Every finding on record at Stallings Court Nursing and Rehabilitation

Based on observation, interview and record reviews, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection and new pressure ulcers from developing for 1 of 3 (Resident #1) residents reviewed for pressure injuries.1.The facility did not ensure Resident #1's interventions were in place with heel protectors and keep heels floating while in bed on 5/27/2026.2.The facility failed to ensure Resident #1 did not develop a pressure-related deep tissue injury on 4/23/2026. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and a decreased quality of life.Findings include:Record review of Resident #1's admission Record, dated 5/27/2026, indicated an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (affects memory, thinking, and social abilities that can interfere with a person's daily life), hypertension (high blood pressure), acute embolism and thrombosis of deep veins of her right lower extremity (blood clot in the right leg).Record review of Resident #1's active physician orders, dated 5/27/2026, indicated an order for wound care, dated 5/13/2026, which indicated: an unstageable pressure wound to the right heel with wound care to be provided one time a day to promote wound healing. Wound care orders were to clean the area with normal saline/wound cleanser, pat dry with 4x4 gauzes, apply leptospermum honey (used to aid in wound healing) and cover with gauze island border dressing.Record review of Resident #1's care plan, dated 4/23/2026, indicated she had a pressure injury unstageable DTI to her right heel. Interventions included pressure relieving devices: heel protectors.Record review of Resident #1's admission MDS Assessment, dated 4/21/2026, indicated she had severe impairment in thinking with a BIMS score of 3. Resident #1 was at risk of developing pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries.Record review of Resident #1's Braden scale for predicting pressure sore risk, dated 4/16/2026, indicated a low risk with a score of 19.Record review of Resident #1's admission skin assessment, dated 4/16/2026, by LVN B, indicated the resident did not have any pressure injuries or wounds. Her skin was intact.Record review of Resident #1's weekly skin assessment, dated 4/23/2026, by the Treatment Nurse, indicated she had redness to her left heel that was blanchable (skin can turn white or pale when pressure is applied and then returns to its normal color when pressure is removed). New open area was indicated to her right heel with a suspected deep tissue injury that measured 2 cm x 2 cm. The RP and physician were notified. There were not any pressure reducing devices in place.Record review of Resident #1's weekly skin assessment, dated 4/29/2026, by the Treatment Nurse, indicated she had redness to her left heel that was blanchable. Her right heel with a deep tissue injury that measured 1.4 cm x 1 cm. The RP and physician were notified. Pressure reducing devices in place included heel protectors.Record review of Resident #1's wound physician notes, dated 4/29/2026, revealed the resident had an unstageable DTI of the right heel that measured 1.4 cm x 1 cm, no drainage, with the skin being intact with purple/maroon discoloration. Orders for skin prep to be applied once daily. Recommendations to float heels in bed.Record review of a clinical unavoidable pressure injury for Resident #1, dated 4/29/2026, by the wound care physician, indicted she had interventions in place prior to the development or worsening of a pressure injury.Record review of a facility wound report, dated 5/21/2026, indicated Resident #1 had an in-house wound to her right heel that was a deep tissue injury that was identified on 4/23/2026.Record review of Resident #1's wound physician notes, dated 5/27/2026, revealed the resident had an unstageable wound of the right heel that measured 1.5 cm x 1.8 cm x 0.1 cm. Wound progress had improved as evidenced by decreased surface area. The wound was undergoing autolytic debridement. The goal of treatment was healing as evidenced by a 2.7% decrease in surface area within the wound bed in comparison to the previous wound care visit.During an observation and interview on 5/27/2026 at 12:55 PM, revealed Resident #1 was in bed awake and alert to person only with confusion noted. Her RP was present in the room and said the resident had dementia and would not be able to answer questions appropriately. The RP said the resident had a wound on her right heel that had been there since 4/23/2026. The resident was lying on her back with a pillow under her knees. She was wearing one heel protector on her right foot, and both heels were touching the mattress.During an interview on 5/27/2206 at 1:15 PM, CNA A said she was assigned to care for Resident #1 that day. She said the facility told her to put heel protectors on both feet on Resident #1 and to keep her heels floating. She said the RP requested the staff to place a pillow under her knees while in bed as it helped to lift her heels up off the mattress. She said Resident #1 only had one of the heel protectors in place on her right foot because the other heel protector had gotten dirty from a bowel movement about 2 weeks ago and she threw it away. She said she had been using the one heel protector on her right heel. She said the heel protectors were used to prevent pressure sores and Resident #1 had a wound to her right heel. She said the facility was aware Resident #1 only had one heel protector and said they were ordering more.During an observation and interview on 5/27/2026 at 1:29 PM, the Treatment Nurse said she was responsible for completing the skin assessments in the facility for the residents. She said Resident #1 admitted to the facility without any wounds but developed a DTI to her right heel after admission. She said they had wound treatment orders in place, and the wound physician saw the resident weekly. She said Resident #1 did not like to be repositioned and liked to lie on her back, but they had heel protectors in place for her. She observed Resident #1 in bed moving around with the covers pulled back. She said the resident was supposed to have two heel protectors on but only had one on her right heel and her heels should not be on the mattress. She said the heel protectors came in a set of two. She said if a resident did not wear heel protectors as ordered then they could develop more wounds. She said she would get another heel protector for the resident.During an observation on 5/28/2026 at 9:10 am, the Treatment Nurse was in the room of Resident #1 to provide wound care. She gathered wound care supplies in the hallway and placed them on wax paper, donned (put on) a gown and entered the room. She washed her hands in the bathroom and donned gloves. Resident #1 was in bed awake with her feet on top of the linens. She had heel protectors on both feet, and her heels were floated on a pillow. She was wearing nonskid socks. The Treatment Nurse removed the heel protector from her right foot and along with Resident #1's sock. The Treatment Nurse removed her gloves and placed them in the trash; sanitized her hands; and applied clean gloves. A dressing was noted to Resident #1's right heel dated 5/27 and she removed the dressing and placed it in the trash. An open wound was noted to Resident #1's right heel with a small amount of bleeding noted. The Treatment Nurse sanitized her hands and put on clean gloves and cleaned the wound with wound cleanser and 4x4 gauze and patted the area dry with gauze. She removed her gloves and placed them in the trash and sanitized her hands. She applied medihoney to the wound bed and placed a dressing on her right heel that was dated 5/28/26 along with her initials. She removed her gloves and placed them in the trash. She washed her hands and applied gloves; placed the sock back on Resident #1's right foot along with the heel protector. The linens were pulled back over resident in bed, and a pillow was placed under her feet to float her heels. She gathered the trash and lowered Resident #1's bed; doffed (took off) her gown and placed it in the trash; sanitized her hands and exited the room.During an interview on 5/28/2026 at 9:42 AM, LVN B said she was the nurse who completed the admission for Resident #1. She Resident #1 admitted to the facility on [DATE] and had some bruises from a fall she had prior to her admission and a skin cancer lesion that was on her forehead. She said she did not have any open wounds or pressure ulcer injuries on admission. She said the facility had a Treatment Nurse that did weekly skin assessments on the residents in the facility. She said Resident #1 had a wound to her right heel with an order for heel protectors after she was admitted . She said the heel protectors were to relieve pressure on their heels, and the heels should be floated with a pillow positioned on the shins so the heels would not touch the bed.During an interview on 5/28/2026 at 1:34 PM, the ADON said Resident #1 had a DTI to her heel and had the heel protectors in place with wound care daily. She said the Treatment nurse performed wound care and the facility had a wound physician that visited weekly. She said the heel protectors should be on while a resident was in bed, and all staff were responsible for ensuring they were in place. She said they had a stock supply of foam heel protectors in the facility. She said the purpose of the heel protectors was to prevent wounds. She said they tried to float the heels with a pillow under the ankles, so the heel did not touch the bed. She said she was not aware Resident #1 only had one heel protector.During an interview on 5/28/2026 at 1:50 PM, the DON said she received a phone call from the Treatment nurse one day and was informed Resident #1 had a DTI to her heel and she questioned the Treatment Nurse when the last skin assessment was conducted and was told Resident #1 did not have any wounds observed between that week and that was when the heel protectors were put in place for Resident #1 when the wound was identified. She said the heel protectors should be on a resident while they were in bed and should have both heel protectors on. She said her feet should be positioned offloaded and not touching the mattress. She said she was made aware yesterday (5/27/2026) that Resident #1 only had one heel protector on and her heels were not floating. She said Resident #1's heels should be floated with a pillow so the heels should not touch the mattress. She said the heel protectors were to prevent the skin from touching the mattress and relieve pressure. She said on admission Resident #1 did not have any wounds on her feet and acquired the wound in house. She said the facility had a wound physician who visited weekly and was seeing Resident #1.During an interview on 5/28/2026 at 2:39 PM, the Administrator said she had been at the facility since March 2026. She said she was made aware in a morning meeting by the Treatment nurse that Resident #1 had developed a wound to her heel that was not present on admission to the facility. She said the Treatment nurse put heel protector orders in place for Resident #1 to ensure the wound did not get any worse. She said the heel protectors were for both feet. She said the staff would place a pillow under her legs to keep the heels from touching the mattress. She said she was not aware the resident was not wearing heel protectors. She said the purpose of the heel protectors was to help prevent pressure wounds. She said she planned to reeducate the staff to communicate, and it was not acceptable to not have things in place. She said all staff were responsible for ensuring residents had heel protectors if ordered and should be worn when in bed. She said the risk would be that they could develop more wounds if they did not wear them.Record review of the facility's policy titled Prevention of Pressure Ulcers, revised March 2005, indicated .The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. 5. Risk factor-immobility c. when in bed, every attempt should be made to float heels' (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #5) and of 1 of 2 staff (CNA A) reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene between glove changes and that she changed gloves when going from dirty area to clean area on 2/19/26 during perineal care for Resident #5. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings include: Record review of a facility face sheet dated 2/19/26 for Resident #5 indicated she was an [AGE] year-old female admitted to the facility on [DATE] and subsequently re-admitted on [DATE] with diagnosis of encephalopathy (brain disease, damage, or malfunction that causes an altered mental state). Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated she had a BIMS score of 7, which indicated she had severely impaired cognition. She was dependent on staff for toileting hygiene and was always incontinent to bowel and bladder. Record review of a comprehensive care plan dated 1/30/26 for Resident #5 indicated she had an ADL self-care performance deficit and had an intervention that read: .toileting: requires extensive assist X1 staff participation. During an observation on 2/19/26 at 2:35 pm CNA A was observed providing incontinent care to Resident #5. She was observed to wash her hands upon entrance to room. She was then observed to put on gloves before unfastening the resident's brief and proceeding to clean peri-area. After cleaning peri-area, she then rolled resident over and removed soiled brief. Without removing dirty gloves, she disposed of soiled brief in trash bag, then removed her gloves and applied new gloves without performing hand hygiene. She proceeded to clean resident's rectal area, and without removing dirty gloves, she was observed to retrieve a clean draw sheet. She was observed putting the clean draw sheet underneath the resident, along with the clean brief, still wearing gloves that she wore during cleaning rectal area. She then rolled the resident back over, fastened the brief, straightened the draw sheet and repositioned the resident. CNA A then removed her gloves, tied trash bag and washed her hands before exiting room. During an interview on 2/19/26 at 2:50 pm CNA A said she did not perform hand hygiene when she changed her gloves. She said she did not know if she changed her gloves after cleaning resident's rectal area and before applying new brief and clean draw sheet. She said she knew she was supposed to use sanitizer when she changed her gloves. She said residents could be at risk for infections if proper hand hygiene was not performed. She said she must have just forgotten because she was nervous. During an interview on 2/19/26 at 3:10 pm the ADON said she expected her staff to wash their hands and use sanitizer between glove changes. She said it put residents at risk for UTI's, infections, or possibly skin breakdown. She said going forward, she would provide further education for staff members. During an interview on 2/19/26 at 3:20 pm Administrator (interim) said he expected the staff to follow policies and procedures regarding infection control. He said going forward, they would provide more skills checkoffs and in-services. Record review of a facility policy titled Handwashing/Hand Hygiene dated August 2015 read: .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: .h. Before moving from a contaminated body site to a clean body site during resident care; and .after removing gloves.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 3 of 17 residents reviewed for quality of care. (Resident #19, Resident #38, and Resident #40)The facility failed to remove worn and damaged mechanical lift slings from service for Resident's #19, #38, and #40.This failure could result in a loss of quality of life due to injuries.Findings include:Record review of a facility face sheet dated 2/4/26 for Resident #19 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness following a stroke). Record review of a Quarterly MDS assessment dated [DATE] for Resident #19 indicated a BIMS score of 13, which indicated he was cognitively intact. He was dependent for transfers. Record review of a comprehensive care plan dated 1/5/26 for Resident #19 indicated he had an ADL self-care performance deficit and required assistance of 2 staff members for transfer using a mechanical lift.Record review of a facility face sheet dated 2/5/26 for Resident #38 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia (characterized by elevated carbon dioxide levels in the blood, leading to significant respiratory distress and requiring prompt medical intervention).Record review of a comprehensive MDS assessment dated [DATE] for Resident #38 indicated a BIMS score of 4, which indicated she had severe cognitive impairment. She required substantial/maximum assistance for transfers. Record review of a comprehensive care plan dated 11/21/25 for Resident #38 indicated she had an ADL self-care performance deficit and required assistance of 2 staff members for transfer using a mechanical lift.Record review of a facility face sheet dated 2/5/26 for Resident #40 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses on Intracranial injury without loss of consciousness (a type of closed head injury where the brain is damaged without immediate fainting or unconsciousness. The skull remains intact, but the brain can shift or sustain trauma, potentially causing concussions, contusions, or other forms of traumatic brain injury).Record review of a quarterly MDS assessment dated [DATE] for Resident #40 indicated BIMS assessment should not be conducted due to being rarely/never understood. She had severe cognitive impairment. She was dependent for transfers.Record review of a comprehensive care plan dated 12/16/25 for Resident #40 indicated she had an ADL self-care performance deficit and required assistance of 2 staff members for transfer using a mechanical lift.During an observation on 02/04/2026 at 10:35 a.m., Resident #19 was observed in common area in geri-chair with a mechanical lift sling observed underneath him loops that were faded in color. During an observation on 02/05/2026 at 9:00 a.m., Resident #38 was observed in common area up in wheelchair with mechanical sling underneath her, loops were faded in color and label was unreadable. During an observation on 2/5/26 at 9:10 a.m., Resident's #19 and #40 were observed in activities, both up in geri-chairs with mechanical slings underneath them with loops that were faded in color. During an interview on 2/5/26 at 9:15 a.m., CNA B said when she transferred a resident using the lift, she would inspect the sling for any loose strings or fading. She said if the sling had any loose strings or fading, it could be unsafe to use, and a resident could fall and possibly get hurt . During an interview on 2/5/26 at 9:20 a.m., the DON said that residents could get hurt if they were transferred using a sling that was unsafe. She said she looked for faded colors and loose strings, rips, tears. She said they had just replaced the slings about 6 months ago and she does not n't know why they keep fading unless laundry is using bleach . During an interview on 2/5/26 at 9:30 a.m., the Laundry Aide said she had been employed at the facility here for 4 years. She said she did not use bleach on the lift slings and said they were washed in hot water and air dried. She said if she noticed any rips, tears, fading or loose strings, she would put that sling to the side show that sling to the administrator to possibly be removed from service. She said the CNAs were supposed to check them when they come get them and before they use them for transfers. During an interview on 2/5/26 at 9:35 a.m., the Administrator said the laundry supervisor was responsible for checking the slings and removing them from service. She said if an unsafe sling was used, a resident could fall and get hurt. Record review of a facility policy titled Lifting Machine, Using a Mechanical dated July 2017 read: .Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition . and .examine all hooks, clips or fasteners . and .discard any work, frayed, or ripped slings . Record review of a facility form titled [Service Company C] Sling Log undated read: .Laundry Aide should inspect for rips, tears, frays, or discoloration after each laundering .

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation.The facility failed to ensure the temperature for the dish machine was at the appropriate temperature of 120 degrees Fahrenheit during the wash cycle according to the manufacturer's guidelines to sanitize dishes appropriately on 02/04/2026.This failure could place residents who eat from the kitchen at risk of foodborne illnesses. Findings included :During an initial observation and interview on 02/04/2026 at 09:00 a.m., Dietary Aide A was running the dish machine after the breakfast meal. Dietary Aide A ran the machine and checked the Dish Machine gauge for required temperature of compliance with manufactures requirements of 120 degrees Fahrenheit during the wash cycle. After 4 attempts the temperature reached 100 degrees Fahrenheit. Dietary Aide A said the machine was tested early this morning and reached a temperature of 120 degrees Fahrenheit for wash cycle and tested for final rinse - 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. During an interview on 02/04/2026 at 9:15 a.m., the Dietary Manager said he had been the Dietary Manager for two years. He said he would contact the Maintenance Director to ensure the hot water heater was functioning as the morning load at the facility would pull the hot water supply down. The Dietary Manager said the facility would serve using disposable products until the dish machine had reached the required 120 degrees for sanitation. He said that if the dishes were not properly sanitized the residents could develop a food borne illness.During an interview on 02/04/2026 at 9:30 a.m., the Maintenance Director said he had adjusted the temperature on the hot water heater and the dish machine. He said that after laundry had been done this morning the heater was not keeping up with demand. He said he would recheck the hot water after two hours to see if the temperature was meeting requirements. During an observation on 02/04/2026 at 11:30 am the Dietary Aide ran the dish machine, and the Dish Machine meet the required temperature of compliance with manufactures requirements of 120 degrees Fahrenheit during the wash cycle and final rinse - 50 ppm (parts per million) hypochlorite (chlorine) on dish surface as required. During an interview on 2/4/2026 at 2:00 p.m., the Director of Health Care Operations said the dish machine should reach 120 degrees during operation to ensure sanitation and the sanitation should be 50-100 parts per million chlorine in the rinse cycle. She said the Dietary Aide would be in-serviced on proper sanitation procedures for dishwashing and to report when the machine was not reaching the required temperatures. The Director of Health Care Operations said the facility would remain on paper products until the water temperature reached the required temperatures for sanitation. She said if the dishes were not properly sanitized the residents could develop a food borne illness.During an interview and record review on 2/5/2026 at 11:00 a.m., the Administrator said the low temp dish machine should reach 120 degrees during operation. The Administrator said that the hot water heater was not functioning properly and had been adjusted to meet the required temperature. The Administrator said a new part was ordered to repair the hot water heater. The receipt for the part was reviewed with the Administrator. The Administrator said she was not aware of any problems with the hot water heater until 02/04/2026. She said that if the dishes were not properly sanitized the residents could develop a food borne illness.Record review of an undated dietary policy indicated:Ware washing Policy and ProcedurePolicy StatementWe prioritize the cleanliness and sanitation of all dishware, service ware, and utensils to uphold the highest health and safety standards.Procedures1.Training and Handling: Our Dietary Services staff undergo comprehensive training to proficiently operate dishwashing machinery and handle clean dishware, ensuring strict adherence to sanitary protocols.2.Machine Temperature Management: We regulate the temperature of dishwashing machine water according to the specifications provided by the manufacturer, whether utilizing high-temperature or low-temperature cleaning systems.3.Record Keeping: Meticulous logs are maintained to track either temperature or sanitizer concentration, depending on the type of machine, always guaranteeing compliance with sanitation standards.4.Drying and Storage: Cleaned dishware is air dried and stored appropriately to prevent any potential contamination prior to use, maintaining the integrity of our sanitary practices.Required Documentation:Dish Machine LogReferencesThis policy is aligned with: CMS Conditions of Participation: Food and Dietetic Services (A-0618, S482.28) CMS Manual System: Store, Prepare, Distribute, and Serve Food (F812, S483.60) Joint Commission Standards on Food and Nutrition AvailabilityRecord review of the manufacturer's instructions for Auto- Chlor Dishwasher operating requirements for low temp dish machine indicated the wash cycle is supposed to reach 120 degrees. Low Temperature Dishwasher (chemical sanitization): Wash - 120 degrees F; and Final Rinse - 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines.

Based on interview and record review the facility failed to make sure a comprehensive care plan was prepared by an interdisciplinary team, that included but not limited to a nurse aide with responsibility for the resident and a member of food and nutrition services staff for 4 of 4 residents (Residents #6, #27, #54 and #58) reviewed for care plans. The facility failed to ensure the dietary manager and nurse aides with responsibility for the residents were invited and attended the resident care plan conferences. This failure could place residents at risk for not receiving the care and services to meet their needs. Findings include: 1. Record review of Resident #6's facility face sheet reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis which included senile degeneration of the brain (disease that affect memory, thinking, and the ability to perform daily activities). Record review of Resident #6's comprehensive quarterly assessment, dated 10/9/2024, reflected the resident had a BIMS of 02, which indicated severe cognitive impairment. Record review of Resident #6's care plan conference reflected no evidence of attendance by the dietary manager and nurse aide with responsibility for the resident on 10/28/2024. 2. Record review of Resident #27 facility face sheet reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis which included cerebral infarction . Record review of Resident #27 comprehensive quarterly assessment, dated 10/2/2024, reflected the resident had a BIMS of 11, which indicated moderate cognitive impairment. Record review of Resident #27 care plan conference reflected no evidence of attendance by the dietary manager and nurse aide with responsibility for the resident on 10/22/2024. 3. Record review of Resident #54's facility face sheet reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis which included cerebral infarction. Record review of Resident #54's comprehensive quarterly assessment, dated 8/19/2024, reflected the resident had a BIMS of 15, which indicated no cognitive impairment. Record review of Resident #54's care plan conference reflected no evidence of attendance by the dietary manager and nurse aide with responsibility for the resident on 11/05/2024. 4. Record review of Resident #58 facility face sheet reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain) and epilepsy (brain disorder that causes recurring, unprovoked seizures). Record review of Resident #58 comprehensive quarterly assessment, dated 8/29/2024, reflected the resident had a BIMS of 12, which indicated moderate cognitive impairment. Record review of Resident #58 care plan conference reflected no evidence of attendance by the dietary manager and nurse aide with responsibility for the resident on 10/22/2024. During an interview on 11/20/2024 at 10:00 AM with the Dietary Manager, he said he had been in his position for 2 years . He stated he did not attend care plan meetings, he said he would attend the IDT meeting when he was not working in the kitchen related to staffing challenges. He said he attended half of the meetings. He said he usually was working in the kitchen when care plan meeting occurred. He said he communicated any dietary changes during the morning stand up meeting and he communicated with the unit managers. He said he did not initiate or update care plans and the nursing staff did the care plans for the residents. He said he did an assessment on all residents who were admitted to the facility and any residents who were readmitted to the facility. He said the registered dietician came to the facility every other week and she also performed assessments on residents that were new admissions, readmissions, or had weight loss or weight gains. He said dietary recommendations were given to the nursing staff to implement. In an interview with the MDS Coordinator on 11/20/2024 at 10:15 AM, she said she was responsible for completing the MDS for residents and she was also responsible for updating the care plans. She stated she and the Social Worker coordinated the care conference meetings. She said IDT meetings, or care conferences, were done weekly and the members present were herself, social services, unit manager, therapy, and family representatives at times and residents at times. She said the Dietary Manager did attend some of the meetings, but he was usually working in the kitchen and was unable to come to the meetings. She stated certified nurse assistants did not participate in the meetings. In an interview with the Director of Nursing on 11/20/2024 at 10:25 AM, he said he participated in the care plan meetings. He said he was responsible for updating the care plans along with the MDS Coordinator. He said the IDT team consisted of himself, social services, MDS coordinator, therapy, activities, and dietary. He said dietary did not always participate in care plan meetings due to staffing. He said dietary was hit and miss . He said he communicated with dietary before and after care plan meetings. He said he did all the dietary care plans and updated them as needed. He stated he electronically signed the dietary section of the care conference summary. He said the Dietary Manager attended about 50% of care plan meetings. He stated certified nurse aides did not attend care conference meetings. He stated that the dietary manager and a certified nurse assistant should attend care conferences to communicate any changes in the residents condition and it would allow for a team approach to the residents care. In an interview with the Social Worker on 11/20/2024 at 10:35 AM, she said she participated in the care conference meetings weekly. She said she participated in the IDT meetings. She said the MDS Coordinator, therapy, the Director of Nurses, activities, and dietary participated in the weekly meetings. She said dietary did not attend the IDT regularly due to staffing issues. She said the DON usually signed and completed the dietary responsibilities for the care conferences. She said the certified nurse aides did not participate in the care conferences . In an interview on 11/20/2024 at 2:35 PM with the Administrator, she stated she and the DON were responsible for making sure all members of the IDT team were present for the care plan conferences. She was able to name all members who were required to be present at the care plan conference. She said a risk for a member of the IDT team not being present and participating was not being able to communicate changes in the residents and everyone contributing to goal setting to help maintain the residents' highest level of functioning. Record review of the facility's policy titled Care Planning- Interdisciplinary Team revised September 2013, reflected the care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which include . the dietary manager/Dietician .nursing assistants responsible for the residents care

46273 46436 Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good, nutrition, grooming and personal and oral hygiene for 4 of 12 residents (Residents #34, #37, #48, #69) reviewed for activities of daily living . 1.The facility failed to ensure Resident #37's had clean linens on 11/19/2024. 2. The facility failed to provide nail and mouth care to Resident #34 on 11/18/24 and 11/19/2024. 3. The facility failed to provide nail care to Resident #48 on 11/18/24 and 11/19/24. 4. The facility failed to ensure Resident #69 did not have oily hair and body odor on 11/18/24. These failures could place residents at risk of not having their needs met which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings include: 1. Record review of Resident #37's Admission Record, dated 11/20/2024, reflected she admitted to the facility on [DATE] and was a [AGE] year old female. Resident #37 had diagnoses which included Parkinsonism (brain condition that causes slowed movements and tremors), Major depressive disorder (persistent feeling of sadness or loss of interest) and hypertension and retention of urine (condition where the bladder does not empty completely). Record review of Resident #37's Quarterly MDS Assessment, dated 8/20/2024, reflected she had moderate impairment in thinking with a BIMS score of 9. She required substantial/maximal assistance with toileting and personal hygiene. She was always incontinent of urine and bowel. Record review of Resident #27's care plan, revised on 4/12/2022, reflected she was incontinent of bowel/bladder and had the potential for impaired skin and UTI's. Interventions included to check the resident during rounds and as required for incontinence. Change clothing PRN after incontinence episodes. During an observation on 11/19/2024 at 3:32 PM, revealed Resident #37 was in bed awake, the ADON and the Treatment Nurse were in the room to perform a skin assessment. They pulled back her linens and a strong ammonia odor permeated (filled) the room. Her brief was dry and the draw sheet was soaked and yellow stained. The ADON and Treatment Nurse removed the draw sheet and the resident said she was scheduled to get a shower that day on 11/19/2024. There were no skin issues noted during the assessment. During an interview on 11/19/2024 at 3:40 PM, the ADON said the staff assigned to Resident #37 earlier that day was CNA D. She said there was a strong urine odor in Resident #37's room and the draw sheet was wet and yellow stained. She said the staff should have changed Resident #37's draw sheet when they changed her if it was wet. She said residents could be at risk for skin breakdown if staff did not remove wet linens. Attempted a phone interview on 11/19/2024 at 4:09 PM with CNA D, there was no answer and a message for a return phone call was left. During a phone interview on 11/20/2024 at 7:45 AM, CNA D said she worked at the facility PRN and had only worked at the facility for 4 days and started on 11/9/2024. She said she worked on 11/19/2024 on the 6 am - 2 PM shift and was assigned the hall with Resident #37. She said she made rounds after breakfast, before lunch and after lunch. She said she changed Resident #37 about 4 times on 11/19/2024. She said she did not change the sheets but changed the draw sheet once during the shift. She said the draw sheet was changed about 1-1:15 PM on 11/19/2024 during her last round before her shift ended at 2 PM. She said there was a risk for skin breakdown if a resident was left on wet sheets. She said on her first day of work on 11/9/2024, she was told her hall she was assigned and given report and then allowed to work by herself. During an observation and interview on 11/20/2024 at 8:14 AM, in the room of Resident #37, Resident #37 said she received a shower yesterday 11/19/2024 after the skin assessment that was conducted by the ADON and Treatment Nurse. She said yesterday, 11/19/2024, she was changed 3 times during the day shift. She said her draw sheet was changed once, but it was wet yesterday afternoon (11/19/2024) and it did not get changed until the ADON and Treatment Nurse came in the room. She said being left on a wet draw sheet happened often because the urine would run out of her brief on the left side. She said she could feel when the draw sheet or linens were wet underneath her. She said she usually had to tell the staff her linens were wet because if not, they would not get changed. She said some of the older staff knew what to do and would place a thicker layer underneath her. During an interview on 11/20/2024 at 8:24 AM, CNA E said she had been employed at the facility since June 2024 and worked full time. She said she usually made rounds every 2 hours and more often as needed. She said if the entire bed was wet, she would change them along with the draw sheet. She said if the draw sheet was wet, she would not leave it under the resident. She said residents could be at risk for skin breakdown, discomfort or residents could start to smell if they were left on wet linens. She said she had training when she was hired by other nurse aides and had skills check off. During an interview on 11/20/2024 at 2:27 PM, the DON said staff should be changing linens anytime they were dirty. He said he was not aware of the incident with Resident #37 yesterday 11/19/2024. He said there could be a risk for nonhygienic and skin issues if residents were left on wet or dirty linens. He said he in-serviced staff that day 11/20/2024 on pericare. He said the facility did not have a policy on changing linens with incontinent care. During an interview on 11/20/2024 at 3:10 PM, the Administrator said she was made aware of Resident #37 who had wet linens on yesterday, 11/19/2024. She said linens should be changed when soiled by the nurse aides. She said residents could have skin breakdown and expected for linens to be changed when they were soiled. Record review of a CNA Proficiency Evaluation for CNA D met expectations on 11/11/2024 with perineal care conducted by the ADON. 2. Record review of Resident #34's facility face sheet, dated 11/19/2024, reflected Resident #34 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis which included Alzheimer's (loss of memory). Record review of Resident #34's comprehensive care plan, dated 8/23/2024, reflected Resident #34 had history of skin tears and nails should be kept short to reduce risk of scratching or injury from picking at skin. Record review of Resident #34's quarterly MDS assessment, dated 10/11/2024, reflected Resident #34 had a BIMS of 4, which indicated severe cognition. Resident #34 was maximum assistance with personal hygiene. During an observation and interview on 11/18/24 at 9:38 AM revealed Resident #34's fingernails were long and had a dark thick substance under them. Resident #34 said no one cleaned them but would like them cleaned. She said she had a shower that morning. She said her teeth were never brushed and her teeth were observed with food particles and white buildup around teeth . During an observation and interview on 11/19/24 at 8:05 AM revealed Resident #34's fingernails had a thick dark substance under them, and teeth had food particles. She said she needed her toenails trimmed as well. During an observation and interview on 11/19/24 at 9:43 AM revealed Resident #34's feet were inspected with the Treatment nurse. The toenails on both feet were thick and overgrown. The Treatment Nurse said toenail care was to be completed on bath days unless the resident was diabetic. She said untrimmed nails cold cause skin issues and discomfort . 3. Record review of Resident #48's facility face sheet reflected Resident #48 was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis which included Dementia (loss of memory). Record review of Resident #48's comprehensive care plan, dated 5/21/24, reflected Resident #48 had potential impairment to skin integrity and avoid scratching and required assistance with ADL's and staff to assist with personal hygiene and oral care. Record review of Resident #48's quarterly MDS assessment, dated 8/16/24, reflected Resident #48 had a BIMS of 13, which indicated intact cognition. Resident #48 was dependent on staff for personal hygiene. During an observation and interview on 11/18/24 at 10:17 AM revealed Resident #48's fingernails were long and had a dark thick substance under them. She said the staff cleaned them maybe once a week but would like them done more often . During an observation on 11/18/24 at 3:00 PM revealed Resident #48's fingernails had a dark thick substance under them. During an observation and interview on 11/19/24 at 8:10 AM revealed Resident #48's fingernails were long and dark substance under them. She said she had a bath, but the staff did not clean or trim her fingernails . During an interview on 11/19/24 at 1:23 PM, CNA A said she had been a CNA for [AGE] years and the CNAs were responsible for ensuring residents nails were cleaned and trimmed at least on shower days and as needed if they were dirty. She said mouthcare should be done daily. She said if nails were left dirty and untrimmed it could cause skin breakdown and infections and if mouth care was not provided it could affect their eating and cause mouth sores. During an interview on 11/19/24 at 2:00 PM, LVN B said she had been a LVN for 3 1/2 years and at the facility 6 months . She said the CNA's were responsible for all ADL care and should be cleaning nails and performing mouth care daily. She said the charge nurse should be checking that ADL care was performed with rounds and she missed that ADL care had been missed for Resident #34 and Resident #48. She said ADL care should be completed to prevent infections, injuries or skin changes. During an interview on 11/20/24 at 1:50 PM, the DON said the CNAs were responsible for performing ADL care and the charge nurses and management nursing were to oversee that care was provided. He said all staff were trained on hire, annually and as needed on ADL care, and expected nail care and mouth care to be provided to each resident daily. He said if ADL care was not provided it caused infections or injuries. During an interview on 11/20/24 at 2:16 PM, the Administrator said the charge nurses and management nurses were responsible for oversight of ADL care. She said nails should be cleaned when soiled, trimmed as needed and mouth care should be performed daily. She said she expected every resident to receive all required ADL care daily to prevent infections and injuries. Record review of the facility's policy, titled Mouthcare, dated April 2007 reflected, .cleanse and freshen the resident's mouth to prevent infections of the mouth . Record review of the facility's policy, titled Care of Fingernails/Toenails, dated April 2007, reflected, .nail care includes daily cleaning and regular trimming . 4. Record review of Resident #69's facility face sheet, dated 11/19/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and subsequently readmitted on [DATE]. Resident #66 had diagnoses which included cerebral infarction (stroke), hypertension (high blood pressure) and dementia (a group of symptoms affecting memory, thinking, and social abilities). Record review of Resident #69's comprehensive MDS assessment, dated 8/19/24, reflected he had a BIMS score of 10, which indicated he had moderately impaired cognition. He exhibited rejection of care 1 to 3 days during previous 7-day period. He required partial to moderate assistance with showers. He was occasionally incontinent of bowel and bladder. Record review of Resident #69's comprehensive care plan, dated 9/23/24, reflected he was resistive to treatment/care by refusing bathing. He had the following intervention: .document care being resisted .monitor behaviors and document number of episodes Record review of the facility's, undated, shower schedule located inside linen closet, reflected Resident #69 was scheduled for showers on Tuesdays, Thursdays and Saturdays on the 2-10PM shift. Record review of Resident #69's bathing care record, dated 11/19/24, reflected he did not get a shower on 10/22/24, 10/31/24 or 11/7/24 with no resident refusal documented. Record review of nursing progress notes for Resident #69 reflected there was no nursing progress note which indicated the resident was offered and refused his shower on 10/22/24, 10/31/24 or 11/7/24. During an observation and interview on 11/18/24 at 10:20 AM revealed Resident #69 was observed in his room sitting up in his wheelchair. There was an odor in his room indicative of body odor. The resident said he did not get his showers and staff had not washed his hair. The resident's hair was observed to appear oily and had white flakes on the top of his hair. He said staff did not offer to give him a shower or wash his hair, he said they did shave him occasionally. He said it made him feel not good when he had dirty hair and had not been showered. During an interview on 11/20/24 at 11:20 AM, LVN B said Resident #69 was on the 2-10 schedule for showers, so she was not familiar if he refused often or not. She said the nurse was responsible for ensuring residents received their showers. During an interview on 11/20/24 at 11:30 AM, CNA J said she did not work with Resident #69 very often, but if a resident refused their shower, then the CNA was responsible to notify the charge nurse and document in the kiosk that the resident had refused. During an interview on 11/20/24 at 2:30 PM, CNA K said she did care for Resident #69. She said he refused his shower most of the time. She said when he refused, she would notify the charge nurse and sometimes the nurse could convince him to take it. She said if a resident continued to refuse and she was not able to shower him, she would then document the resident's refusal in the kiosk. During an interview on 11/20/24 at 2:55 PM, the DON said Resident #69 refused showers all the time and the nurses were responsible for documenting his refusals, but they had not been documenting this. He said going forward he would educate the staff and make sure the nurses were properly documenting when a resident refused showers. During an interview on 11/20/24 at 3:00 PM, LVN M said if a resident refused showers, then she would notify the nurse practitioner and document in a progress note the resident refused, if she was made aware of the refusal by the CNA. She said Resident #69 did sometimes refuse his showers. During an interview on 11/20/24 at 3:10 PM, the Administrator said she expected her staff to properly document resident refusals. She said going forward, she would educate the nurses to document when a resident refused care. She said residents could be at risk for skin breakdown if they did not receive proper ADL care. Record review of the facility policy titled Shower/Tub Bath, dated 2001 and revised in October 2009, reflected .Documentation: The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 4. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken .Reporting: 1. Notify the supervisor if the resident refuses the shower/tub bath

