Every finding on record at The Blossoms at Breckenridge Rehab & Nursing Cente

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure a safe, clean, comfortable and homelike environment was maintained for three (Resident #1, Resident # 37 and Resident #16) of three residents reviewed.The findings include: Resident #1 Review of Resident #1's admission Record revealed the facility admitted Resident #1 on 06/30/2021 with diagnoses which included schizoaffective disorder, chronic obstructive pulmonary disease, asthma, shortness of breath, and abnormal results of liver function studies. Review of Resident #1's annual Minimum Safety Data Set (MDS) with Assessment Reference Date (ARD) 02/16/2026, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also revealed Resident #1 was independent of Activities of Daily Living (ADLs) but frequently displayed delusions and needed guidance in safe decision making. Review of Resident #1's Order Summary revealed an order with a start date of 04/13/2025 to monitor resident behaviors for the following: scratching, itching, biting, sexually inappropriate behavior, hitting, attention seeking behaviors, hand wrenching, cussing, elopement attempts, refusal of care, or hallucinations. Resident #16Review of Resident #16's admission Record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, paranoid schizophrenia, delusional disorders, unspecified psychosis, bipolar disorder, depression, anxiety disorder and heart failure. Review of Resident # 16's quarterly MDS with an ARD 03/02/2026, revealed Resident #16 had a BIMS score 11, which indicated the resident had moderate cognitive impairment. Resident #16's self-care ability revealed the resident required moderate assistance to shower/bathe self and for toileting hygiene. Review of Resident #16's Order Summary revealed an order with a start date of 03/15/2026, to monitor Resident #16 for headaches, fatigue, dizziness, blurred vision, nausea, weight gain or loss, agitation and uncontrollable shaking.Resident #37 Review of Resident #37's admission Record revealed the facility admitted Resident #37 on 03/26/2024 with diagnoses which included cerebral ischemia, polyosteoarthritis, delusional disorder, dementia, cognitive communication deficit, psychosis, malignant neoplasm (cancer) of brain. Review of Resident #37's annual MDS with ARD dated 01/28/2026 revealed Resident #37 had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS revealed Resident #37 required set up for eating, supervision or touch assistance for bathing, and was independent with oral hygiene, toileting hygiene, upper and lower body dressing. The MDS also revealed Resident #37 was continent of bowel and bladder with occasional incontinent episodes. Review of Resident #37's Order Summary revealed an order to admit to secure unit with a start date of 03/26/2024. The Order Summary also revealed an order with a start date of 01/11/2026 to monitor resident behaviors for the following: scratching, itching, biting, sexual inappropriate behavior, hitting, attention seeking behaviors, hand wrenching, cussing, elopement attempts, refusal of care, or hallucinations.Review of the Maintenance Director (MD)'s Job Description revealed it was the MD's responsibility to create and maintain an atmosphere of warmth, personal interest, and positive emphasis as well as a calm environment throughout the facility. The MD also developed, maintained and implemented infection control, and universal precaution, policies and procedures to assure that a sanitary environment was maintained at all times and that aseptic and isolation techniques are followed by all maintenance personnel. The Job description also included that the MD would ensure understanding of and compliance with all rules regarding residents' rights. During an observation and concurrent interview on 03/02/2026 at 10:33 AM, this surveyor observed Resident #1 and Resident #16's shared bathroom had a bathtub with an unsecured quarter inch thick flat plywood board placed over the bathtub. When asked the purpose of the board, the MD stated, prior to July of 2025 under the previous ownership there was an issue with a blockage in the water flow which caused the gray water lines to back up into the bathtub. The facility elected to cover the bathtub with the plywood board so residents would not try to get into the bathtub. When the MD removed the plywood board there was orangish brown colored stains on the entire floor of the bathtub with some flaky, cracked areas noted particularly at the area beneath the waterspout. There were no noted odors in the bathroom. The MD stated the bathtub being covered with a board did not make the resident area feel like a homelike environment, it could be a source of infection. The MD also stated that since the plywood board was not secured it could break if resident tried to sit on it and cause resident injury. During an observation on 04/02/2026 at 11:45 PM, Resident #37's bathroom tub revealed four, approximately four inch by four inch by 12-inch, wooden blocks with numerous black oval shaped pieces of matter on the blocks and in the tub. During an interview on 04/02/2026 at 11:35 AM, Housekeeping #1 stated Resident #1 and Resident #16's bathtub had a clay colored substance in it, it was not clean, had a slight odor and it looked like it had been there for a while. She reported the tub was not draining. She stated Resident #37's tub had rat feces, and wooden blocks in the tub. Housekeeping #1 stated, inhaling rat feces could cause breathing problems for residents, and it was not proper, safe or healthy. She stated she was told the residents did not use the tubs in the locked down unit and she had not received any instructions for what she should do with the wooden covers on the bathtubs. She indicated she had not cleaned the tubs under the wooden covers.During an interview on 04/02/2026 at 11:08 AM, the Housekeeping Supervisor described Resident #37's bathroom tub as terribly, terribly filthy, not homelike, and would most likely get you sick because fungus could grow there. She confirmed there were big wooden blocks inside the tub and small, black pieces of something and indicated the tub condition was not at all acceptable and it was unsanitary. She described Resident #1 and Resident #16's bathtub as having a brown solid, dry substance in the tub and stated, the tub does not drain. She reported she added water and cleaner to the tub to soften the dried substance and used a scraper to remove the brown solid matter. She indicated housekeeping did not clean the bathtubs because the residents use the shower rooms and not the bathtubs for bathing/showering on the locked units. She reported she thought the wooden boards on top of the bathtubs were secured and was unsure of the reason for the wooden boards on top of the bathtub. The Housekeeping Supervisor reported she would expect housekeeping to clean the entire bathroom including the bathtubs. She reported she had never received a complaint or report from anyone about the bathtub covers.During an interview on 04/02/2026 at 11:47 AM, the Housekeeping Regional Manager described Resident #1 and Resident #16's bathtub as not operable and stated inside the tub looked like droppings of a rodent, the cover was not attached to the tub and not acceptable. He indicated the condition of the bathtub affected the residents because of environmental concerns, stating rodents should not be in your living place and indicated it could be hazardous to the residents' health.During an interview on 04/02/2026 at 1:24 PM, the Director of Nursing indicated she had seen the wooden covers on top of the bathtubs on 200 Hall but had not seen the inside of the covered tubs. She indicated she thought the wooden covers were bolted down. She reported Housekeeping was responsible for cleaning the bathtubs.During an interview on 04/02/2026 at 2:06 PM, the Administrator reported he was unaware of the wooden covers on the bathtubs until this week. He described Resident #1 and Resident #16's bathroom tub as having debris and dust in the tub, looked like brown with dirt, looked dry. He described Resident # 37's bathroom tub as having wood blocks in the tub, and he saw black dots in the tub. He indicated if a resident got into one of these tubs, they would get dirty. He stated, anything dirty can lead to getting sick. He reported the condition of the two bathtubs was not acceptable for resident living areas. He reported housekeeping was responsible for servicing the bathtubs with covers adding they [housekeeping] should clean everything in the room daily. He indicated the wooden covers on top of the bathtubs were to keep a resident from falling in the tub and keeping an unattended resident from taking a bath. Review of facility Grievance Logs dated September 2025 to February 2026, revealed no reported bathtub issues.

Based on observations, interviews, record review, and facility document review, the facility failed to ensure a resident who was at risk for elopement was adequately supervised in order to prevent the resident eloping from the secure unit for one (Resident #2) of three residents reviewed for accidents and supervision. The failed practice resulted in past noncompliance at the level of harm, which had the likelihood of causing more than minimal harm to Resident #2, who resided on the secure unit. The Administrator was notified of the past harm situation on 09/12/2025 at 3:50 PM. The findings include: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 05/15/2025, revealed Resident #2 had a Brief Interview for Mental Status score of 11which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #2 had active diagnoses which included non-Alzheimer's dementia, psychotic disorder, schizophrenia, and Parkinsonism. A review of Resident #2's Care Plan, with an initiation date of 02/12/2025, had interventions related to preventing elopement, which included having the resident on the secure neighborhood, with a goal of having no episodes of elopement. A form titled “NSG (Nursing)-Elopement Risk with Care Plan”, dated 04/09/2025 at 2:24 PM, indicated the resident had a score of 13, which was “High Risk”. The form indicated Resident #2 was ambulatory, had a history of wandering, and had medical diagnoses of dementia /cognitive impairment and a diagnosis impacting gait/mobility or strength. No care plan interventions were delineated on the Care Plan section of the form. A review of the form titled “OLTC (Office of Long-Term Care) Witness Statement Form” dated 05/18/2025 at 7:00 AM, with signature of Certified Nursing Assistant (CNA) #3, indicated on 05/17/2025 at approximately 11:30 AM, Resident #2 was wandering the halls, asking to leave, and wanted cigarettes. A review of the form titled “OLTC Witness Statement Form”, dated 05/19/2025 at 11:04 AM, with signature of CNA # 2, indicated on 05/17/2025 she could not locate Resident #2 at 4:50 PM, and the resident was last seen during rounds on the unit at 4:00 PM. A review of the Excerpt of Disaster Plan – Elopement, indicated if the missing resident was not found following an expedient search to call 911, and coordinate with public safety agencies in searching for the missing resident. A review of the Emergency Medical Services (EMS) run sheet report, dated 05/17/2025, indicated bystanders observed Resident #2 staggering and confused. Bystanders notified EMS at 4:44 PM. EMS was on the scene at 5:29 PM, near a business location approximately 0.7 miles from the facility, with Resident #2 lying in the grass, accompanied by local Police Department and Fire Department personnel. The EMS report also indicated Resident #2 stated to have escaped the facility because of being paranoid. Resident #2 was released after LPN (Licensed Practical Nurse) #1 signed a Refusal of Treatment at 5:50 PM. During an interview on 09/09/2025 at 10:47 AM, LPN #1 indicated when the resident was thought to be missing just before 5:00 PM on 05/17/2025, staff were instructed to search for the resident but were unable to locate Resident #2 in the secure unit, or anywhere in the facility or facility grounds. LPN #1 left the facility in her private vehicle to begin looking for Resident #2. LPN #1 indicated she was made aware of Resident #2's location because she received a phone call from a CNA that saw the resident with EMS. LPN #1 found Resident #2 in the care of EMS, signed the Refusal of Treatment and EMS assisted Resident #2 to the passenger side of LPN#1's personal vehicle. LPN #1 made the first attempt to contact the Director of Nursing (DON) when in route back to the facility. LPN #1 indicated Resident #2 did not have the capacity to enter a code into a keypad to exit the facility, and it was more likely that the resident exited through a facility door that did not close completely. During an additional interview on 09/12/2025 at 12:41 PM, LPN #1 indicated she made the decision to take the resident out of the care of EMS and did not attempt to contact the provider or Administrator at that time. LPN #1 indicated the only assessment concern for Resident #2 was the resident's temperature was up “just a bit” because it was hot that day, and she was trying to get Resident #2 back to the facility. A review of a website for local weather indicated the temperature on the afternoon of 05/17/2025 was 87 degrees Fahrenheit (F) at 4:53 PM, and 87 degrees F at 5:53 PM. A review of a Progress Note, effective date 05/18/2025 at 10:49 AM, indicated Resident #2's physician was notified of the elopement incident on 05/17/2025 at 6:00 PM. A review of the DMS (Division of Medical Services) form 762 indicated Resident #2 had skin tears to both hands noted upon return to the facility. A review of the Treatment Administration Record (TAR) for May 2025, indicated Resident #2 received treatment on 05/19/2025, for the skin tears to both hands, including cleansing, applying medicated gauze, and covering with a dry dressing three times a week, until healed. During an interview on 09/12/2025 at 1:20 PM, the DON indicated LPN #1 did attempt to contact her, but they did not communicate until Resident #2 and LPN #1 were back in the facility. CORRECTIVE ACTION: The facility provided the following evidence of corrective actions that were initiated after the 05/17/2025 incident, but prior to entrance of surveyors for the survey: During an interview with CNA #2 on 09/09/2025 at 4:44 PM, it was indicated the immediate action taken on 05/17/2025 at 4:50 PM was: 1. The nurse was notified, doors were checked, and a unit and facility search began. During an interview on 09/09/2025 at 10:47 AM, LPN #1 indicated Resident #2 was put on one-to-one monitoring upon return to the facility. Other immediate actions by the nursing staff included: 1. A body audit was completed on 05/17/2025 at 5:50 PM for Resident #2. 2. An Elopement Risk assessment with Care Plan was completed on 05/17/2025 at 10:12 PM, for Resident #2, as well as all other residents in the facility During an interview at 09/09/2025 at 11:28 AM, the Maintenance Director indicated he came up the night of the incident and checked all doors, checked all alarms on the doors and changed all the codes for the doors. The Maintenance Director also indicated that since there was nothing wrong with the doors, Resident #2 must have followed another person out of the door. The facility provided timecard sheets to demonstrate the presence of the Maintenance Director at 8:00 PM on 05/17/2025 until 8:17 PM. During an interview on 09/09/2025 at 12:48 PM, the DON indicated the Root Cause Analysis (RCA) Elopement Protocol and Root Cause Analysis, done between 05/17/2025 and 05/19/2025, revealed the only feasible way Resident #2 could have gotten out was the resident knew the codes to the door(s). The interventions implemented were as follows: 1. The process was changed immediately when taking Resident #2 out of the unit – the door was to be opened first, then Resident #2 would be taken through the door. This process change did not allow Resident #2 the opportunity to see the code being used. 2. Doors on the secure unit were monitored three times per week, for June 2025 and July 2025, then weekly, to ensure the doors were locked and the alarms were functioning correctly. 3. Keypad covers were installed on 05/19/2025 to decrease visibility of the code entry 4. In-services to all staff on elopement policy and procedure began 05/17/2025 with a completion date of 05/19/2025. Education included in the training was to ensure doors are secure, not to allow residents to view the keypads when codes were entered, not to use exit doors on the secure unit unless it was an emergency.: Interviews with staff were conducted to verify they were in serviced on how to prevent elopement and the correct process if a resident eloped. Staff interviewed were as follows: LPN #1, CNA #2, CNA #3, RN #4, CNA #5, LPN #6, Med Tech #7, LPN #8, Housekeeping #9, LPN #10, and CNA #11. These interviews were conducted with staff that worked on all shifts.

