58 PM, during an observation of the facility kitchen revealed four out of four knobs on the gas griddle were missing. B. On 11/05/25 at 2:02 PM, during an interview, the Dietary Manager (DM) confirmed that the knobs were missing.

Based on record review, observation, and interview, the facility failed to maintain proper infection prevention measures when staff failed to ensure facility staff follow transmission-based precautions (actions to prevent the spread of infectious agents from individuals who are suspected to be infected, such as (gloves, facemasks, and gowns) for residents diagnosed with COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) for 1(R #24) of 1(R #24) resident reviewed. Failure to adhere to an infection control program could likely cause the spread of infections and illness to all 72 residents in the facility (residents were identified by the resident census provided by the administrator on 11/05/25) when staff failed to properly dispose of a disposable isolation gown. The findings are: A. Record review of R #24's face sheet, no date revealed R #24 was admitted to the facility on [DATE]. B. On 11/05/25 at 11:17 AM, during an observation of the 100 unit outside of R #24's room, a yellow disposable gown was left hanging on rail in hallway and a sign posted outside the room which indicated the room was under droplet/covid precautions, (is infection control measures designed to prevent the spread of infectious diseases), and staff should wear N95 mask, (respirators and surgical masks are examples of personal protective equipment that are used to protect the wearer from particles or from liquid contaminating the face) gown, and face shield or goggles to enter. C. On 11/05/25 at 11:17 AM, during an interview with LPN #25, she stated R #24 was positive for COVID. The gown should not be hanging on the rails exposed. LPN #25 stated it should be disposed of after it is used and thrown away in the bin. D. On 11/10/25 at 10:51 AM, during an interview with the DON, she stated that gowns, gloves, goggles, and N95 masks are to be worn in resident room when on precautions for COVID. R #24 was isolated to his room for 14 days when R #24 contracted COVID here at the facility when he returned for the hospital. DON stated her expectation is that staff follow infection control and remove their PPE inside of residents' room before exiting to main hall.

Based on observation and interview, the facility failed to safeguard resident's personal privacy and medical record information for 3 (R #12, R #13 and R #24) of 3 (R #12, R #13 and R #24) residents sampled for privacy and confidentiality of records when the facility failed to do the following: 1. Repair the privacy curtain between R #12 and R #13's room. 2. Keep resident's vital signs and name confidential for R #24. These deficient practices could likely result in the residents feeling that their privacy is not valued and their information could be viewed by unauthorized residents, visitors, and staff. The findings are: A. On 11/05/25 at 10:03 AM, during an observation of R #12 and R #13's room, the privacy curtain had a section that was off track, leaving an open gap at the top of the curtain. B. On 11/06/25 at 10:06 AM, during an interview, Nurse Aide (NA) confirmed the privacy curtain in R #12 and R #13's room was off track and not completely closed. The NA stated that the curtain had been like that for several months. C. On 11/06/25 at 11:12 am, during an interview, LPN #8 confirmed the privacy curtain was off the track. LPN #8 stated that it had been off the track for a couple of months. D. On 11/05/25 at 11:17 AM, during an observation of the 100 Unit outside of R #24's room, a paper towel with R #24's name and vital signs was found on a wheelchair and staff were not present. E. On 11/05/25 at 11:20 AM, during an interview LPN #25 stated R #24's private information should not be exposed in the hallway for everyone to see. R #24 F. On 11/05/25 at 11:17 AM, during observation of the 100 Unit outside of R #24's room, a paper towel with R #24's name and vital signs was found on a wheelchair and staff were not present. G. On 11/05/25 at 11:20 AM, during an interview LPN #25 stated R #24's private information should not be exposed in the hallway for everyone to see. H. On 11/10/25 at 10:51 AM, during an interview with the DON, she confirmed that resident name and vital signs should not be written on a paper towel. DON stated there is a vital sheet that is covered and protected that is used by staff to protect residents' privacy.

Based on record review and interview, the facility failed to ensure care plan revisions occurred for 2 (R #3 and R #8) of 6 (R #1, R #2, R #3, R #4, R #8, and R #9) residents reviewed for care plan accuracy when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #3 A. Record review of R #3’s admission record (no date) revealed R #3 was admitted to the facility on [DATE]. B. Record review of R #3’s progress notes revealed the following: 1. Nurse note dated 05/06/25 at 6:12 PM: “Guardian in to visit with resident. Resident voiced concerns of wanting to go home or possible assisted living. Guardian stated she educated resident that it is a process and will assist in process for resident.” 2. Care plan meeting note dated 07/02/25 at 1:47 PM: “Plan is to move to assisted living in Las [NAME].” C. Record review of R #3’s care plan dated 07/02/24 revealed the following: Focus: R #3 is not expected to be discharged related to inability to care for self at home. Goal: R #3 will be accepting of and appropriate for long-term placement through next review. Interventions: (actions taken by facility staff): Identify, discuss and document resident/patient desires and concerns/barriers regarding discharge. D. On 08/27/25 at 4:32 PM, during an interview with the DON, the following was confirmed: 1. R #3 expressed the desire to be discharged from the nursing facility to an assisted living facility. 2. R #3’s care plan was not updated to reflect the change in his discharge plan. R #8 E. Record review of R #8’s admission documents, no date, revealed she was admitted to the facility on [DATE]. F. Record review of R #8's physician's orders, multiple dates, revealed the following: 1. An order dated 06/10/25, for trazodone (prescription antidepressant medication that belongs to the class of drugs known as serotonin antagonist and reuptake inhibitors) 100 mg 1 tablet by mouth once a day for circadian rhythm disorder (a sleep disorder that occurs when your body's internal clock, known as the circadian rhythm, is out of sync with your environment or your desired schedule). 2. An order dated 07/15/25, for mirtazapine (is an atypical tetracyclic antidepressant used primarily to treat major depressive disorder) 15 mg give one tablet at bedtime for depression. G. Record review of R #8’s care plan, dated 07/08/25, revealed the care plan did not contain any interventions or goals for trazadone or mirtazapine. H. On 08/26/25 at 1:39 PM, during an interview, the DON confirmed R #8’s care plan did not have interventions or goals for R #8’s trazodone or mirtazapine. The DON stated her expectation is that there should be interventions and goals for all psychotropic medications.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #1 and R #8) of 6 (R #1, R #2, R #3, R #4, R #8 and R #9) residents reviewed for documentation accuracy when staff failed to: 1. Document blood pressure and heart rate readings for R #1. 2. Document the correct diagnosis on the medication administration record for R #8. This deficient practice has the potential to have a negative impact on the care staff provide to residents due to missing or inaccurate records and resident information. The findings are: R #1 A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 diagnoses included: a. Essential primary hypertension (HTN, abnormally high blood pressure that is often influenced by lifestyle factors and not the result of a medical condition). b. Paroxysmal atrial fibrillation (A FIB, episodes of rapid and irregular heartbeats that can last from a few minutes to several days). B. Record review or R #1’s Physicians orders revealed the following: 1. Order dated 01/20/25; metoprolol (medication used to treat blood pressure) 25 mg give half tablet by mouth one time a day for HTN/A FIB, hold (do not give medication) for systolic blood pressure (SBP, top number of blood pressure reading) less than 100, diastolic blood pressure (DBP, bottom number of blood pressure reading) less than 50 or heart rate less than 60. 2. Order dated 03/18/25; lisinopril (medication used to treat high blood pressure) give 30 mg by mouth one time a day for hypertension hold for SBP less than 100 or DBP less than 50. 3. Order dated 07/20 25; furosemide (diuretic medication that helps the body get rid of excess fluid) give 20 mg by mouth one time a day for lower extremity edema (swelling of the legs) hold SBP less than 100 or DBP less than 50 C. Record review of R #1's MAR dated August 2025, revealed the following: 1. Staff did not document R #1’s blood pressure or heart rate when administering metoprolol. 2. Staff did not document R #1’s blood pressure when administering lisinopril. 3. Staff did not document R #1’s blood pressure when administering furosemide. D. Record review of R #1’s vital signs (measurements of basic functions of the body that are essential for life including blood pressure, heart rate, body temperature and respiratory rate) for August 2025 revealed the following: 1. Staff did not document R #1’s blood pressure on August 6th, 7th, 14th, 15th, 16th, 17th, 19th, 20th, 21st, 22nd, 23rd and 24th. 2. Staff did not document R #1’s heart rate on August 4th, 6th, 7th, 14th, 15th, 16th, 17th, 19th, 20th, 21st, 22nd, 23rd and 24th. E. On 08/27/25 at 4:22 PM, during an interview with the DON, the following was confirmed: 1. Staff should document the required vital signs when administering medications if the MAR has that option. 2. If staff do not have the option to document vital signs on the MAR they should document them in the vital signs section of the resident’s medical record. 3. Her expectation is that staff will document the vital signs in the medical record as indicated on the physician’s orders. R #8 F. Record review of R #8’s admission documents, no date, revealed she was admitted to the facility on [DATE] with a diagnosis of circadian rhythm sleep disorder. G. Record review of R #8's MAR for the month of August 2025 revealed, mirtazapine 15 mg give one tablet at bedtime for depression. H. Record review of a psychiatric provider progress note, dated 07/15/25, revealed mirtazapine was prescribed for circadian rhythm disorder (a sleep disorder that occurs when your body's internal clock, known as the circadian rhythm, is out of sync with your environment or your desired schedule). I. On 08/26/25 at 1:39 PM, during an interview, the DON stated R #8’s prescription for mirtazapine is for circadian rhythm disorder and that depression is the indication. The DON stated that staff entered the order wrong.

Based on observation, record review, and interview, the facility failed to provide foot care for 1 (R #1) of 1 (R #1) resident reviewed for foot care when staff failed to provide nail care for R #1's toenails or make an appointment to a podiatrist for foot care. This deficient practice could likely cause podiatric complications (foot and ankle health issues, often arising from underlying systemic diseases like diabetes or poor circulation, that can lead to problems such as ulcers, infections, nerve damage (neuropathy), and, in severe cases, amputation in residents with diabetes). The findings are: A. Record review of R #1's admission record, no date, revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 has a diagnosis of type 2 diabetes mellitus (a chronic metabolic condition characterized by insulin resistance, where the body's cells don't respond to insulin properly, and a gradual decline in the pancreas's ability to produce enough insulin) without complications. B. On 08/25/25 at 1:16 PM, during an observation, R #1's toenails were overgrown, and her feet were callused (a thickened and hardened part of the skin or soft tissue). C. On 08/25/25 at 1:16 PM, during an interview, R #1 stated staff had not offered to cut her toenails and that she had not seen a podiatrist (a person who treats the feet and their ailments) since her admission. R #1 stated she had lost a toenail but that it was growing back. D. Record review of R #1's progress note, dated 07/11/25, revealed R #1 resident's nail fell off with no pain or blood. There was a recommendation from the provider to cleanse with wound cleanser pat dry apply triple antibiotic ointment, cover with dry gauze and secure with tape until healed. E. On 08/25/25 at 2:25 PM, during an interview, CNA #8 confirmed R #1's toenails were long and had not been cut. F. On 08/25/25 at 2:29 PM, during an interview, LPN #8 confirmed R #1 had a diagnosis of type 2 diabetes mellitus. LPN #8 stated that if a resident has a diagnosis of diabetes that a podiatrist will provide foot care for residents. LPN #8 stated the facility does not have a podiatrist that comes to the facility. G. On 08/25/25 at 3:31 PM, during an interview, RN #8 stated she had not seen R #1's toenails and that she had not made any referrals for R #1 to be seen by a podiatrist. RN #8 stated that residents' nails should be checked once a week. RN #8 confirmed R #1 is a diabetic. RN #8 confirmed that R #1's toenails are long and callused. H. On 08/26/25 at 2:46 PM, during an interview, the Schedular (staff who schedules appointments) stated he had scheduled an appointment last week for R #1 to see a podiatrist.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse/mistreatment for 1 (R #16) of 3 (R #1, R #16, and R #17) residents reviewed when they failed to: 1. Identify that staff using a deceased resident to carry out a prank/joke on another staff member was abuse/mistreatment of the resident. 2. Thoroughly investigate all components of the allegation. 2. Prevent further abuse/mistreatment by not removing RN #1 [initiator of the prank] from resident care. 3. Initiate corrective action to ensure staff are not dehumanizing residents and continue to treat residents with respect even after they are deceased . If the facility is not adequately investigating allegations of abuse, then corrective action is not implemented to prevent other residents from similar abuse which puts residents at risk of adverse serious outcomes. The findings are: Cross Reference findings from F550 A. Record review the admission record revealed R #16 was initially admitted on [DATE]. B. Record review of Physician Orders revealed R #16 was full code (medical term indicating patient wishes to receive all possible life saving measures in the event of a medical emergency). C. Record review of R #16's progress notes dated [DATE] revealed: 1. 2205 (10:05 pm) resident assessed during hourly rounds. Semifowler (reclining position with head and torso raised between ,d+[DATE] degrees) in bed, room in good order no issues whatsoever resident unresponsive to when called out attempting to arouse. Assess results radial pulse weak faintly palpable (to be felt). Visible respiration inadequate to sustain life due to rate of 4 -8 per minute. Code blue initiated. Code blue called out, crash cart obtained, 911 call for assistance from emergency response teams. CPR (cardiopulmonary resuscitation) protocol breaths and chest compression provided 2208 (10:08 pm). 2211(10:11 pm) patient assessment resulting in no detectable heart beat, respirations, CPR resumption at which time ems entered room and immediately deployed team in rendering/continuing care. At this time care center employees and this nurse removed ourselves from that role. 2. Progress note identified notification to next of kin (Son #1) and he indicated that he would need to contact Son #2 to get funeral information. Per progress note dated [DATE] at 5:44 am, still waiting on funeral information. D. On [DATE] at 4:36 PM, during an interview, NA #1 stated she got to work on [DATE] at 6:00 am. NA #1 said that she noticed R #16's door was closed, and the door being closed was unusual. NA #1 said that at 6:30 AM, RN #1 [night shift manager] asked her to take R #16's vital signs. NA #1 stated when she went into R #16's room, the room was cold. NA #1 said R #16 would usually respond to her right away when entering the room. NA #1 said R #16's dentures did not seem to be sitting right in her mouth. NA #1 further stated that she nudged R #16 and noticed at that time she was cold. NA #1 stated she realized R #16 had passed, so she left the room to let staff know and RN #1 was standing outside the room laughing. NA #1 stated RN #1 said it was a cruel rookie joke that he was playing and RN #1 told NA #1 not to say anything because he wanted to play the joke on another staff member. NA #1 said that she was so distraught that emergency medical services had to be called to check her out because she was having a panic attack. E. On [DATE] at 12:07 PM, during an interview, the Administrator said she is the abuse coordinator. The Administrator stated R #16 passed during the night on [DATE] at 10:56 PM. The Administrator said RN #1 told NA #1 to go check vitals on R #16 who had already passed. The Administrator said RN #1 used the passing of R #16 as a teaching opportunity to teach NA #1 what to do when someone passes away. The Administrator further stated she was not told what happened to NA #1 was a joke/prank and she did not report the incident to the state because she thought it was a staff thing. The Administrator stated she received an email from [Name of NA #1's] family member [on ,d+[DATE]] informing her that NA #1 was sent to R #16's room after she had passed away, was a joke and only after she received the email did she initiate an investigation [[DATE]]. The Administrator investigated the incident as the facility not performing proper postmortem care because the emailed mentioned that when NA #1 entered the room to take vitals, she noticed that R #16's dentures were free floating in her mouth. The Administrator further stated that RN #1 was not suspended because he was scheduled to be off the days following the incident (RN #1 was still working in the facility until [DATE]. See plan of removal.) RN #1 received a written reprimand for sending NA # 1, to get vitals on a deceased resident (R #16). The Administrator did not document any reprimand for disrespecting a deceased resident. During the interview, the Administrator reported that she did not believe that there was any effect to R #16 because she was already deceased when it happened. The Administrator confirmed that there was not any education for RN #1 or other staff regarding respecting deceased residents. F. Record review of the facility's self report dated [DATE] identified Care concerns have been reported for this resident [R #16]. Investigation started. G. Record review of the follow-up report dated [DATE] revealed On [DATE] an email was sent to [Corporate name] legal department about allegations of possible mistreatment of a resident after she passed. The lady writing the email claimed to be the mother of one of our nursing assistants and this lady made accusations that her daughter told her that the residents dentures didn't look quite right when she was sent in the room by her charge nurse. Her daughter worked here as a nursing assistant and was working that AM shift after [Name of R #16] had passed away. An investigation was started and the NOC (night) shift were interviewed about the post mortem care done for [Name of R #16] after she passed away on the NOC shift. The nurse on shift and the CNA on shift both stated they did the care together and [Name of R #16]'s dentures were removed during this care and placed in a denture cup to be sent to the mortuary with her. An AM shift CNA that helped the mortuary staff transfer her to their gurney supported their statement and said she gave the mortuary staff her dentures that had been sitting on the bedside table. Future Preventative Actions included Spot checks performed by the charge nurses to ensure the CNA's are performing proper postmortem care. No additional evidence was provided to include acknowledgement of the prank, any reprimand to the staff member who initiated the prank or any staff education to staff involved or aware of the incident related to mistreatment of the resident. H. Record review of the individual performance improvement plan date [DATE] revealed that the policy violation was RN #1 should not have told NA #1 to do vitals on a dead resident. It states that NA #1 could not handle it and that some people cannot handle, especially a young person that has not dealt with death before. The expected result was to not do it again. The developmental process was that death is a serious thing for people to deal with and it's not something that comes naturally. The measurement of expected results were that this will not happen again. Target date for the improvement was immediately. I. Record review of the Abuse Prohibition Policy dated [DATE], revealed the following: 1. Suspected abuse will be reported to immediately. 2. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. J. On [DATE], three attempts were made to contact RN #1 for an interview. RN #1 did not answer, voicemails were left, and RN #1 did not return any of the calls. The above findings resulted in an Immediate Jeopardy that was called on [DATE] at 4:55 PM. The facility submitted a final plan of removal on [DATE] at 4:45 PM and the IJ was lifted, implementation was verified onsite. Training was reviewed, staff were interviewed and policy verified. Abuse Prohibition Policy was obtained and reviewed. Scope and Severity was reduced to level 2, D. Plan of Removal .The following identification/corrections will be completed by [DATE]: -The Administrator and DON were re-educated on [DATE] through [DATE] by the Market level staff, including the Market President special projects, Market Operation Advisor, Market Clinical Advisor, The training was on the policy and procedures for resident abuse and neglect with an emphasis on allegations of abuse being identified, immediate interventions put in place to prevent reoccurrence, immediately reporting to the appropriate state agencies, thorough investigation, and resident rights. -A full investigation occurred within the facility to ensure no other residents have been mistreated or have felt they were treated undignified was completed by [DATE]. Residents that are alert and able to answer questions were asked if they felt they had been treated in an undignified manner. The residents that are unable to answer appropriately or fully, their families/POA's (Power of Attorney the authority to act for another person in specified or all legal or financial matters) or guardians were called and asked the same question. If any further mistreatment or undignified treatment is identified, the facility will remove any resident from the situation, and proper monitoring and interventions will be initiated immediately upon notification. No new allegations were identified or alleged during the interview process. -If any staff are identified in an allegation of abuse, neglect, undignified behavior or mistreatment, the staff member will be removed from the situation to ensure resident safety and dignity, and the staff member will immediately be placed on administrative leave until the investigation is completed. -On [DATE] the identified RN of concern was placed on administrative leave pending the investigation. The RN's last scheduled work day in the facility was on [DATE] and on [DATE] RN was placed on Admin leave. Should the RN be allowed to return to work following the investigation; additional retraining will be offered by the Administrator and DON along with New Mexico Market level clinical leads under the guidance of corporate legal/risk/compliance staff on ensuring resident dignity and treating co-workers with respect and with a monitoring plan in place to ensure this does not recur.

Based on record review and interview, the facility failed to have an effective administration that maintained the highest practicable well-being of residents for 1 (R #16) of 3 (R #1, R #16, and R #17) residents reviewed when the administration failed to recognize the mistreatment, dehumanization (the process of depriving a person or group of positive human qualities) and disrespect to R #16 when she was used by staff to prank another staff member after she was deceased . If the administration is unable to adequately identifying the mistreatment of residents, even of deceased residents still under the care of the facility and establish a standard of practice by implementing adequate corrective action when failures are identified, then residents remain at risk of serious adverse outcomes. The findings are: Cross reference findings from F550 and F610 A. On [DATE] at 4:36 PM, during an interview, NA #1 stated she got to work on [DATE] at 6:00 am. NA #1 said that she noticed R #16's door was closed, and the door being closed was unusual. NA #1 said that at 6:30 AM, RN #1 asked her to take R #16's vital signs. NA #1 stated when she went into R #16's room, the room was cold. NA #1 said R #16 would usually respond to her right away when entering the room. NA #1 said R #16's dentures did not seem to be sitting right in her mouth. NA #1 further stated R #16 did not respond to her, she nudged R #16 and noticed at that time she was cold. NA #1 stated she realized R #16 had passed, so she left the room to let staff know and RN #1 was standing outside the room laughing. NA #1 stated RN #1 said it was a cruel rookie joke that he was playing and RN #1 told NA #1 not to say anything because he wanted to play the joke on another staff. NA #1 said that she was so distraught that emergency medical services had to be called to check her out because she was having a panic attack. B. Record review of a written statement dated [DATE], from CMA #1 revealed there was another staff member that was going to be asked to take vital signs on the deceased resident as a friendly joke but that staff member did not report to work. CMA #1 wrote NA #1 was the one sent into the room [to be pranked]. C. On [DATE] at 12:07 PM, during an interview, the Administrator said she is the Abuse Coordinator and she is the one that took the lead on the investigation of R #16 not the DON. The Administrator said R #16 passed away during the night on [DATE] at 10:56 am, and she was not at the facility. The Administrator said the morning after R #16 passed away, she was told that RN #1 told NA #1 to go check vital signs on R #16. The Administrator said she was not told checking the vitals was a joke that was being played on NA #1. The Administrator said RN #1 used the passing of R #16 as a teaching opportunity to teach NA #1 what to do when a resident passes. The Administrator said when she arrived to the facility on [DATE], NA #1 was passing trays. The Administrator said NA #1 became upset and started breathing heavy and NA #1 said she had a rough morning. The Administrator said they called an ambulance to come check NA #1. The Administrator said NA #1 ended up going home for the day. The Administrator said she did not submit a report to the state because she thought it was a staff thing. The Administrator stated she received an email from [Name of NA #1's] family member informing her that NA #1 was sent to R #16's room after she had passed away, was a joke and only after she received the email did she initiate an investigation [[DATE]]. The Administrator said NA #1 was not interviewed because she did not return the phone calls. The Administrator said RN #1 was not suspended because he was already scheduled to be off the days following the incident on [DATE] (RN #1 was still working in the facility until [DATE]. See plan of removal.) The Administrator said RN #1 received a written reprimand and was told not to do anything like that again without running it by herself or the DON. The Administrator said that RN #1 should not have told NA #1 to do vitals on a dead resident because NA #1 was young and could not handle it. The Administrator confirmed that the incident involving R #16 was not reported to the state as a staff to resident incident because she did not understand how this incident would have affected R #16 because she was already deceased . The Administrator confirmed that there was not any education or correction provided for RN #1 or other staff regarding respecting deceased residents. The Administrator never acknowledged that the prank was inappropriate. D. Record review of a written statement, no date (the Administrator did not date her statement), from the Administrator [detailing the events as she recalled them. The statement was made as part of the facility's investigation.], revealed NA #1 told her a joke had been played on her when RN #1 sent her into the resident's room do vitals on a dead lady. E. Record review of the facility's investigation report dated [DATE], revealed no written statement from the DON. The Administrator did not document DON's involvement in the investigation or the incident or as it related to the oversight of RN #1 and other nursing staff involved. F. Record review of the individual performance improvement plan for RN #1 dated [DATE], revealed RN #1 was given a written reprimand for sending NA #1 to get vitals on a deceased resident [due to NA #1 being inexperienced]. The Administrator did not document any reprimand related to the mistreatment of a deceased resident. G. On [DATE], three attempts were made to contact RN #1 for an interview. RN #1 did not answer, voicemails were left, and RN #1 did not return any of the calls. The above findings resulted in an Immediate Jeopardy that was called on [DATE] at 4:55 PM The facility submitted a final plan of removal on [DATE] at 4:45 PM and the IJ was lifted, implementation was verified onsite. Training was reviewed, staff were interviewed and policy verified. Scope and severity was reduced to level 2, D. Plan of Removal .The following identification/corrections will be completed by [DATE]: -The Administrator and DON were re-educated on [DATE] - [DATE] on numerous calls by the Market level staff, including the Market President special projects, Market Operation Advisor, Market Clinical Advisor, on the policy and procedures on Resident abuse and neglect with emphasis on dignity, respect and mistreatment, allegations of abuse being identified, immediate intervention put in place to prevent reoccurrence, immediate reporting to the appropriate state agencies and thorough investigation and resident rights. -The Market Operations Advisor and Market Clinical Advisor will have oversight of the Administration of the facility effective immediately. Current Administrator and Director of Nursing to be placed on administrative leave pending additional retraining by New Mexico Market level and facility National legal/risk staff on thorough investigations, federal definitions of abuse/neglect and facility policy. All aspects of all investigations will be reviewed by the Market Ops Advisor and/or Market Clinical Advisor, and reviewed to ensure the investigation is complete and thorough. -The Senior Operation resource lead and the Market Clinical resource lead will monitor and run the operational and clinical affairs of the facility to ensure quality care is provided to the residents at the facility. The Senior Operation resource lead also will assume the role of the facility abuse coordinator and will receive reports on all alleged abuse/neglect concerns. -A full investigative audit occurred within the facility from [DATE] through [DATE] to ensure no other current residents have been mistreated or have felt they were treated undignified. Residents that are alert and able to answer questions were asked if they felt they have been treated undignified and for the residents not able to answer, their families/POA's (Power of Attorney the authority to act for another person in specified or all legal or financial matters) /guardians were called and asked the same question. and if any further mistreatment or undignified treatment comes forward, the facility will remove any resident from the situation, and proper monitoring and interventions will be initiated immediately upon notification. No new allegations of abuse have been provided. -If any staff are identified in an allegation of abuse, neglect, undignified behavior or mistreatment, the staff member will be removed from the situation to ensure resident safety and dignity, and the staff member will immediately be placed on administrative leave pending the investigation completion. -On [DATE] the identified RN of concern was placed on administrative leave pending the investigation. The RN's last scheduled day of work was [DATE].

