Every finding on record at The Springs of Mine Creek

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review and facility policy reviews, it was determined that the facility failed to ensure infection control practices were followed during the medication administration observation and within the medication room to prevent the spread of infection(s) for three (Resident #30, Resident #49, and Resident #66) of three residents reviewed. Specifically, a communal glucometer was not disinfected properly before or after use for Resident #30; a blood pressure cuff was not disinfected after use on Resident #49, who was on contact isolation; a urine specimen for Resident #66 was housed within a fridge that contained medication and food. The findings include: Resident #30 Review of an admission Record, indicated the facility admitted Resident #30 with diagnoses that included diabetes mellitus. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2025, revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score 11, which indicated the resident had moderate cognitive impairment. Further review indicated the resident received insulin injections. Review of a Care Plan Report, revised on 10/14/2025, revealed Resident #30 had diabetes mellitus, with an intervention to administer medications as ordered. Review of an Order Summary Report, revealed Resident #30 had a Physician's Order for a sliding scale insulin based on the resident's finger stick blood sugar before meals and at bedtime. During a concurrent observation and interview on 02/19/2026 at 8:09 AM, Medication Aide (MAC) #1 pulled a glucometer and other supplies from the medication cart to check the blood sugar of Resident #30. Registered Nurse (RN) #2, who was the assigned Infection Preventionist (IP), monitored MAC #1 during this observation. After getting Resident #30's blood sugar, MAC #1 placed the glucometer back in the cart without disinfecting it. At 8:40 AM, after providing Resident #49 with their medications, MAC #1 started prepping medications for another resident. At this time, this Surveyor asked both MAC #1 and RN #2 about the glucometer. RN #2 stated MAC #1 should have disinfected the glucometer after use because it could cause cross contamination. RN #2 asked MAC #1 if he had any disinfecting wipes on his medication cart. MAC #1 stated he did not but started looking through the cart and located [brand name] germicidal disposable wipes. MAC #1 stated he disinfected the glucometer with alcohol wipes before the surveyor approached the cart and should have disinfected the glucometer [with the appropriate wipes] before placing it back in the cart. He stated, he was not aware he could not use alcohol wipes [to disinfect the glucometer]. During an interview on 02/20/2026 at 2:30 PM, the Director of Nursing (DON) stated Medication Aides were educated on how to use, test, and clean a glucometer. The DON stated an in-service was just completed on 02/19/2026 after she was notified that MAC #1 did not disinfect the glucometer properly. The DON stated, alcohol wipes cannot be used to clean a glucometer because the wipes do not have the proper components to kill certain bacteria and [brand name] germicidal disposable wipes should be used. Resident #49 Review of an admission Record, indicated the facility admitted Resident #49 with diagnoses that included chronic viral hepatitis C, urine retention, high blood pressure, and a heart murmur. Review of an Annual MDS, with an ARD of 01/27/2026, revealed Resident #49 had a BIMS score 14, which indicated the resident was cognitively intact. Review of a Care Plan Report, revised on 02/13/2026, revealed Resident #49 was on contact isolation for Extended-Spectrum Beta-Lactamases (ESBL), which was a type of enzyme or chemical produced by bacteria that make some antibiotics ineffective in treating bacterial infections, in the urine. Care Plan interventions included to maintain contact isolation precautions when caring for the resident. The Care Plan also indicated Resident #49 had liver disease related to hepatitis C. Review of an Order Summary Report, revealed Resident #49 had an order for contact isolation due to ESBL in the urine, with a start date of 02/12/2026. During concurrent observation and interview of the medication administration task on 02/19/2026 at 8:18 AM, MAC #1 and RN #2, who was the assigned IP and monitored MAC #1, both applied gowns and gloves before entering Resident #49's room due to the resident being on contact isolation for ESBL, in the urine. This resident was also positive for hepatitis C. The Contact Precautions sign on the door indicated staff were to use dedicated or disposable equipment and to clean and disinfect reusable equipment before use on another person. MAC #1 took the electronic blood pressure machine from the medication cart and both MAC #1 and RN #2 walked into Resident #49's room. MAC #1 acquired the residents' blood pressure. Both staff removed their PPE in the room and MAC #1 placed the blood pressure cuff back on the cart. At 8:40 AM, after providing Resident #49 with their medications, MAC #1 started prepping medications for another resident. At this time, both MAC #1 and RN #2 were asked about the blood pressure machine. RN #2 stated Resident #49 should have their own blood pressure cuff in the resident's room, and they should have disinfected the blood pressure cuff after use because it could cause cross contamination. RN #2 asked MAC #1 if he had any disinfecting wipes on his cart. MAC #1 stated he did not but started looking through the cart and located [brand name] germicidal disposable wipes and then disinfected the machine. During an interview on 02/20/2026 at 2:30 PM, the Director of Nursing (DON) stated if a resident was on contact isolation and had an order to have their blood pressure checked, staff should clean the blood pressure machine before and after use, unless the resident had their own equipment in their room. Resident #66 Review of an Order Summary Report, revealed Resident #66 had a laboratory order for a urinalysis (UA), with a start date of 02/17/2026. During a concurrent observation and interview on 02/20/2026 at 11:46 AM, RN #2, who was also the IP, showed the surveyor the medication room. There were two fridges inside the medication room, with one being the medication fridge and another small fridge that was for food items. The medication fridge contained Resident #66's urine specimen that was in a small lab specimen bag. RN #2 did not remove the urine or acknowledge that the specimen should not be in the fridge. This Surveyor asked RN #2 about the specimen, RN #2 stated the urine should not be in the medication fridge and it could cause contamination. RN #2 stated she did not know where the specimen fridge was located, but she would find out. At 12:27 PM, RN #2 stated the facility removed the contents of the small fridge inside the medication room, cleaned the fridge, and made the small fridge for specimens only. During a concurrent interview and observation on 02/20/2026 at 12:52 PM, Licensed Practical Nurse (LPN) #3 was in the medication room and stated she had previously seen the urine specimen in the fridge and notified the DON earlier that day. LPN #3 went to get the specimen out of the medication fridge but was advised by the surveyor that it had been moved to the smaller fridge that was now labeled that the fridge was for specimens only. LPN #3 examined the bag and the specimen container, which did not include the time or who collected the specimen. Review of Progress Notes for Resident #66 did not indicate when or who collected the UA. During an interview on 02/20/2026 at 1:20 PM, Nurse Consultant #4 confirmed the UA was in the wrong fridge, but it had been moved. During an interview on 02/20/2026 at 2:30 PM, the DON stated prior to lab specimens being picked up, they should be stored away from any food or medications. She stated after she was notified of the urine specimen being in the medication fridge, she cleaned out the small fridge, put the specimen in the small fridge and placed a sign on the fridge indicating it was dedicated to lab specimens only. The DON stated she also disinfected the medication fridge where the urine specimen was stored previously. Review of a facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised on 10/2018, indicated, blood pressure cuffs were considered non-critical items, which were items that could come into contact with intact skin, but not mucous membranes and reusable items should be cleaned and disinfected between residents. The policy also indicated, Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin. Such devices should be free from all microorganisms. Semi-critical items will be sterilized/disinfected in a central processing location and stored appropriately until use. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. Review of a facility policy titled, Isolation – Categories of Transmission-Based Precautions, revised on 10/2018, indicated, Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.

Based on observation, record review and interview, the facility failed to ensure the ice machine was maintained in clean and sanitary condition to prevent potential growth of harmful bacteria that could be transferred to the resident's food. This failed practice had the potential to affect 72 residents who received drinks from the kitchen. The findings are: 1. On 08/05/24 at 10:50 AM, the area in the ice machine where ice forms before dropping into the ice collector had water dripping. The surveyor asked Dietary Manager (DM) to wipe the area. The DM took a white paper towel and wiped the area, and a residue was on the towel. The DM was asked to describe what was on the towel, the DM stated, Grungy, dirty, it needs to be cleaned inside and out. Surveyor asked the DM who was responsible for cleaning the ice machine. The DM indicated the Maintenance Director. The surveyor asked the DM when was the last time the ice machine was cleaned? The DM indicated July 23. 2. On 8/08/24 at 2:45 PM, Surveyor asked the Administrator (AD) who was responsible for cleaning the ice machine? The AD indicated the Maintenance Director. 3. Surveyor asked the AD who all gets ice from the ice machine the AD indicated all the residents, except for the two tube feeders. 4. A facility policy titled Ice Machines and Ice Storage Chest provided by the Administrator on 08/08/2024 at 2:50 PM documented, Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. 5. [Name Brand] cleaning and Sanitization was provided by the Administrator on 8/08/2024 at 3:37 PM documented, Cleaning or de-liming an ice machine refers to the process of removing mineral buildup and scale from the evaporator and other components. [Name Brand] recommends cleaning the ice machine every 6 months, but no more than once per month to avoid potential damage to the machine. Frequency of cleaning may depend on water quality and filtration system used. 6. On 8/08/24 at 4:10 PM, Surveyor spoke with the Maintenance Director regarding the cleaning of the ice machine. The Maintenance Director indicated that he does a deep clean once a month where he changes the filters and takes the ice out and sanitizes the machine, then once a week he does a weekly wipe down. He indicated the last deep clean was July 23, 2024, and the last weekly wipe down clean was 7/31/2024. He indicated that he was extremely hard to keep the stuff out of the ice machine. It will build up in just a few days.

Based on record review and interview, the facility failed to ensure the water management program contained the necessary components to monitor for legionella and other water-borne pathogens in 1 of 1 facility. The findings are: On 08/07/2024 at 1:02 PM, the water management binder, provided by the Administrator on 08/07/2024, was reviewed and it included the following: [City Name] Waterworks 2022 Annual Drinking Water Quality Report, Legionella Environmental Assessment Form, and information, Developing a Water Management Program to Reduce Legionella Growth & Spreading in Buildings dated June 24, 2021. The Legionella Water Management Program policy, revised July 2017, was reviewed and it listed elements that would be included such as, a detailed description and diagram of the water system in the facility, identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria and documentation of the program. Upon review of the provided information, there was no water flow diagram, no documentation if any resident rooms were tested for water temperatures, no documentation of a monitoring system or documentation of the program. On 08/07/2024 at 1:05 PM, the Administrator was interviewed and she confirmed the binder she provided was the facility's water management program. On 08/07/2024 at 1:06 PM, the Maintenance Director was interviewed and asked to provide the facility's documentation of what had been monitored regarding the water management program. He confirmed the facility did not actually have anything and they didn't test unless they suspected something. The Maintenance Director was asked to provide documentation regarding other components that were monitored regarding their water system. He confirmed that he needed to get documentation from his office. On 08/07/2024 at 1:14 PM, the Maintenance Director provided a document titled, Appendix D. Other Water Devices. The form was reviewed, and it indicated a date of Aug (August) 2 (second) with no year and it indicated a location of Hall 1 washroom that was indoors with no heat source and water temperature of 78.8. The form did not indicate if the temperature was Fahrenheit or Celsius. He was asked if that was all the information he had for the year and confirmed that it was not, and he needed to go back to his office. As he turned to go to his office, he confirmed that his information was kept in his computer, and he was not able to access his program from his office. The Administrator instructed him to use her computer. On 08/07/2024 at 1:18 PM, the Maintenance Director confirmed the he could not access his program at this time and would make a phone call. On 08/07/2024 at 1:26 PM, the Administrator came to the conference room and confirmed the facility did not have the information requested. She confirmed the Maintenance Director checked the water temperatures every two weeks but had not documented anything. She was asked if that was the only monitoring the Maintenance Director did for their water management program, and she confirmed there was a report from the city and they had a toilet that was not working that maintenance checked. She was asked if that was the only monitoring that was done for their water management program, and she verbalized they had hot water temperatures in their life safety book, and she would provide that information. On 08/07/2024 at 2:05 PM, the Administrator came to the conference room on Hall 2, and provided a form titled, Ice machine cleaning and stated with two other surveyors present, Here's the information on the ice machine, but he doesn't have the life safety information here. He looked for it in his office and he couldn't find it . On 08/07/2024 at 2:58 PM, the Administrator provided a copy of documents titled, Weekly Water Temperatures and it indicated, . Room . Whirlpools, Laundry, Kitchen, Resident Rooms . A Weekly Water Temperatures form dated 07/31/2024 was reviewed and it indicated the following areas had the indicated water temperatures: whirlpools on Hall #2 -104; the laundry room-173, the kitchen-154, Hall 3 room [ROOM NUMBER] -106 and hall 3 room [ROOM NUMBER]- 105. None of the temperatures were listed as Fahrenheit or Celsius. The section labeled hot water heaters for Hall #5, kitchen, and Hall #4 did not indicate a water temperature on the form dated 7/31/24 or any of the forms provided.

Based on record review and interview, the facility failed to ensure the Ombudsman was notified of a resident's transfer to the hospital for 1 (Resident #58) of 1 sampled resident who was reviewed for hospitalization . The findings are: On 08/07/2024 at 12:25 PM, Resident #58's Notice of Transfer / Bed hold form, dated 01/17/2024, was reviewed and it indicated the resident was transferred to the hospital on 01/16/2024 and the Adult Protective Services (APS) case worker was notified, but it did not indicate that the Ombudsman was notified. On 08/08/2024 at 10:34 AM, the Administrator provided a copy of The Springs of Mine Creek Admission/Discharge To/From Report that included a list of residents transferred out of the facility from January 2024 through July 2024 and emails of the dates that information was provided to the Ombudsman. This information was reviewed, and Resident #58 was listed for a discharge on 01/23/2024 to home with home health, but it did not list the resident's transfer to the hospital on 01/16/2024. On 08/08/2024 at 11:48 AM, the Administrator was interviewed, and she confirmed the information provided earlier was the only information =sent to the Ombudsman for the January 2024 transfers from the facility. She was informed that Resident#58 was transferred out to the hospital in January 2024 and that name was not listed. She was asked how the Ombudsman was notified of those residents who were transferred out of the facility that may have gone to the hospital but did not stay. She confirmed the Business Office Manager (BOM) would have to be asked. At 11:49 AM, the Administrator asked the BOM if the resident was not on the discharge list, but was on a bed hold, how does the Ombudsman know that? The BOM confirmed she would have to enter that information on the email was sent to the Ombudsman. The BOM confirmed that information was not on the email sent for the January 2024 transfer notifications to the Ombudsman. On 08/08/2024 at 3:20 PM, the Administrator provided a Transfer or Discharge Notice policy, revised March 2021, that was reviewed and indicated a copy of the notice is sent to the Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

F921 Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 cook stoves. This failed practice had the potential to affect 74 residents as documented on the Daily Census provided by the Administrator on 10/23/2023 at 09:15 AM. The findings are: a. On 10/25/23 at 11:36 AM Dietary worker #1 turned on the gas stove top burner and it did not ignite. Dietary worker #1 lit the stove top burner after turning on the gas with an orange in color multi-purpose lighter with flex wand and it blew a flame of fire once lit. b. On 10/25/23 at 11:50 AM Dietary worker #1 turned on the gas stove top burner and it did not ignite. Dietary worker #1 lit stove top burner after turning on the gas with an orange in color multi-purpose lighter with a flex wand. c. On 10/25/23 at 12:01 AM Dietary worker #1 turned on the gas stove top burner and it did not ignite. Dietary worker #1 lit stove top burner after turning on the gas with an orange in color multi-purpose lighter with a flex wand. d. On 10/25/23 at 12:26 AM Dietary worker #2 turned on two gas stove top burners and both did not ignite. Dietary worker #2 lit stove top burners after turning on the gas with an orange in color multi-purpose lighter with a flex wand. e. On 10/25/23 at 02:19 PM Dietary worker #1 was asked, Why did you light the stove top burner with a lighter? Dietary worker #1 responded, It does not light. Dietary worker #1 was asked, How long have you been lighting the stove top burner with a lighter? Dietary worker #1 responded, A month. Dietary worker #1 was asked, Have you told maintenance? Dietary worker #1 responded, No Dietary worker #1 was then asked, Is there another way of lighting the stove top burners? Dietary worker #1 responded, You can turn the burner on and wait and the gas smell will fill the air. Some people then come from the hallway smelling gas. f. On 10/25/23 at 02:21 PM Dietary manager was asked, How long have you been lighting the stove top burner with a lighter? Dietary manager responded, A year as far as I know, It's dangerous. Dietary manager was asked, Have you told maintenance and what was their response? Dietary manager responded, Yes, they were going to get a guy to come blow out the burners Dietary manager was then asked, Is there another way of lighting the stove top burners? Dietary manager responded, No unless you light paper. g. On 10/25/23 at 02:25 PM The administrator was asked for a maintenance work order for the stove top burner. h. On 10/25/23 at 02:51 PM The administrator stated they had talked to the maintenance director and there was no work order. Surveyor asked the administrator for the user manual for operating instructions for the range. i. On 10/25/23 at 03:11 PM A user manual titled [NAME] Installation, Operating, and Service Manual provided by the administrator states .Regular maintenance and servicing by competent and qualified personnel is recommended for the continued safe and efficient operation of cooking equipment . j. On 10/26/23 at 11:12 AM A policy titled Hazardous Areas, Devices and Equipment provided by the administrator. The policy stated . Hazardous areas and objects in the resident environment will be identified and addressed by the safety committee . a. Equipment and devices that are left unattended or are malfunctioning; .

Based on Observation and Interview, the facility failed to ensure that the refrigerated narcotic medications were stored in a permanently affixed compartment to prevent the potential of misappropriation of resident property. This failed practice had the potential to affect all 74 residents in the facility as documented on the Daily Census provided by the Administrator on 10/23/23 at 09:15AM. The findings are: 1. On 10/25/23 at 10:16 AM, the Medication room was inspected with the Assistant Director of Nurses. Inside the refrigerator was a locked narcotic box containing narcotics, but it was not permanently affixed. 2. The narcotics inside were Lorazepam 2mg (milligrams)/ml (milliliter), 30 ml prescription # noted, and 2 vials of Lorazepam 2mg/ml Prescription # noted. 3. On 10/26/23 At 02:11PM, Licensed Practical Nurse (LPN) #3 was asked the process for securing refrigerated narcotics. LPN # 3 stated, It must be locked up behind 2(two) locks. LPN # 3 was asked who had a key to the refrigerator. LPN #3 stated, The nurse who works the other med cart, today {named nurse} #2 but there is only 1 (one) key to the narcotic box. LPN # 3 was asked, if a nurse has a key to the refrigerator can they take the narcotic box without anyone knowing. LPN #3 stated, Yes. 4. On 10/26/23 at 02:20PM LPN #2 was asked if they had a key to the locked refrigerator that contained the narcotics in the medication room. LPN #2 stated Yes, I have insulin in there I have to get sometimes. LPN #2 was asked to enter the medication room and unlock the refrigerator and hand the surveyor narcotic box. The nurse was asked the narcotic box could be taken without anyone knowing. LPN stated, Yes. 5. On 10/26/23 at 02:31PM, the Director of Nursing (DON)was asked the process for securing refrigerated narcotics. The DON stated, Its double locked in the refrigerator. The DON was asked if the narcotic box was permanently in the refrigerator. The DON stated, No the Surveyor asked, What could happen if it is not secured. DON stated, It could get stolen. The Nurse consultant stated, I told you to make sure that the narcotic box was permanently affixed in the refrigerator. The DON stated, I know but the Pharmacist told me just to lock the refrigerator. 6. On 10/26/23 at 11:12 AM, a policy provided by the Administrator titled, Storage of Medications documented, . The facility stores all drugs and biologicals in a safe, secure, and orderly manner . Schedule 2-5 controlled medications are stored in separately locked, permanently affixed compartments .

Based on observation, record review and interview, the facility failed to ensure that residents who self-administered medications were assessed to safely self-administer medications for 1 (Resident #58,) of 1 sampled residents who had a Physician's Order for nebulizer treatments as documented on a list provided by the Administrator on 10/27/23 at 8:19:Am. The findings are: 1. On 10/23/23 at 10:20 AM, Resident #58 was in bed. A nebulizer machine at the bedside had clear liquid in the reservoir. The resident was asked what is that liquid in the reservoir? The resident answered, That is my breathing medicine. 2. On 10/23/23 at 10:40AM, Resident #58 was asked, do you perform your own breathing treatments? Resident #58 answered, Yes. Resident #58 was asked, does the nurse stay in the room with you when you do them? Resident #58 stated, No. Resident #58 was asked if they self-administered all of the medication one time. The resident responded, No; once I can breathe good, I turn it off. 3. On 10/23/23 at 02:40 PM, Resident #58 was in bed. A nebulizer machine at the bedside had clear liquid in the reservoir. The surveyor asked the nurse to bring a syringe to measure the liquid. There was 2 milliliters of clear liquid in the reservoir. 4. On 10/24/23 at 08:15 AM Resident #58 was in bed. A nebulizer machine at the bedside had clear liquid in the reservoir. Licensed Practical Nurse (LPN) #1 was asked what is that liquid? LPN #1 stated, Breathing medication. The LPN was asked should the medication be left in the room without a nurse? LPN #1 stated. It's not from me, the one I give isn't due till 10. The clear liquid measured 2.2 milliliters. 5. A Physician's Order dated 10/24/23 documented, Levalbuterol HCl Nebulization Solution 0.63 MG/3ML3 ml inhale orally via nebulizer two times a day related to Chronic Obstructive Pulmonary Disease . 6. A Care Plan dated 09/28/22 documented, Give aerosol or bronchodilators as ordered . 7. On 10/24/23 at 10:41 PM during a review of Resident #58's electronic medical record, there was no assessment to self-administer medication or a care plan to self-administer medications. 8. On 10/25/23 at 01:04 PM, LPN #2 was asked, do you have any residents on the hall who are assessed to self-administer medications? LPN #1answered, No. 9. On 10/26/23 at 02:27 PM, LPN #3 was asked if there was anyone on the hall who was assessed to self-administer medications. LPN #3 answered, No. 10. On 10/26/23 at 02:27 PM, LPN #3 was asked, what is your process for administering a nebulizer treatment? LPN #3 stated, You fill the reservoir with medication, you explain the procedure and apply the mask turn it on. Stay with them so they get the medication correctly. 11. On 10/26/23 at 02:41 PM, the Director of Nursing (DON) was asked to explain the process for administering a nebulizer treatment. The DON stated, Check the order then put the meds in the nebulizer. The DON was asked if the resident should be left alone. DON stated, No because they may get it wrong, take it the wrong way, or give it to a friend. The DON was asked how many residents were approved to self-administer their own medications? The DON stated, None. 12. A Policy titled, Self-Administration of Medications which was provided by the Administrator on 10/26/23 at 11:12AM documented, . Residents have the right to self- administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so .3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical record and/or decision-making status . 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents . 13. On 10/26/23 at 11:12 AM, A Policy titled, Nebulizer Therapy with an implementation date of 6/2/23 documented, It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions . 13. Observe resident during the procedure for any change in condition .

Based on observation, record review and interview, the facility failed to ensure that a nebulizer mask and tubing were changed out weekly and bagged in a closed container to prevent bacteria from accumulating for 1 (Resident # 58) sampled resident who had a Physician's Order for Nebulizer treatments as documented on list provided by the Administrator on 10/27/23 at 08:19AM. The findings are: 1. On 10/23/23 at 10:20 AM Resident # 58's nebulizer mask and tubing was dated 10/6/23 and lying on the bedside table not bagged. 2. On 10/23/23 at 02:40 PM Resident #58's nebulizer mask and tubing was dated 10/6/23 and lying on the bedside table not bagged. 3. On 10/24/23 at 08:15 AM, Resident #58's nebulizer mask and tubing was dated 10/6/23 and lying on the bedside table not bagged. Resident #58 was asked if they were receiving breathing treatments with the Nebulizer. Resident #58 stated, Yes, 2(two) times a day. 4. A Physicians order dated 10/24/23 documented Levalbuterol HCl Nebulization Solution 0.63 MG (milligrams)/3ML (milliliters) inhale orally via nebulizer two times a day related to Chronic Obstructive Pulmonary Disease (COPD) with (Acute) Exacerbation. 5. A Physician's order dated 9/25/23 documented, Updraft: Change tubing weekly on Sunday, place in Ziploc bag, date and initial bag and tubing. Every night shift every Sun for Infection Control. 6. A Care Plan dated 09/21/2022 with a revision date of 09/28/2022 documented, . has COPD r/t (related to) smoking. Give aerosol or bronchodilators as ordered. Observe for side effects and effectiveness. 7. On 10/26/23 at 10:48AM Licensed Practical Nurse (LPN) # 2 was asked how often the Nebulizer masks and tubing were change. LPN #2 stated, Weekly on Sundays. If we do not change the equipment, it wouldn't be labeled with the correct date and they cold get pneumonia and die. 8. On 10/26/23 at 2:11PM, the Director of Nursing (DON) was asked when the respiratory supplies were changed out and to explain their expectations. The DON stated, They are changed out every Sunday because if not they can accumulate bacteria and get bacteria pneumonia. 9. On 10/26/23 at 11:12AM the Administrator provided a policy titled Nebulizer Therapy which documented, . Care of the Equipment: 7.store the nebulizer cup and the mouthpiece in a plastic bag. 8. Change nebulizer tubing once a week or as needed.

Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items, 1 of 1 ice machine was maintained in a clean condition to prevent potential contamination of residents' food or beverages, cold food items were maintained at 41 degrees or below to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 70 residents who received food from the kitchen (total census: 72 ), according to the diet list provided by the Dietary Employee dated 7/22/2022 at 9:01 AM The findings are: 1. On 7/20/22 at 3:32 PM, Dietary Employee #1 was wearing gloves on her hands. She opened the door for the Surveyor to come in. At 3:33 PM, she opened the refrigerator door and took out a pitcher of tea and placed it on the counter. Without changing gloves and washing her hands, she picked up a loose tea bag and placed it in a brewing basket. The brewing basket with tea bag was set on top of a container to brew tea to be served to the residents for the supper meal. 2. On 7/20/22 at 3:42 PM, Dietary Employee #1 was wearing gloves on her hands. She lifted the trash can lid and threw away tissue papers. Without changing gloves and washing her hands, she sorted out condiments to be served to the residents for super meal. 3. On 7/20/22 at 3:51 PM, the air vent in the dish washing machine had a grease-like dirt hanging down from it. 4. On 7/20/22 at 3:58 PM, the ice machine in the dining room had an accumulation of wet black sediments on the panel of the ice machine. The Dietary Supervisor was asked to wipe the accumulation of wet black sediments on the interior surfaces of the ice machine. She did, and the wet black slimy colored residue easily transferred to the tissue. She was asked to describe the appearance of what was found on the panel. She stated, It was black slimy residue. She was asked, Who uses the ice from the ice machine? How often do you clean it? She stated, I think the maintenance man cleans it. The CNAs [Certified Nursing Assistants] use it for the water pitchers in the residents' rooms. They use it in the kitchen to fill beverages served to the residents at meals. 5. On 7/20/22 at 4:06 PM, Dietary Employee #2 took out a zip lock bag that contained slices of cheese and a bag that contained slices of ham from the refrigerator and placed them on the counter. Without washing her hands, she removed gloves from the glove box and placed them on her hands, contaminating the gloves. She untied the bread bag, used her contaminated gloved hand to remove slices of bread from the bag and placed them in a pan. She removed slices of cheese and ham from each individual bag and placed them on each slice of bread. Then, topped it with another slice of bread to be served to the residents for supper meal. On 7/21/2022 at 11:59 AM, Dietary Employee #1 was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have changed gloves and washed my hands. 6. On 7/20/22 at 4:52 PM, Dietary Employee #1 took out a bag that contained lids from the storage room and placed it on the counter. She opened the refrigerator, took out a pitcher of tea and placed it on the counter. Without washing her hands, she picked up cups by the rims and poured tea to the be served to the residents for the supper meal. On 7/21/22 at 11:35 AM, Dietary Employee #1 was asked what should you have done after touching dirty objects and before handling clean equipment and she stated, I should have changed gloves and washed my hands. 7. On 7/20/22 at 5:12 PM, the temperatures of the cold food items located on pans of ice on cold side of the steam table, checked and read by Dietary Employee were: a. Pureed ham 59 degrees Fahrenheit. b. Pureed bread with milk 71 degrees Fahrenheit. c. Regular ham and cheese 53 degrees Fahrenheit. d. Ground ham and cheese 57 degrees Fahrenheit. 8. The facility's preview policy on hand washing documented, Wash hands immediately before engaging in food preparation including working with exposed food, clean equipment or service utensils and or after engaging in any other activity that contaminates the hands.

Based on observation, record review, and interview, the facility failed to ensure that medication/biologicals were stored safely and according to professional standards of practice on Hallway 1. The findings are: On 7/19/22 at 10:00 AM, the wound care cart on hallway 1 facing center of hall, was unattended and unlocked. There were no staff near the wound care cart. Registered Nurse (RN) #1 came out of Resident room [ROOM NUMBER] and opened the wound care cart and got supplies out of the cart and went back into Resident room [ROOM NUMBER]. The RN did not lock the wound treatment care. a. On 7/19/22 at 10:10 AM, RN#1 came out of Resident room [ROOM NUMBER]. RN#1 was asked to pull the drawers open to the cart to allow the Surveyor to see what was in the wound care cart. The cart contained two 16 ounce of bottles of Hy[DATE] percent, one 16-ounce bottle of [MEDICATION(S)], one -16 ounce bottle of Dakins solution, and 4 [MEDICATION(S)] 4% patches. There were wound care dressings in several drawers in cart. The RN was asked, Should this be locked while in the hallway? She stated, Yes, it should be locked. b. On 7/21/22 at 9:00 AM, the Director of Nursing (DON) was asked, Should the wound care cart be locked in the hall if it is not attended by staff? She stated, Yes, it should be locked anytime it is not attended. The DON was asked, What could happen if it is left open unattended in the hallway? She stated, The residents could get in it and take something or use it. c. On 7-21-22 at 9:10 AM the Administrator provided a Policy and Procedure titled Security of Medication Cart with revised date April 2007. The policy documented, . Medication cart must be securely locked at all times when out of the nurse's view .

Based on observation, record review, and interview the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complications for 1 (Resident #15) of 4 (Resident #15, #28, #47, and #63) sampled residents who were receiving oxygen therapy. This failed practice had the potential to affect 9 residents who were receiving oxygen therapy as documented on a list provided by the Director of Nursing on 07/21/22 at 11:55 AM. The findings are: Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/28/22 documented that the resident scored 2 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS) and was dependent for eating and required extensive assistance with bed mobility, transfer, toileting, dressing, and personal hygiene. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ 2-5 Liters/Nasal Canula as needed may remove per self for ADL's [Activities of Daily Living] every 1 hours as needed for Shortness of Breath related to COVID-19 (U07.1); Other Specified Respiratory Disorders . b. The Care Plan with a revision date of 02/15/22 documented, . [Resident #15] has altered respiratory status/difficulty breathing r/t [related to] CHF [Congestive Heart Failure], SOB [Shortness of Breath], WHEEZING .Goal: [Resident #15] will have no complications related to SOB . Intervention: Administer medication/treatment as ordered. Observe for effectiveness and side effects . c. On 07/18/22 at 11:31 AM, 07/19/22 at 09:32 AM, and 07/21/22 at 10:35 AM, Resident #15 was lying in bed on his back with his eyes closed. The resident was receiving oxygen at 1.5 liters per nasal cannula. d. On 7/21/22 at 10:40 AM, Licensed Practical Nurse (LPN) #1 was asked to accompany the surveyor to Resident # 15's room and was asked, What is [Resident #15's] oxygen flow rate set at? LPN #1 stated, It is set between 1.5 to 2 liters. I have put it on 2. LPN #1 was asked, What should the residents oxygen flow rate have been set at? LPN #1 stated, I know it is ordered as needed. Let me look in the record and see what the orders says. LPN #1 looked in the electronic record and stated, The orders states 2 to 5 liters. LPN #1 was asked, Who is responsible for ensuring the oxygen is set at the correct rate? LPN #1 stated, The nurses are responsible. LPN #1 was asked, How often should the oxygen flow rate be checked? LPN #1 stated, It should be checked every shift. LPN #1 was asked, Should doctor's orders for oxygen flow rate be followed? LPN #1 stated, Yes, Ma'am. e. On 07/21/22 at 11:20 AM, the Director of Nursing (DON) was asked, Who is responsible for ensuring the oxygen flow rate is correct? The DON stated, The nurses are responsible. The DON was asked, How often should the oxygen flow rate be checked? The DON stated, It should be checked once a shift. The DON was asked, Should doctor's orders for oxygen flow rate be followed? The DON stated, Yes. f. The policy titled Oxygen Administration, with a revision date of October 2010, provided by the Administrator On 7/21/22 at 11:55 AM documented, . Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration . Steps of the Procedure: . 8. Turn the oxygen on. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute .

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect one resident who received pureed diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 7/22/22. The findings are: On 7/20/22 the menu for the supper meal documented residents who receive pureed diets were to receive a #6 scoop 6 oz [ounces] of pureed ham and cheese sandwich, ½ cup of mashed potatoes, #8 scoop of macaroni salad and #8 scoop of carrots. a. On 7/20/22 at 5:57 PM, Dietary Employee #2 used a #10 scoop which was equivalent to 1/3 cup to serve a single portion of pureed ham to the resident on a puree diet. There was no pureed cheese, pureed bread, and pureed macaroni salad served to the resident on pureed diet. b. On 7/21/22 at 11:59 AM, Dietary Employee #2 was asked, What scoop size did you use to serve pureed ham and how many servings of pureed ham did you serve to the resident on a puree diet? She stated, I used #10 scoop and I gave one serving. I should have used #6 scoop. She was asked the reason why the cheese, bread and macaroni salad were not pureed? She stated, I forgot. I just did pureed ham.

Based on observation, record review and interview, the facility failed to ensure a resident was free from physical and mental abuse by staff kicking her doll around on floor and holding her down for 1 (Resident #1) of 1 sampled resident who was abused by staff. The failed practice resulted in Immediate Jeopardy, which caused or was likely to cause serious harm, injury, or death to Resident #1 who was emotionally and physically abused by staff resulting in bruising and swelling to the face. The Administrator was informed of the Past Immediate Jeopardy on 4/26/22 at 4:05 PM. The findings are: Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 1/12/22 documented the resident scored 2 (0-7 indicates severely cognitively impaired) on a Brief interview for Mental Status, required supervision with walking and limited physical assistance of one person for locomotion on the unit. a. The Witness Statement dated 4/18/22 by Hospitality Aide documented, .[CNA (Certified Nursing Assistant) #3], and [CNA #2] held the resident down and took a sock off of her foot, then [CNA #2] took resident doll and pitched cross floor. Then left her in the area were [where] she were [was] . b. The Witness Statement 4/18/22 at 1:15 PM by CNA #4 documented, .When I came into work on 4/18/22 @ [at] 10:35 PM, an aide informed me that I had missed something that was going on with [Resident #1] and her baby doll. When I saw her she was upset and irritated. Later we changed her, and she was very upset and combative, but she was physically OK. When me and the nurse [Registered Nurse (RN) #1) made 1:30-ish rounds [Resident #1] was in bed, and nothing wrong with her, but when I checked again around 4-ish. She had a knot on her head and was crying. I didn't witness the baby doll incident, but was told when I came into work by [CNA #5] . c. The Witness Statement dated 4/18/22 at 2:15 PM by CNA #3 documented, .Around 8:00 PM a resident was upset and wanted to get her sock from another resident. I and another aide said we'd get it for her. I bent down forward with my back toward her and took her sock off. The other aide had her arms to the side of her. In my peripheral I did see the resident spit on the other aide. I and the other aid walked off. I wasn't really paying attention to what was going on. I was talking to the lady at the door and me and the resident was hugging. She thank [thanked] me for getting her sock back. I may have heard the doll hit the floor, but I was still turned the opposite way hugging the other resident . d. The Witness Statement dated 4/19/22 by CNA #2 documented, .[Resident #1] had took [Resident #6's] socks ([Resident #6] informed). I held [Resident #1's] hands and arms to her side while a co-worker removed her sock. The next time seen [Resident #1] was when she came in the dining room (talking gibberish) . e. The Nurses Note dated 4/19/22 at 6:22 AM documented, . When nurse entered room this am at 0435 [4:35 AM] resident was lying in bed awake with a bruised and swollen area to left side of forehead. resident was unable to tell nurse what happened due to decreased mental status per normal . f. The Hospital Record dated 4/19/22 at 6:26 AM documented, .Large left frontal scalp hematoma . g. The Witness Statement dated 04/19/22 at 10:00 AM by the Door Screener documented, [Resident #5] came to me and told me that yesterday evening there was two workers picking on [Resident #1]. He told me that they threw her baby doll down and when she went to pick it up, they were kicking at her . h. The Incident Report dated 4/19/22 at 10:10 AM documented, .On 4/19/22 at 10:00 AM the door screener came to the DON [Director of Nursing] and stated that [Resident #4] reported to her that he witnessed two CNAs [Certified Nursing Assistants] trying to remove socks from [Resident #1]. [Resident #1] has dementia and got upset and spit on the CNA. The CNAs took the baby doll that she believes to be a real baby and tossed it back and forth and threw it on the ground . After the investigation, we terminated employment for [CNA #1], and [CNA #2] . i. On 4/25/22 at 1:35 PM, Resident #1 was sitting in the Day Area. She had a large hematoma to the left side of her forehead and bruising under her left eye all the way down to her neck. j. On 4/26/22 at 12:12 PM, Resident #5 was asked, Can you tell me about the incident that happened with [Resident #1]? He stated, The woman that carries the baby doll? This surveyor stated, Yes. He stated, I don't know what night, but it wasn't that long ago. I was talking to a lady at the desk and a short woman, and a taller woman was beating up on this poor lady. They grabbed her doll, and throwed it across the floor. They both were beating on her with their fist. I asked the lady that was sitting at the desk why she didn't do anything about it, and she said she didn't want to get involved. They were the ones who put a knot on her head. The lady didn't swing at them not one time. She was screaming. I'm surprised they don't have cameras in this place. He was asked, What did the CNA's do after they stopped hitting her? He stated, They went outside and had a little chat. I don't know who took her to her room. They supposed to help us not hurt us. I'm done talking about it. I don't want to say anything else about it. He was asked, What time did the incident happen? He stated, It happened around 8:30- 9:00 that night. They wanted me to do a little written statement, but I couldn't because my eyes are so bad. k. On 4/27/22 at 2:38 PM, Licensed Practical Nurse (LPN) #2 was asked, Can you tell me what happened to [Resident #1's] eye? She stated, I don't know. All I know is what was told in the in-service this morning. I noticed her eye, but I didn't know what happened. The Administrator said we don't take things from residents. Her doll was taken, but I don't know what happened to her face. All I know is the Administrator said her doll was taken and was being thrown back and forth. l. On 4/28/22 at 5:12 AM, during a phone interview with Registered Nurse (RN) #1, she was asked, Did you work with [Resident #1] on the day she was found with a knot on her head? She stated, Yes. She was asked, Can you tell me what happened? She stated, Nobody saw her fall at night at 2:00 o'clock [AM] during checks, and at 4:00 [AM] I noticed that on her head. She had a big knot on her head. We thought she may have fell because she is ambulatory, and she could get back up if she fell that day. She was asked, How do you perform checks on residents? She stated, I have my phone flashlight of the lil [little] light by their bed to make sure their okay. She was asked, What type of interactions did she have with the staff before she went to bed? She stated, [CNA #4], one of the aids said she was fighting before she went to bed. She was asked, Did you see the staff take her doll? She stated, No ma'am. m. On 4/28/22 at 5:30 AM, CNA #4 was asked, What time did you come to work that evening [Resident #1's] incident? She stated, About 10:30 PM. When I came in, I saw her at the nurses station. She was asked, When did you assist with her care? She stated, [CNA #2], [CNA #6] and [LPN #6] was going down to change her. When they passed by, they said [CNA #4] come to help her. She was trying to fight when we were trying to change her. We put her brief on. She kicks, bites and spits, and they were trying to get her cleaned up. When they finished, I put the covers over her head and walked out. She was asked, Did you know about the incident with the baby doll? She stated, When I got here [CNA #5] the aide was sitting at the nurse's station, and she told me they were playing kick away with the baby doll. She was asked, Did [CNA #5] say what she did when she saw or was informed of the staff kicking the doll? She stated, No, that's just what she told me when I was walking through the door. n. On 4/28/22 at 1:29 PM, the DON was asked, What was the immediate outcome of the investigation with [Resident #1]? She stated, I suspended [CNA #2] and [CNA #3]. I called all the staff to come to me and get statement. She was asked, What all staff was terminated because of the incident with [Resident #1]? She stated, [CNA #2], [CNA #3], [Hospitality Aide], and [Door Screener]. She was asked, Can you tell me why they were terminated? She stated, Because [CNA #2] admitted she threw the baby doll and kicked. [CNA #3] because in her report she basically said she saw it, but she didn't do anything, and [Hospitality Aide] because she didn't report it. An inservice was completed on 04/24/22 on abuse and neglect.

Based on observation, record review and interview, the facility failed to ensure physical and mental abuse was immediately reported of staff kicking a resident's doll around on the floor and holding the resident down for 1 (Resident #1) of 1 sampled resident. The failed practice resulted in Immediate Jeopardy, which caused or was likely to cause serious harm, injury, or death to Resident #1 who was emotionally and physically abused by staff resulting in bruising and swelling to the face. The Administrator was informed of the Past Immediate Jeopardy on 4/26/22 at 4:05 PM. The findings are: Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 1/12/22 documented the resident scored 2 (0-7 indicates severely cognitively impaired) on a Brief interview for Mental Status and required supervision with walking and limited physical assistance of one person for locomotion on the unit. a. The Witness Statement dated 4/18/22 by Hospitality Aide documented, .[CNA (Certified Nursing Assistant) #3], and [CNA #2] held the resident down and took a sock off of her foot, then [CNA #2] took resident doll and pitched cross floor. Then left her in the area were [where] she were [was] . b. The Witness Statement 4/18/22 at 1:15 PM by CNA #4 documented, .When I came into work on 4/18/22 @ [at] 10:35 PM, an aide informed me that I had missed something that was going on with [Resident #1] and her baby doll. When I saw her she was upset and irritated. Later we changed her, and she was very upset and combative, but she was physically OK. When me and the nurse (RN #1) made 1:30-ish rounds [Resident #1] was in bed, and nothing wrong with her, but when I checked again around 4-ish. She had a knot on her head and was crying. I didn't witness the baby doll incident, but was told when I came into work by [CNA #5] . c. The Witness Statement dated 4/18/22 at 2:15 PM by CNA #3 documented, .Around 8:00 PM a resident was upset and wanted to get her sock from another resident. I and another aide said we'd get it for her. I bent down forward with my back toward her and took her sock off. The other aide had her arms to the side of her. In my peripheral I did see the resident spit on the other aide. I and the other aid walked off. I wasn't really paying attention to what was going on. I was talking to the lady at the door and me and the resident was hugging. She thank [thanked] me for getting her sock back. I may have heard the doll hit the floor, but I was still turned the opposite way hugging the other resident . d. The Witness Statement dated 4/19/22 by CNA #2 documented, .[Resident #1] had took [Resident #6's] socks ([Resident #6] informed). I held [Resident #1's] hands and arms to her side while a co-worker removed her sock. The next time seen [Resident #1] was when she came in the dining room (talking gibberish) . e. The Nurses Note dated 4/19/22 at 6:22 AM documented, . When nurse entered room, this am at 0435 [4:35 AM] resident was lying in bed awake with a bruised and swollen area to left side of forehead. resident was unable to tell nurse what happened due to decreased mental status per normal . f. The Hospital Record dated 4/19/22 at 6:26 AM documented, .Large left frontal scalp hematoma . g. The Witness Statement dated 04/19/22 at 10:00 AM by the Door Screener documented, [Resident #5] came to me and told me that yesterday evening there was two workers picking on [Resident #1]. He told me that they threw her baby doll down and when she went to pick it up, they were kicking at her . h. The Incident Report dated 4/19/22 at 10:10 AM documented, .On 4/19/22 at 10:00 AM the door screener came to the DON [Director of Nursing] and stated that [Resident #4] reported to her that he witnessed two CNAs [Certified Nursing Assistants] trying to remove socks from [Resident #1]. [Resident #1] has dementia and got upset and spit on the CNA. The CNAs took the baby doll that she believes to be a real baby and tossed it back and forth and threw it on the ground . After the investigation, we terminated employment for [CNA #1], and [CNA #2] . The incident was submitted to the Office of Long Term Care on 04/24/22. i. On 4/25/22 at 1:35 PM, Resident #1 was sitting in the Day Area. She had a large hematoma to the left side of her forehead and bruising under her left eye all the way down to her neck. j. On 4/26/22 at 12:12 PM Resident #5 was asked, Can you tell me about the incident that happened with [Resident #1]? He stated, The woman that carries the baby doll? This surveyor stated, Yes. He stated, I don't know what night, but it wasn't that long ago. I was talking to a lady at the desk and a short woman, and a taller woman was beating up on this poor lady. They grabbed her doll, and throwed it across the floor. They both were beating on her with their fist. I asked the lady that was sitting at the desk why she didn't do anything about it, and she said she didn't want to get involved. They were the ones who put a knot on her head. The lady didn't swing at them not one time. She was screaming. I'm surprised they don't have cameras in this place. He was asked, What did the CNA's do after they stopped hitting her? He stated, They went outside and had a little chat. I don't know who took her to her room. They supposed to help us not hurt us. I'm done talking about it. I don't want to say anything else about it. He was asked, What time did the incident happen? He stated, It happened around 8:30- 9:00 that night. They wanted me to do a little written statement, but I couldn't because my eyes are so bad. k. On 4/27/22 at 2:38 PM, Licensed Practical Nurse (LPN) #2 was asked, Can you tell me what happened to [Resident #1's] eye? She stated, I don't know. All I know is what was told in the in-service this morning. I noticed her eye, but I didn't know what happened. The Administrator said we don't take things from residents. Her doll was taken, but I don't know what happened to her face. All I know is the Administrator said her doll was taken and was being thrown back and forth. l. On 4/28/22 at 5:12 AM, during a phone interview with Registered Nurse (RN) #1, she was asked, Did you work with [Resident #1] on the day she was found with a knot on her head? She stated, Yes. She was asked, Can you tell me what happened? She stated, Nobody saw her fall at night at 2:00 o'clock [AM] during checks, and at 4:00 [AM] I noticed that on her head. She had a big knot on her head. We thought she may have fell because she is ambulatory, and she could get back up if she fell that day. She was asked, How do you perform checks on residents? She stated, I have my phone flashlight of the lil [little] light by their bed to make sure their okay. She was asked, What type of interactions did she have with the staff before she went to bed? She stated, [CNA #4], one of the aids said she was fighting before she went to bed. She was asked, Did you see the staff take her doll? She stated, No ma'am. m. On 4/28/22 at 5:30 AM, CNA #4 was asked, What time did you come to work that evening [Resident #1's] incident? She stated, About 10:30 PM. When I came in, I saw her at the nurses station. She was asked, When did you assist with her care? She stated, [CNA #2], [CNA #6] and [LPN #6] was going down to change her. When they passed by, they said [CNA #4] come to help her. She was trying to fight when we were trying to change her. We put her brief on. She kicks, bites and spits, and they were trying to get her cleaned up. When they finished, I put the covers over her head and walked out. She was asked, Did you know about the incident with the baby doll? She stated, When I got here [CNA #5] the aide was sitting at the nurse's station, and she told me they were playing kick away with the baby doll. She was asked, Did [CNA #5] say what she did when she saw or was informed of the staff kicking the doll? She stated, No, that's just what she told me when I was walking through the door. n. On 4/28/22 at 1:29 PM, the DON was asked, What was the immediate outcome of the investigation with [Resident #1]? She stated, I suspended [CNA #2] and [CNA #3]. I called all the staff to come to me and get statement. She was asked, What all staff was terminated because of the incident with [Resident #1]? She stated, [CNA #2], [CNA #3], [Hospitality Aide], and [Door Screener]. She was asked, Can you tell me why they were terminated? She stated, Because [CNA #2] admitted she threw the baby doll and kicked. [CNA #3] because in her report she basically said she saw it, but she didn't do anything, and [Hospitality Aide] because she didn't report it. An inservice was completed on 04/24/22 on abuse and neglect. o. The facility policy titled, Abuse, Neglect and Exploitation, provided by the Administrator on 4/27/22 at 3:51 PM documented, .Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation . This includes but is limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends other individuals .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including caretaker .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Willful means the individual deliberately, not that the individual must have intended to inflict injury or harm . Physical Abuse includes, but not limited to hitting slapping, pinching and kicking. It also includes controlling behavior through corporal punishment . Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation .

Based on record review and interview, the facility failed to ensure the care plan was correctly implemented by not using two staff for bed mobility during incontinent care for 1 (Resident #4) of 1 sampled resident who required 2 plus persons for bed mobility. The failed practice resulted in Past Immediate Jeopardy which caused or was likely to cause serious harm, injury or death to Resident #4 who fell out of bed during incontinent and sustained a fracture to the wrist and tibia and had the potential to affect 13 residents who required 2 plus persons for bed mobility. The Administrator was informed of the Past Immediate Jeopardy on 04/26/22 at 4:05 PM. The findings are: Resident #4 had diagnosis of Acquired Absence of Left Leg Below Knee and diagnosis of Encounter for Orthopedic Aftercare following Surgical Amputation and Dependence on [CONDITION(S)]. The 5 Day Minimum Data Set with an Assessment Reference Date of 3/15/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief interview for Mental Status and required extensive two-plus persons physical assistance for bed mobility and was always incontinent of bowel and bladder. a. The Care Plan with a revision date of 01/18/22 documented, .Bed mobility: [Resident #4] is extensive assistance x [times] 2 for repositioning and turning in bed. May use positioning rail on both side of bed as enabler to maximize independence with bed mobility . b. The Incident and Accident Report dated 3/20/22 documented, .On 3/20/22 at 10:10 AM, [LPN (Licensed Practical Nurse) #1] called this nurse DON [Director of Nursing] and informed me that while [CNA (Certified Nursing Assistant) #1] was performing incontinence care the resident rolled off the right side of the bed on the floor. Resident was sent to the emergency room at [Hospital #1] where it was determined that her left upper leg has an acute fracture of the lateral tibial plateau with intra articular extension as well as extension into the amputation site. Upon return to the facility [Resident #4] stated to the staff that [CNA #1] pushed her to hard during the turn to her right side and she was unable to stop herself and rolled off the bed . Steps taken to prevent continued abuse or neglect during the investigation .Begin in-service with staff on abuse and neglect .[CNA #1] suspended . c. The Witness Statement dated 3/20/22 at 10:30 AM by CNA #1 documented, .I [CNA #1] was changing residents' bed. I told her to role [roll] over to the right side so I could change the sheets. She did and roled [rolled] off the bed. [Resident #4] had diarrhea, [and] bed had to be changed. [I] asked for help, and everyone was busy . d. The [Hospital] Diagnostic Results dated 3/20/22 documented, Exam: Knee 3 views LT [left] . Findings .There is an acute vertical fracture of the lateral tibial plateau with intra-articular extension as well as extension to the amputation site . e. The Radiology Interpretation report dated 03/20/2022 documented, .Procedure Left (2V [views] . Impression .Possible nondisplaced fracture of the radial styloid . f. The Inservice titled, POC [Plan of Care] Task Bar, Assist Rails, Care Plans . dated 03/20/22 only had one name, [CNA #1] on the Inservice. g. On 4/26/22 at 9:00 AM, a reportable documented Resident #4 had a fall with an injury, and there was no documentation in the record that all staff had been inserviced on bed mobility, and there were no new interventions put in place to keep this incident from happening again. h. On 4/26/22 at 11:05 AM, the Director of Nursing (DON) was asked, How much assistance does [Resident #4] require with bed mobility. She stated, She requires one person assist [assistance] with all her ADL's [activities of daily living]. She was asked, Did you retrain [CNA #1] on bed mobility for [Resident #1] after she fell ? She stated, We discussed it, nothing in writing. I put her with another CNA. She was asked, What is the name of the CNA you put her with. She stated, It was whatever CNA that was assigned to the hall. i. On 4/26/22 at 11:49 AM, CNA #1 was asked, How does [Resident #4] reposition in the bed? She stated, She turns from side to side by herself. She's a one person assist. She was asked, When she turns in the bed does she hold onto the bed rail? She stated, I asked her to turn to left. She had bad diarrhea, when I asked her to turn to the right she kept rolling and I couldn't catch her. She kept rolling. She was asked, Was she holding on to anything when she was turning? She stated, No. She was asked, How were you informed of how much assistance she required when turning? She stated, Well I can look it up on my kiosk. I would never mess with her if she wasn't a one person assist. She was asked, Did you ask for assistance with changing her? She stated, Yes, but there wasn't anyone available at that time. I thought it would've been easier if two people changed the bed. She was asked, After [Resident #4] rolled out of bed what did the facility do to ensure it doesn't happen again? She stated, We had an inservice on 1 person assist, 2 persons assist, and I had to be re-trained with 2 people on the hall. She was asked, Is there anything you could've done different to prevent [Resident #4] from falling? She stated, I really don't think so. The only thing I can say is, if I would have had another person, she wouldn't have rolled off the bed. I don't think I did anything wrong. I think I did what I was supposed to do at that time. j. The ADL-Bed Mobility task for Resident #4 in the kiosk provided by the DON on 4/26/22 at 12:15 PM documented, .ADL-Bed Mobility-Total Assist x 2 . k. On 4/28/22 at 12:55 PM, the DON was asked, Can you tell me why all staff weren't inserviced on bed mobility after [Resident #4] had a fall with an injury? She stated, I inserviced them on how to find what they need to do for ADLs with the care plan. She was asked, Were the staff not aware of how to find the ADLs on the care plan? She stated, They should have known. She was asked, Can you tell me why there were no interventions put in place immediately to prevent this incident from happening again or to another resident? She stated, I don't remember what interventions I put in place. Can I go look on my computer and check? This surveyor stated, Yes. l. On 4/28/22 at 1:20 PM, the DON stated, My intervention was I put her 2-person assist. The DON was informed that Resident #4 was already a 2-person assist before the incident occurred according to the care plan. m. On 4/28/22 at 3:33 PM, the Administrator was asked, Can you tell me why there were no interventions put in place immediately to prevent this incident from happening again or to another resident? She stated, The DON is responsible for doing an intervention, and she told me she made her a 2 person assist. She was asked, Is there a reason all the staff weren't inserviced after the fall on ways to prevent the resident from falling again? She stated, No. n. The facility policy titled, Falls Management, provided by the Administrator on 4/27/22 at 3:57 PM documented, .Adjust/add interventions on the Plan of Care - Fall Risk Reduction . Review and revise Interdisciplinary Plan of Care . Provide appropriate training for caregivers, noting any changes implemented .

Based on observation and interview, the facility failed to ensure food items on the shelf and in the freezer were properly stored or sealed, dishes were allowed to air dry, and the dining room ice machine was maintained in a clean condition to prevent potential food borne illness for residents who received meals and ice from the 1 of 1 kitchen. These failed practices had the potential to affect 70 residents who received meals and ice from the kitchen (Total Census: 71), as documented on a list provided by the Dietary Manager on 04/21/2021. The findings are: 1. On 04/18/2021 at 11:14 AM, the ice machine in the main dining room had a pinkish, red spot near the corner of the internal protective shield on the left side. Dietary Employee #1 took a white napkin and wiped the spot. The pinkish red splotch transferred to the napkin. When asked to describe what she saw, the Dietary Employee #1 said, Looks like it's punch. 2. 04/19/2021 at 10:59 AM, the following observations were made: a. There were several wet clear plastic glasses that were stacked. The Dietary Manager was asked to describe what she saw. She stated, Those cups are not dry. So they need to be separated so they can air dry. b. There was one an 18-ounce bottle of BBQ sauce which had previously been opened sitting on the bottom shelf of the main worktable. The bottle was on the bottom shelf of the worktable on 4/18/2021 as well. The Dietary Manager was asked if the BBQ sauce should be refrigerated after opening, and she stated, Yes. The label on the side of the bottle documented . refrigerate after opening. c. In the reach in freezer located in the storage room, there was a bag of cinnamon rolls that had been opened and was not re-sealed tightly exposing the rolls to air. The Dietary Manager was asked how the cinnamon rolls be stored, and she stated, Tightly closed. d. The ice machine in the main dining room had a pinkish spot near the corner of the internal protective shield on the left side. The Dietary Manager took a white napkin and wiped the spot. A reddish color transferred on the napkin. The Dietary Manager was asked to describe what she saw, and she stated, I don't know. I'm baffled. It' s pinkish color.

Based on observation, record review and interview the facility failed to provide routine nail care to 2 (Resident (R) #11 and R #22) of 4 (R #6, #31, #59 and #60) sample residents dependent on staff for nail care and failed to ensure facial hair was removed for 1 (Resident #22) of 38 female residents who required assistance with personal hygiene. This failed practice had the potential to affect 71 residents' dependent on staff for nail care per a list provided by the Administrator and 4 female resident who had facial hair according to a list provided by the DON on 5/4/21 at 3:27 PM. The findings are: 1. Resident #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/4/2021 documented the resident scored 12 (8 - 12 indicates moderately impaired on a Brief Interview for Mental Status (BIMS), and required limited assistance of one staff for personal hygiene. a. The Plan of Care dated 2/4/2021 documented, Problem: [R #11] has an ADL [Activities of daily living] self-care performance deficit r/t [related/to] Alcoholic Dementia, Alcohol Induced Mahor [Major] Neurocognitive Disorder, Amnestic Confabulatory type, with moderate or severe use disorder. Interventions: Nail care: Check nail length and trim and clean as necessary. b. On 04/18/21 at 11:38 AM, the resident ' s fingernails were dirty, long, and approximately 1/8 of an inch in length past the fingertips. c. On 04/19/21 at 09:51 AM, Resident #11 still had long dirty fingernails that were approximately 1/8 of an in length past the fingertips. Resident #11 stated, My fingernails have been attended to once in the year I have been here. d. On 04/20/21 at 09:40 AM, Certified Nursing Assistant (CNA) #1 was asked, Who performs [R #11's] nail care? She stated, He never said he wanted it. He does it himself. She was asked, How he obtained nail care supplies. She stated, We would provide clippers if he asked. She was asked, Are you familiar with his care plan for nail care? She stated, No. I work part-time. He showers himself, does most things himself, except he likes us to make his bed. e. On 04/20/21 at 09:45 AM, CNA #2 was asked, Who performs R #11 nail care? She stated, He does them himself. She was asked, Who watches him? She stated, CNAs watch him perform nail care. She was asked, Who monitors his nails? She stated, We monitor nails on shower days. f. On 04/20/21 at 10:10 AM, Director of Nursing (DON) was asked, Who is to perform [R #11's] nail care? The DON stated, Nurses trim and CNAs can trim since he is not a diabetic. She was asked, Has resident ever refused? The DON stated, Yes. She was asked, How are refusals documented? The DON stated, The CNAs' report refusals to me. She was asked, What do you do when he refuses? The DON stated, We reattempt nail care at a later time. She was asked, When should nails be looked at? The DON stated, Nails should be checked during all cares. g. On 04/20/21 at 10:10 AM, Licensed Practical Nurse (LPN) #1 was asked, When is [R #11's] nail care performed? LPN #1 stated, They are supposed to be done at bath time. She was asked, Who checks his nails. LPN #1 stated, We [nurses] should check them. She was asked, When is his nail care performed? LPN #1 stated, I am not sure when they are done. h. On 04/20/21 at 11:14 AM, the DON provided three months' worth of nail care documentation which noted one documented refusal in past three months. 2. Resident #22 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/16/21 documented the resident scored 6 (0-6 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS); required extensive assistance for dressing, personal hygiene, and was totally dependent with bathing. a. The Care Plan with an revision date of 11/29/18 documented . Focus: has an ADL Self Care Performance Deficit r/t Alzheimer's, Confusion, Dementia, Significant changes and alterations in ADL's alternate with her mental status and health . Interventions: Bathing: check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. b. On 04/18/21 at 1:11 PM, Resident #22 was in her wheelchair. Her nails on her right hand were jagged. Her left hand was contracted. There was facial hair noted to be greater than ½ inch long. c. On 04/19/21 at 11:45 AM, Resident #22 ' s nails were jagged. Her left hand contracted. When her left hand was opened the 3rd and 4th fingernail was long, soft, and had an odor to her hand. The nails on some fingers were greater than 1/4 of an inch in length and cut into her palm. d. On 04/20/21 at 12:43 PM, Resident #22 had facial hair greater than ½ of an inch long. e. On 4/21/21 at 2:10 PM, CNA #2 was asked, Tell me what you do when bathing a Resident? She stated, I either give them a shower or bed bath, help them with dental care and clean and trim their nails unless they are diabetic. CNA #2 was asked, Should the ladies have facial hair? She stated, No. They shouldn't. f. On 4/21/21 at 2:15 PM, CNA #3 was asked, Should the ladies have facial hair? She stated, No. They shouldn't. g. On 4/21/21 at 2:28 PM, the DON was asked, Should the ladies have facial hair? She stated, No. My ladies should not have facial hair. 3. The Policy and Procedure for Personal Needs provided by the Administrator on 04/20/21 at 12:58 PM documented, The facility strives to promote a healthy environment by meeting the personal care needs of the residents as indicated. The facilities also provide the needed support when the resident performs their activities of daily living (ADLs). Personal care and ADL support will be provided according to the residents Plan of Care. Personal care and support include but is not limited to the following: Nail care.

Based on record review and interview, the facility failed to ensure written information regarding the right to formulate an advanced directive was provided to residents, or their responsible parties, to enable them to make informed decisions regarding end of life care was saved in the resident medical record for 4 (Residents (R) #172, #60, #3, and #9) sampled residents whose medical records were reviewed. The findings are: 1. Resident #172 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/15/21 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); required extensive assistance for bed mobility, dressing, toileting and personal hygiene; and required physical help for bathing. On 04/19/21 at 02:43 PM, there was no documentation of an Advance directive in the medical record. 2. Resident #60 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) within Assessment Reference Date of 3/29/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); required extensive assistance with bed mobility, dressing, toileting, and personal hygiene; and required physical help bathing. a. On 04/18/21 at 04:25 PM, there was no documentation of an Advance directive in the medical record. 3. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); required extensive assistance for bed mobility, dressing, toileting, and personal hygiene; and required physical help for bathing. On 04/20/21 at 10:21 AM, there was no documentation of an Advance directive in the medical record. 4. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS); was totally dependent for dressing, personal hygiene, and bathing. b. On 04/20/21 at 9:15 AM and at 10:21 AM, there was no documentation of an Advance directive in the medical record. 5. On 4/20/2021 at 1:30 PM the binder that the facility used for Advance Directives was reviewed and there was no Advanced Directive for the resident. 6. On 4/20/2021 at 2:00 p.m., the Administrator was asked, Where would I locate an Advance Directive if it is not in the electronic record or in the binder that was provided? She stated, I will look. 7. On 4/20/21 at 3:00 PM, the Administrator entered the Conference room and had the Advance Directive's in her hand. She stated, [R #172] was put in the business office. [R #60] [R #9] and [R #3] those were in the old charts boxed up. The Administrator was then asked, So, those were not in the resident's medical record? She stated, No.

Based on record review and interview, the facility failed to ensure that an accurate assessment was completed for 2 (Resident (R) #31 and R #59) of 4 (R #31, #6, #59, and #60) sample residents who received anticoagulant medication. This failed practice had the potential to affect 6 residents anticoagulant medication per a list provided by the Director of Nursing (DON) on 04/21/21 at 2:45 PM. The findings are: 1. Resident #31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/25/21 documented that the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); received Anticoagulant Medication for 7 days out of the 7 day look back period. a. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan with a revision dated of 6/25/20 documented, . Focus. [Resident #31] is on anticoagulant therapy r/t [related to] HISTORY OF MI [Myocardial Infarction], CORONARY ANGIOPLASTY IMPLANT, HISTORY OF CVA [Cerebral Vascular Accident] . Interventions . [MEDICATION(S)] HAS A BLACK BOX WARNING [Bleeding risk [MEDICATION(S)] can cause significant, sometimes fatal, bleeding. Do not use [MEDICATION(S)] in patients with active pathological bleeding or a history of transient ischemic attack (TIA) or stroke . 2. Resident #59 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-Day MDS with an ARD of 03/27/2021 documented the resident scored 13 (13 - 15 indicates cognitive intact) on a BIMS; received anticoagulant therapy 2 days of last 7 days . a. The April 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Plan of Care dated 02/28/21 documented, .FOCUS: [R #59] is on anticoagulant therapy r/t [related to] CABG (Coronary Artery Bypass Graft), CAD (Coronary Artery Disease) .Interventions; [[MEDICATION(S)]/[MEDICATION(S)]] HAS A BLACK BOX WARNING [Diminished antiplatelet effect in patients with two loss-of-function alleles of CYP2C19 gene . 3. On 04/21/21 at 02:30 PM, the Minimum Date Set (MDS) Coordinator was asked, What drug classification are the medications [MEDICATION(S)] and [MEDICATION(S)]? The MDS Coordinator stated, [MEDICATION(S)] and [MEDICATION(S)] are both antiplatelet, but when you look them up, it says they are blood thinners. The MDS Coordinator was asked, What drug classification did you document Resident #59's [MEDICATION(S)] and Resident #31's [MEDICATION(S)] as on their MDS? The MDS Coordinator stated, I probably marked them both as anticoagulants because I care plan them that way to ensure staff monitor for possible side effects such as bleeding. The MDS Coordinator reviewed her documentation in the electronic record and stated, Yes ma'am, on Resident #59 and Resident # 31, I documented on the MDS that they were on Anticoagulants. The MDS Coordinator was asked, Should information that is documented on the MDS be accurate? The MDS coordinator stated, Yes ma'am. They (the MDS's) need to be corrected.

Based on observation, record review, and interview the facility failed to ensure interventions were in place for 2 Residents (Resident (R) #22 and R#9) of sampled Residents who were dependent on staff for observation and treatment had interventions in place to prevent contractures or further deterioration of contractures to the hands this had the potential to effect all 8 Residents who have contractures that reside in the facility according to the list provided by the Director of Nurses (DON) on 4/21/21 at 2:33 p.m. The findings are: Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/16/21 documented the resident scored 6 (0-6 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS); required extensive assistance for dressing, personal hygiene, was totally dependent with the bathing; and had functional limitation in range of motion and impairment to both sides upper and lower extremities. a. The Care Plan documented, [Resident #22] has an alteration in musculoskeletal status r/t contractures of bilateral hands and legs, ARTHRITIS. Date Initiated: 09/01/2019 Revision on: 02/14/2021 There was no documentation on the care plan on any interventions on the care plan to provide any positioning devices to improve, maintain or prevent decline of contractures to the hands. b. On 04/18/21 at 1:11 PM, both of Resident #22 hands were contracted. There was no splint or hand roll in her hands. Her left hand was extremely stiff and she was unable to open her hands. c. On 4/19/21 at 10:00 am, the resident was up in common area Both the resident ' s hands were contracted and there was no hand roll or splint in place. The resident ' s fingernails were digging into the right hand. d. On 4/20/21 at 2:30 pm and on 4/21/21, the resident ' s hand were contracted ad there were no hand roll or splint in place. 2. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/21 documented the resident was severely impaired in cognitively skills for daily decision making per a Staff Assessment for Mental Status (SAMS); was totally dependent for dressing, personal hygiene, was totally dependent for bathing; and had . functional limitation in range of motion, and impairment to both sides upper and lower extremities. a. The Care Plan with an revision date of 6/17/19 documented, Focus: [Resident] has potential for impairment for pain r/t [related to] total care status, contractures of upper and lower extremities and immobility. b. On 04/18/21 at 1:20 PM, Resident #9 was lying in bed. Both of her hands were contracted. There was no splint or hand roll in place. c. On 4/19/21 at 10:30 AM, Resident #9 was lying in bed. Both of her hands were contracted. There was no splint or hand roll in place. 3. On 4/21/21 2:30 PM, the DON was asked, Are Contractures Care Planned with interventions? She stated, Yes. The DON was asked, Should there be interventions in place to prevent further decline with contractures? She stated, Yes. There should be.

Complaint # (AR 740) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure a transfer was conducted with a mechanical lift and two-person assistance in accordance with the resident's assessed and care planned needs to prevent accidents / injuries; failed to ensure staff reported to licensed nursing staff when an incident with injury occurred during an improper transfer to allow a licensed nurse to assess the resident for injury and possible treatment needs prior to moving the resident; and failed to ensure after being informed of the incident, licensed nursing staff communicated the information to the physician, administration, and the oncoming shift, which resulted in a delay of treatment and an ongoing risk of exacerbation of the injury for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents who required a mechanical lift for transfer. This failed practice resulted in past noncompliance at the level of actual harm, which caused or could have caused serious harm, injury, or death to Resident #1, who sustained a spiral [MEDICAL CONDITION] tibia and fibula when staff conducted a one-person manual transfer, then placed the resident back in the bed without informing a licensed nurse of an injury sustained during the transfer. The failed practice also had the potential to cause more than minimal harm to 11 residents who required a 2-person transfer with the use of a mechanical lift at the time of the incident, as documented on a list provided by the Director of Nursing on 6/30/2020 at 10:00 a.m. The facility removed the Immediate Jeopardy and corrected the failed practices on 5/15/2020, prior to the survey entrance date. The Administrator was notified of the past noncompliance condition 6/30/2020 at 1:25 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED].; had functional limitation in range of motion on one side of the lower extremities; and had one fall without injury since admission. a. The Care Plan dated 3/24/19 documented, .The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia . At risk for falls . Transfer . Requires total assist (assistance) (times) 2 using a mechanical lift with purple trim lift pad . (uses a Geri chair for locomotion) . b. A facility Incident Report dated 5/12/2020 at 12:33 p.m. for Resident #1 documented, . Resident was flopping her right leg on Geri chair and bumped on metal braces . Immediate action . Resident put to bed and ice applied . Sheep skin applied to chair . c. A Nurses Note dated 5/13/2020 at 18:19 (6:19 p.m.) documented, .2 (Two) Tylenol given for moderate pain . d. A Nurses Noted dated 5/13/2020 at 22:57 (10:57 p.m.) documented, .[MEDICATION NAME] 50 mg (milligrams) given for pain . e. A Nurses Note dated 5/13/2020 at 23:57 (11:57 p.m.) documented, .Resident moaning in pain when [MEDICATION NAME] given. Ice pack applied to right ankle for swelling . f. A Witness Statement dated 5/14/2020 at 2:45 p.m. and signed by CNA #1 documented, . I transferred (Resident #1) from her chair to the bed. When I started to roll her, she was saying that it hurt when I moved her leg, so I rolled her back and saw that it looked like something was poking out under her skin on her leg, so I told my nurse to come look at it because I wasn't sure what it was . g. A Nurses Note dated 5/14/2020 at 19:01 (7:01 p.m.) documented, .Right leg is swollen, an ice pack applied . h. A Nurses Note dated 5/15/2020 at 0400 (4:00 a.m.) documented, .Right ankle swollen. Ice pack applied. Some bruising noted to ankle and shin . i. A Nurses Note dated 5/15/2020 at 12:43 (a.m.) documented, .Right ankle swollen. X-ray ordered . j. A Radiology Report dated 5/15/20 documented, .There is a spiral [MEDICAL CONDITION] tibial diaphysis with mild anterior and lateral displacement . There is minimally displaced [MEDICAL CONDITION] malleolus . Impression . 1. Mildly displaced spiral [MEDICAL CONDITION] tibia without extension into the tibial plafond . 2. Minimally displaced [MEDICAL CONDITION] malleolus . 3. Osteopenia . k. A Witness Statement dated 5/15/2020 at 1430 (2:30 p.m.) and signed by Licensed Practical Nurse (LPN) #1 documented, .CNA came to writer and states, 'Can you look at (Resident #1)? Her bone is sticking out of her skin.' When I entered patient room, she (the resident) (was) lying in bed. Right shin had a small quarter-size area that was soft to touch. No bruising present to area. Tender to touch. CNA states, 'I don't know what happened.' . l. The Care Plan with a revised date of 5/28/2020 documented, .(Resident) has fracture of right lower leg . m. On 6/1/2020 at 4:18 p.m., the Director of Nursing was asked, Did you witness the resident flopping in her chair? She stated, Yes. She was asked, How did the resident receive a spiral fracture from hitting leg on the chair? She stated, Well, she didn't. When I got the report, I started asking questions, and found out a CNA (Certified Nursing Assistant) transferred her by herself when she was a two-person assist (assistance). I suspended her and terminated her. She was asked, Did you do a Reportable to the Office of Long-Term Care? She stated, I didn't do one because I know what happened. n. On 6/2/2020 at 11:10 a.m., CNA #1 was notified by telephone and was asked, Was (Resident #1) a two-person transfer? She stated, Yes, that is what they said. She was asked, What happened to (Resident #1)? She stated, She is always in bed when we come on shift. She was tired and not acting herself. After supper I just went in to put her to bed. I stood her pivoted her and put her on the bed. She did not say anything or make any sound until I rolled her toward the wall, and that's when she said it hurt. She was asked, Did you fill out a Witness Statement? She stated, I did a few days later when they asked for it. She was asked, Do you remember what day? She stated, No. She was asked, When were you terminated? She stated, The CNA Coordinator called me in on the 19th (5/19/2020). 2. The facility removed the Immediate Jeopardy and corrected the failed practices on 5/15/2020 when the facility implemented the following: a. The Director of Nursing conducted two staff in-services on 5/15/20. The first in-service documented, .See attached list of residents on lifts . The in-service included an attached handout which documented, .How to view resident Care Plan in POC (Plan of Care) . (This in-service included a Staff Signature Sheet to indicate staff in attendance.) The second in-service dated 5/15/2020 documented, .How to Use a Lift . (This in-service included a mechanical lift check-sheet and a Staff Signature Sheet was attached to indicate staff in attendance). b. A facility Employee Memorandum dated 5/19/2020 documented, .CNA #1 didn't follow the Care Plan. She transferred (Resident #1) by hand instead of using lift. Resident was on a lift pad and the Care Plan is on the CNA Kiosk . When asked if the resident was on the lift pad she said, 'Yes.' This improper transfer resulted in twisted resident legs causing a fracture . Suspension of 3 days . Termination . c. The Director of Nursing performed individual CNA Skills / Competency Check-Offs with all CNAs regarding the use of mechanical lifts from 5/20/2020 through 6/26/2020. d. On 6/30/2020 at 12:30 p.m., the Administrator was asked, Was this injury discussed and addressed in your Quality Assurance (QA) meeting? She stated, Yes. She was asked for a copy of that documentation, and she stated, I don't think I am allowed to give that, but I can ask the Nurse Consultant.