51477 Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents were free from abuse for 2 (Residents #3 and #5) of 3 sampled residents reviewed for abuse. Specifically, the facility failed to ensure Resident #3 and #5 were free from emotional and physical abuse. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to the residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, S483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of J. The IJ began on 12/30/2024 at 10:40 PM, when Licensed Practical Nurse (LPN) #3 made loud and aggressive statements while standing over Resident #5. At 10:45 PM, LPN # 3 was seen going into Resident #5's room and then coming out, wheeling Resident #5 out of the room in a wheelchair with a blood-soaked towel held to the resident ' s face. LPN #3 took Resident #5 up to the nurses cart on 400 Hall and was heard telling Resident #5 to Hold your [explicit language] head back, while the towel was held up to Resident #5's face. On 12/31/2024 at 12:35 AM, LPN #2 was sent by the Director of Nursing (DON) to check on Resident #5, and Resident #5 was found to be unresponsive to stimuli. The Administrator was informed of the alleged abuse on 12/30/2024 at 11:22 PM by the DON. The Administrator completed an OLTC Incident and Accident (I&A) Report on 12/31/2024 at 12:23 AM. The report indicated that the alleged abuse occurred on 12/30/2024 and indicated that LPN #3 was heard speaking loud and aggressively while standing over Resident #5. The Administrator, Chief Nursing Officer, and LPN Nursing Consultant were notified of the IJ on 01/02/2025 at 5:44 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 01/08/2025 at 4:05 PM. These are the findings: A review of the undated facility policy titled Prevention and Prohibition of Abuse, indicted Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. The significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/04/2024, revealed Resident #5 had a Brief Interview for Mental Status [BIMS] score of 1, which indicated Resident #5 had significant cognitive impairment. A review of Resident #5's care plan, initiated on 02/13/2023, revealed the resident had an Activity of Daily Living (ADL) self-care performance deficit with poor safety awareness. Interventions included that the resident could perform most ADL function with 1 person assist; had the potential to be physically aggressive related to dementia and schizoaffective disorder, was aggressive and hit at other residents on 12/20/2024. Interventions included When the resident becomes agitated: intervene before agitation escalates; If response is aggressive, staff to walk calmly away and approach later. Resident #5 had a diagnosis of post-traumatic stress disorder, and a review of the resident ' s care plan revealed it did not address this diagnosis. A review of a Progress Note, dated 12/30/2024 at 10:44 PM, indicated Resident #5 was sitting on the side of the bed with nose bleeding, area was cleaned, pressure was applied, and blood pressure was 148/82, bleeding stopped with head tilted and pressure applied. A review of an incident and accident (I&A) Progress Note, dated 12/30/2024 at 11:50 PM indicated Resident #5 was found unresponsive to commands with dried blood to nose and inside mouth, was not rousable with sternum rub (painful stimulus applied with closed fist used to firmly rub the bone in the center of the chest) and blood pressure of 68/40. A review of a Progress Note, dated 12/31/2024 at 12:38 AM, indicated LPN #2 entered Resident #5's room, Resident #5 was in a sitting position, unresponsive to commands, dried blood to nose and inside of mouth. At this time this LPN #2 continued to try and awaken the resident via sternum rub and calling out with no success. An ambulance was called due to Resident #5 ' s reduced level of consciousness. A review of hospital records, dated 12/31/2024, indicated Resident #5 was unresponsive and had a scalp hematoma. Principal problem was identified as physical assault. A review of [hospital name] conversations, dated 12/31/2024 at 10:19 AM, indicated dried blood was observed in mouth, on tongue, and left nostril, and a hematoma was discovered on the left side of Resident #5 ' s scalp, remained unresponsive to all stimuli until 10:00 . A review of [hospital name] history and physical (H&P) dated 12/31/2024 at 08:21 AM, indicated dried blood was observed on tongue and back of oropharynx (middle of the throat above the voice box); pupils were pinpoint and non-reactive. A review of the ED to Hosp-Admission hospital records indicated the chief complaint was listed as altered mental status and the Final Diagnoses, included physical assault and confusion. A review of intensive care unit (ICU) records dated 01/01/2025 indicated assessment for Resident #5 revealed indications of verbal and physical abuse, and scalp hematoma. A review of a computed tomography (CT) scan, dated 12/31/2024 at 02:03 AM, revealed Resident #5 had a scalp hematoma. A review of page 32 of Licensed Practical Nurse (LPN) #3's personnel file revealed LPN #3 signed a document titled Working Together to Prevent Abuse Brochure Acknowledgement on 03/04/2024. Also noted in the file on page 38, LPN #3 signed a document titled Resident Rights, it indicates that every resident has the right to Be free of verbal, psychological, physical, and sexual abuse. During an interview on 01/01/2025 at 3:45 PM, Certified Nursing Assistant (CNA) #6 indicated on 12/30/24 at 10:40 PM he was passing Resident #5's room and saw LPN #3 standing over Resident #5 speaking loudly and aggressively. CNA #6 indicated that on 12/30/2024 at 10:45 PM he saw LPN #3 get up from the nurses station and go to Resident #5's room, then he observed LPN #3 wheeling Resident #5 up to the nurses cart out by the nurses station on 400 Hall. CNA #6 indicated that he heard LPN #3 yelling at Resident #5 saying Hold your [explicit language] head back and observed Resident #5 with a towel up to his face with blood on the towel. CNA #6 indicated that Resident #5 looked at him in the eyes and he knew something was wrong. CNA #6 indicated that Resident #5 had the look of fear in his eyes. CNA #6 was asked if Resident #5 had fallen out of the bed. CNA #6 indicated that he had not. CNA #6 was asked if Resident #5 had a history of nose bleeds. CNA #6 indicted Resident #5 had never had a nosebleed while he was working. During an interview with the DON on 01/02/2025 at 10:13 AM, the DON was asked if Resident #5 had fallen out of bed and indicated that she had asked all the staff working that night and they all indicated that Resident #5 had not fallen out of bed. The DON verified Resident #5 did not have a history of nose bleeds. On 01/02/2025 at 11:13 AM, the DON indicated that she was notified by phone on 12/30/2024 at 11:00 PM, of the alleged abuse. The DON indicated that she tried to call LPN #3, but he didn't answer so she called the Administrator. The DON indicated that she and the Administrator spoke to LPN #3 by phone. The DON indicated that she asked him what happened to Resident #5. LPN #3 indicated that Resident #5 attempted to get out of bed three different times and LPN #3 went to put him back in bed and Resident #5 was sitting on the edge of the bed and LPN #3 noticed his nose was bleeding, so LPN #3 put Resident #5 in a wheelchair and took Resident #5 up to the nurses station on 400 Hall. LPN #3 indicated that he [LPN #3] had a towel up to Resident #5's nose due to the blood and told Resident #5 to keep his head back to stop the bleeding. The DON indicated that she asked LPN #3 why Resident #5's nose was bleeding. LPN #3 indicated that Resident #5's blood pressure was up. LPN #3 indicated Resident #5 ' s blood pressure was 130/87. A Police Department Incident Report, report generation date of 01/02/2025 at 12:39 PM, indicated the police department received a call from the facility on 12/31/2024 at 01:19 AM. The type of call was identified as Battery, and the narrative read, Officers were dispatched to the listed address due to a battery. Upon arrival, officers made contact with the Director of Nurse on the phone (DON named) who stated she needs to make a police report on an incident that occurred where a nurse (named LPN #3) allegedly punched an elderly resident (named Resident #5). Both [LPN #3] and [Resident #5] was not on scene (sic). Officers attempted to make contact with [Resident #5] at [named Hospital] with negative results as he was sedated and asleep for hours. [DON] was given the incident report number. Resident #5's Medication Administration Record (MAR) for December 2024 Indicated that on 12/30/2024 at 5:00 PM, Resident #5 did not receive his Midodrine (Midodrine is used to treat low blood pressure). The MAR had a documented BP for Resident #5 as 130/70. Removal Plan 12/30/2024 at 11:30 p.m., Licensed Practical Nurse (LPN) #3 was suspended via phone pending further investigation of alleged abuse. 12/31/2024 at 6:00 p.m., Licensed Practical Nurse was terminated via phone and did not return to work. 12/31/2024 at 12:57 a.m., Resident #5 was transferred to emergency room (ER) upon assessment from Night Nurse and Director of Nursing. 12/31/2024 at 12:30 a.m., In-service/Education started for all staff on Abuse to prevent serious harm, serious injury, serious impairment or death. Completion date 01/03/2025. If education is not provided via phone or in person, staff will be educated on Abuse Policy and Procedures prior to the start of their shift by In-service and education on Abuse Policy and Procedure, the types of abuse and when to report. Follow up is completed by verifying employee signatures to in-service document and compare to Employee Roster, as well as staff interviews. 12/31/2024 at 1:00 a.m., all 21 residents on 400 hall secured unit were assessed by the night nurse, due to alleged abuse with no negative findings, and was verified with follow up by the Director of Nursing/Chief Nursing Officer. The night nurse and two 3/11 shift Certified Nursing Assistants (CNA's) were verified no other residents witnessed the incident. 12/31/2024 Director of Nursing/Designee will begin assessing other 64 residents per census roster for needs of mental health services with follow up from Psychosocial Services with completion date of 01/03/2025. 12/31/2024 Body Audits on remaining 20 residents on 400 hall secured unit completed by treatment nurse with no negative findings. Treatment Nurse/Designee will complete other 64 residents body audits per census roster by 01/03/2025. Onsite Verification: The IJ was removed on 01/08/2025 at 4:05 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 01/03/2025 at 5:05 PM when the facility began educating staff on abuse. Termination of employment documentation for LPN #3 indicated last date worked was 12/30/2024, suspended on 12/30/2024, and terminated by telephone on 12/31/2024. Metro EMS Ambulance Patient Care Record for Resident #5 indicated the Incident #24-107185, date 12/30/2024 at 00:28 AM. Completed body audits for 28 of 28 100-Hall residents; Completed body audits for 25 of 25 200-Hall residents; Completed body audits for 15 of 15 300-Hall residents; Completed body audits for 21 of 21 400-Hall residents. OLTC Witness Statement from DON stating 400 Hall residents were assessed due to abuse allegation with no negative findings on 12/31/2024. A total of 17 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants, Medication Aide certified, Licensed Practical Nurses, and Housekeeping. The staff interviewed verified they had been trained on abuse, neglect and misappropriation of property. [Those staff who were not physically present to receive the in-services were messaged via telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding. The following was cited at F600 at a lower severity: A facility policy titled, PP Abuse Prevention indicated To provide a safe environment for all residents free of abuse. An Admission Record indicated the facility admitted Resident #3 with schizoaffective disorder. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2024 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had significant cognitive impairment. Review of Resident #3 Care Plan, initiated 10/23/2024, revealed the resident at risk for alteration psychosocial wellbeing related to living in skilled facility for long term care. No interventions in place at the time of review. An OLTC Incident and Accident Report (I&A) dated 12/18/2024 revealed LPN #2 stated that CNA #1 confirmed that they popped the resident on the butt trying to get her to go the bathroom. LPN #2 revealed that they heard ouch with each of four swats. LPN #2 stated from the sound, it was not a clap that was heard. A witness statement from LPN #2 was included and read, This nurse was sitting at nurse ' s station .when [Resident #3] was screaming ouch, ouch from the swats from aide [CNA #1] x4 times. This nurse then asked aide if she hit resident. She [CNA #1] stated, No I was popping her on the butt. During interview on 12/30/2024 at 1:50pm, Resident #3 stated that they (indicating CNA #1) hit me on the butt and I hit them back first. During an interview on 12/30/2024 at 2:01pm, Human Resources (HR) stated CNA #1 was no longer with us. During an interview on 12/30/2024 at 8:18am, LPN #2 indicated that CNA #1 wasn't very welcoming with the residents. LPN #2 noticed that CNA #1 didn't like to repeat herself. LPN #2 reported sitting at nurses station, when CNA #1 went into Resident #3 room, then heard loud smacking sounds and CNA #1 saying, Get up and go to the bathroom. LPN #2 heard Resident #3 say ow, ow, ow with each hit. LPN#1 got the wound care nurse and informed CNA #1 that they had to leave. LPN#2 verbalized that they did not see Resident #3 being struck but heard her being struck. During an interview on 12/31/2024 at 9:24am, CNA #1 said they clapped their hands like it was time to get up, stating that Resident #3 and CNA #1 had a good relationship. CNA #1 pulled covers back, patted them on their booty, and told Resident #3 time to get up and go to the bathroom, to which Resident #3 told the CNA to not do that. CNA #1 then took care of other resident in room. LPN #2 asked if they had hit Resident #3, to which CNA #1 stated, No I clapped my hands like I always do, I don't hit residents. During an interview on 12/31/2024 at 11:52am, the DON stated that they were reported to by LPN #2 regarding the incident. A full body assessment and body audit was done on Resident #3 and their roommate during that time. The DON reported the incident to the Administrator, provider, and family. I heard from LPN #2 loud [NAME] were heard at the nurses station. LPN #2 asked if CNA #1 hit Resident #3 and that CNA #1 stated that they clapped her hand but patted her buttocks.

Based on interview, record review, and facility policy review, it was determined the facility failed to report an alleged violation involving abuse to the proper state agency within the allotted time frame for 1 (Resident #3) of 1 sampled resident reviewed for abuse allegations. The findings are: Review of a facility policy titled Prevention and Prohibition of Abuse indicated The facility administrator or designee shall complete a report to be made to the mandated state agency and may also be made to the local law enforcement agency after corporate approval or immediately if the abuse constitutes an emergency. Administrator or designee will have 5 working days from the initial report of abuse to complete SIMS (Statewide Incident Management System) report. Immediately means as soon as possible, in the absence of a shorter State time frame requirement, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. A review of an Admission Record indicated the facility admitted Resident #3 with a diagnosis of schizoaffective disorder (combination of symptoms that affect a person's emotional state and a disorder that affects a person's ability to think, feel, and behave clearly). A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had severe cognitive impairment. A review of Resident #3 ' s Reportable, dated 12/18/2024, indicated Nurse was at nurse ' s station and heard a popping noise that they thought was a slap. Upon entering the resident's room, Certified Nursing Assistant (CNA) #1 was getting resident up to go use the bathroom. Licensed Practical Nurse (LPN) #2 asked CNA #1 if they hit the resident. CNA #1 answered back that she ' popped resident on the butt with the back of the hand ' trying to get her to go to the bathroom. LPN #2 dismissed CNA #1 from the room, assessment of resident completed with no negative findings. Resident stable with no distress noted. CNA #1 immediately suspended with investigation started. During an interview with the Administrator on 12/31/2024 at 12:05pm, the Administrator was familiar with Resident #3 ' s care and confirmed knowledge of alleged abuse on 12/18/2024. The Director of Nurses (DON) notified the Administrator of the alleged abuse. The Administrator confirmed the incident and accident was on 12/18/2024 at 6:00AM but notification was sent in on 12/19/2024 at 10:58AM. A body audit and assessment of Resident was completed, and the employee was suspended. The Administrator confirmed a representative and the attending practitioner were both notified. The Administrator confirmed the abuse was reported to the Office of Long-Term Care. The Administrator confirmed that an investigation had been completed and was awaiting notice from the Office of Long-Term Care. The Administrator confirmed the employee was suspended and removed from facility for their actions and to protect the alleged victim from further abuse during the investigation process. The results of the investigation were founded, and the staff member was terminated. The Administrator revealed there were no warning signs to facility to indicate prior to the incident and the facility tried to send in the reportable within a timely manner but had difficulty.

Based on interview, record review, and policy review, the facility failed to develop a comprehensive care plan for one (Resident #5) of one resident reviewed for care plans, specifically that a resident ' s post-traumatic stress disorder diagnosis was addressed in the resident ' s care plan. The findings are: Resident #5 had diagnoses including schizoaffective disorder bipolar type, nightmare disorder, post-traumatic stress disorder, and type 2 diabetes mellitus without complications. A review of the significant change in status Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/04/2024, revealed the resident received a score of 1 (severely impaired) on the Brief Interview for Mental Status (BIMS). The resident required moderate assistance with bed mobility and transfers. The resident required substantial assistance with personal hygiene and dressing. A review of Resident # 5's care plan, initiated on 02/13/2023, revealed the resident had an Activity of Daily Living (ADL) self-care performance deficit with poor safety awareness: interventions included the resident could perform most ADL functions with 1 person assist; had the potential to be physically aggressive related to dementia and schizoaffective disorder, was aggressive and hit at other residents on 12/20/2024: interventions included When the resident becomes agitated: intervene before agitation escalates; If response is aggressive, staff to walk calmly away and approach later. Resident #5 has a diagnosis of Post-Traumatic Stress Disorder, and a review of the care plan did not address this diagnosis. A review of Resident #5 ' s Admission Record indicated that the resident was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder bipolar type, post-traumatic stress disorder, nightmare disorder, and pseudobulbar affect (a condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying). On 01/03/2025 at 2:42 PM, Licensed Practical Nurse (LPN) #13 was asked who was responsible for completing resident care plans. LPN #13 indicated that she was responsible for completing the care plans. LPN #13 was asked if the care plan should address the goals, preferences, needs and strengths of Resident #5. LPN #13 indicated that it should. LPN #13 was asked what Resident #5's mental health diagnoses were. LPN #13 indicated schizoaffective, major depressive disorder (MDD), dementia, and pseudobulbar affect (a condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying). LPN #13 was asked how active diagnoses are identified for the care plan. LPN #13 indicated the physician would give the orders on medications they [physician] let us know the diagnoses, upon admission with their paperwork and any physician they see and diagnosis they coordinate with us [facility]. LPN #13 was asked if the care plan described corresponding interventions for care that account for Resident #5's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization's? LPN #13 indicated that would be a question for the physician. On 01/03/2025 at 3:01 PM, the Director of Nursing (DON) was asked who was responsible for completing the care plans. The DON indicated LPN #13. The DON was asked how the active diagnoses are identified for the care plan. The DON indicated you look in the care plan. On 01/03/2025 at 3:12 PM, the Administrator was asked why it was important for the care plan to reflect Resident #5's goals, preferences, needs, strengths and interventions for care. The Administrator indicated so staff would know and understand how to provide proper care for the resident. The Administrator was asked what the policy and procedure for completing the care plan was. The Administrator indicated it meets their needs assessment in the time frame and completed upon admission within 48 hours and person-centered care based on RAI, reviewed with resident Inter-Disciplinary Team (IDT) team and responsible party and updated quarterly and as needed. A review of the facility's undated policy titled Care Plan Policy and Procedure, provided by the Administrator on 01/03/2025, indicated Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches It is the policy of this facility to utilize an advanced care planning approach to review and determine patient centered care plans.

Based on observation, interview and record review, the facility failed to ensure foods stored in the dry storage areas were covered, sealed and dated; 1 of 2 ice machines were maintained in clean and sanitary condition; the kitchen light fixtures were covered; ceiling tiles and door frames were maintained in good repair and were free of chips, stains and rust; baseboards were secured and were maintained in clean sanitary conditions, and dietary staff washed their hands before handling clean equipment or food items for 2 of 2 meals observed. The findings are: 1. On 11/19/24 at 2:34 PM, the following observations were made in the kitchen: a. An opened box of salt was on the food counter. The box was not covered. b. An opened box of mashed potatoes was on the counter. The box was not fully covered. c. An opened bag of grits was in a basket on the counter. The bag had no opened date on it. 2. On 11/19/24 at 2:38 PM, Dietary [NAME] (DC) #2 pushed a cart toward the counter that contained bowls to be used in portioning dessert to be served to the residents for supper. He picked up gloves and placed them on his hands, contaminating the gloves in the process. On 11/18/24 at 11:55 AM, he used his contaminated glove to pick up slices of frosted vanilla cake in the bowls to be served to the residents for supper. DC #2 was asked what he should have done after touching dirty objects and before handling clean equipment, DC #2 stated he should have washed his hands. 3. On 11/18/24 at 2:40 PM, the following observations were made in the kitchen: a. The outside of a black utility cart, where 2 baskets of condiments were kept, had stains all over it. There were loose food crumbs inside of the baskets. The Dietary Manager (DM) was interviewed and was asked how often the kitchen should be cleaned. He stated the kitchen staff were supposed to clean it every shift. b. Five (5) of eight (8) leg supports of the food preparation counter had accumulation of grease stains on them. There was an accumulation of dry food crumbs on the floor under food preparation counter. c. One of 2 drip pans above the deep fryer had accumulation of grease build up hanging down from it. One vent had buildup of greasy stains in them d. The ceiling tile above the plate warmer, by the steam table, was cracked. e. Six (6) of six (6) fluorescent lights in the kitchen did not have a covering over them. f. Two (2) of two (2) bottom door frames leading to the storage room were missing, exposing the metal, g. The baseboards throughout the storage room were missing and the door frames leading to the dining room from the dish washing machine had rust on them. h. One (1) ceiling tile in the storage room was loose and had ten (10) areas with water damage. i. The floor in front of a 3-door freezer in the storage room was chipped exposing the cement. Floor in front of the storage rack was chipped exposing the cement. j. The floor in front of the hand washing sink was chipped exposing the cement k. The ceiling tiles above the refrigerator had water damage in six (6) different areas. l. The bottom of the door frames leading to the rest room were rotten, exposing the concrete. 4. On 11/18/24 at 2:45 PM, the following observations were made on a rack in the storage room. a. An opened gallon of barbeque sauce. The manufacture ' s specification on the gallon indicated to refrigerate after opening. b. An opened of gallon of stir fry sauce. The manufacture ' s specification on the gallon indicated to refrigerate after opening. 5. On 11/18/24 at 3:06 PM, two (2) of two (2) air vents in the dish washing room had brown -yellow stains on them. The Dietary Manager (DM) stated the two air vents were dirty and needed to be cleaned. 6. On 11/18/24 at 3:17 PM, the ice machine, on the hall leading to the laundry, had wet black residue on the panel where ice touched before dropping into the ice collector. The surveyor asked the Dietary Manager if DM could wipe the wet black residue on the ice machine panel. He did so, and the wet black substance easily transferred to the paper towel, and he stated it had a black dirt. The DM was asked who uses the ice from the ice machine and how often he cleans the ice machine. He stated Certified Nursing Assistants (CNA)s used it to fill the water pitchers for the residents' rooms and the kitchen staff used it to fill beverages served to the residents at mealtimes. The maintenance man cleans the ice machine once a month. 7. On 11/19/ 24 at 4:10 PM, Dietary [NAME] (DC) #2 used a scissor to open a bag of shredded lettuce. As he opened it, he emptied it into a pan and poured shredded cheese on it. DC #2 picked up gloves and placed them on his hands, contaminating the gloves in the process. On 11/19/24 at 4:11 AM, he used his contaminated gloved hands to mix it. DC #2 when he was asked what he should have done after touching dirty objects, and before handling clean equipment, DC #2 stated he should have washed his hands. On 11/19/24 at 4:12 PM DC #2 placed the pan of salad on a shelf in the refrigerator. 8. On 11/20/24 at 11:16 AM, Dietary [NAME] (DC) #3 turned on the food preparation sink and rinsed the blender blade with hot water. However, DC #3 did not apply soap when washing the blade or sanitized it properly. DC #3 then attached the blade, which was not thoroughly washed at the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets. As DC #3 prepared to place food items into the blender. DC #3 was asked what she should you have done after touching dirty objects and before handling clean equipment, she stated she should have washed her hands. 9. On 11/20/24 at 3:09 PM, DC #2 removed a pan of tuna salad from the freezer and placed it on the counter. DC #2 then picked up a bag of bread from the bread rack and placed it on the counter, contaminating his hands, further contaminating the gloves, using his contaminated gloved hand, DC #2 removed slices of bread from the bag as he was ready to put them into the blender. DC #2 was interviewed and asked what he should have done after touching dirty objects and before handling clean equipment, he stated he should have washed his hands. 10. A review of facility policy titled, Hand Hygiene Policy and Procedure not dated, and provided by the Dietary Manager on 11/21/2024 indicated hands should be washed prior to food preparation, before and after eating or handling food.

Based on record review and interview, the facility failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents in 1 of 1 facility. This deficient practice had the potential to affect all residents of the facility. The total census was 81 residents. The findings are: The Facility Assessment 2024, dated as completed 05/15/2024, was reviewed and did not contain the following required information: -The involvement of the medical director, director of nursing and direct care staff (these signatures were missing on the review page dated 08/22/2024). -Staffing plan which addressed staffing needs for each resident unit and each shift. -The facilities resources including all personnel (management, direct care staff and volunteers) which included employees and contracted employees along with their education and competencies. On 11/21/2024 at 1:26 PM, the Administrator was interviewed and stated this was the first facility assessment she had completed. She stated a member of the governing body, and the Director of Nursing (DON) assisted her with completing the facility assessment. The Administrator stated she did not speak with the medical director during the completion of the facility assessment. She stated the purpose of the facility assessment was to provide overall quality of care for the residents. A Facility Assessment Tool Policy and Procedure, not dated and provided by the Administrator on 11/21/2024, was reviewed and indicated the intent of the facility assessment was for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents required.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a bottle of acid reducer liquid medication was properly stored in the refrigerator, per the pharmacy instructions on the bottle, for 1 (Resident #33) of 1 sampled resident whose medication was in the 100-hall medication cart. The findings are: On 11/19/2024 at 3:18 PM, this surveyor reviewed the contents inside the 100-hall medication cart with Registered Nurse (RN) #1. A drawer on the right side of the 100-hall medication cart contained a bottle of acid reducer 2 milligrams per milliliter (mg/ml) liquid for Resident #33 with instructions to give 10 ml (20 mg) by percutaneous endoscopic gastrotomy (PEG) (a tube inserted through a surgical opening in the abdominal wall leading into the stomach). The bottle of acid reducer had a blue sticker which indicated to refrigerate the medication and contained approximately 210 ml to 240 ml of liquid. The bottle was not cold and did not have any condensation on the outside. Resident #33's electronic Medication Administration Record (eMAR) was reviewed and indicated the medication was last administered on 11/19/2024 at 0630 (6:30 AM), by RN #1. On 11/19/2024 at 3:26 PM, RN #1 was interviewed with concurrent observations. She stated the resident did receive the liquid acid reducer around 6:00 AM each morning. She stated the stickers on the bottle of acid reducer indicated to shake well and refrigerate. She confirmed the bottle of acid reducer liquid should have been stored in the refrigerator. A Medication Storage Policy and Procedure, not dated and provided by the Director of Nursing (DON) on 11/21/2024, was reviewed and indicated the purpose was to properly secure medications and biologicals according to the Centers for Medicare and Medicaid Services (CMS) guidelines. The procedure indicated designated personnel would perform weekly and as needed review of medication storage areas and carts for compliance of policy.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned, written menu to ensure that nutritionally balanced meals were provided for the residents for 1of 1 meal observed. The findings are: 1. On 11/19/2024, the menu for the supper meal revealed residents on pureed diets were to receive two #8 scoops (1 cup) of pureed chili. a. On 11/19/24 at 5:13 PM, Dietary [NAME] (DC) #2 used a #8 scoop (1/2 cup) to serve a single portion of pureed chili to all the residents on pureed diets, instead of 2 #8 scoop s (1 cup). b. On 11/19/24 at 5:40 PM, DC #2 was asked, during an interview, what scoop size he had used when serving pureed chili to the residents who required pureed diets. DC #2 stated he used the gray scoop (#8), which was equivalent to 1/2 cup, to give a single serving of pureed chili to each resident. When asked if he had looked at the menu. DC #2 confirmed he had not.