Based on observation, interview and record review the facility failed to ensure drugs and biologicals were store in locked compartments under proper temperature controls for 2 of 3 medication carts (medication aide cart and nurse cart for halls 300 and 400), 1 of 1 medication rooms and 1 of 16 residents (Resident #18) reviewed for pharmacy services. The facility failed to ensure Fluticasone nasal spray was properly stored and locked in accordance with currently accepted professional standards for Resident #18 from 11/18/2024-11/19/2024 that was at her bedside. 1. The facility failed to dispose of expired medications from the medication aide and nurse medication carts on 11/19/2024 which included: (3) packages of Juven nutrition powder with use by date of November 1, 2024. (2) bottles of Glucerna 1.2 cal dated November 1, 2024. 2. The facility failed to dispose of expired medications in the medication room on 11/19/2024 which included: (1) box of phenylephrine hcl expired 9/2024 (1) box of I-caps expired 6/2023 (3) boxes of gas relief expired 8/2024 (1) bottle of Geri Lanta expired 11/2023. These failures could place residents at risk for adverse effects and reduced therapeutic effects of medication and supplies. Findings include: 1. Record review of Resident #18's Admission Record, dated 11/20/2024, reflected the resident admitted to the facility on [DATE] and was [AGE] years old female. Resident #18 had diagnoses which included Alzheimer's Disease, atherosclerotic heart disease (buildup of plaque in the arteries), major depressive disorder (persistent sadness or loss of interest), and hypertension. Record review of active physician orders for Resident #18, dated 11/20/2024, reflected an order for Flonase allergy relief suspension 50 mcg/act 1 spray in both nostrils one time a day for allergic rhinitis with a start date of 9/22/2021. Record review of Resident #18's Quarterly MDS Assessment, dated 11/7/2024, reflected she had moderate impairment in thinking with a BIMS score of 8. She required supervision or touching assistance with ADLs except for showering/bathing with partial/moderate assistance. Record review of Resident #18's care plan, last review dated 9/6/2024, did not indicate she was care planned to self-administer her nasal spray. During an observation and interview on 11/18/24 at 9:24 AM, in the room of Resident #18 was sitting up in a recliner dressed. She said she had been at the facility for a while. There was a bottle of fluticasone spray on a table by her recliner that was not in a box and Resident #18 said the nurse brought it into the room for her to use and she used it once a day. During an observation on 11/18/2024 at 2:27 PM, in the room of Resident #18 revealed the resident was not in the room, the bottle of nasal spray was still on the table. During an observation on 11/19/2024 at 7:44 AM, MA N was assigned the medication cart for hall 300 and 400. The State Surveyor checked the cart and it had (3) packages of Juven nutrition powder (supplement that supports wound healing) indicated a use by date of [DATE]. During an observation and interview during medication administration on 11/19/2024 at 8:26 AM, MA G was in the room of Resident #18 to give her morning medications. Resident #18 still had the bottle of nasal spray on the table by her recliner. MA G said Resident #18 did not get her nasal spray yesterday, 11/18/2024, because she did not have a box to it inside of the medication cart. She said she was not aware Resident #18 had her nasal spray in her room. She said medications should not be left at the bedside. She said Resident #18 had not been deemed to take medications on her own and the medication aides and nurses gave her medications. She said she observed the nasal spray at the bedside of Resident #18 before and removed it and placed it back inside of the medication cart. She said the facility had a lot of PRN staff on the weekends and was not sure if that was who left it in the room or not. She said if medications were left in the rooms of residents, they could get confused and someone could come along and take them. During an observation on 11/19/2024 at 9:29 AM, in the medication room with RN F revealed: (1) box of phenylephrine hcl expired 9/24, (1) box of I-caps expired 6/2023, (3) boxes of gas relief expired 8/24, and (1) bottle gerilanta expired 11/23. During an interview on 11/19/2024 at 9:49 AM, RN F said the ADON, and unit managers were responsible for the medication rooms and storing of medications. She said anytime they placed an order for medications or when medications were pulled, they checked the medication room. She said they checked the medication room at least monthly. She said there could be a risk of sickness if residents were taking medications that were expired. During an interview on 11/19/2024 at 1:43 PM, the ADON said she and the unit managers were responsible for checking the medication carts and the medication room for expired medications. She said she checked the medication cart for hall 100 last week and the Pharmacist visited the facility last week and checked the medication room as well. She said she was not sure how the expired medications were missed. She said there could be a risk of sickness if residents received medications that were expired. She said medications should not be stored at the bedside, she Resident #18 had not been deemed to administer medications to herself. She said there was a risk for other residents to get the medications if they were left at the bedside or the resident could take too much. During an observation on 11/19/2024 at 3:42 PM, the nurse cart for halls 300 and 400 was assigned to the NP and revealed: (2) bottles of Glucerna 1.2 cal dated [DATE]. During an interview on 11/20/2024 at 2:27 PM, the DON said whoever was responsible for the carts that day was responsible for ensuring the carts did not have expired medications and the Unit Managers were responsible for checking them weekly along with the medication rooms. He said medications should always be stored in the carts or in the medication room. He said there were not any residents in the facility that were deemed safe to self-administer any medications in the facility. He said the Pharmacist visited the facility monthly and checked the carts and medication rooms during visits. He said there was a risk for adverse effects to the residents if residents took expired medications or the residents could take too much if medications were left at the bedside. He said he started an in-service with staff yesterday (11/19/2024) about medication storage. During an interview on 11/20/2024 at 3:10 PM, the Administrator said the nurse and nurse aides were responsible for checking the carts daily. She said the medication room was the responsibility of Nursing for checking it daily to make sure there were not any expired medications. She said medications should not be stored at the bedside and should be kept in the medication carts. She said there were not any residents in the facility that could self-administer medications. She said she planned to have nursing supervise and monitor the medication carts and the room. She said there could be negative effects for the residents if they were given medications that were expired or left at the bedside. Record review of an in-service, dated 11/19/2024, titled Nurse & Med Carts by the DON reflected, no medications that are expired can be on the medication cart. It is your responsibility to check daily. Record review of an in-service, dated 11/19/2024, titled Meds at Bedside by the DON indicated, no medication at all are allowed to be kept by residents or at bedside. Pull the medication and give to charge nurse if found. Record review of the facility's policy titled Storage of Medication, revised April 2007, reflected, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals

Based on observation, interview and record review the facility failed to ensure each resident was provided food prepared in a form designed to meet individual needs for 3 of 3 residents (Residents #27, Resident #12 and Resident # 24) reviewed for pureed diets. The facility failed to prepare the pureed diet to the consistency required for Resident #27, Resident #12 and Resident #24. This failure could place residents at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes. Findings include: 1. Record review of Resident #27's facility face sheet, dated 11/20/2024, for reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #27 had diagnoses which included aphasia following cerebral infarction (a disorder resulting from damage or injury to the language area in the brain), dysphagia (A condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink), and protein calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets). Record review of Resident #27's quarterly MDS assessment, dated 10/2/2024, reflected she had a BIMS score of 11, which indicated she had moderate cognitive impairment. Section GG indicated she required supervision assistance for eating. Record review of Resident #27's comprehensive care plan, dated 7/20/2022 and revised on 10/22/2024, reflected Resident #27 was on a low salt pureed diet. Record review of Resident #27's physician's order summery report, dated 11/20/2024, reflected she was ordered a low sodium, dysphagia pureed level 1 regular diet with a start date of 9/5/2024. 2. Record review of Resident #12's facility face sheet, dated 11/20/2024, for reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included dysphagia (A condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink), aphasia (a disorder resulting from damage or injury to the language area in the brain) and cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain). Record review of Resident #12's annual MDS assessment, dated 10/14/2024, reflected he had a BIMS score of 04, which indicated he had severe cognitive impairment. Section GG indicated he required supervision assistance for eating. Record review of Resident #12's comprehensive care plan, dated 1/13/2023 and revised on 9/23/2024, reflected Resident #12 was on a 2 Gram sodium, pureed texture, honey consistency liquid diet and was at risk for malnutrition. Record review of Resident #12's physician's order summery report, dated 11/20/2024, reflected he was ordered a 2 Gram sodium, dysphagia pureed level 1 regular diet with honey consistency for pleasure with a start date of 8/6/2024. 3. Record review of Resident #24's facility face sheet, dated 11/20/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #24 had diagnoses which included dysphagia (A condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink) and cerebral palsy (a group of conditions that affect movement and posture). Record review of Resident #24's significant change in status MDS assessment, dated 8/13/2024, reflected she had a BIMS score of 08, which indicated she had moderate cognitive impairment. Section GG indicated she required supervision assistance for eating. Record review of Resident #24's comprehensive care plan, dated 6/11/2024 and revised on 10/15/2024, reflected Resident #24 was on a therapeutic regular pureed diet. Record review of Resident #24's physician's order summery report, dated 11/20/2024, reflected she was ordered a regular, dysphagia pureed level 1 diet with a start date of 7/10/2024. During an observation and interview on 11/19/24 at 11:35 AM with the Administrator and Director of Nursing, revealed they sampled the pureed pork on the State Surveyors' test tray was observed to be chewy and not a smooth, pudding-like consistency by the surveyor. During an interview with the Dietary District Manager on 11/19/2024 at 1:00 PM, she said she has been in her current position for 1 year. She stated after the test tray was served, she pureed more meat for the residents and replaced the original meat served with the meat with a smoother [NAME]. She said she started an in-service with the dietary staff on pureed texture and consistency. She said the consistency of pureed foods should be smooth and no texture should be detected. She said a smooth texture allowed for the foods to be swallowed easily. She stated broth or other recommended liquids should be added to foods to achieve the right consistency and texture. She stated foods should be precut to smaller pieces to allow the food to break down to a smoother texture. She said the registered dietician came to the facility every other week and did sample test treys with every visit. She said if pureed foods did not have a smooth consistency, it could cause the resident to choke. During an interview with the Dietary Manager on 11/20/2024 at 10:00 AM, revealed he had been working at the facility for 2 years. He said an in-service was started for staff on the correct consistency of pureed foods. He said the cook was responsible for preparing the pureed foods and pureed foods should have a smooth, mousse like consistency. He said the person who prepared the pureed foods should look at the food, take a spoon and check for smoothness. He said the meat should be chopped prior to the puree process. He said a resident could be at risk for choking if the ordered diet was not served. During an interview with the Administrator on 11/20/2024 at 10:30 AM, she said she had been in her position for 1 month. She stated the pureed consistency needed to be correct. She said she would be monitoring the consistency of the pureed diets. She said she was also going to get the speech therapists and dietician involved in the observation and the consistency. She said a resident could possibly aspirate or effect intake by pocketing food. Record review of the facility's document titled texture modification in-service from the dietary operations v2 policy reflected All foods must be pureed to a mousse-like texture . Blend food items until fine and smooth.

Based on an interview and record review the facility failed to maintain a Quality Assessment and Assurance Committee which consisted at a minimum of the director of nursing services, the Medical Director or designee, at three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role and the infection preventionist and the facility failed to ensure the Quality assessment and assurance committee met quarterly and as needed to coordinate and evaluate activities, including performance improvement projects required under QAPI program for 4 of 11 months (April 2024, May 2024, July 2024 and October 2024. reviewed for QAA/QAPI. 1. The facility failed to ensure the Medical Director attended their QAA and QAPI meetings for the months of April 2024, May 2024 and July 2024. 2. The facility failed to ensure they had QAA and QAPI meetings for the month of October 2024. These failures could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings include: Record review of the facility's QAA/QAPI meeting signature logs for the months of April 18, 2024, May 16, 2024, and July 18, 2024 reflected meetings were conducted each month during that period. Neither the Medical Director nor his/her designee signed the sign-in sheets, nor was it indicated on the sign-in sheet the Medical Director or his designee attended the QAA/QAPI meetings via zoom or by phone. Record review of the facility's QAA/QAPI meeting signature logs for the past year from October 18, 2023, to September 19, 2024. There was no record of a signature log for the month of October 2024. During an interview on 11/20/2024 at 1:30 PM, the Administrator said she had been employed at the facility since October 1, 2024. She said the facility had meetings for QA monthly. She said she was in the learning process of what the facility wanted. She said she was not aware the facility policy indicated they would have meetings monthly and knew the state regulation was for quarterly meetings. She said they had not had a meeting since she took over as the Administrator. She said in the meetings they should be discussing weights, skin issues, infection control, medications, and anything pertinent to care. She said recently she had been focused on falls with an action plan in place. She said all department heads and IDT team members would be included in the meetings along with the Medical Director. She said they planned to have monthly meetings going forward with it being scheduled on or around the 3rd week of the month. She said there was a risk of information being missed when all team members were not in attendance at the meetings. Record review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Committee, dated July 2016 reflected .This facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI program. 3. The following individuals will serve on the committee: c. Medical Director; Committee Meetings 1. The committee will meet monthly at an appointed time

46436 Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 10 residents (Residents #11, #65, and #181) and 2 of 6 staff (CNA C and CNA H) reviewed for infection control. 1.CNA C failed to change gloves and perform hand hygiene during incontinent care for Resident #11 on 11/18/2024. 2.The facility failed to ensure CNA C did not enter the isolation rooms of Residents #65 and #181 without PPE on 11/18/24. These failures could place residents at risk of exposure to infectious diseases . Findings include: 1.Record review of Resident #11's facility face sheet, dated 11/19/2024, reflected Resident #11 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #11 had a diagnosis which included Atrial Fibrillation (an irregular heartbeat). Record review of Resident #11's comprehensive care plan, dated 9/19/2024, reflected Resident #11 had bowel and bladder incontinence and required incontinent care from staff. Record review of Resident #11's quarterly MDS assessment, dated 9/21/2024, reflected Resident #11 had a BIMS of 11, which indicated moderately impaired cognition. Resident #11 was dependent on staff for toileting. During an observation on 11/18/24 at 2:34 PM revealed CNA C and the ADON provided incontinent care to Resident #11. Both entered the room and applied gown and gloves for enhanced barrier precautions. CNA C opened Resident #11's brief and cleaned the front with wipes using a front to back technique. The ADON assisted Resident #11 to her right side. CNA C then cleaned Resident #11's buttock with wipes and the soiled brief and draw sheet was rolled under Resident #11. CNA C then placed a clean sheet and brief without removing her gloves or performing hand hygiene. CNA C proceeded to apply the clean brief, positioned Resident #11 in bed and adjusted Resident #11's pillows and linen with the ADON's assistance. CNA C then removed her gloves and gown, performed hand sanitization and left room. During an interview on 11/18/24 at 2:44 PM, CNA C said she had been a CNA for 2 years and at the facility 1 year . She said she was recently checked off on incontinent care and infection control. She said during incontinent care she should have removed her gloves and performed hand hygiene when going from soiled to clean. She said by not doing so she could cause spread of infections . During an interview on 11/18/24 at 2:50 PM, the ADON said she had been at the facility for 3 years . She said she was responsible for competency checks for all staff and she and the CNA had recently had annual competency training. She said she should have talked to the CNA and made sure she was properly prepared and not nervous to perform care. She said care from soiled to clean gloves should be changed and hand hygiene performed. She said by not doing so, it put the residents at risk for cross contamination and infections. During an interview on 11/20/24 at 1:50 PM, the DON said the ADON was responsible for training on infection control and skill check offs for CNA's. He said all nursing staff were trained on infection control measures on hire, annually and as needed. He said he expected infection control measures were followed by all staff to prevent the spread of infections and cross contamination. During an interview on 11/20/24 at 2:13 pm , the Administrator said the DON and the ADON were responsible for the infection control program and training. She said training was completed on hire, annually and as needed. She said she expected infection control measures were always followed to prevent the spread of infections. Record review of a competency skills checkoff dated 9/11/24, reflected CNA C was competent on incontinent care and infection control. Record review of the facility's policy titled Perineal Care, dated December 2011, reflected, .the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations and to observe the resident's skin condition. 12. remove gloves and discard into designated container. Wash and dry your hands thoroughly. Put on clean gloves and place new brief and secure in place. Reposition the bed covers and make the resident comfortable 2. Record review of Resident #65's facility face sheet, dated 11/21/24, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] and subsequently readmitted on [DATE]. Resident #65 had diagnoses which included intraspinal abscess and granuloma (a collection of pus and infectious material in the spine), sepsis (a serious condition in which the body responds improperly to an infection, causing organ damage and sometimes death) and metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body). Record review of Resident #65's Nursing Home PPS MDS assessment, dated 11/9/24, reflected Resident #65 had a BIMS score of 15, which indicated he was cognitively intact. He was on isolation or quarantine for active infectious disease. Record review of Resident #65's comprehensive care plan, dated 11/6/24, for reflected Resident #65 was on MSSA/contact precautions and had the following intervention: .contact precautions due to MSSA Record review of Resident #65's physician's order summary report, dated 11/21/24, reflected he had the following order dated 11/5/24: .Contact Isolation Precautions for MSSA in wound Record review of Resident #181's facility face sheet, dated 11/19/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #181 had diagnoses which included infective endocarditis (a potentially fatal inflammation of your heart valves' lining and sometimes heart chambers' lining), sepsis (a serious condition in which the body responds improperly to an infection, causing organ damage and sometimes death) and hyperlipidemia (high cholesterol). Record review of Resident #181's electronic medical record indicated her entry MDS was in process and had not been completed yet. Record review of Resident #181's physician's order summary report, dated 11/19/24, reflected she had the following order dated 11/14/24: .Contact and Isolation Precautions for (MRSA) every shift Record review of Resident #181's comprehensive care plan, dated 11/15/24, reflected she required contact isolation and had the following intervention: .follow facility isolation policy During an observation on 11/18/24 at 11:13 AM revealed Resident #65's room had a contact isolation sign on door and a PPE box located outside doorway. During an observation on 11/18/24 at 11:15 AM revealed Resident #181's room had a contact isolation sign on the door and a PPE box located outside doorway. During an observation on 11/18/24 at 11:45 AM revealed CNA H passing meal trays and she entered Resident #65's room without donning PPE. When Resident #65 refused his meal, she returned to the hallway with his tray in hand and placed it back on the tray cart. She was then observed removing the meal tray for Resident #181 and entered her room without donning PPE. The DON walked down hall at this time and saw her in Resident #181's room. When she exited the room, the DON said something inaudible to her and she was then observed going into the shower room to wash her hands. During an interview on 11/18/24 at 11:55 AM, the DON said CNA H should not have entered the isolation rooms without donning PPE. He said she had been trained and the 2 residents were on Contact Isolation Precautions. During an interview on 11/18/24 at 12:00 PM, CNA H said she thought she only had to wear PPE if she was providing resident care. She said she thought Resident #65 was on precautions due to his wound and Resident #181 was on precautions due to having an IV. She said infections could be spread between residents if infection control techniques were not followed. During an interview on 11/20/24 at 2:55 PM, the DON said Enhanced Barrier Precautions had everyone confused and going forward he would continue to educate the staff regarding Contact Precautions versus Enhanced Barrier Precautions. He said residents could be at risk for cross-contamination if proper infection control procedures were not followed. During an interview on 11/20/24 at 3:10 PM, the Administrator said she would be in-servicing the staff on PPE usage and the different isolation types. She said if staff did not follow proper infection control precautions, infections could spread. Record review of a CNA Proficiency Evaluation, dated 8/6/24, reflected CNA H had received training on Infection Control. Record review of the facility's policy titled Infection Prevention and Control Program, dated 2001 and revised in August of 2016, reflected .7. Prevention of Infection a. Important facets of infection prevention include .(6) implementing appropriate isolation precautions when necessary Record review of the facility's policy titled Isolation - Initiating Transmission-Based Precautions, dated 2001 and revised in January 2012, reflected .Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions .Transmission-Based Precautions shall remain in effect until the Attending Physician or Infection Preventionist (or designee) shall: a. Ensure that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need

Based on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or quality of life, recognizing each resident's individuality for 1 of 6 residents (Resident # 11) observed for resident rights. CNA C and the ADON failed to provide Resident #11 with full privacy while receiving care on 11/18/2024. This failure could place residents at risk of not being treated with dignity and respect. Findings include: Record review of Resident #11's facility face sheet, dated 11/19/2024, reflected Resident #11 was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis which included Atrial Fibrillation (an irregular heartbeat). Record review of Resident #11's comprehensive care plan, dated 9/19/2024, reflected Resident #11 had bowel and bladder incontinence and required incontinent care from staff. Record review of Resident #11's quarterly MDS assessment, dated 9/21/2024, reflected Resident #11 had a BIMS of 11, which indicated moderately impaired cognition and was dependent on staff for toileting. During an observation on 11/18/24 at 2:34 PM revealed CNA C and the ADON entered Resident #11's room to provide incontinent care. The privacy curtain on the door side of the room was not pulled during care and left Resident #11 exposed. A visitor opened the door and entered the room during care and Resident #11 was exposed. During an interview on 11/18/24 at 2:42 PM, Resident # 11 said the staff usually pulled both privacy curtains but not always. She said she would be embarrassed if someone walked in and saw her naked. During an interview on 11/18/24 at 2:44 PM, CNA C said she had been a CNA for 2 years and at the facility 1 year . She said she was recently checked off resident rights . She said she pulled her curtain on her side and did not recognize the curtain on the door side was not pulled. She said by not pulling the curtain it could cause the resident to be exposed and embarrassed. During an interview on 11/18/24 at 2:50 PM, the ADON said she had been at the facility for 3 years . She said she was responsible for competency checks for all staff and she and the CNA had recently had annual competency training. She said she should have pulled the curtain to provide privacy during care and by not doing so residents could be exposed and embarrassed . During an interview on 11/20/24 at 1:50 PM, the DON said every person employed at the facility was responsible for ensuring resident rights and dignity. He said the privacy curtain should always be pulled to provide the resident with full privacy and expected that to occur with each resident encounter during personal hygiene and care. He said by not respecting resident rights and dignity it could cause embarrassment if they were exposed during care. During an interview on 11/20/24 at 2:16 PM, the Administrator said resident rights and dignity were the responsibility of every employee. She said during resident personal care like incontinent care the privacy curtain should always be pulled to avoid exposing the resident. She said she expected all staff to maintain dignity for every resident and by not doing so it could cause embarrassment. Record review of the facility policy titled Quality of Life - Dignity, dated October 2009, reflected, .Residents shall be treated with dignity and respect at all times, Staff shall promote maintain and protect resident privacy including bodily privacy during assistance with personal care

Based on observation, interview, and record review the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable for 1 of 6 residents (Resident #14) reviewed for quality of care. The facility failed to ensure Resident #14 had her splints for contractures in her hands on 11/18/24. This failure could place residents at risk of increased contractures, not receiving care and services to maintain their highest level of well-being and decline. Findings include: Record review of Resident #14's facility face sheet, dated 11/19/2024, reflected Resident #14 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14 had a diagnosis which included Parkinson's (a movement disorder of the nervous system that worsens over time). Record review of Resident #14's comprehensive care plan, dated 8/19/2024, reflected Resident #14 had limited physical mobility related to contractures and to apply hand splint to the right hand and left-hand palm protector. Record review of Resident #14's quarterly MDS, dated [DATE], reflected Resident #14 had a BIMS of 09, which indicated moderately impaired cognition. Resident #14 did not receive restorative nursing services for splint assistance. During an observation on 11/18/24 at 9:22 AM revealed Resident # 14's hands were contracted and there was no splint or device in her hands. There was a carrot device on her bedside table. During an phone interview on 11/18/24 at 2:22 PM, Resident #14's family member said Resident #14 should have a carrot in her hands because of contractures and had a history of getting skin breakdown from her fingernails . During an observation and interview on 11/18/24 at 3:23 PM revealed Resident #14 shook her head no when asked if she had her hand splints in place today. She was observed with no device in her hands and the carrot device remained on the bedside table. During an interview on 11/19/24 at 1:23 PM, CNA A said she had been a CNA for [AGE] years and at the facility 3 1/2 years . She said residents who had splints were usually on therapy or restorative and they applied the devices, but the CNAs were also trained to apply them. She said the devices should be applied daily as the resident allowed to prevent further contractures or skin breakdown. During an interview on 11/19/24 at 1:33 PM, the Restorative Aide said she had been the restorative aide care for 1 1/2 years . She said Resident #14 was on restorative but no longer and the CNA's and nurses were responsible for applying her splints. She said the nurses were given a list of residents who required splints and should be checking them and ensuring they were in place every day. She said if splints were not placed, contractures could worsen or there could be skin breakdown. During an interview on 11/19/24 at 1:35 PM, the PTA said residents who required special devices like splints the restorative aide or therapist applied the device, but all CNA's and nurses were trained so they could apply the devices on the weekends. She said Resident #14 was off therapy, but the DON was given a list of all residents who required devices and the nurses or CNAs should have been applying Resident #14's splints daily . She said by not applying them resident contractures could worsen or they could have pain. During an interview on 11/19/24 at 1:45 PM, LVN B said she had been an LVN for 3 1/2 years and at the facility 6 months . She said she was aware Resident #14 required splints on her hands and she had them on today. She said she was not sure why she did not have them on yesterday. She said there was a list at the nurse's station, and she checked devices on her rounds. She said if devices were not in place contractures could increase, or skin breakdown and pain could occur. During an interview on 11/20/24 at 1:50 PM, the DON said the CNA's and restorative aide were responsible for ensuring devices like splints were put in place as outlined in the resident's care plan. He said they did not do orders for devices and only placed a list at the nurse's station for the nurses to know who required what devices. He said there was no system in place to oversee and ensure the devices were in place but would start a new system. He said he expected all needed devices, such as hand splints, were in place as the resident required, and by not doing so contractures could worsen. During an interview on 11/20/24 at 2:16 PM, the Administrator said devices like hand splints should be in place as the care plan stated and the CNA's or nurses should be applying them. She said the DON was responsible for oversight and would make sure there was a system in place to check devices daily. She said she expected all residents with hand splints got them to prevent an increase in contractures. Record review of the facility's policy titled Contracture Management, dated March 2012, reflected .treatments and techniques employed by nursing home staff helps prevent or slow down contractures. Splinting devices are often utilized to prevent further contractures

Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and service to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #76) reviewed for indwelling catheter. The facility failed to ensure Resident #76's indwelling catheter securement device was in place. This failure could place residents at risk for urethral tears, discomfort, infection and hospitalization . Findings include: Record review of Resident #76's facility face sheet, dated 11/19/24, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and subsequently readmitted on [DATE]. Resident #76 had diagnoses which included pulmonary mycobacterial infection (lung infections are caused by a common type of bacteria called mycobacteria), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Record review of Resident #76's Nursing Home PPS MDS assessment, dated 10/23/24, reflected Resident #76 had a BIMS score of 10, which indicated that he had moderately impaired cognition. Resident had an indwelling catheter and was always incontinent of bowel. Record review of Resident #76's comprehensive care plan, dated 11/12/24, reflected he had an indwelling catheter and had the following intervention: .check tubing for kinks each shift The care plan did not address securing the catheter with an anchor. Record review of Resident #76's physician's order summary report, dated 11/19/24, reflected he had the following order, dated 11/12/24: .Foley catheter 16FR 10cc bulb to bedside drainage, Diagnosis: Urinary retention During an observation on 11/19/24 at 1:20 PM revealed Resident #76 in bed with no securement device on his foley catheter. During an interview on 11/19/24 at 1:30 PM, the Restorative Aide said Resident #76 should have an anchor on his catheter to prevent it from pulling. She said he had just returned from the hospital with the catheter. During an interview on 11/19/24 at 1:48 PM, the DON said anchors were not normally used unless the residents requested them. During an interview on 11/20/24 at 2:42 PM, LVN L said the nurses are responsible to use anchors on the catheters to prevent them from pulling and causing pain. She said Resident #76 had recently returned from the hospital and it must have gotten missed. During an interview on 11/20/24 at 2:55 PM, the DON said Resident #76 had only been back from the hospital for a few days. He said the anchor helped to prevent the catheter from becoming dislodged and getting yanked out. He said going forward he would educate the nurses and ensure securement devices were used. During an interview on 11/20/24 at 3:10 PM, the Administrator said she expected her staff to use anchors to secure foley catheters. She said she would educate the staff and ensure the policy was followed going forward. She said residents needing indwelling catheters could be at risk for pain if tubing was not anchored to prevent it from pulling. Record review of the facility's policy titled Catheter Care, Urinary, dated 2001 and revised in April 2010, reflected .17. Secure catheter utilizing a leg band

Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 2 of 16 residents (Resident #3 and Resident #4) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service. This deficient practice could place residents at risk of a loss of quality of life due to injuries. Findings included: Record review of a facility face sheet dated 9/10/24 for Resident #3 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including: anxiety disorder, dysphagia (trouble swallowing) and aphasia (a brain disorder that affects speaking or understanding language). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #3 indicated that she had a BIMS score of 9, which indicated that she had a moderate cognitive impairment. She was dependent for transfers. Record review of a comprehensive care plan dated 7/24/24 for Resident #3 indicated that she had as ADL self-care deficit and interventions included: .The resident requires extensive assist X2 staff participation with transfers. Hoyer Lift . Record review of a facility face sheet dated 9/10/24 for Resident #4 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: paraplegia (a form of paralysis that mostly affects the movement of the lower body), dysphagia (trouble swallowing), and aphonia (inability to speak). Record review of a Quarterly MDS assessment dated [DATE] for Resident #4 indicated that the Brief Interview for Mental Status should not be conducted due to resident being rarely/never understood. She had a severe cognitive impairment. She was dependent for transfers. Record review of a comprehensive care plan dated 8/27/24 for Resident #4 indicated that she had an ADL self-care deficit and interventions included: .The resident requires Mechanical Aid, Sling, for transfers . During an observation on 9/10/24 at 12:15 PM Resident #4 was observed up in chair in common area of facility with blue mesh lift sling observed underneath her. The colors of the loops were faded in color. During an observation on 9/10/24 at 12:20 PM Resident #3 was observed up in dining room in chair with a blue mesh mechanical lift sling underneath her. The colors of the loops on sling were observed to be faded in color . During an observation on 9/10/24 at 1:00 PM CNA A and CNA B were observed to use Hoyer lift (mechanical lift used to transfer dependent residents). They were observed to transfer Resident #4 from her chair to her bed with the lift pad that was underneath her with the faded colored loops. During an interview on 9/10/24 at 1:30 CNA B said using lift slings that were faded meant they were worn and could cause a resident to fall . During an interview on 9/11/24 at 1:35 PM CNA A said faded colors on the slings were a sign of wear and tear, and those slings should not be used. She said using slings that have signs of wear and tear could cause a resident to get hurt . During an interview on 9/11/24 at 9:15 AM DON said laundry was responsible for checking slings before sending them back out to the floor for use and CNAs were responsible for checking before using to ensure safety for the residents. During a joint interview on 9/11/24 at 12:25 PM Housekeeping supervisor and Laundry Aide both said that slings were washed in warm water and air dried. Both said bleach was not used on slings. Both said they look for rips, stains, and discoloration. Both said that slings were not sent back to floor for use, but CNAs were responsible for coming to laundry to get one when they needed it. Both said that residents could be at risk for injury if unsafe slings were used . During an interview on 9/11/24 at 12:30 PM DON said that residents could be at risk of ending up in the floor if unsafe slings were used. He said that Unit Managers would be expected to inspect all slings weekly going forward and remove any that were worn or faded. During an interview on 9/11/24 at 12:35 PM Administrator said that residents could be at risk for falls if unsafe slings were used. He said that they will be doing in-services and education with nursing staff and laundry to prevent unsafe slings from being used and ensuring staff know when to remove slings. Record review of a facility in-service dated 8/8/24 titled Hoyer Lift, stand-up Lift, and Transfer with objectives of educate staff on proper usage of Hoyer Lift and Stand-up lift and transfer. Video demonstration provided Signature page was signed by CNA A, indicating that she had received training on usage of Hoyer lift. Record review of a facility skills validation form titled Mechanical/Hydraulic Lift signed by CNA B and dated 9/2/23 indicated that CNA B had been trained on use of Hoyer Lift. Record review of a facility policy titled Lifting Machine, Using a Portable dated 2001 and revised in April 2007 indicated that policy did not address inspecting the slings before use to monitor for wear and tear . Record review of guidance titled Full Body Slings: Instructions for Use retrieved from www.medline.com on 9/11/24 read .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use . and .Do not remove sling labels. If sling labels are removed or no longer legible, sling must be immediately removed from use .

Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 14 of 14 employees (Administrator, DON, ADON, FSS, AD, LVN G, RN H, LVN J, DOR, CNA K, CNA L, CNA M, CNA N, and CNA D) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to the Administrator, DON, ADON, FSS, AD, LVN G, RN H, LVN J, DOR, CNA K, CNA L, CNA M, CNA N, and CNA D. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring. Findings: Record review of personnel files indicated the following: The Administrator was hired 4/3/23, The DON was hired 7/5/23, The ADON was hired on 12/9/22, The DM was hired 12/2/16, The AD was hired 3/20/23, LVN G was hired 8/10/23, RN H was hired on 8/3/23, LVN J was hired 2/13/23, The DOR was hired 6/13/18, CNA K was hired 10/18/22, CNA L was hired 6/23/22, CNA M was hired on 9/1/23, CNA N was hired on 4/5/23, and CNA D was hired on 12/6/22. Record review of training records indicated the QAPI required training had not been completed on hire for the Administrator, DON, ADON, FSS, AD, LVN G, RN H, LVN J, DOR, CNA K, CNA L, CNA M, CNA N, and CNA D. During an interview on 10/12/23 at 9:20 am the DON said the ADON was responsible for staff trainings. He said that the risks for staff not receiving proper trainings included residents receiving incorrect care. During an interview on 10/12/23 at 9:30 am the ADON said she was responsible for staff trainings and said that she was unaware of the requirements for QAPI trainings. She said she would get the trainings started and train the staff. During an interview on 10/12/23 at 10:40 am the Administrator said he did not know the requirements for QAPI training were to be done on hire and annually. He said he would be working on getting a system in place to ensure that all staff received required trainings. He said the risks to residents included the staff now knowing how to properly care for residents. Record review of facility policy Titled Staff Development dated 2001, revised December 2009 indicated, .The primary purpose of our facility's in-service training program is to provide our employees with an in-depth review of our established operational policies and procedures, their positions, methods and procedures to follow in implementing assigned duties, and to provide up-to-date information that will assist in providing quality care .

Based on interview and record review, the facility failed to provide the required compliance and ethics training for 14 of 14 employees (Administrator, DON, ADON, FSS, AD, LVN G, RN H, LVN J, DOR, CNA K, CNA L, CNA M, CNA N, and CNA D) reviewed for training, in that: The facility failed to ensure compliance and ethics training was provided to the Administrator, DON, ADON, FSS, AD, LVN G, RN H, LVN J, DOR, CNA K, CNA L, CNA M, CNA N, and CNA D. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings : Record review of personnel files indicated the following: The Administrator was hired 4/3/23, The DON was hired 7/5/23, The ADON was hired on 12/9/22, The DM was hired 12/2/16, The AD was hired 3/20/23, LVN G was hired 8/10/23, RN H was hired on 8/3/23, LVN J was hired 2/13/23, The DOR was hired 6/13/18, CNA K was hired 10/18/22, CNA L was hired 6/23/22, CNA M was hired on 9/1/23, CNA N was hired on 4/5/23, and CNA D was hired on 12/6/22. Record review of training report indicated the Compliance and Ethics required training was not completed on hire or annually for the Administrator, DON, ADON, FSS, AD, LVN G, RN H, LVN J, DOR, CNA K, CNA L, CNA M, CNA N, and CNA D. During an interview on 10/12/23 at 9:20 am the DON said that ADON was responsible for staff trainings. He said that the risks for staff not receiving proper trainings included residents receiving incorrect care. During an interview on 10/12/23 at 9:30 am the ADON said that she was responsible for staff trainings and said that she was unaware of the requirements for compliance and ethics trainings. She said that she would get the trainings started and train the staff. During an interview on 10/12/23 at 10:40 am the Administrator said that he did not know the requirements for compliance and ethics training were to be done on hire and annually. He said that he would be working on getting a system in place to ensure that all staff received required trainings. He said that the risks to residents included the staff now knowing how to properly care for residents. Record review of facility policy Titled Staff Development dated 2001, revised December 2009 indicated, .The primary purpose of our facility's in-service training program is to provide our employees with an in-depth review of our established operational policies and procedures, their positions, methods and procedures to follow in implementing assigned duties, and to provide up-to-date information that will assist in providing quality care .