Based on record review and interview, the facility failed to ensure residents had a right to a dignified existence and were treated with respect and dignity for 1 (R #16) of 3 (R #1, R #16, and R #17) residents when facility staff used R #16 (without consent) to play a prank/joke on another staff member after R #16 was deceased . This deficient practice was disrespectful and dehumanizing to R #16 and her family. The findings are: A. Record review the admission record revealed R #16 was initially admitted on [DATE]. B. Record review of Physician Orders revealed that R #16 was full code (medical term indicating patient wishes to receive all possible life saving measures in the event of a medical emergency). C. Record review of R #16's progress notes dated [DATE] revealed: 1. 2205 (10:05 pm) resident assessed during hourly rounds. Semifowler (position of laying in bed on back with head and torso raised between ,d+[DATE] degrees) in bed, room in good order no issues whatsoever resident unresponsive to when called out attempting to arouse. Assess results radial pulse weak thready faintly palpable (to be felt). Visible respiration inadequate to sustain life due to rate of 4 -8 per minute. Code blue initiated. Code blue called out, crash cart obtained, 911 call for assistance from emergency response teams. CPR (cardiopulmonary resuscitation) protocol breaths and chest compression provided 2208 (10:08 pm). 2211(10:11 pm) patient assessment resulting in no detectable heart beat, respirations, CPR resumption at which time ems entered room and immediately deployed team in rendering/continuing care. At this time care center employees and this nurse removed ourselves from that role. 2. Progress note identified notification to next of kin (Son #1) and he indicated that he would need to contact Son #2 to get funeral information. Per progress note dated [DATE] at 5:44 am, still waiting on funeral information. D. On [DATE] at 4:36 PM, during an interview, NA #1 said she arrived at work on [DATE] at 6:00 AM and at 6:30 AM, RN #1 asked her to go take R #16's vital signs (measurements of the body's essential functions). NA #1 said when she went into R #16's room and usually R #16 would respond to her right away when entering her room but this time she did not. NA #1 said R #16's dentures did not seem to be sitting right in her mouth and R #16 did not respond to her. NA #1 stated she nudged R #16 and noticed she was cold. NA #1 said she realized R #16 had passed away. NA #1 said she thought R #16 had just passed away, so she left the room to let staff know, and RN #1 was standing outside R #16's room laughing. RN #1 stated that it was a cruel rookie joke that he was playing on her. RN #1 told NA #1 not to say anything because he wanted to play the same joke on another staff. NA #1 said that she was so distraught after the incident that eventually emergency medical services had to be called because she was having a panic attack. E. On [DATE] at 6:57 PM, during an interview, CNA #1 stated R #16 passed away on [DATE] at 10:56 PM. CNA #1 said RN #1 wanted to play a joke on NA #1 (RN #1 is the night shift manager on the unit). CNA #1 said that when NA #1 got to work on [DATE], RN #1 told NA #1 to go take R #16's vital, knowing that R #16 was deceased . CNA #1 confirmed that she did not try to prevent the prank. F. On [DATE] at 7:16 PM, during an interview, NA #2 said that R #16 had passed away and RN #1 wanted to play a joke on staff. NA #2 said when NA #1 got to work around 6:00 am on [DATE], she heard RN #1 ask NA #1 to go take R #16's vital signs. NA #2 said the joke was supposed to be played on another coworker too, but that the other coworker did not report to work. G. On [DATE] at 12:01 PM, during an interview, Unit Manager (UM) #1 said she arrived at work on [DATE] at 6:00 am. UM #1 said she did not witness the prank that was played on NA #1, but was told about the joke after it happened. UM #1 did not remember who told her. UM #1 said she did not know whose idea it was to play the joke. UM #1 said she was told that someone was told to take vitals on a resident that was deceased . H. On [DATE] at 12:07 PM, during an interview, the Administrator said R #16 passed away during the night. The Administrator said that the morning ([DATE]) after R #16 passed, RN #1 told NA #1 to go check vitals on a resident that had already passed. The Administrator said RN #1 wanted to use the passing of R #16 as a teaching opportunity to see what NA #1 would do if a resident passed away. The Administrator said that she was not told that it was meant to be a joke. The Administrator said that she received an email from NA #1's family member later on [received on [DATE]] informing her of what was done to NA #1 was a joke. During the interview, the Administrator reported that she did not believe that there was any effect to R #16 because she was already deceased when it happened. I. Record review of CMA #1's written statement dated [DATE], revealed NA #1 was asked to take R #16's vitals and R #16 had already passed away and checking the vital signs was as a friendly joke. J. Record review of SSD's written statement dated [DATE], revealed NA #1 told her that she was asked to get R #16's vitals, and R #16 was already dead. SSD said that NA #1 stated she was freaked out really bad by what had happened. K. On [DATE], three attempts were made to contact RN #1 for an interview. RN #1 did not answer, voicemails were left, and RN #1 did not return any of the calls. L. On [DATE] at 4:13 PM, during an interview with R #16's son (Son #2), he said that R #16 would have been horrified that a staff member was sent into her room after she had passed away to check her vitals as a prank. Son #2 said it was disgusting that they [staff] did that to his mother.

During a complaint survey the following was discovered: 1) Allegations of abuse and neglect for R #1 (03/08/18) and R #2 (03/03/18) were not thoroughly investigated or reported to the State Agency. 2) Staff (The Administrator and LPN #1) who allegedly abused R #1 and R #2 were allowed to continue to come into the facility without regard for resident safety pending the outcome of the investigation. 3) Staff were not aware of who to report allegations against the Administrator, due to the ADON and DON leaving their positions, resulting in a delay in reporting to corporate staff. 4) Staff did not want to get involved in the investigation into allegation against the Administrator for fear of retaliation from corporate office. 5) The Administrator attempted to retaliate against a staff member for writing a grievance for R #1 against the Administrator. This resulted in an Immediate Jeopardy that was called on 03/14/18 at 12:24 pm. A Plan of Removal were submitted at 03/14/18 at 1:15 pm and 3:09 pm, and 03/15/18 at 10:35 am and were rejected. A final Plan of Removal was approved on 03/15/18 at 1:45 pm. 1. The self report of the allegation of abuse of (Name of R #1) and (Name of R #2) will be submitted today to (Name of State Agency) by the DON. 2. The investigation in regards to the allegation of abuse with (Name of R #1) has begun at the corporate level and will be completed within 5 days by regional/corporate staff and lead by (Name of Corporate Regional Director). The allegation of abuse investigation of (Name of R #2) will be today and will be completed by (Name of DON). 3. In order to keep both residents safe both alleged staff members will be placed on administrative leave pending investigation. 4. In-service has been initiated and will be complete with all staff members about reporting abuse within 2 hours, to the abuse coordinator, if the abuse coordinator is not available then staff will follow the chain of command. In the event the allegation is directed at the administrator/abuse coordinator the Regional Director of Operation will be notified. No staff member will be allowed to return to work until they have received this re-education regarding abuse reporting. 5. Social Services director will interview eight (8) alert and oriented residents to ensure there are no other allegations to investigate. 6. H.R. director (sic) will interview staff members to ensure they are comfortable reporting and have reported any allegations they are aware of. No staff member will be allowed to return to work until they have been interviewed. 7. Due to the current transition, The (sic) Regional Director of operation (sic) phone number will be listed so that corporate will be notified of any allegation of abuse to give direction to staff on other steps to follow. 8. Due to the current transition, The (sic) Regional Director of Operation (RDO) will be designated as the abuse coordinator and will be responsible for reporting and investigating allegations of abuse. The RDO's phone number will be listed at all Nursing stations so the staff can notify RDO of all allegation (sic) of abuse. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted on 03/15/18 at 2:45 pm. This resulted in the scope and severity being reduced from a K to an E. Based on observation, interview, and record review, the facility failed to keep residents free from abuse for 2 (R #1 and R #2) of 4 (R #1, R #2, R #3, & R #4) residents sampled for abuse and neglect, when they 1) failed to suspend the Administrator pending an investigation of an allegation of abuse made by R #1, 2) No staff members interviewed R #1after the allegation because it involved the Administrator, 3) failed to suspend LPN #1 pending an investigation of an allegation of abuse involving R #2, 4) failed to thoroughly investigate and report the allegation of abuse of R #2 by LPN #1, and 5) failed to provide goods such as adult briefs (Attends), pull-ups, and wipes to residents. If staff members who allegedly abuse residents are allowed to continue to come into the building after their allegations have been reported and allegations of abuse are not thoroughly investigated, then residents have the high likelihood of continuing to be abused. The findings are: A. Record review of the Administrative Standards of Practice Manual, revision date (MONTH) (YEAR), revealed the following: Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property . V. Investigation: When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: · Interview the involved resident if possible and document all responses . A. The facility must have evidence that all violations, including allegations, are thoroughly investigated . B. The results of the investigation must be reported to the Administrator and other officials in accordance with state law (including the state survey and certification agency) within 5 working days of the incident. VI. In order to provide protection to the resident during an investigation of abuse, neglect or exploitation the following will be done: · The alleged abuser will be removed from the facility immediately, and not allowing the facility, pending the outcome of the investigation . · Protection of staff, residents and /or family members from retaliation VII. Reporting and response to alleged Incidents: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment . will be reported by the facility Administrator, or his/her designee, to the following agencies: the state licensing/certification agency responsible for surveying/licensing the facility; . 2. Suspected abuse, neglect, exploitation or mistreatment . will be reported within two hours. 3. Alleged abuse, neglect, exploitation or mistreatment . will be reported within two hours if the alleged events resulted in serious bodily injury; 4. If events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours . Note: If the alleged abuse/neglect involves the Administrator, report the incident immediately to the DON. If the Don in not available, report the incident immediately to the Regional Director of Operations or regional Quality Consultant. Allegation for R #1 B. On 03/14/18 at 11:13 am, during an interview, R #1 stated that he had concerns that he went to talk to the Administrator about on 03/08/18. She told me that she was not going to listen to me or anyone. And no one is going to tell me what to do. I am not going to put up with you (R #1) or anyone else. R #1 continued, It was abusive to me. R #1 also stated that he filed a grievance with the front receptionist on the same day. C. On 03/14/18 at 11:23 am, during an interview, the Social Services Director (SSD) stated The grievance (R #1's) was put it my box on Thursday (03/08/18 SSD was not in the facility that date), and I did not get to it till late Friday (03/09/18). I went to ask the DON for guidance because it was against the Administrator. They did not know (what to do). I emailed it to Corporate Regional Director (CRD) on Monday (03/12/18). I did not think this was abuse. The SSD was asked if she ever interviewed R #1 or talked to him about the incident. The SSD stated, I did not talk to (Name of R #1). D. On 03/14/18 at 11:36 am, during an interview, the DON was asked if she would categorize the incident between the Administrator and R #1 as abuse. The DON stated No. The DON continued to state that at one point there was a concern that R #1 may have had his hand hit by the door during this incident, but after asking staff the DON determined that this did not happen. The DON was asked if she talked to R #1. The DON stated, I did not talk to (Name of R #1) because I was getting ready to leave (her position as DON) and corporate came down and told the department heads that we were pinning residents against the Administrator. I wanted corporate to handle that investigation for fear of retaliation. At the standup meeting, CRD told us 'As department heads we are held to higher standard, we should not be pinning residents against the Administrator'. At other places I would always be able to go to the Administrator's boss, but if corporate was not supportive then . they are not. E. On 03/14/18 at 12:04 pm, during an interview, the Receptionist stated I was on smoking break. (Name of R #1) came out. He was saying 'I'm very upset' I asked him is that anything I could do? He asked me if he could file a grievance. So I wrote up his grievance. The Receptionist continued to state that on 03/12/18 she got called into the Administrators office because the Administrator was upset about R #1's grievance. The Receptionist continued that the Administrator did not like that she wrote R #1's statement saying she was prejudice, and that she was not supposed to take grievances. They were supposed to go to SSD. I tried to tell her that I just wrote down what (name of R #1) told me. (Name of SSD) was out that day, and that it involved her. My training was that anyone could take a grievance; that's why the forms are all over the building. That afternoon, she (the Administrator) called me back to her office said I was being written up. I did not sign the paper, because I talked to the SDC and she said that anyone could take grievance. Then she got phone call and told us to leave her office. F. Record review of the Complaint/Grievance Report dated 03/08/18 revealed: 1. Resident feels Administrator is being pregidust (sic) towards her (sic). Lack of supplies. Concern of residents during lunch. (neglect) not enough CNA's. not enough wipes, shaving cream, lotion, laundry not properly done. 2. Statement attached revealed, (Name of Administrator) has no time for residents. Only for certain ones. Not Being equal. Not following rules. He does not think that the Administrator should be allowed to go into the kitchen without a hairnet. She caters to certain residents. He had been here for 35 days and his sheets have never been changed. Not receiving all of his clothes, they all have his name and room #. (gave resident a copy) . G. Record review of an email from SSD to CRD dated 03/12/18 revealed, I received this grievance late Friday afternoon, not sure what to do as DON and ADON will no longer be here after Wednesday to assign. Can you please look at and provide some direction, thank you. H. Record review of an email from CRD to SSD dated 03/13/18 revealed Thanks (Name of SSD). I will address. Allegation for R #2 I. Record review of the Resident Incident Report dated 03/03/18 revealed, Resident stated to this nurse, 'If that male nurse, (wrong Name of LPN #1), (right Name of LPN #1), or whatever, ever puts his hands on me again I will have something for him, I'll stab him.' J. On 03/12/18 at 12:36 pm, during an interview, the Administrator was asked if the R #2's incident with LPN #1 had been investigated and reported to the state agency. The Administrator stated, He (R #2) did not tell me the nurse put his hands on him. This is the first time I am reading this (copy of the incident report). They (staff) are supposed to bring these things (allegations) to me every day during stand up. The Administrator was asked if she thought this should have been investigated and reported, the Administrator stated, No, I don't think I would have. Everyone and even his roommate said he (LPN #1) did not touch him (R #1). K. Record review of the Complaint/Grievance Report dated 03/05/17 revealed: resident report (sic) 'my hand is swollen and left leg I can't move. (Name of LPN #1) (night nurse) hit my hand.' Handwritten note attached revealed, per (Name of Administrator), (Name of LPN #1), LPN is not to work 200 side, or if needs to, cannot care or go into (name of R #2)'s room . Neglect L. On 03/14/18 at 11:13 am, during an interview, R #1 stated that the facility had a supply issue and that residents were not getting the attends and wipes they need. R #1 also stated that he filed a grievance about this issue. M. Record review of the Complaint/Grievance Report 03/08/18 revealed: Resident feels Administrator is being pregidust (sic) towards her (sic). Lack of supplies. Concern of residents during lunch. (neglect) not enough CNA's. not enough wipes, shaving cream, lotion, laundry not properly done. N. Record review of the Complaint/Grievance Report taken by Ombudsman for R #8 dated 02/06/18 revealed: Reported to Ombudsman that she asked for an omelette + (and) wasn't given one, happened in the last 2 weeks. Resident wants to know why there are no wipes? . plan to resolve complaint/grievance: DON reported she did get her omelette (sic) . There was no documentation of R #8's concern of there being no wipes. O. On 03/12/18 at 2:36 pm, during an observation of the central supply room and interview Central Supply (CS) stated, I ran out of supplies this weekend. The Attends (briefs) and wipes. The Administrator tells me to have my order in by 3:00 pm, but it does not get approved (by the Administrator). I have not been trained in how to do central supply. I had been working as Medical Records. Then they said I need to do central supply now or I am fired. It seems like this is a constant thing between the Administrator not approving my order. She is trying to save money, but the residents need these things. Like, (Name of R #8) needs [MEDICATION NAME] depends but I can't order it. P. On 03/12/18 at 2:59 pm, during an interview, CNA #3 was asked if she had enough supplies for residents. CNA #3 stated, Lately, our nurses are buying us wipes. We don't use wet wipes anymore; we use the dry wipes and peri wash spray to wet the wipes. Sometimes we don't have the spray, so we have the water. Last weekend (03/10/18 and 03/11/18), we ran out of Attends. They (Administration) bought 1 pack large and 1 pack extra-large on each side of the building. For the entire weekend. We had to use the small attends on bigger residents like R #7. Q. On 03/12/18 at 3:06 pm, during an interview, CNA #4 was asked if she had enough supplies for residents. CNA #4 stated, Sometimes we run out of supplies like Attends and wipes and peri spray. All the time we run out of the wipes. We have the dry wipes but no peri-spray and I run under water for them. Also, body wash. R. On 03/12/18 at 3:10 pm, during an interview, LPN #2 was asked if she had enough supplies for residents. LPN #2 stated, Sometime yes, sometimes no. There was an issue with the truck, we were told. During the interview at that time LPN #4 confirmed she has had to buy wipes and disinfectant spray. S. On 03/12/18 at 3:14 pm, during an interview, CNA #5 was asked if she had enough supplies for residents. CNA #5 stated, No. The Attends, the pull up, the wipes, the peri-spray, the soap to shower; our resident run out of the things we use every day. 2 ½ to 3 months and it has been getting worse. (Name of R #5), she wears the size 3. We were using the size 2. They were cutting into her and she had chaffing. It is frustrating for us and the residents because we don't have what they need. It's hurting them. We need these things to take care them correctly. T. On 03/12/17 at 4:00 pm, during an interview, the Administrator and DON were asked about the supplies for residents. The Administrator stated that the CS did not properly stock the supplies and that he was not getting the orders in to her before the 3:00 pm order deadline. They also confirmed that the CS was suspended at that time. The Administrator was asked how long supplies on hand should last; the Administrator stated, Two weeks. During an observation at that time of the Central Supply room and outside storage shed revealed the facility did have enough wipes for residents during the night shift. Staff was sent to buy wipes. U. On 03/13/18 at 10:28 am, during an interview, R #8 stated that the CNAs told her They did not have the wipes this morning, they said they were unavailable. V. On 03/13/18 at 10:53 am, during an interview, the DON stated She (the Administrator) has the ability to approve and amend supply orders. The DON confirmed that the Administrator would be able to see what CS ordered and approve it. The Administrator would have known that CS was not ordering enough supplies, because she approves all orders. W. On 03/13/18 at 11:08 am, during an interview, R #5 and Family Member (FM) #1 stated, They run out wipes and of size 3. Then they give her smaller one. It's too tight. R #5 stated, It itches and burns, it gets into you. FM #1 continued, It doesn't hold anything either because it the wrong size. She'll leak everywhere. X. On 03/13/18 at 11:28, during an interview, CNA #2 stated, We've been running out of Attends and wipes. They (staff) had to use the Number 1 (small weight/size requirements) Attends on everyone. Twice a month, every other week, we run out of everything. (Name of R #8) used to have the purple ones ([MEDICATION NAME] attends), but they have not been providing those. Y. On 03/13/18 at 12:01 pm, during an interview, the DON confirmed that R #8 used to have [MEDICATION NAME] Attends but was using regular Attends. Z. Record review of the Departmental Notes dated 05/16/15 revealed, Resident (R #8) has red rash on perineal area--- using zinc oxide cream on areas and using pullup rather than depends (sic) =-- pssible (sic) allergy to depend (sic) plastic--- AA. On 03/13/18 at 4:07 pm, during an interview with the DON and observation of the Central Supply room and outdoor storage shed revealed the facility did not have enough size 2 Attends for residents to last the night shift. Staff were sent to buy some. BB. On 03/14/18 at 10:50 am, during an interview, the DON was asked is there system in place for supplies when CS and the Administrator are out of the building. The DON stated, I am assuming we go through corporate. The DON stated that the facility found one box of size 2 attends the night of 03/13/18 in a closet storage room. CC. On 03/14/18 at 3:45 pm, during an interview with the DON and observation of the Central Supply room and outdoor storage shed revealed the facility did not have enough size 3 Attends or pull ups for residents to last the night shift. Staff were sent to buy the Attends and pull ups. DD. On 03/15/17 at 10:25 am, during an interview, the DON stated that the facility found some pull ups the night of 03/14/18. EE. Record Review of the (Name of the Facility) Abuse Prohibition Standards of Practice dated 01/02/18 revealed Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property . Local Law enforcement, the state survey agency . will be notified in accordance with federal and state law . allegation a written or verbal communication by an individual having seen or heard an individual during an act of abuse, neglect, or misappropriation of resident's property . Neglect: 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, mental anguish, or emotional distress . The Administrator's signature was on the document and dated 01/26/18.

During a complaint survey the following was discovered: 1) Allegations of abuse and neglect for R #1 (03/08/18) and R #2 (03/03/18) were not thoroughly investigated or reported to the State Agency. 2) Staff who allegedly abused R #1 and R #2 (The Administrator and LPN #1) were aloud to continue to come into the facility without regard for resident safety pending the outcome of the investigation. 3) Staff were not aware of who to report allegations against the Administrator, due to the ADON and DON leaving their positions, resulting in a delay in reporting to corporate staff. 4) Staff did not want to get involved in the investigation into allegation against the Administrator for fear of retaliation from corporate office. 5) The Administrator attempted to retaliate against a staff member for writing a grievance for R #1 against the Administrator. This resulted in an Immediate Jeopardy that was called on 03/14/18 at 12:24 pm. A Plan of Removal were submitted at 03/14/18 at 1:15 pm and 3:09 pm, and 03/15/18 at 10:35 am and were reject. A final Plan of Removal was approved on 03/15/18 at 1:45 pm. 1. The self report of the allegation of abuse of (Name of R #1) and (Name of R #2) will be submitted today to (Name of State Agency) by the DON. 2. The investigation in regards to the allegation of abuse with (Name of R #1) has begun at the corporate level and will be completed within 5 days by regional/corporate staff and lead by (Name of Corporate Regional Director). The allegation of abuse investigation of (Name of R #2) will be today and will be completed by (Name of DON). 3. In order to keep both residents safe both alleged staff members will be placed on administrative leave pending investigation. 4. In-service has been initiated and will be complete with all staff members about reporting abuse within 2 hours, to the abuse coordinator, if the abuse coordinator is not available then staff will follow the chain of command. In the event the allegation is directed at the administrator/abuse coordinator the Regional Director of Operation will be notified. No staff member will be allowed to return to work until they have received this re-education regarding abuse reporting. 5. Social Services director will interview eight (8) alert and oriented residents to ensure there are no other allegations to investigate. 6. H.R. director (sic) will interview staff members to ensure they are comfortable reporting and have reported any allegations they are aware of. No staff member will be allowed to return to work until they have been interviewed. 7. Due to the current transition, The (sic) Regional Director of operation (sic) phone number will be listed so that corporate will be notified of any allegation of abuse to give direction to staff on other steps to follow. 8. Due to the current transition, The (sic) Regional Director of Operation (RDO) will be designated as the abuse coordinator and will be responsible for reporting and investigating allegations of abuse. The RDO's phone number will be listed at all Nursing stations so the staff can notify RDO of all allegation (sic) of abuse. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted at 2:45 pm. This resulted in the scope and severity being reduced from a K to an E. Based on observation, interview, and record review, the facility failed to report allegations of abuse for 2 (R #1, R #2) of 4 (R #1, R #2, R #3, R #4) residents sampled for abuse and neglect, when they 1) failed suspend the administrator pending an investigation of an allegation of abuse made by R #1, 2) No staff members interviewed R #1 after the allegation because it involved the Administrator, 3) failed to suspend LPN #1 pending an investigation of an allegation of abuse involving R #2, and 4) failed to thoroughly investigate and report the allegation of abuse for R #2 against LPN #1. If staff members who allegedly abuse residents are allowed to continue to come into the building after their allegations have been reported and allegation of abuse are not thoroughly investigated, then resident have the high likelihood of continuing to be abused. The findings are: Allegation for R #1 A. On 03/14/18 at 11:13 am, during an interview, R #1 stated that he had concerns that he went to talk to the Administrator about on 03/08/18. She told me that she was not going to listen to me or anyone. And no one is going to tell me what to do. I am not going to put up with you (R #1) or anyone else. R #1 continued, It was abusive to me. R #1 also stated that he filed a grievance with the front receptionist on the same day. B. On 03/14/18 at 11:23 am, during an interview, the Social Services Director (SSD) stated The grievance (R #1's) was put it my box on Thursday (03/08/18 SSD was not in the facility that date), and I did not get to it till late Friday (03/09/18). I went to ask the DON for guidance because it was against the Administrator. They did not know (what to do). I emailed it to Corporate Regional Director (CRD) on Monday (03/12/18). I did not think this was abuse. The SSD was asked if she ever interviewed R #1 or talked to him about the incident. The SSD stated, I did not talk to (Name of R #1). C. On 03/14/18 at 11:36 am, during an interview, the DON was asked if she would categorize the incident between the Administrator and R #1 as abuse. The DON stated No. The DON continued to state that at one point there was a concern that R #1 may have had his hand hit by the door during this incident, but after asking staff the DON determined that this did not happen. The DON was asked if she talked to R #1. The DON stated, I did not talk to (Name of R #1) because I was getting ready to leave (her position as DON) and corporate came down and told the department heads that we were pinning residents against the Administrator. I wanted corporate to handle that investigation for fear of retaliation. At the standup meeting, CRD told us 'As department heads we are held to higher standard, we should not be pinning residents against the Administrator'. At other places I would always be able to go to the Administrator's boss, but if corporate was not supportive then . they are not. D. On 03/14/18 at 12:04 pm, during an interview, the Receptionist stated I was on smoking break. (Name of R #1) came out. He was saying 'I'm very upset' I asked him is that anything I could do? He asked me if he could file a grievance. So I wrote up his grievance. The Receptionist continued to state that on 03/12/18 she got called into the Administrators office because the Administrator was upset about R #1's grievance. The Receptionist continued that the Administrator did not like that she wrote R #1's statement saying she was prejudice, and that she was not supposed to take grievances. They were supposed to go to SSD. I tried to tell her that I just wrote down what (name of R #1) told me. (Name of SSD) was out that day, and that it involved her. My training was that anyone could take a grievance; that's why the forms are all over the building. That afternoon, she (the Administrator) called me back to her office said I was being written up. I did not sign the paper, because I talked to the SDC and she said that anyone could take grievance. Then she got phone call and told us to leave her office. E. Record review of the Complaint/Grievance Report dated 03/08/18 revealed: 1. Resident feels Administrator is being pregidust (sic) towards her (sic). Lack of supplies. Concern of residents during lunch. (neglect) not enough CNA's. not enough wipes, shaving cream, lotion, laundry not properly done. 2. Statement attached revealed, (Name of Administrator) has no time for residents. Only for certain ones. Not Being equal. Not following rules. He does not think that the Administrator should be allowed to go into the kitchen without a hairnet. She caters to certain residents. He had been here for 35 days and his sheets have never been changed. Not receiving all of his clothes, they all have his name and room #. (gave resident a copy) . F. Record review of an email from SSD to CRD dated 03/12/18 revealed, I received this grievance late Friday afternoon, not sure what to do as DON and ADON will no longer be here after Wednesday to assign. Can you please look at and provide some direction, thank you. G. Record review of an email from CRD to SSD dated 03/13/18 revealed Thanks (Name of SSD). I will address. Allegation for R #2 H. Record review of the Resident Incident Report dated 03/03/18 revealed, Resident stated to this nurse, 'If that male nurse, (wrong Name of LPN #1), (right Name of LPN #1), or whatever, ever puts his hands on me again I will have something for him, I'll stab him.' I. On 03/12/18 at 12:36 pm, during an interview, the Administrator was asked if the R #2's incident with LPN #1 had been investigated and reported to the state agency. The Administrator stated, He (R #2) did not tell me the nurse put his hands on him. This is the first time I am reading this (copy of the incident report). They (staff) are supposed to bring these things (allegations) to me every day during stand up. The Administrator was asked if she thought this should have been investigated and reported, the Administrator stated, No, I don't think I would have. Everyone and even his roommate said he (LPN #1) did not touch him (R #1). J. Record review of the Complaint/Grievance Report dated 03/05/17 revealed: resident report (sic) 'my hand is swollen and left leg I can't move. (Name of LPN #1) (night nurse) hit my hand.' Handwritten note attached revealed, per (Name of Administrator), (Name of LPN #1), LPN is not to work 200 side, or if needs to, cannot care or go into (name of R #2)'s room . K. Record review of the Administrative Standards of Practice Manual, revision date (MONTH) (YEAR), revealed the following: Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property . V. Investigation: When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: Interview the involved resident if possible and document all responses . A. The facility must have evidence that all violations, including allegations, are thoroughly investigated . B. The results of the investigation must be reported to the Administrator and other officials in accordance with state law (including the state survey and certification agency) within 5 working days of the incident. VI. In order to provide protection to the resident during an investigation of abuse, neglect or exploitation the following will be done: The alleged abuser will be removed from the facility immediately, and not allowing the facility, pending the outcome of the investigation . Protection of staff, residents and /or family members from retaliation VII. Reporting and response to alleged Incidents: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment . will be reported by the facility Administrator, or his/her designee, to the following agencies: the state licensing/certification agency responsible for surveying/licensing the facility; . 2. Suspected abuse, neglect, exploitation or mistreatment . will be reported within two hours. 3. Alleged abuse, neglect, exploitation or mistreatment . will be reported within two hours if the alleged events resulted in serious bodily injury; 4. If events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours . Note: If the alleged abuse/neglect involves the Administrator, report the incident immediately to the DON. If the Don in not available, report the incident immediately to the Regional Director of Operations or regional Quality Consultant.