Based on record review and interview, the facility failed to convey funds within 30 days and send conveyed funds to the individual or probate jurisdiction administering the resident's estate for 7 ( Residents #5, #6, #7, #8, #9, #10, and #11) of 7 case mix residents reviewed for personal funds. 1. Resident #5 was admitted to facility on [DATE] and expired on [DATE]. A review of the resident #5'spersonal funds account managed by the facility revealed on [DATE] at 10:27 AM the resident's personal fund had a balance of $6,124.80. Resident #5 is receiving a social security check each month which is deposited into the resident trust fund even thought Resident #5 expired on [DATE]. 2. Resident #6 was admitted to the facility on [DATE] and expired on [DATE]. A review of the resident #6's personal funds account managed by the facility revealed on [DATE] at 12:25 PM that the residents' personal fund has a balance of $1,425.87. Resident #5 expired 14 months ago. 3. Resident #7 was admitted to the facility on [DATE] and expired on [DATE]. A review of the resident #7's personal funds account managed by the facility revealed on [DATE] at 1:07 PM the residents' personal fund has a balance of $953.55. Resident #7 expired 18 months ago. 4. Resident #8 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. A review of resident #8's personal funds account managed by the facility revealed on [DATE] at 12:02 PM the resident ' s personal fund has a balance of $3,882.06. Resident #8 was discharged 16 months ago to the hospital and did not return. 5. Resident #9 was admitted to the facility on [DATE] and was discharged to another nursing facility on [DATE]. A review of the resident #9's personal funds account managed by the facility revealed on [DATE] at 11:45 AM that the resident's personal fund has a balance of $2,065.56. Resident #9 was discharged 10 months ago to another facility. 6. Resident #10 was admitted to the facility on [DATE] and was discharged to another nursing facility on [DATE]. A review of the resident #10's personal funds account managed by the facility revealed on [DATE] at 11:36 AM that the resident's personal fund has a balance of $4,185.00. Resident #10 was discharged 7 months ago to another facility. 7. Resident #11 was admitted to the facility on [DATE] and expired on [DATE]. A review of the resident #11's personal funds account managed by the facility revealed on [DATE] at 2:21 PM that the resident's personal fund has a balance of $1,221.04. Resident #11 expired 3 months ago. 8. On [DATE] at 10:15 AM, the Business office manager (BOM) was asked if she had contacted the social security office when these residents expired. She said yes, she had. Surveyor asked her to show the documentation where she had notified the social security office on the expired residents facility managed personal funds. She said, I messed up and I didn't do it. There was no documentation that the residents, families, or beneficiaries had been notified of the funds in the resident's accounts. There was no documentation that the social security office had been notified of the overpayment in the resident personal accounts. 9. On [DATE] at 1:18 PM, the administrator presented to the surveyor the facilities policy on personal funds.This facility manages resident personal funds as requested and in accordance with all applicable law . 10. On [DATE] at 6:00 PM, after reviewing the facility policy it does not address the requirement. 11. On [DATE] at 1:18 PM, the Administrator stated the funds should have been addressed and returned to the residents social security office or beneficiaries. .

Based on observation, interview and record review, the facility failed to ensure food stored in the freezer was covered or sealed to prevent potential contamination or freezer burn; 1 of 2 ice machines was maintained in clean and sanitary condition to prevent potential contamination of resident beverages; the kitchen wall and door frames were maintained in good repair and were free of chips, paint peeling, stains and rust; baseboards were secured and were maintained in clean sanitary conditions; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 86 residents who received meal trays from the kitchen, (total census of (88), as identified on a list provided by the Dietary Supervisor on 12/15/2023 at 12:01 PM. The findings are. 1. On 12/11/23 at 9:30 AM, the counters in the kitchen had crumbs on them. The floors were dirty and had crumbs on them. The food cart had standing water in it and the outside of it was dirty. A package of cheese was not sealed. The refrigerator had crumbs at the bottom. A resealable plastic bag with 2 pork fritters had a 'use by date' of 10/23/23. In the dry storage there was a backpack hanging on the food storage shelf. 2. On 12/13/23 at 08:17 AM, the following observations were made on a shelf in the freezer: a. An opened bag of diner rolls. The bag was not covered or sealed. b. An opened box of bread sticks. The box was not covered or sealed. c. An opened box of cookies. The box was not covered or sealed. 3. On 12/13/23 at 08:21 AM, the following observations were made on a shelf in the refrigerator: a. An opened box of turkey sausage. The box was not covered or sealed. 4. On 12/13/23 at 08:28 AM, the following observations were made in the 3 door refrigerator: a. There were 2 opened boxes of bacon at the bottom of the refrigerator. The boxes were not covered or sealed. 5. On 12/13/23 at 08:44 AM, the following observations were made in the kitchen areas: a. The door frames leading to the Kitchen, Janitor's Closet, Dish Washing Machine room, the first and second dining rooms from the dish washing room, and the storage room were chipped exposing the metal. b. The dish washing floor was chipped in 3 different areas exposing the concrete. Two tiles were missing in the dish washing machine room. The areas where tiles were missing or chipped had milky water standing on them. c. The dish washing floor leading to the storage room was rusty. The walls throughout the kitchen had paint peeling, spillage stains and the cement was exposed. d. The baseboards throughout the kitchen were missing, the door frames leading to the room where the hand washing sink was located were loose from the walls. e. The ceiling tiles in the storage room were loose and had 3 areas with water damage. f. The right side of the hand washing sink had brown stains on it. g. The bottom of the door frames leading to the storage room were rotten. h. The ceiling tiles in the area where the hand washing sink was located had stains on them. i. The outside of a black utility cart, where condiments were kept, had stains all over it. There were loose food crumbs inside of it. j. The floors and the edges of the food preparation counter had an accumulation of loose food crumbs and grease. k. All 8 leg supports of the food preparation counter had stains on them. l. The bottom of the food preparation counter where the scale was kept had loose black residue on it. m. On 12/15/23 at 12:54 PM, the Surveyor asked the Dietary Supervisor how often the kitchen should be cleaned. She stated, They are supposed to clean it every shift. 6. On 12/13/23 at 8:50 AM, one unopened clear bag on the bread rack in a room leading to the storage room contained 8 hamburger buns, there was a bug crawling inside the bag. The Surveyor asked the Dietary Supervisor what was crawling inside the bag. She stated, That was a gnat, and the bag has not been opened. 7. On 12/13/23 at 09:05 AM, there was a big clump of wet black residue inside the ice machine spout where ice empties into the reservoir. The Surveyor asked Dietary Employee (DE) #1 to wipe the wet black residue inside the ice machine opening. She did so, and the wet black substance easily transferred to the paper towel. The Dietary Supervisor stated, It had a black nasty residue. She was asked, Who uses the ice from the ice machine and how often do you clean ice machine? She stated, That's the ice Certified Nursing Assistants [CNAs] use for the water pitchers in the residents' rooms. We use it to fill beverages served to the residents at mealtimes. Clean it every week. 8. On 12/13/23 at 10:51 AM, DE #3 was wearing gloves on her hands when she turned on the food preparation sink and rinsed tomatoes. She turned off the sink faucet, contaminating the gloves in the process. Without changing gloves, and washing her hands, she removed tomatoes from the pan and placed them on the cutting board. She cut the tomatoes and placed them in a pan to be served to the residents for the noon meal. The Surveyor asked the DE #3 what should you have done after touching dirty objects and before handling clean equipment? DE #3 stated, I should change gloves and wash my hands. 9. On 12/13/23 at 11:03 AM, the following observations were made during the noon and supper meal preparations: a. DE #2 picked up the water hose with his bare hand, used it to spray off leftover food items from the dishes contaminating his hands, and placed the dishes in the dirty racks and pushed them into the dish washing machine to wash. After the dishes stopped washing, DE #2 moved to the clean side in dishwasher area and without washing his hands picked up a clean blade and attached it to the base of the blender to be used to puree food items to be served to the residents for the noon meal. At 11:05 AM, when DE #2 was ready to place meat items into the blender to ground, the Surveyor immediately asked DE #2 what should you have done after touching dirty equipment/objects and before handling clean equipment? DE #2 stated, I should have washed my hands. 10. On 12/13/23 at 11:37 AM, DE #2 pulled his pants up and then pushed a food cart out of the way. At 11:41 AM, he removed a saucepan from a clean rack and placed it on the stove. He picked up gloves and placed them on his hands, contaminating the gloves in the process. At 11:44 AM, he unzipped the bag that contained the slices of bread and used his contaminated gloved hands to remove slices of bread and placed them on a to go plate. He also opened the refrigerator door, removed an unzipped bag that contained slices of cheese and used his contaminated gloved hands to remove slices of cheese and placed the cheese on top of the bread. He then turned on the stove, used the same hands to pick up slices of bread and cheese and placed them on the pan to be grilled and served to the residents who requested a grill sandwich with their lunch meal. The Surveyor asked immediately, What should you have done after touching dirty objects and before handling clean equipment or food items? He stated, I should have changed gloves and washed my hands. 11. On 12/13/23 at12:25 PM, DE #4 was on the tray line assisting with the lunch meal. He picked up packages of condiments and cartons of supplements and placed them on the trays. Without washing his hands, he picked up glasses that contained beverages by their rims and placed them on the trays to be served to the residents for lunch. On 12/14/23 at 12:32 PM, the Surveyor asked DE #4 what he should have done after touching dirty objects and before handling clean equipment? He stated, I should have picked them up from the bottom. 12. A facility policy titled, Hand Hygiene Policy And Procedure documented, .Procedure: Hand Hygiene will be performed via utilizing hand sanitizer or hand washing in the following situations: .g. Before and after eating or handling food (hand washing with soap and water); .t. After handling soiled equipment or utensils; u. After handling soiled dietary equipment or resident dishes . 13. A facility policy titled, Cleaning Instructions: Counter Space Policy And Procedure, provided by the Administrator on 12/15/23 at 12:31 PM documented, Policy: Counter space will be wiped and sanitized prior to and following food preparation and meal service and as needed. Procedure: 1. Spills will be wiped up as needed using a clean cloth and warm water. 2. To sanitize: Remove small appliances and other items from the counter. Wipe off debris. Use sanitizing and wipe with a clean cloth. Wipe the outer surfaces of small appliances. Allow countertops and small appliances to air dry . 37634

Based on observation, record review and interview, the facility failed to ensure a resident was assessed and deemed safe for self-administration for 1 (Resident #86) of 1 sampled resident on the 400 Hall whose medication was left at the bedside. This failed practice had the potential to affect 20 residents who resided on the 400 Hall. The findings are: Resident #86 had diagnoses of chronic kidney disease, dementia, hypertension, and depression. a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/2023 documented the resident scored 03 (00-07 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). b. On 12/11/2023 at 10:55 a.m., 11:49 a.m., and 1:15 p.m., observed Resident #86 lying in his bed with 6 pills in a medicine cup on his bedside table. c. On 12/14/2023 at 10:00 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #1 what is the proper way for a nurse to give a resident their medication. LPN (#1) said stay with them while they take their medicine. The Surveyor asked if they refuse to take their medication, what do you do. LPN (#1) said try to be positive with them to take them. If they don ' t take them, I take them back to cart and try again later. The Surveyor asked should medications be left on a bedside table in a resident room. LPN (#1) said absolutely not. d. On 12/14/2023 at 10:45 a.m., the Director of Nursing (DON) was asked what is the proper way for a nurse to administer medication to a resident? The DON said the nurse should take the medication in the room and stay with them until the resident takes them. e. On 12/14/2023 at 11:00 a.m., a review of Resident #86's electronic health records revealed no physicians order to self-administer medications, no assessment to self-administer medications and no care plan to self-administer medications. f. On 12/14/23 at 11:23 a.m., a review of Resident #86's chart revealed no order from the Medical Doctor or Advanced Practice Registered Nurse (APRN) for Resident #86 to self-administer his medications. g. On 12/15/2023 at 9:07 a.m., the DON stated, There is no self-administration of medication assessment on [Resident #86].

Based on observation, record review and interview, the facility failed to ensure the bathroom sink was in working order to ensure access to running water to perform activities of daily living (ADLs) for 1 (Resident #86) of 20 residents who resided on the 400 Hall. The findings are: Resident #86 had diagnoses of chronic kidney disease, and dementia. The Quarterly Minimum Data Set with an Assessment Reference Date of 08/30/23 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and was independent with all ADLs. a. On 10/14/15 at 10:07 a.m., observed in Resident #86's bathroom there were no knobs on his sink to turn on his water. b. On 10/14/23 at 10:07 a.m., the Surveyor asked Resident #86 how long the sink has been like this. Resident #86 replied I really don't know, but it has been a while. I go into another resident room and brush my teeth. c. On 10/14/23 at 10:18 a.m., the Surveyor asked Maintenance Supervisor if he was aware there was no way for Resident #86 to get water from his sink in his bathroom. Maintenance Supervisor replied no ma'am no one has informed me that there was a problem with his sink, or I would have fixed it. d. On 10/14/23 at 10:20 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #1 should a resident have access to water in his bathroom sink. LPN #1 replied yes, they should. The Surveyor asked if she was aware that Resident #86 did not have access to his water in his bathroom. LPN #1 replied no, I didn't know the knobs were not on the sink.

Based on observation and interview, the facility failed to ensure 4 rooms on the 100 Hall were clean and maintained a homelike environment, and staff changed gloves when cleaning resident rooms. The findings are: On 12/11/23 at 11:09 AM, Resident room [ROOM NUMBER], the blind to left side of the double window were missing 4 of the slats. On 12/11/23 at 11:15 AM, the bathroom floor, toilet, and tub in the shared bathroom in Resident Rooms 117/116 had brown stains on them. On 12/11/23 at 11:24 AM, in Resident room [ROOM NUMBER], the bathroom floor and the toilet had brown stains on them. On 12/11/23 at 11:30 AM, in Resident room [ROOM NUMBER], the toilet and bathtub had brown stains on them. On 12/13/23 at 9:59 AM, the Surveyor asked Housekeeper #1, Can you tell me what's on the toilet, and floor in room [ROOM NUMBER]? He stated, It's dirty. On 12/13/23 at 10:14 AM, Housekeeper #1 went into Resident room [ROOM NUMBER] and wiped the yellowish/brownish stains off the toilet. He walked out of the room with the paper towels he wiped the toilet with and stated, It wasn't stained. He continued to clean the bathroom without changing gloves. On 12/13/23 at 10:14 AM, without changing his gloves, Housekeeper #1 went into Resident room [ROOM NUMBER]. He grabbed the privacy curtains and sprayed them. On 12/13/23 at 11:15 AM, in Resident room [ROOM NUMBER], the blind to left side of the double window was missing 4 of the slats. On 12/13/23 at 11:30 AM, the bathroom floor, toilet, and tub in the shared bathroom in Resident Rooms 117/116 had brown stains on them. On 12/15/23 at 11:22 AM, during an interview Housekeeper #2 was asked, How often should the bathroom be cleaned? She stated, I do them daily, but if it's not bad it can skip a day. She confirmed that the floors and toilets should be clean. She was asked, What should you do with your gloves after you finish cleaning a resident's bathroom? She stated, I should discard them before I leave out of the room. On 12/15/23 at 11:37 AM, the Surveyor asked the Maintenance Supervisor, Can you tell me why rooms [ROOM NUMBERS] blinds have slats missing? He stated, I'm waiting on some to come in now. We ' ve already ordered them.

Based on observation, interview and record review, the facility failed to ensure 3 (Residents #1 #75, and #92) of 3 sampled residents who were dependent on staff for nail care to promote good hygiene and cleanliness. The findings are: 1. On 12/11/2023 at 10:48 AM, observed Resident #75 in his room with fingernails 1/2 inch past the fingertip on both hands with a dark brown substance under the nails. a. On 12/11/2023 at 02:51 PM, observed Resident #75 in his room with fingernails 1/2 inch past the fingertip on both hands with a brown substance under the nails on both hands. b. On 12/12/2023 at 9:45 AM, observed Resident #75 in his room sitting on the side of the bed. The Surveyor asked to see his hands. He had fingernails 1/2 inch past the fingertip on both hands with a brown substance under the nails. The Surveyor asked if the facility staff clean and cut his nails. Resident #75 stated, Nope. 2. On 12/11/23 at 11:12 AM, observed Resident #92 in his room. with fingernails 1/2 inch past the fingertip with a brown substance under the nails on both hands. a. On 12/12/23 at 11:38 AM, observed Resident #92 up in a chair in the hallway by the nurses' station with fingernails 1/2 inch past the fingertip with a brown substance under the nails on both hands. b. On 12/14/23 at 10:46 AM, observed Resident #92 in the hallway with fingernails 1/2 inch past the fingertip with a brown substance under the nails on both hands. c. On 12/14/2023 at 2:14 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 how often should the residents receive nail care? CNA #1 stated, Everyday. The Surveyor asked who is responsible for making sure nail care is done. CNA #1 replied The CNAs are. The Surveyor asked should a brown substance be under the resident's nails. CNA #1 replied, No it should not. d. On 12/14/2023 at 2:16 PM, the Surveyor asked CNA #2 how often do the residents receive nail care? CNA #2 stated, Daily or every shift. The Surveyor asked who is responsible for making sure nail care is provided to the residents. CNA #2 stated, We are. The Surveyor asked should a brown substance be under the resident's nails. CNA #2 stated, No it shouldn't. 37634 3. Resident #1 had a diagnosis of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/23 documented the resident had short and long-term memory problems and was dependent on staff for personal hygiene. a. The Care Plan with a revision date of 06/13/20 indicated Resident #1's nails should be cleaned, and trimmed during bathing, and that she likes getting her nails done. b. On 12/11/23 at 11:00 AM, Medication Tech #1 moved the blanket back on Resident #1. Her nails were 1/2 inch past the fingertips with a brown substance under her nails. c. On 12/15/23 at 11:43 AM, the Surveyor asked CNA #1, Who's responsible for trimming [Resident #1's] nails? He stated, I am, but we have been short staffed, and I haven't been able to get to them this week. I've been out on the floor. He was asked, How does [Resident #1's] nails look to you? He confirmed that her nails were dirty.

