Every finding on record at Trinity Health Care of Logan

Based on record review and staff interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASSAR) accurately reflected each resident's diagnoses. This was true for four (4) of six (6) residents reviewed for the care area of PASSAR during the long-term care survey. Resident Identifiers: #9, #13, #23, and #51. Facility Census: 112 a) Resident #9 A review of Resident #9's medical record on 02/10/26 found the following relevant diagnoses Adjustment Disorder with depressed mood and schizoaffective disorder bipolar type. A review of the most recent PASSAR, dated 09/09/25, found the aforementioned diagnoses were not included on the PASSAR. An interview with the Director of Nursing (DON), at 10:00 AM on 02/10/26, confirmed the PASSAR did not accurately reflect the resident's current diagnoses. She stated the nurse who rounds with the doctor is doing these and it looks like she needs some more education. b) Resident #13 A review of Resident #13's medical record on 02/10/26 found the following relevant diagnoses Post Traumatic Stress Disorder, Major depressive disorder and generalized anxiety disorder. A review of Resident #13's most recent PASSAR, dated 12/19/25, found the aforementioned diagnoses were not included on the PASSAR. An interview with the DON, at 10:00 AM on 02/10/26, confirmed the PASSAR did not accurately reflect the resident's current diagnoses. She stated the nurse who rounds with the doctor is doing these and it looks like she needs some more education. c) Resident #23 A review of Resident #23's medical record on 02/10/26 found the following relevant diagnoses Schizoaffective Disorder, Bipolar unspecified psychosis and intellectual disabilities. A review of Resident #23's most recent PASSAR, dated 12/22/25, found the aforementioned diagnoses were not included on the PASSAR. An interview with the DON, at 10:00 am on 02/10/26. confirmed the PASSAR did not accurately reflect the resident's current diagnoses. She stated the nurse who rounds with the doctor is doing these and it looks like she needs some more education. d) Resident #51 On 02/04/26 at 9:03 AM, a record review was completed for Resident #51. The review found the PASSAR dated 03/26/24 did not include the diagnosis of Generalized Anxiety Disorder (GAD). The diagnosis of GAD was present in the medical record since 06/14/23. On 02/05/26 at 10:00 AM, the DON was notified and confirmed the diagnosis was not listed on the PASSAR dated 03/26/24.

Based on observation, temperature measurements, and staff interview, the facility failed to ensure they held food for service at a safe temperature to prevent the spread of food borne illnesses. In addition, when the food was identified as having a temperature within the danger zone the facility failed to reheat to an appropriate temperature before serving the food. This failed practice had the potential to affect more than an isolated number of residents. Facility Census: 112. An observation of the noontime meal service, on 02/09/26 beginning at 11:17 AM, in the facility's kitchen found the following issues: 1. [NAME] Slaw Temperature The first temperature of the coleslaw was 45.9 degrees Fahrenheit (F). This temperature was obtained when it was taken from the cooler and was placed near the steam table on a cart in preparation of service. The coleslaw remained in this position, and a temperature was again obtained by facility staff at 12:01 PM. This temperature was 47 degrees F. The Certified Dietary Manager (CDM) was made aware of the temperatures. The coleslaw was never returned to the cooler to be brought down to 41 degrees or below in order to ensure it was safe to serve to prevent the spread of food borne illnesses. The staff began serving the meal directly after obtaining the last temperature of 47 degrees F. The facility proceeded with serving the coleslaw even though it was not held at a safe temperature. The coleslaw they served was not held at 41 or below. The CDM acknowledged cold food should be held at 41 degrees F or below and agreed the kitchen staff served the coleslaw anyway. 2. BBQ Pork Sandwiches Upon entering the kitchen at 11:17 AM, the BBQ pork sandwiches were already on the steam table being held for service. There were two (2) pans each with four (4) layers of sandwiches. The top two layers on each tray had temperatures which ranged from 116.9 degrees G to 122.7 degrees F. The staff placed one (1) pan of sandwiches back into the oven to reheat. They then removed the top two layers off the remaining pan and placed them in a pan also on the steam table. The temperatures of the sandwiches on the bottom two (2) layers were greater than 135 degrees F. The top two (2) layers they removed eventually raised in temperature and was temped at 142.3 degrees F. The sandwiches were then served to residents. An interview with the Dietary manager, after the meal service was complete, confirmed the BBQ sandwiches should not have been reheated on the steam table. She also agreed they should have been reheated to 165 degrees F. In addition, she agreed the coleslaw should have been held at a temperature of 41 degrees or below.

Based on record review and staff interview, the facility failed to report the results of all investigations to the appropriate state officials within five (5) working days of a Facility Reported Incident involving an unusual occurrence. Resident Identifier: #23 Facility Census: #112. Findings Include:a) Resident #23 (FRI #240863)On 02/03/26, a review of a Facility Report Incident involving Resident #23 showed an incident occurred on 09/15/24 at 4:00 AM and was reported to the Office of Health Facility Licensure and Certification (OHFLAC) on 09/16/24 at 8:00 AM.The unwitnessed incident involved Resident #23 removing the toilet seat from his toilet and crashing it into a mirror, breaking it. Staff responded to the resident's room after hearing the loud noise and provided safety for the resident. The resident had verbal behaviors towards the staff. The in-house physician was contacted with new orders for Haldol 15 mg X 1 via intramuscular (IM) and Benadryl 125 mg IM X 1 dose. The staff had the glass cleaned up and found and removed multiple sharp objects from the room as well as any other objects that could be used to injure himself or others. The 5-Day Follow-up was due on 09/21/24 (5 days after the incident was reported). On 09/25/24 at 1:00 PM there was a Nursing Home Program 5-Day Follow-up Investigation completed. However, there was no documentation of fax or email receipts that confirms the facility sent the 5 Day Follow up to OHFLAC. On 02/10/26 at 10:02 AM, it was confirmed with the Director of Nursing and Administrator that there was no documentation confirming the 5 Day Follow-up had been sent to OHFLAC.

Based on record review and staff interview, the facility failed to revise a care plan for Resident #92 and Resident #51. This was true for two (2) of five (5) residents reviewed under the care area of abuse. Resident Identifier: #92 and #51. Facility Census: 112.Findings Include:a) Resident #92On 02/03/26 at 12:20 PM, a record review was completed for Resident #92. The review found the care plan had not been revised regarding eyes on resident for monitoring of behaviors. The resident has a history of multiple events with other residents.On 02/03/26 at 12:58 PM, the Director of Nursing (DON) was notified and confirmed this type of monitoring was in effect.b) Resident #51On 02/04/26 at 9:03 AM, a record review was completed for Resident #51. The review found the care plan had not been revised to include the diagnosis of Generalized Anxiety Disorder (GAD). The diagnosis of GAD was present in the medical record since 06/14/23. On 02/05/26 at 10:00 AM, the DON was notified and confirmed the diagnosis was not listed on the care plan.