During a complaint survey the following was discovered: 1) Allegations of abuse and neglect for R #1 (03/08/18) and R #2 (03/03/18) were not thoroughly investigated or reported to the State Agency. 2) Staff (The Administrator and LPN #1) who allegedly abused R #1 and R #2 were allowed to continue to come into the facility without regard for resident safety pending the outcome of the investigation. 3) Staff were not aware of who to report allegations against the Administrator, due to the ADON and DON leaving their positions, resulting in a delay in reporting to corporate staff. 4) Staff did not want to get involved in the investigation into allegation against the Administrator for fear of retaliation from corporate office. 5) The Administrator attempted to retaliate against a staff member for writing a grievance for R #1 against the Administrator. This resulted in an Immediate Jeopardy that was called on 03/14/18 at 12:24 pm. A Plan of Removal were submitted at 03/14/18 at 1:15 pm and 3:09 pm, and 03/15/18 at 10:35 am and were rejected. A final Plan of Removal was approved on 03/15/18 at 1:45 pm. 1. The self report of the allegation of abuse of (Name of R #1) and (Name of R #2) will be submitted today to (Name of State Agency) by the DON. 2. The investigation in regards to the allegation of abuse with (Name of R #1) has begun at the corporate level and will be completed within 5 days by regional/corporate staff and lead by (Name of Corporate Regional Director). The allegation of abuse investigation of (Name of R #2) will be today and will be completed by (Name of DON). 3. In order to keep both residents safe both alleged staff members will be placed on administrative leave pending investigation. 4. In-service has been initiated and will be complete with all staff members about reporting abuse within 2 hours, to the abuse coordinator, if the abuse coordinator is not available then staff will follow the chain of command. In the event the allegation is directed at the administrator/abuse coordinator the Regional Director of Operation will be notified. No staff member will be allowed to return to work until they have received this re-education regarding abuse reporting. 5. Social Services director will interview eight (8) alert and oriented residents to ensure there are no other allegations to investigate. 6. H.R. director (sic) will interview staff members to ensure they are comfortable reporting and have reported any allegations they are aware of. No staff member will be allowed to return to work until they have been interviewed. 7. Due to the current transition, The (sic) Regional Director of operation (sic) phone number will be listed so that corporate will be notified of any allegation of abuse to give direction to staff on other steps to follow. 8. Due to the current transition, The (sic) Regional Director of Operation (RDO) will be designated as the abuse coordinator and will be responsible for reporting and investigating allegations of abuse. The RDO's phone number will be listed at all Nursing stations so the staff can notify RDO of all allegation (sic) of abuse. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted on 03/15/18 at 2:45 pm. This resulted in the scope and severity being reduced from a K to an E. Based on observation, interview, and record review, the facility failed to report allegations of abuse for 2 (R #1, R #2) of 4 (R #1, R #2, R #3, R #4) residents sampled for abuse and neglect, when they 1) failed suspend the administrator pending an investigation of an allegation of abuse made by R #1, 2) No staff members interviewed R #1 after the allegation because it involved the Administrator, 3) failed to suspend LPN #1 pending an investigation of an allegation of abuse involving R #2, and 4) failed to thoroughly investigate and report the allegation of abuse for R #2 against LPN #1. If staff members who allegedly abuse residents are aloud to continue to come into the building after their allegations have been reported and allegation of abuse are not thoroughly investigated, then resident have the high likelihood of continuing to be abused. The findings are: R #1 A. On 03/14/18 at 11:13 am, during an interview R #1 stated that he had concerns that he went to talk to the administrator about. She told me that she was not going to listen to me or anyone. And no one is going to me what to do. I am not going to put up with you (R #1) or anyone else. R #1 continued It was abusive to me. R #1 also stated that he filed a grievance with the front receptionist. B. On 03/14/18 at 11:23 am, during an interview the Social Services Director (SSD) stated The grievance (R #1's) was put it my box on Thursday (SS was not in the facility on Thursday), and I did not get to it till late Friday. I went to ask the DON for guidance because it was against the Administrator. They did not know. I emailed it to Corporate Regional Director CRD on Monday. I did not think this was abuse. The SSD was asked if she ever interviewed R #1 or talked to him about the incident, the SSD stated I did not talk to (Name of R #1). C. On 03/14/18 at 11:36 am, during an interview the DON was asked if she would categorize the incident between the administrator and R #1 as abuse, the DON stated No. The DON continued to state at one point there was a concern that R #1 may have had his hand hit by the door during this incident, but after asking staff the don determined that this did not happen. The DON was asked if she talked to R #1, the Don stated I did not talk to (Name of R #1) because I was getting ready to leave (her position as DON) and corporate came down and told the department heads that we were pinning residents against the Administrator. I wanted corporate to handle that investigation for fear of retaliation. At the standup meeting CRD told us 'as department heads we are held to higher standard, we should not be pinning residents against the Administrator'. At other places I would always be able to go to the Administrators boss but if corporate was not supportive then . they are not. D. On 03/14/18 at 12:04 pm, during an interview the Receptionist stated I was on smoking break (Name of R #1) came out. He was saying 'I'm very upset' I asked him is that anything I could do? He asked me if he could file a grievance. So I wrote up his grievance. The Receptionist continued to state that on 03/12/18 she got called into the Administrators office because the Administrator was upset about R #1's grievance. The Receptionist continued that the Administrator did not like that she wrote R #1's statement saying she was prejudice, and that she was not supposed to take grievances they were supposed to go to SSD. I tried to tell her that I just wrote down what (name of R #1) told me, (Name of SSD) was out that day, and that it involved her, my training was that anyone could take a grievance that's why the form are all over the building. That afternoon I she (the Administrator) called me back to her office said I was being written up. I did not sign the paper, because I talked to the SDC and she said that anyone could take grievance. Then she got phone call and told us to leave her office. E. Record review of the Complaint/Grievance Report 03/08/18 revealed 1. Resident feels Administrator is being pregidust (sic) towards her (sic). Lack of supplies. Concern of residents during lunch. (neglect) not enough CNA's. not enough wipes, shaving cream, lotion, laundry not properly done. 2. Statement attached revealed (Name of Administrator) has no time for residents. Only for certain ones. Not Being equal. Not following rules. He does not think that the Administrator should be allowed to go into the kitchen without a hairnet. She caters to certain residents. He had been here for 35 days and his sheets have never been changed. Not receiving all of his clothes, they all have his name and room #. (gave resident a copy) . F. Record review of an email from SSD to CRD dated 03/12/18 revealed I received this grievance late Friday afternoon, not sure what to do as DON and ADON will no longer be here after Wednesday to assign. Can you please look at and provide some direction, thank you. G. Record review of an email from CRD to SSD dated 03/13/18 revealed Thanks (Name of SSD). I will address. R #2 H. Record review of the Resident Incident Report dated 03/03/18 revealed Resident stated to this nurse If that male nurse, (wrong Name of LPN #1), (right Name of LPN #1), or whatever, ever puts his hands on me again I will have something for him, I'll stab him I. On 03/12/18 at 12:36 pm, during an interview the Administrator was asked if the R #2's incident with LPN #1 had been investigated and reported to the state agency, the Administrator stated He (R #2) did not tell me the nurse put his hands on him. This is the first time I am reading this (copy of the incident report). They (staff) are supposed to bring these things (allegations) to me every day during stand up. The Administrator was asked if she thought this should have been investigated and reported, the Administrator stated, No, I don't think I would have. Everyone and even his roommate said he (LPN #1) did not touch him (R #1). J. Record review of the Complaint/Grievance Report dated 03/05/17 revealed resident reportmy hand is swollen and left leg I can't move. (Name of LPN #1) (night nurse) hit my hand. Hand written note attached revealed per (Name of Administrator), (Name of LPN #1), LPN is not to work 200 side, or if needs to, cannot care or go into (name of R #2)'s room . K. Record Review of the (Name of the Facility) Abuse Prohibition Standards of Practice dated 01/02/18 revealed Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property . Local Law enforcement, the state survey agency . will be notified in accordance with federal and state law . allegation a written or verbal communication by an individual having seen or heard an individual during an act of abuse, neglect, or misappropriation of resident's property . Neglect: 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, mental anguish, or emotional distress . The Administrator's signature was on the document and dated 01/26/18. L. Record review of the Administrative Standards of Practice Manual revision date (MONTH) (YEAR) revealed the following: Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property . V. Investigation: When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: · Interview the involved resident if possible and document all responses . A. The facility must have evidence that all violations, including allegations, are thoroughly investigated . B. The results of the investigation must be reported to the Administrator and other officials in accordance with state law (including the state survey and certification agency) within 5 working days of the incident. VI. In order to provide protection to the resident during an investigation of abuse, neglect or exploitation the following will be done: · The alleged abuser will be removed from the facility immediately, and not allowing the facility, pending the outcome of the investigation . · Protection of staff, residents and /or family members from retaliation VII. Reporting and response to alleged Incidents: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment . will be reported by the facility Administrator, or his/her designee, to the following agencies: the state licensing/certification agency responsible for surveying/licensing the facility; . 2. Suspected abuse, neglect, exploitation or mistreatment . will be reported within two hours. 3. Alleged abuse, neglect, exploitation or mistreatment . will be reported within two hours if the alleged events resulted in serious bodily injury; 4. If events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours . Note: If the alleged abuse/neglect involves the Administrator, report the incident immediately to the DON. If the Don in not available, report the incident immediately to the Regional Director of Operations or regional Quality Consultant.

The facility failed to ensure that effective isolation precautions were maintained for 2 residents (R #31 and R #120) diagnosed with [REDACTED].#32 and #82) because two large biohazard bins, containing contaminated wound dressings, were found in the bathroom shared by the 4 residents. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of level K being identified on 08/22/16 at 7:05 pm. The facility administrator was notified at that time. The facility took corrective action by providing an acceptable Plan of Removal on 08/23/16 at 8:20 am. Based on the Plan of Removal, interventions included: 1. Biohazard bins removed from the shared bathroom 2. Deep cleaning of the shared bathroom. 3. Relocation of the uninfected residents to vacant beds in the facility. 4. Immediate staff education on the placement of biohazard bins and general infection control procedures. 5. Updating of daily room rounds documentation sheets to include checks for breaches of isolation in isolation rooms. Based on the Plan of Removal and interview, the IJ was lifted on 08/23/16 at 8:20 am. This resulted in the scope and severity being reduced from level K to level E. Based on observation, interview, and record review, the facility failed to ensure: 1) that isolation protocols were maintained for 2 residents (R #32 and R #82) of 3 residents (R # 32, 82 and 128) identified by nursing staff as having MRSA infection. 2 residents (R #31 and R #120) sharing a bathroom with the infected residents, both of whom had [DIAGNOSES REDACTED]. 2) the area that room trays were placed were cleaned prior to placing the tray with food on it for 3 (R 18, 23, & 105) of 3 (R 18, 23, & 105) sampled residents for room trays, and 3) the nurse washed her hands after she placed potentially hazardous materials in the biohazard bin and cleaned her hands after touching a dirty surface and before she re-gloved for 1 (R #82) of 2 (R #32 and R #82) residents with MRSA. These deficient practices have the potential to cause a life-threatening infection of the residents, and their [DIAGNOSES REDACTED]. The findings are: Biohazard Bins A. On 08/22/16 at 6:10 pm, during observation of the bathroom shared by R #'s 31, 32, 82 and 120, two large red Biohazard bins were found next to the toilet. Inspection of the contents found discarded paper, plastic and tape. B. On 08/22/16 at 6:31 pm, during interview with the DON, he examined the contents of the bins, and stated that they were old dressings that had likely been removed from the MRSA-infected leg wounds of R #32 and R #82. He confirmed that the residents in the adjoining rooms (R #31 and R #120) were generally incontinent, but that they both sometimes used the shared bathroom. Regarding the bins, he stated I see now that they shouldn't have been in (the shared) bathroom. C. On 08/22/16 at 6:45 pm, during interview with the DON, 1. He stated that R #31 had been diagnosed with [REDACTED]. Due to a surgical procedure which had reopened the wound, a [MEDICATION NAME] (precautionary) course of Bactrim was then begun, and R #31 was considered to still be MRSA-infected. 2. He stated that R #120 had been diagnosed with [REDACTED]. He stated that a follow-up culture of R #120's wound would not be done until 14 days after the completion of the antibiotic, so R #120 was still considered to be MRSA-infected. D. On 08/22/16 at 6:45 pm, during interview with the Administrator, she stated that it was impossible to tell when the bins had been moved from the bedroom of R #31 and R #120 into the shared bathroom. She indicated that the large bins had likely been in the way in the bedroom, and that a staff member had moved them into the bathroom so that they'd be out of the bedroom traffic area. E. On 08/23/16 at 8:40 am, during interview with R #31, he stated If I had to guess, I'd say (that the bins had been in the bathroom) for a couple of months. F. Record review of the [DIAGNOSES REDACTED].#32 and R #82 found dementia among their diagnoses. Room Trays G. On 08/22/16 between 5:22 pm and 5:30 pm, during observation of CNA #1 passing dinner trays, the following was observed: 1. CNA #1 entered R # 105's room and placed the dinner tray next to a full urinal which was placed on the bedside table. CNA #1 removed and emptied the urinal and did not clean off tray table. R #105 proceeded to eat his dinner. 2. CNA #1 entered R # 23's room and placed the dinner tray next to a full urinal which was placed on the bedside table. CNA #1 removed and emptied the urinal and did not clean off tray table. R #23 proceeded to eat his dinner tray. 3. CNA #1 entered R# 18's room and placed the dinner tray next to a full urinal which was placed on the bedside table. CNA #1 removed and emptied the urinal and did not clean off tray table. R # 18 proceeded to eat his dinner tray. Wound Care H. On 08/23/16 at 10:07 pm, during an observation of RN # 3 performing wound care on the left foot of R #82 with MRSA, RN #3 removed gloves and disposed in the regular trash can after she placed the other dirty materals in the biohazard bin. RN #3 then placed a sheet of wax paper on her lap, with an ungloved hand, lifts up resident's dirty foot and places it on the wax paper. RN #3 applies fresh gloves and cleanses R #82's two open wounds with 4X4 Gauze pads and Wound Cleanser spray. RN #3 then disposed the gauze in the biohazard bag, removes her soiled gloves and disposed of the gloves in the regular trash can. After donning new gloves, RN #3 opened sterile dressing, Xeroform (medicated petroleum gauze) and applied to both wounds followed by clean 4X4 gauze placed over wound and Xeroform dressing, wrapped the ankle and foot with clean Kerlix (fluffy gauze dresssing wrap), taped it and removed her gloves and disposed them in the regular trash can. RN # 3 applied soiled sock over the clean dressing which she had changed. I. On 08/26/16 at 10:23 am, during an interview, RN #3 explained that she knew that disposing of the gloves during the dressing change was not good and stated, It is a habit I am trying to break. She further confirmed that she knew that she should have cleaned her hands after touching a dirty area and before she re-gloved.