46436 Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 5 residents (Resident #69) and 2 of 5 (medication cart for halls 300 and 400 and nurse medication cart for halls 100 and 200) reviewed for pharmacy services. The facility did not ensure medications were properly administered to Resident #69. The facility failed to remove a bottle of levothyroxine (thyroid medication) 50 mcg tablets that expired on 6/14/2023 for Resident #52 from the medication cart for halls 300 and 400. The facility failed to remove 4 bottles of Glucerna 1.5 Cal with a used by date of September 1, 2023 from the medication cart for halls 100 and 200. These failures could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and not receiving the intended therapeutic benefit of the medications. Findings included: 1.Record review of facility face sheet dated 10/10/2023 indicated Resident # 69 was a [AGE] year-old female admitted to facility on 09/11/2023 with diagnosis of cerebral infarction (stroke) and pneumonia (lung infection). Record Review of comprehensive care plan dated 9/11/2023 indicated Resident # 69 had an alteration in gastrointestinal status and to give medications as ordered, had arthritis (pain in joints) and to give analgesics as ordered, and had acute ischemic stroke and give medications as ordered. Care plan did not indicate Resident # 69 could safely self-administer medications. Record review of Admission MDS dated [DATE] indicated Resident # 69 had a BIMS of 15 indicating intact cognition. Record review of consolidated physician orders dated 10/10/2023 indicated Resident #69 had an order for acetaminophen (Tylenol) 500 mg give 2 tablets by mouth daily, atorvastatin 40mg give 1 tablet by mouth at bedtime, docusate sodium 100mg give 1 capsule by mouth two times a day, omeprazole 40mg give 1 capsule by mouth daily, and Plavix 75mg give 1 tablet by mouth daily with start date of 9/11/23 and stop date of 9/12/23. During an observation on 10/09/23 at 09:45 am Resident # 69 was observed with medications in a medicine cup inside open drawer of nightstand. She stated she does not always take her medicine when the aide gives them to her because she knew what they are and took them at specific times in the morning depending on her breakfast. She stated the pills were Plavix, omeprazole, a stool softener, Tylenol, and atorvastatin. She stated the doctor stopped the Plavix, but she never took it because she did not feel she needed it to begin with. She stated she had not told anyone she was not taking her medicine when they gave them to her. She stated she was smart enough to know her medicine and how and when she wanted to take them. She stated she did leave her room unattended when she was at therapy but was mostly in her room. During an observation on 10/09/2023 at 9:55 am Resident #69 had the following medications identified at bedside: two white round tablets with imprint R 196 (Plavix), a brown capsule with imprint E69 (omeprazole), a white and red capsule (docusate sodium), a white oblong tablet with imprint M2A4-57344 (acetaminophen) and a white oblong tablet with imprint APO ATV40 (atorvastatin). During an interview on 10/11/2023 at 8:33 am MA A stated she had been a medication aide for [AGE] years and at the facility for 8 months. She stated she worked Monday through Friday. She stated she administered medications to Resident #69 on 10/09/2023 and she watched Resident #69 take her medicine that morning. She stated when medications were given, the medicine had to be taken with medication aide present and medicine was not to be left at the bedside. She stated she was not aware Resident #69 had not taken her medicine. She stated she had been trained on proper administering of medications and not leaving medications at bedside. She stated the purpose of ensuring medications were taken, was to ensure another resident did not get the medicine and proper action of the medicine. Record review of competency training for MA A on 01/24/2023 indicated all criteria met including, #14. medications are not left on top of the cart or at resident's bedside. During an interview on 10/11/2023 at 8:45 am LVN B stated she had been at the facility since February 2023. She stated the medication aides administered most oral medications, but it was the nurse's responsibility to ensure medications were being given. She stated when medications were administered whoever gave the medicine were responsible for ensuring the resident took them before leaving the room and if they did not take them or refused the medication the medication aide was to tell the nurse. She stated she was not aware Resident #69 had not been taking her medicine when they were administered. She stated the risk could be resident health and ineffective disease management. During an interview on 10/11/23 at 4:04 PM the DON stated the nurse and medication aides were responsible for making sure residents were taking their medicine. He stated the staff were to stay with the resident until the medications were taken and the staff had been trained on proper administering of medications. The DON stated he oversaw the nursing staff and all training. He stated if medications were not taken when administered could cause ineffective disease management, or another resident could accidently take medicine left in a resident room. He stated all staff would be in-serviced and rounds would be made regularly to check for medications in resident rooms. 2. Record review of an Admission Record dated 10/11/2023 for Resident # 52 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COPD (a group of lung diseases that affect breathing), schizoaffective disorder (a combination of mood disorders such as depression or bipolar disorder), and bipolar disorder (a mental health condition that causes extreme mood swings). Record review of a physician order summary report dated 10/11/2023 for Resident #52 indicated there was no order for levothyroxine. Record review of an Annual MDS Assessment for Resident #52 dated 8/21/2023 indicated she did not have any impairment in thinking with a BIMS score of 15. During an observation on 10/10/2023 at 8:42 AM, the medication cart for halls 300 and 400 had a bottle of levothyroxine 50 mcg for Resident #52. The prescription was filled by a local pharmacy on 6/14/2022, written on 3/8/2022 with a discard date of 6/14/2023. During an interview on 10/10/2023 at 8:45 AM, MA E said she had been employed at the facility for 3 months. She said she was designated to work halls 300 and 400 when she worked. She said the medication aides were responsible for checking the medication carts for expired and discontinued medications on a daily basis. She said she had been very busy and has been working extra shifts and did not check the medication cart. She said Resident #52 did not have an order to take levothyroxine and was not sure why the medication was in the cart. She said residents could have an adverse reaction if they took expired medications. Record review of a medication administration observation report dated 7/27/2023 for MA E indicated her medication cart was observed for halls 200 and 400 and the medication cart did not have any missing or expired items. 3. Record review of a glucose testing competency observation report dated 5/31/2023 for LVN B indicated her medication cart was observed by the ADON for halls 100 and 200 and the medication cart did not have any missing or expired items. During an observation on 10/10/2023 at 11:25 AM, the nurse medication cart for halls 100 and 200 had four- 8 fluid ounce bottles of Glucerna 1.5 Cal (nutrition supplement) with a used by date of September 1, 2023. During an interview on 10/10/2023 at 11:30 AM, LVN B said she had been employed at the facility since February 2023. She said she worked the day shift on 6 am -2 pm shift and was assigned the nurse cart for halls 100 and 200. She said the nurses and unit managers were responsible for checking the nurse carts for expired medications and supplements. She said the carts were supposed to be check daily after every shift. She said she was trained by a previous LVN on medication administration and the pharmacist visited the facility and conducted random audit checks of medication carts monthly. She said the pharmacist conducted an audit with her about a month ago and she had some items that were expired or out of date in her cart at that time. She said if a resident drank supplements that were out of date, they could get sick. During an interview on 10/12/2023 at 8:30 AM, the ADON said she had been employed at the facility since December 2022. She said the medication aides and nurses were responsible for checking their carts daily and the unit managers were responsible for checking medication carts weekly for expired medications, supplements, or discontinued medications. She said the pharmacy consultant checked all carts a couple of weeks ago. She said she started an in-service on 10/10/2023 on cleaning out medication carts. She said for residents that admitted to the facility that had medications brought in from home such as Resident #52, the nurse should have contacted families about picking them up or if they wanted the facility to discard them. She said residents could get sick if they took medicine or supplements that were expired. During an interview on 10/12/2023 at 9:40 AM, the DON said the nurses and medication aides were responsible for checking carts every shift and should be looking for anything expired. He said the unit managers would be checking the carts weekly going forward. He said he conducted an in-service on 10/10/2023 about checking carts. He said residents could be at risk of taking expired medications. He said the pharmacist visited the facility monthly but did not have a copy of the report for the audit that was conducted a few weeks ago. During an interview on 10/12/2023 at 9:52 am the Administrator stated that the nurses and medication aides were responsible for administering medications per the regulation and it was everyone's responsibility on room rounds to report medications left in rooms. He stated if medications were left in resident's rooms the risk could be resident health and risk of another resident taking them. He stated he expected all medications to be administered as ordered and at the time of administration. He said going forward they would in-service staff and conduct random medication cart checks. He said residents could get hurt if a medication was no longer needed, then it needed to be discarded. Record review of an In-Service dated 10/11/2023 conducted by the DON for nurses and medication aides indicated, .You must watch resident swallow pills or document refusal. You will not leave meds in the room . Record review of an In-Service dated 10/10/2023 conducted by the DON for nurses and medication aides indicated, .You must check your cart at the beginning of each shift and ensure all items (meds, foods, etc.) are not expired. Everything must be dated . Record Review of facility policy dated December 2012 titled Administering Medications indicated, .3. medications must be administered in accordance with the orders, including any required time frame . Facility policy titled Storage of Medications with a revised date of April 2007 indicated, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 staff (MA E and LVN F) and 4 of 7 residents (Resident #8, Resident #18, Resident #58, and Resident #45) reviewed for infection control in that: MA E did not clean the blood pressure cuff between residents (Resident #8, #18, #58) and she did not wash or sanitize her hands in between any of the residents (Resident #8, #58, #18 and #45) observed during medication administration . LVN F did not wash or sanitize her hand in between glove changes while checking the blood sugar of Resident #45. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: 1.Record review of an Admission Record dated 10/11/2023 for Resident # 8 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of PVD (decreased blood flow to legs and feet), type 1 diabetes (a condition where the pancreas produces little or no insulin), bipolar disorder (a condition that causes extreme mood swings), and hypertension (high blood pressure). Record review of a Quarterly MDS assessment dated [DATE] for Resident #8 indicated he did not have any impairment in thinking with a BIMS score of 15. He required extensive assistance with bed mobility and was totally dependent in transfers, dressing, toilet use and personal hygiene. Record review of a care plan dated 3/15/2023 for Resident #8 indicated he had hypertension with interventions to give anti-hypertensive medications as ordered. Observe for side effects such as orthostatic hypertension and increased heart rate and effectiveness. During an observation on 10/10/2023 at 7:48 AM, MA E was at the medication cart to administer medications to Resident #8. She had a blood pressure cuff sitting on the top of the medication cart and entered the room of Resident #8 and checked his blood pressure using a digital cuff. MA E did not wash or sanitize her hands before contact with Resident #8. MA E exited the room and placed the blood pressure cuff on top of the medication cart without sanitizing it. MA E unlocked the medication cart and placed the medications for Resident #8 in a plastic cup and went back into the room and administered the medications to Resident #8. MA E did not wash or sanitize her hands before or after contact with Resident #8. 2. Record review of an Admission Record dated 10/11/2023 for Resident # 58 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (loss of memory, language, problem-solving that interferes with daily life) , heart failure (the heart's inability to pump effectively and efficiently), anemia (low red blood cells in the body), and hypertension (high blood pressure). Record review of a Quarterly MDS assessment dated [DATE] for Resident #58 indicated she had moderate impairment in thinking with a BIMS score of 10. She required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. Record review of a care plan dated 3/2/2023 for Resident #58 indicated she had a diagnosis of hypertension with interventions to give antihypertensive medications as ordered. Observe for side effects such as orthostatic hypertension and increased heart rate and effectiveness. During an observation on 10/10/2023 at 7:58 AM, MA E was at the medication cart to administer medications to Resident #58. She had a blood pressure cuff sitting on the top of the medication cart and entered the room of Resident #58 and checked her blood pressure using a digital cuff. MA E did not wash or sanitize her hands before contact with Resident #58. MA E exited the room and placed the blood pressure cuff on top of the medication cart without sanitizing it. MA E unlocked the medication cart and placed the medications for Resident #58 in a plastic cup and went back into the room and administered the medications to Resident #58. MA E did not wash or sanitize her hands before or after contact with Resident #58. 3. Record review of an Admission Record dated 10/11/2023 for Resident # 45 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of encephalopathy (disease that affects the brain), hypotension (low blood pressure), type 2 diabetes and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements and difficulty with balance and coordination). Record review of a Quarterly MDS assessment dated [DATE] for Resident #45 indicated she had a BIMS score of 12. She required supervision with bed mobility, transfers, and eating. She required limited assistance with all other ADL's. During an observation on 10/10/2023 at 8:08 AM, MA E was at the medication cart to administer medications to Resident #45. MA E unlocked the medication cart and placed the medications for Resident #45 in a plastic cup and went back into the room and administered the medications to Resident #45. MA E did not wash or sanitize her hands before or after contact with Resident #58. 4. Record review of an Admission Record dated 10/11/2023 for Resident # 18 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's disease, dementia, major depressive disorder, and hypertension. Record review of a Significant Change MDS assessment dated [DATE] for Resident #18. She had moderate impairment in thinking with a BIMS score of 11. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Record review of a care plan dated 12/9/2018 for Resident #18 indicate she had a diagnosis of hypertension with interventions to give antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate. During an observation on 10/10/2023 at 8:14 AM, MA E was at the medication cart to administer medications to Resident #18. She had a blood pressure cuff sitting on the top of the medication cart and entered the room of Resident #18 and checked her blood pressure using a digital cuff. MA E did not wash or sanitize her hands before contact with Resident #18. MA E exited the room and placed the blood pressure cuff on top of the medication cart without sanitizing it. MA E unlocked the medication cart and placed the medications for Resident #18 in a plastic cup and went back into the room and administered the medications to Resident #18. MA E did not wash or sanitize her hands before or after contact with Resident #18. During an interview on 10/10/2023 at 8:45 AM MA E said she had been employed at the facility for 3 months. She said during the observation of medication administration, she should have sanitized the blood pressure cuffs between residents and slowed down during the process. She said she was the designated medication aide on halls 300 and 400 on the 6 am-2 pm shift. She said she was checked off on medication administration before and was never told anything about cleaning equipment. She said she should have washed or sanitized her hands between residents, and she did not today because she was nervous. She said residents were at risk of infection if staff did not clean equipment or wash/sanitize their hands. Record review of a medication administration observation report dated 7/27/2023 for MA E indicated she followed proper hand washing technique/gloves at appropriate times. 5. Record review of an Admission Record dated 10/11/2023 for Resident # 45 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of encephalopathy (disease that affects the brain), hypotension (low blood pressure), type 2 diabetes and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements and difficulty with balance and coordination). Record review of a Quarterly MDS assessment dated [DATE] for Resident #45 indicated she had a BIMS score of 12. She required supervision with bed mobility, transfers, and eating. She required limited assistance with all other ADL's. During an observation on 10/10/2023 at 10:50 AM, LVN F was at the door of Resident #45's room. LVN F placed wax paper on the over bed table and put a glucometer, test strips, and alcohol wipes on it. LVN F placed gloves on her hands but did not wash or sanitize them. She checked Resident #45's blood sugar and removed her gloves and placed them in the trash. LVN F went back to the medication cart that was at the doorway and unlocked the cart to get Resident #45's insulin. LVN F applied gloves to both hands and administered the insulin to Resident #45's left lower abdomen. LVN F removed her gloves and placed them in the trash and removed the needle from the insulin pen and placed it in the sharps container. LVN F cleaned the glucometer with a Clorox wipe and placed the wipe in the trash. LVN F removed her gloves and placed them in the trash and then sanitized her hands. During an interview on 10/10/2023 at 11:05 AM, LVN F said she had been employed at the facility since February 2023. She said during the medication administration, she should have washed or sanitized her hands before and after gloves changes. She said she did not have any sanitizer on the cart. She said residents could be at risk of infection or cross contamination if staff did not wash or sanitize their hands. She said she did not have any excuses why she did not wash or sanitize her hands. Record review of glucose testing competency dated 2/27/2023 for LVN F indicated she was observed by the ADON and washed her hands appropriately. During an interview on 10/12/2023 at 8:30 AM, the ADON said she had been employed at the facility since December 2022. She said she was the Infection Preventionist in the facility and staff were supposed to sanitize or wash their hands before and after glove changes and clean equipment used between residents. She said staff were observed on handwashing monthly. She said she would start doing check offs biweekly instead of monthly. She said residents could be at risk of infections if staff did not wash or sanitize their hands and clean equipment between residents. During an interview on 10/12/2023 at 9:40 AM, the DON said the ADON and Unit managers were responsible for making sure staff were trained on infection control and conducted check offs with them. He said staff should be washing or sanitizing their hands between gloves changes. He said staff had been in-serviced on hand hygiene and cleaning equipment and would schedule to have someone come in to train staff from an outside source. He said going forward, he would continue to educate staff. He said residents could be at risk of infection if staff did not wash or sanitize their hand between gloves changes or clean equipment between residents. Record review of an In-Service titled Infection Control dated 10/10/2023 conducted by the DON indicated, .While using equipment between resident cuff, glucometer, etc. you must ensure it is cleaned with the provided wipes before and after each use . Record review of an In-Service titled Handwashing dated 10/10/2023 conducted by the DON indicated, .Remember when performing patient care when removing gloves to perform hand hygiene. Hand sanitizer is effective unless visibly soiled then use soap and water before donning another set of gloves. When in doubt wash your hands . Record review of a facility policy titled Handwashing/Hand Hygiene with a revised date of August 2015 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment . Record review of a facility policy titled Cleaning and Disinfection of Environmental Surfaces with a revised date of June 2009 indicated, .Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. 1. c. Non-critical items are those that come in contact with intact skin but not mucous membranes. 2. Non-critical surfaces will be disinfected with an EPA-registered intermediate or low-level hospital disinfectant according to the label's safety precaution and use directions .

Based on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 6 residents (Resident # 224) observed for care in that: CNA D failed to sit while feeding Resident #224 in his room. This failure could affect residents in the facility who received care and could result in residents not being treated with dignity and respect. Findings included: Record review of an Admission Record dated 10/10/2023 indicated Resident #224 admitted to the facility on [DATE] for a respite stay and was [AGE] years old with diagnoses of type 2 diabetes, hypertension, arthropathy (joint stiffness and pain) and osteoarthritis of left knee (the flexible tissue at the ends of the bones wear down). Record review of an Admission MDS assessment dated [DATE] for Resident #224 was in progress and not complete. Record review of an Interim Plan of Care dated 10/6/2023 for Resident #224 indicated he required a regular diet. During an observation on 10/09/23 at 11:55 AM, CNA D was feeding Resident #224 standing with family present in his room and Resident #224 was sitting up in the bed. During an observation on 10/9/2023 at 12:10 PM, CNA D was still feeding Resident #224 standing by his bed with family present. During an interview on 10/10/2023 at 12:15 PM, CNA D said she had been employed at the facility for a year. She said she had been trained and checked off on feeding residents. She said she fed Resident #224 on 10/9/2023 at lunch and should have been sitting while she fed him. She said his bed was up high and she did not lower the bed and stood while feeding him. She said residents could feel rushed if staff stood to feed the residents. During an interview on 10/12/2023 at 8:30 AM, the ADON said she had been employed at the facility since December 2022. She said she was responsible for conducting competency skills check offs with the nursing staff on hire and annually. She said staff should be sitting at eye level while feeding residents. She said residents could feel forced to eat or make them not want to eat if staff were standing while feeding them. She said going forward she would ensure staff had chairs on the halls for them to use if needed to feed residents. During an interview on 10/12/2023 at 9:40 AM, the DON said he started an in-service on 10/10/2023 about feeding residents. Staff should be at their level sitting. He said going forward unit managers would be making observation rounds daily. He said residents may not be pleased and it was a dignity issue. During an interview on 10/12/2023 at 10:49 AM, the Administrator said they staff should be at eye level with the resident when feeding. Staff should be sitting with the bed lowered. He said going forward he would continue to in-service staff and observe staff daily to ensure residents are being treated with dignity. Record review of an In-service dated 10/10/2023 conducted by the DON to all staff indicated, .You cannot stand over a resident and feed them. You must sit in a chair next to them and feed them. This is a dignity issue . Record review of a facility policy titled Resident Rights with a revised date of October 2009 indicated, .Employees shall treat all residents with kindness, respect, and dignity . Record review of a facility policy titled Quality of Life Dignity with a revised date of August 2009 indicated, .Each resident shall be care for in a manner that promoted and enhances quality of life, dignity, respect and individuality. 2. Treated with dignity means the resident will be assisted in maintained and enhancing his or her self-esteem and self-worth .

Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 6 Residents (Resident #6) reviewed for PASSAR (Preadmission Screening and Resident Review Services) in that: Resident #6 did not have a PASSR level II evaluation with diagnosis of psychotic disorder(abnormal thinking and perceptions) and major depressive disorder(persistent feeling of sadness or loss of interest). The MDS Coordinator failed to refer Resident #6 for a resident review after being diagnosed with major depressive disorder on 1/23/2023 and psychotic disorder on 5/16/2023. These failures could place residents at risk of not receiving the needed PASSAR services to meet their individual needs and could result in a decrease quality of life. The findings were: Record review of a PL1 (PASSR Level 1 Screening) dated 6/8/2022 for Resident #6 indicated she was negative for mental illness, intellectual disability, and developmental disability. Record review of an Admission Record dated 10/10/2023 for Resident #6 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that affect daily life), psychotic disorder (abnormal thinking and perceptions) on 5/16/2023, and major depressive disorder (persistent feeling of sadness or loss of interest) on 1/23/2023. Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated she had severe impairment in thinking with a BIMS score of 4. She had psychiatric/mood disorders of depression and psychotic disorder. A referral to the local contact agency was not needed. Record review of an Annual MDS assessment dated [DATE] for Resident #6 indicated she had severe impairment in thinking with a BIMS score of 4. She had psychiatric/mood disorders of depression and psychotic disorder. A referral to the local contact agency was not needed. Record review of a care plan for Resident #6 dated 6/23/2023 indicated she had delusion disorder and used antipsychotic medications. During an interview on 10/12/2023 at 9:04 AM, the interim MDS nurse said she had been employed with the company for [AGE] years and was filling in to assist. She said when a resident was admitted to the facility, the facility should have a PL1. She said if there were any discrepancies with the diagnosis, then the facility should complete the form 1012 that would be signed by the physician that alerts the local authority about a new diagnosis. She said the local authority would complete a PE and make a determination. She said if a resident admitted with a negative PL1 and later identified new mental illness diagnosis, the facility should complete the form 1012, contact local authority and have them complete a PE if needed. She said the MDS nurse was responsible for coordination of PASSR services. She said there could be a risk to staff and others if residents were having behaviors. Residents could miss out on services. She said she was unaware that Resident #6 was not referred to the local authority for her new mental illness diagnosis. During an interview on 10/12/2023 at 9:40 AM, the DON said the MDS nurse was responsible for coordination of PASSR. He said Resident #6 should have been evaluated by the local authority when she had a new diagnosis of mental illness. He said going forward any new diagnosis with a psychological diagnosis from the physician that he wanted to know to ensure new diagnosis were not missed. He said the risk to residents could be missing out on screenings or what they needed if they qualified for services. During an interview on 10/12/2023 at 10:46 AM, the Administrator said the MDS nurse and SW were responsible for PASSR coordination. He said the facility hired a new MDS nurse that would start on 10/18/2023. He said he was not aware of the new diagnosis for Resident #6. Record review of a Mental Illness/Dementia Resident Review Form 1012 undated indicated Resident #6 had a primary diagnosis of dementia that was not signed by the physician. The nursing facility action was blank and did not indicate if the PL1 remained negative and no new PL1 needed to be completed or if a new positive PL1 was submitted. Record review of a PASSR Clinical Policy with a revised date of May 2014 indicated, .The PASSR level 1 (PL1) Screening form is designed to identify persons who are suspected to having Mental Illness (MI), Intellectual Disability (ID) of a Developmental Disability (DD) also referred to as related conditions. The PASSR Evaluation (PE) is designed to confirm the suspicion of MI, ID, or DD/RC and ensure the individual is placed in the most integrated residential setting receiving specialized services needed to improve and maintain the individual's level of functioning .