Complaint (AR 125) was substantiated, all or in part, with these findings: A. Based on observation, record review and interview, the facility failed to ensure falls were evaluated for causative factors and interventions based on those causative factors were developed, care planned, communicated to staff, consistently implemented, evaluated for effectiveness and revised when necessary to prevent further falls and / or minimize the risk of fall-related injuries for 2 (Residents #1 and #5) of 6 (Residents #1, #2, #4, #5, #6, and #7) case mix residents who had a history of [REDACTED].#1, who sustained a subdural hematoma and lacerations to the head due to falls, and Resident #5, who sustained multiple falls with injuries. The failed practices also had the potential to cause more than minimal harm to 28 residents who had a history of [REDACTED]. The facility Administrator was informed of the Immediate Jeopardy condition on 11/1/18 at 8:46 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/24/18 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS), required 2-person physical assistance to walk, had no falls since admission or reentry, and had an active [DIAGNOSES REDACTED]. a. The Care Plan with a revised date of 9/17/18 documented, .(Resident #1) is high risk for falls r/t (related to) Confusion, Gait / balance problems . Unaware of safety needs . Vision / hearing problems . He (Resident) will be free of minor injury through the review date . Anticipate and meet the resident's needs . Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . The resident needs prompt response to all requests for assistance . Follow facility fall protocol . Review information on past falls and attempt to determine cause of falls . Record possible root causes . Alter / remove any potential causes if possible . Educate resident / family / caregivers / IDT (interdisciplinary team) as to causes . b. An Incident and Accident Report dated 7/28/18 at 7:20 p.m. documented, .Incident Location . Resident's Room . Incident Description . Nursing Description . nurse was called to res (resident) room by aide . res was found lying on R (right) side with bruising to R side of back and abrasion to forehead and upper left eyebrow. Resident Description . Res stated he saw (son's name) in the room and was trying to get to him . Immediate Action Taken Description . (Attending Physician #1), Administrator, DON (Director of Nursing), and ADON (Assistant Director of Nursing) notified . Called (ambulance service) to transport res to ER (emergency room ) . ER was also notified on transport. (Son) notified of fall. Overhead light to stay on so res can be aware of surroundings . Instructed res to use call light if he needed out of the bed . Resident taken to hospital? N (No) . Injuries Observed at Time of Incident . Injury Type . Laceration . 1.) A Nursing Progress Note dated 7/29/18 at 1:29 a.m. documented, .Res (Resident) laying (sic) in bed at this time . Bruising noted to lower back bilaterally . abrasion to forehead and above R (right) eyebrow from fall on 7/28 . Res sent to (Hospital #1) per ambulance to be checked out per (Physician #1) orders . Res returned to facility with no new orders . Overhead light left on so res can be aware of surroundings . Instructed res to use call light if he needed out of the bed . 2.) The hospital Emergency Nursing Record dated 7/28/18 from Hospital #1 documented, .Triage time . (YEAR) (8:15 p.m.) . Chief Complaint . Head Injury poss (possible) Fall occurred . unwitnessed . c/o (complains of) neck pain (cervical) . Mechanism fall (circled) . Past HX (history) . cervical fx (fracture) . c-collar (circled) . Head / Face .tenderness (circled) . Neck / Back . tenderness (circled) . C-spine (cervical spine) . Emergency Physician Record . Head Injury . Date . 7/28/18 . Time Seen . 2025 (8:25 p.m.) . HPI (history present illness) . chief complaint . injury to head (circled) . (and) . neck . onset / duration . just prior to arrival (circled) . where . nursing home . context . fall (circled) . Has recent hx (history of) C3 (cervical 3) vertebral Fracture on 7/10/18 . severity of pain . moderate (circled) . associated symptoms . memory impairment (circled) . Past HX (history) . Dementia . Physical Exam . Head non-tender (marked) . no swelling (marked) . no obvious injury (marked) .Except for Abrasion . Pt (patient) stable . Clinical Impression . Abrasion . Forehead . Fall . c. An Incident and Accident Report dated 8/6/18 at 11:30 a.m. and signed by Licensed Practical Nurse (LPN) #2 documented, .Incident Location . Resident's Room . Incident Description . Nursing Description . walked into resident's room and noted resident on the floor on his right side with his left arm tucked underneath him . blood noted on the floor . Immediate Action Taken . Resident Taken to Hospital? Y (yes) . Injuries Observed at Time of Incident . Injury Type . Laceration . Injury Location Eye (R) (right) . 1.) A Nursing Progress Note dated 8/6/18 at 1:47 p.m. by LPN #2 documented, .Note Text . 1130 (11:30 a.m.) Heard resident holler for help . Went to resident's room and noted resident lying on the floor on his right side with his left arm tucked underneath him and noted blood on the floor where resident had hit his head . Another LPN in the room applied pressure to his head on the floor . 1135 (11:35 a.m.) Ambulance called . 1137 (11:37 a.m.) (Hospital #1) called and report given to (hospital nurse) . 1140 (11:40 a.m.) Ambulance arrived (times) 2 EMTs (Emergency Medical Technicians) . EMTs were notified that resident has a history of C3 (cervical spine disc 3) fx (fracture) .1145 (11:45 a.m.) family notified . 1150 (11:50 a.m.) Resident out of facility, left by ambulance (times) 2 EMTs (Emergency Medical Technicians) . 2.) The hospital Emergency Record dated 8/6/18 from Hospital #1 documented, .Emergency Nursing Record . Trauma . Brief History of Injury . Fall from ground level at Nursing Home . Feet were tangled in oxygen tubing . Injuries head (circled) face (circled) . Mechanism fall (circled) . ground level . laceration (circled) . (right) forehead . Emergency Physician Record . Fall . Date . 8/6/18 . Time Seen . 1212 (12:12 p.m.) .HPI (History of Present Illness) . chief complaint . Fall . injury to head . onset / duration . just prior to arrival . where . nursing home . context . lost balance . location of pain / injuries . head (circled) . severity of pain . mild moderate (circled) . associated symptoms .lost consciousness . no (circled) .Past Hx (history) . (left) hip Fx (fracture) . Dementia prev (previous) C-spine Fx . Procedures . Wound Description / Repair . length 5 cm (centimeters) . location . (right) forehead . stellate (star like pattern) . irregular . X-rays / CT (computerized tomography) .CT done . head (circled) . C spine (cervical spine) . neg (negative) . Head . Subdural 10mm (millimeters) . (no) shift (right) . frontal . Clinical Impression . Skin Laceration forehead . (right) .Subdural . Head Injury . 3.) A Diagnostic Imaging report dated 8/6/18 from Hospital #1 documented, .CT (computed tomography) (of) Head without Contrast . Date of Study . 8/6/18 .Clinical Indication . Head Injury due to fall . Findings . There is an acute mixed attenuation right frontal subdural hematoma measuring up to approximately 10 mm (millimeters) in maximum thickness without evidence of significant midline shift . Impression . 1. Acute mix attenuation right frontal subdural hematoma measuring to 10 mm in maximum thickness without significant midline shift . Short-term CT follow-up of the head recommended . CT Head w/o (without) Contrast . Reason for Test . Trauma . 4.) An Emergency Department (ED) Physician Note dated 8/6/18 from Hospital #2 documented, .Pt (Patient) air vac (air evacuated) .Patient was transferred to ED (Emergency Department) from nursing home after he fell on his head while he was standing up . Fall . The fall occurred while standing . He fell from a height of 1 to 2 ft. (feet) .The point of impact was the head . The pain is present in the head . 5.) A Neurology Consulting Physician Consult report dated 8/6/18 from Hospital #2 documented, .Consulted for . Traumatic right SDH (Subdural Hematoma) .Brief History . Pt is an 81 yo (year old) .resident of a nursing facility with hx (history) of Dementia who fell while standing getting out of bed . He fell forward striking the front of his head, causing a laceration on his right eyebrow . Head CT from OSH (outside hospital) reveal a right SDH without brain compression .Active Hospital Problems . Diagnosis . Subdural Hematoma due to concussion . Active Problems . Subdural hematoma due to concussion . Assessment . Traumatic right SDH s/p (status [REDACTED]. 6.) A Radiology Results Report dated 8/6/18 from Hospital #2 documented, .XR (x-ray) . Chest . History . Dementia with fall . Findings . There are multiple right rib fractures with involvement of the lateral right sixth and seventh ribs . Impression . Right rib fractures with no underlying contusion or pneumothorax . No pleural effusion . 7.) A Physician Discharge Summary dated 8/9/18 from Hospital #2 documented, .admitted . 8/6/2018 . discharge date . 8/9/2018 . Admission [DIAGNOSES REDACTED]. Severe Dementia . Discharge [DIAGNOSES REDACTED]. Traumatic . Additional [DIAGNOSES REDACTED]. Hospital Course . Patient was admitted to the Neurology / Neurosurgery unit and consults were made to Neurosurgeon . No surgery at this time . Patient has progressed gradually on the unit and is now ready for discharge . 8.) An Admission Nursing Evaluation form dated 8/9/18 and signed by the Director of Nursing (DON), contained no documentation to indicate the facility developed any new fall / injury prevention interventions when the resident returned from the hospital. The facility Nursing Progress Note dated 8/9/18 did not reference any fall prevention interventions upon the resident's readmission to the facility. d. A Nursing Progress Note dated 10/5/18 at 2:28 p.m. and signed by LPN #2 documented, .Incident Description . Resident was sitting out in lobby in w/c (wheelchair), when resident was leaning in w/c and grabbed water bottle on concentrator, when he fell forward head first to the floor . Immediate Intervention . Move concentrator out of resident's reach . 1.) An Incident and Accident form dated 10/5/18 at 1:30 p.m. and signed by LPN #2 documented, .Incident Description . Nursing Description . Went into lobby and resident was laying on his right side with a towel under his head . Immediate Action Taken Description . Assessed resident for injuries . cut on his nose and head . sent to ER (emergency room ) for evaluation . Injuries Observed at Time of Incident . Injury Type . Laceration . Injury Location . Forehead . 2.) The Emergency Department Record dated 10/5/18 from Hospital #1 documented, .Emergency Nursing Record . Chief Complaint . fall, face trauma, HA (headache) .fall . Hit face on floor c/o (complained of) HA . The Emergency Physician Record dated 10/5/18 documented, .Fall Date . 10/5/18 . Time Seen . 1415 (2:15 p.m.) .HPI (History of Present Illness) . Fall injury to / from wc (wheelchair) . Resident fell from wc (wheelchair), struck face on floor . No L[NAME] (loss of consciousness) . Abrasion, sm (small) lac (laceration) to Face . Procedures . Wound Description / Repair . length 1.0 cm (centimeter) . Location . Face .Repair . superficial . Wound closed with . Dermabond .X-rays /CT (computed tomography) .CT done (of) head . Interpretation . No acute pathology . old Subdural Hematoma . Clinical Impression . Skin Laceration . Face Abrasion . Face . Stable Rt (right) Subdural Hematoma .Fall .Discharge Instructions . 1. Return to N Home (Nursing Home) / orders done . 2. Fall precautions . 3. Wound care . 3.) A Diagnostic Imaging - Radiology Report dated 10/5/18 from Hospital #1 documented, .CT (computed tomography) (of) Head without Contrast . 10/5/18 . Comparison . 8/6/18 . History . [AGE] year old male status [REDACTED]. Impression . 1. No acute intracranial abnormality is demonstrated . 2. Larger subacute / chronic right front parietal Subdural Hematoma now measuring 1.5 cm (centimeters) in diameter compared to 1.0 cm previously . There is a larger component overlying the right parietal lobe than seen previously . 4.) Nursing Progress Notes dated 10/5/18 at 3:44 p.m. and signed by LPN #1 documented, .Returned to nursing home from ER . Resume previous orders . Res (Resident) on fall precautions . There was no documentation of any new fall prevention interventions that were implemented upon the resident's return from the hospital. 5.) A Nursing to Rehab (Rehabilitation) Communication Form dated 10/5/18 documented, .Circle all that apply Mobility . Frequent faller . Fall . 10/5/18 . A second Nursing to Rehab Communication Form, dated 10/8/18, and signed by the Physical Therapist and Certified Occupational Therapy Assistant, (COTA) documented, .Has been on case load twice with no carry-over due to decreased memory, aggressive, poor safety awareness, and inability to progress . There was no documentation of a therapy evaluations or recommended fall / injury prevention interventions made by the Therapy Department at this time. e. A Nursing Progress Note dated 10/8/18 at 9:35 p.m. and signed by LPN #1 documented, .Nsg (Nursing) I&A (Incident and Accident) Note . Incident Description . Res (Resident) sitting on floor with covers wrapped around him . Immediate Intervention . Educated res on use of call light if trying to get out of bed . There was no additional documentation to indicate any interventions were developed at this time; the only interventions documented were to educate the severely cognitively impaired resident to use the call light. There was no documentation of an evaluation for causative factors to facilitate the development of appropriate interventions after this fall. The Incident and Accident Report dated 10/8/18 and signed by LPN #1 documented, .Incident Description . Res (Resident) lying on floor wrapped in blankets . Resident Description . Res said he fell out of the bed . Immediate Action Taken Description . Assisted res back into bed . There was no documentation of an evaluation of causative factors or of any new interventions that were developed in response to this fall. f. An Incident and Accident form dated 10/18/18 at 9:33 p.m. and signed by LPN #4 documented, .Incident Description / Nursing Description . Received resident sitting in floor with back up against bed with bed draw sheet up under resident . Resident Description . 'Someone pulled me out the bed' . Immediate Action Taken Description . Assessed resident for injury . Vitals (vital signs) taken and CNA (Certified Nursing Assistant) and LPN assisted resident back on bed . Notes . Resident forgetful, gets confused at times of who people are . Other Info (Information) . Res. side rail was up . Res attempts to climb out of bed looking for wife Res draw sheet and incontinent pad was up under (resident's) bottom . There was no further documentation of efforts to determine the cause of the fall or of interventions that were developed in response to this fall. The Nursing Progress Notes dated 10/18/18 at 11:00 p.m. and signed by LPN #4 documented, .Incident Description . Res. (Resident) slid out of bed onto floor with pad underneath bottom . Immediate Intervention . Res. encouraged to use call light and side rails were put in place . Based on the Incident and Accident Report timed approximately 1.5 hours prior to this note, a side rail was already in use on the resident's bed, and there was no documentation of any other interventions, with the exception of encouraging the severely cognitively impaired resident to use the call light. g. An Incident and Accident Report dated 10/25/18 at 12:50 p.m. and signed by LPN #3 documented, .Incident Location . Reception / Lobby .Incident Description . Nursing Description . Summoned to front lobby. Received res laying on floor on right side in front of wheelchair . ADON (Assistant Director of Nursing) and Treatment Nurse with resident . Immediate Action Taken Description . Assessed resident for injuries . Laceration above right eye . Skin tear below right eye . Applied pressure to these areas . Initiated neuros (neurological checks) . Notified Dr. (Doctor) . Received order to send to ER (emergency room ) at (Hospital #1) . Injuries Observed at Time of Incident . Injury Type . Laceration . Injury Location . Eye (R) (Right) . Injury Type . Skin Tear . Injury Location . Eye (R) . There was no documentation of an evaluation for causative factors. 1.) The Emergency Physician Record dated 10/25/18 at 1:55 p.m. from Hospital #1 documented, .Facial / Scalp Injury . Date . 10/25/18 . Time . 1:55 p.m. HP (History of Present Illness) . Chief Complaint . Face . where .nursing home . fall from chair . severity of pain . moderate . Procedures . Wound Description / Repair . length 3 cm (centimeters) . location . (right) Eyebrow . irregular .Anesthesia . local . [MEDICATION NAME] . prep (preparation) . [MEDICATION NAME] . irrigated with saline . Repair . Superficial . Wound closed with . Skin 36.5 ethilon . CT (computed tomography) done . Skull facial . No fracture . Clinical Impression . Skin . Laceration . (right) eyebrow . Abrasion . 3 cm Lac (laceration) (right) Eyebrow . 3 cm . Supra lac intra orbit (supra orbital / intra orbital laceration) . 2.) A Nursing Progress Note dated 10/25/18 at 4:09 p.m. documented, .Res. {Resident) returned from (Hospital #1) with new orders for vital signs with neuro (neurological) checks every 2 hrs (hours) (times) 12 hrs Change dressing daily and remove sutures in 7 days . Will continue to monitor . There was no documentation of any further effort to determine the cause of the fall or to develop any new interventions to minimize the potential for further injury. h. A facility Fall Risk assessment dated [DATE] documented the resident's total fall risk score was 55, with a score of 45 or greater indicating the resident was at high risk for falls. i. On 10/31/18 at 4:15 p.m., LPN #4 was asked about the incident that occurred with this resident on 10/18/18, and whether the resident had a floor mat at that time. LPN #4 stated, No. LPN #4 was asked about the Nurse's Note, which documented the resident had been encouraged to use the call light. LPN #4 was asked if the resident was cognitively intact and stated, At times. LPN #4 was asked if the resident had a good memory. LPN #4 stated, No, he can remember some things. LPN #4 was asked if there were any interventions implemented after the fall. LPN #4 stated, No. LPN #4 was asked if any interventions were implemented after the resident returned from the emergency room . LPN #4 stated, No. LPN #4 was asked if the resident had a history of [REDACTED].#4 stated, Yes. j. On 10/31/18 at 5:15 p.m., the Director of Nursing (DON) was asked what caused the fall on 10/25/18. The DON referred to the Nurses Notes and stated, Ordering a pommel cushion for wheelchair, and until it arrives, we are reclining the wheelchair. The DON was asked if this information was added to the Care Plan. The DON stated, No, we haven't. The DON was asked to go with the surveyor to view the wheelchair and check the resident's position. The DON responded that the resident had been sent out to a hospital for services unrelated to a fall and was not in the facility at this time. At 5:30 p.m., the DON was asked what interventions were implemented for the incident on 10/18/18 after the resident was found sitting on the floor against his bed. The DON stated, Side rails in place. They were not in place. One of the things from a fall before was to hold the air mattress in place with side rails. The DON was asked, what were the interventions to prevent the resident from falling out of bed again? The DON stated, The only thing was to make sure the side rails were in position. The DON was referred to the Nurses Note that documented the resident was encouraged to use call light. The DON was asked if it was a reasonable, or realistic, intervention to instruct a severely cognitively impaired resident to remember to use a call light for help. The DON stated, No. The DON was asked, when the resident was found on the floor on 10/8/18, what caused the fall and what was done about it? The DON stated, That was the day the resident was placed on the air mattress, and it was not the one he needed. The DON was asked why the mattress was not the one that the resident needed. The DON stated, That was the one that was the wrong mattress. The DON was asked if the resident had the wrong mattress. The DON stated, It was from DME (durable medical equipment) and not hospice. We called hospice. The DON was asked to provide the manufacturer's information for the mattress that the resident had first, and for the mattress provided by hospice. The DON left the room at 5:55 p.m. The manufacturer's information was provided the following day, 11/1/18, at 1:40 p.m. after the facility obtained the information from the durable medical supply company. The information was not readily available in the facility for staff to reference in order to determine if a side rail was a safe and appropriate measure with the specific mattress that was in use by the resident. k. On 11/1/18 at 3:30 p.m., LPN #1 was asked what occurred when the resident fell on [DATE]. LPN #1 stated, He was sitting on the floor with his covers wrapped around him by the bed. LPN #1 was asked if the resident had complained of any pain. LPN #1 stated, He said his hip was hurting, and his shoulder. LPN #1 was asked where that information was documented. LPN #1 stated, I didn't put it in here. LPN #1 was asked if there had been any interventions implemented after the resident fell out of bed. LPN #1 stated, I spoke to him about getting up, and if he needed to get up asked him to use his call light. LPN #1 was asked what the cause of the fall was. LPN #1 stated, He said he was trying to get up to go to the bathroom. LPN #1 was asked if there was an air mattress on the resident's bed at that time. LPN #1 stated, He did not have the air mattress then. LPN #1 was asked if the resident was cognitively impaired. LPN #1 stated, Yes. LPN #1 was asked if the resident had a fall mat at the time of the fall on 10/8/18. LPN #1 stated, No. LPN #1 was asked if a fall mat by the bed was considered at that time. LPN #1 stated, No. Doesn't that have to be care planned first? l. On 11/1/18 at 7:35 p.m., the DON was asked, when the resident fell on [DATE], when did the resident return to the facility from the hospital. The DON stated, 8/9/18. The DON was asked what the causative factors were for that fall and stated, He was leaning over reaching for the oxygen concentrator. The DON was asked, what intervention was implemented when the resident returned to the facility from the hospital? The DON stated, I put . will have bed alarm on bed when he attempts to get up. The DON was asked where it was noted in the resident's record that the resident had returned to the facility. The DON reviewed the Nurses Notes, and stated, I've just got an Admission Assessment. The DON was asked if the resident had an alarm prior to the fall. The DON stated, No, I don't think he did. The DON was asked if the resident currently had an alarm. The DON stated, No. The DON was referred to the resident's Care Plan and was asked what the fall protocol consisted of. The DON stated, I'll have to find the fall protocol. The DON was asked if the facility had a fall protocol. The DON stated, I'll have to go find out. The DON left the room at 8:00 p.m., returned at 8:04 p.m., and stated, We don't have a fall protocol. That is something she (former MDS Coordinator) clicked on (when completing the Care Plan). The DON was asked if the nurses could update the Care Plans. The DON stated, They can, but they are not really trained. The DON was asked why the alarm was not in use for the resident. The DON stated, He kept pulling the alarm off the bed. As of 11/1/18, the Care Plan with a revised date of 9/17/18 did not address specific, targeted interventions that addressed the causative factors of the resident's multiple falls. 2. Resident #5 had [DIAGNOSES REDACTED]. The Significant Change MDS with an ARD of 9/24/18 documented the resident scored 0 (0-7 indicates severely cognitively impaired) on a BIMS, was non-ambulatory, required a wheelchair for mobility, and had 2 falls with no injury and 1 fall with injury since admission. a. The Care Plan with a revised date of 9/26/18 documented, .She (Resident) is at risk for falls r/t (related to) Confusion . Unaware of safety needs . Anticipate and meet her needs to the extent possible . Ensure that she is wearing appropriate non-skid footwear when mobilizing in w/c (wheelchair) . Observe for safety every 2 hours as needed for safety . She needs a safe environment that is clutter free . Bed pad alarm to alert staff of attempting transfer without assistance . b. An Incident and Accident Report dated 11/4/17 at 4:17 p.m. documented, .Incident Description / Nursing Description . Resident slipped out of wheelchair in hallway, by bathroom . Resident assisted back into wheelchair by staff . No apparent injuries noted . Resident stated she was trying to go to dining room to eat, but she slipped out of wheelchair . Immediate Action Taken Description . Head to toe assessment performed on resident Resident assisted back into wheelchair . Reconnected wheelchair alarm . A Nursing Progress Note dated 11/4/17 at 6:05 p.m. documented, .Resident slid out of wheelchair onto bottom in hallway, by bathroom. No apparent injuries noted. Resident denied pain. Resident stated she was trying to go to the dining room to eat. Resident assisted back into wheelchair by staff. Skin assessment performed, VS (vital signs) obtained . No signs of distress or discomfort noted. Will continue to observe . There was no documentation of any further effort to determine the causative factors of this fall or of any interventions that were developed to prevent the resident from sliding out of the wheelchair seat to prevent further falls of this nature. c. An Incident and Accident Report form dated 1/22/18 at 1:30 a.m. documented, .Incident Description Nursing Description . Heard bed alarm going off . This nurse and CNA (Certified Nursing Assistant) found resident sitting on her bottom beside her bed. Bed in lowest position . Resident stated she was trying to turn the lights on . Immediate Action Taken Description . Assessed resident . No apparent injuries noted, no skin tears . Assisted resident back into bed. Neuro (neurological) checks started, vital signs (within) normal limits . Resident denies pain . There was no documentation of any new interventions to prevent potential recurrence. A Nursing Progress Note dated 1/22/18 at 2:04 a.m. documented, .Heard bed alarm going off. This nurse and CNA found resident in her room sitting on her bottom beside her bed, bed in lowest position. Resident stated she was trying to turn the lights on. Assessed resident, no apparent injuries noted, no skin tears, resident denies any pain. Assisted resident back into bed. Neuro (neurological) checks started, vital signs within normal limits. Notified DON and Administrator. Will continue to observe . No further effort to determine the causative factors of the fall was documented, nor were any new interventions documented to prevent potential recurrence. d. An Incident and Accident Report dated 2/19/18 at 3:30 p.m. documented, .Incident location . Dining Room . Incident Description Nursing Description . Resident found on bottom in floor sitting in front of wheelchair. Resident stated, 'I'm okay.' Small superficial abrasion noted to outer left elbow . Resident denies any pain . Resident denies any complaint of pain or discomfort . Immediate Action Taken Description . Assessment performed. Resident assisted back into wheelchair. Vitals (vital signs) obtained . There was no documentation of any interventions that were implemented to prevent the resident, who had previously experienced a fall related to sliding out of the wheelchair, from experiencing further recurrence of falls from the wheelchair. The Nursing Progress Note dated 2/19/18 did not document any interventions related to the fall from the wheelchair. e. An Incident and Accident Report dated 4/3/18 at 4:06 a.m. and signed by LPN #3 documented, .Incident Location . Resident's Room . Incident Description . Heard resident talking and hollering out, walked into resident's room . This nurse received resident on floor lying on right side beside bed . No brief on. No gown on. Tab alarm removed. Bed in low position . Immediate Action Taken Description . Obtained vs (vital signs). Initiated neuro (neurological) checks. Assessed resident for injuries. No injuries observed. Resident without c/o (complaints). Assisted resident up X (times 2) (staff) to w/c (wheelchair) and dressed resident. Placed tab alarm on w/c (wheelchair). Assisted to nurse's station. Provided snack . 1.) The Nursing Progress Note dated 4/3/18 at 4:21 a.m. and signed by LPN #3 documented, .Resident tab alarm sounded .This nurse went to resident's room . Resident had pulled tab alarm off . Gown and brief were on, cover pulled up to chest area. Replaced tab alarm to gown and situated res (resident) in bed. Approx (approximately) 10 minutes later, this nurse heard resident talking and hollering. Arrived at res (resident's) room and received res in floor, lying on right side beside of her bed. No brief on. Eyes open. Talking. Res denied pain. Vs (vital signs) wnl (within normal limit) .neuro's (neurological checks) wnl (within normal limits). No injuries noted or c/o (complains of) pain. Assisted res up to w/c (wheelchair) x2 (times 2) (staff) assist (assistance). Dressed and brought res to nurse's station in w/c (wheelchair) with tab alarm in place. Res eating snack at this time. Notified appropriate persons of incident. No distress noted . There was no documentation any further interventions were implemented to address the removal of the tab alarm and fall from bed and prevent potential recurrence. 2.) A Nursing Progress Note dated 4/3/18 at 5:05 a.m., and signed by LPN #3 documented, .Encouraged res (resident) to leave gown and tab alarm on and in place to help