R #3 (Resident) stated that she was pushed by CNA #3 (Certified Nursing Assistant) onto her bed, then CNA #3 roughly put R #3 legs on the bed lifting beyond a comfortable level causing pain. R #3 confirmed that this happened twice about a week apart. R #3 confirmed that she was scared of CNA #3. This was only investigated and was not reported to the State Agency. RN #3 revealed that R #7 had requested pain medication from CNA #3. RN #3 stated that she did not receive the request for pain medication from CNA #3, and this resulted in R #7 to receive her pain medication 45 minutes after initially requesting her pain medications. RN #3 confirmed that this incident was reported to the DON. This was never investigated or reported to the State Agency. RN #3 also stated that it was reported that CNA #3 had spoken inappropriately to another resident (R #13). RN #3 reported this to the DON. CNA #4 revealed she and CNA #3 were working and R #13 needed to be changed. CNA #3 got mad was verbally abusive to R #13 about needing to changed. CNA #3 refused to change him. Also, later that night, R #14 was stating he was leaving (resident does not have full cognition) and CNA #3 was verbally abusive to R #14 as well. CNA #4 reported this to her nurse and the DON. This was never investigated or reported to the State Agency. During interview with R #13 he could not recall that specific incident with CNA #3, however R #13 stated he did recall CNA #3 being rough during transfers. During interview CNA #2 stated that she saw CNA #3 in R #13's room. R #13 had dropped a pitcher of water. CNA #3 yelled at the resident for doing so. CNA #2 reported it to the nurse on duty. This was not investigated or reported to the State Agency. During an interview the DON confirmed that none of these incidences were investigated or reported to the State Agency. The only one investigated was R #3's incident with CNA #3 and this was not reported to the State Agency. This deficient practice resulted in the first Immediate Jeopardy (IJ) being identified at the facility on 12/02/15 at 6:06 pm. The facility took corrective action by providing an acceptable Plan of Removal for the first IJ. Based on the plan, interventions included: 1. The associate is no longer in the facility and is currently on FMLA. When this allegation was brought to our attention an investigation was started with interviews of residents and employees. If the associate is ready to return to work (because of the end of her leave) Prior to the completion of this investigation she will be immediately suspended until the investigation is completed. If the allegation of abuse is substantiated at the completion of the investigation the associate's employment will be immediately terminated. 2. All employees will be in-serviced on abuse and neglect, dignity and respect and the process for reporting abuse and forms utilize. In addition all employees will be in-serviced in alternative interventions including but not limited to conflict resolution. All new employees will be in-serviced at orientation. No employee will be allowed to work until in-serviced on all the above topics. 3. In addition a new process to facilitate reporting of abuse that includes binders at each nurse's station has been implemented. The binders will include the facility policy and reporting process as well as necessary forms. A locked slotted box will be mounted on the wall outside the nursing administration office and checked daily by the administrator or in her absence the DON (director of nursing) or his delegate. All employees will be in-serviced on location of the binders/forms and the box that will collects (sic) them. 4. During morning meeting the IDT (Interdisciplinary Team) will continue to discuss and monitor incident reports, 24 hour reports, grievances and if any, allegations of abuse. A reportable log will be maintained by the DON or delegate. Based on the Plan of Removal and observation, the IJ was lifted on 12/04/15 2:28 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope H. During interview R #17 stated that he was outside smoking one night and RN #4 came up to him and demanded that he give her his lighter and cigarettes. R #17 stated that he refused and RN #4 told him they would have to search him. RN #4 took him to his room along with two CNAs and they stripped searched him (searching someone for concealed items, in a way that involves the removal of their clothes). Review of Departmental Notes written by RN #4 revealed I asked the 2 CNA's on the 200 side to help me take his pants off in his room to get the possible cigarettes and lighter . RN #4 confiscated R #17's cigarettes and lighter. R #17 also revealed that he is still afraid of RN #4. RN #4 continues to intimidate him about having a lighter and cigarettes. R #17 has not reported this because he is afraid of RN #4. DON confirmed there was no investigation or report sent to the State Agency. Also the ADON and the DON, revealed that they would do everything possible to get lighters away from residents citing it as a safety issue. This deficient practice resulted in the second Immediate Jeopardy (IJ) being identified at the facility on 12/03/15 at 9:30 am. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included: 1. The associate is no longer in the facility and will not return to work here. She was suspended yesterday as the investigation into this allegation commenced. The alleged abuse allegation is being investigated and if substantiated the associate will be terminated immediately. 2. All employees will be in-serviced on abuse and neglect, dignity and respect and the process for reporting abuse and forms utilize. In addition all employees will be in-serviced in alternative interventions including but not limited to conflict resolution. All new employees will be in-serviced at orientation. No employee will be allowed to work until in-serviced on all the above topics. 3. In the case that a resident refuses to return a prohibited item, conflict or confrontation will be avoided. Instead an emergency care conference will be scheduled to discuss the issue and possible resolution. The ombudsman will be called in these circumstances as well. If the prohibited object is kept by the resident monitoring for safety of the resident will maintained until the care conference can happen. 4. In addition a new process to facilitate reporting of abuse that includes binders at each nurse's station has been implemented. The binders will include the facility policy and reporting process as well as necessary forms. A locked slotted box will be mounted on the wall outside the nursing administration office and checked daily by the administrator or in her absence the DON (director of nursing) or his delegate. All employees will be in-serviced on location of the binders/forms and the box that will collects (sic) them. 5. During morning meeting the IDT (Interdisciplinary Team) will continue to discuss and monitor incident reports, 24 hour reports, grievances and if any, allegations of abuse. A reportable log will be maintained by the DON or delegate. Based on the Plan of Removal and observation, the IJ was lifted on 12/04/15 2:28 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope H. Based on observations, record review and interview, the facility failed to ensure that residents were free from abuse, neglect, and mistreatment for 5 (R #3, R #7, R #13, R #14, and R #17) of 5 (R #3, R #7, R #13, R #14, and R #17) residents sampled for abuse, neglect, and mistreatment, when they 1) failed to protect R #3 from being pushed and roughly transferred to her bed by CNA #3, 2) failed to protect R #7 from CNA #3 neglecting to inform the nurse about her need for pain medication, 4) failed protect R #13 from being verbally abused and neglected by CNA #3, 5) failed to protect R #14 from being verbally abused CNA #3, 6) failed to protect R #17 from being strip searched (searching someone for concealed items, in a way that involves the removal of their clothes), and 7) failed to protect R #17 from continual intimidation by RN #4 about being searched. This deficient practice resulted in residents living in physical and psychological pain from being abused and neglected, as well as fear due to the facility allowing their abusers to continue to work in the facility. The findings are: R #3 A. On 12/01/15 at 11:57 am, during an interview R #3 stated that she was pushed by CNA #3 (Certified Nursing Assistant) onto her bed. Then she lifted my legs really high, I have a metal in my back, and it really hurt I started crying but I did not tell anyone. She did it a second time. This time my neighbor (roommate) reported it. I was scared of her. They took her off this hallway, but I am still scared. Observation at this time resident was visibly distressed and crying recounting this incident. B. On 12/01/15 at 3:20 pm, during an interview with the Director of Nursing (DON) confirmed that the facility did not substantiate this investigation. The DON stated that he went to interview R #3 and she did not want to say anything, her roommate (R #7) reported it and she did not directly witness the incident. CNA #3 was suspended for the investigation and moved to a different hall. C. On 12/02/15 at 4:21 pm, during an interview CNA #3 stated that she did not push R #3 or help her transfer. CNA #3 stated I saw her (R #3) struggling to get into bed but she transferred herself. I lifted he legs onto the bed and I tried to make her comfortable by putting a pillow behind her back. Her roommate (R #7) was the one that made the complaint not R #3. I was moved to another hallway. D. On 12/02/15 at 12:55 pm, during an interview Social Services Director (SSD) stated (name of R #3) did not want to tell me (about the incidents with CNA #3). She was crying and she was afraid of her . Due to CNA #3's leave no retraining was ever done for CNA #3. E. On 12/02/15 at 04:25 pm, during an interview with R#7 she stated My roommate was (name of R#3). (Name of CNA #3) just picked her up and threw her on the bed. I was in the bathroom but I heard (name of R #3) cry out. I found (name of R #3) crying and she told me what happened. I talked to the DON. I told him I did not want that b**** (profanity) in here. She was rough and rude. She came back that night to our room and I kicked her out. They moved her to work the lock down unit after that . Others told me they are scared of her (CNA #3). I can't give their names, they might get pay back. F. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed R #3 had a Brief interview for Mental Status (BIMS) score of 15. G. On 12/02/15 at 2:40 pm, during interview the MDS Coordinator (MDSC) stated that 15 is at the top of the BIMS score. R #7, R #13, and R #14 H. On 12/01/15 at 6:35 pm, during an interview with Registered Nurse (RN) #3 revealed on the night of R #7's admission, it was reported to her by R #7, that R #7 had requested pain medication from CNA #3. RN #3 stated that she did not receive the request for pain medication from CNA #3. Another CNA working notified her right away, R #7 recieved her pain medication 45 minutes after initially requesting them. For the remainder of the night I had another CNA answer the call lights . Incident reported in writing to DON that day. RN #3 also stated that CNA #4 had reported to her that CNA #3 had spoken inappropriately to another resident. The incident was also reported in writing to DON that day as well. I. On 12/02/15 at 11:24 am, during an interview CNA #4 stated she was working with CNA #3 at night and R #13 needed to be changed. CNA #3 was upset and was telling R #13 how dirty and nasty he is for not calling for help. That night she refused to change him. CNA #4 continued to state that later that night they went to R #14 room. He stated he was leaving (resident does not have full cognition) and CNA #3 stated 'where the F*** (profanity) do you think your (sic) going S*** (profanity) look at you . ' I told RN #3 and told DON. J. On 12/02/15 at 2:25 pm during interview with R #13 he could not recall that specific incident with CNA #3 due to passage of time, however he did recall CNA #3 being rough on transfers. K. On 12/02/15 at 2:30 pm, during interview CNA #2 stated that on her way out of the building after shift CNA #2 walked up the hallway and saw CNA #3 in R #13 room. R #13 had dropped a pitcher of water. She raised her voice and tell (sic) him I have a lot resident to help you are not the only one. I'm so busy and you are making a mess . she still tell (sic) him in rude tone of voice he has to ask for help . CNA #2 reported it to the nurse on duty. L. On 12/02/15 at 3:30 pm, during an interview the DON stated that he was not aware of any of the allegation against CNA #3, (except R #3 being pushed), and that none of these allegation were ever investigated. CNA #3 has been on Family Medical Leave Act (FMLA). M. On 12/03/15 at 10:22 am, during an interview CNA #3 was asked about R #7 medication requests. CNA #3 stated that she asked if she could get her pain medication and I told the nurse. I have no knowledge of these allegations (R #13, R 14). N. On 12/02/15 at 04:25 pm during an interview with R #7 she stated When (name of CNA #3) was on duty and I would ask her for pain meds, she would not get them or tell the nurse. When the nurse came to give scheduled meds I would ask the nurse myself what happened to the pain medications. The nurse told me she did not get the message from (name of CNA #3). This happened frequently. R #7 also stated CNA #3 was very short and abrupt, she might do what you asked, she might not. I had a total knee replacement, she would flop my leg into the motion machine and say every time I'm sorry but she didn't mean it. I was very angry, I'm not a person to be afraid, but she is a big woman, very strong! R #17 O. Record review of the Tobacco and E-Cigarette Policy effective date 06/01/15 revealed the following: 1. Residents who have been assessed as an unsafe smoker will have all their smoking materials stored in a secure area at the nurse's station or other location designated by the facility . 2. Residents that has been assessed as a safe smoker can keep their cigarettes only. All lighters must be secured at the Nurses Station or other location designated by the facility. Lighter must be readily accessible to the assessed safe smokers 24/7 upon request. P. Record review of R #17's medical record revealed R #17 had a transient cerebral ischemic attack (stroke). Q. Record review of Safe Smoking (MDS) data set [DATE] revealed R #17 requires supervision during smoking. R. On 12/02/15 at 10:20 am, during interview RN #2 stated that R #17 requires supervision because he sometimes has weakness on one side of his body due to the stoke. S. On 12/01/15 at 11:10 am, during interview R #17 stated that he was outside smoking one night and RN #4 came up to him and demanded that he give her his lighter and cigarettes. R #17 stated that he refused and told him they would have to search him. RN #4 took him to his room along with two CNAs and they stripped searched him (searching someone for concealed items, in a way that involves the removal of their clothes) without his consent. The CNAs were crying and did not want to do it but they were following what (name of RN #4) told them. T. Record review of Departmental Notes written by RN #4 dated 8/28/15 revealed RN #4 found R #17 outside smoking. RN #4 asked R #17 to hand over his cigarettes and lighter, but R #17 refused. I asked a total of 4 times for the lighter and possible cigarettes in his pockets. He refused all times. I asked the 2 CNA's on the 200 side to help me take his pants off in his room to get the possible cigarettes and lighter. After escorting resident to his room I closed the door for privacy and asked resident to get up on his bed. Resident complied and I went through his pant pockets and found 2 lighters and a pack of Marlboro cigarettes with 8 cigarettes. I confiscated the cigarettes and 2 lighters and placed them in the cigarette box in the locked up nurses room . U. On 12/01/15 at 6:15 pm, during interview RN #4 stated I saw him (R #17) outside smoking. I repeatedly asked him to give me his lighter and cigarettes. I did not know he could have cigarettes. I told him if did not hand over the cigarettes and lighter that he would be searched. He said 'do what you need to do.' I grabbed 2 CNAs and took (name of R #17) to his room. I think I patted him down. I do not remember his pants were off, but if I wrote it in the note then that's what happened . If he wasn't going to give it to me how else would I have gotten it. V. On 12/02/15 at 9:20 am, during interview R #17 stated I did not report this, RN #4 told me that there was going to a meeting the next morning about this with (name of DON). When this was going on I felt bad for the CNAs, they were crying and I know they did not want to do it. They following the nurse. It made me feel very undignified, and powerless. The stroke took more from me, I feel small when you can't do anything. I gave them the lighter in my room to try and stop them and they still continued searched me . there was just this attitude that 'we can do this. We own your a** (profanity).' About a week ago RN #4 found me smoking outside and she again asked for the cigarettes and lighter. I told her I found it lit and she called me a liar, and told me that she was subject to search at any time. If we want it we'll come and get it when asked if he reported this incident R #17 stated, No. I don't want to make trouble I am afraid of her (RN #4). W. On 12/02/15 at 10:35 am, during an interview the DON stated that he was not aware of the incident until sometime later, wasn't sure when but a couple of weeks later in stand up. The DON confirmed that there was no investigation and no disciplinary action taken against RN #4, once he had knowledge this incident. X. Record review of the Incident Report from (name of local police department) dated 09/25/15 revealed R #17 called the police to report being illegally stripped searched by a nurse . (Name of R #17) stated that around three weeks ago he was outside smoking and the nurse asked for his cigarettes and lighter. R #17 had gone into his room with two young female CNA's and they had undressed him. (Name of R #17) stated the CNAs were looking through his clothes . (Name of R #17) stated they took his lighter and cigarettes, but don't know why they had to check him in that way. (Name of R #17) stated it has only happened that one time but is in fear . Y. On 12/02/15 at 10:55 am, during an interview The Administrator was asked about her knowledge about the incident with R #17 and RN #4 on the night of 08/28/15, The Administrator stated that she was not aware for some time after. When asked if she knew why the police were called on 09/25/15, the Administrator stated No, they did not tell me. When asked if she asked the police why they were at the facility, the administrator stated No. The Administrator continued to state It was my understanding that (name of DON) had done the investigation. I did receive report and was given assurances that he (R #17) was not rough handled, he had lighter in his possession. I was told there was a resolution to the concern . It should have been investigated. Z. On 12/02/15 at 11:50 am, during an interview with the ADON and the DON, the ADON stated that she would do everything possible to get that lighter away from them (R #4), because it is a safety issue. DON confirmed that he would as well. AA. On 12/02/15 at 6:18 pm, during an interview CNA #5 stated R #17 had been outside smoking and that he did not want to give R #4 his lighter and cigarettes. Nurse (RN #4) suggested that we check him. (Name of CNA #6) said she did not want to have any part of it (searching R #17) . We went to his room . She asked me and (name of CNA #6) to search him. Found the cigarettes and lighter . Yes he refused to be searched. At no time did he give consent to search . His boxers were up to his waistline and his pants were half way off his bottom. His pants were falling off. BB. On 12/03/15 at 12:10 pm, during an interview RN #4 that she had caught R #17 smoking several times after the incident on 08/28/15, but claims no contact was made with R #17. I told the nurse on his unit. RN #4 continued to state that going back to the incident on 08/28/15 she could not remember if his pants were on or off. CC. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed R #17 had a BIMS score of 15.

R #3 (Resident) stated that she was pushed by CNA #3 (Certified Nursing Assistant) onto her bed, then CNA #3 roughly put R #3 legs on the bed lifting beyond a comfortable level causing pain. R #3 confirmed that this happened twice about a week apart. R #3 confirmed that she was scared of CNA #3. This was only investigated and was not reported to the State Agency. RN #3 revealed that R #7 had requested pain medication from CNA #3. RN #3 stated that she did not receive the request for pain medication from CNA #3, and this resulted in R #7 to receive her pain medication 45 minutes after initially requesting her pain medications. RN #3 confirmed that this incident was reported to the DON. This was never investigated or reported to the State Agency. RN #3 also stated that it was reported that CNA #3 had spoken inappropriately to another resident (R #13). RN #3 reported this to the DON. CNA #4 revealed she and CNA #3 were working and R #13 needed to be changed. CNA #3 got mad was verbally abusive to R #13 about needing to changed. CNA #3 refused to change him. Also, later that night, R #14 was stating he was leaving (resident does not have full cognition) and CNA #3 was verbally abusive to R #14 as well. CNA #4 reported this to her nurse and the DON. This was never investigated or reported to the State Agency. During interview with R #13 he could not recall that specific incident with CNA #3, however R #13 stated he did recall CNA #3 being rough during transfers. During interview CNA #2 stated that she saw CNA #3 in R #13's room. R #13 had dropped a pitcher of water. CNA #3 yelled at the resident for doing so. CNA #2 reported it to the nurse on duty. This was not investigated or reported to the State Agency. During an interview the DON confirmed that none of these incidences were investigated or reported to the State Agency. The only one investigated was R #3's incident with CNA #3 and this was not reported to the State Agency. This deficient practice resulted in the first Immediate Jeopardy (IJ) being identified at the facility on 12/02/15 at 6:06 pm. The facility took corrective action by providing an acceptable Plan of Removal for the first IJ. Based on the plan, interventions included: 1. The associate is no longer in the facility and is currently on FMLA. When this allegation was brought to our attention an investigation was started with interviews of residents and employees. If the associate is ready to return to work (because of the end of her leave) Prior to the completion of this investigation she will be immediately suspended until the investigation is completed. If the allegation of abuse is substantiated at the completion of the investigation the associate's employment will be immediately terminated. 2. All employees will be in-serviced on abuse and neglect, dignity and respect and the process for reporting abuse and forms utilize. In addition all employees will be in-serviced in alternative interventions including but not limited to conflict resolution. All new employees will be in-serviced at orientation. No employee will be allowed to work until in-serviced on all the above topics. 3. In addition a new process to facilitate reporting of abuse that includes binders at each nurse's station has been implemented. The binders will include the facility policy and reporting process as well as necessary forms. A locked slotted box will be mounted on the wall outside the nursing administration office and checked daily by the administrator or in her absence the DON (director of nursing) or his delegate. All employees will be in-serviced on location of the binders/forms and the box that will collects (sic) them. 4. During morning meeting the IDT (Interdisciplinary Team) will continue to discuss and monitor incident reports, 24 hour reports, grievances and if any, allegations of abuse. A reportable log will be maintained by the DON or delegate. Based on the Plan of Removal and observation, the IJ was lifted on 12/04/15 2:28 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope H. During interview R #17 stated that he was outside smoking one night and RN #4 came up to him and demanded that he give her his lighter and cigarettes. R #17 stated that he refused and RN #4 told him they would have to search him. RN #4 took him to his room along with two CNAs and they stripped searched him (searching someone for concealed items, in a way that involves the removal of their clothes). Review of Departmental Notes written by RN #4 revealed I asked the 2 CNA's on the 200 side to help me take his pants off in his room to get the possible cigarettes and lighter . RN #4 confiscated R #17's cigarettes and lighter. R #17 also revealed that he is still afraid of RN #4. RN #4 continues to intimidate him about having a lighter and cigarettes. R #17 has not reported this because he is afraid of RN #4. DON confirmed there was no investigation or report sent to the State Agency. Also the ADON and the DON, revealed that they would do everything possible to get lighters away from residents citing it as a safety issue. This deficient practice resulted in the second Immediate Jeopardy (IJ) being identified at the facility on 12/03/15 at 9:30 am. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included: 1. The associate is no longer in the facility and will not return to work here. She was suspended yesterday as the investigation into this allegation commenced. The alleged abuse allegation is being investigated and if substantiated the associate will be terminated immediately. 2. All employees will be in-serviced on abuse and neglect, dignity and respect and the process for reporting abuse and forms utilize. In addition all employees will be in-serviced in alternative interventions including but not limited to conflict resolution. All new employees will be in-serviced at orientation. No employee will be allowed to work until in-serviced on all the above topics. 3. In the case that a resident refuses to return a prohibited item, conflict or confrontation will be avoided. Instead an emergency care conference will be scheduled to discuss the issue and possible resolution. The ombudsman will be called in these circumstances as well. If the prohibited object is kept by the resident monitoring for safety of the resident will maintained until the care conference can happen. 4. In addition a new process to facilitate reporting of abuse that includes binders at each nurse's station has been implemented. The binders will include the facility policy and reporting process as well as necessary forms. A locked slotted box will be mounted on the wall outside the nursing administration office and checked daily by the administrator or in her absence the DON (director of nursing) or his delegate. All employees will be in-serviced on location of the binders/forms and the box that will collects (sic) them. 5. During morning meeting the IDT (Interdisciplinary Team) will continue to discuss and monitor incident reports, 24 hour reports, grievances and if any, allegations of abuse. A reportable log will be maintained by the DON or delegate. Based on the Plan of Removal and observation, the IJ was lifted on 12/04/15 2:28 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope H. Based on observations, record review and interview, the facility failed to ensure that residents were free from abuse, neglect, and mistreatment for 5 (R #3, R #7, R #13, R #14, and R #17) of 5 (R #3, R #7, R #13, R #14, and R #17) residents sampled for abuse, neglect, and mistreatment, when they 1) failed to protect R #3 from being pushed and roughly transferred to her bed by CNA #3, 2) failed to protect R #7 from CNA #3 neglecting to inform the nurse about her need for pain medication, 4) failed protect R #13 from being verbally abused and neglected by CNA #3, 5) failed to protect R #14 from being verbally abused CNA #3, 6) failed to protect R #17 from being strip searched (searching someone for concealed items, in a way that involves the removal of their clothes), and 7) failed to protect R #17 from continual intimidation by RN #4 about being searched. This deficient practice resulted in residents living in physical and psychological pain from being abused and neglected, as well as fear due to the facility allowing their abusers to continue to work in the facility. The findings are: A. On 12/01/15 at 11:57 am, during an interview R #3 stated that she was pushed by CNA #3 (Certified Nursing Assistant) onto her bed. Then she lifted my legs really high, I have a metal in my back, and it really hurt I started crying but I did not tell anyone. She did it a second time. This time my neighbor (roommate) reported it. I was scared of her. They took her off this hallway, but I am still scared. Observation at this time resident was visibly distressed and crying recounting this incident. B. On 12/01/15 at 3:20 pm, during an interview with the Director of Nursing (DON) confirmed that the facility did not substantiate this investigation. The DON stated that he went to interview R #3 and she did not want to say anything, her roommate (R #7) reported it and she did not directly witness the incident. CNA #3 was suspended for the investigation and moved to a different hall. C. On 12/02/15 at 4:21 pm, during an interview CNA #3 stated that she did not push R #3 or help her transfer. CNA #3 stated I saw her (R #3) struggling to get into bed but she transferred herself. I lifted he legs onto the bed and I tried to make her comfortable by putting a pillow behind her back. Her roommate (R #7) was the one that made the complaint not R #3. I was moved to another hallway. D. On 12/02/15 at 12:55 pm, during an interview Social Services Director (SSD) stated (name of R #3) did not want to tell me (about the incidents with CNA #3). She was crying and she was afraid of her . Due to CNA #3's leave no retraining was ever done for CNA #3. E. On 12/02/15 at 04:25 pm, during an interview with R#7 she stated My roommate was (name of R#3). (Name of CNA #3) just picked her up and threw her on the bed. I was in the bathroom but I heard (name of R #3) cry out. I found (name of R #3) crying and she told me what happened. I talked to the DON. I told him I did not want that b**** (profanity) in here. She was rough and rude. She came back that night to our room and I kicked her out. They moved her to work the lock down unit after that . Others told me they are scared of her (CNA #3). I can't give their names, they might get pay back. F. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed R #3 had a Brief interview for Mental Status (BIMS) score of 15. G. On 12/02/15 at 2:40 pm, during interview the MDS Coordinator (MDSC) stated that 15 is at the top of the BIMS score. R #7, R #13, and R #14 H. On 12/01/15 at 6:35 pm, during an interview with Registered Nurse (RN) #3 revealed on the night of R #7's admission, it was reported to her by R #7, that R #7 had requested pain medication from CNA #3. RN #3 stated that she did not receive the request for pain medication from CNA #3. Another CNA working notified her right away, R #7 recieved her pain medication 45 minutes after initially requesting them. For the remainder of the night I had another CNA answer the call lights . Incident reported in writing to DON that day. RN #3 also stated that CNA #4 had reported to her that CNA #3 had spoken inappropriately to another resident. The incident was also reported in writing to DON that day as well. I. On 12/02/15 at 11:24 am, during an interview CNA #4 stated she was working with CNA #3 at night and R #13 needed to be changed. CNA #3 was upset and was telling R #13 how dirty and nasty he is for not calling for help. That night she refused to change him. CNA #4 continued to state that later that night they went to R #14 room. He stated he was leaving (resident does not have full cognition) and CNA #3 stated 'where the F*** (profanity) do you think your (sic) going S*** (profanity) look at you . ' I told RN #3 and told DON. J. On 12/02/15 at 2:25 pm during interview with R #13 he could not recall that specific incident with CNA #3 due to passage of time, however he did recall CNA #3 being rough on transfers. K. On 12/02/15 at 2:30 pm, during interview CNA #2 stated that on her way out of the building after shift CNA #2 walked up the hallway and saw CNA #3 in R #13 room. R #13 had dropped a pitcher of water. She raised her voice and tell (sic) him I have a lot resident to help you are not the only one. I'm so busy and you are making a mess . she still tell (sic) him in rude tone of voice he has to ask for help . CNA #2 reported it to the nurse on duty. L. On 12/02/15 at 3:30 pm, during an interview the DON stated that he was not aware of any of the allegation against CNA #3, (except R #3 being pushed), and that none of these allegation were ever investigated. CNA #3 has been on Family Medical Leave Act (FMLA). M. On 12/03/15 at 10:22 am, during an interview CNA #3 was asked about R #7 medication requests. CNA #3 stated that she asked if she could get her pain medication and I told the nurse. I have no knowledge of these allegations (R #13, R 14). N. On 12/02/15 at 04:25 pm during an interview with R#7 she stated When (name of CNA #3) was on duty and I would ask her for pain meds, she would not get them or tell the nurse. When the nurse came to give scheduled meds I would ask the nurse myself what happened to the pain medications. The nurse told me she did not get the message from (name of CNA #3). This happened frequently. R #7 also stated CNA#3 was very short and abrupt, she might do what you asked, she might not. I had a total knee replacement, she would flop my leg into the motion machine and say every time I'm sorry but she didn't mean it. I was very angry, I'm not a person to be afraid, but she is a big woman, very strong! R #17 O. Record review of the Tobacco and E-Cigarette Policy effective date 06/01/15 revealed the following: 1. Residents who have been assessed as an unsafe smoker will have all their smoking materials stored in a secure area at the nurse's station or other location designated by the facility . 2. Residents that has been assessed as a safe smoker can keep their cigarettes only. All lighters must be secured at the Nurses Station or other location designated by the facility. Lighter must be readily accessible to the assessed safe smokers 24/7 upon request. P. Record review of R #17's medical record revealed R #17 had a transient cerebral ischemic attack (stroke). Q. Record review of Safe Smoking (MDS) data set [DATE] revealed R #17 requires supervision during smoking. R. On 12/02/15 at 10:20 am, during interview RN #2 stated that R #17 requires supervision because he sometimes has weakness on one side of his body due to the stoke. S. On 12/01/15 at 11:10 am, during interview R #17 stated that he was outside smoking one night and RN #4 came up to him and demanded that he give her his lighter and cigarettes. R #17 stated that he refused and told him they would have to search him. RN #4 took him to his room along with two CNAs and they stripped searched him (searching someone for concealed items, in a way that involves the removal of their clothes) without his consent. The CNAs were crying and did not want to do it but they were following what (name of RN #4) told them. T. Record review of Departmental Notes written by RN #4 dated 8/28/15 revealed RN #4 found R #17 outside smoking. RN #4 asked R #17 to hand over his cigarettes and lighter, but R #17 refused. I asked a total of 4 times for the lighter and possible cigarettes in his pockets. He refused all times. I asked the 2 CNA's on the 200 side to help me take his pants off in his room to get the possible cigarettes and lighter. After escorting resident to his room I closed the door for privacy and asked resident to get up on his bed. Resident complied and I went through his pant pockets and found 2 lighters and a pack of Marlboro cigarettes with 8 cigarettes. I confiscated the cigarettes and 2 lighters and placed them in the cigarette box in the locked up nurses room . U. On 12/01/15 at 6:15 pm, during interview RN #4 stated I saw him (R #17) outside smoking. I repeatedly asked him to give me his lighter and cigarettes. I did not know he could have cigarettes. I told him if did not hand over the cigarettes and lighter that he would be searched. He said 'do what you need to do.' I grabbed 2 CNAs and took (name of R #17) to his room. I think I patted him down. I do not remember his pants were off, but if I wrote it in the note then that's what happened . If he wasn't going to give it to me how else would I have gotten it. V. On 12/02/15 at 9:20 am, during interview R #17 stated I did not report this, RN #4 told me that there was going to a meeting the next morning about this with (name of DON). When this was going on I felt bad for the CNAs, they were crying and I know they did not want to do it. They following the nurse. It made me feel very undignified, and powerless. The stroke took more from me, I feel small when you can't do anything. I gave them the lighter in my room to try and stop them and they still continued searched me . there was just this attitude that 'we can do this. We own your a** (profanity).' About a week ago RN #4 found me smoking outside and she again asked for the cigarettes and lighter. I told her I found it lit and she called me a liar, and told me that she was subject to search at any time. If we want it we'll come and get it when asked if he reported this incident R #17 stated, No. I don't want to make trouble I am afraid of her (RN #4). W. On 12/02/15 at 10:35 am, during an interview the DON stated that he was not aware of the incident until sometime later, wasn't sure when but a couple of weeks later in stand up. The DON confirmed that there was no investigation and no disciplinary action taken against RN #4, once he had knowledge this incident. X. Record review of the Incident Report from (name of local police department) dated 09/25/15 revealed R #17 called the police to report being illegally stripped searched by a nurse . (Name of R #17) stated that around three weeks ago he was outside smoking and the nurse asked for his cigarettes and lighter. R #17 had gone into his room with two young female CNA's and they had undressed him. (Name of R #17) stated the CNAs were looking through his clothes . (Name of R #17) stated they took his lighter and cigarettes, but don't know why they had to check him in that way. (Name of R #17) stated it has only happened that one time but is in fear . Y. On 12/02/15 at 10:55 am, during an interview The Administrator was asked about her knowledge about the incident with R #17 and RN #4 on the night of 08/28/15, The Administrator stated that she was not aware for some time after. When asked if she knew why the police were called on 09/25/15, the Administrator stated No, they did not tell me. When asked if she asked the police why they were at the facility, the administrator stated No. The Administrator continued to state It was my understanding that (name of DON) had done the investigation. I did receive report and was given assurances that he (R #17) was not rough handled, he had lighter in his possession. I was told there was a resolution to the concern . It should have been investigated. Z. On 12/02/15 at 11:50 am, during an interview with the ADON and the DON, the ADON stated that she would do everything possible to get that lighter away from them (R #4), because it is a safety issue. DON confirmed that he would as well. AA. On 12/02/15 at 6:18 pm, during an interview CNA #5 stated R #17 had been outside smoking and that he did not want to give R #4 his lighter and cigarettes. Nurse (RN #4) suggested that we check him. (Name of CNA #6) said she did not want to have any part of it (searching R #17) . We went to his room . She asked me and (name of CNA #6) to search him. Found the cigarettes and lighter . Yes he refused to be searched. At no time did he give consent to search . His boxers were up to his waistline and his pants were half way off his bottom. His pants were falling off. BB. On 12/03/15 at 12:10 pm, during an interview RN #4 that she had caught R #17 smoking several times after the incident on 08/28/15, but claims no contact was made with R #17. I told the nurse on his unit. RN #4 continued to state that going back to the incident on 08/28/15 she could not remember if his pants were on or off. CC. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed R #17 had a BIMS score of 15.