Based on observation, record review and interview, the facility failed to ensure an intervention for a fall was implemented for 1 (Resident #19) of 1 sampled resident with a major injury in the last 30 days, and razors were removed from the bathroom for 1 (Resident #78) of 2 (Residents #77 and #78) sampled residents on the 100 Hall. The findings are: 1. An Incident Report dated 12/2/23 at 12:00 pm noted Resident #19 fell out of his bed and broke his left wrist. a. A Late Entry Progress Note dated 12/02/23 at 12:00 pm, noted Long-term/Care Planned Intervention: Bolster Mattress. b. On 12/12/2323 at 3:51 pm, observed Resident #19 lying in bed with no bolster mattress on bed. c. On 12/13/23 at 8:37 am, observed Resident #19 lying in bed with no bolster mattress on bed. d. On 12/14/23 at 9:29 am, observed Resident #19 lying in bed with no bolster mattress on bed. e. On 12/14/23 at 10:19 am, the Surveyor asked Licensed Practical Nurse (LPN) #1 if a resident has an incident happen how do you know what the intervention is. LPN #1 said if it happens on my shift, and I do the incident report then I put whatever the intervention is in place. If it happens on another shift, it is given to me in report, or a department head will inform me. The Surveyor asked if the resident has an intervention for a bolster mattress to be on the bed, should it be on the bed. LPN #1 said yes it should. The Surveyor accompanied LPN #1 to Resident #19's room. The Surveyor asked can you please tell me if this resident has a bolster in place. LPN #1 said no he doesn't, but I will get one on his bed right now. f. On 12/14/23 at 10:55 am, the Surveyor asked the Director of Nursing (DON) if a resident has an intervention for a bolster mattress on the bed, what should be done. The DON said it should be placed on the bed immediately. g. On 12/15/23 at 10:22 am, DON provided a policy titled, Fall Protocol, which documented, Purpose: To identify residents at risk for falls, initiate, preventative approaches, and provide appropriate strategies and interventions . 37925 2. Resident #78 had diagnoses of suicidal ideation and unspecified dementia, mild, with mood disturbance. a. A Care Plan initiated on 7/17/23 documented, .[Resident name] has an ADL [activities of daily living] self-care performance deficit r/t [related to] periods of forgetfulness/disorientation secondary to history of Dementia Date Initiated: 07/21/2023 Revision on: 08/08/2023 . [Resident name] has an increased risk for suicidal ideation/plan/threat/gesture d/t [due to] had a plan in past to cut his throat Date Initiated: 07/14/2023 Revision on: 07/17/2023 . Be alert to any signs that the resident may be actively initiating a suicidal plan . requesting items to that could be used for self harm . b. On 12/12/23 at 9:13 am, Resident #78 was resting quietly in bed. He had facial hair on his cheeks, chin, and neck. He was asked, When was the last time you had a shave? Resident #78 stated, I asked them for a razor two days ago and they gave it to me. Resident #78 was asked, Do you shave yourself? Resident #78 stated, Yes. c. On 12/13/23 at 12:37 pm, Resident #78 was resting in bed awake. He was asked, Did you get a shave? Resident #78 stated, Yes. Resident #78 was asked, Did a staff member shave you? Resident #78 stated, No. I shaved myself. He was asked, How did you shave yourself? Resident #78 stated, They gave me a razor. He was asked, Do you have any razors now? Resident #78 stated, Yes, in the bathroom. The Surveyor knocked on the bathroom door and then opened it and observed three blue razors and a can of shaving cream on the sink. The resident had facial hair on his chin and neck but none on his cheeks. d. On 12/15/23 at 11:25 am, the Surveyor knocked and then entered Resident #78's bathroom from the adjoining room and observed 3 blue razors on the residents sink and none of them had a protective cover over the blade. e. On 12/15/23 at 11:42 am, during an interview, Certified Nursing Assistant (CNA) #1 stated residents get shaved on their shower days. He also confirmed no razors should be left in the residents' bathrooms because they could cut themselves. f. On 12/15/23 at 2:00 am, during an interview, the DON was confirmed no razors should be left in Residents' bathrooms because other residents could get them and cause harm to themselves. She also confirmed that all the staff are responsible for ensuring razors are removed from the residents' bathroom.

Based on observation, interview, and record review, the facility failed to ensure fluids were readily accessible to promote adequate hydration for 3 (Residents #39, #75 and #352) sampled residents and interventions were promptly implemented after continued weight loss was identified to attain or maintain acceptable nutritional status for 1 (Resident #92) of 2 (Residents #92 and #352) with weight loss. The findings are: 1. Resident #39, the physician orders documented Resident #39 had diagnoses of dementia, major depressive disorder, and anxiety disorder. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/08/2023 documented a Brief Interview of Mental Status (BIMS) score of 04, (0-7 indicates severe cognitive impairment) and required no supervision or assistance with meals. a. On 12/11/23 at 11:40 AM, 1:14PM, 1:59PM, and 2:56 PM, Resident #39 did not have fluids at the bedside. b. On 12/12/23 at 10:14 PM, there was not a water pitcher, or fluids in Resident #39's room. c. On 12/14/23 at 10:33 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 how often do you pass water. CNA #1 replied every shift. The Surveyor asked what type of device do you put the water in? CNA #1 replied they each have their own water pitcher. The Surveyor accompanied CNA #1 to Resident #39's room and asked CNA #1, can you show me his water pitcher? CNA #1 said he doesn't have one. The Surveyor asked what about a cup. CNA #1 replied he doesn't have one or any water. The Surveyor asked if a resident should have water. CNA #1 replied yes, they should. 2. Resident #75 had diagnoses of dementia, and unspecified lack of coordination. The MDS with an ARD of 09/06/2023 documented a BIMS score of 06, (0-7 indicates severe cognitive impairment) and required no supervision or assistance with meals. a. On 12/11/23 at 10:49 am and 2:51 pm, Resident #75 had no water or liquids in his room. b. On 12/13/23 at 9:17 am, surveyor observed Resident #75 had no liquids or water in his room. c. On 12/14/23 at 8:36 am, surveyor observed Resident #75 had no water or liquids in his room. 3. Resident #352 had diagnoses of cognitive social or emotional deficit following a Cerebral Infarction, Covid -19, communication deficit, muscle wasting and atrophy, and vascular dementia with moderate agitation. The Quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 11/24/2023 documented a Brief Interview of Mental Status (BIMS) score of 00, (a score of 0-7 indicates severe cognitive impairment). Resident #352 and required to be fed her meals. a. On 12/11/23 at 10:31 am, and 2:34 pm, observed Resident #352 with no water or any liquid in her room. On 12/14/23 at 10:55 am, the Surveyor asked the Director of Nursing (DON) what is your protocol for residents to receive water? The DON replied every two hours the resident should be offered water. The Surveyor asked so should there be water in their room. The DON replied yes there should be. The Surveyor asked how often water is delivered to the resident rooms water. The DON replied we pass water every shift and we refill it as needed. On 12/14/23 at 1:47 pm, the DON provided a policy titled, Hydration Policy and Procedure which documented, Purpose: To assure that the resident receives the adequate amount of fluid based on individual needs to prevent hydration .Procedure: .2. C.N.A. will offer fluid to the resident at mid-morning, mid-afternoon, and at bedtime . 1. Resident #92, the physician orders noted diagnoses of dementia, vitamin B deficiency and vitamin D deficiency. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/23 documented Resident #92's weight was 202 pounds. A Significant Change in Status MDS with and ARD of 11/26/23 documented Resident #92 weighed 152 pounds. A 24.75% weight loss in less than 6 months. A Physicians Order dated 07/31/23 noted Resident #92 was to be weighed monthly. A Physicians Order dated 08/18/23 noted Resident #92 was to receive nutritional supplement two times a day. Monitor and evaluate any weight loss. Monitor and record food intake at each meal. Offer substitutes as requested or indicated, such as finger foods and shakes. Weigh weekly until weight is stabilized/or as directed. A Care Plan with a revision date of 08/31/23 noted Resident #92 had unplanned/unexpected weight loss and was to be given supplements as ordered. A Care Plan with a revision date of 09/28/23 noted Resident #92 was at risk for significant weight loss. Was to be assisted with meals as he allowed. Large portions with lunch and dinner A Physicians Order dated 11/27/23 noted Resident #92 was to receive a regular mechanically soft diet, large portions for nutrition. The December 2023 Medication Administration Record (MAR) revealed Resident #92 was to receive snacks between meals and a nutritional supplement 2 times a day. Review of the Dietary Snack Summary provided by LPN #1 on 12/15/23 at 1:05 pm, for December 1 - 14, 2023 revealed Resident #92 consumed 0 of the snack 7 days for the 10:00 snack 5 days for the 2:00 PM snack with no documentation on 2 days. Review of the MAR provided by the DON on 12/15/23 at 1:40 pm revealed Resident #92 consumed 0 to 100% of the nutritional supplement offered at 8:00 am and 8:00 pm. On 12/12/19 at 12:45 pm, Resident #92 was in the dining area and was being fed by staff. Resident #92 ate 35% of his lunch. There was no nutritional supplement on his tray. On 12/12/19 in the afternoon, Resident #92 did not receive an afternoon snack. On 12/13/23 at 10:03 am, Resident #92 was sitting up in a chair by the nurse's station and he had a few (4) cheese puffs on his bedside table by his chair. He was not eating them or being encouraged by staff to eat them. No nutritional drink was offered. On 12/13/23 at 12:53 am, observed Resident #92 being fed his lunch in the dining area by staff. He had large portions; no nutritional supplement and he ate 50% of his lunch. In the afternoon at 2:13 pm, observed Resident #92 sitting in a chair at the nurse's station, no nutrition supplement or snack was given. On 12/14/23 at 9:57 am, observed Resident #92 sitting in a chair at the nurse's desk. He was eating a cookie and had another one on his lap. No nutritional supplement was given.

Based on interview and record review, the facility failed to ensure as needed antipsychotic and antianxiety medications were discontinued or reevaluated for use after 14 days for 1 (Resident #92) of 2 sampled residents who were reviewed for unnecessary medication. The findings are: A review of Resident #92 record indicated he had a diagnosis of unspecified psychosis, muscle wasting and atrophy, cognitive community deficit, unspecified dementia, insomnia, anxiety disorder, and alcohol abuse. A significant change Minimum Data Set (MDS) with an Assessment Reference Date of 12/7/2023 documented Resident #92 was severely cognitively impaired per a Staff Assessment for Mental Status. Resident #92's active Physician Orders as of 12/12/2023 documented the resident had the following: a. Lorazepam 0.5 milligrams IM (intramuscular) every 4 hours as needed. b. Lorazepam 0.5 milligrams every 6 hours as needed. Order Date 11/23/23. c. Haloperidol 5 milligrams IM every 4 hours as needed. Order Date 11/23/23. d. Haloperidol 2.5 milligrams every 6 hours as needed. On 12/14/23 at 11:02 am, the Surveyor asked the Director of Nursing (DON) what the protocol was for a resident taking PRN (as needed) antipsychotic or antianxiety medications. The DON said after 14 days the PRN should be discontinued or rescheduled. The Surveyor asked how do you determine which of those to do? DON said, we look to see if they have been receiving the medication and we contact the APN (Advanced Practice Nurse) or MD (Medical Doctor) and tell them if they have been receiving the medication or not and they determine what to do. On 12/15/23 at 11:42 AM, the Surveyor asked the Director of Nursing (DON) if the resident is receiving an antidepressant and an antiseizure medication, should they have a diagnosis to support the medication. The DON replied, yes, they should. The Surveyor asked who monitors your physician orders to assure that each medication has a diagnosis to support it. The DON replied, I monitor it, the nurse, and the Unit Manager. The Surveyor asked what your process is when medications are ordered without a diagnosis to support it? The DON replied, they notify the APRN (Advanced Practice Registered Nurse), or doctor and try to get it scheduled or discontinued or change the medication in general.

Based on observations, interviews, and record review, the facility failed to ensure a call light was accessible to 3 (Residents #28, #59, and #89) of 11 (Residents #14, #22, #28, #39, #59, #60, #75, #86, #89, #90, and #92) sampled residents and the call light was in working order for 2 (Rooms 415-B and 303-B) of 2 rooms. The findings are: Resident #28 1. Resident #28's diagnoses showed mild vascular dementia with behavioral disturbance, cerebral infarction, muscle wasting, fracture of T5-T6 vertebra. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/23 showed a Brief Interview for Mental Status (BIMS) of 8 (8-12 indicates moderate cognitive impairment) and required partial and/or moderate assistance with toileting and personal hygiene. 1a. The Care Plan showed Resident #28 is at risk for falls and to be sure the resident's call light is within reach and is to be encouraged to use it for assistance and prompt response to all requests for assistance. 1b. On 12/11/23 at 02:34 PM, observed Resident #28's call light on the floor. 1c. On 12/12/23 at 10:00 AM, observed Resident #28's call light on the floor. 1d. On 12/13/23 at 09:20 AM, observed Resident #28's call light on the floor and out of the reach of the resident. 1e. On 12/13/23 at 09:35 AM, Resident #28's call light on the floor. 1f. On 12/12/23 at 02:34 PM, the Surveyor asked Resident #28, Do you use your call light? Resident #28 stated, Yes, when I have it. The Surveyor asked if he/she knew where it was. Resident #28 stated, No. 1g. On 12/13/23 at 02:34 PM, the Surveyor asked Resident #28, Can you reach your call light? Resident #28 stated, No. 1h. On 12/13/23 at 09:38 AM, the Surveyor accompanied Licensed Practical Nurse (LPN) #1 to Resident #28's room and asked where is the resident's call light? LPN #1 stated, It is on the floor. The Surveyor asked if the resident was able to reach it. LPN #1 confirmed the call light was out of reach. Resident #59 2. Resident #59's diagnoses showed vascular dementia with other behavioral disturbance and hemiplegia affecting the left nondominant side. The MDS with an ARD of 10/17/23 showed a BIMS of 5 (a score of 0-7 indicates severe cognitive impairment) and required partial or moderate assistance with oral and personal hygiene and substantial/maximal assistance with toileting hygiene. 2a. The Care Plan with a revision date of 05/10/21 showed the resident had an activities of daily living (ADL) self-care performance deficit and was to be encouraged to use the call light for assistance. 2b. The Care Plan with a revision date of 07/07/23 showed d Resident #56 was at risk for falls and was to have a working and reachable call light. Be sure the call light was to be within reach and he was to be encouraged to use it for assistance as needed with prompt response to all requests for assistance. 2c. On 12/12/23 at 09:58 AM, Resident #59's call light was clipped to a cord on the wall out of reach of the resident. 2d. On 12/12/23 at 09:57 AM, Resident #59's call light was clipped to a cord on the wall out of reach of the resident. 2e. On 12/13/23 at 08:59 AM, Resident #59's call light was clipped to a cord on the wall out of reach of resident. 2f. On 12/13/23 at 09:04 AM, the Surveyor asked Certified Nursing Assistant (CNA) #2, Can you tell me where Resident #59's call light is located? CNA #2 stated, On the floor. The Surveyor asked, How would the resident be able to call for assistance? CNA #2 stated, The resident wouldn't. The Surveyor asked, Where should it be placed? CNA #2 stated, By the resident. 2g. On 12/13/23 at 09:09 AM, the Surveyor asked LPN #1, How should a resident be left when in bed? LPN #1 stated, They should have a call light in reach. The Surveyor asked, Is Resident #59's call light in reach? LPN #1 confirmed the call light was not in reach. Resident #89 3. Resident #89's diagnoses showed hypertension, chronic obstructive pulmonary disease (COPD), muscle wasting and lack of coordination. The Quarterly MDS with an ARD of 9/21/23 showed a BIMS of 15 (13-15 indicates cognitively intact) and required extensive assistance with toilet use and personal hygiene. 3a. The Care Plan showed the resident is at risk of falls. Be sure the call light is within reach and encourage the resident to use it for assistance as needed with prompt response to all requests for assistance. 3b. On 12/11/23 at 09:38 AM, observed Resident #89's call light lying at the end of the bed on the floor. 3c. On 12/12/23 at 09:01 AM, observed Resident #89's call light lying on the floor at the end of the bed. 3d. On 12/12/13 at 11:45 AM, observed Resident #89's call light lying on the floor at the end of the bed. 3e. On 12/14/23 at 10:30 AM, the Surveyor asked LPN #2, Is Resident #89's call light in reach for the resident? LPN #2 confirmed the call light was not in reach. 3f. On 12/15/23 at 08:52 AM, the Surveyor asked CNA #3, What is your process when you lay a resident down or put them up in the chair in their room? CNA #3 stated, Put the bed in the lowest position and leave a call light in reach. room [ROOM NUMBER]-B 4. On 12/13/23 at 09:35 AM, room [ROOM NUMBER]-B's call light was activated above the door. The Surveyor asked LPN #1, Does room [ROOM NUMBER]-B's light above the door come on by itself? LPN #1 stated The light is broken. It comes on all the time without it being pushed. The Surveyor asked has it been reported to maintenance. LPN #1 stated, I'm sure it has. The Surveyor asked for the Maintenance Log. LPN #1 stated, I don't even think I have one back here. 4a. On 12/13/23 at 09:44 AM, LPN #1 notified Maintenance that room [ROOM NUMBER]-B's call light was coming on randomly. 4b. On 12/13/23 at 09:46 AM, the Surveyor asked the Administrator if there was a Maintenance Logbook on 400 Hall. The Administrator asked LPN #1, who stated, No. The Administrator stated it is probably on 300 Hall. I know there was one here once, but it probably got moved. The Surveyor asked should there be a Maintenance Logbook at each Nurse's station. The Administrator stated, Yes, I'm going to get one to put back here. 4c. On 12/14/23 at 01:57 PM, the Surveyor accompanied LPN #1 to room [ROOM NUMBER]-B. LPN #1 activated the call light for room [ROOM NUMBER]-B with success. LPN #1 showed the Surveyor a Maintenance Logbook located at the nurse's station for 400 Hall. room [ROOM NUMBER]-B 5. On 12/15/23 at 08:54 AM, the call light be activated above room [ROOM NUMBER]-B with no audible sound from the nurse's station. 5a. On 12/15/23 at 08:54 AM, the Surveyor asked CNA #3, Does the call light sound at the nurse's station when activated? CNA #3 stated, No it doesn't. It's supposed to, but it doesn't. 5b. On 12/15/23 at 08:57 AM, the Surveyor requested CNA #3 to activate the call light. The Surveyor then accompanied Maintenance to the 300 Hall nurse's station. The Surveyor asked Maintenance, Were you aware the call light was not working properly? Maintenance stated, No. 5c. On 12/15/23 at 08:58 AM, Maintenance confirmed there was no sound when the call light was activated. 5d. On 12/15/23 at 08:59 AM, the Surveyor reviewed the 300 Hall Maintenance Logbook. There was no requisition noted for a broken call light. 5e. On 12/14/23 at 10:57 AM, the Surveyor asked the Director of Nursing (DON), Where should a call light be placed when a resident is in bed or up in a chair in their room? The DON stated, It should be within reach. The Surveyor asked, Is Resident 89's call light in reach? The DON confirmed the call light was not in reach. The Surveyor asked, Should a call light above the door activate intermittently on its own? The DON stated, No. The Surveyor asked when a call light is activated should it sound at the nurse's station. The DON stated, Yes. The Surveyor asked, Should a maintenance logbook be available at each nurse's station? The DON stated, Yes. 6. A policy titled, Call Light, Use of Policy and Procedure provided by the Administrator on 12/14/23 at 2:21 PM showed, . 7. When providing care to residents be sure to position the call light conveniently for the resident to use . 9. Notify the maintenance department and enter defective call light location(s) in the maintenance log, if the [there] is any noted concern with the call system. 10. Be sure to position the call light conveniently for the resident to use .

Based on interviews, the facility failed to ensure residents were informed of who the Ombudsman is, what the Ombudsman does and where the Ombudsman's contact information is located in the facility. The findings are: 1. On 12/13/23 at 10:30 AM, during a Resident Council Meeting the Surveyor asked Residents #50, #64, #70 and #82 if they knew how to contact their Ombudsman. All 4 residents stated, No. what is an Ombudsman. 2. On 12/13/23 at 10:30 AM, the Surveyor asked the 4 Residents if anyone ever explained to them what an Ombudsman does or where to find their information. All 4 residents shook their heads no, and stated, We have never heard of this person. 3. On 12/15/23 at 9:47 AM, the Surveyor asked the Administrator who was responsible for informing the residents who their Ombudsman is. The Administrator stated our Activities Director, Myself, the Director of Nursing, and the Social Worker. The Surveyor asked who educates the residents to let them know what the Ombudsman does, and where the poster with their contact information is located. The Administrator stated the Activity Director, the Administrator, the Director of Nursing or Social Worker.