Complaint (AR 125) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility's nursing administration failed to identify and intervene to correct an ongoing, systemic problem with regard to falls and injury prevention, as evidenced by failure to ensure falls were evaluated for causative factors and that effective interventions based on those causative factors were developed, care planned, communicated to staff, consistently implemented, evaluated for effectiveness and revised when needed to prevent further falls to the extent possible and minimize the potential for fall-related injuries for 2 (Residents #1 and #5) of 6 (Residents #1, #2, #4, #5, #6, and #7) case mix residents who were at high risk for falls. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who sustained a subdural hematoma due to a fall and experienced multiple subsequent falls with injury, and Resident #5, who had numerous falls without any follow-up interventions and experienced fall-related injuries. The failed practices also had the potential to cause more than minimal harm to 28 residents who were high risk for falls, as identified on a list provided by the Administrator on 11/7/18. The facility Administrator was informed of the Immediate Jeopardy condition on 11/1/18 at 8:46 p.m. The findings are: 1. The facility's Administrator job description, received from the Administrator on 11/5/18 at 1:45 p.m., documented, .Purpose of Your Job Position . The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our patients at all times . Delegation of Authority as the Administrator . You are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Duties and Responsibilities . Administrative Functions . Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities . Maintain written policies and procedures that govern the operation of the facility . Ensure that all employees . follow established policies and procedures . Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility . Staff Development Functions . Assist department directors in the planning, conducting, and scheduling of in-service training classes, on-the-job training and orientation programs to assure that current material and programs are continuously provided . Review accident / incident reports and establish an effective accident prevention program . Ensure that each patient receives the necessary nursing, medical and psycho-social services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and care plan . 2. The facility's Director of Nursing job description, received from the Administrator on 11/5/18 at 1:45 p.m., documented, .The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Administrator and Medical Director, to ensure that the highest degree of quality care is maintained at all times . Delegation of Authority as Director of Nursing Services you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties . Administrative Functions . Plan, develop, organize, implement, evaluate, and direct the nursing services department as well as its programs and activities . Maintain written policies and procedures that govern the day-to-day functions of the nursing service department and ensure that personnel comply with such policies and procedures . Assist in developing methods for coordinating nursing services with other patient services to ensure the continuity of the patients' total regimen of care . Ensure that all nursing service personnel are in compliance with their respective job descriptions . Interpret the department's policies and procedures to personnel . as required . Perform administrative duties such as . evaluations, studies, charting, including I & A (Incident and Accident) forms . as necessary . Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the patient's response to the care, and that such care is provided in accordance with the patient's wishes . Participate in developing, planning, conducting, and scheduling in-service training classes that provide instructions on 'how to do the job, ensure a well-educated nursing service department . Care Plan and Assessment Functions . Participate in the development of written preliminary and comprehensive assessments of the nursing needs of each patient that identifies the problems / needs of the patient, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care as necessary . Review patient care plans for appropriate patient goals, problems, approaches, and revisions based on nursing needs . Ensure that all personnel involved in providing care to the patient are aware of the patient's care plan . Ensure that nursing personnel refer to the patient's care plan prior to administering daily care to the patient . Review nurses' notes to determine if the care plan is being followed . Assist the Patient Assessment / Care Plan Coordinator in planning, scheduling, and revising the MDS (Minimum Data Set) . Review patient's medical and nursing treatments to ensure that they are provided in accordance with the patient's care plan and wishes . 3. The facility's Charge Nurse / Shift Supervisor job description received from the Administrator on 11/5/18 at 1:45 p.m. documented, .The primary purpose of your job position is to provide direct nursing care to the patients, and to supervise day-to-day nursing activities performed by nursing assistants . Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services to ensure that the highest degree of quality care is maintained at all times . As a Charge Nurse / Shift Supervisor, you are delegated the authority, responsibility, and accountability necessary for carrying out your assigned duties . Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility . Complete accident / incident reports as necessary . Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc (et cetera), as necessary . Complete . forms / charts upon the patient's admission, transfer, and / or discharge . Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the patient, as well as the patient's response to the care . Fill out and complete accident / incident reports . Submit to Director of Nursing as required . Chart all reports of accidents / incidents involving patients . Follow established procedures . Report all discrepancies noted concerning . charting error . Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures . 4. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/24/18 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS), required 2-person physical assistance to walk, had no falls since admission or reentry, and had an active [DIAGNOSES REDACTED]. a. The Care Plan with a revised date of 9/17/18 documented, .(Resident #1) is high risk for falls r/t (related to) Confusion, Gait / balance problems . Unaware of safety needs . Vision / hearing problems . He (Resident) will be free of minor injury through the review date . Anticipate and meet the resident's needs . Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . The resident needs prompt response to all requests for assistance . Follow facility fall protocol . Review information on past falls and attempt to determine cause of falls . Record possible root causes . Alter / remove any potential causes if possible . Educate resident / family / caregivers / IDT (interdisciplinary team) as to causes . b. An Incident and Accident Report dated 7/28/18 at 7:20 p.m. documented, .Incident Location . Resident's Room . Incident Description . Nursing Description . nurse was called to res (resident) room by aide . res was found lying on R (right) side with bruising to R side of back and abrasion to forehead and upper left eyebrow. Resident Description . Res stated he saw (son's name) in the room and was trying to get to him . Immediate Action Taken Description . (Attending Physician #1), Administrator, DON (Director of Nursing), and ADON (Assistant Director of Nursing) notified . Called (ambulance service) to transport res to ER (emergency room ) . ER was also notified on transport. (Son) notified of fall. Overhead light to stay on so res can be aware of surroundings . Instructed res to use call light if he needed out of the bed . Resident taken to hospital? N (No) . Injuries Observed at Time of Incident . Injury Type . Laceration . 1.) A Nursing Progress Note dated 7/29/18 at 1:29 a.m. documented, .Res (Resident) laying (sic) in bed at this time . Bruising noted to lower back bilaterally . abrasion to forehead and above R (right) eyebrow from fall on 7/28 . Res sent to (Hospital #1) per ambulance to be checked out per (Physician #1) orders . Res returned to facility with no new orders . Overhead light left on so res can be aware of surroundings . Instructed res to use call light if he needed out of the bed . 2.) The hospital Emergency Nursing Record dated 7/28/18 from Hospital #1 documented, .Triage time . (YEAR) (8:15 p.m.) . Chief Complaint . Head Injury poss (possible) Fall occurred . unwitnessed . c/o (complains of) neck pain (cervical) . Mechanism fall (circled) . Past HX (history) . cervical fx (fracture) . c-collar (circled) . Head / Face .tenderness (circled) . Neck / Back . tenderness (circled) . C-spine (cervical spine) . Emergency Physician Record . Head Injury . Date . 7/28/18 . Time Seen . 2025 (8:25 p.m.) . HPI (history present illness) . chief complaint . injury to head (circled) . (and) . neck . onset / duration . just prior to arrival (circled) . where . nursing home . context . fall (circled) . Has recent hx (history of) C3 (cervical 3) vertebral Fracture on 7/10/18 . severity of pain . moderate (circled) . associated symptoms . memory impairment (circled) . Past HX (history) . Dementia . Physical Exam . Head non-tender (marked) . no swelling (marked) . no obvious injury (marked) .Except for Abrasion . Pt (patient) stable . Clinical Impression . Abrasion . Forehead . Fall . c. An Incident and Accident Report dated 8/6/18 at 11:30 a.m. and signed by Licensed Practical Nurse (LPN) #2 documented, .Incident Location . Resident's Room . Incident Description . Nursing Description . walked into resident's room and noted resident on the floor on his right side with his left arm tucked underneath him . blood noted on the floor . Immediate Action Taken . Resident Taken to Hospital? Y (yes) . Injuries Observed at Time of Incident . Injury Type . Laceration . Injury Location Eye (R) (right) . 1.) A Nursing Progress Note dated 8/6/18 at 1:47 p.m. by LPN #2 documented, .Note Text . 1130 (11:30 a.m.) Heard resident holler for help . Went to resident's room and noted resident lying on the floor on his right side with his left arm tucked underneath him and noted blood on the floor where resident had hit his head . Another LPN in the room applied pressure to his head on the floor . 1135 (11:35 a.m.) Ambulance called . 1137 (11:37 a.m.) (Hospital #1) called and report given to (hospital nurse) . 1140 (11:40 a.m.) Ambulance arrived (times) 2 EMTs (Emergency Medical Technicians) . EMTs were notified that resident has a history of C3 (cervical spine disc 3) fx (fracture) . 1145 (11:45 a.m.) family notified . 1150 (11:50 a.m.) Resident out of facility, left by ambulance (times) 2 EMTs (Emergency Medical Technicians) . 2.) The hospital Emergency Record dated 8/6/18 from Hospital #1 documented, .Emergency Nursing Record . Trauma . Brief History of Injury . Fall from ground level at Nursing Home . Feet were tangled in oxygen tubing . Injuries head (circled) face (circled) . Mechanism fall (circled) . ground level . laceration (circled) . (right) forehead . Emergency Physician Record . Fall . Date . 8/6/18 . Time Seen . 1212 (12:12 p.m.) .HPI (History of Present Illness) . chief complaint . Fall . injury to head . onset / duration . just prior to arrival . where . nursing home . context . lost balance . location of pain / injuries . head (circled) . severity of pain . mild moderate (circled) . associated symptoms .lost consciousness . no (circled) .Past Hx (history) . (left) hip Fx (fracture) . Dementia prev (previous) C-spine Fx . Procedures . Wound Description / Repair . length 5 cm (centimeters) . location . (right) forehead . stellate (star like pattern) . irregular . X-rays / CT (computerized tomography) .CT done . head (circled) . C spine (cervical spine) . neg (negative) . Head . Subdural 10mm (millimeters) . (no) shift (right) . frontal .Clinical Impression . Skin Laceration forehead . (right) .Subdural . Head Injury . 3.) A Diagnostic Imaging report dated 8/6/18 from Hospital #1 documented, .CT (computed tomography) (of) Head without Contrast . Date of Study . 8/6/18 .Clinical Indication . Head Injury due to fall . Findings . There is an acute mixed attenuation right frontal subdural hematoma measuring up to approximately 10 mm (millimeters) in maximum thickness without evidence of significant midline shift . Impression . 1. Acute mix attenuation right frontal subdural hematoma measuring to 10 mm in maximum thickness without significant midline shift . Short-term CT follow-up of the head recommended . CT Head w/o (without) Contrast . Reason for Test . Trauma . 4.) An Emergency Department (ED) Physician Note dated 8/6/18 from Hospital #2 documented, .Pt (Patient) air vac (air evacuated) .Patient was transferred to ED (Emergency Department) from nursing home after he fell on his head while he was standing up . Fall . The fall occurred while standing . He fell from a height of 1 to 2 ft. (feet) .The point of impact was the head . The pain is present in the head . 5.) A Neurology Consulting Physician Consult report dated 8/6/18 from Hospital #2 documented, .Consulted for . Traumatic right SDH (Subdural Hematoma) .Brief History . Pt is an 81 yo (year old) .resident of a nursing facility with hx (history) of Dementia who fell while standing getting out of bed . He fell forward striking the front of his head, causing a laceration on his right eyebrow . Head CT from OSH (outside hospital) reveal a right SDH without brain compression .Active Hospital Problems . Diagnosis . Subdural Hematoma due to concussion . Active Problems . Subdural hematoma due to concussion . Assessment . Traumatic right SDH s/p (status [REDACTED]. 6.) A Radiology Results Report dated 8/6/18 from Hospital #2 documented, .XR (x-ray) . Chest . History . Dementia with fall . Findings . There are multiple right rib fractures with involvement of the lateral right sixth and seventh ribs . Impression . Right rib fractures with no underlying contusion or pneumothorax . No pleural effusion . 7.) A Physician Discharge Summary dated 8/9/18 from Hospital #2 documented, .admitted . 8/6/2018 . discharge date . 8/9/2018 . Admission [DIAGNOSES REDACTED]. Severe Dementia . Discharge [DIAGNOSES REDACTED]. Traumatic . Additional [DIAGNOSES REDACTED]. Hospital Course . Patient was admitted to the Neurology / Neurosurgery unit and consults were made to Neurosurgeon . No surgery at this time . Patient has progressed gradually on the unit and is now ready for discharge . 8.) An Admission Nursing Evaluation form dated 8/9/18 and signed by the Director of Nursing (DON), contained no documentation to indicate the facility developed any new fall / injury prevention interventions when the resident returned from the hospital. The facility Nursing Progress Note dated 8/9/18 did not reference any fall prevention interventions upon the resident's readmission to the facility. d. A Nursing Progress Note dated 10/5/18 at 2:28 p.m. and signed by LPN #2 documented, .Incident Description . Resident was sitting out in lobby in w/c (wheelchair), when resident was leaning in w/c and grabbed water bottle on concentrator, when he fell forward head first to the floor . Immediate Intervention . Move concentrator out of resident's reach . 1.) An Incident and Accident form dated 10/5/18 at 1:30 p.m. and signed by LPN #2 documented, .Incident Description . Nursing Description . Went into lobby and resident was laying on his right side with a towel under his head . Immediate Action Taken Description . Assessed resident for injuries . cut on his nose and head . sent to ER (emergency room ) for evaluation . Injuries Observed at Time of Incident . Injury Type . Laceration . Injury Location . Forehead . 2.) The Emergency Department Record dated 10/5/18 from Hospital #1 documented, .Emergency Nursing Record . Chief Complaint . fall, face trauma, HA (headache) .fall . Hit face on floor c/o (complained of) HA . The Emergency Physician Record dated 10/5/18 documented, .Fall Date . 10/5/18 . Time Seen . 1415 (2:15 p.m.) .HPI (History of Present Illness) . Fall injury to / from wc (wheelchair) . Resident fell from wc (wheelchair), struck face on floor . No L[NAME] (loss of consciousness) . Abrasion, sm (small) lac (laceration) to Face . Procedures . Wound Description / Repair . length 1.0 cm (centimeter) . Location . Face .Repair . superficial . Wound closed with . Dermabond .X-rays /CT (computed tomography) .CT done (of) head . Interpretation . No acute pathology . old Subdural Hematoma . Clinical Impression . Skin Laceration . Face Abrasion . Face . Stable Rt (right) Subdural Hematoma .Fall .Discharge Instructions . 1. Return to N Home (Nursing Home) / orders done . 2. Fall precautions . 3. Wound care . 3.) A Diagnostic Imaging - Radiology Report dated 10/5/18 from Hospital #1 documented, .CT (computed tomography) (of) Head without Contrast . 10/5/18 . Comparison . 8/6/18 . History . [AGE] year old male status [REDACTED]. Impression . 1. No acute intracranial abnormality is demonstrated . 2. Larger subacute / chronic right front parietal Subdural Hematoma now measuring 1.5 cm (centimeters) in diameter compared to 1.0 cm previously . There is a larger component overlying the right parietal lobe than seen previously . 4.) Nursing Progress Notes dated 10/5/18 at 3:44 p.m. and signed by LPN #1 documented, .Returned to nursing home from ER . Resume previous orders . Res (Resident) on fall precautions . There was no documentation of any new fall prevention interventions that were implemented upon the resident's return from the hospital. 5.) A Nursing to Rehab (Rehabilitation) Communication Form dated 10/5/18 documented, .Circle all that apply Mobility . Frequent faller . Fall . 10/5/18 . A second Nursing to Rehab Communication Form, dated 10/8/18, and signed by the Physical Therapist and Certified Occupational Therapy Assistant, (COTA) documented, .Has been on case load twice with no carry-over due to decreased memory, aggressive, poor safety awareness, and inability to progress . There was no documentation of a therapy evaluations or recommended fall / injury prevention interventions made by the Therapy Department at this time. e. A Nursing Progress Note dated 10/8/18 at 9:35 p.m. and signed by LPN #1 documented, .Nsg (Nursing) I&A (Incident and Accident) Note . Incident Description . Res (Resident) sitting on floor with covers wrapped around him . Immediate Intervention . Educated res on use of call light if trying to get out of bed . There was no additional documentation to indicate any interventions were developed at this time; the only interventions documented were to educate the severely cognitively impaired resident to use the call light. There was no documentation of an evaluation for causative factors to facilitate the development of appropriate interventions after this fall. The Incident and Accident Report dated 10/8/18 and signed by LPN #1 documented, .Incident Description . Res (Resident) lying on floor wrapped in blankets . Resident Description . Res said he fell out of the bed . Immediate Action Taken Description . Assisted res back into bed . There was no documentation of an evaluation of causative factors or of any new interventions that were developed in response to this fall. f. An Incident and Accident form dated 10/18/18 at 9:33 p.m. and signed by LPN #4 documented, .Incident Description / Nursing Description . Received resident sitting in floor with back up against bed with bed draw sheet up under resident . Resident Description . 'Someone pulled me out the bed' . Immediate Action Taken Description . Assessed resident for injury . Vitals (vital signs) taken and CNA (Certified Nursing Assistant) and LPN assisted resident back on bed . Notes . Resident forgetful, gets confused at times of who people are . Other Info (Information) . Res. side rail was up . Res attempts to climb out of bed looking for wife Res draw sheet and incontinent pad was up under (resident's) bottom . There was no further documentation of efforts to determine the cause of the fall or of interventions that were developed in response to this fall. The Nursing Progress Notes dated 10/18/18 at 11:00 p.m. and signed by LPN #4 documented, .Incident Description . Res. (Resident) slid out of bed onto floor with pad underneath bottom . Immediate Intervention . Res. encouraged to use call light and side rails were put in place . Based on the Incident and Accident Report timed approximately 1.5 hours prior to this note, a side rails was already in use on the resident's bed, and there was no documentation of any other interventions, with the exception of encouraging the severely cognitively impaired resident to use the call light. g. An Incident and Accident Report dated 10/25/18 at 12:50 p.m. and signed by LPN #3 documented, .Incident Location . Reception / Lobby .Incident Description . Nursing Description . Summoned to front lobby. Received res laying on floor on right side in front of wheelchair . ADON (Assistant Director of Nursing) and Treatment Nurse with resident . Immediate Action Taken Description . Assessed resident for injuries . Laceration above right eye . Skin tear below right eye . Applied pressure to these areas . Initiated neuros (neurological checks) . Notified Dr. (Doctor) . Received order to send to ER (emergency room ) at (Hospital #1) . Injuries Observed at Time of Incident . Injury Type . Laceration . Injury Location . Eye (R) (Right) . Injury Type . Skin Tear . Injury Location . Eye (R) . There was no documentation of an evaluation for causative factors. 1.) The Emergency Physician Record dated 10/25/18 at 1:55 p.m. from Hospital #1 documented, .Facial / Scalp Injury . Date . 10/25/18 . Time . 1:55 p.m. HP (History of Present Illness) . Chief Complaint . Face . where .nursing home . fall from chair . severity of pain . moderate . Procedures . Wound Description / Repair . length 3 cm (centimeters) . location . (right) Eyebrow . irregular .Anesthesia . local . [MEDICATION NAME] . prep (preparation) . [MEDICATION NAME] . irrigated with saline . Repair . Superficial . Wound closed with . Skin 36.5 ethilon . CT (computed tomography) done . Skull facial . No fracture . Clinical Impression . Skin . Laceration . (right) eyebrow . Abrasion . 3 cm Lac (laceration) (right) Eyebrow . 3 cm . Supra lac intra orbit (supra orbital / intra orbital laceration) . 2.) A Nursing Progress Note dated 10/25/18 at 4:09 p.m. documented, .Res. {Resident) returned from (Hospital #1) with new orders for vital signs with neuro (neurological) checks every 2 hrs (hours) (times) 12 hrs Change dressing daily and remove sutures in 7 days . Will continue to monitor . There was no documentation of any further effort to determine the cause of the fall or to develop any new interventions to minimize the potential for further injury. h. A facility Fall Risk assessment dated [DATE] documented the resident's total fall risk score was 55, with a score of 45 or greater indicating the resident was at high risk for falls. i. On 10/31/18 at 4:15 p.m., LPN #4 was asked about the incident that occurred with this resident on 10/18/18, and whether the resident had a floor mat at that time. LPN #4 stated, No. LPN #4 was asked about the Nurse's Note, which documented the resident had been encouraged to use the call light. LPN #4 was asked if the resident was cognitively intact and stated, At times. LPN #4 was asked if the resident had a good memory. LPN #4 stated, No, he can remember some things. LPN #4 was asked if there were any interventions implemented after the fall. LPN #4 stated, No. LPN #4 was asked if any interventions were implemented after the resident returned from the emergency room . LPN #4 stated, No. LPN #4 was asked if the resident had a history of [REDACTED].#4 stated, Yes. j. On 10/31/18 at 5:15 p.m., the Director of Nursing (DON) was asked what caused the fall on 10/25/18. The DON referred to the Nurses Notes and stated, Ordering a pommel cushion for wheelchair, and until it arrives, we are reclining the wheelchair. The DON was asked if this information was added to the Care Plan. The DON stated, No, we haven't. The DON was asked to go with the surveyor to view the wheelchair and check the resident's position. The DON responded that the resident had been sent out to a hospital for services unrelated to a fall and was not in the facility at this time. At 5:30 p.m., the DON was asked what interventions were implemented for the incident on 10/18/18 after the resident was found sitting on the floor against his bed. The DON stated, Side rails in place. They were not in place. One of the things from a fall before was to hold the air mattress in place with side rails. The DON was asked, what were the interventions to prevent the resident from falling out of bed again? The DON stated, The only thing was to make sure the side rails were in position. The DON was referred to the Nurses Note that documented the resident was encouraged to use call light. The DON was asked if it was a reasonable, or realistic, intervention to instruct a severely cognitively impaired resident to remember to use a call light for help. The DON stated, No. The DON was asked, when the resident was found on the floor on 10/8/18, what caused the fall and what was done about it? The DON stated, That was the day the resident was placed on the air mattress, and it was not the one he needed. The DON was asked why the mattress was not the one that the resident needed. The DON stated, That was the one that was the wrong mattress. The DON was asked if the resident had the wrong mattress. The DON stated, It was from DME (durable medical equipment) and not hospice. We called hospice. The DON was asked to provide the manufacturer's information for the mattress that the resident had first, and for the mattress provided by hospice. The DON left the room at 5:55 p.m. The manufacturer's information was provided the following day, 11/1/18, at 1:40 p.m. after the facility obtained the information from the durable medical supply company. The information was not readily available in the facility for staff to reference in order to determine if a side rail was a safe and appropriate measure with the specific mattress that was in use by the resident. k. On 11/1/18 at 3:30 p.m., LPN #1 was asked what occurred when the resident fell on [DATE]. LPN #1 stated, He was sitting on the floor with his covers wrapped around him by the bed. LPN #1 was asked if the resident had complained of any pain. LPN #1 stated, He said his hip was hurting, and his shoulder. LPN #1 was asked where that information was documented. LPN #1 stated, I didn't put it in here. LPN #1 was asked if there had been any interventions implemented after the resident fell out of bed. LPN #1 stated, I spoke to him about getting up, and if he needed to get up asked him to use his call light. LPN #1 was asked what the cause of the fall was. LPN #1 stated, He said he was trying to get up to go to the bathroom. LPN #1 was asked if there was an air mattress on the resident's bed at that time. LPN #1 stated, He did not have the air mattress then. LPN #1 was asked if the resident was cognitively impaired. LPN #1 stated, Yes. LPN #1 was asked if the resident had a fall mat at the time of the fall on 10/8/18. LPN #1 stated, No. LPN #1 was asked if a fall mat by the bed was considered at that time. LPN #1 stated, No. Doesn't that have to be care planned first? l. On 11/1/18 at 7:35 p.m., the DON was asked, when the resident fell on [DATE], when did the resident return to the facility from the hospital. The DON stated, 8/9/18. The DON was asked what the causative factors were for that fall and stated, He was leaning over reaching for the oxygen concentrator. The DON was asked, what intervention was implemented when the resident returned to the facility from the hospital? The DON stated, I put . will have bed alarm on bed when he attempts to get up. The DON was asked where it was noted in the resident's record that the resident had returned to the facility. The DON reviewed the Nurses Notes, and stated, I've just got an Admission Assessment. The DON was asked if the resident had an alarm prior to the fall. The DON stated, No, I don't think he did. The DON was asked if the resident currently had an alarm. The DON stated, No. The DON was referred to the resident's Care Plan and was asked what the fall protocol consisted of. The DON stated, I'll have to find the fall protocol. The DON was asked if the facility had a fall protocol. The DON stated, I'll have to go find out. The DON left the room at 8:00 p.m., returned at 8:04 p.m., and stated, We don't have a fall protocol. That is something she (former MDS Coordinator) clicked on (when completing the Care Plan). The DON was asked if the nurses could update the Care Plans. The DON stated, They can, but they are not really trained. The DON was asked why the