R #3 (Resident) stated that she was pushed by CNA #3 (Certified Nursing Assistant) onto her bed, then CNA #3 roughly put R #3 legs on the bed lifting beyond a comfortable level causing pain. R #3 confirmed that this happened twice about a week apart. R #3 confirmed that she was scared of CNA #3. This was only investigated and was not reported to the State Agency. RN #3 revealed that R #7 had requested pain medication from CNA #3. RN #3 stated that she did not receive the request for pain medication from CNA #3, and this resulted in R #7 to receive her pain medication 45 minutes after initially requesting her pain medications. RN #3 confirmed that this incident was reported to the DON. This was never investigated or reported to the State Agency. RN #3 also stated that it was reported that CNA #3 had spoken inappropriately to another resident (R #13). RN #3 reported this to the DON. CNA #4 revealed she and CNA #3 were working and R #13 needed to be changed. CNA #3 got mad was verbally abusive to R #13 about needing to changed. CNA #3 refused to change him. Also, later that night, R #14 was stating he was leaving (resident does not have full cognition) and CNA #3 was verbally abusive to R #14 as well. CNA #4 reported this to her nurse and the DON. This was never investigated or reported to the State Agency. During interview with R #13 he could not recall that specific incident with CNA #3, however R #13 stated he did recall CNA #3 being rough during transfers. During interview CNA #2 stated that she saw CNA #3 in R #13's room. R #13 had dropped a pitcher of water. CNA #3 yelled at the resident for doing so. CNA #2 reported it to the nurse on duty. This was not investigated or reported to the State Agency. During an interview the DON confirmed that none of these incidences were investigated or reported to the State Agency. The only one investigated was R #3's incident with CNA #3 and this was not reported to the State Agency. This deficient practice resulted in the first Immediate Jeopardy (IJ) being identified at the facility on 12/02/15 at 6:06 pm. The facility took corrective action by providing an acceptable Plan of Removal for the first IJ. Based on the plan, interventions included: 1. The associate is no longer in the facility and is currently on FMLA. When this allegation was brought to our attention an investigation was started with interviews of residents and employees. If the associate is ready to return to work (because of the end of her leave) Prior to the completion of this investigation she will be immediately suspended until the investigation is completed. If the allegation of abuse is substantiated at the completion of the investigation the associate's employment will be immediately terminated. 2. All employees will be in-serviced on abuse and neglect, dignity and respect and the process for reporting abuse and forms utilize. In addition all employees will be in-serviced in alternative interventions including but not limited to conflict resolution. All new employees will be in-serviced at orientation. No employee will be allowed to work until in-serviced on all the above topics. 3. In addition a new process to facilitate reporting of abuse that includes binders at each nurse's station has been implemented. The binders will include the facility policy and reporting process as well as necessary forms. A locked slotted box will be mounted on the wall outside the nursing administration office and checked daily by the administrator or in her absence the DON (director of nursing) or his delegate. All employees will be in-serviced on location of the binders/forms and the box that will collects (sic) them. 4. During morning meeting the IDT (Interdisciplinary Team) will continue to discuss and monitor incident reports, 24 hour reports, grievances and if any, allegations of abuse. A reportable log will be maintained by the DON or delegate. Based on the Plan of Removal and observation, the IJ was lifted on 12/04/15 2:28 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope H. During interview R #17 stated that he was outside smoking one night and RN #4 came up to him and demanded that he give her his lighter and cigarettes. R #17 stated that he refused and RN #4 told him they would have to search him. RN #4 took him to his room along with two CNAs and they stripped searched him (searching someone for concealed items, in a way that involves the removal of their clothes). Review of Departmental Notes written by RN #4 revealed I asked the 2 CNA's on the 200 side to help me take his pants off in his room to get the possible cigarettes and lighter . RN #4 confiscated R #17's cigarettes and lighter. R #17 also revealed that he is still afraid of RN #4. RN #4 continues to intimidate him about having a lighter and cigarettes. R #17 has not reported this because he is afraid of RN #4. DON confirmed there was no investigation or report sent to the State Agency. Also the ADON and the DON, revealed that they would do everything possible to get lighters away from residents citing it as a safety issue. This deficient practice resulted in the second Immediate Jeopardy (IJ) being identified at the facility on 12/03/15 at 9:30 am. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included: 1. The associate is no longer in the facility and will not return to work here. She was suspended yesterday as the investigation into this allegation commenced. The alleged abuse allegation is being investigated and if substantiated the associate will be terminated immediately. 2. All employees will be in-serviced on abuse and neglect, dignity and respect and the process for reporting abuse and forms utilize. In addition all employees will be in-serviced in alternative interventions including but not limited to conflict resolution. All new employees will be in-serviced at orientation. No employee will be allowed to work until in-serviced on all the above topics. 3. In the case that a resident refuses to return a prohibited item, conflict or confrontation will be avoided. Instead an emergency care conference will be scheduled to discuss the issue and possible resolution. The ombudsman will be called in these circumstances as well. If the prohibited object is kept by the resident monitoring for safety of the resident will maintained until the care conference can happen. 4. In addition a new process to facilitate reporting of abuse that includes binders at each nurse's station has been implemented. The binders will include the facility policy and reporting process as well as necessary forms. A locked slotted box will be mounted on the wall outside the nursing administration office and checked daily by the administrator or in her absence the DON (director of nursing) or his delegate. All employees will be in-serviced on location of the binders/forms and the box that will collects (sic) them. 5. During morning meeting the IDT (Interdisciplinary Team) will continue to discuss and monitor incident reports, 24 hour reports, grievances and if any, allegations of abuse. A reportable log will be maintained by the DON or delegate. Based on the Plan of Removal and observation, the IJ was lifted on 12/04/15 2:28 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope H. Based on observations, record review and interview, the facility failed to ensure that residents were free from abuse, neglect, and mistreatment for 5 (R #3, R #7, R #13, R #14, and R #17) of 5 (R #3, R #7, R #13, R #14, and R #17) residents sampled for abuse, neglect, and mistreatment, when they 1) failed to protect R #3 from being pushed and roughly transferred to her bed by CNA #3, 2) failed to protect R #7 from CNA #3 neglecting to inform the nurse about her need for pain medication, 4) failed protect R #13 from being verbally abused and neglected by CNA #3, 5) failed to protect R #14 from being verbally abused CNA #3, 6) failed to protect R #17 from being strip searched (searching someone for concealed items, in a way that involves the removal of their clothes), and 7) failed to protect R #17 from continual intimidation by RN #4 about being searched. This deficient practice resulted in residents living in physical and psychological pain from being abused and neglected, as well as fear due to the facility allowing their abusers to continue to work in the facility. The findings are: A. Record review of the (name of the facility) Abuse and Neglect Policy revealed the following: 1. It is the responsibility of our employees, facility consultants, attending physicians, family members, visitor, ect., to promptly report any incident or suspected incident of neglect or resident abuse . to facility management . Our facility does not condone resident abuse by anyone, including staff members . Abuse is defined as the willful infliction of injury . intimidation, or punishment with resulting physical harm, pain or mental anguish . Verbal Abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . regardless of their age, ability to comprehend, or disability . Mental Abuse is defined as, but limited to, humiliation, harassment, treats of punishment . Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . All personnel, resident . are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff . Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the administrator or director of nursing . When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred . R #3 B. On 12/01/15 at 11:57 am, during an interview R #3 stated that she was pushed by CNA #3 (Certified Nursing Assistant) onto her bed. Then she lifted my legs really high, I have a metal in my back, and it really hurt I started crying but I did not tell anyone. She did it a second time. This time my neighbor (roommate) reported it. I was scared of her. They took her off this hallway, but I am still scared. Observation at this time resident was visibly distressed and crying recounting this incident. C. On 12/01/15 at 3:20 pm, during an interview with the Director of Nursing (DON) confirmed that the facility did not substantiate this investigation. The DON stated that he went to interview R #3 and she did not want to say anything, her roommate (R #7) reported it and she did not directly witness the incident. CNA #3 was suspended for the investigation and moved to a different hall. D. On 12/02/15 at 4:21 pm, during an interview CNA #3 stated that she did not push R #3 or help her transfer. CNA #3 stated I saw her (R #3) struggling to get into bed but she transferred herself. I lifted he legs onto the bed and I tried to make her comfortable by putting a pillow behind her back. Her roommate (R #7) was the one that made the complaint not R #3. I was moved to another hallway. E. On 12/02/15 at 12:55 pm, during an interview Social Services Director (SSD) stated (name of R #3) did not want to tell me (about the incidents with CNA #3). She was crying and she was afraid of her . Due to CNA #3's leave no retraining was ever done for CNA #3. F. On 12/02/15 at 04:25 pm, during an interview with R#7 she stated My roommate was (name of R#3). (Name of CNA #3) just picked her up and threw her on the bed. I was in the bathroom but I heard (name of R #3) cry out. I found (name of R #3) crying and she told me what happened. I talked to the DON. I told him I did not want that b**** (profanity) in here. She was rough and rude. She came back that night to our room and I kicked her out. They moved her to work the lock down unit after that . Others told me they are scared of her (CNA #3). I can't give their names, they might get pay back. G. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed R #3 had a Brief interview for Mental Status (BIMS) score of 15. H. On 12/02/15 at 2:40 pm, during interview the MDS Coordinator (MDSC) stated that 15 is at the top of the BIMS score. R #7, R #13, and R #14 I. On 12/01/15 at 6:35 pm, during an interview with Registered Nurse (RN) #3 revealed on the night of R #7's admission, it was reported to her by R #7, that R #7 had requested pain medication from CNA #3. RN #3 stated that she did not receive the request for pain medication from CNA #3. Another CNA working notified her right away, R #7 recieved her pain medication 45 minutes after initially requesting them. For the remainder of the night I had another CNA answer the call lights . Incident reported in writing to DON that day. RN #3 also stated that CNA #4 had reported to her that CNA #3 had spoken inappropriately to another resident. The incident was also reported in writing to DON that day as well. J. On 12/02/15 at 11:24 am, during an interview CNA #4 stated she was working with CNA #3 at night and R #13 needed to be changed. CNA #3 was upset and was telling R #13 how dirty and nasty he is for not calling for help. That night she refused to change him. CNA #4 continued to state that later that night they went to R #14 room. He stated he was leaving (resident does not have full cognition) and CNA #3 stated 'where the F*** (profanity) do you think your (sic) going S*** (profanity) look at you . ' I told RN #3 and told DON. K. On 12/02/15 at 2:25 pm during interview with R #13 he could not recall that specific incident with CNA #3 due to passage of time, however he did recall CNA #3 being rough on transfers. L. On 12/02/15 at 2:30 pm, during interview CNA #2 stated that on her way out of the building after shift CNA #2 walked up the hallway and saw CNA #3 in R #13 room. R #13 had dropped a pitcher of water. She raised her voice and tell (sic) him I have a lot resident to help you are not the only one. I'm so busy and you are making a mess . she still tell (sic) him in rude tone of voice he has to ask for help . CNA #2 reported it to the nurse on duty. M. On 12/02/15 at 3:30 pm, during an interview the DON stated that he was not aware of any of the allegation against CNA #3, (except R #3 being pushed), and that none of these allegation were ever investigated. CNA #3 has been on Family Medical Leave Act (FMLA). N. On 12/03/15 at 10:22 am, during an interview CNA #3 was asked about R #7 medication requests. CNA #3 stated that she asked if she could get her pain medication and I told the nurse. I have no knowledge of these allegations (R #13, R 14). O. On 12/02/15 at 04:25 pm during an interview with R#7 she stated When (name of CNA #3) was on duty and I would ask her for pain meds, she would not get them or tell the nurse. When the nurse came to give scheduled meds I would ask the nurse myself what happened to the pain medications. The nurse told me she did not get the message from (name of CNA #3). This happened frequently. R #7 also stated CNA#3 was very short and abrupt, she might do what you asked, she might not. I had a total knee replacement, she would flop my leg into the motion machine and say every time I'm sorry but she didn't mean it. I was very angry, I'm not a person to be afraid, but she is a big woman, very strong! R #17 P. Record review of the Tobacco and E-Cigarette Policy effective date 06/01/15 revealed the following: 1. Residents who have been assessed as an unsafe smoker will have all their smoking materials stored in a secure area at the nurse's station or other location designated by the facility . 2. Residents that has been assessed as a safe smoker can keep their cigarettes only. All lighters must be secured at the Nurses Station or other location designated by the facility. Lighter must be readily accessible to the assessed safe smokers 24/7 upon request. Q. Record review of R #17's medical record revealed R #17 had a transient cerebral ischemic attack (stroke). R. Record review of Safe Smoking (MDS) data set [DATE] revealed R #17 requires supervision during smoking. S. On 12/02/15 at 10:20 am, during interview RN #2 stated that R #17 requires supervision because he sometimes has weakness on one side of his body due to the stoke. T. On 12/01/15 at 11:10 am, during interview R #17 stated that he was outside smoking one night and RN #4 came up to him and demanded that he give her his lighter and cigarettes. R #17 stated that he refused and told him they would have to search him. RN #4 took him to his room along with two CNAs and they stripped searched him (searching someone for concealed items, in a way that involves the removal of their clothes) without his consent. The CNAs were crying and did not want to do it but they were following what (name of RN #4) told them. U. Record review of Departmental Notes written by RN #4 dated 8/28/15 revealed RN #4 found R #17 outside smoking. RN #4 asked R #17 to hand over his cigarettes and lighter, but R #17 refused. I asked a total of 4 times for the lighter and possible cigarettes in his pockets. He refused all times. I asked the 2 CNA's on the 200 side to help me take his pants off in his room to get the possible cigarettes and lighter. After escorting resident to his room I closed the door for privacy and asked resident to get up on his bed. Resident complied and I went through his pant pockets and found 2 lighters and a pack of Marlboro cigarettes with 8 cigarettes. I confiscated the cigarettes and 2 lighters and placed them in the cigarette box in the locked up nurses room . V. On 12/01/15 at 6:15 pm, during interview RN #4 stated I saw him (R #17) outside smoking. I repeatedly asked him to give me his lighter and cigarettes. I did not know he could have cigarettes. I told him if did not hand over the cigarettes and lighter that he would be searched. He said 'do what you need to do.' I grabbed 2 CNAs and took (name of R #17) to his room. I think I patted him down. I do not remember his pants were off, but if I wrote it in the note then that's what happened . If he wasn't going to give it to me how else would I have gotten it. W. On 12/02/15 at 9:20 am, during interview R #17 stated I did not report this, RN #4 told me that there was going to a meeting the next morning about this with (name of DON). When this was going on I felt bad for the CNAs, they were crying and I know they did not want to do it. They following the nurse. It made me feel very undignified, and powerless. The stroke took more from me, I feel small when you can't do anything. I gave them the lighter in my room to try and stop them and they still continued searched me . there was just this attitude that 'we can do this. We own your a** (profanity).' About a week ago RN #4 found me smoking outside and she again asked for the cigarettes and lighter. I told her I found it lit and she called me a liar, and told me that she was subject to search at any time. If we want it we'll come and get it when asked if he reported this incident R #17 stated, No. I don't want to make trouble I am afraid of her (RN #4). X. On 12/02/15 at 10:35 am, during an interview the DON stated that he was not aware of the incident until sometime later, wasn't sure when but a couple of weeks later in stand up. The DON confirmed that there was no investigation and no disciplinary action taken against RN #4, once he had knowledge this incident. Y. Record review of the Incident Report from (name of local police department) dated 09/25/15 revealed R #17 called the police to report being illegally stripped searched by a nurse . (Name of R #17) stated that around three weeks ago he was outside smoking and the nurse asked for his cigarettes and lighter. R #17 had gone into his room with two young female CNA's and they had undressed him. (Name of R #17) stated the CNAs were looking through his clothes . (Name of R #17) stated they took his lighter and cigarettes, but don't know why they had to check him in that way. (Name of R #17) stated it has only happened that one time but is in fear . Z. On 12/02/15 at 10:55 am, during an interview The Administrator was asked about her knowledge about the incident with R #17 and RN #4 on the night of 08/28/15, The Administrator stated that she was not aware for some time after. When asked if she knew why the police were called on 09/25/15, the Administrator stated No, they did not tell me. When asked if she asked the police why they were at the facility, the administrator stated No. The Administrator continued to state It was my understanding that (name of DON) had done the investigation. I did receive report and was given assurances that he (R #17) was not rough handled, he had lighter in his possession. I was told there was a resolution to the concern . It should have been investigated. AA. On 12/02/15 at 11:50 am, during an interview with the ADON and the DON, the ADON stated that she would do everything possible to get that lighter away from them (R #4), because it is a safety issue. DON confirmed that he would as well. BB. On 12/02/15 at 6:18 pm, during an interview CNA #5 stated R #17 had been outside smoking and that he did not want to give R #4 his lighter and cigarettes. Nurse (RN #4) suggested that we check him. (Name of CNA #6) said she did not want to have any part of it (searching R #17) . We went to his room . She asked me and (name of CNA #6) to search him. Found the cigarettes and lighter . Yes he refused to be searched. At no time did he give consent to search . His boxers were up to his waistline and his pants were half way off his bottom. His pants were falling off. CC. On 12/03/15 at 12:10 pm, during an interview RN #4 that she had caught R #17 smoking several times after the incident on 08/28/15, but claims no contact was made with R #17. I told the nurse on his unit. RN #4 continued to state that going back to the incident on 08/28/15 she could not remember if his pants were on or off. DD. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed R #17 had a BIMS score of 15.

Based on observation, interview and record review the facility failed to keep resident free from accidents for 2 (R #2, R #17) of 5 (R #2, R #3, R #17, R #19, R #20) residents sampled for falls, when they failed to 1) provide adequate supervision for R #2 and R #17, and 2) notify the nurse that R #17 had fallen. This deficient practice likely resulted in R #2's fall, as well as R #17's fall that resulted a fractured femur that required hemiarthroplasty (partial hip replacement) surgery. The findings are: R#2 A. Record review of Face Sheet dated 10/02/15 reveals an admission [DIAGNOSES REDACTED]. B. Record review of Facility Resident Incident Report dated 10/06/15 at 5:45 am revealed: (Name of R #2) sustained a fall in smoking area of courtyard. Described as: resident wheeling himself from dining room through the courtyard door to smoking area when his wheelchair left the concrete and he toppled out. Resident found lying on his right side in courtyard just off the cement. The incident report was signed by LPN (Licensed Practical Nurse) #2. C. On 12/03/15 at 9:00 am, during an interview with CNA #1, she stated (Name of R #2) was alarmed (on his wheelchair and his bed to alert staff to his getting up) because he was real unsteady. He always wanted to smoke, but he always had to have someone with him, even to smoke, because he was shaky. D. On 12/04/15 at 10:00 am, during an interview with LPN #2, she stated I was just starting report when it happened. (Name of R #2) must have went (sic) out of the dining room courtyard door toward smoking. They (residents) smoke at the other end of the courtyard. He must have opened the door on his own. He needed to have supervision. No one (staff) was there, just (Name of R #3) . He was always trying to get out, we would remind him--he had attempted to smoke on his own before. I saw him and cautioned him not to go out without us helping him. He and (Name of R #3) were out there with unlit cigarettes. E. On 12/03/15 at 3:00 pm, during an interview with Registered Nurse #2, she stated R#2 was at risk for falls. He was shaky and unsteady when he tried to get up. That is why we put the bed and chair alarms on him the 2nd day he was here. We were concerned he would try and get up, or get out the wheelchair by himself. He went out at scheduled times to smoke. He was supposed to be accompanied. He shouldn't have been out by himself. F. Record review of Safe Smoking (MDS) data set [DATE] reveals R #2 does not require supervision when smoking. G. Record review of Care Plan dated 10/03/15 reveals: 1. Risk for injury Falls AEB (As evidenced by) history of falls with humeral fracture with additional risk of right weakness, late effects of CVA (stroke), osteoporosis (thinning of bones). 2. Intervention under fall risk: Bed, chair alarm (handwritten addition, undated) 3. Intervention under SMOKER (sic): Provide transport to and assistance for engagement as needed. R #17 H. On 12/01/15 at 11:09 am, during observation, Assistant Director of Nursing (ADON) lead surveyor out to the smoking area, and opened the door to the smoking area. From the door, R #17 was visible outside smoking by himself. ADON did not check to see if R #17 was supervised. I. On 12/01/15 at 11:10 am, during an interview R #17 stated he had fallen outside in the courtyard. R #17 standing up from his wheelchair to get his lighter and lost his balance. R #17 stated that he broke his femur. J. Record review of Safe Smoking (MDS) data set [DATE] revealed R #17 requires supervision during smoking. K. Record review of the Investigative Finding and Summary dated 10/02/15 revealed R #17 was out in the smoking area when he stood up to get the lighter in his pocket. R #17 lost his balance and fell . CNA #7, who was not present for the fall, walked out into the smoking area and found R #17 on the floor asking another resident for help. After reviewing the CNA's statement and the nurse's incident report it was very obvious that the CNA had not informed the nurse of the fall . Later that night R #17 was complaining of pain and was sent to the emergency room (ER). Resident had a left femoral neck fracture. As a result R #17 had hemiarthroplasty (partial hip replacement) surgery. L. On 12/01/15 at 3:20 pm, during interview the Director of Nursing (DON) stated that R #17 and R #2 should be supervised during smoking. Due to R #17's independence it is hard to keep track of him. Also the DON Confirmed that CNA #7 did not informed the nurse that R #17 had fallen, and that he should have informed the nurse immediately. M. Record review of the Tobacco and E-Cigarette Policy effective date 06/01/15 revealed the following: 1. All residents who smoke will be assessed using the Safe Smoking Assessment form upon admission . to determine any special smoking needs. Resident specific smoking needs will be addressed in the resident's plan of care. 2. A Resident deemed incapable of independent smoking may only smoke under staff supervision.