Complaint # (AR 870) was substantiated, all or in part, in these findings: Based on observation, record review, and interview, the facility failed to ensure bed rails were present and in the raised position for a resident on a low air loss mattress, in accordance with the manufacturer's instructions, to prevent further potential falls / injury and failed to ensure a planned intervention to maintain the bed in the lowest position was consistently implemented to minimize the potential for fall-related injury for 1 (Resident #2) of 2 (Residents #1 and #2) case mix residents who used the Primatech Medical System TheraFlo Low Air Loss Mattress Replacement System. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #2, who fell out of bed and sustained a large hematoma to the head, and had the potential to cause more than minimal harm for 3 residents who used the Primatech Medical System TheraFlo Low Air Loss Replacement Mattress System, according to a list received from the Administrator on 5/22/17. The facility was informed of the Immediate Jeopardy condition on 5/22/17 at 9:29 p.m. The findings are: Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/4/17 documented the resident scored 6 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS), was totally dependent on 2-plus persons for bed mobility and transfers, had no functional limitation in range of motion in the upper extremities, had functional limitation in range of motion of the lower extremity on one side, and had a pressure reducing device on the bed. a. The Comprehensive Care Plan dated 1/18/17 documented, .At risk for decline in ADLs (activities of daily living) as related to CVA (Cerebrovascular Accident) as evidenced by left sided weakness, limited mobility .bed mobility .staff to keep bed in lowest position .air mattress and bilateral ½ (one-half) rails for mobility .date initiated .1/18/17 . b. The Corporate Fall Risk Review dated 4/7/17 at 8:20 a.m., and signed by the MDS Coordinator documented the resident's fall risk score was 10, which indicated a moderate risk for falls. c. The Facility Incident Report dated 5/3/17 at 5:40 a.m., with a revision date of 5/6/17 at 7:27 p.m., documented, .Incident Description: Nurse (writer) was doing AM (morning) pill call, someone was yelling. Entered room. Resident noted lying in floor close to bed, face down with bed linens underneath her. Bed in low position. Resident yelling. 'I fell .' Nurse called resident's name and responded appropriately. Assessed resident for obvious injuries. No blood noted on floor around resident. Nurse rolled resident over slowly off of her face and onto her back while supporting her neck. Resident has left BKA (below knee amputation). Call light noted clipped to resident gown across her chest. Nurse removed call light from gown. A large knot about 4-5 cm (centimeters) in size noted to right side of resident forehead without broken skin, abrasion or bleeding noted to head and face area. No bleeding noted to any area of the body. Nurse left resident lying on floor on her back. Called for assistance from staff to remain with resident . Resident was unable to give an accurate description of what happened. States, 'I fell out of bed' .MMES (Mobile Medical Emergency Service) notified 911 . The report documented the planned intervention to prevent further falls as, .Bed at lowest level. Floor mat . An unsigned, handwritten note on the Facility Incident Report documented, Resident diagnosed with [REDACTED]. This could contribute to increased confusion and resident therefore rolling out of bed. Attached to the Facility Incident Report was a copy of the manufacturer's instructions for the use of the Primatech Medical System TheraFlo Low Air Loss Mattress Replacement System. d. The Neurological Post Fall Evaluation dated 5/3/17 documented, .Effective Date 5/3/17 05:40 (5:40 a.m.), 1. Incident Report of Incident . Unwitnessed fall . 2. If incident was unwitnessed is there any evidence of visible injury? If yes, describe in detail . Yes, hematoma to right side of forehead about 3-4 cm in diameter. No broken skin, abrasion, nor bleeding noted . 3. Was treatment necessary? Be specific . Yes, applied ice pack, sent to ER (emergency room ) for evaluation . The form was signed by Licensed Practical Nurse (LPN) #1. e. The Hospital emergency room record dated 5/3/17 documented, .Arrival 5/3/17 at 6:23 a.m. Chief Complaint Elderly .with hx (history) HTN (Hypertension) presents from NH (Nursing Home) s/p (status [REDACTED]. Pt (Patient) with hematoma to R (right) frontal scalp. AAO (Awake, Alert and Oriented) to baseline . CT (computed tomography) of head final results, Impression Large right frontal scalp hematoma without underlying calvarial fracture or acute intracranial injury . Impression 1. Fall initial encounter 2. Acute Cystitis without hematuria. Imaging revealed no traumatic injuries. Urinalysis shows bacteria, leukocytes, nitrites. discharged with Keflex . Transferred back to her Nursing Home . f. The Comprehensive Care Plan with a revised date of 5/3/17 documented, .(Resident) is at risk for falls as related to limited mobility Left AKA and Cognition . Alzheimer/Dementia diagnosis . 5/3/17 Fall w/ (with) injury . Goal (Resident) will be protected from serious injury due to risk of falls through next review period .Interventions: .Staff in-service on air mattress / fall mat / bed alarms . date initiated 5/4/17 created by (MDS Coordinator) . g. On 5/22/17 at 4:43 p.m., the resident was lying in bed on her back, with the head of the bed elevated approximately 30 degrees. The resident had a low air loss mattress in place and no side rails were in use. The bed height was approximately 33 inches above the floor, not in the lowest position. The resident was on a Primatech TheraFlo Low Air Loss Mattress. There was one floor mat on the right side of the bed. There was a bedside table on the left side of the bed and no floor mat. The Assistant Director of Nursing (ADON) stated the resident was alert and oriented to person, occasionally sat up in a wheelchair and was transferred with a mechanical lift. She stated the resident required total assistance with activities of daily living and had experienced one fall approximately one month ago, when the resident rolled out of bed. The resident had a low air loss mattress on her bed at the time of the fall on 5/3/17. The ADON was asked for the manufacturer's instructions for the Primatech TheraFlo Low Air Loss Mattress at 5:05 p.m. h. On 5/22/17 at 5:25 p.m., the Primatech Medical System TheraFlo Low Air Loss Mattress Replacement System manufacturer's instructions were received from the Administrator. The manufacturer's instructions documented, .Warnings . Patient Falls: Failure to use bed rails in raised position could lead to accidental patient falls. Air mattresses have soft edges that may collapse when patient rolls to the edge . i. On 5/22/17 at 6:18 p.m., the Treatment Nurse was asked if there were any special requirements for the use of the low air-loss mattress and stated, I know they check them when they are set up and are set according to the resident's weight; they are not supposed to have sheets, and there is a static button that can be used to inflate the mattress all the way. The Treatment Nurse was asked if she had knowledge regarding the safety measures for the use of the low air-loss mattress. The Treatment Nurse stated, No. j. On 5/22/17 at 7:50 p.m., the Director of Nursing (DON) stated she had been the DON since January 2017. The DON was asked about any interventions that were implemented after Resident #2's fall on 5/3/17. The DON stated, Low bed and mat at the bedside. The DON was asked about the low air-loss mattress and stated the equipment supplier set the computer system to the air mattress, to prevent the staff from adjusting the pressure on the mattress. The DON was asked where this was documented in the resident's clinical record and stated, I don't know . We were looking at all possibilities of what could have happened. The DON was asked if she had read the manufacturer's instructions for the Primatech TheraFlo Low Air Loss Mattress and stated, No. The DON was asked if the manufacturer's instructions that were attached to the incident report for this mattress had been reviewed after the fall on 5/3/17. The DON stated, No, because we determined the reason for the fall. Her level of confusion and she had a [DIAGNOSES REDACTED]. We put a fall mat in place and her bed in the lowest positron. The DON was asked what safety measures were necessary for residents with a low air-loss mattress and stated, Side rails or bolsters, if deemed safe for the resident. The DON was asked if this was documented on the Primatech TheraFlo Low Air Low Mattress instructions. The DON stated, No, it was for the Plexic (other brand of low air-loss mattress). The DON was asked if she had read the warnings in the manufacturer's instructions for the PrimaTech TheraFlo Low Air Loss Mattress and stated, No I did not. The DON stated a floor mat was to be in place, and the bed was to be in the lowest position. k. On 5/22/17 at 8:05 p.m., the DON accompanied the surveyors to Resident #2's room. Certified Nursing Assistants (CNAs) #1 and #2 were in the resident's room providing care. At 8:29 p.m., as the CNAs started to leave the room, CNA #1 was asked if they were finished with the resident's care. The CNA looked around the room, then stated, Yes. The CNA was asked if there was anything else they needed to do. The CNA stated, No. The CNAs proceeded out of the resident's room, leaving the bed elevated to approximately 33 inches above the floor. The DON and Surveyors remained in the room. The DON went over to the bed and lowered it to the lowest position, which was approximately 12 inches above the floor. The resident had a mat on the right side of the bed. There was a night stand on the left side of the bed between the wall and the resident's bed. The DON was asked if only one mat was to be used. The DON stated, Yes, she was an amputee of the left side, and if they roll, they roll to the heavier side. That was the right side of the bed, and that was the side of the bed that the resident rolled out of. The DON was asked if the staff had knowledge that the resident's bed was to be in the lowest position. The DON stated, Yes. The DON was asked who was responsible for ensuring the bed was in the lowest position. The DON stated, All the staff. l. On 5/22/17 at 8:50 p.m., Certified Nursing Assistant (CNA) #1 was asked staff knew what care to provide each resident. The CNA stated, The care plan on the Kiosk, or the closet care plan in the resident's closet. The CNA checked in Resident #2's closet and there was no closet care plan available. The CNA was asked if there were any precautions that were supposed to be in place for Resident #2. The CNA stated, Yes, her bed is to be in the lowest position and a mat at her bedside . I got busy, and I just forgot and didn't do it. m. On 5/22/17 at 8:53 p.m., the Administrator and the Director of Nursing were asked if they had reviewed the manufacturer's instructions for the low air-loss mattresses that were in use in the facility. The Administrator stated, No. The Surveyor asked the Administrator to read the warning section of manufacturer's instructions for the Primatech TheraFlo Low Air Loss Mattress System. The Administrator read the warnings and stated, Side rails are to be used. The Administrator was asked if Resident #2 had side rails on her bed. The Administrator and DON stated, No. The Administrator and DON were asked if this could lead to resident falls. The DON stated, According to the guidelines. The Administrator was asked if the manufacturer's instructions should have been read by the facility prior to using the low air-loss mattress system. The Administrator stated, Yes. The Administrator was asked who was responsible for reviewing the Incident and Accident Reports. The Administrator stated, I review them frequently. The Administrator was asked who was responsible for monitoring the low air-loss mattresses and ensuring the manufacturer's safety instructions were being followed. The Administrator stated, Myself and Maintenance. n. On 5/24/17 at 10:50 a.m., Licensed Practical Nurse (LPN) #1 was asked, After (Resident #2's) fall on 5/3/17, what instructions were you given? LPN #1 stated, They changed the box on the foot of the bed, so that the setting couldn't be changed, and the fall mat. LPN #1 was asked if she was instructed, prior to this week, on the need to keep the bed in the lowest position for residents on low air-loss mattresses. LPN #1 stated, No. LPN #1 was asked, Who is responsible for ensuring the residents' beds are in the lowest position? LPN #1 stated, Everybody. o. On 5/24/17 at 3:22 p.m., CNA #3 stated she worked on the 300 Hall. CNA #3 was asked, When were you instructed regarding (Resident #2), for her bed to be in the lowest position? CNA #3 stated, This week. p. The Immediate Jeopardy was removed and the scope and severity decreased to G on 5/22/17 at 10:15 p.m., when the facility initiated the following plan of removal: 1.) On May 22, 2017 at 8:59 p.m. (Resident #2's) bed was placed in the low position by the Director of Nursing. On May 22, 2017 at 10:15 p.m. side rails were applied to the bed of (Resident #2) by the Maintenance Supervisor. On May 22, 2017 at 9:49 p.m. the Administrator read the Manufacturer Guidelines for the low air loss mattresses. On May 22, 2017 at 10:00 p.m. all residents who have low air loss mattresses were assessed for the need for side rails for prevention of falls and safety per the Manufacturer's Guidelines by the Director of Nurses or designee. All residents requiring side rails were provided with side rails. All beds of residents with planned interventions for low beds were immediately checked to ensure that they were in the lowest position. 2.) On May 22, 2017 at 9:45 p.m. in-servicing was started. All Nursing Staff in the building was in-serviced on the necessity of side rails on beds with (low) air loss mattresses in compliance with Manufacturer's Guidelines and requirement to place beds in lowest position for safety unless care planned otherwise by (the) Director of Nurses or designee. Beginning on May 22, 2017 all oncoming Nursing Staff for the 3-11 (3:00 p.m. to 11:00 p.m.) shift were immediately in-serviced by (the) Assistant Director of Nursing BEFORE ALLOWING THEM TO WORK. Any Nursing Staff not working at this time (weekends as needed, staff on paid time off) will be in-serviced by (the) Director of Nurses or designee before starting to work. No Nursing Staff will be allowed to work until they have been in-serviced. 3.) Compliance for in-service completion will be monitored by the Administrator or designee every day for four weeks, three times per week for two weeks until consistent compliance is established by the Quality Assurance Committee. This will be reported monthly to the Equability Assurance Committee. 4.) Monitoring regarding the need for side rails for prevention of falls and safety per the Manufacturer's Guidelines will be monitored by the Director of Nurses or designee daily for 2 weeks, then three times weekly for 6 weeks by the Director of Nurses or designee and reported weekly to the Administrator. This will continue until compliance is determined by the Equability Assurance Committee. This will be reported monthly to the Quality Assurance Committee. All monitoring will be accomplished by the Director of Nursing or designee to ensure the side rails are in use on the beds where the Manufacturer Guidelines required side rails for safety. Monitoring regarding the beds being in the lowest position after care will be completed daily for 2 weeks by the Director of Nursing or designee, then three times weekly for 6 weeks by the Director of Nursing or designee and reported to the Administrator weekly. This will continue until compliance daily for 2 weeks by the Director of Nursing or designee, then three times weekly for 6 weeks by the Director of Nursing or designee and reported to the Administrator weekly. This will continue until compliance is determined by the Quality Assurance Committee which will receive monthly reports on this monitoring.

Complaint # (AR 870) was substantiated, all or in part, in these findings: Based on observation, record review, and interview, the facility's administration and nursing administration failed to ensure resident safety hazards were promptly identified and addressed, as evidenced by failure to review and operationalize manufacturer's instructions for the use of low air-loss mattresses, to include the use of bed rails to prevent further potential falls / injury and failure to ensure a planned intervention to maintain the bed in the lowest position was consistently implemented to minimize the potential for fall-related injury for 1 (Resident #2) of 2 (Residents #1 and #2) case mix residents who used the Primatech Medical System TheraFlo Low Air Loss Mattress Replacement System. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #2, who fell out of bed and sustained a large hematoma to the head, and had the potential to cause more than minimal harm for 3 residents who used the Primatech Medical System TheraFlo Low Air Loss Replacement Mattress System, according to a list received from the Administrator on 5/22/17. The facility was informed of the Immediate Jeopardy condition on 5/22/17 at 9:29 p.m. The findings are: 1. The Director of Nursing Job Description, received from the Administrator on 5/23/17 at 1:29 p.m., documented, .The purpose of this position is to provide Nursing Management, set resident care standards for all direct care providers and provide complete supervision and management for the Nursing Department . Delegation of authority . Authority is delegated to the individual in this position . Set resident care standards in accordance with accepted current standards of care to provide high quality care to residents . Develop and implement policies and procedures for nursing care of residents . Supervise and manage all aspects of the Nursing Department . Assess, direct and supervise resident care needs . 2. The Administrator Job Description, received from the Administrator on 5/24/17 at 9:25 p.m., documented, .The purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet the resident's needs in compliance with Federal, State and Local requirements . To establish and maintain systems that are effective and efficient to operate the facility in financially sound manner . Develop, maintain and implement operational policies and procedure to meet residents' needs in compliance with federal, state and local requirements . 8. Supervise all department supervisors and administrative staff . 3. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/4/17 documented the resident scored 6 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS), was totally dependent on 2-plus persons for bed mobility and transfers, had no functional limitation in range of motion in the upper extremities, had functional limitation in range of motion of the lower extremity on one side, and had a pressure reducing device on the bed. a. The Comprehensive Care Plan dated 1/18/17 documented, .At risk for decline in ADLs (activities of daily living) as related [MEDICAL CONDITION] as evidenced by left sided weakness, limited mobility .bed mobility .staff to keep bed in lowest position .air mattress and bilateral ½ (one-half) rails for mobility .date initiated .1/18/17 . b. The Corporate Fall Risk Review dated 4/7/17 at 8:20 a.m., and signed by the MDS Coordinator documented the resident's fall risk score was 10, which indicated a moderate risk for falls. c. The Facility Incident Report dated 5/3/17 at 5:40 a.m., with a revision date of 5/6/17 at 7:27 p.m., documented, .Incident Description: Nurse (writer) was doing AM (morning) pill call, someone was yelling. Entered room. Resident noted lying in floor close to bed, face down with bed linens underneath her. Bed in low position. Resident yelling. 'I fell .' Nurse called resident's name and responded appropriately. Assessed resident for obvious injuries. No blood noted on floor around resident. Nurse rolled resident over slowly off of her face and onto her back while supporting her neck. Resident has left BKA (below knee amputation). Call light noted clipped to resident gown across her chest. Nurse removed call light from gown. A large knot about 4-5 cm (centimeters) in size noted to right side of resident forehead without broken skin, abrasion or bleeding noted to head and face area. No bleeding noted to any area of the body. Nurse left resident lying on floor on her back. Called for assistance from staff to remain with resident . Resident was unable to give an accurate description of what happened. States, 'I fell out of bed' .MMES (Mobile Medical Emergency Service) notified 911 . The report documented the planned intervention to prevent further falls as, .Bed at lowest level. Floor mat . An unsigned, handwritten note on the Facility Incident Report documented, Resident diagnosed with [REDACTED]. This could contribute to increased confusion and resident therefore rolling out of bed. Attached to the Facility Incident Report was a copy of the manufacturer's instructions for the use of the Primatech Medical System TheraFlo Low Air Loss Mattress Replacement System. d. The Neurological Post Fall Evaluation dated 5/3/17 documented, .Effective Date 5/3/17 05:40 (5:40 a.m.), 1. Incident Report of Incident . Unwitnessed fall . 2. If incident was unwitnessed is there any evidence of visible injury? If yes, describe in detail . Yes, hematoma to right side of forehead about 3-4 cm in diameter. No broken skin, abrasion, nor bleeding noted . 3. Was treatment necessary? Be specific . Yes, applied ice pack, sent to ER (emergency room ) for evaluation . The form was signed by Licensed Practical Nurse (LPN) #1. e. The Hospital emergency room record dated 5/3/17 documented, .Arrival 5/3/17 at 6:23 a.m. Chief Complaint Elderly .with hx (history)[MEDICAL CONDITION](Hypertension) presents from NH (Nursing Home) s/p (status [REDACTED]. Pt (Patient) with hematoma to R (right) frontal scalp. AAO (Awake, Alert and Oriented) to baseline . CT (computed tomography) of head final results, Impression Large right frontal scalp hematoma without underlying calvarial fracture or acute intracranial injury . Impression 1. Fall initial encounter 2. Acute [MEDICATION NAME] without hematuria. Imaging revealed no traumatic injuries. Urinalysis shows bacteria, leukocytes, [MEDICATION NAME]. discharged with Keflex . Transferred back to her Nursing Home . f. The Comprehensive Care Plan with a revised date of 5/3/17 documented, .(Resident) is at risk for falls as related to limited mobility Left AKA and Cognition . Alzheimer/Dementia diagnosis . 5/3/17 Fall w/ (with) injury . Goal (Resident) will be protected from serious injury due to risk of falls through next review period .Interventions: .Staff in-service on air mattress / fall mat / bed alarms . date initiated 5/4/17 created by (MDS Coordinator) . g. On 5/22/17 at 4:43 p.m., the resident was lying in bed on her back, with the head of the bed elevated approximately 30 degrees. The resident had a low air loss mattress in place and no side rails were in use. The bed height was approximately 33 inches above the floor, not in the lowest position. The resident was on a Primatech TheraFlo Low Air Loss Mattress. There was one floor mat on the right side of the bed. There was a bedside table on the left side of the bed and no floor mat. The Assistant Director of Nursing (ADON) stated the resident was alert and oriented to person, occasionally sat up in a wheelchair and was transferred with a mechanical lift. She stated the resident required total assistance with activities of daily living and had experienced one fall approximately one month ago, when the resident rolled out of bed. The resident had a low air loss mattress on her bed at the time of the fall on 5/3/17. The ADON was asked for the manufacturer's instructions for the Primatech TheraFlo Low Air Loss Mattress at 5:05 p.m. h. On 5/22/17 at 5:25 p.m., the Primatech Medical System TheraFlo Low Air Loss Mattress Replacement System manufacturer's instructions were received from the Administrator. The manufacturer's instructions documented, .Warnings . Patient Falls: Failure to use bed rails in raised position could lead to accidental patient falls. Air mattresses have soft edges that may collapse when patient rolls to the edge . i. On 5/22/17 at 6:18 p.m., the Treatment Nurse was asked if there were any special requirements for the use of the low air-loss mattress and stated, I know they check them when they are set up and are set according to the resident's weight; they are not supposed to have sheets, and there is a static button that can be used to inflate the mattress all the way. The Treatment Nurse was asked if she had knowledge regarding the safety measures for the use of the low air-loss mattress. The Treatment Nurse stated, No. j. On 5/22/17 at 7:50 p.m., the Director of Nursing (DON) stated she had been the DON since January 2017. The DON was asked about any interventions that were implemented after Resident #2's fall on 5/3/17. The DON stated, Low bed and mat at the bedside. The DON was asked about the low air-loss mattress and stated the equipment supplier set the computer system to the air mattress, to prevent the staff from adjusting the pressure on the mattress. The DON was asked where this was documented in the resident's clinical record and stated, I don't know . We were looking at all possibilities of what could have happened. The DON was asked if she had read the manufacturer's instructions for the Primatech TheraFlo Low Air Loss Mattress and stated, No. The DON was asked if the manufacturer's instructions that were attached to the incident report for this mattress had been reviewed after the fall on 5/3/17. The DON stated, No, because we determined the reason for the fall. Her level of confusion and she had a [DIAGNOSES REDACTED]. We put a fall mat in place and her bed in the lowest positron. The DON was asked what safety measures were necessary for residents with a low air-loss mattress and stated, Side rails or bolsters, if deemed safe for the resident. The DON was asked if this was documented on the Primatech TheraFlo Low Air Low Mattress instructions. The DON stated, No, it was for the Plexic (other brand of low air-loss mattress). The DON was asked if she had read the warnings in the manufacturer's instructions for the PrimaTech TheraFlo Low Air Loss Mattress and stated, No I did not. The DON stated a floor mat was to be in place, and the bed was to be in the lowest position. k. On 5/22/17 at 8:05 p.m., the DON accompanied the surveyors to Resident #2's room. Certified Nursing Assistants (CNAs) #1 and #2 were in the resident's room providing care. At 8:29 p.m., as the CNAs started to leave the room, CNA #1 was asked if they were finished with the resident's care. The CNA looked around the room, then stated, Yes. The CNA was asked if there was anything else they needed to do. The CNA stated, No. The CNAs proceeded out of the resident's room, leaving the bed elevated to approximately 33 inches above the floor. The DON and Surveyors remained in the room. The DON went over to the bed and lowered it to the lowest position, which was approximately 12 inches above the floor. The resident had a mat on the right side of the bed. There was a night stand on the left side of the bed between the wall and the resident's bed. The DON was asked if only one mat was to be used. The DON stated, Yes, she was an [MEDICAL CONDITION] of the left side, and if they roll, they roll to the heavier side. That was the right side of the bed, and that was the side of the bed that the resident rolled out of. The DON was asked if the staff had knowledge that the resident's bed was to be in the lowest position. The DON stated, Yes. The DON was asked who was responsible for ensuring the bed was in the lowest position. The DON stated, All the staff. l. On 5/22/17 at 8:50 p.m., Certified Nursing Assistant (CNA) #1 was asked staff knew what care to provide each resident. The CNA stated, The care plan on the Kiosk, or the closet care plan in the resident's closet. The CNA checked in Resident #2's closet and there was no closet care plan available. The CNA was asked if there were any precautions that were supposed to be in place for Resident #2. The CNA stated, Yes, her bed is to be in the lowest position and a mat at her bedside . I got busy, and I just forgot and didn't do it. m. On 5/22/17 at 8:53 p.m., the Administrator and the Director of Nursing were asked if they had reviewed the manufacturer's instructions for the low air-loss mattresses that were in use in the facility. The Administrator stated, No. The Surveyor asked the Administrator to read the warning section of manufacturer's instructions for the Primatech TheraFlo Low Air Loss Mattress System. The Administrator read the warnings and stated, Side rails are to be used. The Administrator was asked if Resident #2 had side rails on her bed. The Administrator and DON stated, No. The Administrator and DON were asked if this could lead to resident falls. The DON stated, According to the guidelines. The Administrator was asked if the manufacturer's instructions should have been read by the facility prior to using the low air-loss mattress system. The Administrator stated, Yes. The Administrator was asked who was responsible for reviewing the Incident and Accident Reports. The Administrator stated, I review them frequently. The Administrator was asked who was responsible for monitoring the low air-loss mattresses and ensuring the manufacturer's safety instructions were being followed. The Administrator stated, Myself and Maintenance. n. On 5/24/17 at 10:50 a.m., Licensed Practical Nurse (LPN) #1 was asked, After (Resident #2's) fall on 5/3/17, what instructions were you given? LPN #1 stated, They changed the box on the foot of the bed, so that the setting couldn't be changed, and the fall mat. LPN #1 was asked if she was instructed, prior to this week, on the need to keep the bed in the lowest position for residents on low air-loss mattresses. LPN #1 stated, No. LPN #1 was asked, Who is responsible for ensuring the residents' beds are in the lowest position? LPN #1 stated, Everybody. o. On 5/24/17 at 3:22 p.m., CNA #3 stated she worked on the 300 Hall. CNA #3 was asked, When were you instructed regarding (Resident #2), for her bed to be in the lowest position? CNA #3 stated, This week. p. The Immediate Jeopardy was removed and the scope and severity decreased to G on 5/22/17 at 10:15 p.m., when the facility initiated the following plan of removal: 1.) On May 22, 2017 at 8:59 p.m. (Resident #2's) bed was placed in the low position by the Director of Nursing. On May 22, 2017 at 10:15 p.m. side rails were applied to the bed of (Resident #2) by the Maintenance Supervisor. On May 22, 2017 at 9:49 p.m. the Administrator read the Manufacturer Guidelines for the low air loss mattresses. On May 22, 2017 at 10:00 p.m. all residents who have low air loss mattresses were assessed for the need for side rails for prevention of falls and safety per the Manufacturer's Guidelines by the Director of Nurses or designee. All residents requiring side rails were provided with side rails. All beds of residents with planned interventions for low beds were immediately checked to ensure that they were in the lowest position. 2.) On May 22, 2017 at 9:45 p.m. in-servicing was started. All Nursing Staff in the building was in-serviced on the necessity of side rails on beds with (low) air loss mattresses in compliance with Manufacturer's Guidelines and requirement to place beds in lowest position for safety unless care planned otherwise by (the) Director of Nurses or designee. Beginning on May 22, 2017 all oncoming Nursing Staff for the 3-11 (3:00 p.m. to 11:00 p.m.) shift were immediately in-serviced by (the) Assistant Director of Nursing BEFORE ALLOWING THEM TO WORK. Any Nursing Staff not working at this time (weekends as needed, staff on paid time off) will be in-serviced by (the) Director of Nurses or designee before starting to work. No Nursing Staff will be allowed to work until they have been in-serviced. 3.) Compliance for in-service completion will be monitored by the Administrator or designee every day for four weeks, three times per week for two weeks until consistent compliance is established by the Quality Assurance Committee. This will be reported monthly to the Equability Assurance Committee. 4.) Monitoring regarding the need for side rails for prevention of falls and safety per the Manufacturer's Guidelines will be monitored by the Director of Nurses or designee daily for 2 weeks, then three times weekly for 6 weeks by the Director of Nurses or designee and reported weekly to the Administrator. This will continue until compliance is determined by the Equability Assurance Committee. This will be reported monthly to the Quality Assurance Committee. All monitoring will be accomplished by the Director of Nursing or designee to ensure the side rails are in use on the beds where the Manufacturer Guidelines required side rails for safety. Monitoring regarding the beds being in the lowest position after care will be completed daily for 2 weeks by the Director of Nursing or designee, then three times weekly for 6 weeks by the Director of Nursing or designee and reported to the Administrator weekly. This will continue until compliance daily for 2 weeks by the Director of Nursing or designee, then three times weekly for 6 weeks by the Director of Nursing or designee and reported to the Administrator weekly. This will continue until compliance is determined by the Quality Assurance Committee which will receive monthly reports on this monitoring.