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure that policies and procedures were implemented to prevent neglect for 1 (Resident #1) of 5 (Residents #1 through #5) case mix residents who were cognitively impaired. The facility failed to immediately protect Resident #1 after the resident made an allegation of sexual misconduct toward her from Resident #2. This failure resulted in immediate jeopardy which caused or could have caused serious harm, injury or death to Resident #1, and had the potential to affect 43 residents in the facility who were cognitively impaired according to a list provided by the Administrator on 9/23/13 at 4:50 p.m. The facility was informed of the immediate jeopardy situation on 9/23/13 at 7:08 p.m. The findings are: 1. The facility's Abuse Prohibition Policy and Procedure documented, "It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property ("alleged violations"), are reported immediately to the Administrator of the facility... The Administrator or his/her designee will direct a thorough investigation of each such alleged violation... Procedure: The facility shall take the following steps to prevent detect and report abuse, neglect, injuries of unknown source and the misappropriation of resident property... Protection: If the suspected perpetrator is another resident, the DNS (Director of Nursing Services) or his/her designee shall separate the residents so they do not have access to each other until the circumstances of the alleged incident can be determined... The facility shall make reasonable efforts to determine the cause of the alleged violation and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident... Appropriate steps shall be taken to prevent recurrence of the incident. This may include in-services or other measure and should be documented... Definitions: Neglect - Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness." 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/2/13 documented the resident scored 4 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), was independent with most activities of daily living and had verbal behavioral symptoms directed toward others. Resident #2 had [DIAGNOSES REDACTED]. The 30 day Medicare MDS with an ARD of 9/9/13 documented the resident scored 0 (0-7 indicates severe impairment) on the BIMS, required supervision or limited assist with most activities of daily living and had no behaviors. a. A Nurse's Note dated 9/15/13 at 9:45 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "...0830 - CNA (Certified Nursing Assistant) asked LPN to speak with resident. Resident (Resident #1) stated, '(Resident #2) came to my bed last night and put 3 fingers inside of me. It felt like a dick. But I didn't like it and told her to stop.' LPN asked resident if anything else happened. Stated, 'No. I was just laying there and she did that. I told her I was gonna tell.' LPN asked when this occurred. Resident stated, 'Last night.' DON (Director of Nursing) and Administrator notified. LPN instructed to move resident from room and close monitoring of other resident. No physical injuries noted." b. A Nurse's Note dated 9/15/13 at 1:00 p.m. and signed by LPN #1 documented, "Resident (Resident #1)states she does not want to move to a new room. States, 'I forgive her. I'm not moving to that other room.' Administrator notified." c. On 9/23/13 at 2:43 p.m. during initial rounds, Resident #1 was observed in bed. Resident #2 was also observed in bed in the same room. d. On 9/23/13 at 4:15 p.m., Resident #1 was asked during an interview if she remembered anything happening about a week ago that she reported to her nurse. She stated, "You mean about (Resident #2)? I sure do." She was asked to explain what happened. She stated, "(Resident #2) came over to me and put her fingers up in me (made a hand motion upward). It felt like.... you know, a dick." She was asked if she meant inside her vagina. She stated, "Yes." Resident #1 was asked why she thought Resident #2 would do that. She stated, "I don't know. To be funny I guess." She was asked if Resident #2 had ever done something like that to her before. She stated, "No. She ain't never done that before." She was asked if anything else had happened since the incident a week ago. She stated, "Last night (Resident #2) climbed on top of me in the bed... You know like a guy would do it if he was gonna do something to you? That's what she did." She was asked what she did when Resident #2 did this. She stated, "I wanted to hit her." She was asked if she had told anyone about the incident last night. She stated, "No. I ain't told nobody about that." She was asked if she was afraid of Resident #2. She stated, "I don't want to move rooms. She just needs to stay on her side." e. On 9/23/13 at 4:45 p.m., LPN #1 was asked during a telephone interview about the alleged incident on 9/15/13. She stated, "It was Sunday morning at breakfast time...(CNA #1) told me (Resident #1) had a complaint so I went and asked her what was wrong. She told me (Resident #2) came over to her, put 3 fingers inside her and it felt like a dick. I asked her if she was sure about this. She said yes and that she told (Resident #2) that she was gonna tell." She was asked what she did after the allegation. She stated, "I tried to investigate to the best of my ability. I called the DON and asked what should I do. She told me to call the Administrator. I did and she told me to put (Resident #1) in another room. I tried to put her in the room with another resident and that resident refused. And (Resident #1) refused to go to another room. Then (Resident #1) said she forgave (Resident #2) and that she didn't want to change rooms. I told the Administrator that (Resident #1) said she forgave (Resident #2). So she said if (Resident #1) didn't want to move, just let her stay and she would take care of it tomorrow." She was asked if she felt like (Resident #1) had been protected from further potential sexual aggression since the allegation. She stated, "She's still in the same room with her, so...I don't know. I don't know what else I could have done." She was asked if she was aware of any other incidents involving Resident #2. She stated, "I've never observed any, but a CNA who used to work at (another long term care facility) told me that when she was there, they heard screaming and found (Resident #2) on top of a resident on the floor. She had her skirt pulled up and panties pulled down." She was asked if she believed Resident #1. She stated, "Yes I do. Her story hasn't changed since this happened." f. On 9/23/13 at 5:27 p.m., CNA #1 was asked during a telephone interview about the alleged incident on 9/15/13. She stated, "Early, around 6:30 a.m., she called me over to her table in the dining room. She was crying. I asked her what was wrong. She was whispering to me and told me about her roommate sticking fingers up in her. She said it hurt her. I immediately went and got the nurse and (Resident #1) told her the same thing. She was so scared that she wouldn't even take a shower because (Resident #2) was in there." CNA #1 was asked if she believed Resident #1. She stated, "Her story has not changed. Yes I do. And she was crying." She was asked what the facility did to protect Resident #1 after the allegation. She stated, "I told (LPN #1). I wrote out a witness statement as to what (Resident #1) said. I can tell you they asked (Resident #1) if she wanted to go to another room and she said no. I can tell you that (LPN #1) called the Administrator, but other than that... I don't think anything was done because they're both confused and they have no family." She was asked if she was aware that any previous incidents had occurred with Resident #2. She stated, "I don't think so here at this facility. When she was at (a different long term care facility), I heard that she did stuff to residents there." She was asked if she had been inserviced on anything since the incident. She stated, "No." g. On 9/23/13 at 5:51 p.m., the DON was asked about the allegation Resident #1 made on 9/15/13. She stated, "(LPN #1) called me at home and told me. I told her to call the Administrator. I called her back after she called the Administrator. We had several phone conversations." She was asked what the facility did after she became aware of the allegation. She stated, "Me and (Administrator) talked to (Resident #1). (Resident #1) often delivers babies...she has some pretty good tales. And her stories are never consistent." The DON was asked what the facility did to protect Resident #1 after the allegation. She stated, "She doesn't want to move. My understanding was that (Resident #2) and (Resident #1) were roommates at (a different long term care facility). I talked to the nurse that worked the 11/7 shift and she said that (Resident #2) had been up most of the night around the nurse's station so she didn't see how that could've happened." The DON was asked if anything else was done. She stated, "That's really about it. We offered on Monday to (Resident #1) if she wanted to move or wanted another room and she said no. Then she started laughing and said she was gonna get married." She was asked if moving Resident #2 was ever discussed. She stated, "I don't think we specifically talked about moving (Resident #2)." She was asked if Resident #1 had ever made an allegation like this before. She stated, "To my knowledge, no. Certainly not since I've been here. I believe if she had said this before, then it would've come up." She was asked if the alleged incident had been investigated. She stated, "Me and (Administrator) typed up some stuff." She was asked if it was reported to the appropriate agencies. She stated, "No." When asked why, she stated, "With the stories she tells, we just didn't feel like it should be reported. After talking to staff and (Resident #1), we just didn't feel that anything happened." The DON was asked if the facility collected witness statements from staff she spoke with. She stated, "No." She was asked if staff had been inserviced on abuse/neglect since the alleged incident. She stated, "No." h. On 9/23/13 at 6:20 p.m., the Administrator was asked during an interview about the alleged incident on 9/15/13. She stated, "When we visited with (Resident #1), we couldn't see to where it was possible because what she told (DON) was that she was getting dressed for bed and (Resident #2) came over and poked her. She said she told her to stop or she was gonna tell. We asked her if that was all that happened. She said yes. We asked her if she wanted to change rooms and she said no. Then she started saying she was gonna get married." The Administrator was asked what the facility did to protect the resident after she made the allegation. She stated, "I do know they put her in a room to take a nap. At least that was the plan, but (Resident #1) might not have went and laid down." She was asked if moving Resident #2 was an option that was discussed since it was obvious that Resident #1 did not want to change rooms. She stated, "If you try to move (Resident #2), she's gonna go back to that same room. One time we put her on the unit and we couldn't keep her back there. She kept getting out." She was asked if the resident was placed 1:1 after the allegation to ensure nothing happened to Resident #1 or any other resident. She stated, "No. That one fell between the cracks." The Administrator was asked if staff and residents were interviewed after the allegation. She stated, "We talked to (LPN #1), (Resident #1)...I'm not sure who else." She was asked if the alleged incident was reported. She stated, "No, because (Resident #1) is always telling stories." i. On 9/24/13 at 8:20 a.m., the Administrator provided a typed statement dated 9/16/13 that was signed by her and the DON. It documented, "On Monday, September 16, 2013, (DON) and myself sat down with (Resident #1) to discuss any problems between her and her roommate (Resident #2). (Resident #1) stated that she was changing clothes getting ready for bed while (Resident #2) was sitting on her own bed. (Resident #1) stated that (Resident #2) 'poked her' and she told her to stop. She was going to tell on her. (DON) asked (Resident #1) what did (Resident #2) do then and she stated that she stopped. We asked (Resident #1) if she could tell us when this happened and she was not sure when it was. We asked (Resident #1) if she wanted to move to a different room and she said no, she liked having (Resident #2) as a roommate. During this discussion, (Resident #1) changed the subject to start talking about she wanted to get married and we asked her to whom and she said a name that neither of us could understand. During this conversation, (Resident #1) was in a very good mood and laughing. We spoke with night shift LPN. She stated that the night before (Resident #1) stated this took place, (Resident #2) had not been in her room. (Resident #2) did not sleep that night and she was up walking around the nurse's station and in the lobby. They had no knowledge of any time something could have happened. In conclusion, after talking with (Resident #1) regarding anything that might have happened between her and (Resident #2), the DON and I do not feel this incident is something that actually happened. (Resident #1) has a history of telling staff that she delivered a baby in her room and to the best of my knowledge, there has been no incident in the past that would lead us to believe that (Resident #2) would actually do something of this nature." j. On 9/24/13 at 8:20 a.m., the Administrator also provided a DMS-7734 dated 9/23/13 that documented, "(Resident #1) alleged that her roommate (Resident #2) came to her bed and stuck three fingers inside of her and it felt like a 'dick' but I didn't like it so I told her to stop." The section titled Steps Taken to Prevent Continued Abuse or Neglect During the Investigation documented, "On 9/15/13 at 8:30 a.m., initially residents were separated..." 1) On 9/24/13 at 9:25 a.m., LPN #1 was asked if the residents were separated as the DMS-7734 documented. She stated, "No they weren't." 2) On 9/24/13 at 9:40 a.m., CNA #2 was asked if she knew anything about the alleged incident on 9/15/13. She stated, "I really do believe that (Resident #1) wouldn't say something like that unless it happened. (Resident #2) is bi-sexual. I used to work with her at (a different long term care facility). She would grab my breasts... I know that every once in a while, (Resident #1) will have a funny story and it's like where did that come from? But her story hasn't changed about this. She wouldn't have said this if it didn't happen." She was asked if she was aware of any previous incidents. She stated, "I haven't seen her do anything here, but other CNAs said she was caught kissing another resident and that resident had to be moved. I have heard (Resident #1) say that lady tried to mess with me last night, but she would never say who." 3) On 9/24/13 at 10:15 a.m., LPN #2, who was on duty the 11/7 shift on 9/14/13-9/15/13, was asked during a telephone interview about Resident #2's activities that night on her shift. She stated, "She was at the nurse's station 90% of the night or she was in the dining room. She is very restless and very mobile." She was asked if she could say without a doubt that Resident #2 was not in her room at all that night. She stated, "No. I can't. I can't watch a resident every minute I'm there." She was asked if Resident #1 had made allegations like this before. She stated, "She has never alleged that (Resident #2) or anyone has done anything like that, but she does tell stories." 4) On 9/24/13 at 10:50 a.m., LPN #3 was asked if she had ever observed any sexually inappropriate behaviors from Resident #2. She stated, "No I haven't." She was asked if Resident #1 had a history of [REDACTED]. She stated, "She's not made any allegations like that that I'm aware of, and I do believe her. She knows. Especially if she was visibly upset like they say she was. She might be impaired, but I believe her." 3. On 9/23/13 at 9:30 p.m., the immediate jeopardy was removed and the scope and severity reduced to an "E" when the facility initiated the following plan of removal: a. On 9/23/13 at 6:45 p.m., Resident #2 was placed on 1:1 monitoring until investigation is complete. b. On 9/23/13 at 6:45 p.m., DON contacted physician for Resident #1 and Resident #2. Physician stated due to the nature of the allegation that it is not necessary to sent Resident #1 to ER. Physician gave authorization to send Resident #2 to Geri-psych facility. c. On 9/23/13 at 7:10 p.m., DON contacted Geri-psych facility for possible admission. Information faxed but Geri-psych staff informed DON that no decisions could be made until morning of 9/24/13. d. On 9/23/13 at 7:30 p.m., an inservice was begun on resident abuse and neglect and how to report in a timely manner. Any employee on scheduled days off, vacation or leave of absence will be inserviced prior to returning to work. e. On 9/23/13 at 7:30 p.m., Administrator was inserviced by RDO (Regional Director of Operations) on investigating and reporting abuse. f. On 9/23/13 at 6:45 p.m. began interviewing all cognitive residents regarding any issues that they have had with Resident #2. No negative findings were noted. g. On 9/23/13 at 9:30 p.m., Administrator completed facility investigation report form 762 on alleged sexual abuse between Resident #1 and Resident #2 and faxed in to OLTC (Office of Long Term Care). h. On 9/23/13 at 8:10 p.m. began interviewing staff of any knowledge they have of sexual issues with Resident #2. i. Ongoing QA will be to interview all alert and oriented residents weekly regarding abuse, neglect, misappropriation. Any negative findings will be corrected and investigated immediately. CNAs will be randomly interviewed weekly to determine if there are any suspicions of abuse, neglect or misappropriation. Any negative findings will be corrected and investigated immediately. j. Resident council minutes will be reviewed monthly to ensure all concerns are identified. All negative findings will be addressed and corrected immediately. k. Grievance log will be reviewed and updated daily. All negative findings will be addressed and corrected immediately. l. Administrator or designee will present all negative findings to the QA&A committee monthly for tracking and trending.