Based on observation, record review and staff interview, the facility failed to ensure medical records were kept private and confidential. This was a random opportunity for discovery. Facility Census: 112.Findings Include:a) Facility PolicyThe Director of Nursing (DON) provided a document entitled, HIPPA Education: Computer Screen Security. Under the heading of Computer Screen Security Requirements, the first bullet states, All workforce members must: Lock their computer screen whenever stepping away, even briefly.b) Hallway ComputerOn 02/03/26 at 3:00 PM, during a tour of the facility, a computer screen was left unlocked and open to view. No staff member was near the computer. On 02/03/26 at 3:05 PM, Nurse Aide (NA) #153 returned to the computer. At this time, NA #153 closed the computer. NA #153 stated, I never leave my computer up.On 02/03/26 at 4:00 PM, the Director of Nursing (DON) was notified and confirmed the computer screen should be locked whenever staff have stepped away.

Based on observation and staff interview, the facility failed to provide activities of daily living (ADL) care for a dependent resident #45. This was true for one (1) of one (1) residents reviewed under the care area of ADLs. Resident Identifier: #45. Facility Census: 112Findings Include: a) Resident #45On 02/02/2026 at 2:07 PM, Resident #51 was yelling out. Upon entering the room, a strong urine smell was noted. Upon further observation, the resident was soiled and wet. Dried, brown rings were seen on the fitted sheet. On 02/02/26 at 2:12 PM, Licensed Practical Nurse (LPN) #53 stated, I don't know when she was changed last .we will get her cleaned up. On 02/02/26 at 3:15 PM, the Director of Nursing (DON) was notified and confirmed the resident should have been changed sooner. On 02/02/26 at approximately 3:30 PM, the DON notified this Surveyor that Resident #45 was clean, dry and odor-free.

Based on record review and staff interview, the facility failed to obtain consent for a psychotropic medication for Resident #2. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #2. Facility Census: 112.Findings Include: a) Resident #2 On 02/09/26 at 8:44 PM, a record review was completed for Resident #2. The review found a physician's order for Klonopin 0.5 milligrams (mg) by mouth every day for anxiety that was started on 08/27/25. The facility did not obtain a consent for this psychotropic medication until 02/09/26. On 02/10/26 at 8:55 AM, the Director of Nursing (DON) confirmed the medication was administered without consent from the resident's legal representative.

Based on observation and staff interview, the facility failed to ensure all supplies used in the facility were stored in accordance with current accepted professional practices. This was true for one (1) of two (2) medication/supply storage rooms. The facility failed to ensure expired supplies were discarded and maintained within the acceptable expiration dates. This practice had the potential to affect a minimal number of residents. Facility Census: #112. Findings include:a) [NAME] Wing Medication/Storage roomOn [DATE] at 1:16 PM, during an observation of the medication/supply storage room on the [NAME] Wing with Licensed Practical Nurse (LPN) #18 found supplies were expired beyond manufacturer's instructions which were posted on each item.The following items were found to be expired according to the manufacturer's instructions:Amsino [NAME]: Six (6) [NAME] had expired on [DATE]Suction Catheter Kits: One (1) Suction Catheter Kit had expired on [DATE]Urinary Catheter Statlock: One (1) Statlock had expired on [DATE]Urinary Catheter Statlock: One (1) Statlock had expired on [DATE]Urinary Catheter Statlock: One (1) Statlock had expired on [DATE]Urinary Catheter Statlock: One (1) Statlock had expired on [DATE]Urine Test Kit: One (1) urine test kit had expired on [DATE] On [DATE] at 1:30 PM, LPN #18 agreed the stamped expiration dates on the items listed above were in the past and the items should have been discarded. This was also confirmed, on [DATE] at 1:45 PM, with the Director of Nursing.

Based on record review and staff interview, the facility failed to ensure an updated Physician's Order for Scope of Treatment (POST) form was completed for Resident #50. This was true for one (1) of four (4) residents reviewed under the care area of Advanced Directives. Resident identifier: #50. Facility census: 112. Findings include: a) Resident #50 On 02/04/26 at approximately 2:00 pm a review of Resident #50's Physicians Order for Scope of Treatment (POST) form, dated 03/28/23, named the resident's husband as surrogate. The resident's daughter was made surrogate on 05/21/24 without a review and updated POST form. During an Interview with the Director of Nursing (DON), on 02/04/26 at approximately 2:35 PM, the DON confirmed the daughter was made surrogate on 05/21/24 after Resident #50's husband became incapacitated. The DON also confirmed the facility did not get a new POST form reviewed and completed at the time the resident's daughter became health care surrogate. Record review and interview with the Director of Nursing, on 02/09/26 at 1:36 PM, revealed the facility had obtained verbal consent from the daughter and a new POST form was obtained after surveyor intervention.

Based on observation and staff interview, the facility failed to maintain an effective infection control program for urinary storage bags. This was a random opportunity for discovery. Resident Identifier: #10. Facility Census: 112.Findings Include: a) Resident #10 On 02/02/2026 at 2:05 PM, an observation found Resident #10's urinary storage bag on the floor. On 02/02/26 at 2:09 PM, Licensed Practical Nurse (LPN) #53 was notified and stated, it's because it's a low bed. LPN #53 then stated, I'll take care of it. On 02/02/26 at approximately 3:30 PM, the Director of Nursing (DON) was notified and confirmed the urinary storage bags should not be touching the floor.

Based on record review and staff interview, the facility failed to maintain accurate and complete record for Resident #92. This was true for one (1) of five (5) residents reviewed under the care area of abuse. Resident Identifier: #92. Facility Census: 112.Findings Include:a) Resident #92On 02/03/26 at 12:20 PM, a review of the care plan was completed for Resident #92. The review found under the focus area of the resident uses psychotropic medications, the incorrect dates of an inpatient psychiatric stay. The dates listed were 12/17/25 until 01/10/25. The correct dates should have been 12/17/24 until 01/10/25.On 02/03/26 at 12:58 PM, the Director of Nursing (DON) was notified and confirmed the dates would be corrected on the care plan.