Complaints # (AR 789) were substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure a resident was free from staff-to-resident verbal abuse, as evidenced by failure of management staff to immediately intervene when a Certified Nursing Assistant was heard cursing and threatening a resident and failure to ensure the incident was immediately reported to administration, which resulted in failure to ensure an investigation was promptly initiated and that the accused staff member was removed from the building or constantly supervised to protect residents from further potential abuse while the investigation was ongoing for 1 (Resident #7) of 1 case mix resident who was the victim of verbal abuse by Certified Nursing Assistant (CNA) #2. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, and had the potential to cause more than minimal harm to 26 residents who resided on the 400 Hall (where CNA #2 remained after the abuse incident occurred), as documented on a list provided by the Administrator on 3/15/17. The facility removed the immediate jeopardy on 2/20/17; however, there were current failed practices requiring correction at the time of the survey. The Administrator was informed of the removed Immediate Jeopardy condition on 3/11/17 at approximately 3:20 p.m. The findings are: 1. Resident #7 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/2/17 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive to total assistance with activities of daily living (ADLs), did not ambulate, had a total mood severity score of 1 (1-4 indicates minimal depression) and had no documented behaviors. a. The Care Plan dated 3/7/17 documented, .history of verbally abusive behaviors r/t (related to) history of ineffective coping skills and puts him at risk for psychosocial decline . Interventions . Intervene before agitation escalates; move away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away . b. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities OLTC (Office of Long Term Care) Witness Statement Form, (Division of Medical Services (DMS) Form 762) dated 2/20/17 documented, .Date Incident Reported to OLTC: 2/21/17. Time: 9:00 a.m. Date and Time of Incident (if known): 2/20/17. Time: 12:30 p.m. Date and Time of Discovery: 2/20/17 1400 p.m. (2:00 p.m.) Type of Incident: .Abuse: Verbal .Name of Involved Resident: (Resident #7) .(Resident #7) was upset at staff member (Certified Nursing Assistant (CNA) #2) for not getting him up as soon as he wanted. (CNA #2) told him she would get him up after lunch. (Resident #7) became very upset and started using derogatory words toward (CNA #2). (CNA #2) stated when (Resident #7) called her a name under her breath, she said, your momma, but did not realize it was loud enough for (Resident #7) to hear. Another nurse heard the noise and came in the room and heard both (Resident #7) and (CNA #2) saying derogatory words to each other. Nurse (Licensed Practical Nurse (LPN) #3) separated the CNA and resident. And informed charge who then had the CNA and another CNA go in to get resident up. (CNA #2) was never alone with resident. Once (Resident #7) was taken care of, (CNA #2) was removed from the hall till administrator was contacted. Administrator was notified at 1400 (2:00 p.m.) . Upon notification Administrator met with (CNA #2) and witness statement was obtained. c. An OLTC Witness Statement Form dated 2/20/17 documented, .Witness Full Name (Resident #7) . Real bad about my momma (and) my daddy, real bad, a lot of crazy stuff. She was talking crazy about my momma (and) my dad. F . you, F . your momma (and) F . your daddy. Said she (CNA #2) was going to have a grievance written up about him (Resident #7) by (LPN #3). d. An OLTC Witness Statement Form written by Registered Nurse (RN) Supervisor #1 documented, .2/20/17 Time 1200 p.m . Female (CNA #2) stated to male (Resident #7) 'I'm not fixing to mess with you n .r (racial epithet) . e. An OLTC Witness Statement Form dated 2/20/17 by LPN #5 documented, This nurse went into resident's room to inquire about incident. Resident states he asked CNA to get him up for lunch and she said no. She came into room and got roommate up and left him in the bed. Resident states 'she talked about my mama and my daddy and they both dead and gone.' I informed resident that staff will assist him to w/c (wheelchair) as soon as possible. f. An OLTC Witness Statement dated 2/20/17 at 12:00 p.m. by LPN #3 documented, This nurse heard resident yelling loudly (and) started toward resident's room; as I opened the door, both the staff member (CNA #2) (and) resident (Resident #7) were cursing one another . Staff member returned with 'F . (expletive) you N . (racial epithet) . I'm not playing with you N (racial epithet) . staff member returning with 'I'm not doing s . (expletive) for you; .I ain't doing nothing for you. Difficult re-directing both the resident (and) staff member. Staff member then approached by her charge nurse (and) told charge nurse, I ain't the one . g. On 3/10/17 at 10:00 p.m., the Administrator was asked if staff should curse in front of residents or in the facility and stated, No. The Administrator was then asked if there had been any incidents of this problem and stated, Yes. The Administrator was asked what had occurred and when. The Administrator stated, They were in a room. This nurse walked in a room; they just heard yelling . As soon as the nurse went in the room, they removed her from the room. I removed her from the floor. The Administrator was asked what time this occurred and stated, The staff member put her out of the room. The Administrator gave no response as to the time of the incident. The Administrator was asked who had removed the staff member from the room and stated, That nurse (pointing to a Witness Statement signed by LPN #3). The Administrator was asked what time the incident had occurred and stated, 12 noon. The Administrator was asked what time the CNA had been removed from the resident's room and stated, Immediately. The Administrator was asked where the CNA was assigned after the incident and stated, They had her off the hall. h. On 3/10/17 at 10:10 p.m., LPN #3 was asked which staff member was involved in the incident with Resident #7 and stated, (CNA #2), aide, I don't really know her. The LPN was asked where CNA #2 went after being removed from the resident's room and stated, I made her leave the room, and I stayed in the room. She walked toward the dining room. The LPN was asked if anyone had accompanied CNA #2 and stated I stayed in the room. The LPN was asked if the incident was reported to anyone and stated, Yes, tried to call the nurse on the floor . I asked where (LPN #4) was and a minute later, she showed up. I heard (LPN #4) telling her (CNA #2) she can't talk like that. The LPN was asked who he had informed of this incident and stated, Just the nurse . My ADON (Assistant Director of Nursing) and (Registered Nurse #1) were in my office when we heard the yelling. The LPN was asked who the incident had been reported to and stated, I stayed in the room and told (LPN #5). The LPN was asked if the CNA was verbally abusing the resident and stated, Yes. The LPN was asked if the CNA had also made a threat to neglect the resident and not provide any care. The LPN stated, Yes. LPN #3 was asked who verbal abuse should be reported to and stated, My superior. The LPN was asked who that was and stated, (Administrator), (Assistant Administrator), (Director of Nursing), (Assistant Director of Nursing (ADON)). The LPN was asked when this should be reported and stated, Immediately . (ADON) was in the office. The LPN was asked if he knew that by law, as a nurse in a long term care facility, he was a mandated reporter for resident abuse and neglect. The LPN stated, What's that? The Administrator was present in the room during this interview. i. On 3/10/17 at 10:25 p.m., the ADON stated, The CNA (CNA #2) came up to me, the CNA who yelled (CNA #2) told me about it. I notified the Administrator, not the DON. The ADON was asked when this occurred and stated, Maybe a quarter to 3. The ADON was asked to describe what the CNA told her and stated, .she told me her and the resident got into a yelling match. The ADON was asked where the CNA was when the CNA talked with the ADON. The ADON stated, She was still in the hallway. The ADON was asked which hall and stated, 400 hall, by the ice machine. The ADON was asked if, after the incident, the CNA had provided care to any residents and stated, I don't know. j. On 3/10/17 at 10:50 p.m., the Assistant Administrator was asked if he was in the facility on 2/20/17 and the stated, Yes. The Assistant Administrator was asked if he was aware of the incident with the CNA yelling at a resident and stated, I was later, not when it happened. (Resident #7) came and told me . We did a report and wrote a witness statement. The Assistant Administrator was asked, if a CNA is verbally abusive and makes threats to neglect a resident should it be reported? The Assistant Administrator stated, Yes, immediately. The Assistant Administrator was asked if any of the licensed nursing staff or CNAs had reported the incident to him and stated, No. The Assistant Administrator was asked what should be done about an incident like this and stated, Remove them from the building. The Assistant Administrator was asked when the LPN or RN Supervisor should have informed him of the incident and stated, I should have known immediately. k. On 3/10/17 at 11:00 p.m., the ADON was asked where she was and what she did when she heard the yelling from Resident #7s room. The ADON stated, On 100 hall seeing about a resident. The ADON was asked if LPN #3 had reported the incident to her and stated, No. The ADON was asked if she found out what had occurred after she was finished with the other resident and stated, No. The ADON was asked if the CNA should have been removed from the work place sooner and stated, Yes a lot sooner. The ADON was asked when the CNA was actually removed from the hall or from access to residents and stated, We pulled her. l. On 3/10/17 at 11:10 p.m., the Administrator was asked when the CNA was removed from contact with residents and stated, It was right at 2 (p.m.). m. The employee time card report for CNA #2, received from the Administrator on 3/11/17 at 11:55 a.m., documented CNA #2 clocked out at 3:00 p.m. on 2/20/17, approximately 3 hours after the incident of verbal abuse occurred. n. On 3/11/17 at 12:25 p.m., the Director of Nursing (DON) was asked when she became aware of the incident between Resident #7 and a CNA on 2/20/17 and stated It must have been around 2:00 p.m., because they brought her (CNA #2) to my office. The DON was asked who brought the CNA to the office and stated, I want to say (ADON) and (Administrator) . I want to say she said she filed a grievance against him (Resident #7) and (Administrator) said, 'it's not about how they talk to you, it's about how you talk to them' . The DON was asked, when there is an allegation of abuse or abuse has occurred, who is staff to report to? The DON stated, Supposed to report it to Administrator and DON. The DON was asked when the Administrator and DON were out of the building on 2/20/17 and verbal abuse occurred, who were staff to have reported the incident to? The DON stated, The ADON; actually we had an RN Supervisor too, and I guess she would have over-ridden the ADON. The DON was asked, When (LPN #3) became aware of verbal abuse to a resident and the CNA's statements, should the LPN have reported this immediately? The DON stated, Yes. The DON was asked if other staff members should have reported the verbal abuse immediately and stated, Yes. o. On 3/11/17 at 12:45 p.m., Registered Nurse (RN) #1 was asked if she was the RN supervisor and stated, Yes. The RN was asked if she was responsible to cover all halls in the facility as the RN Supervisor and stated, Yes. The RN was asked if she was present when the incident occurred between CNA #2 and Resident #7 on 2/20/17 and stated, Yes, I was in Medical Records. The RN was asked if the Medical Records office was in close proximity to the resident's room and stated, Yes. The RN was asked what was heard and stated, I didn't hear, muffled, then getting louder .CNA said 'I'm not about to do anything for you' . The RN was asked who was in the Medical Records office at that time and who went to the resident's room. The RN stated, Me, (LPN #3); he (LPN #3) left the room. The RN was asked why she did not go to the resident's room and stated, I didn't leave because (LPN #3) left when we heard the cussing; we were both doing work, and we both looked at each other, and he got up, and with (Resident #7), he doesn't do well with a lot of people around. With his behaviors, a lot of people around make it worse. The RN was asked what behaviors the resident had and stated, He is very difficult when he wants something. The RN was then asked to describe what she heard the CNA saying to the resident and stated, I'm not fixing to mess with you n .er (racial epithet), after (LPN #3) went in the room. RN #1 was asked what she was doing while LPN #3 went to the resident's room and stated, I was on my lunch break. I was in there 'til when I finished lunch. The RN was asked if she reported the incident and stated, I went and told (DON and ADON) about it. The RN was asked when the incident was reported to the DON and stated, Probably about 1:30 p.m. The RN was asked why she had waited to report the incident and stated, After my lunch break, we had a standard of care meeting, and afterwards, that's when I told her (DON) about it. The RN was asked when staff becomes aware of abuse, when is it to be reported? The RN stated, To be immediately reported. RN #1 was asked to whom was abuse to be reported and stated, DON, Administrator. The RN was asked if, after lunch, she reported the verbal abuse and stated, I thought (LPN #3) took care of it . That was the first time I heard any staff curse at him. The RN was asked if the resident was dependent on staff and stated, Yes. The RN was then asked if she had intervened to protect the resident and stated, No. The RN was asked where the CNA was after the incident and until she left the building and stated, All I know, she went down front of 400 hall. I don't know where she went. The RN was asked if she should have known where the CNA was in the building and stated, Yes. The RN was asked if she had received abuse training when she came to work at the facility and stated, Yes. RN #1 was asked what was to be done when there was possible abuse and stated, You separate that person, you go and report. The RN was asked, who do you report to? The RN stated, Usually have an RN supervisor in the building. The RN was asked, as the RN supervisor, if she was responsible for reporting to the Administrator and DON that day and stated, Yes. The RN was asked who was present for the standards of care meeting after the incident occurred. The RN stated, (DON), (ADON) . The RN was asked if she reported the incident of verbal abuse at that time and stated, No. The RN was asked if the CNA should have been removed from the hall and stated, Yes. The RN was asked if she knew who the CNA had contact with after the incident and stated, No. The RN was asked if she had received abuse training after the incident and the RN stated, Yes. p. On 3/11/17 at 1:30 p.m., the Administrator was asked if the facility's surveillance video was viewed to determine if CNA #2 had remained in the facility after the incident on 2/20/17. The Administrator stated, .we could see she was in the building. The Administrator was asked if the CNA had contact with other residents after the incident and stated, .we just know that she was on that hall (400 Hall) and the dining room, and she just had contact with residents on that hall. She did go out the door to laundry and later came back in. We can give the hall she was on, but we cannot tell the rooms she went in. She did remain on the hall. The Administrator was asked when the CNA was removed from the hall and stated, It was 2:40, 2:42 (p.m.) she was taken to the DON's office . The Administrator was asked who reported the incident of verbal abuse and stated, (ADON) came up to me first. The Administrator was asked if the RN supervisor (RN #1) had reported anything that day and the Administrator stated, Not that I remember. The Administrator was asked if anyone else, such as LPN #3, had reported the incident and who staff could have reported the verbal abuse to while the Administrator was out of the building. The Administrator stated, After he did come to me, right after 3:00, (Assistant Administrator) was in the building. The Administrator was asked if the RN Supervisor should have reported the incident and stated, Yes. q. On 3/11/17 at 2:55 p.m., Resident #7 was asked if he recalled the incident when a CNA had cursed at him recently and stated, Yes, it upset me; it really upset me. r. The facility removed the immediate jeopardy and reduced the scope / severity to E on 2/20/17, by completing the following corrective actions: 1.) The DMS form dated 2/20/17, provided by the Administrator on 3/10/17 at 10:15 p.m., documented, . (CNA #2) was placed on administrative leave. Witness statements were obtained from staff and (Resident #7). Police notified and interviewed (Resident #3). On 2/21/17 after investigating the incident, (CNA #2) employment was terminated. Training on our abuse policy was initiated by Assistant Administrator. Residents were interviewed with no negative findings noted. (Medical Doctor) was notified with no new orders received at this time. A skin assessment was performed on (Resident #7) with no negative findings. (Resident #7) is currently able to propel self in wheelchair. In summary, through the investigation, there seems to be findings that a slight verbal altercation may have occurred between (Resident #7) and (CNA #2). (CNA #2) was terminated and staff was in serviced on our Abuse policy. (Resident #7) seems to have no long-term effects from verbal altercation. 2.) An Employee Attendance Sign-in sheet received from the Administrator on 3/11/17 documented, Date 2/21 In-service Instructor (Administrator) In-service Topics Abuse and neglect Policy (and) Procedure . The names listed on the sign-in sheet included the 400 Hall CNA staff, (LPN #3), and (RN #1) as the staff members who had received the in-service training from the facility. Attached to the in-service sign in sheet was a copy of the facility Abuse and Neglect Policy and Procedure. The Administrator stated, I read from this. All of 400 staff. No other facility staff names were documented on the sign-in sheet. The additional documentation indicated CNA #2 was not allowed to return to work after she was removed from the facility on 2/20/17 at approximately 3:00 p.m.