Complaint # was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to ensure Resident #1 was provided the necessary care and services to attain her highest practicable physical, mental and psychosocial well being. The facility failed to thoroughly investigate an allegation of resident to resident sexual abuse and to immediately protect from the potential of further sexual abuse for 1 (Resident #1) of 5 (Residents #1 through #5) case mix residents who was cognitively impaired. This failure resulted in immediate jeopardy which caused or could have caused serious harm, injury or death to Resident #1, and had the potential to affect 43 residents in the facility who were cognitively impaired according to a list provided by the Administrator on 9/23/13 at 4:50 p.m. The facility was informed of the immediate jeopardy situation on 9/23/13 at 7:08 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/2/13 documented the resident scored 4 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), was independent with most activities of daily living and had verbal behavioral symptoms directed toward others. Resident #2 had [DIAGNOSES REDACTED]. The 30 day Medicare MDS with an ARD of 9/9/13 documented the resident scored 0 (0-7 indicates severe impairment) on the BIMS, required supervision or limited assist with most activities of daily living and had no behaviors. a. A Nurse's Note dated 9/15/13 at 9:45 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "...0830 - CNA (Certified Nursing Assistant) asked LPN to speak with resident. Resident (Resident #1) stated, '(Resident #2) came to my bed last night and put 3 fingers inside of me. It felt like a dick. But I didn't like it and told her to stop.' LPN asked resident if anything else happened. Stated, 'No. I was just laying there and she did that. I told her I was gonna tell.' LPN asked when this occurred. Resident stated, 'Last night.' DON (Director of Nursing) and Administrator notified. LPN instructed to move resident from room and close monitoring of other resident. No physical injuries noted." b. A Nurse's Note dated 9/15/13 at 1:00 p.m. and signed by LPN #1 documented, "Resident (Resident #1)states she does not want to move to a new room. States, 'I forgive her. I'm not moving to that other room.' Administrator notified." c. On 9/23/13 at 2:43 p.m. during initial rounds, Resident #1 was observed in bed. Resident #2 was also observed in bed in the same room. d. On 9/23/13 at 4:15 p.m., Resident #1 was asked during an interview if she remembered anything happening about a week ago that she reported to her nurse. She stated, "You mean about (Resident #2)? I sure do." She was asked to explain what happened. She stated, "(Resident #2) came over to me and put her fingers up in me (made a hand motion upward). It felt like.... you know, a dick." She was asked if she meant inside her vagina. She stated, "Yes." Resident #1 was asked why she thought Resident #2 would do that. She stated, "I don't know. To be funny I guess." She was asked if Resident #2 had ever done something like that to her before. She stated, "No. She ain't never done that before." She was asked if anything else had happened since the incident a week ago. She stated, "Last night (Resident #2) climbed on top of me in the bed... You know like a guy would do it if he was gonna do something to you? That's what she did." She was asked what she did when Resident #2 did this. She stated, "I wanted to hit her." She was asked if she had told anyone about the incident last night. She stated, "No. I ain't told nobody about that." She was asked if she was afraid of Resident #2. She stated, "I don't want to move rooms. She just needs to stay on her side." e. On 9/23/13 at 4:45 p.m., LPN #1 was asked during a telephone interview about the alleged incident on 9/15/13. She stated, "It was Sunday morning at breakfast time...(CNA #1) told me (Resident #1) had a complaint so I went and asked her what was wrong. She told me (Resident #2) came over to her, put 3 fingers inside her and it felt like a dick. I asked her if she was sure about this. She said yes and that she told (Resident #2) that she was gonna tell." She was asked what she did after the allegation. She stated, "I tried to investigate to the best of my ability. I called the DON and asked what should I do. She told me to call the Administrator. I did and she told me to put (Resident #1) in another room. I tried to put her in the room with another resident and that resident refused. And (Resident #1) refused to go to another room. Then (Resident #1) said she forgave (Resident #2) and that she didn't want to change rooms. I told the Administrator that (Resident #1) said she forgave (Resident #2). So she said if (Resident #1) didn't want to move, just let her stay and she would take care of it tomorrow." She was asked if she felt like (Resident #1) had been protected from further potential sexual aggression since the allegation. She stated, "She's still in the same room with her, so...I don't know. I don't know what else I could have done." She was asked if she was aware of any other incidents involving Resident #2. She stated, "I've never observed any, but a CNA who used to work at (another long term care facility) told me that when she was there, they heard screaming and found (Resident #2) on top of a resident on the floor. She had her skirt pulled up and panties pulled down." She was asked if she believed Resident #1. She stated, "Yes I do. Her story hasn't changed since this happened." f. On 9/23/13 at 5:27 p.m., CNA #1 was asked during a telephone interview about the alleged incident on 9/15/13. She stated, "Early, around 6:30 a.m., she called me over to her table in the dining room. She was crying. I asked her what was wrong. She was whispering to me and told me about her roommate sticking fingers up in her. She said it hurt her. I immediately went and got the nurse and (Resident #1) told her the same thing. She was so scared that she wouldn't even take a shower because (Resident #2) was in there." CNA #1 was asked if she believed Resident #1. She stated, "Her story has not changed. Yes I do. And she was crying." She was asked what the facility did to protect Resident #1 after the allegation. She stated, "I told (LPN #1). I wrote out a witness statement as to what (Resident #1) said. I can tell you they asked (Resident #1) if she wanted to go to another room and she said no. I can tell you that (LPN #1) called the Administrator, but other than that... I don't think anything was done because they're both confused and they have no family." She was asked if she was aware that any previous incidents had occurred with Resident #2. She stated, "I don't think so here at this facility. When she was at (a different long term care facility), I heard that she did stuff to residents there." She was asked if she had been inserviced on anything since the incident. She stated, "No." g. On 9/23/13 at 5:51 p.m., the DON was asked about the allegation Resident #1 made on 9/15/13. She stated, "(LPN #1) called me at home and told me. I told her to call the Administrator. I called her back after she called the Administrator. We had several phone conversations." She was asked what the facility did after she became aware of the allegation. She stated, "Me and (Administrator) talked to (Resident #1). (Resident #1) often delivers babies...she has some pretty good tales. And her stories are never consistent." The DON was asked what the facility did to protect Resident #1 after the allegation. She stated, "She doesn't want to move. My understanding was that (Resident #2) and (Resident #1) were roommates at (a different long term care facility). I talked to the nurse that worked the 11/7 shift and she said that (Resident #2) had been up most of the night around the nurse's station so she didn't see how that could've happened." The DON was asked if anything else was done. She stated, "That's really about it. We offered on Monday to (Resident #1) if she wanted to move or wanted another room and she said no. Then she started laughing and said she was gonna get married." She was asked if moving Resident #2 was ever discussed. She stated, "I don't think we specifically talked about moving (Resident #2)." She was asked if Resident #1 had ever made an allegation like this before. She stated, "To my knowledge, no. Certainly not since I've been here. I believe if she had said this before, then it would've come up." She was asked if the alleged incident had been investigated. She stated, "Me and (Administrator) typed up some stuff." She was asked if it was reported to the appropriate agencies. She stated, "No." When asked why, she stated, "With the stories she tells, we just didn't feel like it should be reported. After talking to staff and (Resident #1), we just didn't feel that anything happened." The DON was asked if the facility collected witness statements from staff she spoke with. She stated, "No." She was asked if staff had been inserviced on abuse/neglect since the alleged incident. She stated, "No." h. On 9/23/13 at 6:20 p.m., the Administrator was asked during an interview about the alleged incident on 9/15/13. She stated, "When we visited with (Resident #1), we couldn't see to where it was possible because what she told (DON) was that she was getting dressed for bed and (Resident #2) came over and poked her. She said she told her to stop or she was gonna tell. We asked her if that was all that happened. She said yes. We asked her if she wanted to change rooms and she said no. Then she started saying she was gonna get married." The Administrator was asked what the facility did to protect the resident after she made the allegation. She stated, "I do know they put her in a room to take a nap. At least that was the plan, but (Resident #1) might not have went and laid down." She was asked if moving Resident #2 was an option that was discussed since it was obvious that Resident #1 did not want to change rooms. She stated, "If you try to move (Resident #2), she's gonna go back to that same room. One time we put her on the unit and we couldn't keep her back there. She kept getting out." She was asked if the resident was placed 1:1 after the allegation to ensure nothing happened to Resident #1 or any other resident. She stated, "No. That one fell between the cracks." The Administrator was asked if staff and residents were interviewed after the allegation. She stated, "We talked to (LPN #1), (Resident #1)...I'm not sure who else." She was asked if the alleged incident was reported. She stated, "No, because (Resident #1) is always telling stories." i. On 9/24/13 at 8:20 a.m., the Administrator provided a typed statement dated 9/16/13 that was signed by her and the DON. It documented, "On Monday, September 16, 2013, (DON) and myself sat down with (Resident #1) to discuss any problems between her and her roommate (Resident #2). (Resident #1) stated that she was changing clothes getting ready for bed while (Resident #2) was sitting on her own bed. (Resident #1) stated that (Resident #2) 'poked her' and she told her to stop. She was going to tell on her. (DON) asked (Resident #1) what did (Resident #2) do then and she stated that she stopped. We asked (Resident #1) if she could tell us when this happened and she was not sure when it was. We asked (Resident #1) if she wanted to move to a different room and she said no, she liked having (Resident #2) as a roommate. During this discussion, (Resident #1) changed the subject to start talking about she wanted to get married and we asked her to whom and she said a name that neither of us could understand. During this conversation, (Resident #1) was in a very good mood and laughing. We spoke with night shift LPN. She stated that the night before (Resident #1) stated this took place, (Resident #2) had not been in her room. (Resident #2) did not sleep that night and she was up walking around the nurse's station and in the lobby. They had no knowledge of any time something could have happened. In conclusion, after talking with (Resident #1) regarding anything that might have happened between her and (Resident #2), the DON and I do not feel this incident is something that actually happened. (Resident #1) has a history of telling staff that she delivered a baby in her room and to the best of my knowledge, there has been no incident in the past that would lead us to believe that (Resident #2) would actually do something of this nature." j. On 9/24/13 at 8:20 a.m., the Administrator also provided a DMS-7734 dated 9/23/13 that documented, "(Resident #1) alleged that her roommate (Resident #2) came to her bed and stuck three fingers inside of her and it felt like a 'dick' but I didn't like it so I told her to stop." The section titled Steps Taken to Prevent Continued Abuse or Neglect During the Investigation documented, "On 9/15/13 at 8:30 a.m., initially residents were separated..." 1) On 9/24/13 at 9:25 a.m., LPN #1 was asked if the residents were separated as the DMS-7734 documented. She stated, "No they weren't." 2) On 9/24/13 at 9:40 a.m., CNA #2 was asked if she knew anything about the alleged incident on 9/15/13. She stated, "I really do believe that (Resident #1) wouldn't say something like that unless it happened. (Resident #2) is bi-sexual. I used to work with her at (a different long term care facility). She would grab my breasts... I know that every once in a while, (Resident #1) will have a funny story and it's like where did that come from? But her story hasn't changed about this. She wouldn't have said this if it didn't happen." She was asked if she was aware of any previous incidents. She stated, "I haven't seen her do anything here, but other CNAs said she was caught kissing another resident and that resident had to be moved. I have heard (Resident #1) say that lady tried to mess with me last night, but she would never say who." 3) On 9/24/13 at 10:15 a.m., LPN #2, who was on duty the 11/7 shift on 9/14/13-9/15/13, was asked during a telephone interview about Resident #2's activities that night on her shift. She stated, "She was at the nurse's station 90% of the night or she was in the dining room. She is very restless and very mobile." She was asked if she could say without a doubt that Resident #2 was not in her room at all that night. She stated, "No. I can't. I can't watch a resident every minute I'm there." She was asked if Resident #1 had made allegations like this before. She stated, "She has never alleged that (Resident #2) or anyone has done anything like that, but she does tell stories." 4) On 9/24/13 at 10:50 a.m., LPN #3 was asked if she had ever observed any sexually inappropriate behaviors from Resident #2. She stated, "No I haven't." She was asked if Resident #1 had a history of [REDACTED]. She stated, "She's not made any allegations like that that I'm aware of, and I do believe her. She knows. Especially if she was visibly upset like they say she was. She might be impaired, but I believe her." 2. On 9/23/13 at 9:30 p.m., the immediate jeopardy was removed and the scope and severity reduced to an "E" when the facility initiated the following plan of removal: a. On 9/23/13 at 6:45 p.m., Resident #2 was placed on 1:1 monitoring until investigation is complete. b. On 9/23/13 at 6:45 p.m., DON contacted physician for Resident #1 and Resident #2. Physician stated due to the nature of the allegation that it is not necessary to sent Resident #1 to ER. Physician gave authorization to send Resident #2 to Geri-psych facility. c. On 9/23/13 at 7:10 p.m., DON contacted Geri-psych facility for possible admission. Information faxed but Geri-psych staff informed DON that no decisions could be made until morning of 9/24/13. d. On 9/23/13 at 7:30 p.m., an inservice was begun on resident abuse and neglect and how to report in a timely manner. Any employee on scheduled days off, vacation or leave of absence will be inserviced prior to returning to work. e. On 9/23/13 at 7:30 p.m., Administrator was inserviced by RDO (Regional Director of Operations) on investigating and reporting abuse. f. On 9/23/13 at 6:45 p.m. began interviewing all cognitive residents regarding any issues that they have had with Resident #2. No negative findings were noted. g. On 9/23/13 at 9:30 p.m., Administrator completed facility investigation report form 762 on alleged sexual abuse between Resident #1 and Resident #2 and faxed in to OLTC (Office of Long Term Care). h. On 9/23/13 at 8:10 p.m. began interviewing staff of any knowledge they have of sexual issues with Resident #2. i. Ongoing QA will be to interview all alert and oriented residents weekly regarding abuse, neglect, misappropriation. Any negative findings will be corrected and investigated immediately. CNAs will be randomly interviewed weekly to determine if there are any suspicions of abuse, neglect or misappropriation. Any negative findings will be corrected and investigated immediately. j. Resident council minutes will be reviewed monthly to ensure all concerns are identified. All negative findings will be addressed and corrected immediately. k. Grievance log will be reviewed and updated daily. All negative findings will be addressed and corrected immediately. l. Administrator or designee will present all negative findings to the QA&A committee monthly for tracking and trending.

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, facility Administration and Nursing Administration failed to ensure a thorough investigation of an allegation of resident to resident sexual abuse and to ensure the provision of immediate protection from the potential of further sexual abuse for 1 (Resident #1) of 5 (Residents #1 through #5) case mix residents who was cognitively impaired. This failure resulted in immediate jeopardy which caused or could have caused serious harm, injury or death to Resident #1, and had the potential to affect 43 residents in the facility who were cognitively impaired according to a list provided by the Administrator on 9/23/13 at 4:50 p.m. The facility was informed of the immediate jeopardy situation on 9/23/13 at 7:08 p.m. The findings are: 1. The job description titled "Executive Director" dated 8/31/09 documented, "General Purpose: To lead and direct the overall operations of the facility... Duties: Leads the facility management staff and consultants in developing and working from a business plan that focuses on all aspects of (facility)... Oversees regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility; moral of the staff; and ensures resident needs are being addressed..." 2. The job description titled "Director of Nursing Services" dated 8/31/09 documented, "General Purpose: To manage overall operation of the Nursing Services Department in accordance with (facility) policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs... Essential job functions: Assure residents of a comfortable, clean, orderly and safe environment... Organize, develop, and direct the administration and resident care of the nursing service department..." 3. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/2/13 documented the resident scored 4 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), was independent with most activities of daily living and had verbal behavioral symptoms directed toward others. Resident #2 had [DIAGNOSES REDACTED]. The 30 day Medicare MDS with an ARD of 9/9/13 documented the resident scored 0 (0-7 indicates severe impairment) on the BIMS, required supervision or limited assist with most activities of daily living and had no behaviors. a. A Nurse's Note dated 9/15/13 at 9:45 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "...0830 - CNA (Certified Nursing Assistant) asked LPN to speak with resident. Resident (Resident #1) stated, '(Resident #2) came to my bed last night and put 3 fingers inside of me. It felt like a dick. But I didn't like it and told her to stop.' LPN asked resident if anything else happened. Stated, 'No. I was just laying there and she did that. I told her I was gonna tell.' LPN asked when this occurred. Resident stated, 'Last night.' DON (Director of Nursing) and Administrator notified. LPN instructed to move resident from room and close monitoring of other resident. No physical injuries noted." b. A Nurse's Note dated 9/15/13 at 1:00 p.m. and signed by LPN #1 documented, "Resident (Resident #1)states she does not want to move to a new room. States, 'I forgive her. I'm not moving to that other room.' Administrator notified." c. On 9/23/13 at 2:43 p.m. during initial rounds, Resident #1 was observed in bed. Resident #2 was also observed in bed in the same room. d. On 9/23/13 at 4:15 p.m., Resident #1 was asked during an interview if she remembered anything happening about a week ago that she reported to her nurse. She stated, "You mean about (Resident #2)? I sure do." She was asked to explain what happened. She stated, "(Resident #2) came over to me and put her fingers up in me (made a hand motion upward). It felt like.... you know, a dick." She was asked if she meant inside her vagina. She stated, "Yes." Resident #1 was asked why she thought Resident #2 would do that. She stated, "I don't know. To be funny I guess." She was asked if Resident #2 had ever done something like that to her before. She stated, "No. She ain't never done that before." She was asked if anything else had happened since the incident a week ago. She stated, "Last night (Resident #2) climbed on top of me in the bed... You know like a guy would do it if he was gonna do something to you? That's what she did." She was asked what she did when Resident #2 did this. She stated, "I wanted to hit her." She was asked if she had told anyone about the incident last night. She stated, "No. I ain't told nobody about that." She was asked if she was afraid of Resident #2. She stated, "I don't want to move rooms. She just needs to stay on her side." e. On 9/23/13 at 4:45 p.m., LPN #1 was asked during a telephone interview about the alleged incident on 9/15/13. She stated, "It was Sunday morning at breakfast time...(CNA #1) told me (Resident #1) had a complaint so I went and asked her what was wrong. She told me (Resident #2) came over to her, put 3 fingers inside her and it felt like a dick. I asked her if she was sure about this. She said yes and that she told (Resident #2) that she was gonna tell." She was asked what she did after the allegation. She stated, "I tried to investigate to the best of my ability. I called the DON and asked what should I do. She told me to call the Administrator. I did and she told me to put (Resident #1) in another room. I tried to put her in the room with another resident and that resident refused. And (Resident #1) refused to go to another room. Then (Resident #1) said she forgave (Resident #2) and that she didn't want to change rooms. I told the Administrator that (Resident #1) said she forgave (Resident #2). So she said if (Resident #1) didn't want to move, just let her stay and she would take care of it tomorrow." She was asked if she felt like (Resident #1) had been protected from further potential sexual aggression since the allegation. She stated, "She's still in the same room with her, so...I don't know. I don't know what else I could have done." She was asked if she was aware of any other incidents involving Resident #2. She stated, "I've never observed any, but a CNA who used to work at (another long term care facility) told me that when she was there, they heard screaming and found (Resident #2) on top of a resident on the floor. She had her skirt pulled up and panties pulled down." She was asked if she believed Resident #1. She stated, "Yes I do. Her story hasn't changed since this happened." f. On 9/23/13 at 5:27 p.m., CNA #1 was asked during a telephone interview about the alleged incident on 9/15/13. She stated, "Early, around 6:30 a.m., she called me over to her table in the dining room. She was crying. I asked her what was wrong. She was whispering to me and told me about her roommate sticking fingers up in her. She said it hurt her. I immediately went and got the nurse and (Resident #1) told her the same thing. She was so scared that she wouldn't even take a shower because (Resident #2) was in there." CNA #1 was asked if she believed Resident #1. She stated, "Her story has not changed. Yes I do. And she was crying." She was asked what the facility did to protect Resident #1 after the allegation. She stated, "I told (LPN #1). I wrote out a witness statement as to what (Resident #1) said. I can tell you they asked (Resident #1) if she wanted to go to another room and she said no. I can tell you that (LPN #1) called the Administrator, but other than that... I don't think anything was done because they're both confused and they have no family." She was asked if she was aware that any previous incidents had occurred with Resident #2. She stated, "I don't think so here at this facility. When she was at (a different long term care facility), I heard that she did stuff to residents there." She was asked if she had been inserviced on anything since the incident. She stated, "No." g. On 9/23/13 at 5:51 p.m., the DON was asked about the allegation Resident #1 made on 9/15/13. She stated, "(LPN #1) called me at home and told me. I told her to call the Administrator. I called her back after she called the Administrator. We had several phone conversations." She was asked what the facility did after she became aware of the allegation. She stated, "Me and (Administrator) talked to (Resident #1). (Resident #1) often delivers babies...she has some pretty good tales. And her stories are never consistent." The DON was asked what the facility did to protect Resident #1 after the allegation. She stated, "She doesn't want to move. My understanding was that (Resident #2) and (Resident #1) were roommates at (a different long term care facility). I talked to the nurse that worked the 11/7 shift and she said that (Resident #2) had been up most of the night around the nurse's station so she didn't see how that could've happened." The DON was asked if anything else was done. She stated, "That's really about it. We offered on Monday to (Resident #1) if she wanted to move or wanted another room and she said no. Then she started laughing and said she was gonna get married." She was asked if moving Resident #2 was ever discussed. She stated, "I don't think we specifically talked about moving (Resident #2)." She was asked if Resident #1 had ever made an allegation like this before. She stated, "To my knowledge, no. Certainly not since I've been here. I believe if she had said this before, then it would've come up." She was asked if the alleged incident had been investigated. She stated, "Me and (Administrator) typed up some stuff." She was asked if it was reported to the appropriate agencies. She stated, "No." When asked why, she stated, "With the stories she tells, we just didn't feel like it should be reported. After talking to staff and (Resident #1), we just didn't feel that anything happened." The DON was asked if the facility collected witness statements from staff she spoke with. She stated, "No." She was asked if staff had been inserviced on abuse/neglect since the alleged incident. She stated, "No." h. On 9/23/13 at 6:20 p.m., the Administrator was asked during an interview about the alleged incident on 9/15/13. She stated, "When we visited with (Resident #1), we couldn't see to where it was possible because what she told (DON) was that she was getting dressed for bed and (Resident #2) came over and poked her. She said she told her to stop or she was gonna tell. We asked her if that was all that happened. She said yes. We asked her if she wanted to change rooms and she said no. Then she started saying she was gonna get married." The Administrator was asked what the facility did to protect the resident after she made the allegation. She stated, "I do know they put her in a room to take a nap. At least that was the plan, but (Resident #1) might not have went and laid down." She was asked if moving Resident #2 was an option that was discussed since it was obvious that Resident #1 did not want to change rooms. She stated, "If you try to move (Resident #2), she's gonna go back to that same room. One time we put her on the unit and we couldn't keep her back there. She kept getting out." She was asked if the resident was placed 1:1 after the allegation to ensure nothing happened to Resident #1 or any other resident. She stated, "No. That one fell between the cracks." The Administrator was asked if staff and residents were interviewed after the allegation. She stated, "We talked to (LPN #1), (Resident #1)...I'm not sure who else." She was asked if the alleged incident was reported. She stated, "No, because (Resident #1) is always telling stories." i. On 9/24/13 at 8:20 a.m., the Administrator provided a typed statement dated 9/16/13 that was signed by her and the DON. It documented, "On Monday, September 16, 2013, (DON) and myself sat down with (Resident #1) to discuss any problems between her and her roommate (Resident #2). (Resident #1) stated that she was changing clothes getting ready for bed while (Resident #2) was sitting on her own bed. (Resident #1) stated that (Resident #2) 'poked her' and she told her to stop. She was going to tell on her. (DON) asked (Resident #1) what did (Resident #2) do then and she stated that she stopped. We asked (Resident #1) if she could tell us when this happened and she was not sure when it was. We asked (Resident #1) if she wanted to move to a different room and she said no, she liked having (Resident #2) as a roommate. During this discussion, (Resident #1) changed the subject to start talking about she wanted to get married and we asked her to whom and she said a name that neither of us could understand. During this conversation, (Resident #1) was in a very good mood and laughing. We spoke with night shift LPN. She stated that the night before (Resident #1) stated this took place, (Resident #2) had not been in her room. (Resident #2) did not sleep that night and she was up walking around the nurse's station and in the lobby. They had no knowledge of any time something could have happened. In conclusion, after talking with (Resident #1) regarding anything that might have happened between her and (Resident #2), the DON and I do not feel this incident is something that actually happened. (Resident #1) has a history of telling staff that she delivered a baby in her room and to the best of my knowledge, there has been no incident in the past that would lead us to believe that (Resident #2) would actually do something of this nature." j. On 9/24/13 at 8:20 a.m., the Administrator also provided a DMS-7734 dated 9/23/13 that documented, "(Resident #1) alleged that her roommate (Resident #2) came to her bed and stuck three fingers inside of her and it felt like a 'dick' but I didn't like it so I told her to stop." The section titled Steps Taken to Prevent Continued Abuse or Neglect During the Investigation documented, "On 9/15/13 at 8:30 a.m., initially residents were separated..." 1) On 9/24/13 at 9:25 a.m., LPN #1 was asked if the residents were separated as the DMS-7734 documented. She stated, "No they weren't." 2) On 9/24/13 at 9:40 a.m., CNA #2 was asked if she knew anything about the alleged incident on 9/15/13. She stated, "I really do believe that (Resident #1) wouldn't say something like that unless it happened. (Resident #2) is bi-sexual. I used to work with her at (a different long term care facility). She would grab my breasts... I know that every once in a while, (Resident #1) will have a funny story and it's like where did that come from? But her story hasn't changed about this. She wouldn't have said this if it didn't happen." She was asked if she was aware of any previous incidents. She stated, "I haven't seen her do anything here, but other CNAs said she was caught kissing another resident and that resident had to be moved. I have heard (Resident #1) say that lady tried to mess with me last night, but she would never say who." 3) On 9/24/13 at 10:15 a.m., LPN #2, who was on duty the 11/7 shift on 9/14/13-9/15/13, was asked during a telephone interview about Resident #2's activities that night on her shift. She stated, "She was at the nurse's station 90% of the night or she was in the dining room. She is very restless and very mobile." She was asked if she could say without a doubt that Resident #2 was not in her room at all that night. She stated, "No. I can't. I can't watch a resident every minute I'm there." She was asked if Resident #1 had made allegations like this before. She stated, "She has never alleged that (Resident #2) or anyone has done anything like that, but she does tell stories." 4) On 9/24/13 at 10:50 a.m., LPN #3 was asked if she had ever observed any sexually inappropriate behaviors from Resident #2. She stated, "No I haven't." She was asked if Resident #1 had a history of [REDACTED]. She stated, "She's not made any allegations like that that I'm aware of, and I do believe her. She knows. Especially if she was visibly upset like they say she was. She might be impaired, but I believe her." 4. On 9/23/13 at 9:30 p.m., the immediate jeopardy was removed and the scope and severity reduced to an "E" when the facility initiated the following plan of removal: a. On 9/23/13 at 6:45 p.m., Resident #2 was placed on 1:1 monitoring until investigation is complete. b. On 9/23/13 at 6:45 p.m., DON contacted physician for Resident #1 and Resident #2. Physician stated due to the nature of the allegation that it is not necessary to sent Resident #1 to ER. Physician gave authorization to send Resident #2 to Geri-psych facility. c. On 9/23/13 at 7:10 p.m., DON contacted Geri-psych facility for possible admission. Information faxed but Geri-psych staff informed DON that no decisions could be made until morning of 9/24/13. d. On 9/23/13 at 7:30 p.m., an inservice was begun on resident abuse and neglect and how to report in a timely manner. Any employee on scheduled days off, vacation or leave of absence will be inserviced prior to returning to work. e. On 9/23/13 at 7:30 p.m., Administrator was inserviced by RDO (Regional Director of Operations) on investigating and reporting abuse. f. On 9/23/13 at 6:45 p.m. began interviewing all cognitive residents regarding any issues that they have had with Resident #2. No negative findings were noted. g. On 9/23/13 at 9:30 p.m., Administrator completed facility investigation report form 762 on alleged sexual abuse between Resident #1 and Resident #2 and faxed in to OLTC (Office of Long Term Care). h. On 9/23/13 at 8:10 p.m. began interviewing staff of any knowledge they have of sexual issues with Resident #2. i. Ongoing QA will be to interview all alert and oriented residents weekly regarding abuse, neglect, misappropriation. Any negative findings will be corrected and investigated immediately. CNAs will be randomly interviewed weekly to determine if there are any suspicions of abuse, neglect or misappropriation. Any negative findings will be corrected and investigated immediately. j. Resident council minutes will be reviewed monthly to ensure all concerns are identified. All negative findings will be addressed and corrected immediately. k. Grievance log will be reviewed and updated daily. All negative findings will be addressed and corrected immediately. l. Administrator or designee will present all negative findings to the QA&A committee monthly for tracking and trending.