Based on observation, record review, and staff interview, the facility failed to ensure Resident #12 received liquid which was thick enough to meet his individual needs to prevent the risk of aspiration. This was a random opportunity for discovery and was true for Resident #12. Facility Census: 112. Findings Include:The facility failed to ensure Resident #12 was served liquid in a consistency which met his individual needs. He had an order for pudding thickened liquids and was given liquids which were not pudding thickened. Observations of Resident #12, during the noon time meal on 02/09/26 at 1:04 PM, found Licensed Practical Nurse (LPN) #144 was adding thickener to his orange Kool Aid. The Kool aid was in a 12-ounce cup and was just shy of being completely full. The surveyor entered the room at 1:04 pm and LPN #144 had already added three (3) .23 ounces of Hormel Thick and Easy thickening powder. The LPN continued stirring the drink for at least two (2) more minutes while the resident laid in the bed content. She, at that time, inserted the spoon into the drink and took it out. The liquid easily slid from the surface of the spoon in a dripping motion and did not hold its shape on the spoon. LPN #144 then looked at Resident #12 and asked him if he wanted to sit up and eat. She assisted the resident to a sitting position. As soon as Resident #12 was able to reach his over the bed table he grabbed the Kool aid and took a drink. The drink easily ran into his mouth with the assistance of a utensil. At this time the surveyor advised LPN #144 the resident was on pudding thickened liquids and the liquid in the cup was not the correct consistency. She took the cup from the resident then sat it back on the tray and Resident #12 again grabbed the drink and took another drink of the liquid which again easily ran into his mouth with the assistance of a utensil. LPN #144 again took the cup from the resident and held it in her hand until someone else arrived with more thickening packets. LPN #144 added another packet and got the Kool aid to a thicker state. This time the liquid held its shape on the spoon and the resident had to use a spoon to get the liquid from his cup. He used the spoon after two (2) attempts to drink the liquid from the cup as he did the previous two (2) drinks he took. A previous interview prior to entering the room, with LPN #113, at approximately 12:50 PM on 02/09/26, confirmed Resident #12 was ordered a pureed diet with pudding thickened liquids. The Hormel thickening powder packet was reviewed and found the following directions for Spoon Like Consistency: Add two packets to 4 fluid ounces of liquid. The Kool Aid was in a 12-ounce cup which was not completely full but did contain between 8 to 12 ounces of fluid. A review of the Resident #12's medical record found the following speech language pathologist discharge note: LTG: 2.0 discontinue on 10/22/25 Patient will safely and efficiently swallow thin liquids, nectar thick liquids and honey thick liquids 100 percent of the time without compensatory strategies and or maneuvers as evidenced by no signs or symptoms of aspiration/penetration. This goal indicated his previous level of function was 100% his baseline as of 08/08/25 was 25%. Previous as of 10/09/25 was 60% and at time of discharge on [DATE] was 60%. This indicates the resident was only able to swallow thin, nectar or honey thickened liquids safely on 60 percent of the time. Further review of the record found a physician order, dated 12/16/25, which read as follows: Regular Diet pureed texture, pudding thick consistency pleasure tray at lunch and PRN.The residents care plan contains the following intervention related to his diagnosis of dysphagia. Provide diet as ordered: Regular Diet, pureed texture, Pudding thick consistency. Further review of the record found Resident #12 had a modified barium swallow study (MBSS) on 09/23/25. The impression: Aspiration if thin and nectar consistencies. Please reference the speech pathology report for further findings and recommendations. Resident's pertinent diagnoses include Cerebral infraction affecting right dominant side and Dysphagia following cerebral infarction. An interview with the Director of Nursing (DON), in the afternoon of 02/09/26, confirmed she had spoken with LPN #114 who did say Resident #12 took some drinks of the liquid before it was pudding thick. She indicated she has already provided her with education about thickened liquids.

Based on record review, staff interview, the facility failed to ensure residents were free from physical abuse when Resident#12 physically assaulted another resident , resulting in actual physical injury. This failure resulted in actual harm and had the potential to affect all residents residing in the Long Term Care facility. Residetn Identifier: #11 and #12 Facility Census: 111This failed practice was consider to be at past non-compliance, as the facility identified and corrected the failed practice prior to surveyors entering the building. Findings Include:Review completed on 10/21/25 of Resident #12 clinical record revealed a history of psychiatric illness with repeated verbal and physical aggression toward staff and peersThe care plan (initiated 12/26/24, updated 6/04/25) addressed Verbal/Physical Aggression with interventions to:Redirect using a calm, non-threatening tone.Encourage coping skills (deep breathing, quiet time).Monitor for triggers and increased agitation.Offer sensory tools and reassuranceResident-to-Resident Assault (6/14/25) resulting in actual harmProgress Notes:6/14/2025 14:53Note: Called to [NAME] Wing by staff, resident #11 noted to have altercation with resident #12 from 123-A. Resident from 123-A was attempting to move this residents w/c in the hallway to allow other residents to get by. This resident grabbed resident from 123-A by his shirt and attempted to pull him. Resident from 123-A struck this resident two times in the face with a closed fist. Residents separated resident noted to have superficial lacerations to left eye and large hematoma to left side of his forehead. Staff applied ice packs to areas where resident was refusing to keep ice pack in place. Resident at nurse station at this time. Call placed to POA and made aware of the situation. Dr. aware. 6/14/2025 15:09Note: Called to [NAME] Wing by staff, this resident #11 noted to have altercation with resident #12 from 101-A. This resident stated he was attempting to move resident from 101-A in the hallway when Resident #11t from 101-A grabbed Resident #12 by his shirt. This resident#12 then struck resident #11 from 101-A in the face two times with a close fist. Residents separated. Dr. aware. Message left for DHHR. 6/14/2025 17:11Note: This nurse called ER in concerns to this resident #11. This nurse received report that resident #11 currently has orbital fractures to the left eye, a small subdural hematoma to the left side of the face and resident is currently awaiting approval to be accepted to another hospital due to reported brain bleed. Physician notified, aware. Responsible party was notified. 6/16/2025 08:30Note: Called [NAME] County Sheriff's office at [PHONE NUMBER]. Left message to have one of the officers call facility to discuss recent events regarding the resident's abusive behavior. 6/16/2025 10:45Note: Called [NAME] County Sheriff's office again to speak with officer, Informed that an officer would return call 6/16/2025 10:48Social Services Note: Went to speak to resident about the incident that happen on 6/14/2025. Resident stated, I beat his ass. 6/16/2025 15:12Note: Called Sheriff's office again. Spoke with officer who stated that he would be down to facility to take statement. 6/16/2025Officer Came to Facility. Spoke with this nurse and residents POA who is also Employee. Officer was given details of incident. Stated that he would let us know what he would be able to do. 6/17/2025 10:00Received call from Officer stating he would be in facility to arrest resident. 6/17/2025 10:50Corporal and Deputy Sheriff arrived with active arrest warrant signed by Magistrate listing two counts of felony malicious assault. Resident handcuffed, read [NAME] rights, cooperative, and escorted from facility at 1103 without incident.Review of facility's internal timeline (12/01/24-6/17/25) showed:Resident #12;12/05/24 Resident struck staff member.12/06/24 Psychiatric visit with [NAME], FNP including medication review and Pavilion referral.12/10/24-12/26/24 admission to psychiatric hospitalization at Behavioral Health Pavilion. (medications adjusted and group counselling attended by Resident #12)12/26/25 All staff in-service held by [NAME], FNP addressing topics including abuse, resident redirection.3/30/25 After referral to Behavioral Health Pavilion denied.4/15/25 After a resident-to-resident event involving room mate being punched in the chest, Resident #12 was placed in a room on the opposite side of the building; referral repeated and denied.4/18/25 Psychiatric follow-up addressing room mate altercation; medication regimen reviewed by [NAME], FNP.4/30/25 Resident#12 pushed another resident in a wheelchair; nurse educated Resident #12 to notify nursing staff when other residents needed assistance. Verbalized understanding.5/01/25 Psychiatric follow-up with FNP with another medication review.5/19/25a 6/11/25 All staff in-service held addressing Resident #12 resident-to-resident aggression; 1:1 initiated.6/14/25 Resident #12resident-to-resident aggression towards KD; 1:1 initiated.6/16/25 @ 08:30AMLogan County Sheriff Office contacted; voicemail left regarding resident's abusive behavior.6/16/25 @ 10:45AM [NAME] County Sheriff Office contacted; stated that an officer would return a call.6/16/25 @ 10:48 AM Resident interviewed about the 6/14 event; stated, (I beat his ass.)6/16/25 @ 03:12PM Facility contacted the Sheriff's office again; spoke with Officer stated he would come to the facility to get a statement.6/16/25Officer arrived at the facility and spoke to nurse and PD POA ; Officer given details of incident and stated he would be in contact with facility regarding next steps.6/16/25 Mental hygiene field.6/17/25 @ 10:00 AM Received call from Officer informing intent to arrest Resident #12; informed that arrest would be done privately to avoid distressing residents.6/17/25 @ 10:50 AM Resident #12 arrested by Officer and Deputy ; all parties notified (Administrator, CFO, Attending Physician, NP, Ombudsman, WVDHHR, and responsible party Actual HarmHospital reports confirmed orbital fractures, hematoma, and suspected brain bleed sustained by Resident KD as a result of the 6/14/25 assault.Evidence of Past Noncompliance Correction:Prior to survey, the facility:Coordinated with law enforcement and removed the aggressive resident on 6/17/25.Completed staff retraining on abuse prevention, escalation response, and reporting by 6/20/25.Revised all behavioral care plans to include enhanced supervision and environmental modifications.Implemented 1:1 observation for residents with escalating aggression.QAPI committee reviewed incidents and began monthly audits on behavioral interventions.No further resident-to-resident altercations with harm were reported after corrective actions were implemented