The facility failed to have an effective systematic approach to the identification of hazardous hot water at the hand sinks in resident bathrooms, which could potentially cause serious burns to residents. Hot water was found at the sinks in the resident bathrooms for 13 of the 25 rooms on the 100 Unit and for 3 of the 9 rooms on the 200 Alzheimer's Unit. The water temperature monitoring system was ineffective for identifying the hot water temperatures identified during the survey, and for identifying the need to repair the 100 Unit hot water tank and replacement of the 200 Unit hot water tank. The facility's failed monitoring system resulted in an Immediate Jeopardy (IJ) being identified on 08/26/14 at 5:30 pm. The facility took corrective action by proving an accceptable Plan of Removal. Based on the plan, interventions included lowering water tank temperatures to 105 degrees F on North Hall (100 Unit), and turning the South Hall (200 Unit) water tank off for a period of four hours while actively monitoring for "appropriate temps at or below the 110 degree maximum water temperature," sampling all resident rooms for appropriate temperatures to address concerns accordingly, and providing staff in-service education regarding: 1) Taking water temperatures (110 degree maximum water temperature), 2) Logging the temperatures and corrective actions to take, including adjusting temperatures, contacting the maintenance department for immediate concerns, and ongoing monitoring. Based on the Plan of Removal and observation, the IJ was lifted on 08/26/14 at 11:57 pm. This resulted in the severity and scope being reduced from a level K to a level G (Due to the injury of Resident #1), severity of actual harm that is not immediate jeopardy at a scope of isolated. Based on observation, interview and record review, the facility failed to maintain safe water temperatures in the resident bathrooms for 13 (Rooms 104 - 107, 109, 111, 112, 114, 116, 118 - 121) of the 25 rooms on the 100 Unit and for 3 (Rooms 219, 221, and 223) of the 9 rooms on the 200 Alzheimer's Unit. The facility further failed to provide adequate supervision to prevent accidents with injuries for four of four (R #1, R #12, R #65, R #110) residents reviewed for fall incidents, and further failed to keep the environment free from hazards related to accessible chemicals. This deficient practice could result in avoidable accidents and potentially serious injury. The findings are: Water Temps A. Observation and hand testing of the water temperatures from the hand sinks in the following resident bathrooms revealed water that was very hot to the touch: 1. Room 118 on 08/25/14 at 5:46 pm 2. Room 223 on 08/26/14 at 9:56 am 3. Room 221 on 08/26/14 at 10:34 am 4. Room 106 on 08/26/14 at 1:38 pm 5. Room 105 on 08/26/14 at 2:06 pm 6. Room 119 on 08/26/14 at 2:33 pm 7. Room 219 on 08/26/14 at 2:46 pm 8. Room 112 on 08/26/14 at 2:48 pm 9. Room 105 on 08/26/14 at 3:07 pm 10. Room 111 on 08/26/14 at 3:07 pm 11. Room 119 on 08/26/14 at 3:08 pm B. Testing of water temperatures on 08/26/14 at 5:30 pm with the Maintenance Director (MtceD), who used a calibrated Sysco (brand) dial thermometer, and with the Administrator present, revealed unsafe water temperatures at the hand sinks for the following rooms: 1. Shared sink for room 104 and 106 tested at 121 degrees Farenheit (F). 2. Shared sink for room 105 and 107 tested at 122 degrees F. 3. Shared sink for room 112 and 114 tested at 120 degrees F. 4. Single sink for room 116 tested at 123 degrees F. C. When the MtceD turned the hot water faucet to the open position during the above water testing, the surveyors placed and kept their fingers under the flow of the water. As the water temperature increased, the surveyors' fingers turned red and became painful. The Administrator confirmed these findings after she placed her fingers under the hot running water. D. On 08/26/14 at 6:10 pm, an interview was conducted with the MtceD who stated, "I would say the circulating pump is too small." When he was asked what was the facility's policy regarding water temperatures in residents' bathrooms, he stated, "No higher than 112 degrees F." When he was asked when was the last time he checked the water temperatures in residents' bathrooms, he stated he checked that morning and that all the temperatures were within normal limits. E. On 08/26/14 at 7:26 pm, an interview was conducted with CNA #55. When she was asked if she had identified any problems with the water temperature in the residents' bathrooms, she stated that sometimes the water was not hot enough and sometimes the water was too hot. When she was asked when the water temperature flucuations began, she stated it had been a problem for years. CNA #55 stated she was not sure the last time the flucuation happened and was not sure when and to whom she reported it to. F. During an interview on 08/26/14 at 7:38 pm with CNA #62 in the Alzheimer's Unit concerning hot water temperatures, he stated, "The water temps fluctuate a lot. I always wait until it cools down before I shower anyone." He said he had not had any kind of in-service about water temperatures. G. On 08/26/14 at 7:40 pm, an interview was conducted with R #34, who resides on the 100 Unit. When she was asked if the water temperature from the hand sink in the bathroom felt hot to touch she stated, "Yes, the water is hot. I have to adjust it with cold water." H. The most recent Minimum Data Set (MDS) assessments, particularly Section C for the Brief Interview for Mental Status (BIMS) score and their level of self-performance for the Activities of Daily Living (ADL) related to transfer and walk or locomotion (using the wheelchair) were reviewed for the 25 residents who resided in the rooms listed above. According to the "CMS's RAI Version 3.0 Manual" published October 2011, residents with a BIMS score of "99" were not able to be interviewd; residents with a score of 0 - 7 have cognitive impairment; and residents with a score of 8 - 12 have moderately impaired cognition. Seven of the 25 residents were identified with cognitive impairment and a self-performance of independent or supervision for the ADL of transfer and walk or locomotion placing them at greater risk for injury from exposing their skin to the hot water coming for the hand sinks in their bathrooms: 1. R #32, on the 100 Unit, had a BIMS of 9 and ADL of supervision 2. R #33, on the 100 Unit, had a BIMS of 6 and an ADL of supervision 3. R #34, on the 100 Unit, had a BIMS of 12 and an ADL of supervision 4. R #59, on the 100 Unit, had a BIMS of 12 and an ADL of supervision 5. R #66, on the 200 Unit, had a BIMS of 99 and an ADL of supervision 6. R #79, on the 200 Unit, had a BIMS of (blank) and an ADL of supervision 7. R #83, on the 200 Unit, had a BIMs of 4 and an ADL of supervision I. On 08/26/14 at 9:00 pm, CNA #55 was asked if R #33 and R #85, who share a bathroom on the 100 Unit, could walk or R #85 could walk or use the wheelchair to reach the hand sink in the bathroom sink and turn the water on. CNA #55 stated both of those residents could independently do that. Review of the MDS for R #85, on the 100 Unit, revealed a BIMS score of 8 and an ADL of extensive assistance using a wheelchair. J. Interview on 08/26/14 at 8:25 pm with the Administrator and MtceD revealed the MtceD monitored water temperatures every Monday. He said he would alternate the rooms tested every week on both units. He stated it was his "error" for not identifying hot water temperatures because, "I check them after showers." He further clarified that he tested the water after the "morning meeting; which is usually after showers." The MtceD said they started giving showers "early in the morning, about 5:00 am." K. When reviewing the water temperature log with the MtceD and Administrator during the interview on 08/26/14 at 8:25 pm, the MtceD clarified that the single temperature recorded for the rooms tested on each day was "the highest of all the rooms tested on that date." When asked how he would know which room tested the highest, he acknowledged that he wouldn't be able to since no specific rooms were recorded on the log. L. Further interview on 08/26/14 at 8:25 pm revealed the MtceD participated in the facility's quality assessment (QA) meetings. He said water temperatures had never been discussed at the QA meetings. When informed that some staff reported to the survey team that the water temperatures have fluctuated between too hot or too cold for some time, the Administrator and MtceD both indicated they had received "only verbal reports of (water that was) too cold." M. A review of the water temperature policy printed 08/26/14 revealed "Ensure patient room water temperatures are between 105 (degrees) and 115 (degrees) Fahrenheit (or as specified by state requirements). New Mexico ...100 (degrees) to 110 degrees ... " N. A review of the American Burn Association Scald Injury Prevention Educator's Guide, A Community Fire and Burn Prevention Program Supported by the United States Fire Administration Federal Emergency Management Agency (undated) accessed on the internet at 'http://www.ameriburn.org/Preven/ScaldInjuryEducatorsGuide .pdf <http://www.ameriburn.org/Preven/ScaldInjuryEducator'sGuide%20.pdf> revealed " ...The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed ..." O. The American Burn Association Scald Injury Prevention Educator's Guide identified several high risk groups including children, older adults and people with disabilities or special needs. "...Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids ... "Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. The disability may be permanent or temporary due to illness or injury and vary in severity from minor to total dependence on others. "Mobility impairments, slow or awkward movements, muscle weakness or fatigue, or slower reflexes increase the risk of spills while moving hot liquids. Burns to the lap are common when a person attempts to carry hot liquids or food while seated in a wheelchair. Moving hot liquids can be extremely difficult for someone who uses a cane or walker. Sensory impairments can result in decreased sensation, especially to the hands and feet, so the person may not realized if something is 'too hot.' Changes in a person's intellect, perception, memory, judgment or awareness may hinder the person ' s ability to recognized a dangerous situation (such as a tub filled with scalding water) or respond appropriately to remove themselves from danger. "Other risk factors ...Scald injuries results in considerable pain, prolong treatment, possible lifelong scarring and even death. Prevention of scald injuries is always preferable to treatment and can be largely accomplished through simple changes in behavior and in the home environment." P. The American Burn Association Scald Injury Prevention Educator's Guide further revealed the following time and temperature relationship to severe burns: A third degree burn can occur in one second when the water temperature was 155 degrees Fahrenheit (F). A third degree burn can occur in two second when the water temperature was 148 degrees F. A third degree burn can occur in five second when the water temperature was 140 degrees F. A third degree burn can occur in fifteen second when the water temperature was 133 degrees F. A third degree burn can occur in one minute when the water temperature was 127 degrees F. A third degree burn can occur in three minutes when the water temperature was 124 degrees F. A third degree burn can occur in five minutes when the water temperature was 120 degrees F. A safe temperature for bathing was at 100 degrees F. Q. The American Burn Association Scald Injury Prevention Educator's Guide revealed "...Tap water scalds, common among young children, older adults and people with disabilities, are often more severe than cooking related scalds. For these high risk groups, hospitalization is longer and recovery more difficult ... "Tap water scalds to older adults or someone with a disability usually happen ... when a caregiver fails to recognize that the water is too hot ... "The safest temperature for bathing is about 100 degrees Fahrenheit / 37 (degrees) C (Celsius). "Adequate and constant supervision is the single most important factor in preventing tap water scalds." R. A review of the American Burn Association article titled Scalds: A Burning Issue (undated) accessed on the internet at <http://www.ameriburn.org/Preven>/2000Prevention/Scald2000PreventionKit.pdf revealed "A burn is damage to the skin and underlying tissue caused by heat, chemicals or electricity - a very simplistic definition for a very complex injury. Burns damage or destroy the skin cells. Deeper burns involve the fat, muscle or bone. Scalds result from the destruction of one or more layers of the skin due to contact with hot liquids ..." S. A review of the Burn Foundation article titled Safety Facts on Scald Burns dated 11/24/13 accessed on the internet at <http://www.>burnfoundation.org/programs/resource/cfm?c=1&a=3 revealed " ... Hot tap water is a major cause of burn injury. As with other scald burns, young children and older adults are most at risk.., most people associate burns with flame. In fact, burns are caused more often by liquids than by flames..." T. A review of the "Diabetes and burns: retrospective cohort study" dated 11/24/2013, accessed on the internet at http://www.ncbi.nlm.nih.gov/pubmed/ 365 revealed "... Burn injuries are often associated with multi-systemic complications, even in otherwise healthy individuals. It is therefore intuitive that for the diabetic patient, the underlying pathophysiologic alteration in vascular supply, peripheral neuropathy, and immune function could have a profoundly devastating impact on patient outcomes ...In summary, presence of diabetes in the burn patient was associated with a worse outcome. A predilection for burn injuries in the diabetic was noted in the older adult population. Deeper burns, delayed presentation, higher rates of infection, graft failure and operations, and longer lengths of stay translate into an increase cost to society both economically and in lives. This data would suggest a need for better burn education for diabetics and health care professions, recognizing the elderly population as a 'high-risk' group ..." Accident with injury U. Resident #1 was injured while being assisted to bed on 05/10/14 at approximately 2:45 pm. The resident stated her knee was bumped when she was put to bed. On 05/11/2014 the resident told the day shift nurse her knee was bumped the previous night and was still painful. The day shift nurse called the Physician Assistant (P.A.) who ordered the resident sent to the Emergency Department (ED) for evaluation. The ED ordered a CT scan which showed a fractured right knee (femoral supracondylar and tibial plateau fractures). Review of the resident's MDS revealed the need for extensive assist of two or more for transfers. Documentation of the investigation documentation provided by the facility stated the resident was assisted to bed with the assist of one CNA went the accident occurred. An interview with the Director of Nursing (DON) on 08/28/14 at 2:20 pm revealed she was unsure why the resident would be assisted by one CNA when two or more were required. She stated she did the investigation and had not asked if there was a reason. She also stated she did not attempt to interview any of the other staff members who were on duty during the time of the incident or any other residents in the area. Because the facility failed to do a thorough investigation the resident remains at risk for another injury. No new information was gathered and no new interventions were put in place to protect the resident and possible prevent a recurrence. V. Resident #12 had an unwitnessed fall on 08/01/14 fell in the bathroom, she was found on floor next walker, no injuries. Nursing notes dated 08/01/14 stated that, at 8:00 am, "CNA found resident on floor on buttock in bathroom next to walker." Resident stated, "I fell when I was walking out of bathroom" she stated she hit her head. Neuro check was within normal limits. An incident report was done on 08/01/14 but no investigation was done. Review of the plan of care revealed no changes were made when the Interdisciplinary Team (IDT) met and updated the care plans on 08/16/14. Without an investigation the facility left the resident vulnerable to another fall that may be preventable if the facility discovered the reason for the fall and put a plan in place to keep it from recurring. W. On 8/28/2014 at 5:35 pm during an interview with the Administrator/Abuse Coordinator and the Director of Nursing about the incidents, the Administrator stated the facility doesn't document all of the things they do after an incident of any kind, she could not explain the lack of a thorough investigation. She repeated the facility does not document everything they do. X. During an interview on 08/28/14 at 10:15 am with R #110 and a family member revealed the family member had warned the staff the first day that R #110 moved in that he needed the help of two people. However, that family member stated that in the middle of the first night, one certified nursing assistant (CNA) took R #110 to the bathroom alone and he fell forward resulting in a serious injury to his forehead. R #110 then stated he had fallen seven times since he moved in, and five of those falls had been in the bathroom. The family member also reported she had to post a sign on the wall at the head of R #110's bed, dated 07/07/14, to not get him up before 6:30 am because, on one morning, the staff had gotten him up early and brought him to the main dining room. Someone served him coffee and the cup was set on the half-table on the left armrest of his wheelchair that supported his weak left arm. She demonstrated at that time how wobbly the half-table was. She said the table had wobbled and the cup of coffee fell over and spilled the hot contents onto R #110's lap. She said the staff person who had witnessed the spill didn't do anything to remove the burning coffee before rushing out of the dining room to find a nurse to respond to the incident. By the time R #110 was returned to his room, he had experienced some serious burns on his legs. The family member said the Director of Nursing's (DON) resolution to prevent further burns to R 110 from coffee was for staff to put an ice cube in his coffee. However, the family member thought it was best if R #110 was not brought to the dining room before sufficient staff were present in the facility. Y. Review of the Minimum Data Set (MDS) assessments for R #110 revealed he was admitted on [DATE], then discharged to an acute care hospital on [DATE], and readmitted to the facility on [DATE]. The first comprehensive MDS, with an assessment reference date (ARD) of 03/12/14, revealed his Brief Interview Mental Status (BIMS) score was 12 that meant he had moderately impaired cognition. His orientation to month and day were not answered correctly during the BIMS interview. The quarterly MDS with an ARD of 05/26/14 revealed his BIMS interview still showed moderately impaired cognition but it was lower at a score of 9. Both of the MDS assessements dated 03/12/14 and 05/26/14 revealed R #110's functional status was impaired. He needed extensive assistance with weight-bearing support of "Two+ (plus) persons physical assist" to transfer, dress, and toilet. His balance when "Moving from seated position to standing position," when "Moving on and off toilet," and with a "Surface-to-surface transfer" was "Not steady, only able to stabilize with human assistance." Z. Review of the "Care Plan" for R #110 revealed three problems related to the potential for accidents: 1. A problem with an onset date of 02/28/14 for "Self Care Deficit AEB: (as evidenced by) 2 (two) person level of assistance with additional risk for decline r/t (related to) CVA (cardio vascular accident, or stroke), DM (diabetes mellitus), and [DIAGNOSES REDACTED] (underactive thyroid)." The "Approaches" included "extensive assist of 2 persons" for bed mobility, transfers, and toileting. 2. Another problem with an onset date of 02/28/14 revealed "Impaired Skin integrity AEB laceration to forehead with additional risks R/T hx (history) of falls..." The "Approaches" do not address the "laceration to forehead." A hand-written note on this problem indicated an interdisciplinary team (IDT) meeting occurred on 07/23/14 related to the "scalded inner thighs" from the hot coffee the "resident poured" on his legs on 07/07/14. 3. A third problem was dated 03/28/14 for "Risk of Injury r/t Falls AEB history of falls with additional risk r/t weakness, psychoactive drug, DM." Hand-written notes on this care plan indicated interdisciplinary meetings occurred related to falls on 03/14/14 no injury noted...bruising noted, 05/27/14 with head injury abrasion, and 06/14/14 with head injury (hematoma). AA. The Care Plan did not address the use of bed side rails; however, observation of R #110 on 08/26/14 at 2:59 pm and on 08/28/14 at 10:15 am revealed bilateral quarter bed side rails were up at both the head of the bed and the foot of the bed. In order for the resident to exit the bed, he would have to exit between the bed side rails. BB. A review of documented incidents for R #110 revealed the following: 1. The fall with injury that occurred the first night in the facility, on 02/27/14, had an incident report that was sent to State officials within the first 24 hours after the incident and an investigative report that was sent to State officials within 5 days after the incident. A written statement of the certified nursing assistant (CNA) #21 who assisted R #110 at the time of the incident stated that "around 5:30 am" she took R #110 to the bathroom. He stood and transferred "well with one person assist." As R #110 sat back into his wheelchair, he "slumped/slid forward" and "hit his head on the wall" but CNA #21 was "standing behind his chair" and was unable to prevent him from going forward. "A 6 cm (centimeter) laceration (cut) was noted to his left forehead." The resident was sent to the hospital where he received seven sutures (stitches) and was found to have a "hematoma (collection of blood) to left frontal region," but there was no fracture or hemorrhaging (bleeding) noted. The investigation included written statements from the Licensed Practical Nurse (LPN) #90 and the day shift Certified Medication Assistant (CMA) #91, but the investigation did not address whether CNA #21 followed proper techniques or provided appropriate levels of assistance when toileting R #110. The "Plan of Action/Follow-up" from the investigation stated, "Staff have been instructed to use two persons to assist this resident at all times." The plan of action also placed potential restrictions on the resident, including "a bed/chair alarm in place at all times, a hi-lo bed in place, and fall mat in place while resident is in bed." 2. An incident reported on 03/14/14 at 4:16 pm revealed the resident was "found on floor, bleeding from old laceration. Resident states he was trying to get out of bed to go to restroom and fell ." The old laceration was closed with steri-strips. 3. An incident reported on 06/14/14 at 2:31 am revealed a fall was not witnessed. The "resident stated he was going to bathroom and then look for wife -- legs would not 'work' - he grabbed for siderail - lost balance and fell hitting back of head on floor." The resident received a "large hematoma on back of head -- has skin tear on RT (right) elbow." 4. The hot coffee incident report noted the date and time of 07/07/14 at 5:40 am. The incident was reported by CNA #3 and the incident report was prepared by the night shift LPN #26. The incident was noted as "Non-Witnessed" and described as follows: "CNA reported @ (at) 0540 (5:40 am) that dietary told her that resident has spilled hot coffee in his lap. Resident taken to room, pants removed, noted reddened area to bilateral inner thighs. Cool cloths applied. Resident reports he sat his coffee on 1/2 lap tray and it slid off." BB. Review of the facility's "Incident and Accident Log" revealed the facility did not investigate the circumstances that may have contributed to the incidents above at 2., 3., and 4. In addition, the fall incident of 05/27/14 that was referenced on the care plan was not documented as an incident. CC. Interview on 08/28/14 at 6:45 pm with the Registered Nurse (RN)/Staff Development Coordinator (SDC) revealed she had provided an in-service on "Proper Transfer Techniques." Review of the signatures for this in-service revealed that CNA #21 had attended. Review of the "Guidelines for Using Proper Body Mechanics" revealed a basic principle is to "Square off with the pt (patient) (face head on)." Further interview with the RN/SDC revealed she had recently provided an in-service about how the CNAs should determine "what care to provide to a resident" using the AccuNurse review feature. Review of the in-service "Sign-In Sheet" revealed the in-service occurred on 4/11/14. The RN/SDC stated she "always tells the CNAs that if they don't have AccuNurse instruction" for a particular resident, "which they can review to find out" by saying "review" in their headsets, that the CNAs should ask the nurse on duty and if in doubt, the CNAs should "take two staff to be safe in case the resident needs more assistance." DD. Interview on 08/25/14 at 4:40 pm with resident (R) #65 and a family member revealed the daughter had reported multiple concerns to the facility. The most recent concern was that she received a call in the late evening last week on Monday, 08/18/14, regarding R #65 having an unwitnessed fall with no apparent injury. She said the staff had left his wheelchair away from his bed; they knew this because they saw it on the cameras they had placed in his room. The family said there have been other care concerns including not answering his call bell timely. EE. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 05/13/14 revealed R #65's score from the Brief Interview for Mental Status (BIMS) was 13, meaning he had intact cognition. The MDS indicated that he needed the extensive weight-bearing assistance of one person to transfer, walk, and toilet. His balance was coded as not steady without physical assistance. He was noted as occasionally incontinent of bladder and frequently incontinent of bowel. FF. Review of the "Care Plan" for R #65 revealed a problem statement with an onset date of 11/15/12 for "Risk for injury r/t (related to) Fall r/t predisposing diseases, history of getting up without help, blindness, neuropathy, DM (diabetes mellitus), psychoactive drug." A handwritten note dated 08/20/14 indicated "Resident stated he got confused with directions (legally blind) and thought w/c (wheelchair) was beside commode and sat down." GG. Review of a "Resident Incident Report" dated 08/18/14 revealed the fall was not witnessed. but the resident was "found sitting on floor with right arm holding on to wheelchair" at 10:00 pm. There was no apparent injury. The resident said he "though (sic) my wheelchair was my bedside commode, and I sat down." There was no documentation on the incident report of an investigation into where his wheelchair and commode were positioned in relation to where they should have been relative to his legal blindness. HH. Interview on 08/28/14 at 6:00 pm with the Administrator and DON confirmed there had been no investigation completed or documented regarding the fall on 08/18/14. Chemical Hazards II. Observation during initial tour of the facility on 08/25/14 at 10:15 am on the 200 unit adjacent to room 218 revealed a housekeeping storage room was open. The following items were accessible to residents: Seven bottles of Pro-Bowl cleaner and 1 quart of Topaz cleaner. The label on both bottles read "Do not take internally." JJ. Observation during initial tour of the facility on 08/25/14 at 10:45 am in the locked unit revealed a treatment cart outside of room 226 was unattended with a 12 ounce wound cleanser Sea-clens on top of the cart. KK. Interview with Registered Nurse (RN) #45 on 08/25/14 at 10:50 am revealed that she was aware of the wound cleanser being unattended. RN #45 stated, "This is a dangerous practice in a locked unit with many residents who have dementia and confusion." LL. Observation of the housekeeping closet on the 200 unit, adjacent to room 218 on 08/28/14 at 5:20 am revealed the door was unlocked. The following items were accessible to residents: 1. Pro Bowl, 1 quart container. The label on the Pro Bowl read, "If ingested, seek immediate medical attention." 2. Lime Off #410, five individual quart sized bottles. The label on the Lime Off read, "If ingested, seek immediate medical attention." 3. Glass Cleaner, one liter (Concentrate). The label on the Glass Cleaner read, "Harmful if absorbed through the skin." 4. Comet Deodorizing Cleanser 1.3 pounds, six individual containers. The label on this item read, " Eye irritant." 5. Topaz, one liter container, ready to use gloss restorer. The label on the container read, "Do not take internally." MM. An additional observation was conducted on the same date at 5:44 am of the shower room on the 200 unit. The door to the shower room was open and accessible to residents on the unit. The following items were observed in the shower room: 1. One gallon of Apra Care shampoo. The label read,"For external use only." 2. One gallon of Skin Care Cream; the label read, "For external use only." NN. Interview with the Housekeeping Supervisor on 08/28/14 at 12:20 pm revealed that the housekeeping closets should be locked, as this was a hazard to residents.