Based on interview and record review the facility failed to immediately inform the physician when there was a significant change in the resident's physical and mental status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); for 1 of 7 Residents (Resident #174) whose records were reviewed for change in condition. Facility did not notify physician of Resident #174 change in condition and did not notify physician that the ordered CT Scan for [DATE] was not obtained. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. This failure resulted in the resident not receiving urgent medical care and resulted in death. Findings: Record review of facility face sheet dated [DATE] indicated Resident #174 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE] with completion date of [DATE] for Resident #174 indicated she had severe cognitive impairment, required extensive assistance of 1 person for walking, dressing, eating, toileting, bed mobility, transfers, and personal hygiene. Record review of care plan with a revision date of [DATE] indicated Resident #174 had anxiety and agitation, was taking [CONDITION(S)] medications, was a high risk for falls related to dementia with falls recorded on [DATE], [DATE], [DATE] and [DATE] resulting in a hematoma (solid swelling of blood under skin) to the left side of face. Care plan also indicated to report any changes or delayed healing to primary care physician. Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of SW notes dated [DATE] (12 days after it was ordered) indicated the CT Scan had been scheduled for [DATE]. SW note did not indicate physician was notified the CT had been scheduled. Record review of medication administration note dated [DATE] indicated resident #174 refused medication, had clenching of her teeth and her body became rigid during medication administration. LVN F was notified by CMA L. There is no evidence in nurses note that LVN F assessed resident following notification or that physician was notified. Record review of nurses note dated [DATE] completed by LVN M indicated Resident #174 was not eating, drinking, and not responding when spoken to. Per family request she was sent to the emergency room for treatment. Record review of hospital History and Physical dated [DATE] indicated Resident #174 was admitted to the ICU after 2 days altered mental status and had a subdural hematoma with midline shift (movement of brain) that was approximately 3 weeks old. Resident #174 required a craniotomy (brain surgery). Record review of hospital discharge summary dated [DATE] indicated Resident #174 was terminally extubated and was pronounced dead on [DATE] at 5:37 PM. During an interview on [DATE] at 2:32 PM LVN D stated he had received an order on [DATE] from Resident #174's PCP for a CT Scan due to altered mental status and headaches. PCP did not order CT Scan to be completed STAT or feel need for ER visit. LVN D let the scheduler know to obtain it outpatient on [DATE]. Resident #174's headaches were positional (worsened when changing positions). Tylenol was administered but don't think it helped any, but I can't remember. He stated he did not work for several days after [DATE] and was not aware the CT Scan was not completed. LVN D stated he had been a LVN for 9 months and employed at the facility during that time. Stated he had some training on reporting change in condition but not much. During an interview on [DATE] at 3:55 PM CNA G stated she was responsible for scheduling appointments and transporting residents. She could not remember the full details of the appointment for Resident #174. During an interview on [DATE] at 3:30 PM the DON stated the CT Scan was not ordered stat on [DATE]. She did not think it was urgent. She was unaware Resident #174 had a change in condition until she was sent to the hospital. She stated with a change in condition each resident is to be assessed and the physician is to be notified. She stated the nurses are responsible for identifying and reporting to the doctor. During interview on [DATE] at 3:45 pm the ADM stated the doctor's order for Resident #174 stated tomorrow ([DATE]), but there was no urgency noted to the order. When the CT Scan was not done, she did not think anything of it. We were working on getting it scheduled and days went by and finally the SW took over getting it scheduled. She stated the facility failed to recognize the urgency of the CT Scan. She stated it is facility policy to notify the physician of changes in condition and when orders are not completed as ordered. During an interview on [DATE] at 4:20 PM PCP stated he ordered a CT Scan on [DATE] for Resident #174 because of positional headaches. He did okay it being done the next day because he was told the family requested to not send her to the ER. He was never made aware the CT Scan was not done until Resident #174 went to the hospital on [DATE] with a subdural hematoma. He stated there was no communication from the facility to him regarding the CT Scan not being done or that Resident #174 was having other changes in condition. He stated had he known it was not scheduled he would have ordered for her to go to the ER. During a phone interview on [DATE] at 7:52 AM RP stated her family member fell on [DATE] and it was a bad fall. She came that evening to see her family member and she had visible bruising to her face. The charge nurse told her the doctor had been notified and said to just watch her. She didn't think anything about it as she is not a medical person. A week or so went by (around [DATE]) and her family member was having headaches every day. Her family member would hold the left side of her head and say it hurts. She told the nurse on shift, and they would give her medicine. I didn't really think it was anything, but by the third day she knew something was wrong. On [DATE] the LVN D called the doctor, and he ordered a CT Scan. She thought they were going to take her that night, but LVN D came back about 30 minutes later and stated the doctor said it could wait until the next day. She asked the nurses every day for a week about the CT Scan and was told they were working on getting it scheduled. Her condition stayed the same with headaches and pain, but then her family member started not being as awake. The facility obtained a urinalysis. She was told her family member had a bad urinary tract infection and placed her in isolation. After that she began to not talk or make eye contact. She would just turn her head from side to side. This lasted for several days. When she asked, she was told it was probably just the bacteria infection. Then a few more days passed, then was called by the nurse, and told her family member was going to the ER. She saw her family member at the ER, and she was awake but unresponsive. She went to surgery and later died at the hospital. During an interview on [DATE] at 0848 the ADON stated he had been a LVN for 7 years and employed at facility as ADON for 5 months. He stated you are to report to the doctor any changes in condition. With a change in condition that is reported to the doctor you should give the doctor a full assessment including any falls in the last few weeks with new onsite neurological changes. I haven't had much training on neurological assessments but am currently retraining. If I have concerns, I should report to the DON. Regarding Resident #174 there was a breakdown in communication and the change in condition was not reported. The risk that can occur is hospitalization and even death. During an interview on [DATE] at 9:12 AM LVN F stated she had been an LVN for [AGE] years and employed with the facility almost a year. She stated communication occurs with the 24-hour report and if something remains on the report for more than 2 days it should be brought to the DON. Often in the past, things would be on the report for long times and even just drop off. If an order is received and specifies a date, then that order should be done on that date. If it is not, then the doctor should be notified along with the DON and family. LVN F did not remember any specific details related to Resident #174 but did remember being her nurse after she fell . It had been a while since receiving training reporting to MD immediately of changes in condition. The risk to residents could be significant to resident wellbeing. Review of facility policy titled, Change in a Resident's Condition or status dated [DATE] indicated, .1.the nurse will notify the resident's attending physician when there has been a significant change in condition. 3. Prior to notifying the physician the nurse will make detailed observations and gather relevant and pertinent information for the provider. 9. If a significant change in condition occurs a comprehensive assessment of the resident's condition will be conducted. The facility administrator, facility DON, clinical services director, and regional vice president were notified on [DATE] at 11:29 a.m. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided at this time. The facility's plan of removal was accepted on [DATE] at 4:14 pm and included: [Facility's Name] submits the following Plan of Removal for the alleged failure to notify the physician. By submitting this plan of removal [facility name] does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? Resident with alleged deficient practice was discharged to hospital on [DATE]. How were other residents at risk to be affected by this deficient practice identified? Nursing staff completed an audit on all diagnostics and radiology orders for residents residing in the facility on [DATE]. Residents that have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff audited the 72 hours Summary Report for residents residing in the facility on [DATE] for any changes in condition. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? In-service completed on [DATE] by the CSD with DON and Administrator on reviewing orders in clinical meeting and ensure orders are carried out as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In-service complete on [DATE] by the CSD with DON and Administrator on reviewing all changes in condition in clinical meeting and ensure nursing staff completes timely SBAR on all changes in condition and notifies the physician of the change in condition. Nursing Managers immediately completed an audit of diagnostics and radiology orders for residents residing in the facility on [DATE]. No discrepancies were identified. On [DATE] the DON completed a 1:1 in-service with licensed nursing staff regarding following physician orders, scheduling appointments and effective communication to the physician/DON when unable to schedule radiology or diagnostic tests on the dates ordered by physician. CSD in-serviced DON on [DATE] on the order listing report to be reviewed during the clinical meeting and all diagnostics or radiology orders. DON or designee will immediately report to physician for further guidance when facility experiences delay in scheduling the diagnostic/radiology testing orders or if the diagnostic/radiology order is not completed. DON initiated an in-service on [DATE] with the licensed nursing staff on documentation of changes in condition using the comprehensive assessment SBAR Form and notification to the physician of the findings from the comprehensive assessment. Newly hired licensed nurses will be in-serviced during the orientation process regarding following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Newly hired licensed nursing staff will be trained during the orientation process on completing the SBAR when a change in condition is identified and physician notification of comprehensive assessment. How will the system be monitored to ensure compliance? Facility will print the Order Listing Report Monday through Friday to identify any new orders for diagnostic/radiology services. During the morning clinical meeting the Diagnostic/Radiology Form and Order listing report will be reviewed by DON and Administrator to ensure diagnostic/radiology orders are completed as per physician orders. If unable to complete as ordered, review documentation for physician notification and any new orders received. The Weekend Clinical Supervisor will print the Order Listing Report Saturday and Sunday to identify any new orders for diagnostic/radiology services. If unable to complete as ordered, review documentation for physician notification and any new orders received. DON and Administrator will review changes in condition during clinical meeting to ensure needed care and services are provided and physician notification is evident. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. On [DATE], the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: The facility completed an audit on all radiology and diagnostic orders in the facility. Record review of audit form titled Diagnostic Monitoring Sheet indicated 6 residents with diagnostic tests ordered, date completed and physician notification. The facility initiated a new system to include printing order listing report, weekend supervisor roles for identifying any new orders, and review of changes in condition during the clinical meeting. Training included in-services on reviewing orders in clinical meeting daily to ensure orders are carried out, reviewing changes in condition in clinical meeting, following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . All staff were able to correctly answer these questions. The staff in- serviced included: 16 licensed vocational nurses, 4 registered nurses, DON, and administrator. Eleven (11) licensed vocational nurses, 2 registered nurses, DON and Administrator were interviewed, from different shifts, on training and new system to ensure compliance. All staff were able to verbalize understanding of in-service training regarding radiology and diagnostic orders, scheduling appointments, and communication with physician. As well as documentation of changes in condition using the SBAR form and notification of findings to physician. On [DATE] at 12:00 pm, the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate with a scope identified as isolated. The facility needs to ensure in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure that all alleged violations involving sexual abuse are reported immediately or not later than 2 hours for 1 of 5 residents reviewed for abuse and neglect (Resident #14). Resident #14 made an outcry of sexual assault on 8/8/22 to LVN K. LVN K failed to immediately notify the abuse coordinator (ADMIN) and the facility failed to report this until state surveyor intervention on 8/16/22. On 8/30/22 at 5:52pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 9/1/22, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could potentially place the resident at risk for further abuse and neglect, mental anguish, withdrawal, depression, and anxiety. Findings included: Record review of face sheet dated 08/16/2022 indicated Resident #14 was a [AGE] year-old female and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS dated [DATE] indicated Resident #14 had a BIMS score of 12, which indicated a mild cognitive impairment. MDS also indicated that resident had been suffering from hallucinations and delusions. Resident was also a 1-person supervision or limited assist for most activities of daily living. Record review of a care plan dated 04/07/2022 indicated Resident #14 had impaired cognitive function related to dementia, multiple med use, aging, and pain. Record review of a face sheet 9/8/22 revealed that Resident #8 was a [AGE] year-old female originally admitted to the facility on [DATE], with readmission on 12/7/19, and subsequent readmission on 8/29/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a quarterly MDS dated [DATE] revealed that resident #8 had a BIMS score of 7, indicating severe cognitive impairment. Record review of nurse's note in the electronic chart for Resident #14 dated 08/08/2022 at 01:50pm revealed, Nurse received call from Police Department stating that this patient had called them telling them that ADON had just left her room raping her and her roommate (Resident #8). Nurse went down to patient room, along with a CNA as a witness. Patient had door blocked with nightstand and bathroom door. Staff was able to get into room and patient started using foul language stating that ADON was fired but he just left her room molesting her and her roommate. Nurse notified DON, SW, and RP of situation. RP stated that she's sorry and will be by later to speak with patient about behaviors. Nurses note was signed by LVN K. An interview with LVN K on 08/16/22 at 11:26 AM, she stated that she received report from the previous shift nurse, stating that she told her resident had called 911 during the night shift stating that resident claimed she was raped over the weekend. The Police Department called facility asking nurse to check on her, resident had room barricaded, resident would not let staff in room, stated that ADON had raped her and her roommate. LVN K stated that she told DON and SW, while they were sitting in SW office, and called family member. The family member was aware that resident was calling 911. She stated that she told SW, and DON, that resident had called 911 stating ADON had raped her. She stated that she could not remember if ADON worked that weekend. She stated that she told Dr. office that resident had made an allegation of rape. The MD's nurse stated that she would let MD know. During an interview on 8/16/22 at 11:50am with Resident #8 (Resident #14's roommate) revealed that she was very comfortable in this facility and had never had any staff be mean or abusive towards her. Stated that she felt very safe here and denied any sexual assault ever happening to her. In an interview with Resident #14 on 8/16/22 at 11:55am, she stated that staff have never been abusive to her, but that sometimes they could be rude. She stated that she does not want to talk to surveyor because people were listening to her through the phone and that they watch her on cameras. She also, stated that someone might be listening through the water faucet. Resident #14 denied any allegation of sexual assault. In an interview with ADMIN on 08/16/22 at 10:28 AM, she was asked about incident concerning Resident #14 on 8/8/22, and she said that she was not aware of those allegations being made. ADMIN then said that she was aware that she was having some kind of behaviors related to her confusion and dementia, but had no idea that sexual assault allegations were made. She also said that she was aware that it was a reportable incident. In an interview with the DON on 8/16/22 at 10:49am, she said that she was not informed of the allegation of sexual assault happening, that she was on vacation at the time, and that when she returned on Monday (8/8/22), she had overheard ADON and other staff discussing the allegation of sexual assault. She said she assumed that incident had already been investigated and reported. She said that Resident #14 had been newly diagnosed with dementia. She said that SW had been trying to get her inpatient help at behavioral facility, but that resident was refusing counseling. She was only aware of Resident #14 blocking the door. She said that Resident #14 had recently been taken off the [MEDICATION(S)] patch, and after this incident, she was put back on it. Also said there had been another med change, possibly a couple, but that she couldn't remember what they were at this time. She also said that the administrator did the reporting, but that if she had known it had not been reported, she would have made sure that it was done. In an interview with the SW on 08/16/22 at 10:56am regarding incident with Resident #14, she said that Resident #14 had been on the covid unit some time prior to this incident occurring. She also said that Resident #14 had wanted to change rooms and previously thought that she had heard a previous roommate having sex with her boyfriend, but the only visitor that the roommate ever had was her daughter. Resident #14 was adamantly refusing counseling (for behavioral issues), and that day (08/08/22) the resident's granddaughter had told her that she had been taken off one of her medications recently and that she thought it may be affecting her behaviors. The SW stated when she talked to her that afternoon (08/08/22), the resident acted like absolutely nothing was wrong. She said that she offered to try to get her help (counseling, behavioral facility, etc). The SW stated that she was not informed of the allegation of rape, only that the resident had barricaded the door. She stated that resident's visits resident frequently and stated that was the one that made the reports, but that she knew it was a reportable incident. In an interview with ADMIN on 8/16/22 at 1:46pm, she said that incident had now been reported and police had been notified. The police came and talked to resident and her story had changed again. Staff was being in-serviced and some staff had been written up. The ADON had been suspended pending investigation. In an interview with the ADON on 8/16/22 at 4:06pm, he remembered some behaviors occurring over the weekend, and that Resident #14 had barricaded herself in her room. He stated that he had worked that Saturday 8/6/22 on the 2-10 shift and stated that he thought he had given Resident #14 [MEDICATION(S)] prn. He said he doesn't remember Resident #14 ever accusing him of anything before, and unsure of why she accused him. Record review of witness statement signed on 8/16/2022 by LVN K revealed that .The incident was read off at morning meeting in front of all administration staff from 24-hour report sheet by this nurse and staff acknowledged situation and even knew about appointment that Resident #14 had, so I thought this had been reported and handled as it should by the book, so no further action on my part was needed. In an interview on 8/31/22 at 9:40am with LVN K about her witness statement, she said that she had read the report off in the morning meeting the next morning 8/9/22, and that she remembered that Rehab director, treatment nurse, SW, DON, and ADMIN attended that meeting where she read off her 24-hour report about the incident on 8/8/22 with Resident #14. She cannot remember if ADON was in attendance or not. Record review of police record dated 8/16/22 revealed that .complainant [ADMIN] stated that a tenant (resident #14) had made an outcry of sexual assault. Made contact with resident #14 who stated that she was not assaulted. Well documented mental health history including Alzheimer's and dementia. Resident #14 is also beginning to develop hallucinations. No report. Record review of witness statement dated 8/23/22 and signed by DON, stated On 8/8/22, I returned from vacation and walked into the conference room with several people talking about [Resident #14] stating that she had been raped. [DON] asked when that happened, and they stated, over the weekend. [DON] assumed this had been addressed since they were talking about it. Around lunch time on the 8/8/22, LVN K came to SW office & [DON] was present stating that Resident #14 had barricaded the door and called 911. SW notified, family, MD, and [behavioral facility]. In an interview with the DON on 8/31/22 at 10:01am, she stated that her dates of vacation were 7/29/22 through 8/8/22. She stated that she was in the facility on 8/8/22. In an interview with the ADON on 8/31/22 at 12:15pm, he indicated that ADMIN was the abuse coordinator and when she was not here, that would take responsibility. In an interview with ADMIN on 8/31/22 at 12:30pm regarding normal procedures regarding allegations of sexual abuse, she stated that normally an investigation would be initiated, and anyone accused would be suspended pending investigation. Once the investigation was started, she would make sure that the resident was ok, get as many details as possible, notify the police, and get witness statements. She said that if these procedures were not followed, it could place the resident at risk of further abuse. She also said that her expectations for her staff was that all abuse/neglect allegations would be reported immediately or no later than 2 hours, whether they believed the allegations were true or not. If they did not report immediately as expected, then disciplinary action would occur. She stated that to her recollection LVN K did not read off the report of sexual allegations in the morning meeting on 8/9/22. She stated that in her absence, such as vacation, that DON would take over abuse coordinator responsibilities. Record review of a facility policy titled Reporting suspected cases and/or incidents of rape, dated 2001, with revision date of December 2006 stated, .The following action must be taken in cases of suspected/actual rape: .Verbally notify the proper authorities (e.g., police, Attending Physician, resident's representative (sponsor), state survey and certification agency, and others as may be necessary). Record review of facility policy titled Abuse Investigation and Reporting dated 2001 with revision date of July 2017, stated .An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a) two hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b) twenty-four hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . The facility administrator was notified on 8/31/2022 at 08:52 a.m. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided at 09:13 a.m. The facility's plan of removal was accepted on 8/31/2022 at 4:37 PM and included: What corrective actions have been implemented for the identified residents? Resident with alleged violation was assessed by SW on 8/16/22. Resident denied any sexual misconduct and was calm. Licensed nurse conducted a head-to-toe assessment on 8/16/22 with no abnormal findings. On 8/16/22 LVN K received a 1:1 training on allegations of abuse and reporting to the abuse coordinator. ADON was immediately suspended on 8/16/22. Facility self-reported alleged allegation to HHS on 8/16/22. How were other residents at risk to be affected by this deficient practice identified? Nursing staff and Administrator audited the 72 hours Summary Report and grievances for all residents residing in the facility on 8/16/22 for any reported allegations, none identified. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? In-service completed by Clinical Services Director on 8/16/22 with DON on Abuse and Neglect and reporting to abuse coordinator allegations. Administrator in-serviced by Regional Vice President on 8/16/22 on Abuse and Neglect and reporting guidelines. On 8/16/22 the Administrator initiated an in-service with all facility staff regarding Abuse and Neglect and immediately reporting allegations to abuse coordinator. The Administrator will report the allegation immediately or within 2 hours to the appropriate state agencies. Residents alleging abuse will be assessed immediately by the licensed nurse. This was completed on 8/18/22. Newly hired staff will be in-serviced during the orientation process regarding Abuse and Neglect and reporting allegations to abuse coordinator. How will the system be monitored to ensure compliance? All grievances and abuse and/or neglect allegations will be reported to the administrator by staff, In-service initiated by Administrator with all staff on 8/16/22 and completed on 8/18/22. All allegations of abuse or neglect will be reported immediately or within 2 hours of the allegations by Administrator to the appropriate state agencies, in-service completed with Administrator on 8/16/22 by Regional Vice President. Grievance Log and 24-Hour Summary Report will be monitored daily by Administrator/Designee to ensure any abuse or neglect allegations are identified and reported as per state guidelines. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of was completed on failure to report abuse allegations on 8/16/22 with the Medical Director. The Medical Director has reviewed and agrees with this plan. On 09/01/2022, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During interviews on 9/1/22, twenty-eight (28) staff members, along with DON and Administrator were interviewed, from different shifts, and different departments (housekeeping, dietary, nursing, and administration) on training and new system to ensure compliance. All staff were able to verbalize understanding of in-service training regarding when to report allegations of abuse/neglect, to whom to report allegations, all were able to verbalize who the abuse coordinator is, and where to find the number for the abuse coordinator. Record review of in-services dated 8/18/22 revealed that all staff were trained on reporting abuse/neglect, to immediately report all allegations of abuse/neglect immediately or no later than 2 hours of any allegations. Allegations included: resident saying it happened, suspicion of abuse occurring (evidence supported), and confirmed or witnessed allegations of abuse. Training included that abuse coordinator is administrator, and backup is DON. Phone numbers are located in glass case at nurse's station. Record review of QAPI minutes dated 8/17/22 revealed that facility identified a problem of failure to report allegations of abuse/neglect within two (2) hours to abuse coordinator/designee. Also revealed that the goal was for all staff to immediately, or no later than 2 hours, report any and all allegations of abuse/neglect to abuse coordinator/designee. One on one in-service trainings were held with SW, ADON, MDS, AND LNFA regarding abuse/neglect Policy and Procedure and reporting criteria. In an interview with the DON on 9/1/22 11:05am, she stated that she did one on one training with her regional and corporate nurses. She said that should this happen again, she would not assume that it had been taken care of but would get with to make sure that it had been reported. She said that she expects her staff to report any allegations immediately, no matter whether they think it happened or not, that it still must be reported. She said that her nurses were to do complete head to toe assessment if allegations were made, and going forward, any allegations of rape will be reported, and resident will be sent to ER. She was asked why dementia residents were considered more vulnerable to abuse than other residents and she said that dementia patients were more vulnerable to abuse because they think no one will believe them. In an interview with the Administrator on 9/1/22 at 11:20 am she was asked about her training, and she said that her training was over reporting abuse and neglect allegations. She said that they went over the abuse and neglect, the 2-hour time frame, and reporting allegations whether they believe it occurred or not. She said that training included assessment of the resident, notifying the police department, interviewing the resident, determining if there are any witnesses that could confirm or contribute to incident, notifying the family, physician, ombudsman, assessing patients mental and emotional status. She also said that the resident should be transferred to hospital for rape assessment if allegations are related to sexual assault. She said that she will expect her staff to immediately report to her no matter the date or time, and to ensure resident safety. She said that she expects staff to call and not text with serious situations. She said that she will ensure investigations occur no matter the allegations and will initiate investigations herself. The Administrator was now reviewing nurse notes and order listing report, morning meeting is now more structured, so nothing gets missed. She verbalized that dementia residents were more vulnerable because they were less likely to be believed, and that this could lead to further harm to resident. The [ADMIN] was informed the Immediate Jeopardy was removed on 9/01/2022 at 11:45AM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review the facility failed to ensure that all alleged violations involving sexual abuse are thoroughly investigated for 1 of 5 residents (Resident #14) reviewed for abuse and neglect. Resident #14 made an outcry of sexual assault on 8/8/22 to LVN K. The facility failed to investigate sexual assault allegation until state surveyor intervention on 8/16/22. This failure resulted in Resident #14 not being assessed for actual signs of sexual assault, and also in the ADON being allowed to work for 8 days after allegation was made allowing him continued access to resident. On 8/30/22 at 5:52pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 9/1/22, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents alleging abuse at risk for further abuse and neglect, mental anguish, withdrawal, depression, and anxiety. Findings included: Record review of face sheet dated 08/16/2022 indicated Resident #14 was a [AGE] year-old female and admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS dated [DATE] indicated Resident #14 had a BIMS score of 12, which indicates a mild cognitive impairment. Record review of a care plan dated 04/07/2022 indicated Resident #14 had impaired cognitive function related to dementia, multiple med use, aging, and pain. Record review of a face sheet 9/8/22 revealed that Resident #8 was a [AGE] year-old female originally admitted to the facility on [DATE], with readmission on 12/7/19, and subsequent readmission on 8/29/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a quarterly MDS dated [DATE] revealed that resident #8 had a BIMS score of 7, indicating severe cognitive impairment. Record review of nurse's note in the electronic chart for Resident #14 dated 08/08/2022 at 01:50pm revealed, Nurse received call from Police Department stating that this patient had called them telling them that ADON had just left her room raping her and her roommate (Resident #8). Nurse went down to patient room, along with a CNA as a witness. Patient had door blocked with nightstand and bathroom door. Staff was able to get into room and patient started using foul language stating that ADON was fired but he just left her room molesting her and her roommate. Nurse notified DON, SW, and RP of situation. RP stated that she's sorry and will be by later to speak with patient about behaviors. Nurses note was signed by LVN K. In an interview with administrator on 08/16/22 at 10:28 AM she was asked about incident concerning Resident #14 on 8/8/22, and she said that she was not aware of those allegations being made. Administrator said that she was aware that she was having some behaviors but no idea that sexual assault allegations were made. She also said that she was aware that it was a reportable incident. An interview with LVN K on 08/16/22 at 11:26 AM, she said that she received report from the previous shift nurse, stating that nurse told her resident #14 had called 911 during the night shift saying that resident claimed she had been raped over the weekend. The Police Department called facility asking nurse to check on her, resident had room barricaded, resident would not let staff in room, saying that ADON had raped her and her roommate. LVN K stated that she told DON and SW, while they were sitting in SW office, and called granddaughter. Granddaughter was aware that resident was calling 911. Stated that she told SW, and DON, that resident had called 911 stating ADON had raped her. Stated that she could not remember if ADON worked that weekend. Stated that she told Dr. office that resident had made an allegation of rape. MD's nurse stated that she would let MD know. Appointment was made for next day with MD. During an interview on 8/16/22 at 11:50am with Resident #8 (Resident #14's roommate) revealed Resident #8 stated that she was very comfortable in this facility and had never had any staff be mean or abusive towards her. Stated that she felt very safe here. Denied any allegations of sexual assault happening to her. In an interview with Resident #14 on 8/16/22 at 11:55am, she stated that staff have never been abusive to her, but that sometimes they could be rude. States that she did not want to talk to surveyor because people were listening to her through the phone and that they were watching her on cameras. Also stated that someone might be listening through the water faucet. Resident #14 denied any allegations at this time of sexual assault by ADON. In an interview with DON on 8/16/22 at 10:49am, she stated that she was not informed of event happening, that she was on vacation at the time, and that when she returned on Monday (8/8/22), she overheard ADON and other staff discussing it. She assumed that incident had already been investigated and reported. Stated that resident had been newly diagnosed with dementia. Stated that SW had been trying to get her inpatient help at behavioral facility, but that resident was refusing counseling. She was only aware of the resident blocking the door. Stated that resident had recently been taken off the [MEDICATION(S)] patch, and after this incident, she was put back on it. Also stated there had been another med change, possibly a couple, but that she couldn't remember what they were at this time. Said there had not been a sexual assault examination done on Resident #14 after allegations made. Stated that the administrator did the reporting, but that if she had known it had not been reported, she would have made sure that it was reported and an investigation began by ADMIN. In an interview with SW on 8/16/22 at 10:56am, regarding incident with Resident #14, stated that resident had been on covid unit some time prior to this incident occurring, and stated that she had wanted to change rooms, and previously thought that she had heard a previous roommate having sex with her husband, but the only visitor that the roommate ever had was her daughter. Resident #14 was adamantly refusing counseling, and that particular day (8/8/22) her granddaughter had told her that she had been taken off one of her meds recently and that she thought it may be affecting her behaviors. SW stated when she talked to her that afternoon, resident acted like absolutely nothing was wrong, she offered to try to get her help (counseling, behavioral facility, etc). Stated that she was not informed of the allegation of rape, only that the resident had barricaded the door. Stated that resident's granddaughter visits resident frequently and stated that was the one that made the reports, but that she knew it was a reportable incident and should be investigated. In an interview with ADMIN on 8/16/22 at 1:46pm, she stated that incident had now been reported and police had been notified, they came and talked to resident and her story had changed again. Staff was being in-serviced and some staff had been written up. ADON had been suspended pending investigation. Investigation began on 8/16/22. In an interview with ADON on 8/16/22 at 4:06pm, he remembered behaviors occurring over the weekend, and that she had barricaded herself in her room. He stated that he had worked that Saturday 8/6/22 on the 2-10 shift and stated that he thought he had given her [MEDICATION(S)] prn. Doesn't remember her ever accusing him of anything before, and unsure of why she accused him. Record review of witness statement dated 8/16/22 and signed by LVN K revealed that .The incident was read off at morning meeting in front of all administration staff from 24-hour report sheet by this nurse and staff acknowledged situation and even knew about appointment that resident #14 had, so I thought this had been reported and handled as it should by the book, so no further action on my part was needed. Record review of police record dated 8/16/22 revealed that .complainant [ADMIN name] stated that a tenant (resident #14) had made an outcry of sexual assault. Made contact with resident #14 who stated that she was not assaulted. Well documented mental health history including Alzheimer's and dementia. [Resident #14] is also beginning to develop hallucinations. No report. In an interview with ADON on 8/31/22 at 9:20am, ADON stated that he worked on 8/6/22 on the 2-10 shift, and he was off Sunday 8/7/22. Stated he worked 8/9/22 through 8/11/22 and was off on 8/12/22. Stated that he returned to work on 8/15/22 and 8/16/22 he was working that day until he was suspended pending investigation. He returned to work on 8/18/22, 2 days after suspension after facility investigation and training on reporting guidelines. Record review of a facility policy titled Protection of Residents During Abuse Investigations, dated 2001, with revision date of December, 2006 stated .During abuse investigations, residents will be protected from harm by the following measures: a) employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator . Record review of facility policy titled Abuse Investigation and Reporting dated 2001 with revision date of July 2017, stated .All reports of resident abuse, neglect, exploitation, misappropriation or resident property, mistreatment and/or injuries of unknown source (abuse) shall be .thoroughly investigated by facility management . The facility administrator was notified on 8/31/2022 at 08:52 a.m. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided at 09:13 a.m. The facility's plan of removal was accepted on 8/31/2022 at 4:37 pm and included: [Facility name] submits the following Plan of Removal for the alleged failure to investigate allegations of sexual abuse. By submitting this plan of removal [facility name] does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? Resident with alleged violation was assessed by SW on 8/16/22. Resident denied any sexual misconduct and was calm during interview. Licensed nurse conducted a head-to-toe assessment on 8/16/22 with no abnormal findings. On 8/16/22 LVN K received a 1:1 training on allegations of abuse and reporting to the abuse coordinator. ADON was immediately suspended on 8/16/22. Police was notified of alleged violation on 8/16/22 and completed on site investigation. Facility self-reported alleged allegation to HHS on 8/16/22. How were other residents at risk to be affected by this deficient practice identified? Nursing staff and Administrator audited the 72 hours Summary Report and grievances for all residents residing in the facility on 8/16/22 for any reported sexual allegations, none identified. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? In-service completed by the Clinical Services Director on 8/16/22 with DON on abuse allegations, reporting and investigating. Administrator in-serviced by the Regional Vice President on 8/16/22 on abuse allegation protocol for reporting and investigating abuse allegations per state guidelines. On 8/16/22 the Administrator initiated an in-service with all facility staff regarding Abuse and Neglect and immediately reporting allegations to abuse coordinator. The Administrator will report the allegation immediately or within 2 hours to the appropriate state agencies. Residents alleging abuse will be assessed immediately by the licensed nurse. This was completed on 8/18/22. Newly hired staff will be in-serviced during the orientation process regarding abuse allegations and reporting allegations immediately to abuse coordinator. How will the system be monitored to ensure compliance? All grievances and abuse allegations will be reported to the administrator by staff, In-service initiated by the Administrator with staff on 8/16/22 and completed on 8/18/22. The Administrator and designee(s) will immediately begin an investigation. All allegations of abuse will be investigated and reported per state guidelines by Administrator, in-service completed with Administrator on 8/16/22 by the Regional Vice President. Grievance Log and 24-Hour Summary Report will be monitored daily by Administrator/Designee to ensure abuse allegations are identified, reported and investigated as per state guidelines. The Administrator, DNS and/or Designee will review abuse allegations to the QAPI committee monthly. Any concerns or recommendations will be addressed immediately. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of was completed on failure to report abuse allegations on 8/16/22 with the Medical Director. The Medical Director has reviewed and agrees with this plan. On 09/01/2022, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Nine (9) nurses from different shifts, eight (8) LVN's and one (1) RN were interviewed on 9/1/22, along with DON and ADMIN on training and new system to ensure compliance. All staff were able to verbalize understanding of in-service training regarding investigating, and communication with abuse coordinator, and physician, as well as transferring resident out to emergency room for sexual assault assessment. All nurses interviewed were able to verbalize importance of assessment of resident involving all allegations of abuse or neglect and were able to verbalize that resident should be sent out for sexual assault assessment if allegations involved sexual assault. In an interview with the DON on 9/1/22 11:05am, she stated that she did one on one training with her regional and corporate nurses. She said that her nurses were to do complete head to toe assessment if allegations were made, and going forward, any allegations of rape will be reported to the abuse coordinator, and resident will be sent to ER. She was asked why dementia residents were considered more vulnerable to abuse than other residents and she said that dementia patients were more vulnerable to abuse because they think no one will believe them. In an interview with the Administrator on 9/1/22 at 11:20 am she was asked about her training. She said that training included assessment of the resident, notifying the police department, interviewing the resident, determining if there are any witnesses that could confirm or contribute to incident, notifying the family, physician, ombudsman, assessing patients mental and emotional status. She also said that the resident should be transferred to hospital for rape assessment if allegations were related to sexual assault. She said that she will ensure investigations occur no matter the allegations and will initiate investigations herself. Administrator was now reviewing nurse notes and order listing report, morning meeting was now more structured, so nothing gets missed. Before many people may be talking at once or multitasking. No more than one person allowed to talk at once now, and no multitasking during meetings. She verbalized that dementia residents were more vulnerable because they were less likely to be believed, and that this could lead to further harm to resident. Record review of QAPI minutes dated 8/17/22 reveal that facility identified a problem of failure to report allegations of abuse/neglect within two (2) hours to abuse coordinator/designee. Also reveals that the goal was for all staff to immediately, or no later than 2 hours, report any and all allegations of abuse/neglect to abuse coordinator/designee. One on one in-service trainings were held with SW, ADON, MDS, AND LNFA regarding abuse/neglect Policy and Procedure and reporting criteria. On 9/1/22 at 11:45 am, the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm that is not immediate with a scope identified as isolated. The facility needs to ensure in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and provide ongoing clinical assessment and identification of changes in condition for 1 of 7 Residents (Resident #174) reviewed for treatment and services. The facility did not follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician ordered a CT scan, and it was not completed as ordered on [DATE]. Resident #174's condition declined, and facility staff did not complete a comprehensive assessment. The resident was hospitalized for a subdural hematoma on [DATE] and later died in the hospital on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. This failure could result in the residents not receiving urgent medical care and could result in death. Findings: Record review of facility face sheet dated [DATE] indicated Resident #174 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE] with completion date of [DATE] for Resident #174 indicated she had severe cognitive impairment, required extensive assistance of 1 person for walking, dressing, eating, toileting, bed mobility, transfers, and personal hygiene. Record review of care plan with a revision date of [DATE] indicated Resident #174 had anxiety and agitation, was taking [CONDITION(S)] medications, was a high risk for falls related to dementia with falls recorded on [DATE], [DATE], [DATE] and [DATE] resulting in a hematoma (solid swelling of blood under skin) to the left side of face. Care plan also indicated to report any changes or delayed healing to primary care physician. Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of nurses note dated [DATE] completed by LVN D stated Resident #174's RP reported her family member had been experiencing repeated headaches on the left side of her head every time she sits up. PCP notified and he ordered a CT scan to be completed on [DATE]. RP indicated headaches had been occurring for about a week every time she sits up. Record review of nurses note dated [DATE] completed by LVN E stated Resident #174 was noted by family to not be communicating with staff and family at bedside. All vitals are normal. Family stated that her behavior is abnormal to them. Staff has noted darker urine when resident voids and stronger odor. PCP was notified. Pending orders currently. Record review of nurses note dated [DATE] stated a UA with C&S was sent to primary care physician. New order given to start [MEDICATION(S)] (antibiotic for infection) 100mg by mouth two times a day for 7 days. Record review of medication administration note dated [DATE] indicated resident #174 refused medication, had clenching of her teeth and her body became rigid during medication administration. LVN F was notified by CMA L. There is no evidence in nurses note that LVN F assessed resident following notification or that physician was notified. Record review of SW notes dated [DATE] indicated the CT Scan had been scheduled for [DATE] [CT Scan ordered by physician on [DATE] to be completed [DATE]]. Record review of nurses note dated [DATE] completed by LVN M indicated Resident #174 was not eating, drinking, and not responding when spoken to. PCP and family notified and per family request she was sent to the emergency room for treatment. Record review of hospital History and Physical dated [DATE] indicated Resident #174 was admitted to the ICU after 2 days of altered mental status and had a subdural hematoma with midline shift (movement of brain) that was approximately 3 weeks old. Resident #174 required a craniotomy (brain surgery). Record review of hospital discharge summary dated [DATE] indicated Resident #174 was terminally extubated (breathing tube removed from lungs) and was pronounced dead on [DATE] at 5:37 PM. Record review of Resident #174's medical record from [DATE] to [DATE] indicated there had been no comprehensive assessment completed on [DATE] or at any time afterwards due to significant change in condition. There was no evidence in the medical record the facility contacted the PCP that the CT Scan was not obtained on [DATE]. During an interview on [DATE] at 2:32 PM LVN D stated he had received an order from Resident #174's PCP for a CT Scan due to altered mental status and headaches on [DATE]. PCP did not order CT Scan to be completed STAT or feel need for ER visit. LVN D let the scheduler know to obtain it outpatient on [DATE]. Resident #174's headaches were positional (worsened when changing positions). Tylenol was administered but don't think it helped any, but he stated, I can't remember. LVN D stated he had been a LVN for 9 months and employed at the facility during that time. Stated he had some training on reporting change in condition but not much. Record review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 3:55 PM CNA G stated she was responsible for scheduling appointments and transporting residents. She could not remember the full details of the appointment for Resident #174. During an interview on [DATE] at 3:30 PM the DON stated the CT Scan was not ordered stat on [DATE]. She did not think it was urgent. She was unaware Resident #174 had a change in condition until she was sent to the hospital. She stated with a change in condition each resident is to be assessed and the physician is to be notified. She stated the nurses are responsible for identifying changes and reporting to the doctor. During interview on [DATE] at 3:45 pm the ADM stated the doctor's order for Resident #174 stated tomorrow ([DATE]), but there was no urgency noted to the order. When the CT Scan was not done, she did not think anything of it. We were working on getting it scheduled and days went by and finally the SW took over getting it scheduled. She stated the facility failed to recognize the urgency of the CT Scan and that the physician should have been notified of the change in condition and that the CT Scan was done completed as ordered. During an interview on [DATE] at 4:20 PM PCP stated he ordered a CT Scan on [DATE] for Resident #174 because of positional headaches. He approved it being done the next day because he was told the family requested to not send her to the ER. He was never made aware the CT Scan was not done until Resident #174 went to the hospital on [DATE] with a subdural hematoma. He stated there was no communication from the facility to him regarding the CT Scan not being done or that she was having other changes in condition. He stated had he known it was not scheduled he would have ordered for her to go to the ER. During an interview on [DATE] at 4:52 PM LVN E stated on [DATE] Resident #174 was in the dining room with family. Family stated she was not normal. She checked her vital signs, and they were normal. She contacted the PCP, and he ordered a UA. She had an [CONDITION(S)], and PCP ordered antibiotics. She was not aware Resident #174 had a fall a few weeks ago and needed a CT Scan. She stated communication is placed on the 24-hour report for any changes and procedures that need to be done. She did not know who is responsible for checking the report or what was on the report at that time. Record review of 24-hour report dated [DATE] indicated UA to be collected and waiting on CT Scan to be scheduled. During a phone interview on [DATE] at 7:52 AM Resident #174's RP stated Resident #174 fell on [DATE] and it was a bad fall. She came that evening to see her family member and she had visible bruising to her face. The charge nurse told her the doctor had been notified and said to just watch her. She didn't think anything about it as she is not a medical person. A week or so went by (approximately [DATE]) and Resident #174 was having headaches every day. Resident #174 would hold the left side of her head and say it hurts. She told the nurse on shift, and they would give her medicine. She stated, I didn't really think it was anything, but by the third day she knew something was wrong. On [DATE] LVN D called the doctor, and he ordered a CT Scan. She thought they were going to take her that night, but LVN D came back about 30 minutes later and stated the doctor said it could wait until the next day. She asked the nurses every day for a week about the CT Scan and was told they were working on getting it scheduled. Her condition stayed the same with headaches and pain, but then she started not being as awake. The facility obtained a urinalysis. She was told her family member had a bad urinary tract infection and placed her in isolation. After that she began to not talk or make eye contact. She would just turn her head from side to side. This lasted for several days. When she asked, she was told it was probably just the bacteria infection. Then a few more days passed, then was called by the nurse, and told her family member was going to the ER. She saw her family member at the ER, and she was awake but unresponsive. She went to surgery and later died at the hospital. During an interview on [DATE] at 1:25 pm the DON stated with a change in condition the nurse or aide is to enter the change of condition in the computer and alerts can be seen by management staff as well. I am responsible for making sure alerts are addressed and followed up on. All nursing staff have been trained on notification of change and the risk to resident care could vary depending on severity of the change. She expects that all nursing staff are assessing a resident change in condition and making sure that it is addressed with the PCP. During an interview on [DATE] LVN F stated she had been a nurse for [AGE] years and employed at the facility almost a year. She stated she did not remember the details of Resident #174 but did take care of her during the time after she fell . She stated it had been a while since receiving training on a comprehensive assessment of a resident with a change in condition and how to report effectively to the PCP. The risk to residents could be significant to resident wellbeing. Review of facility policy titled, Change in a Resident's Condition or status dated [DATE] indicated, .1.the nurse will notify the resident's attending physician when there has been a significant change in condition. 3. Prior to notifying the physician the nurse will make detailed observations and gather relevant and pertinent information for the provider. 9. If a significant change in condition occurs a comprehensive assessment of the resident's condition will be conducted. During interview on [DATE] at 3:45 pm the ADM stated the facility did not have a specific policy for radiology or diagnostic orders. The facility administrator, facility DON, clinical services director, and regional vice president were notified on [DATE] at 11:29 am that an Immediate Jeopardy situation had been identified due to the above failures. IJ template given at this time. The facility's plan of removal was accepted on [DATE] at 4:14 pm and included: [Facility's name] submits the following Plan of Removal for the alleged failure to identify and provide needed care and services after a change in condition. By submitting this plan of removal [facility name] does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? Resident with alleged deficient practice was discharged to hospital on [DATE]. How were other residents at risk to be affected by this deficient practice identified? Nursing staff completed audit on all diagnostics and radiology orders for all residents residing in the facility on [DATE]. All residents that have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff audited the 72 hours Summary Report for all residents residing in the facility on [DATE] for any changes in condition, none identified. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? In-service completed by CSD on [DATE] with DON and Administrator on reviewing orders in clinical meeting daily and ensure orders are carried out as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In-service completed by CSD on [DATE] with DON and Administrator on reviewing changes in condition in clinical meeting and ensure nursing staff completes timely SBAR on changes in condition and notifies the physician of the change in condition. On [DATE] the DON completed a 1:1 in-service with licensed nursing staff regarding following physician orders, scheduling appointments and effective communication to the physician/DON when unable to schedule radiology or diagnostic tests on the dates ordered by physician. CSD in-serviced DON on [DATE] on the order listing report to be reviewed during the clinical meeting to identify new orders for diagnostic and radiology orders. DON/Designee will report to physician immediately for further guidance when facility experiences delay in scheduling the diagnostic/radiology testing orders or if the diagnostic/radiology services cannot be completed. DON initiated an in-service on [DATE] with the licensed nursing staff on documentation of changes in condition using the comprehensive assessment SBAR Form and notification to the physician of the findings from the comprehensive assessment. Newly hired licensed nurses will be in-serviced during the orientation process regarding following physician orders, obtaining diagnostics as ordered and reporting and documenting changes in condition by using facility SBAR Tool. Education will include effective communication with physician/DON and evidence of documentation when unable to complete diagnostic or radiology tests as ordered. Newly hired licensed nursing staff will be trained during the orientation process on completing the SBAR when a change in condition is identified and physician notification of comprehensive assessment. How will the system be monitored to ensure compliance? Facility will print the Order Listing Report Monday through Friday to identify any new orders for diagnostic/radiology services. During the morning clinical meeting the Order listing report will be reviewed by DON and Administrator to ensure diagnostic/radiology orders are completed as per physician orders. If unable to complete as ordered, review documentation for physician notification and any new orders received. The Weekend Clinical Supervisor will print the Order Listing Report Saturday and Sunday to identify any new orders for diagnostic/radiology services. If unable to complete as ordered, review documentation for physician notification and any new orders received. DON and Administrator will review changes in condition during clinical meeting to ensure needed care and services are provided and physician notification is evident. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. On [DATE], the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: On record review the facility completed an audit on all radiology and diagnostic orders in the facility. Facility document titled Diagnostic Monitoring Sheet indicated 6 residents had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility initiated a new system to include printing order listing report, weekend supervisor roles for identifying any new orders, and review of changes in condition during the clinical meeting. Training included in-services on reviewing orders in clinical meeting daily to ensure orders are carried out, reviewing changes in condition in clinical meeting, following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . All staff were able to correctly answer these questions. The staff in- serviced included: 16 licensed vocational nurses, 4 registered nurses, DON, and administrator. Eleven (11) licensed vocational nurses, 2 registered nurses, DON, and Administrator were interviewed, from different shifts, on training and new system to ensure compliance. All staff were able to verbalize understanding of in-service training regarding radiology and diagnostic orders, scheduling appointment, and communication with physician. As well as documentation of changes in condition using the SBAR form and notification of findings to physician. On [DATE] at 12:00 pm, the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate with a scope identified as isolated. The facility needs to ensure in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for 1 of 7 residents (Resident #174) reviewed for radiology services. The facility did not obtain an ordered CT scan on [DATE] per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated. This failure resulted in delayed diagnosis, medical treatment, and death. Findings included: Record review of facility face sheet dated [DATE] indicated Resident #174 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE] with completion date of [DATE] for Resident #174 indicated she had severe cognitive impairment, required extensive assistance of 1 person for walking, dressing, eating, toileting, bed mobility, transfers, and personal hygiene. Record review of care plan with a revision date of [DATE] indicated Resident #174 had anxiety and agitation, was taking [CONDITION(S)] medications, was a high risk for falls related to dementia with falls recorded on [DATE], [DATE], [DATE] and [DATE] resulting in a hematoma to the left side of face. Care plan also indicated to report any changes or delayed healing to primary care physician. Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of nurses note dated [DATE] stated Resident #174 RP notified LVN D she had been experiencing repeated headaches on the left side of her head every time she sits up. PCP notified and he ordered a CT scan to be completed on [DATE]. RP indicated headaches had been occurring for about a week every time she sits up. Record review of SW notes dated [DATE] indicated the CT scan had been scheduled for [DATE] (15 days after it was ordered). Record review of nurses note dated [DATE] completed by LVN M indicated Resident #174 was not eating, drinking, and not responding when spoken to. PCP and family notified and per family request she was sent to the emergency room for treatment. Record review of hospital History and Physical dated [DATE] indicated Resident #174 was admitted to the ICU after 2 days altered mental status and had a subdural hematoma with midline shift (movement of brain) and was approximately 3 weeks old. Resident #174 required a craniotomy (brain surgery). Record review of hospital discharge summary dated [DATE] indicated Resident #174 was terminally extubated and was pronounced dead on [DATE] at 5:37 PM. During an interview on [DATE] at 2:32 PM LVN D stated he had received an order from Resident #174's PCP for a CT Scan due to altered mental status and headaches on [DATE]. PCP did not order CT Scan to be completed STAT or feel need for ER visit. LVN D let the scheduler know to obtain it outpatient on [DATE]. Resident #174's headaches were positional (worsened when changing positions). Tylenol was administered but don't think it helped any, but he stated, I can't remember. LVN D stated he had been a LVN for 9 months and employed at the facility during that time. HE stated he had some training on reporting change in condition but not much. During an interview on [DATE] at 3:55 PM CNA G stated she was responsible for scheduling appointments and transporting residents. She could not remember the full details of the appointment for resident #174. During an interview on [DATE] at 3:30 PM the DON stated the CT scan was not ordered stat on [DATE]. She did not think it was urgent. She was unaware Resident #174 had a change in condition until she was sent to the hospital. During interview on [DATE] at 3:45 pm the ADM stated the doctor's order for Resident #174 stated tomorrow ([DATE]), but there was no urgency noted to the order. When the CT scan was not done, she did not think anything of it. We were working on getting it scheduled and days went by and finally the SW took over getting it scheduled. She stated the facility failed to recognize the urgency of the CT scan. It should have been done the day the doctor ordered it and when it was not the doctor should have been notified. During an interview on [DATE] at 4:20 PM PCP stated he ordered a CT scan on [DATE] for Resident #174 because of positional headaches. He did okay it being done the next day because he was told the family requested to not send her to the ER. He was never made aware the CT scan was not done until Resident #174 went to the hospital on [DATE] with a subdural hematoma. He stated there was no communication from the facility to him regarding the CT scan not being done or that she was having other changes in condition. He stated had he known it was not scheduled he would have ordered for her to go to the ER. During an interview on [DATE] at 4:52 PM LVN E stated on [DATE] Resident #174 was in the dining room with family. Family stated she was not normal. She checked her vital signs, and they were normal. She contacted the PCP, and he ordered a UA. She had a [CONDITION(S)], and PCP ordered antibiotics. She was not aware Resident #174 had a fall a few weeks ago and needed a CT scan. She stated communication is placed on the 24-hour report for any changes and procedures that need to be done. She did not know who is responsible for checking the report. During a phone interview on [DATE] at 7:52 AM RP stated her family member fell on [DATE] and it was a bad fall. She came that evening to see her family member and she had visible bruising to her face. The charge nurse told her the doctor had been notified and said to just watch her. She didn't think anything about it as she is not a medical person. A week or so went by (approximately [DATE]) and her family member was having headaches every day. Her family member would hold the left side of her head and say it hurts. She told the nurse on shift, and they would give her medicine. I didn't really think it was anything, but by the third day she knew something was wrong. On [DATE] the LVN D called the doctor, and he ordered a CT scan. She thought they were going to take her that night, but LVN D came back about 30 minutes later and stated the doctor said it could wait until the next day. She asked the nurses every day for a week about the CT scan and was told they were working on getting it scheduled. Her condition stayed the same with headaches and pain, but then started not being as awake. They got a urinalysis and was told she had a bad urinary tract infection and placed her in isolation. After that she began to not talk or make eye contact. She would just turn her head from side to side. This lasted for several days. When she asked, she was told it was probably just the bacteria infection. Then a few more days passed, the facility and was told her family member was going to the ER. She saw her family member at the ER, and she was awake but unresponsive. She went to surgery and later died at the hospital. During interview on [DATE] at 3:45 pm the ADM stated the facility did not have a specific policy for radiology or diagnostic orders. During an interview on [DATE] at 9:12 AM LVN F stated she had been an LVN for [AGE] years and employed with the facility almost a year. She stated communication occurs with the 24-hour report and if something remains on the report for more than 2 days it should be brought to the DON. Often in the past, things would be on the report for long times and even just drop off. If an order is received and specifies a date, then that order should be done on that date. If it is not, then the doctor should be notified along with the DON and family. The risk to residents could be significant to resident wellbeing. The facility administrator, DON, clinical services director, and regional vice president were notified on [DATE] at 11:29 am that an Immediate Jeopardy situation had been identified due to the above failures. IJ template provided at this time. The facility's plan of removal was accepted on [DATE] at 2:07 pm and included: [Facility's name] submits the following Plan of Removal for the alleged failure to provide diagnostic services. By submitting this plan of removal [facility name] does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified resident(s)? Resident with alleged deficient practice was discharged to hospital on [DATE]. How were other residents at risk to be affected by this deficient practice identified? Nursing staff completed audit on all diagnostics and radiology orders for all residents residing in the facility on [DATE]. All residents that have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . What does the facility need to change immediately to keep residents safe and ensure it does not happen again? In-service completed on [DATE] by the CSD with DON and Administrator on reviewing orders in clinical morning meeting and ensure orders are carried out as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing Managers completed immediately an audit on diagnostics and radiology orders for residents residing in the facility on [DATE]. On [DATE] the DON completed a 1:1 in-service with licensed nursing staff regarding following physician orders, scheduling appointments and effective communication when unable to schedule radiology or diagnostic tests on the dates ordered by physician. CSD in-serviced DON on [DATE] on the Order Listing Report to be reviewed at least five times a week and all diagnostics or radiology orders to be tracked on Diagnostic/Radiology Form implemented on [DATE]. Administrator in-serviced by CSD on [DATE] to review the Order listing report, the Radiology/Diagnostic Form to ensure compliance and timely follow up of physician ordered diagnostics during the morning clinical meeting. Newly hired licensed nurses will be in-serviced during the orientation process regarding following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The weekend clinical supervisor will review the Order Listing Report and transcribe diagnostic/radiology orders onto the Diagnostic/Radiology form. The supervisor will review the form to ensure timely follow-up of any pending orders. Any concerns will be communicated to the physician and DON. How will the system be monitored to ensure compliance? Facility will print the Order Listing Report and transcribe diagnostic/radiology test on Diagnostic/Radiology Form. During the morning clinical meeting the Diagnostic/Radiology Form and Order listing report will be reviewed by DON and Administrator to ensure diagnostic/radiology orders are completed as per physician orders. If unable to complete as ordered, review documentation for physician notification and any new orders received. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. On [DATE], the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: The facility completed and audit on all radiology and diagnostic orders in the facility. Record review of audit form titled Diagnostic Monitoring Sheet indicated 6 residents with diagnostic tests ordered, date completed and physician notification. The facility initiated a new system to include printing order listing report, weekend supervisor roles for identifying any new orders, and review of changes in condition during the clinical meeting. Training included in-services on reviewing orders in clinical meeting daily to ensure orders are carried out, reviewing changes in condition in clinical meeting, following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . All staff were able to correctly answer these questions. The staff in- serviced included: 16 licensed vocational nurses, 4 registered nurses, DON, and administrator. Eleven (11) licensed vocational nurses, 2 registered nurses, DON and Administrator were interviewed, from different shifts, on training and new system to ensure compliance. All staff were able to verbalize understanding of in-service training regarding radiology and diagnostic orders, scheduling appointments, and communication with physician. As well as documentation of changes in condition using the SBAR form and notification of findings to physician On [DATE] at 12:00 pm, the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate with a scope identified as isolated. The facility needs to ensure in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse for 1 of 77 residents (Resident #71) reviewed for abuse. The facility failed to protect Resident's #71 from physical abuse from CNA B. This failure resulted in the Resident #71 being physically harmed. Findings included: Record review of an Admission Record for Resident #71 dated 8/17/2022 indicated she admitted on [DATE] and was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #71 did not have any impairment in thinking with a BIMS of 13. She required extensive assistance with bed mobility, transfers, dressing and toilet use. She was totally dependent with bathing and required one person assistance. She was always incontinent of bowel/bladder. Record review of a Care Plan dated 8/12/2022 indicated Resident #71 had a bruise to left dorsal (upper side or back) wrist and left dorsal hand related to transfer. She sustained hematoma (clotted blood in the tissues) to left elbow related to transfer. Interventions included to report abnormalities, failure to heal, signs and symptoms of infection to MD. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Record review of a Care Plan with a revision date of 8/12/2022 for Resident #71 indicated she had an ADL self-care performance deficit related to history of [CONDITION(S)] (stroke) with right dominance. Resident has preference for a specific CNA to complete showers. Sometimes she will refuse or request two CNAs for her shower. Resident's preference changes day to day, shift to shift, and person to person. Interventions included she was totally dependent on 1-2 staff to provide shower 3 times weekly and as necessary. Record review of a facility self-report to the state agency on 8/12/2022 indicated an incident occurred at the facility on 8/12/2022 at 8:30 AM. Resident #71 reported that she was forced to take a shower that morning by CNA B. Resident #71 reported that CNA B told her she needed a bath and started to get her out of the bed to give her a shower. Resident #71 started fighting against CNA B saying that she preferred another CNA. CNA B gave Resident #71 a shower forcefully. Record review of a police report #P22- dated 8/12/2022 indicated at approximately 12:08 PM, an officer responded to the nursing facility after a report was made by the Administrator that Resident #71 made an outcry that CNA B had forced her to take a shower and she sustained an injury. The Administrator advised the officer that CNA B did admit to making Resident #71 take a shower and that she did have to forcer her off the bed. The Administrator stated it was standard practice that CNA's are not to force residents to take a shower if they do not wish to. He then spoke to Resident #71 who said she did not want to take a shower due to her usual CNA not being at work. Resident #71 stated that CNA B then forced her into the shower chair. Resident #71 advised the officer that she held onto the bed with her left arm to prevent CNA B from making her shower. Resident #71 stated after CNA B placed in her the chair there was no further incident. Resident #71 said she possibly sustained the injuries on her arm from trying to hold onto the bed. The officer collected pictures of Resident #71's arms. The officer observed a bruise to the top of her left wrist and a clear bandage on her left elbow that appeared to have bleeding underneath. The officer contacted CNA B that stated she did argue with Resident #71 about showering. CNA B stated Resident #71 then grabbed the bed refusing to go. CNA B advised that she was able to talk Resident #71 into letting go of the bed and going to the shower. Record review of EMR check for CNA B dated on 10/20/2021 indicated no results found and she was employable. Record review of a Criminal history check for CNA B dated on 10/20/2021 indicated no records matching search on the date and time for her. Record review of a NAR for CNA B conducted on 10/20/2021 indicated she had a CNA certification with an expiration date of 6/30/2023. During an observation and interview on 8/15/2022 at 2:23 PM, Resident #71 was lying in bed awake and oriented to person, place, time, and situation. Resident #71 had a contracture to her right hand. Resident #71 was asked about an incident that occurred on 8/12/2022 with a CNA forcing her to take a shower. Resident #71 said that the CNA B told her she was going to take a shower and she told her she was not going to take one with her. Resident #71 said she told the CNA B she wanted CNA C to do it. She said she told her she didn't want her to do anything to her. Resident #71 said CNA B started grabbing her by her arm and she was holding on to the bed frame to avoid her trying to get her out of the bed and each place she grabbed, CNA B would remove her hands. Resident #71 said she received a skin tear on my left elbow because of it. Resident #71 said she immediately reported it to the Administrator, DON, ADON, and the nurse taking care of her arm. Resident #71 also stated that the police were notified. Resident #71 said when CNA B got her loose from everything, she didn't have a choice but to go to the shower. Resident #71 said CNA B gave her a shower and she didn't like the way she treated her. Resident #71 said she only felt comfortable with CNA C giving her a shower. Resident #71 said CNA B has never given her a shower since she has been at the facility. Resident #71 said that CNA B talked down to her and she was going to do what she wanted to do however she could to get it done. Resident #71 said after CNA B took her back to her room from the shower, she noticed her left elbow was bleeding. Resident #71 said she should not be forced or anything like that. Resident #71 said when the police came, they took a statement from her and pictures of her arm. During an interview on 8/16/2022 at 2:00 PM, CNA B said she had been employed at the facility for almost a year. She said she worked the 6am-2 pm shift and was assigned to a dedicated hall at the facility. She said Resident #71's shower day was scheduled on 8/12/2022 and was on Mondays, Wednesdays and Fridays. She said as far as she knew, Resident #71 hadn't had a shower in a while. She said you could smell the urine when you walk into the room. She said she informed Resident #71 that it was her shower day and Resident #71 said she wasn't taking it. She said she came back later, and Resident #71 said no again. She said she left and came back to her again and she told Resident #71 the faster we can get in the shower the faster we can get out. She said while they were in the room the first two times, Resident #71 she was holding on to her bed, because she was afraid, I was going to try and put her on the shower chair. She said the third time Resident #71 was holding onto the bed and she let go and was able to sit her up on the side of the bed and then transferred her to the shower chair and then she was taken into the shower and given a shower and back to her room. She said Resident #71 told her that she was going to tell the nurse that she beat her up to put her in the shower. She said a med aide asked Resident #71 what happened, and she couldn't tell them what happened. She said Resident #71 was bleeding on her left elbow when the med aide came in and asked her what happened, and she told her it was from an old injury. CNA B said it was after she was escorted outside of the building, and the medication aide saw that Resident #71 was bleeding and she asked her what happened. She said she had an in-service on abuse at the facility on hire and at the end of July 2022. She said she was suspended and had not been back to work at the facility since 8/12/2022. During an interview on 8/16/2022 at 1:34 PM, the SW said it was Resident #71's shower day on 8/12/2022 and the CNA that normally does it was off. She said CNA B made Resident #71 take a shower. She said Resident #71 showed her wrist and elbow to her and she had some bruises and she immediately reported it to the DON. She said Resident #71 reported she felt safe. She said after the police came and talked to Resident #71, she went and checked on her and she was feeling guilty about pressing charges but said she didn't want it to happen to anyone else. During an interview on 8/12/2022 at 1:40 PM, the DON said the SW came to the nurse station and told her that Resident #71 had refused a shower and CNA B made her to get up anyway and Resident #71 showed her the injuries. She said she interviewed Resident #71 with the SW being present and Resident #71 said she was holding onto the sheets trying to prevent CNA B from getting her into the shower chair. She said Resident #71 had bruises to her wrist, a hematoma to her left elbow and a skin tear to her left elbow. She said she went and told the Administrator and the Treatment nurse. She said the Treatment nurse assessed her injuries and dressed the skin tear. She said the police were notified by the Administrator and they interviewed Resident #71. She said CNA B was suspended and would be terminated. She said normally Resident #71 was good with showers and liked CNA C to give her showers. During an interview on 8/17/2022 at 3:00 PM, the Administrator said Resident #71 knew what was going on most of the time but would get some events confused. She said she does not have any behavior problems. She said she was told by the DON, that Resident #71 was forced to take a shower by CNA B. Resident #71 said that the CNA B wanted to give her a shower and she only wanted CNA C to give her one. She said CNA B went into Resident #71's room and told her she smelled of urine. CNA B got Resident #71 up of the bed and placed her in a shower chair. She said Resident #71 said she probably received the skin tear to her left elbow trying to fight against CNA B. The Administrator said CNA B reported the incident to CMA A and CMA A denied that she told CNA B to give her a shower anyway. The Administrator said she suspended CNA B pending an investigation, but she would be terminated. She said she in-serviced staff on 8/12/2022 that a resident had a right to refuse, on abuse/neglect and caring for cognitively impaired residents. She said she told the staff to follow policy and procedures for dealing with residents cognitively impaired and the facility must honor the resident's rights but to always ensure their needs were met and to notify the nurse if a resident refused care. Record review of a facility policy titled Abuse Prevention Program with a revised date of August 2006 indicated, . Our residents have the right to be fee from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. 1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual .

Based on interview, and record review, the facility failed to provide adequate supervision to prevent accidents, for 1 of 5 residents reviewed for accidents (Resident #1). CNA A did not provide Resident #1 the required assistance with incontinent care as indicated in her care plan. Resident #1 fell off the bed and suffered a concussion, contusions (bruises) and skin tears. This failure could place residents who require two staff assistance with incontinent care at risk for injury. Findings included: A face sheet dated 11/09/18 indicated Resident #1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #1 was cognitively impaired and required extensive assistance of 2 staff with bed mobility, transfers and toileting . A care plan updated 07/29/18 indicated Resident #1 required 1-2 staff for bed mobility and 1 staff for toileting . An in-service dated 09/15/18 indicated all care provided to Resident #1 required two staff assistance to include incontinent care, repositioning and transfers to decrease skin tears. A care plan dated 11/09/18 indicated Resident #1 required two staff assistance with bed mobility, toilet use and transfers. During an interview on 11/29/18 at 12:11 pm the MDS coordinator said Resident #1's care plan had not been updated until 11/09/18 to reflect she required two staff assistance with bed mobility and toileting. A nursing progress note dated 11/08/18 at 8:05 p.m. indicated LVN C was informed by CNA A that during incontinent care he left Resident #1 unattended while lying on her side and Resident #1 fell out of the bed onto the floor. The note indicated Resident #1 was assessed and sent out to the local hospital for evaluation. An incident report dated 11/08/18 at 8:05 p.m. and revised on 11/20/18 at 9:02 a.m. indicated CNA A informed LVN C that Resident #1 rolled off the bed while lying on her right side. The report indicated when LVN C entered the room and saw Resident #1 lying on the floor on her left side with bleeding from her left arm. The incident report indicated Resident #1 complained of neck and head pain and 911 was called to transport her to the local hospital. A hospital visit summary dated 11/08/18 indicated Resident #1 had a fall at the nursing home while being changed. The summary indicated Resident #1's discharge [DIAGNOSES REDACTED]. During a telephone interview on 11/29/18 at 10:56 a.m., LVN C said CNA A told her that Resident #1 was lying on the floor. LVN C said CNA A told her he had left the room to get some towels and when he returned to the room Resident #1 was lying on the floor . LVN C said to her knowledge Resident #1 was a two person assist with activities of daily living (ADLs) including incontinent care, and CNA A was providing Resident #1 incontinent care without assistance at the time of the incident. During an interview on 11/29/18 at 2:10 p.m., CNA B said she was working the day of the incident on the hall with CNA A . She said she assisted CNA A to transfer Resident #1 to the bed. She said CNA A had not asked her for assistance to do incontinent care on Resident #1. She said Resident #1 was a two person assist prior to the incident and that staff had been in-serviced prior to the incident that Resident #1 was to be a two person assist with ADL's. During an interview on 11/29/18 at 2:40 p.m., CNA A said the day of the incident he was providing incontinent care on Resident #1. CNA A said he did not ask for help because he was in a rush and was trying to get Resident #1's care done. CNA A said he had been in-serviced prior to the incident on 11/08/18 and was aware Resident #1 required 2 staff for care, including incontinent care. He said there was other staff available, but he did not ask for help and no other staff was in the room. CNA A said he had positioned Resident #1 on her right side and he was on the left side of the bed. CNA A said he turned around to get some wipes and before he could turn back around Resident #1 had already fallen off the bed. CNA A said he immediately went to get LVN C. In-services done on 11/09/18 by the DON for staff indicated : * Resident #1 was a two person assist for all care including incontinent care, transfers, turning and repositioning to decrease risk for skin tears (ease of movement ). * When doing incontinent care make sure all supplies are gathered beforehand and brought to room . A one on one in service dated 11/14/18 by the DON and signed by CNA A indicated CNA A was in serviced as followed: * Abuse /Neglect * Incontinent care - have all supplies available and within reach . * Resident #1 - two persons for all direct care. A facility investigation report dated 11/15/18 indicated CNA A was suspended pending the investigation. CNA A was allowed to return to work and one on one in servicing was done. The report indicated the allegation of neglect was unconfirmed. During an interview on 11/29/18 at 2:55 p.m., the DON said an in-service was done on 09/15/18 with staff due to Resident #1 getting a lot of skin tears. She said CNA A signed the in-service and should have known Resident #1 was a two person assist. During an interview on 11/29/18 at 3:14 p.m., the administrator said he was not aware an in-service had been provided on 09/15/18 concerning Resident #1 and her requiring two people for transfers , incontinent care and bed mobility. He said CNA A had signed the in-service on 09/15/18 and he should have been aware Resident #1 required two staff for care.

Based on observation, interview, and record review, the facility failed to ensure 2 of 16 residents reviewed for abuse were free from physical and emotional abuse and involuntary seclusion. (Resident #s 1 and 3) Resident #1 was denied her medicated mouthwash by LVN A on 8/28/14. The resident became angry and the DON and ADON forced the resident to bed during the late afternoon hour. Resident #1 was thrown into the bed by the DON grabbing her legs and the LVN ADON grabbing her left arm. The resident's wheelchair was taken away from her so she could not get up. On 8/29/14 the resident was forced to go to the hospital for a psychiatric evaluation. She was tied down to the stretcher. The resident was crying the night of 8/28/14 and did not eat her supper. She complained of hitting her head, back and foot. LVN A had attempted to make Resident #3 go to the dining room. When the resident yelled at the nurse that he did not want to go, the nurse pointed his finger in the resident's face and told him not to speak to him that way. An Immediate Jeopardy situation was identified on 8/31/14. The Immediate Jeopardy was removed on 9/01/14. The facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 95 residents at risk for physical injury, loss of self-worth, and despair. Findings included: 1. Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years-old, with [DIAGNOSES REDACTED]. The orders also indicated the resident received counseling services, which was originally ordered 9/16/13. A quarterly MDS with an assessment reference date of 7/01/14 indicated the resident had moderately impaired cognition, no signs of [MEDICAL CONDITION], no adverse moods, and no behaviors. Nurse's note entry dated 8/28/14 at 6:25 p.m. and written by LVN ADON indicated she called Resident #1's daughter and informed her the resident was "lashing out" at the nurse and being paranoid about things like people talking behind her back. The daughter told the nurse her mother had these episodes at times and she would try to talk to her. The LVN ADON documented the resident was in her room at that time and there were no signs and symptoms of distress. The next nurse's entry was dated 8/28/14 at 6:00 p.m. (but documented after the 6:25 p.m. entry) indicated there was a new order for urinalysis. Resident #1 refused to give a specimen at that time. There were no other nursing notes for 8/28/14. The next nurse's entry dated 8/29/14 at 9:30 a.m. indicated Resident #1 refused to come out of her room. The resident said, "I am going to stay in my room where I am safe." The resident told the nurse, "Your head nurse and some other people threw me in the bed." The nurse documented the resident complained of back pain. The resident pointed to two discolorations on her arms and said that was what was done to her. She documented there was active range of motion to all extremities and then asked the resident for a urine specimen. The resident attempted but said she was not able to do it at that time and that she would try later. The nurse wrote she informed the DON of the resident's complaint. The DON informed the nurse the resident had been combative the day prior and she was assisted to bed. At 10:00 a.m. the nurse administered pain medication for the resident's complaint of back pain. At 10:30 a.m. the ambulance arrived to transfer the resident to the hospital for evaluation and possible psychiatric admission. A nurse's entry dated 8/29/14 at 11:00 p.m. indicated Resident #1 was sitting on side of bed visiting with another resident. There were no signs or symptoms of distress. A progress note for counseling services dated 8/11/14 indicated Resident #1 said she was doing "pretty good." The resident said she had been in some pain, which escalated her anxiety. The resident was also worried about her brother's health. The counselor documented the resident had positive responses to the support. The Psychoactive Behavior Monitoring for August 2014 for Resident #1 indicated "No behaviors observed" was initialed every day and every shift from 8/01/14-8/30/14. During an interview on 8/29/14 at 3:30 p.m., Resident #2 said she lived on the same hall as Resident #1. Resident #2 said she heard staff raise her voice to Resident #1. She said staff also hurt Resident #1's foot. Resident #2 said she saw Resident #1 get mad at LVN A because he would not give her medication. Resident #2 said LVN A told Resident #1 to shut up. Resident #1 told the LVN not to tell her to shut up. Resident #1 then tried to go into the medication room and the MA shut the door. The resident was kicking the door. The DON came out of her office and said she was taking Resident #1 to bed. Resident #1 said she did not want to go to bed. Resident #2 said the DON dug her nails into Resident #1's arms. She said 3 or 4 staff went into Resident #1's room. Resident #2 said she stayed with Resident #1 after the staff left because she was crying and upset. She said the staff hurt her. During an interview on 8/29/14 at 4:15 p.m., OTA B said OTA C called her and said she saw Resident #1 being mistreated. OTA B said she and OTA C went to check on Resident #1. The resident was sitting on the side of the bed, crying, and rubbing her foot. The resident said "they" took her wheelchair from her because "they" knew she could not get up without it. OTA B said she did not see the wheelchair in the resident's room. OTA B went on to say that Resident #1 was really upset. She said her foot was hurting and she hit her head when she was "thrown" in bed. OTA C told OTA B the DON forcefully took the resident to her room, along with LVN ADON. While, they were consoling the resident, Resident #1 said she needed to go to the bathroom. OTA B said when she looked in the bathroom the resident's wheelchair was in there. OTA B said Resident #1 was sent to the hospital this morning (8/29/14) because the DON said she was combative. OTA B said she had never known Resident #1 to be combative. Resident #1 was placed on the stretcher. She was still in her night gown. OTA B said Resident #1 was always dressed and put together. Resident #1 was upset and yelling that she did not want to go. OTA B said she heard the DON say, "It's all because of me." OTA B said everyone was watching and no one said anything. The DON called a meeting after Resident #1 left. The DON told staff that she and the LVN ADON had not hurt the resident. She told everyone that she did not want to hear any more about it and if she did, she would fire that person. During an interview on 8/29/14 at 5:00 p.m., the Activity Director (AD) said on 8/28/14 Resident #1 wanted her medicated mouthwash because she had mouth pain. LVN A told Resident #1 the medication was discontinued. Resident #1 went to the DON and the DON had the LVN ADON call and get it refilled. Later, the resident overheard LVN A say they did not have the mouthwash. Resident #1 became upset. Resident #1 grabbed LVN A's arm and he pulled away from her. Resident #1 was circling the medication cart to get to the LVN. The AD said she went and got the DON. The resident was at the medication room, kicking the door. The DON attempted to wheel the resident back to her room. The resident put her feet down and the DON tilted the wheelchair back. The resident said the DON broke her leg. The DON said, "I'm not going to deal with this." The DON called the LVN ADON to help put the resident to bed. The AD said the LVN ADON was at the nurses' station. The AD said Resident #1 kept saying she was not ready to go to bed. The AD said the resident was crying and upset. She was "scared." The AD said as the DON was taking the resident down the hall the resident was reaching back, trying to fight the DON. The DON took the palm of her hand and pushed the resident's chest to push her back in the chair. The AD began to cry during the interview. She said the resident was trying to hit the DON and called her a "fat [***] ." The resident said her leg was caught under the seat of the wheelchair while the DON was pushing it. The resident said the DON had broken her leg. The DON took the resident down the hall on two wheels. The DON had to stop along the way because the resident was fighting her. Resident #1 asked to talk to the AD after the events and asked the AD if she was against her. The resident was crying. Resident #1 told the AD she was thrown in bed against the wall. The AD said she went and told the DON the allegation. The DON said it was not true. The AD said the resident said her back, leg, and arms were hurt. The AD said she saw little areas on the resident's arms. She said they looked like little areas similar to how someone's arms look when they were taking certain medications. The AD said she had never seen areas like that on the resident's arms before. The AD said she saw the DON in the administrator's office, so she assumed the DON told the administrator what happened. The DON had a meeting and told everyone if they spoke about what happened they would be fired. The DON told everyone that was a threat. During an interview on 8/29/14 at 5:54 p.m., LVN A said he had been employed at the facility since the second week in July 2014. He said Resident #1 had problems with her jaw. When the resident went to the dentist, the dentist ordered [MEDICATION NAME] mouthwash. When the resident finished the initial bottle, she wanted more because she thought it helped. The resident went back to the dentist and she came back with more, but it was the over-the-counter [MEDICATION NAME]. LVN A said that bottle was finished Friday or Monday (8/22/14 or 8/25/14). LVN A said on Tuesday (8/26/14) the MA said the resident was asking for the [MEDICATION NAME]. LVN A said he tried to explain to the resident that she was out. LVN A said the LVN ADON called the dentist and got a third bottle. On 8/28/14 the MA asked him for clarification on the order. The resident rolled up and was confrontational. The resident wanted the entire bottle to keep in her room. LVN A said the resident grabbed his arm with both hands. The AD diverted the resident's attention. LVN A said he went to the DON's office and told her what was going on. The DON and LVN ADON, who was also in the office, said they would handle it. LVN A said at that point he went to the nurses' station to complete paperwork. The MA had the medication cart at the nurses' station and the resident wanted the bottle. The MA went into the medication room and the resident kicked the door and yelled. LVN A said he was worried because the resident had a broken foot. He said the DON and LVN ADON tried to talk to the resident. LVN A said the DON and LVN ADON took the resident down the hall but he did not see it. LVN A said he felt bad because he was not involved in trying to redirect the resident, but the resident did not like him, so he thought it was best to stay out of it. LVN A said he did not go into the resident's room the rest of the night. He had the MA check on her. During an interview on 8/29/14 at 6:14 p.m., MA D said on 8/28/14 sometime after 3:00 p.m. Resident #1 was asking about her mouthwash. She told the resident she did not have any. While she was giving medications to another resident, the MA pulled some bottles out of the medicine cart. There was a bottle of [MEDICATION NAME] with Resident #1's name on it. Resident #1 saw the bottle and wanted it. MA D said it was not on the MAR. She took the medicine cart to the nurses' station to ask LVN A about it. The resident grabbed LVN A's arm and the LVN walked away. MA D said Resident #1 still wanted the mouthwash. She said she went to the medication room. The resident was knocking on the door. The RN ADON was trying to talk to the resident. The RN ADON entered the medication room and MA D said she explained to her what was going on. The RN ADON went out of the medication room to talk to the resident, who then kicked the door. MA D said there was a therapist there (OTA C). The resident grabbed onto the handrail. MA D said OTA C was trying to talk to the resident. The DON came up and told the resident to listen to her. The DON tried to get the resident's hands off the handrail. The DON said she was going to put the resident to bed. The resident put her feet down and said she did not want to go to bed. The DON pulled the wheelchair back so the resident could not put her feet down. MA D said it just escalated from there. MA D said she went into the resident's room afterwards with CNA E. Resident #1 said someone "threw her around the bed and grabbed her arms." MA D said the resident's arms had bruises. MA D said she told LVN A about the bruises. MA D said she did not remember seeing the resident's wheelchair in her room. She said she knew the resident used it to get up to the bathroom. MA D said CNA E told her she was in the room when the DON and LVN ADON put the resident in bed. CNA E told MA D the two had "flung" the resident in the bed. CNA E told MA D she would not want anyone to treat her mother or grandmother that way. MA D began crying during the interview and said that it had bothered her. During an interview on 8/29/14 at 6:45 p.m., the business office manager (BOM) said on 8/28/14 she heard Resident #1 screaming. She went to the resident and asked what was wrong. Resident #1 told the BOM, "That man (LVN A) is mean to me." The BOM said this was around 3:30 p.m. She went to the DON and told her what Resident #1 said. The DON told the BOM that Resident #1 was "cycling." The BOM said she left the building around 5:00 p.m. and the incident happened after that. The BOM said when she arrived at the building on 8/29/14 the ambulance was taking Resident #1 out. The resident was screaming not to break her leg. The DON called a meeting at about 10:20-10:30 a.m. She announced over the loudspeaker for all staff to come to the conference room. At the meeting, the DON told the staff, "I want this to stop right now." She told the staff Resident #1 was "cycling" and they were trying to get a urinalysis on her. She went on to tell the staff if she heard talk about it, the staff would be fired. The BOM said the AD and administrator were in the meeting and they were both crying. The DON said there was an episode with Resident #1 last night and the resident tried to turn over the medication cart. The DON said she had to lift the wheelchair. She went on to tell the staff there were no bruises on the resident. The BOM said one of the MAs asked the DON about LVN A aggravating the resident for the last two weeks. The DON said the resident was "cycling." The administrator told everyone the resident was sick and they were trying to get her help. The DON talked interrupted the administrator and would not let her talk. The DON went on to tell the staff they would be terminated if they talked about it and, "If you want to take that as a threat, take it as a threat." The BOM said she thought the DON was an excellent nurse, but she talked rough with the residents and staff. During an interview on 8/29/14 at 7:12 p.m., LVN F said she worked the evening of 8/28/14, but she, "did not see a lot." She said the resident was "exceedingly upset." LVN F said Resident #1 would get upset at times, but it was not often. Resident #1 was really mad at LVN A, but she did not know why. LVN F said she was told Resident #1 kicked the medication room door. LVN F said she heard Resident #1 talking loud and sounded angry. LVN A told her, "Your baby is mad at me." LVN F said the therapy people came and got her and wanted her to look at the resident's arms. She said there were three bruises on Resident #1's left arm that were "reminiscent of finger marks", but the resident had frail skin. The resident was complaining of foot pain, but there was no sign of injury. Resident #1 told LVN F "they" jerked her. The resident said, "They picked me up and chunked me in the bed." The resident did not say who they were. LVN F said Resident #1 was angrier than she had ever seen her. LVN F said she would consider what happened to Resident #1 abuse. She said she told the RN ADON. During an interview on 8/29/14 at 7:30 p.m., the RN ADON said Resident #1 told her the MA would not give her medication. The RN ADON entered the medication room to talk to the MA. The MA explained about the mouthwash. When the RN ADON opened the door of the medication room to come out, the resident tried to get into the room. She said she tried to calm the resident down, but she was screaming. The DON came up and tried to explain to the resident. The DON pulled the wheelchair away from the door. The resident was hollering. The RN ADON said the DON was normally loud. Resident #1 was swinging at the DON over her shoulders. The RN ADON said the DON lifted the wheelchair because the resident was putting her feet down. The RN ADON said she only saw the DON do it for a few feet then the RN ADON left. The LVN ADON and a CNA were with the DON. The RN ADON said no one reported bruises to her. The RN ADON said the resident was sent to the hospital the morning of 8/29/14. She said she heard Resident #1 yelling, but she was making rounds with a physician and did not see what was going on. She said Resident #1 had been escalating a couple of weeks. She said the resident threw some plates Sunday (8/24/14). She said they had talked to the family and had gotten an order for [REDACTED]. The RN ADON said she called the emergency room at 6:00 p.m. and was told the resident would not do a voluntary commitment, so they were waiting on the mental health authority to come and do an evaluation. The RN ADON said she would not have handled the situation the way the DON had. During an interview on 8/29/14 at 7:52 p.m., the LVN ADON said LVN A told her Resident #1 wanted him to stay away from her. LVN ADON said she told LVN A to leave her alone. The AD came and told her and the DON on 8/28/14 that Resident #1 was chasing LVN A around the medication cart. LVN ADON said she asked, "Why is he near her?" The LVN ADON said later she came out of the conference room and the resident was holding onto the handrail. The DON was telling her to let go of the rail and that she was going to hurt herself. The LVN ADON said she, the DON and a CNA took the resident to her room. She said they put the resident into bed and she sat on the bed beside the resident. The resident was reaching for her phone and pointing at the DON. The DON left the room. The LVN ADON said the CNA put the resident's wheelchair in the bathroom. She said at that point she left the room. The LVN ADON said she did not see any bruises on the resident's arms. She said she did not see the resident again. The LVN ADON said she called the doctor who ordered a urinalysis. During an observation on 8/30/14 at 8:12 a.m., Resident was #1 was in the dining room eating breakfast. She was sitting in a wheelchair. She was smiling and was pleasant. At this time, she agreed to speak to the surveyor when she finished her breakfast. During an interview on 8/30/14 at 8:23 a.m., Resident #1 said the man nurse (LVN A) would not give her mouthwash. She said the nurse had been here a short time and he did not know his name. She described the physical characteristics of LVN A. The resident said the bones "were working out" on the right side of her jaw. She went to the dentist and he gave her a mouthwash. Resident #1 said the mouthwash helped her a lot. She wanted to keep it in her room because she did not always get it the way she was supposed to. Resident #1 said she was talking to someone about her mouthwash and "she walked up behind me and got a hold of my wheelchair." Resident #1 said "she" (the DON) was yelling at her, saying she did not have a broken leg. "She threw me backwards in the chair and shook me in it. There was nothing I could do. They slung me out of the chair and against the wall." The resident showed her arms to the surveyor and pointed out bruises to both arms. The resident pointed to areas on her left arm and said, "This is where she dug her nails in my arm." There were 3 areas to the resident's left arm that each measured approximately 1.5 cm in diameter. They were reddish-purple in color. Resident #1 said her wheelchair was taken away and put in the bathroom because they knew she could not get up without it. The resident said this was the first time something like this happened to her. She said she knew she said some things that she should not have said. "You know how you say things when you are upset." Resident #1 said they hurt her leg and caused her whole leg to ache. Resident #1 said she was nervous inside. The resident described the staff as wearing red tops and khaki pants. A nurse's entry dated 8/30/14 at 10:00 a.m. indicated Resident #1 was in the wheelchair, propelling herself on the hallway. She was alert and friendly with no behaviors noted. During an interview on 8/30/14 at 12:43 p.m., CNA E said on 8/28/14 she had finished feeding a resident on the 400 hall and was putting the tray on the cart, when she saw the DON coming down the hall with Resident #1. CNA E said the RN ADON told her to help the DON. CNA E said the LVN ADON followed them down to Resident #1's room. She said once in the room the DON grabbed the resident's legs and the LVN ADON grabbed the resident's left arm and swung her in bed. CNA E said she left the room and was looking for her nurse, but could not find her. She said she went back to Resident #1's room to check on her and the therapists were in there with her. CNA E said she told the therapists what happened to the resident. CNA E said the LVN ADON had been watching her and she felt the LVN ADON was afraid she was going to say something. CNA E said Resident #1 was cussing the DON and telling her to leave her alone. CNA E said the DON told the resident, "You're being ridiculous. Until you know how to act, you're going to bed." The resident kept saying she was not going to bed. CNA E repeated that the LVN ADON grabbed the resident's left arm and the resident was "swung" into bed. CNA E said the LVN ADON and DON put the resident in bed upside down. The resident's head was at the foot of the bed. She said you could hear them swinging her and the landing "was not comfortable, not easy." CNA E said when she went back to the room, the resident's wheelchair was in the bathroom and her call light was on the floor. The resident was crying and upset. CNA E said on her way to speak to the surveyor, the LVN ADON told her that the surveyor was going to ask if the resident was thrown in bed and that they had not thrown her. CNA E said she felt Resident #1 was abused. She said grabbing the resident and swinging her in bed upside down was abuse. She said Resident #1 refused to eat that evening. During an interview on 8/30/14 at 1:26 p.m. OTA C said on 8/28/14 she was in the conference room. She said when she came out of the room Resident #1 was at the medication room and had her foot that had been broken in the past out, trying to hold the door open. OTA C said she saw the RN ADON trying to talk to the resident. She was telling her she did not have a medication. OTA C said Resident #1 was upset. She said she had a good rapport with the resident and she thought she could calm her. She said Resident #1 was talking loud, but she was not hitting. OTA C said she approached the resident and began rubbing her back and bent down to talk her when the DON walked up behind her and said, "I've had enough of you. You're going to bed." Resident #1 grabbed the handrails and the DON forcibly removed the resident's hands. OTA C said she was in shock. The DON took the resident down the hallway very quickly and the resident's broken foot (the right one) was drug under the chair. The resident hollered that the DON was breaking her foot. The DON then tilted the wheelchair back on two wheels. OTA C said the resident and DON yelled at each other. A CNA and the LVN ADON followed the DON to the resident's room. OTA C said she heard the LVN ADON say that Resident #1 had been "acting up all day." OTA C said she was standing in the hallway and she heard this "gut curling scream." She went into another resident's room and shut the door because she was afraid. She said she called OTA B and told her what she saw. Once OTA B arrived, the staff had left Resident #1's room. The two OTAs entered the resident's room and found her sitting on the side of the bed, trying to get up. The resident told them that her wheelchair had been taken away. OTA C said the resident was crying and never tried to fight her or OTA B. OTA C said the next morning, her and OTA B go to check on Resident #1. She was lying in bed, crying. She said her back hurt from being thrown in bed. The OTAs left the room. She had heard the resident was sent to the hospital that morning. During an interview on 8/31/14 at 9:35 a.m., CNA G said she worked the morning of 8/29/14. CNA G said Resident #1 was "...an angel. I love her to death." CNA G said right before lunch at about 10:45 a.m. she heard someone hollering and she ran to where it was coming from. CNA G said she saw Resident #1 on a stretcher with her wrists tied down with a sheet. There were two emergency medical service personnel, the DON and the administrator with the resident. Resident #1 asked CNA G if she would help her. CNA G said she told the resident to calm down. She said the resident was crying. CNA G said Resident #1 was yelling the whole time they took her out of the facility. The CNA began to cry during the interview. She said Resident #1 yelled at the DON, "Get that [***] away from me." CNA G said Resident #1 was not a violent or aggressive and for her to act like that, something had to have happened. CNA G said she wondered if LVN A had done something to provoke Resident #1 because she was not like that with everyone else. During an interview on 8/31/14 at 9:55 a.m., LVN H said a CNA told her the resident was crying the morning of 8/29/14. The CNA said the resident was saying the "head person" in the red shirt threw her in bed. LVN H said there were three people that wore red shirts: DON, LVN ADON, and RN ADON. She said the nurses wore blue, the CNAs wore maroon, and the MAs wore light blue. LVN H said she went to talk to the resident and she was not crying at that time. The resident first accused her of being one of them. LVN H said after she talked to the resident for a bit, the resident apologized for thinking she was one of them. LVN H said Resident #1 told her, "I admit I said some things to the big guy on 2-10, but they didn't have to throw me in bed." LVN H said the resident had some bruises that were red to the tops of both of her arms. The resident also complained of back pain and requested pain medication. LVN H said when she left the room, she met the DON in the hall and told her the resident's allegation. The DON said it did not happen. The DON said there were witnesses and she had gotten an order to send the resident to the hospital for a psychiatric evaluation. The LVN said she returned to the resident's room with something for pain and told her about going to the hospital. The resident said she did not want to go to the hospital. LVN H said the resident was not mean; she just did not want to go. LVN H said she told the social worker who went and talked to the DON. The DON said the resident had to go. LVN H said it upset her because the resident was confused at times, but she was "at herself" enough to refuse going to the hospital. When the emergency medical technicians arrived, they went and talked to Resident #1. They came back to the nurses' station and said the resident refused to go. The DON and administrator went to the resident's room. LVN H said she heard the resident yell. LVN H said it was a very emotional day. She said the DON said the resident was having behaviors, but she had not seen it. She said the DON asked her why she was not charting the behaviors. She said she told her she did not document behaviors because she had not seen the resident exhibit any behaviors. All the behaviors seemed to occur when LVN A worked. During an interview on 9/01/14 at 10:40 a.m., the administrator said she was told the DON had a lot of experience and she could learn a lot from her. She said there was a power struggle between her and the DON. She said the problem began when she hired a RN as the ADON. She thought maybe the DON felt threatened. Now, staff was coming to her and saying the DON told them not to go to administrator with anything. The administrator said she asked the DON to take some time off because she was at the facility all the time. During an interview on 8/31/14 at 8:45 a.m., the administrator was informed of the presence of an Immediate Jeopardy in the area of abuse. The facility's plan of removal was accepted on 8/31/14 at 4:50 p.m. and included: "How will the facility correct the deficient practice for those residents identified in the deficiency? The DON and ADON have been terminated. Counseling inservice with the current Abuse Coordinator on identifying and addressing an (sic) noted patterns or trends related to abuse and neglect. All staff who had prior knowledge of abuse/neglect and failed to report it to the Abuse Coordinator will be formally counseled in writing and will be held accountable for following the policy for the prohibition of abuse and neglect. All residents currently in the facility have been interviewed and any incidents related to abuse or neglect have been self-report when indicated. All residents who have a DNR have been assessed for any change in condition-all residents are currently stable. How will the facility identify those at risk for similar deficient practice? All residents in the facility have the potential to be affected. What will be done to prevent the deficient practice from recurring? ALL facility staff will be inserviced on the Abuse/Neglect policy and will demonstrate proficiency through return demonstration prior to returning to their current positions within the facility. All staff will be inserviced on Senior Care's policy on retaliation. Any staff member who is found to have violated wither policy will be immediately suspended pending investigation. The administrator and social worker will convene a resident council meeting and will educate residents on the abuse prohibition policy and retaliation, including where to find names and numbers of who to contact. All nursing staff will be inserviced on identifying, assessment, and notification of change in condition for ALL residents (full code or DNR). How will facility monitor its own corrective action? This process improvement plan will be reviewed monthly at QAPI. Inservice training via SilverChair (online learning resource) will continue to be done on hire of all new facility staff and annually thereafter. This will include a post test." 2. A Face Sheet for Resident #3 dated 8/22/14 indicated the resident was admitted [DATE] and was [AGE] years-old. An admission order dated 8/20/14 indicated the resident had [DIAGNOSES REDACTED]. During an interview on 8/29/14 at 6:45 p.m., the business office manager (BOM) said she had gone to the DON about a concern she had about LVN A. The BOM said Resident #3 had behaviors, but she could talk to him and calm him down. She said he sat in her office often. The BOM said LVN A came to her office and told Resident #3 he was taking him to the dining room. Resident #3 yelled at LVN A that he did not want to go. The BOM said LVN A crouched down, shook his finger in Resident #3's face, and told him not to speak to him like that. The BOM said she would take the resi