Based on observation and staff interviews, the facility failed to ensure that residents were free from skin irritation and rashes associated with the use of a laundry detergent known to cause skin irritation. This deficient practice has the potential to affect all residents within the nursing home and was substantiated for 3 of 3 residents reviewed during the long-term care survey process. Findings include: On 10/20/25 record review of complaint filed with the State Agency (SA) reviled residents that the laundry detergent that the facility was using was causing outbreaks for half of residents from neck to feet. No rashes on hands and face. On 10/21/25 at 1:45 PM this surveyor observed blue detergent stored in the laundry area. Hooked up to the laundry machine was a clear detergent. During an interview competed on 10/21/25 at approximately 1:50 PM with Laundry Aide #93 , who stated the facility has been using a hypoallergenic detergent for approximately two years. The laundry aide # 93 explained that the blue detergent is used when the hypoallergenic detergent is out of stock or unavailable. Laundry aide #93 further reported that when the blue detergent was used, some residents would experience itchiness or develop rashes. Laundry aide #93 also stated the detergent change was implemented after residents complained of itchiness and the development of rashes. This confirming the facility still had access to the Blue Laundry detergent that causes irritations and rashes to residents residing in the long term care facility. On 10/21/25 around 2:00 PM The administrator was informed of Laundry aide#93's statement/interview and of this surveyors observations of the Blue laundry detergent. The Administrator stated he was unaware that the blue detergent was still being stored and used and stated we will get that out of there now. This confirming the facility had previously been aware of skin-related concerns among residents.