The facility failed to have an effective systematic approach to the identification of hazardous hot water at the hand sinks in resident bathrooms, which could potentially cause [MEDICAL CONDITION] residents. Hot water was found at the sinks in the resident bathrooms for 13 of the 25 rooms on the 100 Unit and for 3 of the 9 rooms on the 200 Alzheimer's Unit. The water temperature monitoring system was ineffective for identifying the hot water temperatures identified during the survey, and for identifying the need to repair the 100 Unit hot water tank and replacement of the 200 Unit hot water tank. The facility's failed monitoring system resulted in an Immediate Jeopardy (IJ) being identified on 08/26/14 at 5:30 pm. The facility took corrective action by proving an accceptable Plan of Removal. Based on the plan, interventions included lowering water tank temperatures to 105 degrees F on North Hall (100 Unit), and turning the South Hall (200 Unit) water tank off for a period of four hours while actively monitoring for "appropriate temps at or below the 110 degree maximum water temperature," sampling all resident rooms for appropriate temperatures to address concerns accordingly, and providing staff in-service education regarding: 1) Taking water temperatures (110 degree maximum water temperature), 2) Logging the temperatures and corrective actions to take, including adjusting temperatures, contacting the maintenance department for immediate concerns, and ongoing monitoring. Based on the Plan of Removal and observation, the IJ was lifted on 08/26/14 at 11:57 pm. This resulted in the severity and scope being reduced from a level K to a level G (Due to the injury of Resident #1), severity of actual harm that is not immediate jeopardy at a scope of isolated. Based on observation, interview and record review, the facility failed to maintain safe water temperatures in the resident bathrooms for 13 (Rooms 104 - 107, 109, 111, 112, 114, 116, 118 - 121) of the 25 rooms on the 100 Unit and for 3 (Rooms 219, 221, and 223) of the 9 rooms on the 200 Alzheimer's Unit. This deficient practice could result in avoidable accidents and potentially serious injury. The findings are: A. Observation and hand testing of the water temperatures from the hand sinks in the following resident bathrooms revealed water that was very hot to the touch: 1. Room 118 on 08/25/14 at 5:46 pm 2. Room 223 on 08/26/14 at 9:56 am 3. Room 221 on 08/26/14 at 10:34 am 4. Room 106 on 08/26/14 at 1:38 pm 5. Room 105 on 08/26/14 at 2:06 pm 6. Room 119 on 08/26/14 at 2:33 pm 7. Room 219 on 08/26/14 at 2:46 pm 8. Room 112 on 08/26/14 at 2:48 pm 9. Room 105 on 08/26/14 at 3:07 pm 10. Room 111 on 08/26/14 at 3:07 pm 11. Room 119 on 08/26/14 at 3:08 pm B. Testing of water temperatures on 08/26/14 at 5:30 pm with the Maintenance Director (MtceD), who used a calibrated Sysco (brand) dial thermometer, and with the Administrator present, revealed unsafe water temperatures at the hand sinks for the following rooms: 1. Shared sink for room 104 and 106 tested at 121 degrees Farenheit (F). 2. Shared sink for room 105 and 107 tested at 122 degrees F. 3. Shared sink for room 112 and 114 tested at 120 degrees F. 4. Single sink for room 116 tested at 123 degrees F. C. When the MtceD turned the hot water faucet to the open position during the above water testing, the surveyors placed and kept their fingers under the flow of the water. As the water temperature increased, the surveyors' fingers turned red and became painful. The Administrator confirmed these findings after she placed her fingers under the hot running water. D. On 08/26/14 at 6:10 pm, an interview was conducted with the MtceD who stated, "I would say the circulating pump is too small." When he was asked what was the facility's policy regarding water temperatures in residents' bathrooms, he stated, "No higher than 112 degrees F." When he was asked when was the last time he checked the water temperatures in residents' bathrooms, he stated he checked that morning and that all the temperatures were within normal limits. E. On 08/26/14 at 7:26 pm, an interview was conducted with CNA #55. When she was asked if she had identified any problems with the water temperature in the residents' bathrooms, she stated that sometimes the water was not hot enough and sometimes the water was too hot. When she was asked when the water temperature flucuations began, she stated it had been a problem for years. CNA #55 stated she was not sure the last time the flucuation happened and was not sure when and to whom she reported it to. F. During an interview on 08/26/14 at 7:38 pm with CNA #62 in the Alzheimer's Unit concerning hot water temperatures, he stated, "The water temps fluctuate a lot. I always wait until it cools down before I shower anyone." He said he had not had any kind of in-service about water temperatures. G. On 08/26/14 at 7:40 pm, an interview was conducted with R #34, who resides on the 100 Unit. When she was asked if the water temperature from the hand sink in the bathroom felt hot to touch she stated, "Yes, the water is hot. I have to adjust it with cold water." H. The most recent Minimum Data Set (MDS) assessments, particularly Section C for the Brief Interview for Mental Status (BIMS) score and their level of self-performance for the Activities of Daily Living (ADL) related to transfer and walk or locomotion (using the wheelchair) were reviewed for the 25 residents who resided in the rooms listed above. According to the "CMS's RAI Version 3.0 Manual" published October 2011, residents with a BIMS score of "99" were not able to be interviewd; residents with a score of 0 - 7 have cognitive impairment; and residents with a score of 8 - 12 have moderately impaired cognition. Seven of the 25 residents were identified with cognitive impairment and a self-performance of independent or supervision for the ADL of transfer and walk or locomotion placing them at greater risk for injury from exposing their skin to the hot water coming for the hand sinks in their bathrooms: 1. R #32, on the 100 Unit, had a BIMS of 9 and ADL of supervision 2. R #33, on the 100 Unit, had a BIMS of 6 and an ADL of supervision 3. R #34, on the 100 Unit, had a BIMS of 12 and an ADL of supervision 4. R #59, on the 100 Unit, had a BIMS of 12 and an ADL of supervision 5. R #66, on the 200 Unit, had a BIMS of 99 and an ADL of supervision 6. R #79, on the 200 Unit, had a BIMS of (blank) and an ADL of supervision 7. R #83, on the 200 Unit, had a BIMs of 4 and an ADL of supervision I. On 08/26/14 at 9:00 pm, CNA #55 was asked if R #33 and R #85, who share a bathroom on the 100 Unit, could walk or R #85 could walk or use the wheelchair to reach the hand sink in the bathroom sink and turn the water on. CNA #55 stated both of those residents could independently do that. Review of the MDS for R #85, on the 100 Unit, revealed a BIMS score of 8 and an ADL of extensive assistance using a wheelchair. J. Interview on 08/26/14 at 8:25 pm with the Administrator and MtceD revealed the MtceD monitored water temperatures every Monday. He said he would alternate the rooms tested every week on both units. He stated it was his "error" for not identifying hot water temperatures because, "I check them after showers." He further clarified that he tested the water after the "morning meeting; which is usually after showers." The MtceD said they started giving showers "early in the morning, about 5:00 am." K. When reviewing the water temperature log with the MtceD and Administrator during the interview on 08/26/14 at 8:25 pm, the MtceD clarified that the single temperature recorded for the rooms tested on each day was "the highest of all the rooms tested on that date." When asked how he would know which room tested the highest, he acknowledged that he wouldn't be able to since no specific rooms were recorded on the log. L. Further interview on 08/26/14 at 8:25 pm revealed the MtceD participated in the facility's quality assessment (QA) meetings. He said water temperatures had never been discussed at the QA meetings. When informed that some staff reported to the survey team that the water temperatures have fluctuated between too hot or too cold for some time, the Administrator and MtceD both indicated they had received "only verbal reports of (water that was) too cold." M. A review of the water temperature policy printed 08/26/14 revealed "Ensure patient room water temperatures are between 105 (degrees) and 115 (degrees) Fahrenheit (or as specified by state requirements). New Mexico ...100 (degrees) to 110 degrees ... " N. A review of the American Burn Association Scald Injury Prevention Educator's Guide, A Community Fire and Burn Prevention Program Supported by the United States Fire Administration Federal Emergency Management Agency (undated) accessed on the internet at 'http://www.ameriburn.org/Preven/ScaldInjuryEducatorsGuide .pdf <http://www.ameriburn.org/Preven/ScaldInjuryEducator'sGuide%20.pdf> revealed " ...The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed ..." O. The American Burn Association Scald Injury Prevention Educator's Guide identified several high risk groups including children, older adults and people with disabilities or special needs. "...Older adults, like young children, have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids ... "Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. The disability may be permanent or temporary due to illness or injury and vary in severity from minor to total dependence on others. "Mobility impairments, slow or awkward movements, muscle weakness or fatigue, or slower reflexes increase the risk of spills while moving hot liquids. [MEDICAL CONDITION] the lap are common when a person attempts to carry hot liquids or food while seated in a wheelchair. Moving hot liquids can be extremely difficult for someone who uses a cane or walker. Sensory impairments can result in decreased sensation, especially to the hands and feet, so the person may not realized if something is 'too hot.' Changes in a person's intellect, perception, memory, judgment or awareness may hinder the person ' s ability to recognized a dangerous situation (such as a tub filled with scalding water) or respond appropriately to remove themselves from danger. "Other risk factors ...Scald injuries results in considerable pain, prolong treatment, possible lifelong scarring and even death. Prevention of scald injuries is always preferable to treatment and can be largely accomplished through simple changes in behavior and in the home environment." P. The American Burn Association Scald Injury Prevention Educator's Guide further revealed the following time and temperature relationship to severe burns: A third degree burn can occur in one second when the water temperature was 155 degrees Fahrenheit (F). A third degree burn can occur in two second when the water temperature was 148 degrees F. A third degree burn can occur in five second when the water temperature was 140 degrees F. A third degree burn can occur in fifteen second when the water temperature was 133 degrees F. A third degree burn can occur in one minute when the water temperature was 127 degrees F. A third degree burn can occur in three minutes when the water temperature was 124 degrees F. A third degree burn can occur in five minutes when the water temperature was 120 degrees F. A safe temperature for bathing was at 100 degrees F. Q. The American Burn Association Scald Injury Prevention Educator's Guide revealed "...Tap water scalds, common among young children, older adults and people with disabilities, are often more severe than cooking related scalds. For these high risk groups, hospitalization is longer and recovery more difficult ... "Tap water scalds to older adults or someone with a disability usually happen ... when a caregiver fails to recognize that the water is too hot ... "The safest temperature for bathing is about 100 degrees Fahrenheit / 37 (degrees) C (Celsius). "Adequate and constant supervision is the single most important factor in preventing tap water scalds." R. A review of the American Burn Association article titled Scalds: A Burning Issue (undated) accessed on the internet at <http://www.ameriburn.org/Preven>/2000Prevention/Scald2000PreventionKit.pdf revealed "A burn is damage to the skin and underlying tissue caused by heat, chemicals or electricity - a very simplistic definition for a very complex injury. [MEDICAL CONDITION] or destroy the skin cells. [MEDICAL CONDITION] the fat, muscle or bone. Scalds result from the destruction of one or more layers of the skin due to contact with hot liquids ..." S. A review of the Burn Foundation article titled Safety Facts on [MEDICAL CONDITION] 11/24/13 accessed on the internet at <http://www.>burnfoundation.org/programs/resource/cfm?c=1&a=3 revealed " ... Hot tap water is a major cause of burn injury. As with other scald burns, young children and older adults are most at risk.., most people [MEDICAL CONDITION] flame. In fact,[MEDICAL CONDITION] caused more often by liquids than by flames..." T. A review of the "Diabetes and burns: retrospective cohort study" dated 11/24/2013, accessed on the internet at http://www.ncbi.nlm.nih.gov/pubmed/ 365 revealed "... Burn injuries are often associated with multi-systemic complications, even in otherwise healthy individuals. It is therefore intuitive that for the diabetic patient, the underlying pathophysiologic alteration in vascular supply, [MEDICAL CONDITION], and immune function could have a profoundly devastating impact on patient outcomes ...In summary, presence of diabetes in the burn patient was associated with a worse outcome. A predilection for burn injuries in the diabetic was noted in the older adult population. Deeper burns, delayed presentation, higher rates of infection, graft failure and operations, and longer lengths of stay translate into an increase cost to society both economically and in lives. This data would suggest a need for better burn education for diabetics and health care professions, recognizing the elderly population as a 'high-risk' group ..." Based on observation and interview, the facility failed to ensure the Robo Coupe (blender) blade was maintained in a safe operating condition. This had the potential to affect the residents who received pureed diets. Residents were identified by "Census List" provided by the Administrator on 08/25/14 at 9:49 am. The findings are: A. On 08/25/14 at 10:01 am, a tour of the kitchen and interview was conducted with the Dietary Director (DD). The Robo Coupe blade was observed with a jagged edge. The DD confirmed this finding and stated "It looks like it been dented in or dropped or something. " The DD was asked how many residents received pureed food prepared by the facility and he stated there were five residents. B. On 08/28/14 at 12:35 pm, an observation of the food tray line was conducted. Five pureed meals were observed served to five residents. The DD confirmed that five residents had been served pureed diet during this lunch meal. The DD was asked to provide a policy regarding inspection of the Robo Coupe blade/kitchen equipment but none was provided.

Based on interview and record review, the facility failed to operationalize the facility policies for identification, investigation, and reporting of all allegations of abuse, mistreatment, or neglect for four of four (R #50, 65, 67, and 110) residents with those concerns. This had the potential to allow other opportunities that could have been within the facility's control to affect all or almost all of the 80 residents identified on the "Census List" provided by the Administrator at 9:49 am on 08/25/14. Findings include: A. Interview on 08/25/14 at 10:15 am with the Administrator during the Entrance Conference revealed she was the contact person for the facility's Abuse Prohibition Policies and Procedures and the Social Services Director (SSD) was the contact person regarding facility grievances. B. Review of the facility policy titled, "Grievances/Complaints - Staff Responsibility" (2001 MED-PASS, Inc. (Revised November 2010)) revealed "4. All alleged abuse, mistreatment, neglect, injuries of unknown source...will be reported to the Administrator immediately (Not more than twenty-four (24) hours after the alleged incident)." C. Review of the facility policy titled, "Reporting Abuse to Facility Management" (2001 MED-PASS, Inc. (Revised February 2014)), revealed a "Policy Statement" that "employees, facility consultants, Attending Physicians, family members, visitors, etc" have the responsibility to "promptly report any incident or suspected incident of neglect or residehnt abuse, including injuries of unknown source." The policy provided the "following definitions of abuse" that included: "b. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability... "e. Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. "f. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. "g. Injury of unknown source is defined as an injury that meets both of the following conditions: "(1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and "(2) The injury is suspicious because of: "(a) the extent of the injury; or "(b) the location of the injury...; or "(c) the number of injuries observed at one particular point in time; or "(d) the incidence of injuries over time." D. Review of the facility policy titled, "Abuse Investigations" (2001 MED-PASS, Inc. (Revised February 2014)), revealed a "Policy Statement" that "All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management." The "Policy Interpretation and Implementation" revealed that "Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident." The "Investigation Process" section included conducting interviews with the person reporting the incident; any witnesses; the resident as appropriate; the Attending Physician as needed, "staff members (on all shifts) who have had contact with the resident during the period of the alleged incident;" the resident's roommate, family, or visitors; and other residents. E. During an interview on 08/25/14 at 4:40 pm with resident (R #65) and a family member, R #65 said the Administrator told him that if he "wasn't happy with his care and if he wanted 24-hour care, he should go somewhere else." The family member said it happened on 08/08/13 and she had reported it by a typed letter to the Social Services Director (SSD) and never heard back from her. F. During an interview on 08/27/14 at 4:30 pm with R #65 and another family member, the family member said that shortly after R #65 moved into the facility, the Administrator had come to his room and said something like, "I'm surprised you're still here. With all the complaints you make, I would have thought it better for you to go somewhere else." G. During interview on 08/26/14 at 1:36 pm, R #67 stated the certified nursing assistants (CNA) were "very rough with us in putting us to bed or when we take a bath." She said they don't handle her gently. She said she had filed a grievance about that with the SSD about a year ago. R #67 said "nothing came of it." She also said they the facility had "set a rule" that only women bathe the women, but "they don't follow that rule. Even some of the women are downright rude." H. During an interview on 08/26/14 at 2:50 pm with R #110, the resident said that some staff were really rough with him when providing care. He said they "whip" his clothes off of him. I. During an interview on 08/28/14 at 10:15 am, R #110 repeated the concern about the way in which staff was rough with him when providing care. A family member, who was present at the time explained how staff position R #110 up in bed by pulling on his hands instead of lifting his torso, and they reposition R #110 to transfer him out of bed by first pulling his legs around to the edge of the bed without repositioning his torso at the same time. J. Also during that interview on 8/28/14 at 10:15 am, the family member for R #110 said she used to report her concerns through the grievance process but that hadn't seemed to be effective. She said she had reported a male CNA for not cleaning R #110's bottom after he had a bowel movement. Nothing resulted from that grievance. A recent concern occurred on Monday, 08/25/14, when CNA #12 put wet clothes on R #110 after his shower. The family member reported that concern to the SSD. The family member said she knew she would not be liked for saying it, but wanted it known that she believed the administration of this facility was not equipped for the job. K. Review of the "Silver City Care Concern Log" of concerns filed between 08/01/13 and 08/11/14 revealed there were 20 concerns reported by different residents regarding rough and/or rude staff behavior and 13 concerns from different residents about care needs not being met. The concern for R #65 was filed by the family member on 08/09/13 about "the way the Administrator treated them. (Letter Attached)". The concern from R #67's family was filed on 08/06/13 regarding a CNA being rough. The concerns that R #110's family said they had reported to the SSD were not listed on the log. L. On 08/28/14 at approximately 1:00 pm, the SSD was requested to provide any grievances received regarding R #65, R #67, and R #110. M. Review of the "Complaint/Grievance Report" for the 08/09/13 grievance revealed the typed letter from R #65's family member. The letter described specific statements and body language that displayed "lack of professionalism by the administrator," including: 1. "She referenced how many complaints we had filed and told us if we wanted 24 hour care, we should hire someone." 2. "If you don't like it here, why are you here? If things are so bad here, why don't you leave?" 3. The Administrator "questioned why the potty chair was in his room." R #65 and the family member explained R #65's care needs to the Administrator and that he cannot always wait for staff to attend to him. R #65 said "one nurse...regularly checks and dumps his potty chair." The Administrator then "questioned him, that of the one hundred or so employees she is the only one?" 4. After explaining to the Administrator that R #65's "water cup is hardly ever changed and filled with ice," the Administrator responded with "'He is the only one that never gets fresh water.' She was very sarcastic..." 5. R #65 "told her his breakfast is cold a lot of the time. She dismissed this and didn't respond." 6. "Her final words were: I don't know what to do, file a complaint with (the SSD)." The family member summarized the allegations against the Administrator by saying, "She treated him like a child who was not telling the truth. She was rude, sarcastic, and unprofessional." The family member also noted in the letter that R #65 asked for Tylenol after the incident because "he had a headache. (The Administrator) upset him." N. Further review of the "Complaint/Grievance Report" for this 08/09/13 grievance revealed a staff member was not assigned responsibility to investigate the allegations regarding "lack of professionalism" or possible verbal and/or mental abuse. The Administrator documented in the "Findings of Investigation" section that, in part, the Administrator would not enter R #65's side of the room and would have another staff person with her when she spoke with the family members. O. Review of the "Complaint/Grievance Report" for the 08/06/13 grievance from the family of R #67 regarding a CNA being rough revealed the investigation was assigned to the SSD #28 and the Director of Nursing (DON). The findings of the investigation were documented by the DON as, "Spoke to resident and she did not recall this. Nursing staff report her having hallucinations." There was no plan to resolve the grievance or result of any actions taken. P. The only "Complaint/Grievance Report" provided by the SSD for R #110 did not relate to R #110's concerns about rough staff behavior, neglect with cleaning R #110's bottom after toileting, or with having wet clothes put on him after his shower on 08/25/14. Q. Interview on 08/28/14 at 3:02 pm with the SSD revealed that she did not report any of the concerns on the log regarding rough and/or rude behavior or care needs that were not met as possible abuse, mistreatment, or neglect; including the concerns reported by the family of R #65, R #67, or R #110. She also acknowledged that she had identified the extent of concerns on the "Silver City Care Concern Log" regarding rough and/or rude staff behavior or lack of care and possible neglect. R. Interview on 08/28/14 at 6:00 pm with the Administrator and DON revealed there had not been any trending of concerns on the care concern log other than by department, and they had not reported or investigated the concerns of rough and rude behavior or lack of care as possible abuse, mistreatment, or neglect. S. During the interview on 08/28/14 at 6:00 pm, the Administrator confirmed that no investigation had been conducted or documented regarding R #65's concern about the Administrator's alleged statements and behavior. She indicated that she hadn't thought it was necessary to have someone other than herself respond to the grievance, despite the fact that some of the statements in the letter suggest that she, herself, had committed possible verbal and/or mental abuse per the facility definitions. T. A review of the quarterly Minimum Data Sets ((MDS) dated [DATE] and 05/26/14 revealed R #50 had a Brief Interview of Mental Status (BIMS) score of 6, indicating R #50 was severely impaired. It further revealed required extensive assistance with bed mobility and transfers. U. A review of the New Mexico Department of Health Incident Report completed by the facility on 10/05/14 revealed the following information regarding R #50: Before the incident, R #50 was sitting in her room in her wheelchair. During the incident on 09/26/13 at 10:30 am, R #50 was found lying on her back in her room. R #50 stated that she hit her head and complained of pain in the left lateral rib cage. After the incident, R #50's daughter and physician were notified and R #50 was sent to the emergency room for evaluation and treatment. Confirmation of a left 6th and 8th rib fracture was found. V. A review of the facility's Investigative Finding and Summary dated 10/09/13 revealed the following regarding R #50: "...Plan of Action/Follow-up: Resident was referred to therapy for balance and strengthening. She is now receiving Physical Therapy. She does have an occasional complaint of left rib pain, and scheduled and PRN (as needed) pain meds effective for pain relief. Does have scheduled and PRN pain medication which have been effective for pain relief. The resident has bed/chair alarm in place." W. On 08/28/14 at 4:27 pm an interview was conducted with the DON. When she was asked when was R #50's date of injury, she stated, "Her date of injury was 09/26/13." The DON stated R #50 went to the hospital on [DATE] and was diagnosed with [REDACTED]." When the DON was asked when she notified the New Mexico Department of Health of R #50's incident, she stated, "I did the 5- day on 10/05/13. She added, "We report to the State when I find out about it." When the DON was asked if the facility notified the New Mexico Department of Health immediately of R #50's incident, she stated, "I guess it was not reported immediately." X. A review of the New Mexico Department of Health Incident Report revised 04/08/09 revealed in Section 5 (Notifications) to "Always notify the DOH/DHI within 24 hour via Fax ...or email ..." Y. A review of the facility's Abuse Prevention Program revised 2006 revealed "...Comprehensive policies and procedures have been developed to aid our facility in preventing abuse ...Our abuse prevention program provides policies and procedures that govern, as a minimum ...Timely and thorough investigation of all reports and allegation of abuse ...The reporting and filing of accurate documents relative to incidents of abuse." Z. A review of the facility's policy titled Abuse Investigations revised 2014 revealed "...All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by the facility management ..."

Based on interview and record review, the facility failed to ensure that all allegations of abuse, mistreatment, neglect, and injuries of unknown source for six of six (R #1, 50, 65, 67, 72, and 11) residents with concerns were immediately reported to the Administrator and State officials and thoroughly investigated with the results of the investigations reported to the Administrator and State officials within five working days. This deficient practice had the potential to allow other opportunities that could have been within the facility's control to affect all or almost all of the 80 residents identified on the "Census List" provided by the Administrator on 08/25/14 at 9:49 am. The findings are: A. Interview on 08/25/14 at 10:15 am with the Administrator revealed she was the contact person for the facility's Abuse Prohibition Policies and Procedures and the Social Services Director (SSD) was the contact person regarding facility grievances. B. Interview on 08/26/14 at 8:30 am with the Ombudsman revealed she had received reports from families that, "the Administrator bullies them (the residents) and doesn't want them to say bad things in the facility." She said she and her district Ombudsman have had conversations with some anonymous staff who also reported they felt "bullied" to not complain, but they wouldn't say anything "because they are concerned about their jobs." C. Interview on 08/25/14 at 4:40 pm with R #65 and a family member revealed they had filed a concern with the SSD on 08/08/13 about the manner in which the Administrator had spoken to R #65. The family member had submitted a typed letter to SSD describing what the Administrator said and did during that incident. The family member said she had never heard back from SSD regarding the concern. D. Interview on 08/26/14 at 1:36 pm with R #67 revealed she had reported a concern to the SSD about a year ago regarding a certified nursing assistant (CNA) who was rough with her in the shower. She said "nothing came of it." E. Interview on 08/26/14 at 2:50 pm with R #110 revealed some staff were really rough with him when providing care. He said they "whip" his clothes off of him. During an interview on 08/28/14 at 10:15 am, R #110 repeated the concern and a family member, who was present at that time, said she used to report her concerns through the grievance process but that hadn't seemed to be effective. She said she had reported a male CNA for not cleaning R #110's bottom after he had a bowel movement. She said, "Nothing resulted from that grievance." The family member reported to the SSD #28 a concern that occurred on Monday, 08/25/14, when CNA #12 put wet clothes on R #110 after his shower. F. Review of the "(The facility name) Concern Log" of concerns filed between 08/01/13 and 08/11/14 revealed there were 20 concerns reported by different residents regarding rough and/or rude staff behavior and 13 concerns from different residents about care needs not being met. The concern for R #65 was filed by the family member on 08/09/13 about "the way the Administrator treated them. (Letter Attached)" There was one concern from R #67's family on 08/06/13 regarding a CNA being rough. There were two concerns documented regarding R #110, but neither of them were regarding the male CNA who did not clean R #110's bottom or CNA #12 who put wet clothes on R #110 after his shower. G. On 08/28/14 at approximately 1:00 pm, the SSD was requested to provide any grievances received regarding R #65, R #67 and R #110. F. Review of the "Complaint/Grievance Report" for R #65 dated 08/09/13 revealed a staff member was not assigned responsibility to investigate the allegations the family member had detailed in an attached typed letter. The Administrator documented in the "Findings of Investigation" section that, in part, the Administrator would not enter R #65's side of the room and would have another staff person with her when she spoke with the family members. The typed letter described specific statements and body language that the family member described as a "lack of professionalism by the administrator," including: 1. "She referenced how many complaints we had filed and told us if we wanted 24 hour care, we should hire someone." 2. "If you don't like it here, why are you here? If things are so bad here, why don't you leave?" 3. The Administrator "questioned why the potty chair was in his room." R #65 and the family member explained R #65's care needs to the Administrator and that he cannot always wait for staff to attend to him. R #65 said "one nurse...regularly checks and dumps his potty chair." The Administrator then "questioned him, that of the one hundred or so employees she is the only one?" 4. After explaining to the Administrator that R #65's "water cup is hardly ever changed and filled with ice, the Administrator responded with 'He is the only one that never gets fresh water.' She was very sarcastic..." 5. R #65 "told her his breakfast is cold a lot of the time. She dismissed this and didn't respond." 6. "Her final words were: I don't know what to do, file a complaint with (the SSD)." The family member summarized the allegations against the Administrator by saying, "She treated him like a child who was not telling the truth. She was rude, sarcastic, and unprofessional." G. Review of the "Complaint/Grievance Report" for R #67 dated 08/06/13 revealed the investigation was assigned to the SSD and the Director of Nursing (DON). The findings of the investigation were documented by the DON as "Spoke to resident and she did not recall this. Nursing staff report her having hallucinations." There was investigation documented beyond that and there was no plan to resolve the grievance or result of any actions taken. H. The only "Complaint/Grievance Report" provided by the SSD regarding R #110 did not relate to R #110's concerns about rough staff behavior, neglect or personal hygiene after toileting R #110, or with having wet clothes put on him after his shower on 08/25/14. I. Review of the facility policy titled, "Grievances/Complaints - Staff Responsibility" (2001 MED-PASS, Inc. (Revised November 2010)) revealed "4. All alleged abuse, mistreatment, neglect, injuries of unknown source...will be reported to the Administrator immediately (Not more than twenty-four (24) hours after the alleged incident)." J. Review of the facility policy titled, "Reporting Abuse to Facility Management" (2001 MED-PASS, Inc. (Revised February 2014)), revealed a "Policy Statement" that "employees, facility consultants, Attending Physicians, family members, visitors, etc" have the responsibility to "promptly report any incident or suspected incident of neglect or residehnt abuse, including injuries of unknown source." The policy provided the "following definitions of abuse" that included: "b. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability... "e. Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. "f. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. "g. Injury of unknown source is defined as an injury that meets both of the following conditions: "(1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and "(2) The injury is suspicious because of: "(a) the extent of the injury; or "(b) the location of the injury...; or "(c) the number of injuries observed at one particular point in time; or "(d) the incidence of injuries over time." K. Review of the facility policy titled, "Abuse Investigations" (2001 MED-PASS, Inc. (Revised February 2014)), revealed a "Policy Statement" that "All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management." The "Policy Interpretation and Implementation" section specifies that "1....the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident." The "Investigation Process" included conducting interviews with the person reporting the incident; any witnesses; the resident as appropriate; the Attending Physician as needed, "staff members (on all shifts) who have had contact with the resident during the period of the alleged incident;" the resident's roommate, family, or visitors; and other residents. L. Neither the policy titled "Reporting Abuse to Facility Management" nor the policy titled "Abuse Investigations" specify a requirement to report the alleged abuse, neglect, or injury of unknown source to the state officials immediately; not more than 24 hours. M. Interview on 08/28/14 at 3:02 pm with the SSD revealed that she would report during morning stand-up meetings how many concerns were received the day before and provide a quick overview of the concern; and then the Administrator assigned an applicable staff member to resolve. She said she had never reviewed the concerns by category of concerns, only by department. She had not identified the extent of concerns on the "(The facility name) Concern Log" regarding rough and/or rude staff behavior or lack of care and possible neglect. She said allegations of rough and rude behavior would be assigned to the nursing and social services departments. She revealed she did not report any of the concerns on the log, including R #65, R #67, or R #110's concerns, as possible abuse, mistreatment, or neglect. N. Interview on 08/28/14 at 6:00 pm with the Administrator and DON revealed there had not been any trending of concerns on the care concern log other than by department, and they had not reported or investigated the concerns of rough and rude behavior or lack of care as possible abuse, mistreatment, or neglect. The Administrator confirmed that no investigation had been conducted or documented regarding R #65's concern about her statements and behavior. She indicated that she hadn't thought it was necessary to have someone other than herself respond to the grievance, despite the fact that some of the statements in the letter suggested that she, herself, was the perpetrator of possible verbal and mental abuse. O. Further review of facility provided documentation revealed that the facility received a complaint relating to multiple concerns regarding R #72. These included the resident not being cleaned properly, the Depends (adult incontinence brief) not being placed on R #72 correctly, the Depends not being marked with time per the request of the wife, a bruise noted on R #72 from incorrect positioning, a nurse not knowing how tight the [MEDICAL CONDITION] collar should be, and a CNA asking about R #72 being on thickened liquids. Review of the documentation revealed there was no investigation for the allegations reported to the State Agency (Department of Health). P. Interview with the DON on 07/28/14 at 4:00 pm revealed that the facility had completed two reports to the state, for the incident on 07/26/14, one on 07/28/14 and the other with an investigation within 5 days. The DON confirmed that the initial report to the state was two days late. She was not aware of the required timeline for reporting. Further interview with the DON relating to the complaint from the NM DOH on 05/16/14 revealed that there was no investigation for this complaint; she felt the implementation of educating staff about this issue was part of the investigation. Q. A review of the quarterly Minimum Data Sets ((MDS) dated [DATE] and 05/26/14 revealed R #50 had a Brief Interview of Mental Status (BIMS) score of 6, indicating R #50 was severely impaired. It further revealed R #50 required extensive assistance with bed mobility and transfers. R. A review of the Incident Report completed by the facility on 10/05/14 revealed the following information regarding R #50: 1. Before the incident, R #50 was sitting in her room in her wheelchair. 2. During the incident on 09/26/13 at 10:30 am, R #50 was found lying on her back in her room. R #50 stated that she hit her head and complained of pain in the left lateral rib cage. 3. After the incident, R #50's daughter and physician were notified and R #50 was sent to the emergency room for evaluation and treatment. Confirmation of a left 6th and 8th rib fracture was found. S. A review of the facility's Investigative Finding and Summary dated 10/09/13 revealed the following regarding R #50: "...Plan of Action/Follow-up: Resident was referred to therapy for balance and strengthening. She is now receiving Physical Therapy. She does have an occasional complaint of left rib pain, and scheduled and PRN (as needed) pain meds effective for pain relief. Does have scheduled and PRN pain medication which have been effective for pain relief. The resident has bed/chair alarm in place." T. On 08/28/14 at 5:30 am, R #50 was observed dressed and sitting in her wheelchair with her eyes closed. R #50 had a lap tray on her wheelchair. When Certified Nursing Assistant (CNA) #70 was asked what was the apparatus being used on R #50's wheelchair, she stated, "It's a lap tray." When she was asked why the lap tray was being used she stated, "It is to stop her from getting up." U. On 08/28/14 at 4:27 pm, an interview was conducted with the DON. When she was asked when was R #50's date of injury, she stated, "Her date of injury was 09/26/13." The DON stated R #50 went to the hospital on [DATE] and was diagnosed with [REDACTED]." When the DON was asked when she notified the New Mexico Department of Health of R #50's incident, she stated, "I did the 5-day on 10/05/13. She added, "We report to the State when I find out about it." When the DON was asked if the facility notified the New Mexico Department of Health immediately of R #50's incident, she stated, "I guess it was not reported immediately." When the DON was asked for documentation of a thorough investigation, including staff/residents interviews, she stated, "I don't see any staff interviews. I should have done some staff interviews." V. A review of the New Mexico Department of Health Incident Report revised 04/08/09 revealed in Section 5 (Notifications) to "Always notify the DOH (Department of Health) /DHI within 24 hour via Fax ...or email ..." W. A review of the facility's Abuse Prevention Program revised 2006 revealed "...Comprehensive policies and procedures have been developed to aid our facility in preventing abuse ...Our abuse prevention program provides policies and procedures that govern, as a minimum ...Timely and thorough investigation of all reports and allegation of abuse ...The reporting and filing of accurate documents relative to incidents of abuse." X. A review of the facility's policy titled Abuse Investigations revised 2014 revealed "...All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by the facility management ...The individual conducting the investigation will, as a minimum: ...Interview the person(s) reporting the incident; ...Interview any witnesses to the incident ...Interview the resident (as medically appropriate ...Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition ...Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident ...Interview the resident's roommate,, family members, and visitors ...Witness reports will be obtained in writing ...The Administrator will provide a written report of the results of all abuse investigation and appropriate action taken to the state survey and certification agency as may be required by state or local laws, within five (5) working days of the reported incident ..." Y. Review of the clinical record for R #1 revealed she was injured while being assisted to bed on 05/10/14 at approximately 2:45 pm. The resident stated her knee was bumped when she was put to bed. The resident complained of pain to her right knee on the same evening and the night nurse applied ice to the area which the nurse identified as swollen and administered Tylenol. On 05/11/14, the resident told the day shift nurse her knee was bumped the previous night and was still painful. The day shift nurse called the Physician Assistant (PA) who ordered the resident be sent to the Emergency Department (ED) for evaluation. The ED ordered a CT scan which showed a fractured right knee (femoral supracondylar and tibial plateau fractures). The resident was returned to the facility via ambulance the afternoon of 05/11/14 with an immobilizer in place. The facility filed an incident report on 05/12/14 as an injury of unknown origin. Review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the need for extensive assist of two or more for transfers. Documentation of the investigation documentation provided by the facility stated the resident was assisted to bed with the assist of one CNA when the accident occurred. Z. An interview with the DON on 08/28/14 at 2:20 pm revealed she was unsure why R #1 would be assisted by one CNA when two or more were required. She stated she did the investigation and had not asked if there was a reason. She also stated she did not attempt to interview any of the other staff members who were on duty during the time of the incident or any other residents in the area. AA. On 08/28/14 at 5:35 pm during an interview with the Administrator, who was the facility desginated Abuse Coordinator, and the DON about the incident, the Administrator stated the facility doesn't document all of the things they do after an incident of any kind. The DON stated she doesn't report incidents of unknown origin within 24 hours if it happens on the weekend. The Administrator was unable to provide any documentation or explanation of the reporting deficit and could not explain the lack of a thorough investigation. She repeated the facility does not document everything they do.