Complaint # was substantiated, all or in part with these findings: Based on observation, record review and interview, the facility failed to provide necessary treatment and services to promote the healing of pressure ulcers for Residents #1 and #4. The facility failed to assess and monitor existing pressure ulcers which resulted in the deterioration of pressure ulcers for 2 (Residents #1 and #4) of 3 (Residents #1, #4 and #5) case mix residents who had pressure ulcers. The facility failed to immediately consult with the physician regarding the development of a new pressure ulcer which resulted in a delay of treatment and the area becoming larger for 1 (Resident #1) of 3 (Residents #1, #4 and #5) case mix residents who had pressure ulcers. The facility failed to develop a plan of care with individualized interventions to prevent pressure ulcers for residents assessed to be at risk for the development of pressure ulcers for 1 (Resident #1) of 3 (Residents #1, #4 and #5) case mix residents who had pressure ulcers. These failures resulted in a pattern of harm for Residents #1 and #4 and according to a list provided by the Director of Nursing on 5/17/12 at 10:00 a.m., had the potential to cause more than minimal harm to 33 residents in the facility who was at risk for developing pressure ulcers. The findings are: 1. The facility's policy and procedure for Prevention of Pressure Ulcers documented, "The purpose of this procedure is to provide guidelines for skin care to assist in preventing the development of pressure ulcers in residents identified to be at risk... Pressure can also come from splints, casts, bandages and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected... Pressure ulcers are a serious skin condition for the resident. Routinely assess and document the condition of the resident's skin... While in bed, every attempt should be made to "float heels" (keeping heels off of the bed)... Monitor nutrition and hydration status..." 2. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, required extensive assistance from staff for bed mobility, was totally dependent on staff for transfers and was at risk for developing pressure ulcers, but had no pressure ulcers at the time of the assessment. The Braden Scale for Predicting Pressure Sore Risk dated 2/21/12 documented a score of 15 (15-18 indicates a mild risk for pressure ulcer development). The Care Plan dated 2/16/11 (Error in date on written careplan. It is signed 2/21/12) did not address the potential for pressure ulcer development or list interventions to prevent pressure ulcer development. a. The Weight Change Comparison form documented the resident's January 2012 weight as 176.0 pounds, the February 2012 weight as 172.5 pounds and on March 1, 2012, the weight was documented as 164.0 pounds. The Weekly Weights form documented the resident's weight on 3/8/12 as 162.0 pounds, 3/12/12 as 160.0 pounds and 3/19/12 as 158 pounds, a 10.2% weight loss since 1/4/12. 1) A Dietary Progress Note dated 3/19/12 and signed by the Registered Dietician (RD) documented, "Now wt (weight) 160# (pounds) given so weight loss confirmed. Nurse reports resident had a period of very poor oral intake, swallowing problem... Remains on LCS (Low Concentrated Sweet) with inadequate intake - not > (greater than) 50%. Plan... Begin SF (sugar free) shake with lunch and supper, continue weekly weight, monitor for safe swallow." The Weekly Weights form documented the resident's weight on 3/27/12 as 155.0 pounds and on 4/2/12 as 153.0 pounds. 2) A Dietary Progress Note dated 4/5/12 and signed by the RD documented, "Wt 153#, down 11# = 6.7% in 30 days. Was 160# at RD review on 3/19/12. Still on LCS diet, no supplements ordered as requested by RD... Meal intake often < (less than) 50% with 0-240 cc (cubic centimeters) liquid/meal. No new lab reports... Plan: Request change to mech soft and LCS, add SF shake lunch and supper. Monitor chew, swallowing." b. A Physician order [REDACTED]." (Initially recommended by RD on 3/19/12) c. A Nurse's Note dated 4/6/12 at 1:00 p.m. documented, "Notified (Physician) of weight loss." d. A Nurse's Note dated 4/9/12 at 2:00 p.m. documented, "This LPN (Licensed Practical Nurse) received TO (telephone order) from (Physician) for treatment of [REDACTED]." A Physician order [REDACTED]." e. A Nurse's Note dated 4/10/12 at 1:30 p.m. and signed by LPN #1 documented, "An open area on right buttock, diaper line area, area has red and purple discoloration. 2.5 x 0.8 cm. Will cont (continue) to monitor and treat per orders." f. The Weekly Weight form documented the resident's weight on 4/10/12 as 151.5 pounds. g. An Other Skin Issues report dated 4/13/12 documented, "Open area lower right buttock. Clean with saf-clens, apply [MEDICATION NAME], change every 3 days and prn." h. A Nurse's Note dated 4/14/12 at 4:10 p.m. and signed by Registered Nurse (RN) #1 documented, "Was called to resident room by CNA (Certified Nurse Assistant) and asked if I was going to change dressing. Resident has order for [MEDICATION NAME]. Removed dressing ([MEDICATION NAME]) and noted 5 cm x 5 cm area to right ischium. Noted dark purple intact skin. Surrounding tissue is red... Suspected deep tissue injury... Cleaned as ordered and applied [MEDICATION NAME]. Will notify physician by charge nurse. Encouraged resident to stay off area. Will continue to monitor." On 5/17/12 at 11:00 a.m., RN #1 was asked during a telephone interview if she notified (Resident #1's) physician on 4/14/12 when she observed the resident's wound and suspected a deep tissue injury. She stated, "I'm not the charge nurse. I'm the weekend RN supervisor. The charge nurse went down there with me." RN #1 was asked if she was supposed to notify the physician. She stated, "No, LPN #4 said he was going to." RN #1 was asked if she remembered what the wound looked like. She stated, "I just knew it looked a lot worse than the last time I looked at it. And a CNA in the room also said it looked a lot worse." 1) A Nurse's Note dated 4/15/12 at 9:55 a.m. documented, "Left message at (physician) home phone regarding area on bottom. (Physician) is on call for (resident's Physician)." 2) A Nurse's Note dated 4/16/12 at 8:30 a.m. and signed by LPN #1 documented, "Area shows no improvement and resident remains uncooperative with attempts to relieve pressure. Will contact (Physician) and report condition of wound and seek new orders. 11:15 a.m. - Spoke with (Physician office), condition of wound reported. New orders received to refer to wound clinic for eval (evaluation) and treatment... Evaluation and treatment orders faxed to wound care as received from (Physician). Call placed to verify that orders had been received, informed at this time that orders had been received." i. A Nurse's Note dated 4/16/12 at 11:00 a.m. documented, "To (hospital) for swallow study. 11:15 a.m. - Transport CNA called, stated resident crying out in pain. Unable to calm down. Instructed CNA to come back to facility. 11:30 a.m. - Complains of right leg pain. [MEDICATION NAME] 1 tab (tablet)PO (by mouth) given." Lab work collected on 4/16/12 documented, "White Blood Count - 19.1 (4.1-9.3), RBC - 2.69 (4.2-5.4), Hemoglobin - 8.9 (12-15.6), Hematocrit - 26.1 (35-46)." LPN #4 had signed the bottom of the form and had written "faxed 4/16/12". j. The Weekly Weight form documented the resident's weight on 4/16/12 as 148 pounds, a 15.9% weight loss since 1/4/12. k. A Nurse's Note dated 4/18/12 at 10:00 a.m. and signed by LPN #1 documented, "Call placed to wound care specialist checking on status of appointment. Told at this time they were trying to obtain permission from responsible party but would call with appointment as soon as possible... 2:30 p.m. - Wound care specialist called, stated resident had appointment on 4/20/12." On 5/16/12 at 10:55 a.m., LPN #1 was asked about the lack of documented assessments/monitoring during the time frame of 4/10/12-4/14/12 and 4/15/12-4/20/12, she stated, "I was off a lot during that time... I put all of my documentation in the chart." l. A Nurse's Note dated 4/20/12 at 9:00 a.m. documented, "...Resident noted slumped in wheelchair... (Physician) notified of VS (vital signs), BP (blood pressure) 87/40, temp 101.9, P (pulse) 43... send to (hospital) for eval/treatment..." m. A hospital History and Physical dated 4/20/12 documented, "This lady is from (nursing home)... (Physician) saw her in the ER (emergency room ). Lab was done which revealed 25,000 WBC with 8.5 Hb (hemoglobin) and 25 hct (hematocrit)... I reviewed the chest x-ray and I agree with findings of a right lower lobe medial patchy infiltrate consistent with pneumonia... admitting [DIAGNOSES REDACTED]. A hospital Decubitus/Pressure Ulcer Report dated 4/20/12 documented, "Unstageable, black, necrotic... appears at least Stage III/IV... 6 cm x 7 cm. Wound not open, but covered with black, necrotic tissue... foul odor... Recommend surgery consult." A hospital Report of Consultation dated 4/20/12 documented, "...(Physician) has asked me to see her regarding the decubitus ulcer... about a 5 cm x 5 cm irregularly shaped foul smelling decubitus with eschar and redness and induration around the periphery... We will plan to debride her right ischial decubitus on Monday." A hospital Discharge Summary dated 5/2/12 documented, "...admitted from the nursing home with right lower lobe pneumonia. She also had a right necrotic decubitus on the buttock that was quite large." n. A Nurse's Note dated 5/2/12 and signed by LPN #1 documented, "This resident admitted this morning, admission body audit revealed a 7.0 cm x 7.5 cm x 5.0 open area on right buttock... pressure wound vac to open area..." o. The Care Plan dated 5/2/12 documented in the Problem section, "Pressure ulcer to right buttock." The Approach section documented, "Measure wound at least weekly. Record HxWxL (height x width x lenght), appearance, amount and odor of any drainage. Report any decline in wound status to physician." p. A Weekly Pressure Ulcer Report dated 5/3/12 documented, "5/2/12 - Open area on lower right... area clean, beefy red... 7.0 x 7.5 x 5.0... stage 4." q. A Nutritional Monitoring of Tube Feedings form dated 5/3/12 and signed by the RD documented the resident's tube feeding rate was 53 cc (cubic centimeters) an hour. It also documented that the resident had sustained a weight loss and had a wound with a wound vac. The Comparative Data section documented the resident's assessed daily needs as 1978-2164 calories, 74-85 grams of protein and 2164 ml (milliliters) of fluid, however, it documented that at 53 cc/hour, the resident was receiving only 1463 calories, 72 grams of protein and 1959 ml of fluid. The RD documented on the form, "Needs more calories and protein for wound healing. Increase by 5 ml/day to 70 ml/hour. [MEDICATION NAME] BID (twice daily). Get wound stage." r. The Weekly Weight form documented the resident's weight on 5/7/12 as 131 pounds. There was no weight documented on 5/14/12 for the resident. s. A Physician order [REDACTED]." A Physician Telephone Order dated 5/11/12 documented, "Increase [MEDICATION NAME] by 5 cc/every day until the goal of 70 cc/hour is reached." (The RD recommendations for the increased tube feeding rate and the increased protein were documented on 5/3/12, 8 days before the physician was consulted) t. A Nurse's Note dated 5/15/12 at 12:00 p.m. documented, "Orders received and noted for NS wet to dry dressing to blister on right foot daily." On 5/15/12 at 1:40 p.m., the resident was in bed. [MEDICATION NAME] feeding formula was infusing at 68 cc/hour per pump. Documented on the bottle was "70 cc/hr." The DON was asked why the actual rate was different than what was written on the bottle. She stated they were in the process of increasing the tube feeding by 5 cc/day until the goal of 70 cc/hour was reached. The DON was asked to raise the sheet at the foot of the bed to observe the resident's feet. The resident's right foot was observed to have a fluid filled blister, light purple in color, approximately 3 cm round just below the 5th toe. The DON was asked about the area. She stated she thought it might have been caused by a splint that therapy had placed on the resident, but that the facility was in the process of getting treatment orders for the area. The resident's heels were not floated. u. On 5/16/12 at 10:34 a.m., the Physical Therapist (PT) was asked if she knew anything about the area on the bottom of Resident #1's right foot since the DON stated it was caused by a splint that therapy had applied. She stated, "We've not really had anything to do with the splint in a long time, probably a year. We initially started it and we showed them how to apply it, but restorative does it now. The splint is specifically to prevent foot drop." She was asked if she knew anything about the sore on the resident's foot. She stated, "One of my techs noticed it on Monday (5/14/12) and told (DON)." At that time, the PT made a phone call to the tech that first observed the sore on the resident's foot. She asked the tech when she first saw the area. The tech informed her she first saw it on Monday and that it was reported to nursing. v. On 5/16/12 at 10:55 a.m., LPN #1 was asked if there were any documented wound assessments for the resident since the one on 5/2/12. She stated, "I have been doing them on a weekly basis, but we changed to a new system and I didn't do it last week." She was asked who was responsible for doing the treatments when she wasn't there. She stated, "The nurse on the hall." On 5/16/12 at 11:57 a.m., the Director of Nursing was asked if there were any documented wound assessments for the resident during the time frame of 4/9/12-4/20/12 and 5/3/12-5/15/12 that was not in the clinical record. She stated, "As far as I know, it's in the chart." She was asked about the RD note dated 3/19/12 where a sugar free shake with lunch and supper was recommended and why that wasn't done at that time. She stated, "I don't think so. She might've intended to put it on 3/19/12, but I don't think she did." The DON was given the chart and shown the RD note dated 3/19/12. She stated, "She gives me a dietary report and that wasn't on the report. It was on the 4/5/12 report and I addressed it that day." The DON was asked about the area on the bottom of Resident #1's foot and why the physician was not informed until 5/15/12 for treatment orders. She stated, "It was observed for the first time yesterday and that's when I became aware of it. A treatment order was obtained at that time." She was informed that therapy stated they identified it on Monday 5/14/12 and that it was reported to nursing that day. She stated, "It was not reported to me." The DON was asked about the RD note dated 5/3/12 where she recommended the tube feeding rate to be increased by 5 ml/day until the goal of 70 ml/hour was reached and why that was not started until 5/11/12. She stated, "Because we had to talk to the family and get an order. Just because the RD recommends it, we still have to have an order." The DON was asked to show the surveyor documentation in the clinical record to indicate the facility had attempted to contact the family during that time frame but was unsuccessful. She reviewed the chart and stated, "I don't see any." w. On 5/16/12 at 12:25 p.m., LPN #1 was observed providing treatment to the resident's Stage 4 pressure ulcer. The area was observed to have a moist, beefy red wound bed with a moderate amount of bloody drainage in the wound vac canister. No odor was noted. There was a small area of yellow colored tissue on the edge of the wound (7 o'clock). The wound edge was smooth. It measured 5.3 cm x 6.0 cm x 5.0 cm. The resident's right foot was observed. The blister was now darker purple in color with the surrounding edge bright red. It had progressed to approximately 5 cm wide. No dressing was on the wound. x. On 5/16/12 at 1:05 p.m., Restorative Nurse Assistant (RNA) #1 was asked when she last placed a splint on Resident #1. She stated, "I had (Resident #1) on restorative for her hand last year and I've not had her on restorative since then." She was asked if the resident had a foot splint. She stated, "She had a boot. Last time I put it on her was like 3 months ago." She was asked if she knew anything about the area on the bottom of the resident's right foot. She stated, "I looked at it. Therapy pointed it out Monday." RNA #1 was asked if she weighed Resident #1 on 5/14/12 since the resident was on weekly weights and the last documented weight was 5/7/12. She stated, "I didn't weigh her that day because she went out to the hospital. She came back a couple hours later but I didn't do it because she'd had such a rough morning." On 5/16/12 at 2:20 p.m., RNA #1 weighed the resident with a lift. The weight was 136.1 pounds. y. On 5/16/12 at 5:25 p.m., the resident's Power of Attorney was contacted and asked if he was difficult to get in touch with, specifically during the time frame of 5/3/12-5/11/12 since that's why the facility stated there was a delay in increasing the resident's tube feeding rate. He stated, "No ma'am. They've been calling me every day since she got back from the hospital." On 5/16/12 at 5:40 p.m., the Dietary Manager was asked if she knew why there was a delay between 3/19/12 - 4/5/12 with starting a sugar free shake for Resident #1 because of her weight loss, and the delay between 5/3/12 - 5/11/12 to increase the tube feeding rate. She stated, "I just started back in January and I'm trying to catch up. I know after they tell the doctor and get an order, they give me a copy, but I don't know anything about the delays you are talking about." z. On 5/16/12 at 5:55 p.m., LPN #4 was asked about Resident #1's 4/16/12 lab results. He stated, "I fax it, usually with a note to review it." He was asked how he knew if the doctor actually saw the fax. He stated, "All I know is I faxed it." He was asked if he thought the doctor would have responded if he had known the resident's WBC was 19.1. He stated, "I would hope so." On 5/17/12 at 9:15 a.m., the DON was asked about the facility's policy and procedure on notifying the physician of lab results. She stated, "We fax and call." 2. Resident #4 had [DIAGNOSES REDACTED]. The 14 day Medicare Minimum Data Set with an Assessment Reference Date of 5/2/12 documented the resident scored 11 (8-12 indicates moderately impaired) on the Brief Interview Mental Status, required extensive assistance with activities of daily living (ADLs) and was at risk for pressure sores. a. A physician's orders [REDACTED]." b. The facility's body audit sheet dated 4/6/12 documented, "Buttock red..." The sheet did not indicate there were any open areas at this time. c. The hospital lab values dated 4/16/12 at 6:35 a.m. documented, "[MEDICATION NAME] - 2.1L (Low) Reference Range: 3.4 - 5.0 g/dl." d. On 4/19/12, Resident #4 returned from a hospital visit and the "Admission Nursing Assessment" sheet dated 4/19/12 documented, "Red area under both breast and fold of abdomen, [MEDICATION NAME] to buttocks - Stage II x (times) 2..." The nurse's notes dated 4/19/12 at 1:30 p.m. documented, "Resident returned to nursing home, body audit revealed a 2 cm(centimeter) x 1 cm x 0 cm open area on upper left buttock and a 1.5 cm x 1 cm x 0 cm open area on lower left buttock..." e. The nurse's notes dated 4/24/12 at 11:35 a.m. documented, "This LPN (Licensed Practical Nurse) noticed a red, yeast type rash under breast, under abdomen fold and right side...." A physician's orders [REDACTED]." f. The nurse's notes dated 4/26/12 at 8:10 p.m. documented, "Areas x 2 on left buttock remains the same, ...left buttock upper 2cm x 1cm x 0.0 cm and left lower buttock 1.5 x 1.0 x 0.0 ...resident refuses to turn off of back, lies on backs at all times." g. The nurse's notes dated 5/1/12 at 9:30 a.m. documented, "Open area on left buttock lower area larger in size remains Stg (stage) II, red surrounding tissue, ...upper left are now closed..., Now has a open area on Right buttock 2.0 x 3.0 x 0.0. Entire buttock and upper thigh red and irritated. Resident conts (continues) to refuse to turn and reposition. Areas under breast and fold of abdomen shows improvement..." h. The Physician's Progress Note dated 5/2/12 documented, "...buttock with (2) Stage II decubti, 1x2 and 1x1 cm... sacral decubiti - needs whirlpool..." A physician's orders [REDACTED]. wound care [MEDICATION NAME] and frequent showers." i. The May 2012 Activitiy of Daily Living (ADL) Sheet documented by the CNAs, Resident #4 did not receive a shower or a whirlpool from 5/2/12 - 5/15/12. However, the DON provided the "Resident Bathing and Skin Check Form" which documented Resident #4 received 2 whirlpools on 5/3/12 and 5/5/12. j. The nurse's notes dated 5/3/12 at 1:00 p.m. documented, "Open area on left buttock shows improvement, smaller in size/red center with red surrounding tissue, no visible sign of infections... 1.0 x 2.0 x 0.0..." There was no documentation to indicate the right buttock was measured. On 5/16/12 at 11:45 a.m., the Treatment Nurse (LPN#1) provided the facility's skin report which documented the measurements for each resident in the facility who had a pressure ulcer. There were no further documented measurements for Resident #4's left buttock after 5/3/12 and no further measurements documented for the right buttock after 5/1/12. 1) On 5/16/12 at 1:30 p.m., the Treatment Nurse (LPN #1) commented that the resident refused to be turned and repositioned and to have baths. The Treatment Nurse was informed there was no documentation found in Resident #4's clinical record that indicated the facility had explained risk versus benefit, such as, if the resident doesn't comply with interventions to help prevent further skin breakdown, the areas will get worse. There was no comment made by the Treatment Nurse. 2) On 5/16/12 at 2:10 p.m., LPN #2 was asked if she documented what she saw yesterday (5/15/12) when she did the treatment on Resident #4. LPN #2 stated, "I don't do body audits. I don't think it was time. I did the treatments on Monday and Tuesday. It didn't look bad to me. From what I've been hearing, it looked the same. I didn't measure the areas." l. On 5/16/12 at 3:38 p.m., with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) present, Resident #4's open areas were observed. There were multiple areas open (Stage II) (at least 7) on Bilateral Upper buttocks. Two square pieces of [MEDICATION NAME] was rolled up on incontinent pad, neither one covering the wounds. All of the noted areas were open. #1 Upper Right side hip area scratches - Stage II - 4 x 1cm #2 Right Buttock - Stage II - 1 x 0.8cm #3 Left Buttock - Stage II - 1.4 x 2.4cm #4 Left Buttock - Stage II - 4 x 2.8cm #5 Under Left Breast - Stage II - 1 x 0.3cm There was a yeasty looking redness under the right arm pit, right breast, left arm pit and left breast. However, an open area was also observed under the left breast.