Based on record review, resident observations and staff interviews the facility failed to ensure Resident #91 was free from nonconsensual sexual contact. In addition the facility failed to ensure Resident #75 was free from verbal abuse. The occurances with Resident #91 and Resident #75 both constituted an Immediate jeopardy (IJ) situation. The state agency (SA) determined the failure to protect Resident #75 from verbal abuse caused Resident #75 fear and anxiety due to verbal abuse from Licensed Practical Nurse (LPN) #28. At the time of the incident Resident #75 was unable to verbalize how this made her feel due to thinking the Facility administration would retaliate against them. Emotional and psychological abuse can have severe short- and long-term effects. This type of abuse can affect both your physical and your mental health. You may experience feelings of fear, confusion, anxiety, shame, guilt, frequent crying, and up to suicide or death. This action not only harmed Resident #75 but placed the remaining 110 residents in an IJ situation because LPN #28 was still employed at the facility and residents voiced fear of her. The facility was first notified of the IJ pertaining to Resident #75 at 2:09 PM, on 05/28/24. The state agency (SA) received the Plan of Correction (POC) at 5:00 PM on 05/29/24. The SA accepted the POC on 05/29/24 at 5:22 PM. The SA observed for the implementation of the POC and the IJ was abated on 06/04/24 at 4:23 PM. In regards to Resident #91 who suffers from end stage dementia and is rarely/to never understood. The staff found Resident #91 and Resident # 61 in bed together on 04/07/24. Through the course of their investigation, they contacted the healthcare decision maker who stated that it was okay and just a way of life and if both wanted to do it to let them have privacy to do it. After this conversation with the family member of Resident #91 the Social Worker stopped her investigation and the facility entered the following intervention on Resident #91's care plan: When resident is displaying sexual behavior and both resident and male resident are willing, Staff to provide privacy for residents, but if behavior is unwanted by either residents, staff to provide redirection. The results of the investigation were that no sexual abuse occurred. Interviews with the Social Worker, Nursing Home Administrator, and the Director of Nursing found none of the three was able to verbalize how Resident #91 was able to consent to sexual contact. They all indicated Resident #91 was seeking out Resident #61 and they felt that was her consent because she sought him out and sat on his bed. The behaviors exhibited by Resident #91 is consistent with her diagnosis of End Stage Dementia and does not constitute consent to sexual contact. The facility's failure to assess Resident #61 for the ability to consent for sexual contact, combined with there thoughts of her consent being constituted by her wandering and setting on Resident #61's bed, and the care plan that indicates the family said if it was okay with both residents to provide them with privacy put Resident #91 in an immediate Jeopardy (IJ) situation. The facility was notified of this IJ at 10:57 am on 05/30/24. The State Agency (SA) accepted the facility's plan of correction (POC) at 4:01 PM on 05/30/24. After review of the implementation of the POC it was determined the IJ was abated at 4:23 PM on 06/04/24. Resident Identifiers: #91 and #75. Facility Census: 111. Findings Include: a) Resident #75 An interview with a Resident who wishes to remain anonymous due to fear of retaliation found they can hear LPN #28 coming and thinks lord please don't let her (staff #28) be in a bad mood. Anonymous resident states LPN #28 has a mean streak and I know my boundaries and stay away or just be quite and continued to say how they get upset and cry with fear of LPN #28. Resident # 75 stated on 05/29/24 at 10:45 AM, LPN #28 still yells a lot to other people and holds herself up to a higher standard. If LPN #28 has to supervise the resident smoke break. She states I hope yall know if someone dies it's your fault because I'm not there to help this statement was made last week. Resident # 75 also states they punish you around here like forgetting to feed you or answer the call light and will not give you a shower. On 05/30/24 at 11:56 AM Resident #21 stated she is concerned for the other residents in the facility. She can hear staff members yelling at them when they don't eat fast enough. On 5/28/24 at 10:00 AM, an interview with the Administrator regarding LPN #28 verbally abusing resident, the Administrator stated, she had been reported and investigated and taken care of. On 5/29/24 at 11:20AM, an interview with Director Of Nursing (DON) found, on a Thursday around May the 22 or 23 she was hiring some new nurses and let LPN #28 set in on the abuse and neglect part of the in service, and LPN #28 is scheduled to watch Abuse and neglect videos starting May31. A review of the facilities reportable on 5/29/24 at 9:00AM revealed Resident # 75 had an argument with Licensed Practical Nurse (LPN) # 28 on 05/08/24 at 11:00 AM. Further review of the facility reportable regarding Resident #75 Showed LPN #28 was verbally cussing at Resident #75 stating, I do my Fucking best to give all my residents the medication that they need a witness states she brought up how she has another resident on morphine and about to pass away, LPN #28 asked Resident #75 who was more important. Further review of witness statements from six(6) other staff members revealed the arguing between LPN #28 and Resident #75 went on for at least 20 minutes, Personal medical information regarding Resident #75 was revealed in front of everyone around during the time of the incident. LPN #28, wrote in her statement, she could have handled the situation better. The facility did not substantiate this reportable saying the arguing and confrontation was not verbal abuse. LPN #28 was not suspended and is currently working at the facility. The following are the witness statements which were collected by the facility as part of the investigation: Certified Nursing Assistant Student #65 witness statement read: During smoke break @ 8:00 PM on May 7, 2024 I was outside with a few residents, they were smoking. A nurse started screaming at a resident. The resident just asked about her meds, the nurse told her she put them in the trash because she wouldn't take them. The resident said no, i just only wanted to take a couple because i haven't used the bathroom and I need something to make me go. The nurse(LPN#28) said no you take Melatonin, Rots, and some other pill, and told her the only reason she has trouble now is because she was shot and the reason was taken to the hospital because she had a fever of 104. This went on for about 20 mins. This happened not only in front of me but three other staff and seven or eight residents. But that wasn't the only resident she screamed at as there was a man in a wheelchair. Certified Nursing Assistant Student #77 witness statement read: Yesterday May 7, 2024 when we took smokers out around 8 Resident #75 was telling LPN #28 that she needed to stop taking one of her medications because it was making her constipate. LPN #28 then started yelling at Resident #75 telling her they would not have prescribed it to her if. Resident #75 told LPN #28 that the medication was causing her to end up in the hospital . LPN#28 yelled to Resident #75 that it was not the medication causing her to be constipated it was that damn gunshot wound that is making her have all the complications LPN#28 told Resident#75 she does her Fucking best to give all her residents the medication that they need. She brought up how she also had a resident who was on morphine and about to pass and asked Resident#75 who was more important. When we went back in LPN #28 said I getta go get Resident #75 a damn book. Certified Nursing Assistant Student #68 witness statement read: Yesterday, May 7, 2024. The residents were outside on a smoke break at around 8:00 PM While setting outside with them, a nurse (LPN #28) was outside as well. She was first speaking to (Resident #75), which resulted in (LPN #28) screaming at (Resident #75). (Resident #75) has just come in from the hospital as well. (Resident #75) had firstly refused her medication, later at the smoke break, (Resident #75) asked if she could have her medication, saying she had refused it because of her bowel issues. (LPN #28) proceeded to scream at (Resident #75), discussing her required medicine, her being shot and her refusal. She (LPN #28) was very unprofessional with (firstname Resident #75) discussing private things, private situations, and medications in front of all other residents on East Wing who smoke. (First Name)LPN #28 also cussed at (Firstname) Resident #75 while (LPN#28) was screaming. LPN #28 witness statement reads: This nurse(LPN#28) took resident(Resident #75) to smoke and resident(Resident #75) and this nurse and resident got into a shouting match this nurse(LPN#28) was wrong and has apologized to the resident(Resident #75). This nurse(LPN#28) will take care of the resident(Resident #75) as long as resident (Resident #75) is ok with it. Nurse(LPN#28) regrets causing resident (Resident #75) any issues. Trying to discuss medications with resident (Resident #75)resident(Resident #75) and nurse(LPN#28) discussed incident. Resident(Resident #75) and nurse(LPN#28) discussed incident resident incident and we are over it Certified Nursing Assistant Student #66 read: On May 7, 2024, I witnessed a nurse (first name)LPN#28 screaming at a resident named (first name) Resident #75 over medications. We were on our smoke break and (First name) Resident #75 had asked for a list of her medications and their side effects. (first name) LPN#28 freaked out at (Resident #75) and was yelling at her about how she had refused her meds and that she was not Digging them out of the garbage and Was not getting more out of the cart. (first name) LPN#28 also made sure to list out every medication that Resident #75 was on as well as bring up all of her medical issues due to being shot. There were 7 other residents outside at the time. This incident lasted roughly about 20 minutes and was very uncalled for. (first name) LPN#28 also cussed at her during this time ( F-word - D- Word) Resident #75 statement read: We were having a shouting match, but I am over it. I was upset and didn't have anyone to take it out on. I know we didn't handle this very well. I don't feel like I was abused in any way. I'm fine with (first name) LPN# 28 working with me. b) Facility Plan of Correction for Verbal Abuse: Tag F 600 IJ Date: 5/29/2024 Time: 1409 1.) On 5/29/2024 the administrator, Director of Nursing and Human Resources Director terminated employee #28. On 5/29/2024 all staff were informed that all or any form of abuse or neglect toward a resident would result in immediate termination. 2.) Because this has the potential to affect all residents, on 5/29/2024 all residents were interviewed by administrative staff to ensure that they felt safe and had never endured any type of abuse or neglect any residents unable to be interviewed were assessed for any visible signs of abuse or neglect during their stay at [NAME] Healthcare Services of [NAME] with any corrective action immediately upon discovery. 3.) The Director of Nursing and Social Worker has begun in-servicing ALL staff on 5/29/2024 about facility abuse and neglect zero tolerance policy and procedure and failure to comply resulting in immediate termination. All staff will be in serviced as of 5/29/2024 prior to their next shift, and virtually if need be. 4.) The Administrator will ensure adherence to the Abuse and Neglect Policy and Procedure, ensure that any employee who commits any act of abuse or neglect will be terminated immediately. The Social Worker will complete the log attached for all reports of abuse and neglect and turn the log in to the Administrator each time a complaint is made so the Administrator can handle corrective action of the staff immediately. To ensure continued compliance, the monitoring log will be re-evaluated. c) Resident #91 A review of a Facility Reported Incident which was received by the state agency on 04/07/24 found the following: Type of Incident was a resident to resident incident. The type of abuse was specified as Sexual. The incident form indicated the the staff became aware of the abuse at 9:00 AM on 04/07/24. Resident #91 was listed as the alleged victim. The perpetrator was listed as Resident #61. The reportable listed four (4) staff members as witnesses to the incident. The staff were identified as QA #66, Licensed Practical Nurse (LPN) #105. Restorative Aide #102, and Prior Employee # 1 (Position unknown), The incident report indicated the residents were witnessed in lying in bed in a sexual position. The place was indicated it was Resident #61' bed. A review of the facility's five day follow up report found the following information: .2. steps taken to investigate the allegation: Provide a detailed summary of ALL steps taken to investigate the allegation. Summary of Interviews with the alleged victim and/or the victims responsible party, if applicable. Indicate any visual cues from the resident of psychosocial distress. (The facility's response) No suspicion of abuse or neglect. Resident to Resident No Harm. Summary of Interviews with witnesses including but not limited to, what the individual observed or knowledge of the alleged incident or injury: (Facility Response) None. Summary of Interviews with the alleged perpetrators identifying whether they are staff, resident, visitor, contractor, etc. (facility response) None. Summary of Interviews with other residents who may have had contact with the alleged perpetrators: (Facility Response): None. Summary of Interviews with staff responsible for oversight and supervision of the location where the alleged victim resides (Facility Response) Residents were separated, and educated about sexual contact with other residents. Summary of the interviews with staff responsible for oversight and supervision of the alleged perpetrator if the perpetrators staff or a resident: (Facility Response) see above. Provide Summary information from the investigation related to the incident from the residents clinical record as relevant portions of the RAI, the residents care plan, nurses' notes. social service note, lab reports, x-ray reports, physician or other practitioner reports, or reports from other disciplines that are related to the incident. If a resident to resident altercation occurred provide any relevant details that may have caused the alleged perpetrators behavior, such as habits, routines, medications, diagnosis, how long he/she may have lived at the building, or BIMS score. (facility response): none. If available within the five working day timeframe provide summary of information of other documents obtained, such as hospital/medical progress notes/orders and discharge summaries, law enforcement reports and death reports if applicable. (facility Response) None. 3. Conclusion Provide a brief description of the conclusion of the investigation and indicate if findings were: (For incidents reported as injuries of unknown source indicate if the injury resulted from abuse or neglect, based on evidence from the investigation) Verified: The allegation was verified by evidence collected during the investigation. Indicate how the allegation was verified by evidence collected during the investigation and describe the evidence. (Facility Response) No abuse or neglect. Not Verified: The allegation was refuted by evidence collected during the investigation. Indicate and describe why the allegation was unable to be verified during the investigation. (Facility Response ) No Abuse or neglect Inconclusive: The allegation could not be verified or refuted because there was insufficient information to determine whether or not the allegation had occurred. If this incident was identified as inconclusive, indicate and describe how this was determined. (Facility Response) No abuse or neglect. 4. Corrective action taken: Provide in detail a summary of all corrective action taken. Describe any actions taken as a result of the investigation or allegation. (Facility Response) Residents were separated and educated about sexual contact with other residents. Describe the plan for oversight of the implementation of the corrective action, if the allegation is verified (Facility Response) Staff will provide oversight and monitor the residents for further contact. As a result of of a verified finding of abuse such as physical, sexual, or mental abuse, identify counseling or other intervention planned and implemented to assist the resident (Facility Response) None . An interview with the Social Worker on 05/29/24 regarding the incident that took place on 04/07/24 found she did not take statements from any of the staff because they had contacted the healthcare decision maker, and she basically said it was okay as long as the resident wanted to do it. She stated, she went to his room and sought him out. The social worker continued to state, She wanders in and out of rooms every day, but she always seems to go to his room. She then stated, she must like him. When asked if Resident #91 was able to give consent to sexual contact she said, Well she wanders into his room and gets in his bed so I guess that means she wants it. She stated, It was not abuse or neglect because the healthcare decision make said as long as both people want it then to let it happen. An interview with the Director of Nursing on the afternoon of 05/29/24 revealed she had called the residents healthcare decision maker and the healthcare decision maker stated that it was just a way of life and if they were both okay with it then to just give them privacy. The DON indicated this is the reason they did not consider