Complaints # (AR 789) and # (AR 765) were substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure an incident of witnessed staff-to-resident verbal abuse was immediately reported to administration, which resulted in failure to ensure an investigation was promptly initiated and that the accused staff member was removed from the building or constantly supervised to protect residents from further potential abuse while the investigation was ongoing for 1 (Resident #7) of 1 case mix resident who was the victim of verbal abuse by Certified Nursing Assistant (CNA) #2. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1 and had the potential to cause more than minimal harm to 26 residents who resided on the 400 Hall (where CNA #2 remained after the abuse incident occurred), as documented on a list provided by the Administrator on 3/15/17. The facility removed the immediate jeopardy on 2/20/17; however, there were current failed practices requiring correction at the time of the survey. The Administrator was informed of the removed Immediate Jeopardy condition on 3/11/17 at approximately 3:20 p.m. The findings are: 1. Resident #7 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/2/17 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive to total assistance with activities of daily living (ADLs), did not ambulate, had a total mood severity score of 1 (1-4 indicates minimal depression) and had no documented behaviors. a. The Care Plan dated 3/7/17 documented, .history of verbally abusive behaviors r/t (related to) history of ineffective coping skills and puts him at risk for psychosocial decline . Interventions . Intervene before agitation escalates; move away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away . b. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities OLTC (Office of Long Term Care) Witness Statement Form, (Division of Medical Services (DMS) Form 762) dated 2/20/17 documented, .Date Incident Reported to OLTC: 2/21/17. Time: 9:00 a.m. Date and Time of Incident (if known): 2/20/17. Time: 12:30 p.m. Date and Time of Discovery: 2/20/17 1400 p.m. (2:00 p.m.) Type of Incident: .Abuse: Verbal .Name of Involved Resident: (Resident #7) .(Resident #7) was upset at staff member (Certified Nursing Assistant (CNA) #2) for not getting him up as soon as he wanted. (CNA #2) told him she would get him up after lunch. (Resident #7) became very upset and started using derogatory words toward (CNA #2). (CNA #2) stated when (Resident #7) called her a name under her breath, she said, your momma, but did not realize it was loud enough for (Resident #7) to hear. Another nurse heard the noise and came in the room and heard both (Resident #7) and (CNA #2) saying derogatory words to each other. Nurse (Licensed Practical Nurse (LPN) #3) separated the CNA and resident. And informed charge who then had the CNA and another CNA go in to get resident up. (CNA #2) was never alone with resident. Once (Resident #7) was taken care of, (CNA #2) was removed from the hall till administrator was contacted. Administrator was notified at 1400 (2:00 p.m.) . Upon notification Administrator met with (CNA #2) and witness statement was obtained. c. An OLTC Witness Statement Form dated 2/20/17 documented, .Witness Full Name (Resident #7) . Real bad about my momma (and) my daddy, real bad, a lot of crazy stuff. She was talking crazy about my momma (and) my dad. F . you, F . your momma (and) F . your daddy. Said she (CNA #2) was going to have a grievance written up about him (Resident #7) by (LPN #3). d. An OLTC Witness Statement Form written by Registered Nurse (RN) Supervisor #1 documented, .2/20/17 Time 1200 p.m . Female (CNA #2) stated to male (Resident #7) 'I'm not fixing to mess with you n .r (racial epithet) . e. An OLTC Witness Statement Form dated 2/20/17 by LPN #5 documented, This nurse went into resident's room to inquire about incident. Resident states he asked CNA to get him up for lunch and she said no. She came into room and got roommate up and left him in the bed. Resident states 'she talked about my mama and my daddy and they both dead and gone.' I informed resident that staff will assist him to w/c (wheelchair) as soon as possible. f. An OLTC Witness Statement dated 2/20/17 at 12:00 p.m. by LPN #3 documented, This nurse heard resident yelling loudly (and) started toward resident's room; as I opened the door, both the staff member (CNA #2) (and) resident (Resident #7) were cursing one another . Staff member returned with 'F . (expletive) you N . (racial epithet) . I'm not playing with you N (racial epithet) . staff member returning with 'I'm not doing s . (expletive) for you; .I ain't doing nothing for you Difficult re-directing both the resident (and) staff member. Staff member then approached by her charge nurse (and) told charge nurse, I ain't the one . g. On 3/10/17 at 10:00 p.m., the Administrator was asked if staff should curse in front of residents or in the facility and stated, No. The Administrator was then asked if there had been any incidents of this problem and stated, Yes. The Administrator was asked what had occurred and when. The Administrator stated, They were in a room. This nurse walked in a room; they just heard yelling . As soon as the nurse went in the room, they removed her from the room. I removed her from the floor. The Administrator was asked what time this occurred and stated, The staff member put her out of the room. The Administrator gave no response as to the time of the incident. The Administrator was asked who had removed the staff member from the room and stated, That nurse (pointing to a Witness Statement signed by LPN #3). The Administrator was asked what time the incident had occurred and stated, 12 noon. The Administrator was asked what time the CNA had been removed from the resident's room and stated, Immediately. The Administrator was asked where the CNA was assigned after the incident and stated, They had her off the hall. h. On 3/10/17 at 10:10 p.m., LPN #3 was asked which staff member was involved in the incident with Resident #7 and stated, (CNA #2), aide, I don't really know her. The LPN was asked where CNA #2 went after being removed from the resident's room and stated, I made her leave the room, and I stayed in the room. She walked toward the dining room. The LPN was asked if anyone had accompanied CNA #2 and stated I stayed in the room. The LPN was asked if the incident was reported to anyone and stated, Yes, tried to call the nurse on the floor . I asked where (LPN #4) was and a minute later, she showed up. I heard (LPN #4) telling her (CNA #2) she can't talk like that. The LPN was asked who he had informed of this incident and stated, Just the nurse . My ADON (Assistant Director of Nursing) and (Registered Nurse #1) were in my office when we heard the yelling. The LPN was asked who the incident had been reported to and stated, I stayed in the room and told (LPN #5). The LPN was asked if the CNA was verbally abusing the resident and stated, Yes. The LPN was asked if the CNA had also made a threat to neglect the resident and not provide any care. The LPN stated, Yes. LPN #3 was asked who verbal abuse should be reported to and stated, My superior. The LPN was asked who that was and stated, (Administrator), (Assistant Administrator), (Director of Nursing), (Assistant Director of Nursing (ADON)). The LPN was asked when this should be reported and stated, Immediately . (ADON) was in the office. The LPN was asked if he knew that by law, as a nurse in a long term care facility, he was a mandated reporter for resident abuse and neglect. The LPN stated, What's that? The Administrator was present in the room during this interview. i. On 3/10/17 at 10:25 p.m., the ADON stated, The CNA (CNA #2) came up to me, the CNA who yelled (CNA #2) told me about it. I notified the Administrator, not the DON. The ADON was asked when this occurred and stated, Maybe a quarter to 3. The ADON was asked to describe what the CNA told her and stated, .she told me her and the resident got into a yelling match. The ADON was asked where the CNA was when the CNA talked with the ADON. The ADON stated, She was still in the hallway. The ADON was asked which hall and stated, 400 hall, by the ice machine. The ADON was asked if, after the incident, the CNA had provided care to any residents and stated, I don't know. j. On 3/10/17 at 10:50 p.m., the Assistant Administrator was asked if he was in the facility on 2/20/17 and the stated, Yes. The Assistant Administrator was asked if he was aware of the incident with the CNA yelling at a resident and stated, I was later, not when it happened. (Resident #7) came and told me . We did a report and wrote a witness statement. The Assistant Administrator was asked, if a CNA is verbally abusive and makes threats to neglect a resident should it be reported? The Assistant Administrator stated, Yes, immediately. The Assistant Administrator was asked if any of the licensed nursing staff or CNAs had reported the incident to him and stated, No. The Assistant Administrator was asked what should be done about an incident like this and stated, Remove them from the building. The Assistant Administrator was asked when the LPN or RN Supervisor should have informed him of the incident and stated, I should have known immediately. k. On 3/10/17 at 11:00 p.m., the ADON was asked where she was and what she did when she heard the yelling from Resident #7s room. The ADON stated, On 100 hall seeing about a resident. The ADON was asked if LPN #3 had reported the incident to her and stated, No. The ADON was asked if she found out what had occurred after she was finished with the other resident and stated, No. The ADON was asked if the CNA should have been removed from the work place sooner and stated, Yes a lot sooner. The ADON was asked when the CNA was actually removed from the hall or from access to residents and stated, We pulled her. l. On 3/10/17 at 11:10 p.m., the Administrator was asked when the CNA was removed from contact with residents and stated, It was right at 2 (p.m.). m. The employee time card report for CNA #2, received from the Administrator on 3/11/17 at 11:55 a.m., documented CNA #2 clocked out at 3:00 p.m. on 2/20/17, approximately 3 hours after the incident of verbal abuse occurred. n. On 3/11/17 at 12:25 p.m., the Director of Nursing (DON) was asked when she became aware of the incident between Resident #7 and a CNA on 2/20/17 and stated It must have been around 2:00 p.m., because they brought her (CNA #2) to my office. The DON was asked who brought the CNA to the office and stated, I want to say (ADON) and (Administrator) . I want to say she said she filed a grievance against him (Resident #7) and (Administrator) said, 'it's not about how they talk to you, it's about how you talk to them' . The DON was asked, when there is an allegation of abuse or abuse has occurred, who is staff to report to? The DON stated, Supposed to report it to Administrator and DON. The DON was asked when the Administrator and DON were out of the building on 2/20/17 and verbal abuse occurred, who were staff to have reported the incident to? The DON stated, The ADON; actually we had an RN Supervisor too, and I guess she would have over-ridden the ADON. The DON was asked, When (LPN #3) became aware of verbal abuse to a resident and the CNA's statements, should the LPN have reported this immediately? The DON stated, Yes. The DON was asked if other staff members should have reported the verbal abuse immediately and stated, Yes. o. On 3/11/17 at 12:45 p.m., Registered Nurse (RN) #1 was asked if she was the RN supervisor and stated, Yes. The RN was asked if she was responsible to cover all halls in the facility as the RN Supervisor and stated, Yes. The RN was asked if she was present when the incident occurred between CNA #2 and Resident #7 on 2/20/17 and stated, Yes, I was in Medical Records. The RN was asked if the Medical Records office was in close proximity to the resident's room and stated, Yes. The RN was asked what was heard and stated, I didn't hear, muffled, then getting louder .CNA said 'I'm not about to do anything for you' . The RN was asked who was in the Medical Records office at that time and who went to the resident's room. The RN stated, Me, (LPN #3); he (LPN #3) left the room. The RN was asked why she did not go to the resident's room and stated, I didn't leave because (LPN #3) left when we heard the cussing; we were both doing work, and we both looked at each other, and he got up, and with (Resident #7), he doesn't do well with a lot of people around. With his behaviors, a lot of people around make it worse. The RN was asked what behaviors the resident had and stated, He is very difficult when he wants something. The RN was then asked to describe what she heard the CNA saying to the resident and stated, I'm not fixing to mess with you n .er (racial epithet), after (LPN #3) went in the room. RN #1 was asked what she was doing while LPN #3 went to the resident's room and stated, I was on my lunch break. I was in there 'til when I finished lunch. The RN was asked if she reported the incident and stated, I went and told (DON and ADON) about it. The RN was asked when the incident was reported to the DON and stated, Probably about 1:30 p.m. The RN was asked why she had waited to report the incident and stated, After my lunch break, we had a standard of care meeting, and afterwards, that's when I told her (DON) about it. The RN was asked when staff becomes aware of abuse, when is it to be reported? The RN stated, To be immediately reported. RN #1 was asked to whom was abuse to be reported and stated, DON, Administrator. The RN was asked if, after lunch, she reported the verbal abuse and stated, I thought (LPN #3) took care of it . That was the first time I heard any staff curse at him. The RN was asked if the resident was dependent on staff and stated, Yes. The RN was then asked if she had intervened to protect the resident and stated, No. The RN was asked where the CNA was after the incident and until she left the building and stated, All I know, she went down front of 400 hall. I don't know where she went. The RN was asked if she should have known where the CNA was in the building and stated, Yes. The RN was asked if she had received abuse training when she came to work at the facility and stated, Yes. RN #1 was asked what was to be done when there was possible abuse and stated, You separate that person, you go and report. The RN was asked, who do you report to? The RN stated, Usually have an RN supervisor in the building. The RN was asked, as the RN supervisor, if she was responsible for reporting to the Administrator and DON that day and stated, Yes. The RN was asked who was present for the standards of care meeting after the incident occurred. The RN stated, (DON), (ADON) . The RN was asked if she reported the incident of verbal abuse at that time and stated, No. The RN was asked if the CNA should have been removed from the hall and stated, Yes. The RN was asked if she knew who the CNA had contact with after the incident and stated, No. The RN was asked if she had received abuse training after the incident and the RN stated, Yes. p. On 3/11/17 at 1:30 p.m., the Administrator was asked if the facility's surveillance video was viewed to determine if CNA #2 had remained in the facility after the incident on 2/20/17. The Administrator stated, .we could see she was in the building. The Administrator was asked if the CNA had contact with other residents after the incident and stated, .we just know that she was on that hall (400 Hall) and the dining room, and she just had contact with residents on that hall. She did go out the door to laundry and later came back in. We can give the hall she was on, but we cannot tell the rooms she went in. She did remain on the hall. The Administrator was asked when the CNA was removed from the hall and stated, It was 2:40, 2:42 (p.m.) she was taken to the DON's office . The Administrator was asked who reported the incident of verbal abuse and stated, (ADON) came up to me first. The Administrator was asked if the RN supervisor (RN #1) had reported anything that day and the Administrator stated, Not that I remember. The Administrator was asked if anyone else, such as LPN #3, had reported the incident and who staff could have reported the verbal abuse to while the Administrator was out of the building. The Administrator stated, After he did come to me, right after 3:00, (Assistant Administrator) was in the building. The Administrator was asked if the RN Supervisor should have reported the incident and stated, Yes. q. On 3/11/17 at 2:55 p.m., Resident #7 was asked if he recalled the incident when a CNA had cursed at him recently and stated, Yes, it upset me; it really upset me. r. The facility removed the immediate jeopardy and reduced the scope / severity to E on 2/20/17, by completing the following corrective actions: 1.) The DMS form dated 2/20/17, provided by the Administrator on 3/10/17 at 10:15 p.m., documented, . (CNA #2) was placed on administrative leave. Witness statements were obtained from staff and (Resident #7). Police notified and interviewed (Resident #3). On 2/21/17 after investigating the incident, (CNA #2) employment was terminated. Training on our abuse policy was initiated by Assistant Administrator. Residents were interviewed with no negative findings noted. (Medical Doctor) was notified with no new orders received at this time. A skin assessment was performed on (Resident #7) with no negative findings. (Resident #7) is currently able to propel self in wheelchair. In summary, through the investigation, there seems to be findings that a slight verbal altercation may have occurred between (Resident #7) and (CNA #2). (CNA #2) was terminated and staff was in serviced on our Abuse policy. (Resident #7) seems to have no long-term effects from verbal altercation. 2.) An Employee Attendance Sign-in sheet received from the Administrator on 3/11/17 documented, Date 2/21 In-service Instructor (Administrator) In-service Topics Abuse and neglect Policy (and) Procedure . The names listed on the sign-in sheet included the 400 Hall CNA staff, (LPN #3), and (RN #1) as the staff members who had received the in-service training from the facility. Attached to the in-service sign in sheet was a copy of the facility Abuse and Neglect Policy and Procedure. The Administrator stated, I read from this. All of 400 staff. No other facility staff names were documented on the sign-in sheet. The additional documentation indicated CNA #2 was not allowed to return to work after she was removed from the facility on 2/20/17 at approximately 3:00 p.m. B. Based on observation, record review and interview, the facility failed to ensure injuries of unknown origin were promptly identified, which resulted in a delay in initiating an investigation to rule out possible abuse or neglect in accordance with State Law for 1 (Resident #4) of 2 (Residents #1 and #4) who had bruises of unknown origin that were not identified or reported. This failed practice had the potential to affect 2 residents who had bruising of unknown origin that were not identified or reported within the past 30 days as documented on a list provided by the Treatment Nurse on 3/10/17 at 10:20 p.m. The findings are: Resident #4 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/21/17 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and was at risk for developing pressure ulcers. a. The Care Plan dated 2/24/17 documented, .(Resident #4) is an elopement risk/wanderer r/t (related to) Alzheimer's . requires . monitoring for safety . b. On 3/2/17 at 11:25 p.m., there were 2 round purplish bruises on the resident's right elbow area that were approximately 1 centimeter (cm) in diameter with a very small scab in the center of the bruised area. c. A Weekly Skin Evaluation form dated 3/6/17 had no documentation of any bruises or skin discolorations. d. On 3/10/17 at 7:25 p.m., a skin audit was conducted with the assistance of LPN #4. At 7:45 p.m., the DON joined the LPN and surveyor and, with the resident's right breast exposed, there was a round bruise that was yellowish on the surrounding edges and blue in the center. The DON was asked, What do you see? and stated, I see discoloration about a quarter size. The DON measured the bruise and stated, 2 by 2 centimeters. On the right elbow area, the 2 round, purple bruises remained visible. The DON measured the areas and stated the area to the front of the elbow measured, 1 by 1 cm and the second area measured 1/2 by 1/2 cm. e. On 3/10/17 at 8:15 p.m., the DON was asked when the most recent skin audit was done and stated, 3/6. The DON was shown the skin audit and asked if it had identified bruises and stated, No. The DON was asked if the skin audit had identified any skin abnormalities and stated, No. The DON was informed that the 2 round bruises on the right elbow were present during the initial rounds at 11:25 p.m. on 3/2/17. The DON was asked if there were any recent incidents or accidents involving the resident and stated, I've got a fall on 23rd (2/23/17) and known fall on 25th 2/25/17). The DON was asked if there were any incident and accident forms completed for the resident since 2/25/17 and stated, No. The DON was asked if the 3/6/17 body audit identified the 2 bruises on the elbow area and stated, No. The DON was asked if the body audit identified anything on the skin of the right breast. The DON stated, No it did not. The DON was asked if, when staff bathed/dressed the resident, they should have noticed the bruises. The DON stated, Yes. The DON was asked if, when body audits were done, bruised or discolored areas should be identified. The DON stated, Yes. The DON was asked if a finding of bruising would need to be investigated to determine the cause. The DON stated, Yes absolutely. f. On 3/10/17 at 8:25 p.m., LPN #4 was asked what a body audit should consist of and stated, Any type discoloration to body, anything abnormal. The LPN was asked if that would include bruises and stated, Yes.