Based on record review and staff interview, the facility failed to ensure that the care plan for two person assistance were followed for 2 (R #1 and 110) of 4 (R #1, 12, 65, and 110) sampled residents for injuries. This failed practice could have lead to the injuries. The findings are: A. Resident #1 was injured while being assisted to bed on 05/10/14 at approximately 2:45 pm. The resident stated her knee was bumped when she was put to bed. B. On 05/11/14 the resident told the day shift nurse her knee was bumped the previous night and was still painful. The day shift nurse called the Physician Assistant (P.A.) who ordered the resident sent to the Emergency Department (ED) for evaluation. The ED ordered a CT scan which showed a fractured right knee (femoral supracondylar and tibial plateau fractures). Review of the resident's MDS revealed the need for extensive assist of two or more for transfers. C. Review of the investigation documentation provided by the facility stated the resident was assisted to bed with the assist of one CNA went the accident occurred. D. An interview with the Director of Nursing (DON) on 08/28/14 at 2:20 pm revealed she was unsure why the resident would be assisted by one CNA when two or more were required. She stated she did the investigation and had not asked if there was a reason. E. During an interview on 08/28/14 at 10:15 am with R #110 and a family member revealed the family member had warned the staff the first day that R #110 moved in that he needed the help of two people. However, that family member stated that in the middle of the first night, one certified nursing assistant (CNA) took R #110 to the bathroom alone and he fell forward resulting in a serious injury to his forehead. R #110 then stated he had fallen seven times since he moved in, and five of those falls had been in the bathroom. The family member also reported she had to post a sign on the wall at the head of R #110's bed, dated 07/07/14, to not get him up before 6:30 am because, on one morning, the staff had gotten him up early and brought him to the main dining room. Someone served him coffee and the cup was set on the half-table on the left armrest of his wheelchair that supported his weak left arm. She demonstrated at that time how wobbly the half-table was. She said the table had wobbled and the cup of coffee fell over and spilled the hot contents onto R #110's lap. She said the staff person who had witnessed the spill didn't do anything to remove the burning coffee before rushing out of the dining room to find a nurse to respond to the incident. By the time R #110 was returned to his room, he had experienced some [MEDICAL CONDITION] his legs. The family member said the Director of Nursing's (DON) resolution to prevent [MEDICAL CONDITION] R 110 from coffee was for staff to put an ice cube in his coffee. However, the family member thought it was best if R #110 was not brought to the dining room before sufficient staff were present in the facility. F. Review of the Minimum Data Set (MDS) assessments for R 110 revealed he was admitted on [DATE], then discharged to an acute care hospital on [DATE], and readmitted to the facility on [DATE]. The first comprehensive MDS, with an assessment reference date (ARD) of 03/12/14, revealed his Brief Interview Mental Status (BIMS) score was 12 that meant he had moderately impaired cognition. His orientation to month and day were not answered correctly during the BIMS interview. The quarterly MDS with an ARD of 05/26/14 revealed his BIMS interview still showed moderately impaired cognition but it was lower at a score of 9. Both of the MDS assessements dated 03/12/14 and 05/26/14 revealed R #110's functional status was impaired. He needed extensive assistance with weight-bearing support of "Two+ (plus) persons physical assist" to transfer, dress, and toilet. His balance when "Moving from seated position to standing position," when "Moving on and off toilet," and with a "Surface-to-surface transfer" was "Not steady, only able to stabilize with human assistance." G. Review of the "Care Plan" for R #110 revealed three problems related to the potential for accidents: 1. A problem with an onset date of 02/28/14 for "Self Care Deficit AEB: (as evidenced by) 2 (two) person level of assistance with additional risk for decline r/t (related to)[MEDICAL CONDITION](cardio vascular accident, or stroke), DM (diabetes mellitus), and [MEDICAL CONDITION] (underactive [MEDICAL CONDITION])." The "Approaches" included "extensive assist of 2 persons" for bed mobility, transfers, and toileting. 2. Another problem with an onset date of 02/28/14 revealed "Impaired Skin integrity AEB laceration to forehead with additional risks R/T hx (history) of falls..." The "Approaches" do not address the "laceration to forehead." A hand-written note on this problem indicated an interdisciplinary team (IDT) meeting occurred on 07/23/14 related to the "scalded inner thighs" from the hot coffee the "resident poured" on his legs on 07/07/14. 3. A third problem was dated 03/28/14 for "Risk of Injury r/t Falls AEB history of falls with additional risk r/t weakness, psychoactive drug, DM ." Hand-written notes on this care plan indicated interdisciplinary meetings occurred related to falls on 03/14/14 no injury noted...bruising noted, 05/27/14 with head injury abrasion, and 06/14/14 with head injury (hematoma). H. A review of documented incidents for R #110 revealed the following: 1. The fall with injury that occurred the first night in the facility, on 02/27/14, a written statement of the certified nursing assistant (CNA) #21 who assisted R #110 at the time of the incident stated that "around 5:30 am" she took R #110 to the bathroom. He stood and transferred "well with one person assist." As R #110 sat back into his wheelchair, he "slumped/slid forward" and "hit his head on the wall" but CNA #21 was "standing behind his chair" and was unable to prevent him from going forward. "A 6 cm (centimeter) laceration (cut) was noted to his left forehead." The resident was sent to the hospital where he received seven sutures (stitches) and was found to have a "hematoma (collection of blood) to left frontal region," but there was no fracture or hemorrhaging (bleeding) noted. The investigation included written statements from the Licensed Practical Nurse (LPN) #90 and the day shift Certified Medication Assistant (CMA) #91, but the investigation did not address whether CNA #21 followed proper techniques or provided appropriate levels of assistance when toileting R #110. The "Plan of Action/Follow-up" from the investigation stated, "Staff have been instructed to use two persons to assist this resident at all times." The plan of action also placed potential restrictions on the resident, including "a bed/chair alarm in place at all times, a hi-lo bed in place, and fall mat in place while resident is in bed." 2. An incident reported on 03/14/14 at 4:16 pm revealed the resident was "found on floor, bleeding from old laceration. Resident states he was trying to get out of bed to go to restroom and fell ." The old laceration was closed with steri-strips. 3. An incident reported on 06/14/14 at 2:31 am revealed a fall was not witnessed. The "resident stated he was going to bathroom and then look for wife -- legs would not 'work' - he grabbed for siderail - lost balance and fell hitting back of head on floor." The resident received a "large hematoma on back of head -- has skin tear on RT (right) elbow." 4. The hot coffee incident report noted the date and time of 07/07/14 at 5:40 am. The incident was reported by CNA #3 and the incident report was prepared by the night shift LPN #26. The incident was noted as "Non-Witnessed" and described as follows: "CNA reported @ (at) 0540 (5:40 am) that dietary told her that resident has spilled hot coffee in his lap. Resident taken to room, pants removed, noted reddened area to bilateral inner thighs. Cool cloths applied. Resident reports he sat his coffee on 1/2 lap tray and it slid off." I. Interview on 08/28/14 at 6:45 pm with the Registered Nurse (RN)/Staff Development Coordinator (SDC) revealed she had provided an in-service on "Proper Transfer Techniques." Review of the signatures for this in-service revealed that CNA #21 had attended. Review of the "Guidelines for Using Proper Body Mechanics" revealed a basic principle is to "Square off with the pt (patient) (face head on)." Further interview with the RN/SDC revealed she had recently provided an in-service about how the CNAs should determine "what care to provide to a resident" using the AccuNurse review feature. Review of the in-service "Sign-In Sheet" revealed the in-service occurred on 04/11/14. The RN/SDC stated she "always tells the CNAs that if they don't have AccuNurse instruction" for a particular resident, "which they can review to find out" by saying "review" in their headsets, that the CNAs should ask the nurse on duty and if in doubt, the CNAs should "take two staff to be safe in case the resident needs more assistance."

Based on observation, record review, and interview, the facility failed to provide services necessary to improve speech ability for 1 (#81) of 4 (#81, 82, 122 and 137) residents reviewed for rehabilitative services. Resident #81 had impaired speech skills and was receiving speech therapy until the speech therapist left the facility for another position elsewhere. The resident was discharged from speech therapy with no effort to determine if further therapy services were needed. The deficient practice had the potential to resident #81 by leaving him with a continued speech impairment to the extent that the resident became tearful when trying to communicate with others. The findings are: A. Review of the record for resident #81 revealed an undated Resident Admission Record documenting admission to the facility on [DATE] with [DIAGNOSES REDACTED]. B. On 08/21/12 at 7:55 am, during an interview, resident #81 had difficulty speaking, struggling to form words and respond to questions, and trying to use gestures to communicate. After a few minutes of trying to communicate, the resident became tearful and the interview was ended. C. On 8/25/12 at 3:00 pm, during an interview, resident #81 signaled by gesture that he wished to speak. The resident again had difficulty speaking, struggling to form words and respond to questions, and trying to use gestures to communicate. He was able to communicate that he wanted something but was unable to communicate what he wanted. The resident again became frustrated and tearful and the interview was ended. D. On 08/28/12 at 3:30 pm, during an interview, resident #81 again signaled by gesture that he wished to speak. The resident again had difficulty speaking, struggling to form words and respond to questions, and trying to use gestures to communicate. He was able to communicate that he wanted something and, when the surveyor mentioned speech therapy, the resident signaled that was what he wanted. E. On 08/28/12 at 3:40 pm, during an interview, Registered Nurse #1 was asked about speech therapy services for resident #81. She stated that he had been receiving speech therapy services. She stated, "He was doing OK, then the speech therapist stopped coming. I don't know who's doing speech therapy." F. Review of resident #81's admission Minimum Data Set (MDS) assessment, dated 03/08/12, revealed that the resident had adequate hearing but no speech. G. Review of resident #81's record revealed a Telephone Order (TO) from the physician dated 03/12/12, ordering speech therapy services. A TO dated 07/27/12 ordered the services to be discontinued. H. Review of resident #81's record further revealed a Speech Therapy Discharge Summary dated 07/27/12. The discharge summary documented that the resident had achieved set goals and documented, "(Name of resident #81) had achieved 75% consistently, but moreover, he was spontaneously producing basic greetings, many single word and short phrase productions, as well as using gestures and facial expressions to communicate his thoughts/intentions. This even though he still demonstrates significant oral/verbal dyspraxia (a disturbance in the programming, control, and execution of making a decision)." Under "Comments," the summary documented, "Therapy has been discontinued as this therapist is leaving (name of facility) for another assignment ..." I. On 08/29/12 at 8:30 am, during an interview, the Director of Nursing (DON) was asked about the facility's speech therapy services. She stated, "There is no speech therapist here right now." When asked how long the facility had been without a speech therapist, the DON stated, "I would have to check the actual date, but its been a few weeks now." When asked about the interim plans for providing speech services, she stated, "We have a speech therapist that is part of the corporate team, and so if there is somebody that needs speech then she can come and evaluate and treat." When asked about speech services for resident #81, she stated, "Speech did work with him while they were in the building. He was DC' d (discharged ), and that's it as far as speech is concerned." When asked if the resident had expressed a need for speech services, she stated, "Yes, due to the communication problems that he has." When asked if the corporate speech therapist had been notified, she stated, "No, because he's already been seen by the speech therapist and the speech therapist discontinued him from speech. As far as I know, there hasn't been a new order for speech." When told that the Speech Therapy Discharge Summary documented the resident was being discharged because the therapist was leaving, she stated, "I wasn't aware that he was being discharged because the therapist was leaving." When asked if the resident would be a candidate for further therapy on that basis, she stated, "Yes." When asked if arrangements had been made for further therapy, she stated, "Not that I'm aware of." J. On 08/29/12 at 9:15 am during an interview, the Director of the Rehabilitation Program was asked about the facility's speech therapy services. She stated, "Right now, we're currently looking for a speech therapist." When asked about the facilities plans for residents who need speech services, she stated, "At this point in time, our Regional Director, (name of regional director), she's a speech therapist, so I usually call her up." When asked about the residents receiving services under the previous speech therapist, she stated, "He discharged the patients, I think most of the people he was working with. He'd been working with them quite a while already." When asked what was done next, she stated, "Once you discharge a patient, they're no longer receiving services. Typically we discharge a patient when they've met there goals, they've achieved maximum functional potential, or they're no longer making progress." When asked if he'd discussed his residents with her, she stated, "Yes, because we have a rehab (rehabilitation) meeting, and typically we discuss patients, when were going to discharge a patient." When asked about resident #81, she stated, "He has a difficult time communicating, and he (the speech therapist) worked with him for quite a while. I believe at the point where he was going to discharge him, he (resident #81) was pretty much at the maximum potential regarding his communication." She stated further, "We had discussed it in one of the meetings, that he was pretty maxed out. At the time of the DC (discharge), I don't know, I didn't read the paperwork at discharge." When asked to review the speech therapist's discharge summary and asked if resident #81 had reached maximum potential, she stated, "I would probably, if he demonstrates potential for further improvement - I know that when I asked him about it, he said that he had pretty much reached his maximum potential." When asked if, based on the discharge summary, resident #81 was a candidate for more speech therapy, she stated, "I would say possibly, but I'd have to have a speech therapist go in there and evaluate; they would be the one to determine whether they can make further progress with him." When asked if this had been done for resident #81, she stated, "No. We don't have a speech therapist right now, so I don't believe so."

Based on observation, interview and record review, the facility failed to accurately assess a resident for pain prior to providing wound treatment for 1 (#35) of 3 residents (#35, 101, and 153) evaluated for pain management. The nurse providing wound care asked the resident prior to providing care, but the resident suffers from dementia and was not able to report pain in the wound area that she had experienced less than 30 minutes earlier. That pain incident had been observed by two Certified Nursing Assistants (CNAs), CNAs #23 and #24, but had not been reported to the nurse. The failure to report observed pain by the CNAs resulted in an inaccurate assessment of pain by the nurse providing wound care, with the result that resident #35 suffered pain during part of wound care. The findings are: A. On 08/23/11 at 10:35 am, during observation of transfer of resident #35 from her wheelchair to her bed by CNAs #23 and #24, the resident grimaced and cried out, "Oh god, god no," as CNA #23 gripped the resident by the calves to move her legs onto the bed. B. On 08/23/11 at 10:35 am, during an interview, CNA #23 was asked if the resident was experiencing pain. The CNA stated, "Yes, her legs. That happened when she came here from home ... she has some skin tears on the backs of her legs." C. On 08/23/11 at 11:00 am, the Assistant Director of Nursing (ADON) conducted wound care on the skin tears at the back of Resident #35's calf. During observation of wound care, the resident cried out and grimaced in pain. The ADON terminated the treatment after completing treatment on one of the two calves and stated that she would continue treatment after getting the resident some pain medication. D. Review of the record of Resident #35 revealed a 07/29/11 Resident Admission Record documenting admission to the facility on [DATE] with [DIAGNOSES REDACTED]." E. Review of Resident #35's 08/10/11 Minimum Data Set (MDS) Admission Assessment revealed that the resident was severely impaired for decision-making. The resident also exhibited impaired long-term memory and was unable to recall season, location of own room, names or faces of staff, or that she was in a nursing home. The resident exhibited symptoms of [MEDICAL CONDITION] including inattention, disorganized thinking, and psychomotor [MEDICAL CONDITION]. F. Review of the record of Resident #35 revealed a 07/29/11 Pain Questionnaire. No more recent pain assessment was found in the record. The Pain Questionnaire documented the following: 1. under, "Any new pain," the form documented, "no;" 2. under "Routine meds ordered for pain," the form documented, "ordered and effective;" 3. under "Frequency of pain," the form documented, "no pain;" 4. under "Intensity of pain (verbal)," the form documented, "no pain;" (0) 5. under "Intensity of pain (nonverbal)," the form documented, "no observation of pain;" G. Review of Resident #35's 08/10/11 Care Plan revealed a care plan documenting, "(Name of Resident #35) has large skin tears on the back of her legs that are very painful ...". Approaches included, "Address c/o (complaint of) pain promptly with meds." H. On 08/24/11, review of the Nursing Notes for 08/23/11 revealed no mention of the pain observed by CNAs #23 and #24 during the 08/23/11 10:35 am observation: an entry at 9:00 am documented that the resident had been seen by a physician assistant and reported no new orders, and the next entry was an 08/24/11 12:30 am documenting that the resident was asleep. I. Review of Resident #35's October 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review further revealed no later administration of pain medication until 12:00 am, when the resident received another scheduled dose of [MEDICATION NAME] 50 mg. J. On 08/31/11 at 4:00 pm, during an interview regarding Resident #35's pain, the Director of Nursing (DON) stated, "The pain should be assessed first, before the transfer or before the wound care, using a numeric value. But, if she's not able to communicate, we can still assess by groaning, body language, signs and symptoms of pain." K. On 09/01/11 at 9:02 am, during an interview regarding the wound care on Resident #35, the ADON stated the following: 1. When asked about her wound care for the resident, she stated, , "When I entered the room, (name of Resident #35) was in the bed. When I started my treatment, I asked her, 'are you in any pain,' and she said, 'No," so I got all my stuff and started doing treatment. She had a 10 (centimeter) by 7 (centimeter) skin tear with missing flaps. According to her daughter, she was diagnosed before with joint pain. So when I pick up that leg (the right leg), she was grimacing. ... So I was finishing and I told (name of nurse surveyor) that I noticed she was grimacing, but I can not let the wound go because I needed to cover it. Then I told (name of nurse surveyor) that I was not going to do the left leg because she was in pain. It was 11:10 am, and I noticed that she was scheduled for [MEDICATION NAME] at 12, so I told the CMA (Certified Medication Aide), 'Can you give her the [MEDICATION NAME] right now,' and she did, and after an hour I come back and finished the other treatment." 2. When asked if she'd been informed of the observation of pain by CNAs #23 and #24 just prior to her delivery of wound care, she stated, "They never told me. I never asked them. I asked the patient in front of the family, but I never asked the CNAs." When asked if Resident #35 suffered from dementia, she stated, "Yes." When asked if that would affect the resident's ability to recall prior incidents of pain, she stated, "Yes. It's been an issue with our pain assessment, our pain assessment is not accurate here." Based on observation, record review, and interview, the facility failed to provide necessary care and services for care of residents receiving [MEDICAL TREATMENT] services for 1 of 1 (#14) residents evaluated for [MEDICAL TREATMENT] care. The facility failed to monitor the condition of a [MEDICAL TREATMENT] access port and to conduct assessments upon return from [MEDICAL TREATMENT]. This deficient practice had the potential for adverse consequence to the resident, including potential for severe drops in blood pressure or bleeding from the access site going unnoticed and untreated. The findings are: A. Record review for Resident #14 revealed the schedule for [MEDICAL TREATMENT] was 3 times a week, on Tuesday, Thursday and Saturday. Nurses Notes from July 2011 to August 2011 revealed when Resident #14 returned from [MEDICAL TREATMENT] treatment, there was no evidence of assessments related to vital signs or to check the dressing at the [MEDICAL TREATMENT] port site for bleeding. 1. Record review of the Vital Signs and Weight Record for 07/01/11 through 08/27/11, revealed on 07/01/11 and 07/07/11, the lines for BP (blood pressure), Temp (temperature), Pulse and Resp. (respiration) were blank. On 07/02/11 "refused" was written. On 08/04/11, vital signs were entered with no time of when they were taken. On 08/05/11 and 08/27/11 there were no vital signs recorded. These were the only dates written on the record. 2. Record review of the Care Plan dated 03/17/11 and revised 08/18/11 revealed Resident #14 was receiving [MEDICAL TREATMENT] due to [MEDICAL CONDITION]. Approaches included, "When returns from [MEDICAL TREATMENT], charge nurse should check dressing over shunt to ensure bleeding has stopped and document. Remove pressure dressing placed after treatment per [MEDICAL TREATMENT] recommendations or MD (Medical Doctor) order. Check vital signs." B. On 08/31/11 at 9:15 am, Resident #14 was interviewed. When asked if the nurses assess her [MEDICAL TREATMENT] port and vital signs when she returns from [MEDICAL TREATMENT], Resident #14 stated, "No they do not. All they do is check my blood sugar and get my lunch. There was a nurse who did check my site but she does not work here anymore. Once in a while the nurses will check my site but it is not regular, not even once a week. I remove the dressing before I go to bed. One night when I took off the dressing, it started spurting blood everywhere. The nurse called 911 and put pressure on it and it stopped. I pretty much take care of myself." C. On 08/31/11 at 11:30 am, the Director of Nurses (DON) was interviewed. The DON was asked if the nurses were assessing Resident #14 following [MEDICAL TREATMENT] to check vital signs and assess the [MEDICAL TREATMENT] port site. The DON reviewed the medical record then stated, "We are not checking the vital signs on return from [MEDICAL TREATMENT] or assessing the site that I can find in the record." D. On 09/01/11 at 8:35 am, an interview was conducted with Licensed Practical Nurse (LPN #10). When asked what assessment she does for Resident #14 after [MEDICAL TREATMENT], LPN #10 stated, "I check her oxygen level and her blood sugar because her sugar levels vary so much."