this sexual abuse. When asked if Resident #91 was able to give sexual consent the DON indicated the resident seeks out Resident #61 and that is what they are basing her consent on. The DON acknowledged the resident has dementia so she stated there are days she will smile, and the resident will sometimes respond to her name. When the DON was asked if Resident #91 was able to find Resident #61's room consistently even though she at times does not even know her own name. She stated, Yes I ' m sorry but she can. An interview with LPN #135 on 05/29/24 at 12:47 PM, confirmed she had witnessed the residents in bed together on 04/07/24. She stated, Resident #91 was in the male resident's room and they were laying on the bed beside each and were interlocked in a sexual position. She stated that she separated them and called the NH and SW. When asked how Resident #91 was acting she stated she had no emotion on her face which is normal due to her dementia. She stated Restorative aide #102 and QA #66 was the nurse aides that told her about the incident. A review of Resident #91's medical record found a Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/18/24 and 03/15/24 both of which indicate the resident is rarely to never understood. The residents diagnosis include: Unspecified dementia, Unspecified severity, with other behavioral disturbance. Resident #91's careplan contained the following focus statement: The resident has increased sexual inhibitions / behavior r/t -Has been striping (SIC) in front of males -Getting into bed with male residents -Touching males in private areas -Allowing male resident to to touch her -Family is aware and stated they wanted the facility to do what is best for both residents, if both resident are willing, to provide privacy for residents, but if behavior is unwanted by either resident, to provide redirection. -uses the medication Tagamet to reduce libido. The interventions included: When resident is displaying sexual behavior and both resident and male resident are willing, Staff to provide privacy for residents, but if behavior is unwanted by either residents, staff to provide redirection. This intervention was added to Resident #91's care plan on 04/12/24 which was five (5) days after the incident on 04/07/24. On 05/30/24 at 8:52 a phone interview with Resident #92's healthcare decision maker found the facility had called and she stated, My brother and I talked about it and told them to just let happen, because how are they going to stop it. When asked if this was her mother's lifestyle prior to her dementia she stated, when she turned 50, she divorced my dad and turned this way. I know she is probably the aggressor. She stated, I do not think it is bothering her in any way. According to the state operations manual (SOM) page 76 the following pertains to an appointed decision maker: While a legal representative may have been empowered to make some decisions for a resident, it does not necessarily mean that the representative is empowered to make all decisions for the resident. The individual arrangements for legal representation will have to be reviewed to determine the scope of authority of the representative on behalf of the resident. A review of the resident's record found the residents daughter was appointed as Durable Power of Attorney on 03/18/14 and this appointment gave her daughter the right to make all financial decisions and medical decisions if Resident #91 was deemed incapacitated to do so. The medical record contained, and incapacity statement dated 08/11/23 which the resident's physician stated the resident does not have capacity to make healthcare decisions due to end stage dementia. According to the SOM page 77 the following pertains to sexual consent: The legal standards and criteria for sexual consent vary across states ([NAME], 2007; [NAME] et al., 1999). The most widely accepted criteria, which are consistent with those applied to consent to treatment, are: (1) knowledge of relevant information, including risks and benefits; (2) understanding or rational reasoning that reveals a decision that is consistent with the individual's values (competence); and (3) voluntariness (a stated choice without coercion). An interview with the Nursing Home Administrator (NHA) at 10:15 PM on 05/30/24, found she thought it was the residents right to have sexual contact if they wanted to. She stated, We felt, (Name of Resident #91) seeks out this resident and climbs in bed with him and gets mad when we try to redirect her. She further stated, Her daughter told us she use to like black men. She then stated, Maybe she walks by his room and sees he is black and wants to be with him. She then stated, the nurse aide who showers him said he never gets hard (a slang term used to indicate an erection), so I know they have never had sex. The SOM on pages 75 to 76 says this in regards to Sexual Abuse: Sexual abuse is non-consensual sexual contact of any type with a resident, as defined at 42 CFR S483.5. Sexual abuse includes, but is not limited to: o Unwanted intimate touching of any kind especially of breasts or perineal area; o All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; o Forced observation of masturbation and/or pornography; and o Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. Generally, sexual contact is nonconsensual if the resident either: o Appears to want the contact to occur, but lacks the cognitive ability to consent; or o Does not want the contact to occur. Other examples of nonconsensual sexual contact may include, but are not limited to, situations where a resident is sedated, is temporarily unconscious, or is in a coma. Any investigation of an allegation of resident sexual abuse must start with a determination of whether the sexual activity was consensual on the part of the resident. A resident ' s apparent consent to engage in sexual activity is not valid if it is obtained from a resident lacking the capacity to consent, or consent is obtained through intimidation, coercion or fear, whether it is expressed by the resident or suspected by staff. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered to be sexual abuse. A facility is required to conduct an investigation and protect a resident from non-consensual sexual relations anytime the facility has reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent. Prior to surveyor intervention the facility failed to evaluate Resident #91 and Resident #61 for the ability to consent to sexual contact. As part of the Plan of Correction the facility evaluated all residents for the ability to consent to sexual contact. A review of Resident #91's and Resident #61's assessment found both lacked the capacity to consent to sexual contact. An interview with the Chief Operating Officer (COO) and the Quality Assurance director at 3:00 PM on 06/03/24 found the facility felt no sexual abuse had occurred. The COO stated we never provided them with privacy eventhough it was in the care plan. He asserted he felt this should not even be a citation. When asked why his DON, NHA, and Social Worker all indicated in their interviews that Resident #91 sought out Resident #61 and that indicated she wanted him and wanted to have sexual contact with him. The COO stated, I think they are just scared for their jobs and was looking at it as a resident rights issue and was trying to say what they thought they needed to say. d) Plan of Correction Tag F 600 IJ Date: 5/30/2024 1.) On 5/30/2024 the administrator assigned 1:1 staffing at all times for resident #91 to ensure she is free from non-consensual sexual acts. On 5/30/2024 all staff were informed that all residents are to be kept free from non-consensual sexual harm despite their mental capacities. 2.) Because this has the potential to affect all residents, on 5/30/2024 all residents were interviewed by administrative staff to ensure that they had never been subject to non-consensual acts of sexual nature during their stay at [NAME] Healthcare Services of [NAME] with any corrective action immediately upon discovery. 3.) The Director of Nursing and Social Worker has begun in-servicing ALL staff on 5/30/2024 about facility ' s policy and procedure about resident engaging in sexual acts and what is prohibited. All staff will be in-serviced as of 5/30/2024 prior to their next shift, and virtually if need be. 4.) The Administrator will ensure adherence to the Resident Sexual Acts Policy and Procedure, ensure that staff intervene prior to any non-consensual sexual acts occur between residents. All resident ' s within the building will be evaluated for their capabilities to consent to sexual acts on 5/30/2024. A monitoring log will be completed to ensure that all residents are evaluated for their capabilities to consent to sexual acts upon admission, at any cognitive change, and/or quarterly thereafter. To ensure continued compliance, the monitoring log will be re-evaluated at the Quarterly and Quality Assurance meeting. 49751