Complaints # (AR 789) and # (AR 765) were substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure the facility policies and procedures for abuse / neglect prohibition were implemented, as evidence by failure to ensure an incident of witnessed staff-to-resident verbal abuse was immediately reported to administration, which resulted in failure to ensure an investigation was promptly initiated and that the accused staff member was removed from the building or constantly supervised to protect residents from further potential abuse while the investigation was ongoing for 1 (Resident #7) of 1 case mix resident who was the victim of verbal abuse by Certified Nursing Assistant (CNA) #2. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1 and had the potential to cause more than minimal harm to 26 residents who resided on the 400 Hall (where CNA #2 remained after the abuse incident occurred), as documented on a list provided by the Administrator on 3/15/17. The facility removed the immediate jeopardy on 2/20/17; however, there were current failed practices requiring correction at the time of the survey. The Administrator was informed of the removed Immediate Jeopardy condition on 3/11/17 at approximately 3:20 p.m. The findings are: 1. The facility's Abuse and Neglect Policy and Procedure, received from the Administrator on 3/10/17, documented, .Suspected action or allegation of abuse including physical, mental verbal, sexual, involuntary seclusion, neglect or misappropriation of property by any individual including resident to resident altercations with injury will be reported to local authorities, state and federal agencies and other appropriate agencies as required by law . The facility will follow State and Federal guidelines on reporting incidents of abuse, neglect or misappropriation of property. d. Investigate procedures will be timely, through and objective . Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability . Mental Abuse is defined as but is not limited to humiliation, harassment, threats of punishment or withholding of treatment or services . Neglect-is defined as when a reasonable person would conclude that a deprivation of the omitted goods and services would cause, among other things, emotional distress (rather than mental disorders) . The facility will act immediately upon notification when an individual(s) has been witnessed suspected or alleged to have caused abuse. a. Employment of this facility who have been accused of resident abuse will be removed from direct care or suspended until cleared by Administration or local and State/Federal Agencies as applicable (or) terminated . All witnessed, suspected alleged statements of abuse, including injuries of unknown source, or unusual deaths will be reported to the Administrator, DON (Director of Nursing) or Designee, to the local Law Officials, attending Physician, resident's representative of record, Office of Long Term Care and appropriate State Agencies required by Law . Any employee or individuals the facility engages with that witness, suspect, alleged statements of abuse including injuries of an unknown source, or unusual deaths must report to the Administrator or Designated Representative according to the following. a. Not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . Reporting is an obligation; failure to report will result in disciplinary action which could result in termination and possible criminal and civil liabilities . All reports of resident abuse, neglect, exploration and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 2. Resident #7 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/2/17 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required extensive to total assistance with activities of daily living (ADLs), did not ambulate, and had a total mood severity score of 1 (1-4 indicates minimal depression) and had no documented behaviors. a. The Care Plan dated 3/7/17 documented, .history of verbally abusive behaviors r/t (related to) history of ineffective coping skills and puts him at risk for psychosocial decline . Interventions . Intervene before agitation escalates; move away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away . b. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities OLTC (Office of Long Term Care) Witness Statement Form, (Division of Medical Services (DMS) Form 762) dated 2/20/17 documented, .Date Incident Reported to OLTC (Office of Long Term Care): 2/21/17. Time: 9:00 a.m. Date and Time of Incident (if known): 2/20/17. Time: 12:30 p.m. Date and Time of Discovery: 2/20/17 1400 p.m. (2:00 p.m.) Type of Incident: .Abuse: Verbal .Name of Involved Resident: (Resident #7) .(Resident #7) was upset at staff member (Certified Nursing Assistant (CNA) #2) for not getting him up as soon as he wanted. (CNA #2) told him she would get him up after lunch. (Resident #7) became very upset and started using derogatory words toward (CNA #2). (CNA #2) stated when (Resident #7) called her a name under her breath, she said, Your momma, but did not realize it was loud enough for (Resident #7) to hear. Another nurse heard the noise and came in the room and heard both (Resident #7) and (CNA #2) saying derogatory words to each other. Nurse (Licensed Practical Nurse (LPN) #3) separated the CNA and resident. And informed charge who then had the CNA and another CNA go in to get resident up. (CNA #2) was never alone with resident. Once (Resident #7) was taken care of, (CNA #2) was removed from the hall till administrator was contacted. Administrator was notified at 1400 (2:00 p.m.) . Upon notification Administrator met with (CNA #2) and witness statement was obtained. c. An OLTC Witness Statement Form dated 2/20/17 documented, .Witness Full Name (Resident #7) . Real bad about my momma (and) my daddy, real bad, a lot of crazy stuff. She was talking crazy about my momma (and) my dad. F . you, F . your momma (and) F . your daddy. Said she (CNA #2) was going to have a grievance written up about him (Resident #7) by (LPN #3). d. An OLTC Witness Statement Form written by Registered Nurse (RN) Supervisor #1 documented, .2/20/17 Time 1200 p.m . Female (CNA #2) stated to male (Resident #7) 'I'm not fixing to mess with you n .r (racial epithet) . e. An OLTC Witness Statement Form dated 2/20/17 by LPN #5 documented, This nurse went into resident's room to inquire about incident. Resident states he asked CNA to get him up for lunch and she said no. She came into room and got roommate up and left him in the bed. Resident states 'she talked about my mama and my daddy and they both dead and gone.' I informed resident that staff will assist him to w/c (wheelchair) as soon as possible. f. An OLTC Witness Statement dated 2/20/17 at 12:00 p.m. by LPN #3 documented, This nurse heard resident yelling loudly (and) started toward resident's room; as I opened the door, both the staff member (CNA #2) (and) resident (Resident #7) were cursing one another . Staff member returned with 'F . (expletive) you N . (racial epithet) . I'm not playing with you N (racial epithet) . staff member returning with 'I'm not doing s . (expletive) for you; .I ain't doing nothing for you. Difficult re-directing both the resident (and) staff member. Staff member then approached by her charge nurse (and) told charge nurse, I ain't the one . g. On 3/10/17 at 10:00 p.m., the Administrator was asked if staff should curse in front of residents or in the facility and stated, No. The Administrator was then asked if there had been any incidents of this problem and stated, Yes. The Administrator was asked what had occurred and when. The Administrator stated, They were in a room. This nurse walked in a room; they just heard yelling . As soon as the nurse went in the room, they removed her from the room. I removed her from the floor. The Administrator was asked what time this occurred and stated, The staff member put her out of the room. The Administrator gave no response as to the time of the incident. The Administrator was asked who had removed the staff member from the room and stated, That nurse (pointing to a Witness Statement signed by LPN #3). The Administrator was asked what time the incident had occurred and stated, 12 noon. The Administrator was asked what time the CNA had been removed from the resident's room and stated, Immediately. The Administrator was asked where the CNA was assigned after the incident and stated, They had her off the hall. h. On 3/10/17 at 10:10 p.m., LPN #3 was asked which staff member was involved in the incident with Resident #7 and stated, (CNA #2), aide, I don't really know her. The LPN was asked where CNA #2 went after being removed from the resident's room and stated, I made her leave the room, and I stayed in the room. She walked toward the dining room. The LPN was asked if anyone had accompanied CNA #2 and stated I stayed in the room. The LPN was asked if the incident was reported to anyone and stated, Yes, tried to call the nurse on the floor . I asked where (LPN #4) was and a minute later, she showed up. I heard (LPN #4) telling her (CNA #2) she can't talk like that. The LPN was asked who he had informed of this incident and stated, Just the nurse . My ADON (Assistant Director of Nursing) and (Registered Nurse #1) were in my office when we heard the yelling. The LPN was asked who the incident had been reported to and stated, I stayed in the room and told (LPN #5). The LPN was asked if the CNA was verbally abusing the resident and stated, Yes. The LPN was asked if the CNA had also made a threat to neglect the resident and not provide any care. The LPN stated, Yes. LPN #3 was asked who verbal abuse should be reported to and stated, My superior. The LPN was asked who that was and stated, (Administrator), (Assistant Administrator), (Director of Nursing), (Assistant Director of Nursing (ADON)). The LPN was asked when this should be reported and stated, Immediately . (ADON) was in the office. The LPN was asked if he knew that by law, as a nurse in a long term care facility, he was a mandated reporter for resident abuse and neglect. The LPN stated What's that? The Administrator was present in the room during this interview. i. On 3/10/17 at 10:25 p.m., the ADON stated, The CNA (CNA #2) came up to me, the CNA who yelled (CNA #2) told me about it. I notified the Administrator, not the DON. The ADON was asked when this occurred and stated, Maybe a quarter to 3. The ADON was asked to describe what the CNA told her and stated, .she told me her and the resident got into a yelling match. The ADON was asked where the CNA was when the CNA talked with the ADON. The ADON stated, She was still in the hallway. The ADON was asked which hall and stated, 400 hall, by the ice machine. The ADON was asked if, after the incident, the CNA had provided care to any residents and stated, I don't know. j. On 3/10/17 at 10:50 p.m., the Assistant Administrator was asked if he was in the facility on 2/20/17 and the stated, Yes. The Assistant Administrator was asked if he was aware of the incident with the CNA yelling at a resident and stated, I was later, not when it happened. (Resident #7) came and told me . We did a report and wrote a witness statement. The Assistant Administrator was asked, if a CNA is verbally abusive and makes threats to neglect a resident should it be reported? The Assistant Administrator stated, Yes, immediately. The Assistant Administrator was asked if any of the licensed nursing staff or CNAs had reported the incident to him and stated, No. The Assistant Administrator was asked what should be done about an incident like this and stated, Remove them from the building. The Assistant Administrator was asked when the LPN or RN Supervisor should have informed him of the incident and stated, I should have known immediately. k. On 3/10/17 at 11:00 p.m., the ADON was asked where she was and what she did when she heard the yelling from Resident #7s room. The ADON stated, On 100 hall seeing about a resident. The ADON was asked if LPN #3 had reported the incident to her and stated, No. The ADON was asked if she found out what had occurred after she was finished with the other resident and stated, No. The ADON was asked if the CNA should have been removed from the work place sooner and stated, Yes a lot sooner. The ADON was asked when the CNA was actually removed from the hall or from access to residents and stated, We pulled her. l. On 3/10/17 at 11:10 p.m., the Administrator was asked when the CNA was removed from contact with residents and stated, It was right at 2 (p.m.). m. The employee time card report for CNA #2, received from the Administrator on 3/11/17 at 11:55 a.m., documented CNA #2 clocked out at 3:00 p.m. on 2/20/17, approximately 3 hours after the incident of verbal abuse occurred. n. On 3/11/17 at 12:25 p.m., the Director of Nursing (DON) was asked when she became aware of the incident between Resident #7 and a CNA on 2/20/17 and stated It must have been around 2:00 p.m., because they brought her (CNA #2) to my office. The DON was asked who brought the CNA to the office and stated, I want to say (ADON) and (Administrator) . I want to say she said she filed a grievance against him (Resident #7) and (Administrator) said, 'it's not about how they talk to you, it's about how you talk to them' . The DON was asked, when there is an allegation of abuse or abuse has occurred, who is staff to report to? The DON stated, Supposed to report it to Administrator and DON. The DON was asked when the Administrator and DON were out of the building on 2/20/17 and verbal abuse occurred, who were staff to have reported the incident to? The DON stated, The ADON; actually we had an RN Supervisor too, and I guess she would have over-ridden the ADON. The DON was asked, When (LPN #3) became aware of verbal abuse to a resident and the CNA's statements, should the LPN have reported this immediately? The DON stated, Yes. The DON was asked if other staff members should have reported the verbal abuse immediately and stated, Yes. o. On 3/11/17 at 12:45 p.m., Registered Nurse (RN) #1 was asked if she was the RN supervisor and stated, Yes. The RN was asked if she was responsible to cover all halls in the facility as the RN Supervisor and stated, Yes. The RN was asked if she was present when the incident occurred between CNA #2 and Resident #7 on 2/20/17 and stated, Yes, I was in Medical Records. The RN was asked if the Medical Records office was in close proximity to the resident's room and stated, Yes. The RN was asked what was heard and stated, I didn't hear, muffled, then getting louder .CNA said 'I'm not about to do anything for you' . The RN was asked who was in the Medical Records office at that time and who went to the resident's room. The RN stated, Me, (LPN #3); he (LPN #3) left the room. The RN was asked why she did not go to the resident's room and stated, I didn't leave because (LPN #3) left when we heard the cussing; we were both doing work, and we both looked at each other, and he got up, and with (Resident #7), he doesn't do well with a lot of people around. With his behaviors, a lot of people around make it worse. The RN was asked what behaviors the resident had and stated, He is very difficult when he wants something. The RN was then asked to describe what she heard the CNA saying to the resident and stated, I'm not fixing to mess with you n .er (racial epithet), after (LPN #3) went in the room. RN #1 was asked what she was doing while LPN #3 went to the resident's room and stated, I was on my lunch break. I was in there 'til when I finished lunch. The RN was asked if she reported the incident and stated, I went and told (DON and ADON) about it. The RN was asked when the incident was reported to the DON and stated, Probably about 1:30 p.m. The RN was asked why she had waited to report the incident and stated, After my lunch break, we had a standard of care meeting, and afterwards, that's when I told her (DON) about it. The RN was asked when staff becomes aware of abuse, when is it to be reported? The RN stated, To be immediately reported. RN #1 was asked to whom was abuse to be reported and stated, DON, Administrator. The RN was asked if, after lunch, she reported the verbal abuse and stated, I thought (LPN #3) took care of it . That was the first time I heard any staff curse at him. The RN was asked if the resident was dependent on staff and stated, Yes. The RN was then asked if she had intervened to protect the resident and stated, No. The RN was asked where the CNA was after the incident and until she left the building and stated, All I know, she went down front of 400 hall. I don't know where she went. The RN was asked if she should have known where the CNA was in the building and stated, Yes. The RN was asked if she had received abuse training when she came to work at the facility and stated, Yes. RN #1 was asked what was to be done when there was possible abuse and stated, You separate that person, you go and report. The RN was asked, who do you report to? The RN stated, Usually have an RN supervisor in the building. The RN was asked, as the RN supervisor, if she was responsible for reporting to the Administrator and DON that day and stated, Yes. The RN was asked who was present for the standards of care meeting after the incident occurred. The RN stated, (DON), (ADON) . The RN was asked if she reported the incident of verbal abuse at that time and stated, No. The RN was asked if the CNA should have been removed from the hall and stated, Yes. The RN was asked if she knew who the CNA had contact with after the incident and stated, No. The RN was asked if she had received abuse training after the incident and the RN stated, Yes. p. On 3/11/17 at 1:30 p.m., the Administrator was asked if the facility's surveillance video was viewed to determine if CNA #2 had remained in the facility after the incident on 2/20/17. The Administrator stated, .we could see she was in the building. The Administrator was asked if the CNA had contact with other residents after the incident and stated, .we just know that she was on that hall (400 Hall) and the dining room, and she just had contact with residents on that hall. She did go out the door to laundry and later came back in. We can give the hall she was on, but we cannot tell the rooms she went in. She did remain on the hall. The Administrator was asked when the CNA was removed from the hall and stated, It was 2:40, 2:42 (p.m.) she was taken to the DON's office . The Administrator was asked who reported the incident of verbal abuse and stated, (ADON) came up to me first. The Administrator was asked if the RN supervisor (RN #1) had reported anything that day and the Administrator stated, Not that I remember. The Administrator was asked if anyone else, such as LPN #3, had reported the incident and who staff could have reported the verbal abuse to while the Administrator was out of the building. The Administrator stated, After he did come to me, right after 3:00, (Assistant Administrator) was in the building. The Administrator was asked if the RN Supervisor should have reported the incident and stated, Yes. q. On 3/11/17 at 2:55 p.m., Resident #7 was asked if he recalled the incident when a CNA had cursed at him recently and stated, Yes, it upset me; it really upset me. r. The facility removed the immediate jeopardy and reduced the scope / severity to E on 2/20/17, by completing the following corrective actions: 1.) The DMS form dated 2/20/17, provided by the Administrator on 3/10/17 at 10:15 p.m., documented, . (CNA #2) was placed on administrative leave. Witness statements were obtained from staff and (Resident #7). Police notified and interviewed (Resident #3). On 2/21/17 after investigating the incident, (CNA #2) employment was terminated. Training on our abuse policy was initiated by Assistant Administrator. Residents were interviewed with no negative findings noted. (Medical Doctor) was notified with no new orders received at this time. A skin assessment was performed on (Resident #7) with no negative findings. (Resident #7) is currently able to propel self in wheelchair. In summary, through the investigation, there seems to be findings that a slight verbal altercation may have occurred between (Resident #7) and (CNA #2). (CNA #2) was terminated and staff was in serviced on our Abuse policy. (Resident #7) seems to have no long-term effects from verbal altercation. 2.) An Employee Attendance Sign-in sheet received from the Administrator on 3/11/17 documented, Date 2/21 In-service Instructor (Administrator) In-service Topics Abuse and neglect Policy (and) Procedure . The names listed on the sign-in sheet included the 400 Hall CNA staff, (LPN #3), and (RN #1) as the staff members who had received the in-service training from the facility. Attached to the in-service sign in sheet was a copy of the facility Abuse and Neglect Policy and Procedure. The Administrator stated, I read from this. All of 400 staff. No other facility staff names were documented on the sign-in sheet. The additional documentation indicated CNA #2 was not allowed to return to work after she was removed from the facility on 2/20/17 at approximately 3:00 p.m. B. Based on observation, record review and interview, the facility failed to ensure injuries of unknown origin were promptly identified, which resulted in a delay in initiating an investigation to rule out possible abuse or neglect in accordance with State Law for 1 (Resident #4) of 2 (Residents #1 and #4) who had bruises of unknown origin that were not identified or reported. This failed practice had the potential to affect 2 residents who had bruising of unknown origin that were not identified or reported within the past 30 days as documented on a list provided by the Treatment Nurse on 3/10/17 at 10:20 p.m. The findings are: 1. The facility's policy and procedures regarding injuries of unknown origin, provided by the Administrator on 3/10/17, documented, .Injury of unknown Source - is defined as an injury that meet both of the following conditions. 1. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident and . The injury is suspicious because of the extent of injury or the location of the injury, (e.g. (for example) the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injuries over time . All reports of resident abuse, neglect, exploration and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 2. Resident #4 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/21/17 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and was at risk for developing pressure ulcers. a. The Care Plan dated 2/24/17 documented, .(Resident #4) is an elopement risk/wanderer r/t (related to) Alzheimer's . requires . monitoring for safety . b. On 3/2/17 at 11:25 p.m., there were 2 round purplish bruises on the resident's right elbow area that were approximately 1 centimeter (cm) in diameter with a very small scab in the center of the bruised area. c. A Weekly Skin Evaluation form dated 3/6/17 had no documentation of any bruises or skin discolorations. d. On 3/10/17 at 7:25 p.m., a skin audit was conducted with the assistance of LPN #4. At 7:45 p.m., the DON joined the LPN and surveyor and, with the resident's right breast exposed, there was a round bruise that was yellowish on the surrounding edges and blue in the center. The DON was asked, What do you see? and stated, I see discoloration about a quarter size. The DON measured the bruise and stated, 2 by 2 centimeters. On the right elbow area, the 2 round, purple bruises remained visible. The DON measured the areas and stated the area to the front of the elbow measured, 1 by 1 cm and the second area measured 1/2 by 1/2 cm. e. On 3/10/17 at 8:15 p.m., the DON was asked when the most recent skin audit was done and stated, 3/6. The DON was shown the skin audit and asked if it had identified bruises and stated, No. The DON was asked if the skin audit had identified any skin abnormalities and stated, No. The DON was informed that the 2 round bruises on the right elbow were present during the initial rounds at 11:25 p.m. on 3/2/17. The DON was asked if there were any recent incidents or accidents involving the resident and stated, I've got a fall on 23rd (2/23/17) and known fall on 25th 2/25/17). The DON was asked if there were any incident and accident forms completed for the resident since 2/25/17 and stated, No. The DON was asked if the 3/6/17 body audit identified the 2 bruises on the elbow area and stated, No. The DON was asked if the body audit identified anything on the skin of the right breast. The DON stated, No it did not. The DON was asked if, when staff bathed/dressed the resident, they should have noticed the bruises. The DON stated, Yes. The DON was asked if, when body audits were done, bruised or discolored areas should be identified. The DON stated, Yes. The DON was asked if a finding of bruising would need to be investigated to determine the cause. The DON stated, Yes absolutely. f. On 3/10/17 at 8:25 p.m., LPN #4 was asked what a body audit should consist of and stated, Any type discoloration to body, anything abnormal. The LPN was asked if that would include bruises and stated, Yes.