Based on observation, interview, and record review the facility failed to implement policies and procedures that prohibit neglect for 1 of 16 residents reviewed for neglect. (Resident #4) Resident #4, who had a DNR directive and had significant neurological and physiological changes and did not receive medical attention. Two LVNs (K and L) and one CNA (M) recognized these changes were not normal for Resident #4. The DON instructed the staff to put the resident in bed to rest. The DON did not want residents with a DNR directive sent to the hospital. The facility did not intervene on the resident's behalf by sending to the hospital or contacting the physician. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 95 residents at risk for physical injury, a decline in condition without medical intervention, or death. Findings included: A Face Sheet dated [DATE] for Resident #4 indicated the resident was admitted [DATE] and was [AGE] years-old. An undated annual physical exam completed by the physician for Resident #4 indicated the resident had a history of [REDACTED]. The chief complaint(s) were listed as an [DATE] hospital stay with gastrointestinal blood loss, urinary tract infection, high blood pressure, diabetes, and acute post-hemorrhagic [MEDICAL CONDITION]. The short-term and long-term goals were listed as long-term care with possible hospice care. A care plan with problem onset date of [DATE] indicated Resident #4 and family had elected to designate an advance directive. The first approach read, "If [MEDICAL CONDITION] Do Not Resuscitate." This care plan was initialed to continue plan of care on [DATE] and [DATE]. An undated care plan for Resident #4 indicated the resident requested a code status of "No CPR". The social worker signed the care plan [DATE]. A daily skilled nurse's note dated [DATE] with a late entry at 11:00 a.m. indicated Resident #4 was seen in the dining room clenching her bottom denture in her hand (grasping denture in hand on lap), tongue rolled up in her mouth, left eye up and to the left, and right eye down and to the right. The resident did not respond to staff. Blood pressure was ,[DATE] and her pulse was 86. The nurse (LVN L) documented the resident's nurse was tied up so she got another nurse (LVN K) and a nurse aide (CNA M) to help her. "At this time, DON walks up and asks what is going on. Looks at resident and says 'she's just tired this is normal for her.' We tried to argue that it wasn't, but she told us to lay her down and let her rest. Notified nurse (LVN J) of what happened." The nurses' notes for Resident #5 dated [DATE]-[DATE] indicated the following blood pressure readings: [DATE]-,[DATE] [DATE]-,[DATE] [DATE]-,[DATE] [DATE]-,[DATE] A physician's telephone order dated [DATE] indicated to admit Resident #4 to hospice with a [DIAGNOSES REDACTED]. During an interview on [DATE] at 3:15 p.m., the daughter of Resident #4 was visiting with her mother in her room. The daughter said she was upset because something happened to her mother on Sunday ([DATE]). She said a nurse called her at home about 11:30 a.m. and said her mother had an episode. She said she did not know what that meant, because an episode could be anything. She said she saw her mother at 5:30 p.m. and she was drooling and her right eye was turned outward. The daughter said the DON would not let the nurses call the doctor and told them to put her in bed. The daughter said her mother had been at the hospital for about 14 days and came back to the facility on [DATE]. The daughter said her mother is on hospice now and she felt her mother was not given the proper attention and the doctor should have been called. During an observation on [DATE] at 3:15 p.m., Resident #4 was in bed. She looked at the surveyor and gave simple yes or no answers. Her right eye was partially closed. The resident's daughter asked if she was in pain and the resident nodded her head. During an interview on [DATE] at 9:50 a.m., LVN L said she was getting the residents ready for lunch on [DATE]. Resident #4 was in the dining room. When she looked at her, she noticed her tongue was rolled, her eyes were pointing in different directions, and she had her bottom dentures clenched in her hand. LVN L said she could not get the resident to respond. Resident #4's nurse was busy so she asked LVN K to look at the resident with her. The resident's CNA was also available to look at her. LVN L said LVN K was "freaking out." CNA M said Resident #4 did not look like that when she brought her to the dining room. LVN L said she had seen the resident earlier that day and she was humming and smiling. The DON walked by and asked what was going on. LVN L said the DON asked, "What's wrong with her?" LVN L replied, "Can't you see her eyes?" The DON said that was normal for Resident #4 and to put her in bed. LVN L said they put Resident #4 to bed and checked her vital signs. Her blood pressure was ,[DATE]. LVN L said she told her nurse and told her to call the family. LVN L said she saw Resident #4 a couple of days later and one of her eyes was wide and fixed and the other eye was barely open, but the resident did smile. LVN L said she thought the resident should have been sent to the hospital. LVN L said the DON did not care about residents that had a DNR. LVN L said if a resident had pneumonia and the nurse sent the resident to the hospital, the DON would ask the nurse why the resident was sent to the hospital because the person was a DNR. During an interview on [DATE] at 9:41 a.m., LVN K said she was working [DATE] when LVN L came and asked her to look at Resident #4. LVN K said the resident's eyes did not look right. The resident's nurse was busy, so the DON was told. The DON looked at the resident and said she always looked like that. LVN K said she would have remembered if the resident's eyes normally looked like that. LVN K said she next saw Resident #4 on Wednesday or Thursday ([DATE] or [DATE]) and she looked like she had a stroke because she had facial drooping. LVN K said if Resident #4 had been her resident she would have called the doctor despite what the DON said. During an interview on [DATE] at 10:20 a.m., CNA M said on [DATE] she saw Resident #4 in the dining room. CNA M said it looked like the resident had a stroke. The resident's hand and mouth were "twisted." CNA M said the DON told them to put the resident to bed and "people always assuming things." CNA M further described Resident #4's appearance as her left arm was contracted; her mouth was crooked; and her head was shifted. CNA M said Resident #4 was normal earlier in the day. CNA M said she heard one of the nurses say that since the resident was a DNR they were not supposed to send them out. During an interview on [DATE] at 9:13 a.m., LVN J said there was an incident Sunday. The LVN said Resident #4 was her resident, but she was busy with another resident and another LVN (LVN L) and the DON assessed her. The DON's perception was that the resident was okay. The other LVN took Resident #4's vital signs and they were a little elevated, but that was normal for her. LVN J said when she saw the resident her right grip was a little weaker than the left, she could follow commands, and her right eye was turned to far to the right all that could be seen was the white of her eye. LVN J said the resident returned to normal later that day. When she left work that day, the resident was normal. She next returned to work Tuesday ([DATE]) and Resident #4 would not eat and she was on hospice. LVN J said as of yesterday ([DATE]) the resident was back to normal. During an interview on [DATE] at 9:35 a.m., CNA G said the DON would not send residents that had a DNR out to the hospital. "Like if they have a [MEDICAL CONDITION], (the DON) says don't send them out." During an interview on [DATE] at 8:25 p.m., the MDS coordinator said if concerns were brought to the DON about a resident that was a DNR, the DON would say, "It's ok, she's going (dying) anyway." The DON had a death list. The death list contained the names of residents who were older or were DNR. The MDS coordinator said the DON would say, "They're on my death list." It made it sound like the residents did not receive the same services if they had a DNR. During an interview on [DATE] at 8:43 p.m., LVN N said the DON would comment that a resident with a DNR was going to die anyway. During an interview on [DATE] at 10:50 a.m., the administrator said she heard the DON refer to the death list. She said she asked the DON more than once to refer it to as an Angel List. The administrator said this was the way to keep up with residents who were not dying so the staff could focus more on that resident. The administrator said she heard, at least once, the DON say that a resident was a DNR and was dying anyway. The administrator said she thought the DON was referring to residents who were receiving hospice services and the DON was telling the signs of the resident's imminent passing. "That's my fault for trusting her." The administrator began crying and said, "It never crossed my mind that someone would do that in long-term care." During an interview on [DATE] at 4:23 p.m., LVN O said she heard the DON questioning other nurses why they were sending a resident to the hospital because they were a DNR. LVN O said months ago a resident was sent to the hospital. The resident's daughter came to the facility and the DON told the daughter her father should not have been sent to the hospital because he was a DNR. LVN O said the daughter became very angry and said DNR did not mean do not treat. The DON told the daughter then she should make her father a full code. LVN O said if she felt someone needed to go to the hospital she called the family. If the family wanted the resident sent to the hospital, then she sent them and documented it was done at family request. An Abuse Prohibition policy effective [DATE] indicated "Each resident has a right to be free from mistreatment, neglect and misappropriation of property." During an interview on [DATE] at 8:45 a.m., the administrator was informed of the presence of an Immediate Jeopardy in the area of neglect. The facility's plan of removal was accepted on [DATE] at 4:50 p.m. and included: "How will the facility correct the deficient practice for those residents identified in the deficiency? The DON and ADON have been terminated. Counseling inservice with the current Abuse Coordinator on identifying and addressing an (sic) noted patterns or trends related to abuse and neglect. All staff who had prior knowledge of abuse/neglect and failed to report it to the Abuse Coordinator will be formally counseled in writing and will be held accountable for following the policy for the prohibition of abuse and neglect. All residents currently in the facility have been interviewed and any incidents related to abuse or neglect have been self-report when indicated. All residents who have a DNR have been assessed for any change in condition-all residents are currently stable. How will the facility identify those at risk for similar deficient practice? All residents in the facility have the potential to be affected. What will be done to prevent the deficient practice from recurring? ALL facility staff will be inserviced on the Abuse/Neglect policy and will demonstrate proficiency through return demonstration prior to returning to their current positions within the facility. All staff will be inserviced on Senior Care's policy on retaliation. Any staff member who is found to have violated wither policy will be immediately suspended pending investigation. The administrator and social worker will convene a resident council meeting and will educate residents on the abuse prohibition policy and retaliation, including where to find names and numbers of who to contact. All nursing staff will be inserviced on identifying, assessment, and notification of change in condition for ALL residents (full code or DNR). How will facility monitor its own corrective action? This process improvement plan will be reviewed monthly at QAPI. Inservice training via SilverChair (online learning resource) will continue to be done on hire of all new facility staff and annually thereafter. This will include a post test." The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Seven CNAs, five LVNs, Rehabilitation Director, Activity Director, MA, Dietary Manager, and the Business Office Manager were interviewed and were able to define neglect and how to report it. The five LVNs verbalized what to do if a resident had a change in condition and how a DNR would impact their interventions. Staff was in-serviced prior to assuming their duties on [DATE] and [DATE]. In-service sign-in sheets were provided, which contained the signatures of staff working [DATE] and [DATE]. During an interview on [DATE] at 3:48 p.m., the administrator said the DON was suspended related to this incident. During an interview on [DATE] at 10:50 a.m., the administrator said the DON was terminated. On [DATE] at 2:15 p.m., the administrator was informed the IJ was removed; however the facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 form completed [DATE] indicated the census was 95.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property were reported immediately to the administrator of the facility for 3 of 16 residents reviewed for abuse and neglect. (Resident #s 1, 4, and 3) Resident #1 was denied her medicated mouthwash by LVN A on [DATE]. The resident became angry and the DON and ADON forced the resident to bed during the late afternoon hour. Resident #1 was thrown into the bed by the DON grabbing her legs and the LVN ADON grabbing her left arm. The resident's wheelchair was taken away from her so she could not get up. On [DATE] the resident was forced to go to the hospital for a psychiatric evaluation. She was tied down to the stretcher. The resident was crying the night of [DATE] and did not eat her supper. She complained of hitting her head, back and foot. This incident was not reported to the administrator. Resident #4, who had a DNR directive and had significant neurological and physiological changes and did not receive medical attention. Two LVNs (K and L) and one CNA (M) recognized these changes were not normal for Resident #4. The DON instructed the staff to put the resident in bed to rest. The DON did not want residents with a DNR directive sent to the hospital. The facility did not intervene on the resident's behalf by sending to the hospital or contacting the physician. LVN A had attempted to make Resident #3 go to the dining room. When the resident yelled at the nurse that he did not want to go, the nurse pointed his finger in the resident's face and told him not to speak to him that way. This incident was not reported to the administrator. The facility's Abuse Prevention policy contained to notify the supervisor of abuse or neglect. The supervisor would then notify the director of nurses and/or the administrator. The policy did not state the administrator had to be notified of all allegations of abuse or neglect. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 95 residents at risk for physical injury, loss of self-worth, despair, a decline in condition without medical intervention, or death. Findings included: 1. Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years-old, with [DIAGNOSES REDACTED]. The orders also indicated the resident received counseling services, which was originally ordered [DATE]. A quarterly MDS with an assessment reference date of [DATE] indicated the resident had moderately impaired cognition, no signs of [MEDICAL CONDITION], no adverse moods, and no behaviors. Nurse's note entry dated [DATE] at 6:25 p.m. and written by LVN ADON indicated she called Resident #1's daughter and informed her the resident was "lashing out" at the nurse and being paranoid about things like people talking behind her back. The daughter told the nurse her mother had these episodes at times and she would try to talk to her. The LVN ADON documented the resident was in her room at that time and there were no signs and symptoms of distress. The next nurse's entry was dated [DATE] at 6:00 p.m. (but documented after the 6:25 p.m. entry) indicated there was a new order for urinalysis. Resident #1 refused to give a specimen at that time. There were no other nursing notes for [DATE]. The next nurse's entry dated [DATE] at 9:30 a.m. indicated Resident #1 refused to come out of her room. The resident said, "I am going to stay in my room where I am safe." The resident told the nurse, "Your head nurse and some other people threw me in the bed." The nurse documented the resident complained of back pain. The resident pointed to two discolorations on her arms and said that was what was done to her. She documented there was active range of motion to all extremities and then asked the resident for a urine specimen. The resident attempted but said she was not able to do it at that time and that she would try later. The nurse wrote she informed the DON of the resident's complaint. The DON informed the nurse the resident had been combative the day prior and she was assisted to bed. At 10:00 a.m. the nurse administered pain medication for the resident's complaint of back pain. At 10:30 a.m. the ambulance arrived to transfer the resident to the hospital for evaluation and possible psychiatric admission. A nurse's entry dated [DATE] at 11:00 p.m. indicated Resident #1 was sitting on side of bed visiting with another resident. There were no signs or symptoms of distress. A progress note for counseling services dated [DATE] indicated Resident #1 said she was doing "pretty good." The resident said she had been in some pain, which escalated her anxiety. The resident was also worried about her brother's health. The counselor documented the resident had positive responses to the support. The Psychoactive Behavior Monitoring for [DATE] for Resident #1 indicated "No behaviors observed" was initialed every day and every shift from [DATE]-[DATE]. During an interview on [DATE] at 3:30 p.m., Resident #2 said she lived on the same hall as Resident #1. Resident #2 said she heard staff raise her voice to Resident #1. She said staff also hurt Resident #1's foot. Resident #2 said she saw Resident #1 get mad at LVN A because he would not give her medication. Resident #2 said LVN A told Resident #1 to shut up. Resident #1 told the LVN not to tell her to shut up. Resident #1 then tried to go into the medication room and the MA shut the door. The resident was kicking the door. The DON came out of her office and said she was taking Resident #1 to bed. Resident #1 said she did not want to go to bed. Resident #2 said the DON dug her nails into Resident #1's arms. She said 3 or 4 staff went into Resident #1's room. Resident #2 said she stayed with Resident #1 after the staff left because she was crying and upset. She said the staff hurt her. During an interview on [DATE] at 4:15 p.m., OTA B said OTA C called her and said she saw Resident #1 being mistreated. OTA B said she and OTA C went to check on Resident #1. The resident was sitting on the side of the bed, crying, and rubbing her foot. The resident said "they" took her wheelchair from her because "they" knew she could not get up without it. OTA B said she did not see the wheelchair in the resident's room. OTA B went on to say that Resident #1 was really upset. She said her foot was hurting and she hit her head when she was "thrown" in bed. OTA C told OTA B the DON forcefully took the resident to her room, along with LVN ADON. While, they were consoling the resident, Resident #1 said she needed to go to the bathroom. OTA B said when she looked in the bathroom the resident's wheelchair was in there. OTA B said Resident #1 was sent to the hospital this morning ([DATE]) because the DON said she was combative. OTA B said she had never known Resident #1 to be combative. Resident #1 was placed on the stretcher. She was still in her night gown. OTA B said Resident #1 was always dressed and put together. Resident #1 was upset and yelling that she did not want to go. OTA B said she heard the DON say, "It's all because of me." OTA B said everyone was watching and no one said anything. The DON called a meeting after Resident #1 left. The DON told staff that she and the LVN ADON had not hurt the resident. She told everyone that she did not want to hear any more about it and if she did, she would fire that person. During an interview on [DATE] at 5:00 p.m., the Activity Director (AD) said on [DATE] Resident #1 wanted her medicated mouthwash because she had mouth pain. LVN A told Resident #1 the medication was discontinued. Resident #1 went to the DON and the DON had the LVN ADON call and get it refilled. Later, the resident overheard LVN A say they did not have the mouthwash. Resident #1 became upset. Resident #1 grabbed LVN A's arm and he pulled away from her. Resident #1 was circling the medication cart to get to the LVN. The AD said she went and got the DON. The resident was at the medication room, kicking the door. The DON attempted to wheel the resident back to her room. The resident put her feet down and the DON tilted the wheelchair back. The resident said the DON broke her leg. The DON said, "I'm not going to deal with this." The DON called the LVN ADON to help put the resident to bed. The AD said the LVN ADON was at the nurses' station. The AD said Resident #1 kept saying she was not ready to go to bed. The AD said the resident was crying and upset. She was "scared." The AD said as the DON was taking the resident down the hall the resident was reaching back, trying to fight the DON. The DON took the palm of her hand and pushed the resident's chest to push her back in the chair. The AD began to cry during the interview. She said the resident was trying to hit the DON and called her a "fat [***] ." The resident said her leg was caught under the seat of the wheelchair while the DON was pushing it. The resident said the DON had broken her leg. The DON took the resident down the hall on two wheels. The DON had to stop along the way because the resident was fighting her. Resident #1 asked to talk to the AD after the events and asked the AD if she was against her. The resident was crying. Resident #1 told the AD she was thrown in bed against the wall. The AD said she went and told the DON the allegation. The DON said it was not true. The AD said the resident said her back, leg, and arms were hurt. The AD said she saw little areas on the resident's arms. She said they looked like little areas similar to how someone's arms look when they were taking certain medications. The AD said she had never seen areas like that on the resident's arms before. The AD said she saw the DON in the administrator's office, so she assumed the DON told the administrator what happened. The DON had a meeting and told everyone if they spoke about what happened they would be fired. The DON told everyone that was a threat. During an interview on [DATE] at 5:54 p.m., LVN A said he had been employed at the facility since the second week in [DATE]. He said Resident #1 had problems with her jaw. When the resident went to the dentist, the dentist ordered [MEDICATION NAME] mouthwash. When the resident finished the initial bottle, she wanted more because she thought it helped. The resident went back to the dentist and she came back with more, but it was the over-the-counter [MEDICATION NAME]. LVN A said that bottle was finished Friday or Monday ([DATE] or [DATE]). LVN A said on Tuesday ([DATE]) the MA said the resident was asking for the [MEDICATION NAME]. LVN A said he tried to explain to the resident that she was out. LVN A said the LVN ADON called the dentist and got a third bottle. On [DATE] the MA asked him for clarification on the order. The resident rolled up and was confrontational. The resident wanted the entire bottle to keep in her room. LVN A said the resident grabbed his arm with both hands. The AD diverted the resident ' s attention. LVN A said he went to the DON's office and told her what was going on. The DON and LVN ADON, who was also in the office, said they would handle it. LVN A said at that point he went to the nurses' station to complete paperwork. The MA had the medication cart at the nurses' station and the resident wanted the bottle. The MA went into the medication room and the resident kicked the door and yelled. LVN A said he was worried because the resident had a broken foot. He said the DON and LVN ADON tried to talk to the resident. LVN A said the DON and LVN ADON took the resident down the hall but he did not see it. LVN A said he felt bad because he was not involved in trying to redirect the resident, but the resident did not like him, so he thought it was best to stay out of it. LVN A said he did not go into the resident's room the rest of the night. He had the MA check on her. During an interview on [DATE] at 6:14 p.m., MA D said on [DATE] sometime after 3:00 p.m. Resident #1 was asking about her mouthwash. She told the resident she did not have any. While she was giving medications to another resident, the MA pulled some bottles out of the medicine cart. There was a bottle of [MEDICATION NAME] with Resident #1's name on it. Resident #1 saw the bottle and wanted it. MA D said it was not on the MAR. She took the medicine cart to the nurses' station to ask LVN A about it. The resident grabbed LVN A's arm and the LVN walked away. MA D said Resident #1 still wanted the mouthwash. She said she went to the medication room. The resident was knocking on the door. The RN ADON was trying to talk to the resident. The RN ADON entered the medication room and MA D said she explained to her what was going on. The RN ADON went out of the medication room to talk to the resident, who then kicked the door. MA D said there was a therapist there (OTA C). The resident grabbed onto the handrail. MA D said OTA C was trying to talk to the resident. The DON came up and told the resident to listen to her. The DON tried to get the resident's hands off the handrail. The DON said she was going to put the resident to bed. The resident put her feet down and said she did not want to go to bed. The DON pulled the wheelchair back so the resident could not put her feet down. MA D said it just escalated from there. MA D said she went into the resident's room afterwards with CNA E. Resident #1 said someone "threw her around the bed and grabbed her arms." MA D said the resident's arms had bruises. MA D said she told LVN A about the bruises. MA D said she did not remember seeing the resident's wheelchair in her room. She said she knew the resident used it to get up to the bathroom. MA D said CNA E told her she was in the room when the DON and LVN ADON put the resident in bed. CNA E told MA D the two had "flung" the resident in the bed. CNA E told MA D she would not want anyone to treat her mother or grandmother that way. MA D began crying during the interview and said that it had bothered her. During an interview on [DATE] at 6:45 p.m., the business office manager (BOM) said on [DATE] she heard Resident #1 screaming. She went to the resident and asked what was wrong. Resident #1 told the BOM, "That man (LVN A) is mean to me." The BOM said this was around 3:30 p.m. She went to the DON and told her what Resident #1 said. The DON told the BOM that Resident #1 was "cycling." The BOM said she left the building around 5:00 p.m. and the incident happened after that. The BOM said when she arrived at the building on [DATE] the ambulance was taking Resident #1 out. The resident was screaming not to break her leg. The DON called a meeting at about 10:,[DATE]:30 a.m. She announced over the loudspeaker for all staff to come to the conference room. At the meeting, the DON told the staff, "I want this to stop right now." She told the staff Resident #1 was "cycling" and they were trying to get a urinalysis on her. She went on to tell the staff if she heard talk about it, the staff would be fired. The BOM said the AD and administrator were in the meeting and they were both crying. The DON said there was an episode with Resident #1 last night and the resident tried to turn over the medication cart. The DON said she had to lift the wheelchair. She went on to tell the staff there were no bruises on the resident. The BOM said one of the MAs asked the DON about LVN A aggravating the resident for the last two weeks. The DON said the resident was "cycling." The administrator told everyone the resident was sick and they were trying to get her help. The DON talked interrupted the administrator and would not let her talk. The DON went on to tell the staff they would be terminated if they talked about it and, "If you want to take that as a threat, take it as a threat." The BOM said she thought the DON was an excellent nurse, but she talked rough with the residents and staff. During an interview on [DATE] at 7:12 p.m., LVN F said she worked the evening of [DATE], but she, "did not see a lot." She said the resident was "exceedingly upset." LVN F said Resident #1 would get upset at times, but it was not often. Resident #1 was really mad at LVN A, but she did not know why. LVN F said she was told Resident #1 kicked the medication room door. LVN F said she heard Resident #1 talking loud and sounded angry. LVN A told her, "Your baby is mad at me." LVN F said the therapy people came and got her and wanted her to look at the resident's arms. She said there were three bruises on Resident #1's left arm that were "reminiscent of finger marks", but the resident had frail skin. The resident was complaining of foot pain, but there was no sign of injury. Resident #1 told LVN F "they" jerked her. The resident said, "They picked me up and chunked me in the bed." The resident did not say who they were. LVN F said Resident #1 was angrier than she had ever seen her. LVN F said she would consider what happened to Resident #1 abuse. She said she told the RN ADON. During an interview on [DATE] at 7:30 p.m., the RN ADON said Resident #1 told her the MA would not give her medication. The RN ADON entered the medication room to talk to the MA. The MA explained about the mouthwash. When the RN ADON opened the door of the medication room to come out, the resident tried to get into the room. She said she tried to calm the resident down, but she was screaming. The DON came up and tried to explain to the resident. The DON pulled the wheelchair away from the door. The resident was hollering. The RN ADON said the DON was normally loud. Resident #1 was swinging at the DON over her shoulders. The RN ADON said the DON lifted the wheelchair because the resident was putting her feet down. The RN ADON said she only saw the DON do it for a few feet then the RN ADON left. The LVN ADON and a CNA were with the DON. The RN ADON said no one reported bruises to her. The RN ADON said the resident was sent to the hospital the morning of [DATE]. She said she heard Resident #1 yelling, but she was making rounds with a physician and did not see what was going on. She said Resident #1 had been escalating a couple of weeks. She said the resident threw some plates Sunday ([DATE]). She said they had talked to the family and had gotten an order for [REDACTED]. The RN ADON said she called the emergency room at 6:00 p.m. and was told the resident would not do a voluntary commitment, so they were waiting on the mental health authority to come and do an evaluation. The RN ADON said she would not have handled the situation the way the DON had. During an interview on [DATE] at 7:52 p.m., the LVN ADON said LVN A told her Resident #1 wanted him to stay away from her. LVN ADON said she told LVN A to leave her alone. The AD came and told her and the DON on [DATE] that Resident #1 was chasing LVN A around the medication cart. LVN ADON said she asked, "Why is he near her?" The LVN ADON said later she came out of the conference room and the resident was holding onto the handrail. The DON was telling her to let go of the rail and that she was going to hurt herself. The LVN ADON said she, the DON and a CNA took the resident to her room. She said they put the resident into bed and she sat on the bed beside the resident. The resident was reaching for her phone and pointing at the DON. The DON left the room. The LVN ADON said the CNA put the resident's wheelchair in the bathroom. She said at that point she left the room. The LVN ADON said she did not see any bruises on the resident's arms. She said she did not see the resident again. The LVN ADON said she called the doctor who ordered a urinalysis. During an observation on [DATE] at 8:12 a.m., Resident was #1 was in the dining room eating breakfast. She was sitting in a wheelchair. She was smiling and was pleasant. At this time, she agreed to speak to the surveyor when she finished her breakfast. During an interview on [DATE] at 8:23 a.m., Resident #1 said the man nurse (LVN A) would not give her mouthwash. She said the nurse had been here a short time and he did not know his name. She described the physical characteristics of LVN A. The resident said the bones "were working out" on the right side of her jaw. She went to the dentist and he gave her a mouthwash. Resident #1 said the mouthwash helped her a lot. She wanted to keep it in her room because she did not always get it the way she was supposed to. Resident #1 said she was talking to someone about her mouthwash and "she walked up behind me and got a hold of my wheelchair." Resident #1 said "she" (the DON) was yelling at her, saying she did not have a broken leg. "She threw me backwards in the chair and shook me in it. There was nothing I could do. They slung me out of the chair and against the wall." The resident showed her arms to the surveyor and pointed out bruises to both arms. The resident pointed to areas on her left arm and said, "This is where she dug her nails in my arm." There were 3 areas to the resident's left arm that each measured approximately 1.5 cm in diameter. They were reddish-purple in color. Resident #1 said her wheelchair was taken away and put in the bathroom because they knew she could not get up without it. The resident said this was the first time something like this happened to her. She said she knew she said some things that she should not have said. "You know how you say things when you are upset." Resident #1 said they hurt her leg and caused her whole leg to ache. Resident #1 said she was nervous inside. The resident described the staff as wearing red tops and khaki pants. A nurse's entry dated [DATE] at 10:00 a.m. indicated Resident #1 was in the wheelchair, propelling herself on the hallway. She was alert and friendly with no behaviors noted. During an interview on [DATE] at 12:43 p.m., CNA E said on [DATE] she had finished feeding a resident on the 400 hall and was putting the tray on the cart, when she saw the DON coming down the hall with Resident #1. CNA E said the RN ADON told her to help the DON. CNA E said the LVN ADON followed them down to Resident #1's room. She said once in the room the DON grabbed the resident's legs and the LVN ADON grabbed the resident's left arm and swung her in bed. CNA E said she left the room and was looking for her nurse, but could not find her. She said she went back to Resident #1's room to check on her and the therapists were in there with her. CNA E said she told the therapists what happened to the resident. CNA E said the LVN ADON had been watching her and she felt the LVN ADON was afraid she was going to say something. CNA E said Resident #1 was cussing the DON and telling her to leave her alone. CNA E said the DON told the resident, "You're being ridiculous. Until you know how to act, you're going to bed." The resident kept saying she was not going to bed. CNA E repeated that the LVN ADON had grabbed the resident's left arm and the resident was "swung" into bed. CNA E said the LVN ADON and DON put the resident in bed upside down. The resident's head was at the foot of the bed. She said you could hear them swinging her and the landing "was not comfortable, not easy." CNA E said when she went back to the room, the resident's wheelchair was in the bathroom and her call light was on the floor. The resident was crying and upset. CNA E said on her way to speak to the surveyor, the LVN ADON told her that the surveyor was going to ask if the resident was thrown in bed and that they had not thrown her. CNA E said she felt Resident #1 was abused. She said grabbing the resident and swinging her in bed upside down was abuse. She said Resident #1 refused to eat that evening. During an interview on [DATE] at 1:26 p.m. OTA C said on [DATE] she was in the conference room. She said when she came out of the room Resident #1 was at the medication room and had her foot that had been broken in the past out, trying to hold the door open. OTA C said she saw the RN ADON trying to talk to the resident. She was telling her she did not have a medication. OTA C said Resident #1 was upset. She said she had a good rapport with the resident and she thought she could calm her. She said Resident #1 was talking loud, but she was not hitting. OTA C said she approached the resident and began rubbing her back and bent down to talk her when the DON walked up behind her and said, "I've had enough of you. You're going to bed." Resident #1 grabbed the handrails and the DON forcibly removed the resident's hands. OTA C said she was in shock. The DON took the resident down the hallway very quickly and the resident's broken foot (the right one) was drug under the chair. The resident hollered that the DON was breaking her foot. The DON then tilted the wheelchair back on two wheels. OTA C said the resident and DON yelled at each other. A CNA and the LVN ADON followed the DON to the resident's room. OTA C said she heard the LVN ADON say that Resident #1 had been "acting up all day." OTA C said she was standing in the hallway and she heard this "gut curling scream." She went into another resident's room and shut the door because she was afraid. She said she called OTA B and told her what she saw. Once OTA B arrived, the staff had left Resident #1's room. The two OTAs entered the resident's room and found her sitting on the side of the bed, trying to get up. The resident told them that her wheelchair had been taken away. OTA C said the resident was crying and never tried to fight her or OTA B. OTA C said the next morning, her and OTA B go to check on Resident #1. She was lying in bed, crying. She said her back hurt from being thrown in bed. The OTAs left the room. She had heard the resident was sent to the hospital that morning. During an interview on [DATE] at 9:35 a.m., CNA G said she worked the morning of [DATE]. CNA G said Resident #1 was "...an angel. I love her to death." CNA G said right before lunch at about 10:45 a.m. she heard someone hollering and she ran to where it was coming from. CNA G said she saw Resident #1 on a stretcher with her wrists tied down with a sheet. There were two emergency medical service personnel, the DON and the administrator with the resident. Resident #1 asked CNA G if she would help her. CNA G said she told the resident to calm down. She said the resident was crying. CNA G said Resident #1 was yelling the whole time they took her out of the facility. The CNA began to cry during the interview. She said Resident #1 yelled at the DON, "Get that [***] away from me." CNA G said Resident #1 was not a violent or aggressive and for her to act like that, something had to have happened. CNA G said she wondered if LVN A had done something to provoke Resident #1 because she was not like that with everyone else. During an interview on [DATE] at 9:55 a.m., LVN H said a CNA told her the resident was crying the morning of [DATE]. The CNA said the resident was saying the "head person" in the red shirt threw her in bed. LVN H said there were three people that wore red shirts: DON, LVN ADON, and RN ADON. She said the nurses wore blue, the CNAs wore maroon, and the MAs wore light blue. LVN H said she went to talk to the resident and she was not crying at that time. The resident first accused her of being one of them. LVN H said after she talked to the resident for a bit, the resident apologized for thinking she was one of them. LVN H said Resident #1 told her, "I admit I said some things to the big guy on ,[DATE], but they didn't have to throw me in bed." LVN H said the resident had some bruises that were red to the tops of both of her arms. The resident also complained of back pain and requested pain medication. LVN H said when she left the room, she met the DON in the hall and told her the resident's allegation. The DON said it did not happen. The DON said there were witnesses and she had gotten an order to send the resident to the hospital for a psychiatric evaluation. The LVN said she returned to the resident's room with something for pain and told her about going to the hospital. The resident said she did not want to go to the hospital. LVN H said the resident was not mean; she just did not want to go. LVN H said she told the social worker who went and talked to the DON. The DON said the resident had to go. LVN H said it upset her because the resident was confused at times, but she was "at herself" enough to refuse going to the hospital. When the emergency medical technicians arrived, they went and talked to Resident #1. They came back to the nurses' station and said the resident refused to go. The DON and administrator went to the resident's room. LVN H said she heard the resident yell. LVN H said it was a very emotional day. She said the DON said the resident was having behaviors, but she had not seen it. She said the DON asked her why she was not charting the behaviors. She said she told her she did not document behaviors because she had not seen the resident exhibit any behaviors. All the behaviors seemed to occur when LVN A worked. During an interview on [DATE] at 10:40 a.m., the administrator said she was told the DON had a lot of experience and she could learn a lot from her. She said there was a power struggle between her and the DON. She said the problem began when she hired a RN as the ADON. She thought maybe the DON felt threatened. Now, staff is coming to her and saying the DON told them not to go to administrator with anything. The administrator said she asked the DON to take some time off because she was at the facility all the time. 2. A Face Sheet dated [DATE] for Resident #4 indicated the resident was admitted [DATE] and was [AGE] years-old. An undated annual physical exam completed by the physician for Resident #4 indicated the resident had a history of [REDACTED]. The chief complaint(s) were listed as an [DATE] hospital stay with gastrointestinal blood loss, urinary tract infection, high blood pressure, diabetes, and acute post-hemorrhagic [MEDICAL CONDITION]. The short-term and long-term goals were listed as long-term care with possible hospice care. A care plan with problem onset date of [DATE] indicated Resident #4 and family had elected to designate an advance directive. The first approach read, "If [MEDICAL CONDITION] Do Not Resuscitate." This care plan was initialed to continue plan of care on [DATE] and [DATE]. An undated care plan for Resident #4 indicated the resident requested a code status of "No CPR". The social worker signed the care plan [DATE]. A daily skilled nurse's note dated [DATE] with a late entry at 11:00 a.m. indicated Resident #4 was seen in the dining room clenching her bottom denture in her hand (grasping denture in hand on lap), tongue rolled up in her mouth, left eye up and to the left, and right eye down and to the right. The resident did not respond to staff. Blood pressure was ,[DATE] and her pulse was 86. The nurse (LVN L) documented the resident's nurse was tied up so she got another nurse (LVN K) and a nurse aide (CNA M) to help her. "At this time, DON walks up and asks what is going on. Looks at resident and says 'she's just tired this is normal for her.' We tried to argue that it wasn't, but she told us to lay her down and let her rest. Notified nurse (LVN J) of what happened." The nurses' notes for Resident #5 dated [DATE]-[DATE] indicated the following blood pressure readings: [DATE]-,[DATE] [DATE]-,[DATE] [DATE]-,[DATE] [DATE]-,[DATE] [DATE]-,[DATE] [DATE]-,[DATE] [DATE]-,[DATE] A physician's telephone o

Based on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibited abuse or neglect for 3 of 16 residents reviewed for abuse and neglect. (Resident #s 1, 4, and 3) Resident #1 was denied her medicated mouthwash by LVN A on [DATE]. The resident became angry and the DON and ADON forced the resident to bed during the late afternoon hour. Resident #1 was thrown into the bed by the DON grabbing her legs and the LVN ADON grabbing her left arm. The resident's wheelchair was taken away from her so she could not get up. On [DATE] the resident was forced to go to the hospital for a psychiatric evaluation. She was tied down to the stretcher. The resident was crying the night of [DATE] and did not eat her supper. She complained of hitting her head, back and foot. This incident was not reported to the administrator. Resident #4, who had a DNR directive and had significant neurological and physiological changes did not receive medical attention. Two LVNs (K and L) and one CNA (M) recognized these changes were not normal for Resident #4. The DON instructed the staff to put the resident in bed to rest. The DON did not want residents with a DNR directive sent to the hospital. The facility did not intervene on the resident's behalf by sending to the hospital or contacting the physician. LVN A had attempted to make Resident #3 go to the dining room. When the resident yelled at the nurse that he did not want to go, the nurse pointed his finger in the resident's face and told him not to speak to him that way. This incident was not reported to the administrator. The facility's Abuse Prevention policy contained to notify the supervisor of abuse or neglect. The supervisor would then notify the director of nurses and/or the administrator. The policy did not state the administrator had to be notified of all allegations of abuse or neglect. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 95 residents at risk for physical injury, loss of self-worth, despair, a decline in condition without medical intervention, or death. Findings included: The Abuse Prohibition policy effective [DATE] indicated: "Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friend or other individuals." "...All employees who suspect abuse at any time it is identified are to report it to their immediate supervisor. If the supervisor is not the charge nurse then the supervisor will report it to the charge nurse who is responsible for the resident suspected of being abused. The charge nurse receiving the allegation shall immediately contact either one of the following: the nurse on call, who will then report the allegation to the director of nursing, or the assistant director of nursing, the director of nursing, and/or the administrator..." 1. Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years-old, with [DIAGNOSES REDACTED]. The orders also indicated the resident received counseling services, which was originally ordered [DATE]. A quarterly MDS with an assessment reference date of [DATE] indicated the resident had moderately impaired cognition, no signs of [MEDICAL CONDITION], no adverse moods, and no behaviors. Nurse's note entry dated [DATE] at 6:25 p.m. and written by LVN ADON indicated she called Resident #1's daughter and informed her the resident was "lashing out" at the nurse and being paranoid about things like people talking behind her back. The daughter told the nurse her mother had these episodes at times and she would try to talk to her. The LVN ADON documented the resident was in her room at that time and there were no signs and symptoms of distress. The next nurse's entry was dated [DATE] at 6:00 p.m. (but documented after the 6:25 p.m. entry) indicated there was a new order for urinalysis. Resident #1 refused to give a specimen at that time. There were no other nursing notes for [DATE]. The next nurse's entry dated [DATE] at 9:30 a.m. indicated Resident #1 refused to come out of her room. The resident said, "I am going to stay in my room where I am safe." The resident told the nurse, "Your head nurse and some other people threw me in the bed." The nurse documented the resident complained of back pain. The resident pointed to two discolorations on her arms and said that was what was done to her. She documented there was active range of motion to all extremities and then asked the resident for a urine specimen. The resident attempted but said she was not able to do it at that time and that she would try later. The nurse wrote she informed the DON of the resident's complaint. The DON informed the nurse the resident had been combative the day prior and she was assisted to bed. At 10:00 a.m. the nurse administered pain medication for the resident's complaint of back pain. At 10:30 a.m. the ambulance arrived to transfer the resident to the hospital for evaluation and possible psychiatric admission. A nurse's entry dated [DATE] at 11:00 p.m. indicated Resident #1 was sitting on side of bed visiting with another resident. There were no signs or symptoms of distress. A progress note for counseling services dated [DATE] indicated Resident #1 said she was doing "pretty good." The resident said she had been in some pain, which escalated her anxiety. The resident was also worried about her brother's health. The counselor documented the resident had positive responses to the support. The Psychoactive Behavior Monitoring for [DATE] for Resident #1 indicated "No behaviors observed" was initialed every day and every shift from [DATE]-[DATE]. During an interview on [DATE] at 3:30 p.m., Resident #2 said she lived on the same hall as Resident #1. Resident #2 said she heard staff raise her voice to Resident #1. She said staff also hurt Resident #1's foot. Resident #2 said she saw Resident #1 get mad at LVN A because he would not give her medication. Resident #2 said LVN A told Resident #1 to shut up. Resident #1 told the LVN not to tell her to shut up. Resident #1 then tried to go into the medication room and the MA shut the door. The resident was kicking the door. The DON came out of her office and said she was taking Resident #1 to bed. Resident #1 said she did not want to go to bed. Resident #2 said the DON dug her nails into Resident #1's arms. She said 3 or 4 staff went into Resident #1's room. Resident #2 said she stayed with Resident #1 after the staff left because she was crying and upset. She said the staff hurt her. During an interview on [DATE] at 4:15 p.m., OTA B said OTA C called her and said she saw Resident #1 being mistreated. OTA B said she and OTA C went to check on Resident #1. The resident was sitting on the side of the bed, crying, and rubbing her foot. The resident said "they" took her wheelchair from her because "they" knew she could not get up without it. OTA B said she did not see the wheelchair in the resident's room. OTA B went on to say that Resident #1 was really upset. She said her foot was hurting and she hit her head when she was "thrown" in bed. OTA C told OTA B the DON forcefully took the resident to her room, along with LVN ADON. While, they were consoling the resident, Resident #1 said she needed to go to the bathroom. OTA B said when she looked in the bathroom the resident's wheelchair was in there. OTA B said Resident #1 was sent to the hospital this morning ([DATE]) because the DON said she was combative. OTA B said she had never known Resident #1 to be combative. Resident #1 was placed on the stretcher. She was still in her night gown. OTA B said Resident #1 was always dressed and put together. Resident #1 was upset and yelling that she did not want to go. OTA B said she heard the DON say, "It's all because of me." OTA B said everyone was watching and no one said anything. The DON called a meeting after Resident #1 left. The DON told staff that she and the LVN ADON had not hurt the resident. She told everyone that she did not want to hear any more about it and if she did, she would fire that person. During an interview on [DATE] at 5:00 p.m., the Activity Director (AD) said on [DATE] Resident #1 wanted her medicated mouthwash because she had mouth pain. LVN A told Resident #1 the medication was discontinued. Resident #1 went to the DON and the DON had the LVN ADON call and get it refilled. Later, the resident overheard LVN A say they did not have the mouthwash. Resident #1 became upset. Resident #1 grabbed LVN A's arm and he pulled away from her. Resident #1 was circling the medication cart to get to the LVN. The AD said she went and got the DON. The resident was at the medication room, kicking the door. The DON attempted to wheel the resident back to her room. The resident put her feet down and the DON tilted the wheelchair back. The resident said the DON broke her leg. The DON said, "I'm not going to deal with this." The DON called the LVN ADON to help put the resident to bed. The AD said the LVN ADON was at the nurses' station. The AD said Resident #1 kept saying she was not ready to go to bed. The AD said the resident was crying and upset. She was "scared." The AD said as the DON was taking the resident down the hall the resident was reaching back, trying to fight the DON. The DON took the palm of her hand and pushed the resident's chest to push her back in the chair. The AD began to cry during the interview. She said the resident was trying to hit the DON and called her a "fat [***] ." The resident said her leg was caught under the seat of the wheelchair while the DON was pushing it. The resident said the DON had broken her leg. The DON took the resident down the hall on two wheels. The DON had to stop along the way because the resident was fighting her. Resident #1 asked to talk to the AD after the events and asked the AD if she was against her. The resident was crying. Resident #1 told the AD she was thrown in bed against the wall. The AD said she went and told the DON the allegation. The DON said it was not true. The AD said the resident said her back, leg, and arms were hurt. The AD said she saw little areas on the resident's arms. She said they looked like little areas similar to how someone's arms look when they were taking certain medications. The AD said she had never seen areas like that on the resident's arms before. The AD said she saw the DON in the administrator's office, so she assumed the DON told the administrator what happened. The DON had a meeting and told everyone if they spoke about what happened they would be fired. The DON told everyone that was a threat. During an interview on [DATE] at 5:54 p.m., LVN A said he had been employed at the facility since the second week in [DATE]. He said Resident #1 had problems with her jaw. When the resident went to the dentist, the dentist ordered [MEDICATION NAME] mouthwash. When the resident finished the initial bottle, she wanted more because she thought it helped. The resident went back to the dentist and she came back with more, but it was the over-the-counter [MEDICATION NAME]. LVN A said that bottle was finished Friday or Monday ([DATE] or [DATE]). LVN A said on Tuesday ([DATE]) the MA said the resident was asking for the [MEDICATION NAME]. LVN A said he tried to explain to the resident that she was out. LVN A said the LVN ADON called the dentist and got a third bottle. On [DATE] the MA asked him for clarification on the order. The resident rolled up and was confrontational. The resident wanted the entire bottle to keep in her room. LVN A said the resident grabbed his arm with both hands. The AD diverted the resident ' s attention. LVN A said he went to the DON's office and told her what was going on. The DON and LVN ADON, who was also in the office, said they would handle it. LVN A said at that point he went to the nurses' station to complete paperwork. The MA had the medication cart at the nurses' station and the resident wanted the bottle. The MA went into the medication room and the resident kicked the door and yelled. LVN A said he was worried because the resident had a broken foot. He said the DON and LVN ADON tried to talk to the resident. LVN A said the DON and LVN ADON took the resident down the hall but he did not see it. LVN A said he felt bad because he was not involved in trying to redirect the resident, but the resident did not like him, so he thought it was best to stay out of it. LVN A said he did not go into the resident's room the rest of the night. He had the MA check on her. During an interview on [DATE] at 6:14 p.m., MA D said on [DATE] sometime after 3:00 p.m. Resident #1 was asking about her mouthwash. She told the resident she did not have any. While she was giving medications to another resident, the MA pulled some bottles out of the medicine cart. There was a bottle of [MEDICATION NAME] with Resident #1's name on it. Resident #1 saw the bottle and wanted it. MA D said it was not on the MAR. She took the medicine cart to the nurses' station to ask LVN A about it. The resident grabbed LVN A's arm and the LVN walked away. MA D said Resident #1 still wanted the mouthwash. She said she went to the medication room. The resident was knocking on the door. The RN ADON was trying to talk to the resident. The RN ADON entered the medication room and MA D said she explained to her what was going on. The RN ADON went out of the medication room to talk to the resident, who then kicked the door. MA D said there was a therapist there (OTA C). The resident grabbed onto the handrail. MA D said OTA C was trying to talk to the resident. The DON came up and told the resident to listen to her. The DON tried to get the resident's hands off the handrail. The DON said she was going to put the resident to bed. The resident put her feet down and said she did not want to go to bed. The DON pulled the wheelchair back so the resident could not put her feet down. MA D said it just escalated from there. MA D said she went into the resident's room afterwards with CNA E. Resident #1 said someone "threw her around the bed and grabbed her arms." MA D said the resident's arms had bruises. MA D said she told LVN A about the bruises. MA D said she did not remember seeing the resident's wheelchair in her room. She said she knew the resident used it to get up to the bathroom. MA D said CNA E told her she was in the room when the DON and LVN ADON put the resident in bed. CNA E told MA D the two had "flung" the resident in the bed. CNA E told MA D she would not want anyone to treat her mother or grandmother that way. MA D began crying during the interview and said that it had bothered her. During an interview on [DATE] at 6:45 p.m., the business office manager (BOM) said on [DATE] she heard Resident #1 screaming. She went to the resident and asked what was wrong. Resident #1 told the BOM, "That man (LVN A) is mean to me." The BOM said this was around 3:30 p.m. She went to the DON and told her what Resident #1 said. The DON told the BOM that Resident #1 was "cycling." The BOM said she left the building around 5:00 p.m. and the incident happened after that. The BOM said when she arrived at the building on [DATE] the ambulance was taking Resident #1 out. The resident was screaming not to break her leg. The DON called a meeting at about 10:,[DATE]:30 a.m. She announced over the loudspeaker for all staff to come to the conference room. At the meeting, the DON told the staff, "I want this to stop right now." She told the staff Resident #1 was "cycling" and they were trying to get a urinalysis on her. She went on to tell the staff if she heard talk about it, the staff would be fired. The BOM said the AD and administrator were in the meeting and they were both crying. The DON said there was an episode with Resident #1 last night and the resident tried to turn over the medication cart. The DON said she had to lift the wheelchair. She went on to tell the staff there were no bruises on the resident. The BOM said one of the MAs asked the DON about LVN A aggravating the resident for the last two weeks. The DON said the resident was "cycling." The administrator told everyone the resident was sick and they were trying to get her help. The DON talked interrupted the administrator and would not let her talk. The DON went on to tell the staff they would be terminated if they talked about it and, "If you want to take that as a threat, take it as a threat." The BOM said she thought the DON was an excellent nurse, but she talked rough with the residents and staff. During an interview on [DATE] at 7:12 p.m., LVN F said she worked the evening of [DATE], but she, "did not see a lot." She said the resident was "exceedingly upset." LVN F said Resident #1 would get upset at times, but it was not often. Resident #1 was really mad at LVN A, but she did not know why. LVN F said she was told Resident #1 kicked the medication room door. LVN F said she heard Resident #1 talking loud and sounded angry. LVN A told her, "Your baby is mad at me." LVN F said the therapy people came and got her and wanted her to look at the resident's arms. She said there were three bruises on Resident #1's left arm that were "reminiscent of finger marks", but the resident had frail skin. The resident was complaining of foot pain, but there was no sign of injury. Resident #1 told LVN F "they" jerked her. The resident said, "They picked me up and chunked me in the bed." The resident did not say who they were. LVN F said Resident #1 was angrier than she had ever seen her. LVN F said she would consider what happened to Resident #1 abuse. She said she told the RN ADON. During an interview on [DATE] at 7:30 p.m., the RN ADON said Resident #1 told her the MA would not give her medication. The RN ADON entered the medication room to talk to the MA. The MA explained about the mouthwash. When the RN ADON opened the door of the medication room to come out, the resident tried to get into the room. She said she tried to calm the resident down, but she was screaming. The DON came up and tried to explain to the resident. The DON pulled the wheelchair away from the door. The resident was hollering. The RN ADON said the DON was normally loud. Resident #1 was swinging at the DON over her shoulders. The RN ADON said the DON lifted the wheelchair because the resident was putting her feet down. The RN ADON said she only saw the DON do it for a few feet then the RN ADON left. The LVN ADON and a CNA were with the DON. The RN ADON said no one reported bruises to her. The RN ADON said the resident was sent to the hospital the morning of [DATE]. She said she heard Resident #1 yelling, but she was making rounds with a physician and did not see what was going on. She said Resident #1 had been escalating a couple of weeks. She said the resident threw some plates Sunday ([DATE]). She said they had talked to the family and had gotten an order for [REDACTED]. The RN ADON said she called the emergency room at 6:00 p.m. and was told the resident would not do a voluntary commitment, so they were waiting on the mental health authority to come and do an evaluation. The RN ADON said she would not have handled the situation the way the DON had. During an interview on [DATE] at 7:52 p.m., the LVN ADON said LVN A told her Resident #1 wanted him to stay away from her. LVN ADON said she told LVN A to leave her alone. The AD came and told her and the DON on [DATE] that Resident #1 was chasing LVN A around the medication cart. LVN ADON said she asked, "Why is he near her?" The LVN ADON said later she came out of the conference room and the resident was holding onto the handrail. The DON was telling her to let go of the rail and that she was going to hurt herself. The LVN ADON said she, the DON and a CNA took the resident to her room. She said they put the resident into bed and she sat on the bed beside the resident. The resident was reaching for her phone and pointing at the DON. The DON left the room. The LVN ADON said the CNA put the resident's wheelchair in the bathroom. She said at that point she left the room. The LVN ADON said she did not see any bruises on the resident's arms. She said she did not see the resident again. The LVN ADON said she called the doctor who ordered a urinalysis. During an observation on [DATE] at 8:12 a.m., Resident was #1 was in the dining room eating breakfast. She was sitting in a wheelchair. She was smiling and was pleasant. At this time, she agreed to speak to the surveyor when she finished her breakfast. During an interview on [DATE] at 8:23 a.m., Resident #1 said the man nurse (LVN A) would not give her mouthwash. She said the nurse had been here a short time and he did not know his name. She described the physical characteristics of LVN A. The resident said the bones "were working out" on the right side of her jaw. She went to the dentist and he gave her a mouthwash. Resident #1 said the mouthwash helped her a lot. She wanted to keep it in her room because she did not always get it the way she was supposed to. Resident #1 said she was talking to someone about her mouthwash and "she walked up behind me and got a hold of my wheelchair." Resident #1 said "she" (the DON) was yelling at her, saying she did not have a broken leg. "She threw me backwards in the chair and shook me in it. There was nothing I could do. They slung me out of the chair and against the wall." The resident showed her arms to the surveyor and pointed out bruises to both arms. The resident pointed to areas on her left arm and said, "This is where she dug her nails in my arm." There were 3 areas to the resident's left arm that each measured approximately 1.5 cm in diameter. They were reddish-purple in color. Resident #1 said her wheelchair was taken away and put in the bathroom because they knew she could not get up without it. The resident said this was the first time something like this happened to her. She said she knew she said some things that she should not have said. "You know how you say things when you are upset." Resident #1 said they hurt her leg and caused her whole leg to ache. Resident #1 said she was nervous inside. The resident described the staff as wearing red tops and khaki pants. A nurse's entry dated [DATE] at 10:00 a.m. indicated Resident #1 was in the wheelchair, propelling herself on the hallway. She was alert and friendly with no behaviors noted. During an interview on [DATE] at 12:43 p.m., CNA E said on [DATE] she had finished feeding a resident on the 400 hall and was putting the tray on the cart, when she saw the DON coming down the hall with Resident #1. CNA E said the RN ADON told her to help the DON. CNA E said the LVN ADON followed them down to Resident #1's room. She said once in the room the DON grabbed the resident's legs and the LVN ADON grabbed the resident's left arm and swung her in bed. CNA E said she left the room and was looking for her nurse, but could not find her. She said she went back to Resident #1's room to check on her and the therapists were in there with her. CNA E said she told the therapists what happened to the resident. CNA E said the LVN ADON had been watching her and she felt the LVN ADON was afraid she was going to say something. CNA E said Resident #1 was cussing the DON and telling her to leave her alone. CNA E said the DON told the resident, "You're being ridiculous. Until you know how to act, you're going to bed." The resident kept saying she was not going to bed. CNA E repeated that the LVN ADON had grabbed the resident's left arm and the resident was "swung" into bed. CNA E said the LVN ADON and DON put the resident in bed upside down. The resident's head was at the foot of the bed. She said you could hear them swinging her and the landing "was not comfortable, not easy." CNA E said when she went back to the room, the resident's wheelchair was in the bathroom and her call light was on the floor. The resident was crying and upset. CNA E said on her way to speak to the surveyor, the LVN ADON told her that the surveyor was going to ask if the resident was thrown in bed and that they had not thrown her. CNA E said she felt Resident #1 was abused. She said grabbing the resident and swinging her in bed upside down was abuse. She said Resident #1 refused to eat that evening. During an interview on [DATE] at 1:26 p.m. OTA C said on [DATE] she was in the conference room. She said when she came out of the room Resident #1 was at the medication room and had her foot that had been broken in the past out, trying to hold the door open. OTA C said she saw the RN ADON trying to talk to the resident. She was telling her she did not have a medication. OTA C said Resident #1 was upset. She said she had a good rapport with the resident and she thought she could calm her. She said Resident #1 was talking loud, but she was not hitting. OTA C said she approached the resident and began rubbing her back and bent down to talk her when the DON walked up behind her and said, "I've had enough of you. You're going to bed." Resident #1 grabbed the handrails and the DON forcibly removed the resident's hands. OTA C said she was in shock. The DON took the resident down the hallway very quickly and the resident's broken foot (the right one) was drug under the chair. The resident hollered that the DON was breaking her foot. The DON then tilted the wheelchair back on two wheels. OTA C said the resident and DON yelled at each other. A CNA and the LVN ADON followed the DON to the resident's room. OTA C said she heard the LVN ADON say that Resident #1 had been "acting up all day." OTA C said she was standing in the hallway and she heard this "gut curling scream." She went into another resident's room and shut the door because she was afraid. She said she called OTA B and told her what she saw. Once OTA B arrived, the staff had left Resident #1's room. The two OTAs entered the resident's room and found her sitting on the side of the bed, trying to get up. The resident told them that her wheelchair had been taken away. OTA C said the resident was crying and never tried to fight her or OTA B. OTA C said the next morning, her and OTA B go to check on Resident #1. She was lying in bed, crying. She said her back hurt from being thrown in bed. The OTAs left the room. She had heard the resident was sent to the hospital that morning. During an interview on [DATE] at 9:35 a.m., CNA G said she worked the morning of [DATE]. CNA G said Resident #1 was "...an angel. I love her to death." CNA G said right before lunch at about 10:45 a.m. she heard someone hollering and she ran to where it was coming from. CNA G said she saw Resident #1 on a stretcher with her wrists tied down with a sheet. There were two emergency medical service personnel, the DON and the administrator with the resident. Resident #1 asked CNA G if she would help her. CNA G said she told the resident to calm down. She said the resident was crying. CNA G said Resident #1 was yelling the whole time they took her out of the facility. The CNA began to cry during the interview. She said Resident #1 yelled at the DON, "Get that [***] away from me." CNA G said Resident #1 was not a violent or aggressive and for her to act like that, something had to have happened. CNA G said she wondered if LVN A had done something to provoke Resident #1 because she was not like that with everyone else. During an interview on [DATE] at 9:55 a.m., LVN H said a CNA told her the resident was crying the morning of [DATE]. The CNA said the resident was saying the "head person" in the red shirt threw her in bed. LVN H said there were three people that wore red shirts: DON, LVN ADON, and RN ADON. She said the nurses wore blue, the CNAs wore maroon, and the MAs wore light blue. LVN H said she went to talk to the resident and she was not crying at that time. The resident first accused her of being one of them. LVN H said after she talked to the resident for a bit, the resident apologized for thinking she was one of them. LVN H said Resident #1 told her, "I admit I said some things to the big guy on ,[DATE], but they didn't have to throw me in bed." LVN H said the resident had some bruises that were red to the tops of both of her arms. The resident also complained of back pain and requested pain medication. LVN H said when she left the room, she met the DON in the hall and told her the resident's allegation. The DON said it did not happen. The DON said there were witnesses and she had gotten an order to send the resident to the hospital for a psychiatric evaluation. The LVN said she returned to the resident's room with something for pain and told her about going to the hospital. The resident said she did not want to go to the hospital. LVN H said the resident was not mean; she just did not want to go. LVN H said she told the social worker who went and talked to the DON. The DON said the resident had to go. LVN H said it upset her because the resident was confused at times, but she was "at herself" enough to refuse going to the hospital. When the emergency medical technicians arrived, they went and talked to Resident #1. They came back to the nurses' station and said the resident refused to go. The DON and administrator went to the resident's room. LVN H said she heard the resident yell. LVN H said it was a very emotional day. She said the DON said the resident was having behaviors, but she had not seen it. She said the DON asked her why she was not charting the behaviors. She said she told her she did not document behaviors because she had not seen the resident exhibit any behaviors. All the behaviors seemed to occur when LVN A worked. During an interview on [DATE] at 10:40 a.m., the administrator said she was told the DON had a lot of experience and she could learn a lot from her. She said there was a power struggle between her and the DON. She said the problem began when she hired a RN as the ADON. She thought maybe the DON felt threatened. Now, staff is coming to her and saying the DON told them not to go to administrator with anything. The administrator said she asked the DON to take some time off because she was at the facility all the time. 2. A Face Sheet dated [DATE] for Resident #4 indicated the resident was admitted [DATE] and was [AGE] years-old. An undated annual physical exam completed by the physician for Resident #4 indicated the resident had a history of [REDACTED]. The chief complaint(s) were listed as an [DATE] hospital stay with gastrointestinal blood loss, urinary tract infection, high blood pressure, diabetes, and acute post-hemorrhagic [MEDICAL CONDITION]. The short-term and long-term goals were listed as long-term care with possible hospice care. A care plan with problem onset date of [DATE] indicated Resident #4 and family had elected to designate an advance directive. The first approach read, "If [MEDICAL CONDITION] Do Not Resuscitate." This care plan was initialed to continue plan of care on [DATE] and [DATE]. An undated care plan for Resident #4 indicated the resident requested a code status of "No CPR". The social worker signed the care plan [DATE]. A daily skilled nurse's note dated [DATE] with a late entry at 11:00 a.m. indicated Resident #4 was seen in the dining room clenching her bottom denture in her hand (grasping de

Based on observation, interview, and record review, the facility failed to ensure the services provided or arranged by the facility met professional standards of quality for 3 of 16 residents reviewed for abuse and neglect. (Resident #s 1, 3 and 4) Resident #1 was denied her medicated mouthwash by LVN A on [DATE]. The resident became angry and the DON and ADON forced the resident to bed during the late afternoon hour. Resident #1 was thrown into the bed by the DON grabbing her legs and the LVN ADON grabbing her left arm. The resident's wheelchair was taken away from her so she could not get up. On [DATE] the resident was forced to go to the hospital for a psychiatric evaluation. She was tied down to the stretcher. The resident was crying the night of [DATE] and did not eat her supper. She complained of hitting her head, back and foot. LVN A had attempted to make Resident #3 go to the dining room. When the resident yelled at the nurse that he did not want to go, the nurse pointed his finger in the resident's face and told him not to speak to him that way. Resident #4, who had a DNR directive had significant neurological and physiological changes. Two LVNs (K and L) and one CNA (M) recognized these changes were not normal for Resident #4. The DON instructed the staff to put the resident in bed to rest. The DON did not want residents with a DNR directive sent to the hospital. The facility did not intervene on the resident's behalf by sending to the hospital or contacting the physician. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 95 residents at risk for physical injury, loss of self-worth, and despair. Findings included: The Texas Administrative Code for Standards of Nursing Practice found at <http://www.bne.state.tx.us/rr_current/,[DATE].asp>, which was accessed on [DATE] indicated: RULE ?217.11 Standards of Nursing Practice "(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ...(D) ...(iii) whose actions constitute abuse, exploitation, fraud, or a violation of professional boundaries; or (iv) whose actions indicate that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior... (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications..." 1. Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years-old, with [DIAGNOSES REDACTED]. The orders also indicated the resident received counseling services, which was originally ordered [DATE]. A quarterly MDS with an assessment reference date of [DATE] indicated the resident had moderately impaired cognition, no signs of [MEDICAL CONDITION], no adverse moods, and no behaviors. Nurse's note entry dated [DATE] at 6:25 p.m. and written by LVN ADON indicated she called Resident #1's daughter and informed her the resident was "lashing out" at the nurse and being paranoid about things like people talking behind her back. The daughter told the nurse her mother had these episodes at times and she would try to talk to her. The LVN ADON documented the resident was in her room at that time and there were no signs and symptoms of distress. The next nurse's entry was dated [DATE] at 6:00 p.m. (but documented after the 6:25 p.m. entry) indicated there was a new order for urinalysis. Resident #1 refused to give a specimen at that time. There were no other nursing notes for [DATE]. The next nurse's entry dated [DATE] at 9:30 a.m. indicated Resident #1 refused to come out of her room. The resident said, "I am going to stay in my room where I am safe." The resident told the nurse, "Your head nurse and some other people threw me in the bed." The nurse documented the resident complained of back pain. The resident pointed to two discolorations on her arms and said that was what was done to her. She documented there was active range of motion to all extremities and then asked the resident for a urine specimen. The resident attempted but said she was not able to do it at that time and that she would try later. The nurse wrote she informed the DON of the resident's complaint. The DON informed the nurse the resident had been combative the day prior and she was assisted to bed. At 10:00 a.m. the nurse administered pain medication for the resident's complaint of back pain. At 10:30 a.m. the ambulance arrived to transfer the resident to the hospital for evaluation and possible psychiatric admission. A nurse's entry dated [DATE] at 11:00 p.m. indicated Resident #1 was sitting on side of bed visiting with another resident. There were no signs or symptoms of distress. A progress note for counseling services dated [DATE] indicated Resident #1 said she was doing "pretty good." The resident said she had been in some pain, which escalated her anxiety. The resident was also worried about her brother's health. The counselor documented the resident had positive responses to the support. The Psychoactive Behavior Monitoring for [DATE] for Resident #1 indicated "No behaviors observed" was initialed every day and every shift from [DATE]-[DATE]. During an interview on [DATE] at 3:30 p.m., Resident #2 said she lived on the same hall as Resident #1. Resident #2 said she heard staff raise her voice to Resident #1. She said staff also hurt Resident #1's foot. Resident #2 said she saw Resident #1 get mad at LVN A because he would not give her medication. Resident #2 said LVN A told Resident #1 to shut up. Resident #1 told the LVN not to tell her to shut up. Resident #1 then tried to go into the medication room and the MA shut the door. The resident was kicking the door. The DON came out of her office and said she was taking Resident #1 to bed. Resident #1 said she did not want to go to bed. Resident #2 said the DON dug her nails into Resident #1's arms. She said 3 or 4 staff went into Resident #1's room. Resident #2 said she stayed with Resident #1 after the staff left because she was crying and upset. She said the staff hurt her. During an interview on [DATE] at 4:15 p.m., OTA B said OTA C called her and said she saw Resident #1 being mistreated. OTA B said she and OTA C went to check on Resident #1. The resident was sitting on the side of the bed, crying, and rubbing her foot. The resident said "they" took her wheelchair from her because "they" knew she could not get up without it. OTA B said she did not see the wheelchair in the resident's room. OTA B went on to say that Resident #1 was really upset. She said her foot was hurting and she hit her head when she was "thrown" in bed. OTA C told OTA B the DON forcefully took the resident to her room, along with LVN ADON. While, they were consoling the resident, Resident #1 said she needed to go to the bathroom. OTA B said when she looked in the bathroom the resident's wheelchair was in there. OTA B said Resident #1 was sent to the hospital this morning ([DATE]) because the DON said she was combative. OTA B said she had never known Resident #1 to be combative. Resident #1 was placed on the stretcher. She was still in her night gown. OTA B said Resident #1 was always dressed and put together. Resident #1 was upset and yelling that she did not want to go. OTA B said she heard the DON say, "It's all because of me." OTA B said everyone was watching and no one said anything. The DON called a meeting after Resident #1 left. The DON told staff that she and the LVN ADON had not hurt the resident. She told everyone that she did not want to hear any more about it and if she did, she would fire that person. During an interview on [DATE] at 5:00 p.m., the Activity Director (AD) said on [DATE] Resident #1 wanted her medicated mouthwash because she had mouth pain. LVN A told Resident #1 the medication was discontinued. Resident #1 went to the DON and the DON had the LVN ADON call and get it refilled. Later, the resident overheard LVN A say they did not have the mouthwash. Resident #1 became upset. Resident #1 grabbed LVN A's arm and he pulled away from her. Resident #1 was circling the medication cart to get to the LVN. The AD said she went and got the DON. The resident was at the medication room, kicking the door. The DON attempted to wheel the resident back to her room. The resident put her feet down and the DON tilted the wheelchair back. The resident said the DON broke her leg. The DON said, "I'm not going to deal with this." The DON called the LVN ADON to help put the resident to bed. The AD said the LVN ADON was at the nurses' station. The AD said Resident #1 kept saying she was not ready to go to bed. The AD said the resident was crying and upset. She was "scared." The AD said as the DON was taking the resident down the hall the resident was reaching back, trying to fight the DON. The DON took the palm of her hand and pushed the resident's chest to push her back in the chair. The AD began to cry during the interview. She said the resident was trying to hit the DON and called her a "fat [***] ." The resident said her leg was caught under the seat of the wheelchair while the DON was pushing it. The resident said the DON had broken her leg. The DON took the resident down the hall on two wheels. The DON had to stop along the way because the resident was fighting her. Resident #1 asked to talk to the AD after the events and asked the AD if she was against her. The resident was crying. Resident #1 told the AD she was thrown in bed against the wall. The AD said she went and told the DON the allegation. The DON said it was not true. The AD said the resident said her back, leg, and arms were hurt. The AD said she saw little areas on the resident's arms. She said they looked like little areas similar to how someone's arms look when they were taking certain medications. The AD said she had never seen areas like that on the resident's arms before. The AD said she saw the DON in the administrator's office, so she assumed the DON told the administrator what happened. The DON had a meeting and told everyone if they spoke about what happened they would be fired. The DON told everyone that was a threat. During an interview on [DATE] at 5:54 p.m., LVN A said he had been employed at the facility since the second week in [DATE]. He said Resident #1 had problems with her jaw. When the resident went to the dentist, the dentist ordered [MEDICATION NAME] mouthwash. When the resident finished the initial bottle, she wanted more because she thought it helped. The resident went back to the dentist and she came back with more, but it was the over-the-counter [MEDICATION NAME]. LVN A said that bottle was finished Friday or Monday ([DATE] or [DATE]). LVN A said on Tuesday ([DATE]) the MA said the resident was asking for the [MEDICATION NAME]. LVN A said he tried to explain to the resident that she was out. LVN A said the LVN ADON called the dentist and got a third bottle. On [DATE] the MA asked him for clarification on the order. The resident rolled up and was confrontational. The resident wanted the entire bottle to keep in her room. LVN A said the resident grabbed his arm with both hands. The AD diverted the resident's attention. LVN A said he went to the DON's office and told her what was going on. The DON and LVN ADON, who was also in the office, said they would handle it. LVN A said at that point he went to the nurses' station to complete paperwork. The MA had the medication cart at the nurses' station and the resident wanted the bottle. The MA went into the medication room and the resident kicked the door and yelled. LVN A said he was worried because the resident had a broken foot. He said the DON and LVN ADON tried to talk to the resident. LVN A said the DON and LVN ADON took the resident down the hall but he did not see it. LVN A said he felt bad because he was not involved in trying to redirect the resident, but the resident did not like him, so he thought it was best to stay out of it. LVN A said he did not go into the resident's room the rest of the night. He had the MA check on her. During an interview on [DATE] at 6:14 p.m., MA D said on [DATE] sometime after 3:00 p.m. Resident #1 was asking about her mouthwash. She told the resident she did not have any. While she was giving medications to another resident, the MA pulled some bottles out of the medicine cart. There was a bottle of [MEDICATION NAME] with Resident #1's name on it. Resident #1 saw the bottle and wanted it. MA D said it was not on the MAR. She took the medicine cart to the nurses' station to ask LVN A about it. The resident grabbed LVN A's arm and the LVN walked away. MA D said Resident #1 still wanted the mouthwash. She said she went to the medication room. The resident was knocking on the door. The RN ADON was trying to talk to the resident. The RN ADON entered the medication room and MA D said she explained to her what was going on. The RN ADON went out of the medication room to talk to the resident, who then kicked the door. MA D said there was a therapist there (OTA C). The resident grabbed onto the handrail. MA D said OTA C was trying to talk to the resident. The DON came up and told the resident to listen to her. The DON tried to get the resident's hands off the handrail. The DON said she was going to put the resident to bed. The resident put her feet down and said she did not want to go to bed. The DON pulled the wheelchair back so the resident could not put her feet down. MA D said it just escalated from there. MA D said she went into the resident's room afterwards with CNA E. Resident #1 said someone "threw her around the bed and grabbed her arms." MA D said the resident's arms had bruises. MA D said she told LVN A about the bruises. MA D said she did not remember seeing the resident's wheelchair in her room. She said she knew the resident used it to get up to the bathroom. MA D said CNA E told her she was in the room when the DON and LVN ADON put the resident in bed. CNA E told MA D the two had "flung" the resident in the bed. CNA E told MA D she would not want anyone to treat her mother or grandmother that way. MA D began crying during the interview and said that it had bothered her. During an interview on [DATE] at 6:45 p.m., the business office manager (BOM) said on [DATE] she heard Resident #1 screaming. She went to the resident and asked what was wrong. Resident #1 told the BOM, "That man (LVN A) is mean to me." The BOM said this was around 3:30 p.m. She went to the DON and told her what Resident #1 said. The DON told the BOM that Resident #1 was "cycling." The BOM said she left the building around 5:00 p.m. and the incident happened after that. The BOM said when she arrived at the building on [DATE] the ambulance was taking Resident #1 out. The resident was screaming not to break her leg. The DON called a meeting at about 10:,[DATE]:30 a.m. She announced over the loudspeaker for all staff to come to the conference room. At the meeting, the DON told the staff, "I want this to stop right now." She told the staff Resident #1 was "cycling" and they were trying to get a urinalysis on her. She went on to tell the staff if she heard talk about it, the staff would be fired. The BOM said the AD and administrator were in the meeting and they were both crying. The DON said there was an episode with Resident #1 last night and the resident tried to turn over the medication cart. The DON said she had to lift the wheelchair. She went on to tell the staff there were no bruises on the resident. The BOM said one of the MAs asked the DON about LVN A aggravating the resident for the last two weeks. The DON said the resident was "cycling." The administrator told everyone the resident was sick and they were trying to get her help. The DON talked interrupted the administrator and would not let her talk. The DON went on to tell the staff they would be terminated if they talked about it and, "If you want to take that as a threat, take it as a threat." The BOM said she thought the DON was an excellent nurse, but she talked rough with the residents and staff. During an interview on [DATE] at 7:12 p.m., LVN F said she worked the evening of [DATE], but she, "did not see a lot." She said the resident was "exceedingly upset." LVN F said Resident #1 would get upset at times, but it was not often. Resident #1 was really mad at LVN A, but she did not know why. LVN F said she was told Resident #1 kicked the medication room door. LVN F said she heard Resident #1 talking loud and sounded angry. LVN A told her, "Your baby is mad at me." LVN F said the therapy people came and got her and wanted her to look at the resident's arms. She said there were three bruises on Resident #1's left arm that were "reminiscent of finger marks", but the resident had frail skin. The resident was complaining of foot pain, but there was no sign of injury. Resident #1 told LVN F "they" jerked her. The resident said, "They picked me up and chunked me in the bed." The resident did not say who they were. LVN F said Resident #1 was angrier than she had ever seen her. LVN F said she would consider what happened to Resident #1 abuse. She said she told the RN ADON. During an interview on [DATE] at 7:30 p.m., the RN ADON said Resident #1 told her the MA would not give her medication. The RN ADON entered the medication room to talk to the MA. The MA explained about the mouthwash. When the RN ADON opened the door of the medication room to come out, the resident tried to get into the room. She said she tried to calm the resident down, but she was screaming. The DON came up and tried to explain to the resident. The DON pulled the wheelchair away from the door. The resident was hollering. The RN ADON said the DON was normally loud. Resident #1 was swinging at the DON over her shoulders. The RN ADON said the DON lifted the wheelchair because the resident was putting her feet down. The RN ADON said she only saw the DON do it for a few feet then the RN ADON left. The LVN ADON and a CNA were with the DON. The RN ADON said no one reported bruises to her. The RN ADON said the resident was sent to the hospital the morning of [DATE]. She said she heard Resident #1 yelling, but she was making rounds with a physician and did not see what was going on. She said Resident #1 had been escalating a couple of weeks. She said the resident threw some plates Sunday ([DATE]). She said they had talked to the family and had gotten an order for [REDACTED]. The RN ADON said she called the emergency room at 6:00 p.m. and was told the resident would not do a voluntary commitment, so they were waiting on the mental health authority to come and do an evaluation. The RN ADON said she would not have handled the situation the way the DON had. During an interview on [DATE] at 7:52 p.m., the LVN ADON said LVN A told her Resident #1 wanted him to stay away from her. LVN ADON said she told LVN A to leave her alone. The AD came and told her and the DON on [DATE] that Resident #1 was chasing LVN A around the medication cart. LVN ADON said she asked, "Why is he near her?" The LVN ADON said later she came out of the conference room and the resident was holding onto the handrail. The DON was telling her to let go of the rail and that she was going to hurt herself. The LVN ADON said she, the DON and a CNA took the resident to her room. She said they put the resident into bed and she sat on the bed beside the resident. The resident was reaching for her phone and pointing at the DON. The DON left the room. The LVN ADON said the CNA put the resident's wheelchair in the bathroom. She said at that point she left the room. The LVN ADON said she did not see any bruises on the resident's arms. She said she did not see the resident again. The LVN ADON said she called the doctor who ordered a urinalysis. During an observation on [DATE] at 8:12 a.m., Resident was #1 was in the dining room eating breakfast. She was sitting in a wheelchair. She was smiling and was pleasant. At this time, she agreed to speak to the surveyor when she finished her breakfast. During an interview on [DATE] at 8:23 a.m., Resident #1 said the man nurse (LVN A) would not give her mouthwash. She said the nurse had been here a short time and he did not know his name. She described the physical characteristics of LVN A. The resident said the bones "were working out" on the right side of her jaw. She went to the dentist and he gave her a mouthwash. Resident #1 said the mouthwash helped her a lot. She wanted to keep it in her room because she did not always get it the way she was supposed to. Resident #1 said she was talking to someone about her mouthwash and "she walked up behind me and got a hold of my wheelchair." Resident #1 said "she" (the DON) was yelling at her, saying she did not have a broken leg. "She threw me backwards in the chair and shook me in it. There was nothing I could do. They slung me out of the chair and against the wall." The resident showed her arms to the surveyor and pointed out bruises to both arms. The resident pointed to areas on her left arm and said, "This is where she dug her nails in my arm." There were 3 areas to the resident's left arm that each measured approximately 1.5 cm in diameter. They were reddish-purple in color. Resident #1 said her wheelchair was taken away and put in the bathroom because they knew she could not get up without it. The resident said this was the first time something like this happened to her. She said she knew she said some things that she should not have said. "You know how you say things when you are upset." Resident #1 said they hurt her leg and caused her whole leg to ache. Resident #1 said she was nervous inside. The resident described the staff as wearing red tops and khaki pants. A nurse's entry dated [DATE] at 10:00 a.m. indicated Resident #1 was in the wheelchair, propelling herself on the hallway. She was alert and friendly with no behaviors noted. During an interview on [DATE] at 12:43 p.m., CNA E said on [DATE] she had finished feeding a resident on the 400 hall and was putting the tray on the cart, when she saw the DON coming down the hall with Resident #1. CNA E said the RN ADON told her to help the DON. CNA E said the LVN ADON followed them down to Resident #1's room. She said once in the room the DON grabbed the resident's legs and the LVN ADON grabbed the resident's left arm and swung her in bed. CNA E said she left the room and was looking for her nurse, but could not find her. She said she went back to Resident #1's room to check on her and the therapists were in there with her. CNA E said she told the therapists what happened to the resident. CNA E said the LVN ADON had been watching her and she felt the LVN ADON was afraid she was going to say something. CNA E said Resident #1 was cussing the DON and telling her to leave her alone. CNA E said the DON told the resident, "You're being ridiculous. Until you know how to act, you're going to bed." The resident kept saying she was not going to bed. CNA E repeated that the LVN ADON had grabbed the resident's left arm and the resident was "swung" into bed. CNA E said the LVN ADON and DON put the resident in bed upside down. The resident's head was at the foot of the bed. She said you could hear them swinging her and the landing "was not comfortable, not easy." CNA E said when she went back to the room, the resident's wheelchair was in the bathroom and her call light was on the floor. The resident was crying and upset. CNA E said on her way to speak to the surveyor, the LVN ADON told her that the surveyor was going to ask if the resident was thrown in bed and that they had not thrown her. CNA E said she felt Resident #1 was abused. She said grabbing the resident and swinging her in bed upside down was abuse. She said Resident #1 refused to eat that evening. During an interview on [DATE] at 1:26 p.m. OTA C said on [DATE] she was in the conference room. She said when she came out of the room Resident #1 was at the medication room and had her foot that had been broken in the past out, trying to hold the door open. OTA C said she saw the RN ADON trying to talk to the resident. She was telling her she did not have a medication. OTA C said Resident #1 was upset. She said she had a good rapport with the resident and she thought she could calm her. She said Resident #1 was talking loud, but she was not hitting. OTA C said she approached the resident and began rubbing her back and bent down to talk her when the DON walked up behind her and said, "I've had enough of you. You're going to bed." Resident #1 grabbed the handrails and the DON forcibly removed the resident's hands. OTA C said she was in shock. The DON took the resident down the hallway very quickly and the resident's broken foot (the right one) was drug under the chair. The resident hollered that the DON was breaking her foot. The DON then tilted the wheelchair back on two wheels. OTA C said the resident and DON yelled at each other. A CNA and the LVN ADON followed the DON to the resident's room. OTA C said she heard the LVN ADON say that Resident #1 had been "acting up all day." OTA C said she was standing in the hallway and she heard this "gut curling scream." She went into another resident's room and shut the door because she was afraid. She said she called OTA B and told her what she saw. Once OTA B arrived, the staff had left Resident #1's room. The two OTAs entered the resident's room and found her sitting on the side of the bed, trying to get up. The resident told them that her wheelchair had been taken away. OTA C said the resident was crying and never tried to fight her or OTA B. OTA C said the next morning, her and OTA B go to check on Resident #1. She was lying in bed, crying. She said her back hurt from being thrown in bed. The OTAs left the room. She had heard the resident was sent to the hospital that morning. During an interview on [DATE] at 9:35 a.m., CNA G said she worked the morning of [DATE]. CNA G said Resident #1 was "...an angel. I love her to death." CNA G said right before lunch at about 10:45 a.m. she heard someone hollering and she ran to where it was coming from. CNA G said she saw Resident #1 on a stretcher with her wrists tied down with a sheet. There were two emergency medical service personnel, the DON and the administrator with the resident. Resident #1 asked CNA G if she would help her. CNA G said she told the resident to calm down. She said the resident was crying. CNA G said Resident #1 was yelling the whole time they took her out of the facility. The CNA began to cry during the interview. She said Resident #1 yelled at the DON, "Get that [***] away from me." CNA G said Resident #1 was not a violent or aggressive and for her to act like that, something had to have happened. CNA G said she wondered if LVN A had done something to provoke Resident #1 because she was not like that with everyone else. During an interview on [DATE] at 9:55 a.m., LVN H said a CNA told her the resident was crying the morning of [DATE]. The CNA said the resident was saying the "head person" in the red shirt threw her in bed. LVN H said there were three people that wore red shirts: DON, LVN ADON, and RN ADON. She said the nurses wore blue, the CNAs wore maroon, and the MAs wore light blue. LVN H said she went to talk to the resident and she was not crying at that time. The resident first accused her of being one of them. LVN H said after she talked to the resident for a bit, the resident apologized for thinking she was one of them. LVN H said Resident #1 told her, "I admit I said some things to the big guy on ,[DATE], but they didn't have to throw me in bed." LVN H said the resident had some bruises that were red to the tops of both of her arms. The resident also complained of back pain and requested pain medication. LVN H said when she left the room, she met the DON in the hall and told her the resident's allegation. The DON said it did not happen. The DON said there were witnesses and she had gotten an order to send the resident to the hospital for a psychiatric evaluation. The LVN said she returned to the resident's room with something for pain and told her about going to the hospital. The resident said she did not want to go to the hospital. LVN H said the resident was not mean; she just did not want to go. LVN H said she told the social worker who went and talked to the DON. The DON said the resident had to go. LVN H said it upset her because the resident was confused at times, but she was "at herself" enough to refuse going to the hospital. When the emergency medical technicians arrived, they went and talked to Resident #1. They came back to the nurses' station and said the resident refused to go. The DON and administrator went to the resident's room. LVN H said she heard the resident yell. LVN H said it was a very emotional day. She said the DON said the resident was having behaviors, but she had not seen it. She said the DON asked her why she was not charting the behaviors. She said she told her she did not document behaviors because she had not seen the resident exhibit any behaviors. All the behaviors seemed to occur when LVN A worked. During an interview on [DATE] at 10:40 a.m., the administrator said she was told the DON had a lot of experience and she could learn a lot from her. She said there was a power struggle between her and the DON. She said the problem began when she hired a RN as the ADON. She thought maybe the DON felt threatened. Now, staff is coming to her and saying the DON told them not to go to administrator with anything. The administrator said she asked the DON to take some time off because she was at the facility all the time. 2. A Face Sheet dated [DATE] for Resident #4 indicated the resident was admitted [DATE] and was [AGE] years-old. An undated annual physical exam completed by the physician for Resident #4 indicated the resident had a history of [REDACTED]. The chief complaint(s) were listed as an [DATE] hospital stay with gastrointestinal blood loss, urinary tract infection, high blood pressure, diabetes, and acute post-hemorrhagic [MEDICAL CONDITION]. The short-term and long-term goals were listed as long-term care with possible hospice care. A care plan with problem onset date of [DATE] indicated Resident #4 and family had elected to designate an advance directive. The first approach read, "If [MEDICAL CONDITION] Do Not Resuscitate." This care plan was initialed to continue plan of care on [DATE] and [DATE]. An undated care plan for Resident #4 indicated the resident requested a code status of "No CPR". The social worker signed the care plan [DATE]. A daily skilled nurse's note dated [DATE] with a late entry at 11:00 a.m. indicated Resident #4 was seen in the dining room clenching her bottom denture in her hand (grasping denture in hand on lap), tongue rolled up in her mouth, left eye up and to the left, and right eye down and to the right. The resident did not respond to staff. Blood pressure was ,[DATE] and her pulse was 86. The nurse (LVN L) documented the resident's nurse was tied up so she got another nurse (LVN K) and a nurse aide (CNA M) to help her. "At this time, DON walks up and asks what is going on. Looks at resident and says 'she's just tired this is normal for her.' We tried to ar

Based on observation, interview, and record review the DON, ADON and administrator failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 3 of 16 residents reviewed for abuse and neglect. (Resident #s 1, 4, and 3) The administrator did not implement the abuse/neglect policy. Facility staff was aware of abuse and neglect and did not report it to the administrator. The DON abused Resident #1 and placed her in involuntary seclusion. The DON coerced the LVN ADON to participate in the abuse. The DON neglected Resident #4, who had a DNR directive and had significant neurological and physiological changes. The DON did not allow the resident to be sent out to the hospital. The DON was informed that LVN A had abused Resident #3 and the DON did not report the abuse. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at widespread potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 95 residents at risk for physical injury, loss of self-worth, despair, a decline in condition without medical intervention, or death. Findings included: 1. Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years-old, with [DIAGNOSES REDACTED]. The orders also indicated the resident received counseling services, which was originally ordered [DATE]. A quarterly MDS with an assessment reference date of [DATE] indicated the resident had moderately impaired cognition, no signs of [MEDICAL CONDITION], no adverse moods, and no behaviors. Nurse's note entry dated [DATE] at 6:25 p.m. and written by LVN ADON indicated she called Resident #1's daughter and informed her the resident was "lashing out" at the nurse and being paranoid about things like people talking behind her back. The daughter told the nurse her mother had these episodes at times and she would try to talk to her. The LVN ADON documented the resident was in her room at that time and there were no signs and symptoms of distress. The next nurse's entry was dated [DATE] at 6:00 p.m. (but documented after the 6:25 p.m. entry) indicated there was a new order for urinalysis. Resident #1 refused to give a specimen at that time. There were no other nursing notes for [DATE]. The next nurse's entry dated [DATE] at 9:30 a.m. indicated Resident #1 refused to come out of her room. The resident said, "I am going to stay in my room where I am safe." The resident told the nurse, "Your head nurse and some other people threw me in the bed." The nurse documented the resident complained of back pain. The resident pointed to two discolorations on her arms and said that was what was done to her. She documented there was active range of motion to all extremities and then asked the resident for a urine specimen. The resident attempted but said she was not able to do it at that time and that she would try later. The nurse wrote she informed the DON of the resident's complaint. The DON informed the nurse the resident had been combative the day prior and she was assisted to bed. At 10:00 a.m. the nurse administered pain medication for the resident's complaint of back pain. At 10:30 a.m. the ambulance arrived to transfer the resident to the hospital for evaluation and possible psychiatric admission. A nurse's entry dated [DATE] at 11:00 p.m. indicated Resident #1 was sitting on side of bed visiting with another resident. There were no signs or symptoms of distress. A progress note for counseling services dated [DATE] indicated Resident #1 said she was doing "pretty good." The resident said she had been in some pain, which escalated her anxiety. The resident was also worried about her brother's health. The counselor documented the resident had positive responses to the support. The Psychoactive Behavior Monitoring for [DATE] for Resident #1 indicated "No behaviors observed" was initialed every day and every shift from [DATE]-[DATE]. During an interview on [DATE] at 3:30 p.m., Resident #2 said she lived on the same hall as Resident #1. Resident #2 said she heard staff raise her voice to Resident #1. She said staff also hurt Resident #1's foot. Resident #2 said she saw Resident #1 get mad at LVN A because he would not give her medication. Resident #2 said LVN A told Resident #1 to shut up. Resident #1 told the LVN not to tell her to shut up. Resident #1 then tried to go into the medication room and the MA shut the door. The resident was kicking the door. The DON came out of her office and said she was taking Resident #1 to bed. Resident #1 said she did not want to go to bed. Resident #2 said the DON dug her nails into Resident #1's arms. She said 3 or 4 staff went into Resident #1's room. Resident #2 said she stayed with Resident #1 after the staff left because she was crying and upset. She said the staff hurt her. During an interview on [DATE] at 4:15 p.m., OTA B said OTA C called her and said she saw Resident #1 being mistreated. OTA B said she and OTA C went to check on Resident #1. The resident was sitting on the side of the bed, crying, and rubbing her foot. The resident said "they" took her wheelchair from her because "they" knew she could not get up without it. OTA B said she did not see the wheelchair in the resident's room. OTA B went on to say that Resident #1 was really upset. She said her foot was hurting and she hit her head when she was "thrown" in bed. OTA C told OTA B the DON forcefully took the resident to her room, along with LVN ADON. While, they were consoling the resident, Resident #1 said she needed to go to the bathroom. OTA B said when she looked in the bathroom the resident's wheelchair was in there. OTA B said Resident #1 was sent to the hospital this morning ([DATE]) because the DON said she was combative. OTA B said she had never known Resident #1 to be combative. Resident #1 was placed on the stretcher. She was still in her night gown. OTA B said Resident #1 was always dressed and put together. Resident #1 was upset and yelling that she did not want to go. OTA B said she heard the DON say, "It's all because of me." OTA B said everyone was watching and no one said anything. The DON called a meeting after Resident #1 left. The DON told staff that she and the LVN ADON had not hurt the resident. She told everyone that she did not want to hear any more about it and if she did, she would fire that person. During an interview on [DATE] at 5:00 p.m., the Activity Director (AD) said on [DATE] Resident #1 wanted her medicated mouthwash because she had mouth pain. LVN A told Resident #1 the medication was discontinued. Resident #1 went to the DON and the DON had the LVN ADON call and get it refilled. Later, the resident overheard LVN A say they did not have the mouthwash. Resident #1 became upset. Resident #1 grabbed LVN A's arm and he pulled away from her. Resident #1 was circling the medication cart to get to the LVN. The AD said she went and got the DON. The resident was at the medication room, kicking the door. The DON attempted to wheel the resident back to her room. The resident put her feet down and the DON tilted the wheelchair back. The resident said the DON broke her leg. The DON said, "I'm not going to deal with this." The DON called the LVN ADON to help put the resident to bed. The AD said the LVN ADON was at the nurses' station. The AD said Resident #1 kept saying she was not ready to go to bed. The AD said the resident was crying and upset. She was "scared." The AD said as the DON was taking the resident down the hall the resident was reaching back, trying to fight the DON. The DON took the palm of her hand and pushed the resident's chest to push her back in the chair. The AD began to cry during the interview. She said the resident was trying to hit the DON and called her a "fat [***] ." The resident said her leg was caught under the seat of the wheelchair while the DON was pushing it. The resident said the DON had broken her leg. The DON took the resident down the hall on two wheels. The DON had to stop along the way because the resident was fighting her. Resident #1 asked to talk to the AD after the events and asked the AD if she was against her. The resident was crying. Resident #1 told the AD she was thrown in bed against the wall. The AD said she went and told the DON the allegation. The DON said it was not true. The AD said the resident said her back, leg, and arms were hurt. The AD said she saw little areas on the resident's arms. She said they looked like little areas similar to how someone's arms look when they were taking certain medications. The AD said she had never seen areas like that on the resident's arms before. The AD said she saw the DON in the administrator's office, so she assumed the DON told the administrator what happened. The DON had a meeting and told everyone if they spoke about what happened they would be fired. The DON told everyone that was a threat. During an interview on [DATE] at 5:54 p.m., LVN A said he had been employed at the facility since the second week in [DATE]. He said Resident #1 had problems with her jaw. When the resident went to the dentist, the dentist ordered [MEDICATION NAME] mouthwash. When the resident finished the initial bottle, she wanted more because she thought it helped. The resident went back to the dentist and she came back with more, but it was the over-the-counter [MEDICATION NAME]. LVN A said that bottle was finished Friday or Monday ([DATE] or [DATE]). LVN A said on Tuesday ([DATE]) the MA said the resident was asking for the [MEDICATION NAME]. LVN A said he tried to explain to the resident that she was out. LVN A said the LVN ADON called the dentist and got a third bottle. On [DATE] the MA asked him for clarification on the order. The resident rolled up and was confrontational. The resident wanted the entire bottle to keep in her room. LVN A said the resident grabbed his arm with both hands. The AD diverted the resident ' s attention. LVN A said he went to the DON's office and told her what was going on. The DON and LVN ADON, who was also in the office, said they would handle it. LVN A said at that point he went to the nurses' station to complete paperwork. The MA had the medication cart at the nurses' station and the resident wanted the bottle. The MA went into the medication room and the resident kicked the door and yelled. LVN A said he was worried because the resident had a broken foot. He said the DON and LVN ADON tried to talk to the resident. LVN A said the DON and LVN ADON took the resident down the hall but he did not see it. LVN A said he felt bad because he was not involved in trying to redirect the resident, but the resident did not like him, so he thought it was best to stay out of it. LVN A said he did not go into the resident's room the rest of the night. He had the MA check on her. During an interview on [DATE] at 6:14 p.m., MA D said on [DATE] sometime after 3:00 p.m. Resident #1 was asking about her mouthwash. She told the resident she did not have any. While she was giving medications to another resident, the MA pulled some bottles out of the medicine cart. There was a bottle of [MEDICATION NAME] with Resident #1's name on it. Resident #1 saw the bottle and wanted it. MA D said it was not on the MAR. She took the medicine cart to the nurses' station to ask LVN A about it. The resident grabbed LVN A's arm and the LVN walked away. MA D said Resident #1 still wanted the mouthwash. She said she went to the medication room. The resident was knocking on the door. The RN ADON was trying to talk to the resident. The RN ADON entered the medication room and MA D said she explained to her what was going on. The RN ADON went out of the medication room to talk to the resident, who then kicked the door. MA D said there was a therapist there (OTA C). The resident grabbed onto the handrail. MA D said OTA C was trying to talk to the resident. The DON came up and told the resident to listen to her. The DON tried to get the resident's hands off the handrail. The DON said she was going to put the resident to bed. The resident put her feet down and said she did not want to go to bed. The DON pulled the wheelchair back so the resident could not put her feet down. MA D said it just escalated from there. MA D said she went into the resident's room afterwards with CNA E. Resident #1 said someone "threw her around the bed and grabbed her arms." MA D said the resident's arms had bruises. MA D said she told LVN A about the bruises. MA D said she did not remember seeing the resident's wheelchair in her room. She said she knew the resident used it to get up to the bathroom. MA D said CNA E told her she was in the room when the DON and LVN ADON put the resident in bed. CNA E told MA D the two had "flung" the resident in the bed. CNA E told MA D she would not want anyone to treat her mother or grandmother that way. MA D began crying during the interview and said that it had bothered her. During an interview on [DATE] at 6:45 p.m., the business office manager (BOM) said on [DATE] she heard Resident #1 screaming. She went to the resident and asked what was wrong. Resident #1 told the BOM, "That man (LVN A) is mean to me." The BOM said this was around 3:30 p.m. She went to the DON and told her what Resident #1 said. The DON told the BOM that Resident #1 was "cycling." The BOM said she left the building around 5:00 p.m. and the incident happened after that. The BOM said when she arrived at the building on [DATE] the ambulance was taking Resident #1 out. The resident was screaming not to break her leg. The DON called a meeting at about 10:,[DATE]:30 a.m. She announced over the loudspeaker for all staff to come to the conference room. At the meeting, the DON told the staff, "I want this to stop right now." She told the staff Resident #1 was "cycling" and they were trying to get a urinalysis on her. She went on to tell the staff if she heard talk about it, the staff would be fired. The BOM said the AD and administrator were in the meeting and they were both crying. The DON said there was an episode with Resident #1 last night and the resident tried to turn over the medication cart. The DON said she had to lift the wheelchair. She went on to tell the staff there were no bruises on the resident. The BOM said one of the MAs asked the DON about LVN A aggravating the resident for the last two weeks. The DON said the resident was "cycling." The administrator told everyone the resident was sick and they were trying to get her help. The DON talked interrupted the administrator and would not let her talk. The DON went on to tell the staff they would be terminated if they talked about it and, "If you want to take that as a threat, take it as a threat." The BOM said she thought the DON was an excellent nurse, but she talked rough with the residents and staff. During an interview on [DATE] at 7:12 p.m., LVN F said she worked the evening of [DATE], but she, "did not see a lot." She said the resident was "exceedingly upset." LVN F said Resident #1 would get upset at times, but it was not often. Resident #1 was really mad at LVN A, but she did not know why. LVN F said she was told Resident #1 kicked the medication room door. LVN F said she heard Resident #1 talking loud and sounded angry. LVN A told her, "Your baby is mad at me." LVN F said the therapy people came and got her and wanted her to look at the resident's arms. She said there were three bruises on Resident #1's left arm that were "reminiscent of finger marks", but the resident had frail skin. The resident was complaining of foot pain, but there was no sign of injury. Resident #1 told LVN F "they" jerked her. The resident said, "They picked me up and chunked me in the bed." The resident did not say who they were. LVN F said Resident #1 was angrier than she had ever seen her. LVN F said she would consider what happened to Resident #1 abuse. She said she told the RN ADON. During an interview on [DATE] at 7:30 p.m., the RN ADON said Resident #1 told her the MA would not give her medication. The RN ADON entered the medication room to talk to the MA. The MA explained about the mouthwash. When the RN ADON opened the door of the medication room to come out, the resident tried to get into the room. She said she tried to calm the resident down, but she was screaming. The DON came up and tried to explain to the resident. The DON pulled the wheelchair away from the door. The resident was hollering. The RN ADON said the DON was normally loud. Resident #1 was swinging at the DON over her shoulders. The RN ADON said the DON lifted the wheelchair because the resident was putting her feet down. The RN ADON said she only saw the DON do it for a few feet then the RN ADON left. The LVN ADON and a CNA were with the DON. The RN ADON said no one reported bruises to her. The RN ADON said the resident was sent to the hospital the morning of [DATE]. She said she heard Resident #1 yelling, but she was making rounds with a physician and did not see what was going on. She said Resident #1 had been escalating a couple of weeks. She said the resident threw some plates Sunday ([DATE]). She said they had talked to the family and had gotten an order for [REDACTED]. The RN ADON said she called the emergency room at 6:00 p.m. and was told the resident would not do a voluntary commitment, so they were waiting on the mental health authority to come and do an evaluation. The RN ADON said she would not have handled the situation the way the DON had. During an interview on [DATE] at 7:52 p.m., the LVN ADON said LVN A told her Resident #1 wanted him to stay away from her. LVN ADON said she told LVN A to leave her alone. The AD came and told her and the DON on [DATE] that Resident #1 was chasing LVN A around the medication cart. LVN ADON said she asked, "Why is he near her?" The LVN ADON said later she came out of the conference room and the resident was holding onto the handrail. The DON was telling her to let go of the rail and that she was going to hurt herself. The LVN ADON said she, the DON and a CNA took the resident to her room. She said they put the resident into bed and she sat on the bed beside the resident. The resident was reaching for her phone and pointing at the DON. The DON left the room. The LVN ADON said the CNA put the resident's wheelchair in the bathroom. She said at that point she left the room. The LVN ADON said she did not see any bruises on the resident's arms. She said she did not see the resident again. The LVN ADON said she called the doctor who ordered a urinalysis. During an observation on [DATE] at 8:12 a.m., Resident was #1 was in the dining room eating breakfast. She was sitting in a wheelchair. She was smiling and was pleasant. At this time, she agreed to speak to the surveyor when she finished her breakfast. During an interview on [DATE] at 8:23 a.m., Resident #1 said the man nurse (LVN A) would not give her mouthwash. She said the nurse had been here a short time and he did not know his name. She described the physical characteristics of LVN A. The resident said the bones "were working out" on the right side of her jaw. She went to the dentist and he gave her a mouthwash. Resident #1 said the mouthwash helped her a lot. She wanted to keep it in her room because she did not always get it the way she was supposed to. Resident #1 said she was talking to someone about her mouthwash and "she walked up behind me and got a hold of my wheelchair." Resident #1 said "she" (the DON) was yelling at her, saying she did not have a broken leg. "She threw me backwards in the chair and shook me in it. There was nothing I could do. They slung me out of the chair and against the wall." The resident showed her arms to the surveyor and pointed out bruises to both arms. The resident pointed to areas on her left arm and said, "This is where she dug her nails in my arm." There were 3 areas to the resident's left arm that each measured approximately 1.5 cm in diameter. They were reddish-purple in color. Resident #1 said her wheelchair was taken away and put in the bathroom because they knew she could not get up without it. The resident said this was the first time something like this happened to her. She said she knew she said some things that she should not have said. "You know how you say things when you are upset." Resident #1 said they hurt her leg and caused her whole leg to ache. Resident #1 said she was nervous inside. The resident described the staff as wearing red tops and khaki pants. A nurse's entry dated [DATE] at 10:00 a.m. indicated Resident #1 was in the wheelchair, propelling herself on the hallway. She was alert and friendly with no behaviors noted. During an interview on [DATE] at 12:43 p.m., CNA E said on [DATE] she had finished feeding a resident on the 400 hall and was putting the tray on the cart, when she saw the DON coming down the hall with Resident #1. CNA E said the RN ADON told her to help the DON. CNA E said the LVN ADON followed them down to Resident #1's room. She said once in the room the DON grabbed the resident's legs and the LVN ADON grabbed the resident's left arm and swung her in bed. CNA E said she left the room and was looking for her nurse, but could not find her. She said she went back to Resident #1's room to check on her and the therapists were in there with her. CNA E said she told the therapists what happened to the resident. CNA E said the LVN ADON had been watching her and she felt the LVN ADON was afraid she was going to say something. CNA E said Resident #1 was cussing the DON and telling her to leave her alone. CNA E said the DON told the resident, "You're being ridiculous. Until you know how to act, you're going to bed." The resident kept saying she was not going to bed. CNA E repeated that the LVN ADON had grabbed the resident's left arm and the resident was "swung" into bed. CNA E said the LVN ADON and DON put the resident in bed upside down. The resident's head was at the foot of the bed. She said you could hear them swinging her and the landing "was not comfortable, not easy." CNA E said when she went back to the room, the resident's wheelchair was in the bathroom and her call light was on the floor. The resident was crying and upset. CNA E said on her way to speak to the surveyor, the LVN ADON told her that the surveyor was going to ask if the resident was thrown in bed and that they had not thrown her. CNA E said she felt Resident #1 was abused. She said grabbing the resident and swinging her in bed upside down was abuse. She said Resident #1 refused to eat that evening. During an interview on [DATE] at 1:26 p.m. OTA C said on [DATE] she was in the conference room. She said when she came out of the room Resident #1 was at the medication room and had her foot that had been broken in the past out, trying to hold the door open. OTA C said she saw the RN ADON trying to talk to the resident. She was telling her she did not have a medication. OTA C said Resident #1 was upset. She said she had a good rapport with the resident and she thought she could calm her. She said Resident #1 was talking loud, but she was not hitting. OTA C said she approached the resident and began rubbing her back and bent down to talk her when the DON walked up behind her and said, "I've had enough of you. You're going to bed." Resident #1 grabbed the handrails and the DON forcibly removed the resident's hands. OTA C said she was in shock. The DON took the resident down the hallway very quickly and the resident's broken foot (the right one) was drug under the chair. The resident hollered that the DON was breaking her foot. The DON then tilted the wheelchair back on two wheels. OTA C said the resident and DON yelled at each other. A CNA and the LVN ADON followed the DON to the resident's room. OTA C said she heard the LVN ADON say that Resident #1 had been "acting up all day." OTA C said she was standing in the hallway and she heard this "gut curling scream." She went into another resident's room and shut the door because she was afraid. She said she called OTA B and told her what she saw. Once OTA B arrived, the staff had left Resident #1's room. The two OTAs entered the resident's room and found her sitting on the side of the bed, trying to get up. The resident told them that her wheelchair had been taken away. OTA C said the resident was crying and never tried to fight her or OTA B. OTA C said the next morning, her and OTA B go to check on Resident #1. She was lying in bed, crying. She said her back hurt from being thrown in bed. The OTAs left the room. She had heard the resident was sent to the hospital that morning. During an interview on [DATE] at 9:35 a.m., CNA G said she worked the morning of [DATE]. CNA G said Resident #1 was "...an angel. I love her to death." CNA G said right before lunch at about 10:45 a.m. she heard someone hollering and she ran to where it was coming from. CNA G said she saw Resident #1 on a stretcher with her wrists tied down with a sheet. There were two emergency medical service personnel, the DON and the administrator with the resident. Resident #1 asked CNA G if she would help her. CNA G said she told the resident to calm down. She said the resident was crying. CNA G said Resident #1 was yelling the whole time they took her out of the facility. The CNA began to cry during the interview. She said Resident #1 yelled at the DON, "Get that [***] away from me." CNA G said Resident #1 was not a violent or aggressive and for her to act like that, something had to have happened. CNA G said she wondered if LVN A had done something to provoke Resident #1 because she was not like that with everyone else. During an interview on [DATE] at 9:55 a.m., LVN H said a CNA told her the resident was crying the morning of [DATE]. The CNA said the resident was saying the "head person" in the red shirt threw her in bed. LVN H said there were three people that wore red shirts: DON, LVN ADON, and RN ADON. She said the nurses wore blue, the CNAs wore maroon, and the MAs wore light blue. LVN H said she went to talk to the resident and she was not crying at that time. The resident first accused her of being one of them. LVN H said after she talked to the resident for a bit, the resident apologized for thinking she was one of them. LVN H said Resident #1 told her, "I admit I said some things to the big guy on ,[DATE], but they didn't have to throw me in bed." LVN H said the resident had some bruises that were red to the tops of both of her arms. The resident also complained of back pain and requested pain medication. LVN H said when she left the room, she met the DON in the hall and told her the resident's allegation. The DON said it did not happen. The DON said there were witnesses and she had gotten an order to send the resident to the hospital for a psychiatric evaluation. The LVN said she returned to the resident's room with something for pain and told her about going to the hospital. The resident said she did not want to go to the hospital. LVN H said the resident was not mean; she just did not want to go. LVN H said she told the social worker who went and talked to the DON. The DON said the resident had to go. LVN H said it upset her because the resident was confused at times, but she was "at herself" enough to refuse going to the hospital. When the emergency medical technicians arrived, they went and talked to Resident #1. They came back to the nurses' station and said the resident refused to go. The DON and administrator went to the resident's room. LVN H said she heard the resident yell. LVN H said it was a very emotional day. She said the DON said the resident was having behaviors, but she had not seen it. She said the DON asked her why she was not charting the behaviors. She said she told her she did not document behaviors because she had not seen the resident exhibit any behaviors. All the behaviors seemed to occur when LVN A worked. During an interview on [DATE] at 10:40 a.m., the administrator said she was told the DON had a lot of experience and she could learn a lot from her. She said there was a power struggle between her and the DON. She said the problem began when she hired a RN as the ADON. She thought maybe the DON felt threatened. Now, staff is coming to her and saying the DON told them not to go to administrator with anything. The administrator said she asked the DON to take some time off because she was at the facility all the time. 2. A Face Sheet dated [DATE] for Resident #4 indicated the resident was admitted [DATE] and was [AGE] years-old. An undated annual physical exam completed by the physician for Resident #4 indicated the resident had a history of [REDACTED]. The chief complaint(s) were listed as an [DATE] hospital stay with gastrointestinal blood loss, urinary tract infection, high blood pressure, diabetes, and acute post-hemorrhagic [MEDICAL CONDITION]. The short-term and long-term goals were listed as long-term care with possible hospice care. A care plan with problem onset date of [DATE] indicated Resident #4 and family had elected to designate an advance directive. The first approach read, "If [MEDICAL CONDITION] Do Not Resuscitate." This care plan was initialed to continue plan of care on [DATE] and [DATE]. An undated care plan for Resident #4 indicated the resident requested a code status of "No CPR". The social worker signed the care plan [DATE]. A daily skilled nurse's note dated [DATE] with a late entry at 11:00 a.m. indicated Resident #4 was seen in the dining room clenching her bottom denture in her hand (grasping denture in hand on lap), tongue rolled up in her mouth, left eye up and to the left, and right eye down and to the right. The resident did not respond to staff. Blood pressure was ,[DATE] and her pulse was 86. The nurse (LVN L) documented the resident's nurse was tied up so she got another nurse (LVN K) and a nurse aide (CNA M) to help her. "At this time, DON walks up and asks what is going on. Looks at resident and says 'she's just tired this is normal for her.' We tried to argue that it wasn't, but she told us to lay her down and let her rest. Notified nurse (LVN J) of what happened." The nurses' notes for Resident #5 dated [DATE]-[DATE] indicated the following blood pressure readings: [DATE]-,[DATE] [DATE]-,[DATE] [DATE]-,[DATE] [DATE]-,[DATE] A physician's telephone order dated [DATE] indicated to admit Resident #4 to hospice with a [DIAGNOSES REDACTED]. During an interview on [DATE] at 3:15 p.m., the daughter of Resident #4 was visiting with her mother in her room. The daughter said she was upset because something happened to her mother on Sunday ([DATE]). She said a nurse called her at home about 11:30 a.m. and said her mother had an episode. She said she did not know what that meant, because an episode could be anything. She said she saw her mother at 5:30 p.m. and she was drooling and her right eye was turned outward. The daughter said the DON would not let the nurses call the doctor and told them to put her in bed. The daughter said her mother had been at the hospital for about 14 days and came back to the facility on [DATE]. The daughter said her mother is on hospice now and she felt her mother was not given the proper attention and the doctor should have been called. During an observation on [DATE] at 3:15 p.m., Resident #4 was in bed. She looked at the surveyor and gave simple yes or no answers. Her right eye was partially closed. The resident's daughter asked if she was in pain and the resident nodded her head. Duri