Based on observation, record review, and staff interview, the facility failed to ensure the resident environment, over which it had control, was as free of accident hazards as possible, by leaving the Central Supply room door open, and the cabinet inside the Central Supply room unlocked, exposing residents to hazards that could potentially cause serious injury or death. This was a random opportunity for discovery. Resident identifier: 91, 73, 95, 106, 70, 30 and 65. Facility census: 111. The State Agency (SA) determined these failures put the residents residing in the facility at risk for serious harm/death due to residents in the facility having access to the Central Supply room which contained potentially hazardous chemicals that could be ingested, and needles and scalpels that could cause serious injury or death. This placed all residents in the facility in an Immediate Jeopardy (IJ) situation. The facility was first notified of the IJ at 1:03 PM on 05/30/24, The SA received the Plan of Correction (POC) at 5:05 PM on 05/30/24. The SA accepted the POC at 5:05 on 05/30/24. The IJ was abated at 3:30 PM 06/05/24. After the IJ was removed, a deficient practice remained due to Resident #30 having cigarettes at their bedside, and due to the facility failing to implement fall interventions for Resident #65. Therefore the scope and severity was decreased from a k to a e after the IJ was abated. Findings include: A1) Observation At approximately 2:50 PM on 05/29/24, Resident #91 was observed wandering on the east wing of the facility. Resident #91 attempted to enter the Central Supply room multiple times, attempting to turn the handle to open the door, however the door was locked. At approximately 9:45 PM on 05/29/24, during a tour of the facility, the door to the Central Supply room, located on the east side of the facility, was discovered to be open. Five (5) staff members were observed at the East nurse station eating pizza. When the staff members noticed the surveyor in the building, one (1) staff member stood up with the pizza box and walked past the open Central Supply door to discard the pizza box, and did not attempt to close the Central Supply door. Upon entering the Central Supply room, the following was discovered on the shelves accessible to residents : One case of disposable razors Eight orange sticks (sharp sticks used to clean under fingernails) Two bottles of isopropyl rubbing alcohol Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Seventeen bottles of povidone iodine prep solution Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Five bottles of hydrogen peroxide Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Twelve bottles of hand sanitizer Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Eight bottles of antiperspirant deodorant spray Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Nine fleet saline enemas Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Eight bottles of hair conditioner Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Nineteen bottles of body lotion Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Five bottles of perineal cleanser Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Seven bottles of aftershave lotion Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Eight bottles of listerine mouthwash Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Upon further investigation, a cabinet in the back of the central supply room was discovered to be unlocked. The following items were discovered in the cabinet: One case of 25 gauge by five eighths of an inch tuberculin syringes with needles Two cases of 27 gauge by one half inch tuberculin syringes with needles One box of ten stainless steel scalpels One bottle of Gentian [NAME] topical solution Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Two bottles of Dakins Half Strength Solution Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Two bottles of Caldesene Medicated Powder Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Two boxes of glucose monitor control solution Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Ten cases of safety lancets Two cases of 100 insulin syringes Two cases and a one gallon ziplock bag of safety glide needles One box of vacutainer blood collection kit Two boxes of auto shield pro lancets One box of filter needles with five micron filters One box labeled Needles Different Sizes contained 25 gauge by five eighths inch needles and 18 gauge by one inch hypodermic safety needles. Five boxes of sheathed IV catheters One case of BioFreeze packets Labeled reads Keep out of reach of children. If swallowed, get medical help or contach a poison control center right away Nine tubes of Selan Plus Zinc Oxide Formula Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away 12 tubes of calmoseptine ointment Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Four cases of calmoseptine ointment packets Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Two bottles of Sting Free Liquid Skin Prep and Shield Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away Four bottles of Skin Prep protective spray Labeled reads Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away A2) Staff interview On 05/29/24 at approximately 9:58 PM, Nurse Aide (NA) #40 entered the Central Supply room. NA #40 was asked if the door to Central Supply was usually left open and they stated I don ' t think so, at least it shouldn ' t be. On 05/29/24, at approximately 10:03 PM, an interview was conducted with Licensed Practical Nurse (LPN) #26. LPN #26 was asked if the door to Central Supply was usually left open on night shift, to which LPN #26 replied, Maintenance was cleaning the floors and probably left it open. When LPN #26 was asked about the unlocked cabinet they stated, That ' s where we keep all of our needles. It was probably unlocked because the nurse came in here to get something and then other staff yelled at her and she just left the room and left it unlocked. A3) Record review On 05/30/24 at approximately 9:10 AM a list of wanderers on the east wing of the facility was requested from the Director of Nursing (DON). At approximately 9:20 AM the DON supplied a list of residents on the east wing with the wanderers highlighted. The following residents were identified by the facility as wanderers on the east wing: Resident #91 Resident #73 Resident #95 Resident #106 Resident #70 A4) Plan of Correction The facility ' s POC was accepted at 5:05 PM on 05/30/24 and the IJ was abated at 3:30 PM on 06/05/24. The POC is typed as written: 1.) On 5/30/2024, the administrator ensured that all razors, needles, scalpels, medicated powders, creams, and any other solution if consumed could be harmful was moved from the Central Supply Room to the East Wing Medication Room. On 5/30/2024 all staff were informed that the items were relocated and even though those items are being placed elsewhere the Central Supply Room door is to remain closed at all times and locked. 2.) Because this has the potential to affect all residents, on 5/30/2024 video footage with full view of the Central Supply Room door was reviewed to ensure no residents entered the room for potential to have consumed any toxic substance with any corrective action immediately upon discovery. 3.) The administrator completed an in-service for all staff to ensure they are aware that the Central Supply Room door is to remain closed and locked at all times and the new location of the potentially harmful substances in the East Wing Medication Room. All staff will be in-serviced as of 5/30/2024 prior to their next shift, and virtually if need be. 4.) The Administrator will ensure adherence to the Keeping Residents Free from Potentially Harmful Substances and Items Policy and Procedure, ensure that staff keep all doors locked and all substances out of reach as appropriate. A monitoring log will be completed to ensure that all doors with locks are locked and all potentially harmful substances are kept in a safe area of of residents reach daily for 30 days, weekly for one month, and quarterly thereafter. To ensure continued compliance, the monitoring log will be re-evaluated at the Quarterly and Quality Assurance meeting. b) Resident #30 An observation on 06/04/24 at 12:00 PM, of Resident #30's room revealed, he had cigarettes at his bedside, sitting on top of his bedside dresser. During an interview on 06/04/24 at 12:00PM, Resident #30 stated, It's almost smoke time. A record review on 06/04/24 of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/24 section C for Resident #30 revealed a Brief Interview for Mental Status (BIMS) score of 99. Further record review revealed the following care plan focus for Resident #30: Focus: {Initiated on 05/09/24} Typed as written. - Memory problems / dementia - is not aware of his surroundings or safety needs. Focus: {Initiated on 05/29/24} The resident is a wanderer AEB -Disoriented to place at times -Resident wanders at times During an observation on 06/04/24 at 1:00PM of the [NAME] Wing where Resident #30 resides in room [ROOM NUMBER]-B revealed (2) two other residents that wander. Resident #94 and Resident #77. A record review on 06/04/24 at 1:30PM, revealed that Resident #94 has a diagnosis of Alzheimer's. Further record review revealed the following care plan focus for Resident #94: Focus: {Revised on 05/17/24} Typed as written. -The resident is at risk for falls r/t -H/O falls -Unsteady -Lacks safety awareness -Restless at times, frequently repositions self in bed/chair -Med use -poor balance -poor cognition -is ambulatory throughout facility and wanders in and out of rooms. A record review on 06/04/24 at 1:40 PM, revealed that Resident #72 has a diagnosis of unspecified Dementia with other behavioral disturbances. Further record review revealed the following care plan focus for Resident #77: Focus: {Revised on 05/29/24} The resident is an elopement risk/wanderer AEB -Confusion -Disoriented to place -Impaired safety awareness A review on the Federal Drug Administration (FDA) warning for Nicotine 06/04/24 at 2:15PM, read as follows: Nicotine, the addictive ingredient in tobacco, is not safe - whether it is eaten, touched or inhaled. Symptoms of mild nicotine poisoning include stomach problems like nausea, vomiting and diarrhea. More severe cases can include dizziness, sweating, headache, hyperactivity or restlessness. During an interview on 06/04/24 at 2:30PM, Registered Nurse (RN) #4 stated, We used to keep the cigarettes locked up, but residents complained and wanted to keep their own. That is why they do it that way now. I will talk to them. It will be hard to get them to agree to lock them up again. c) Resident #65 A review of Resident #65's care plan on the afternoon of 05/28/24 found the following care plan related to fall prevention: Focus Statement Read: - The resident is at risk for falls r/t (Related To) -Not aware of safety needs -H/O (History of) falls at home was in floor on 12/12/23 in floor 3/10/24 was off matt in floor slid out of chair on 3/18/24 Date Initiated: 11/21/2023 Revision on: 03/19/2024 The goal related to this focus statement read as follows: --The resident will be free of falls through the review date. Date Initiated: 05/14/2024 Revision on: 05/17/2024 Target Date: 08/15/2024 The Interventions related to this goal included: -- Safety mat to bilateral side(s) of bed d/t safety precaution, risk of falls. Date Initiated: 12/19/2023 Revision on: 12/29/2023 -- Dycem to w/c at all times to prevent sliding. Date Initiated: 05/28/2024 -- Alarm to chair while in chair. Observe and report to nurse Adverse consequences of alarm use which can include, but are not limited to: fear, anxiety, or agitation related to the alarm sound; decreased mobility; sleep disturbances; and infringement on freedom of movement, dignity, and privacy -- Alarm to bed when in bed. Observe and report to Nurse Adverse consequences of alarm use which can include, but are not limited to: fear, anxiety, or agitation related to the alarm sound; decreased mobility; sleep disturbances; and infringement on freedom of movement, dignity, and privacy Date Initiated: 11/26/2023 An observation of Resident #65 on 05/2/24 at 4:19 PM found the fall mats at her bed side had an over the bed table and oxygen concentrator parked on them. This was confirmed the invention preventions at the time of the observation. She confirmed the fall mats should not have items parked on them. An additional observation of Resident #65 on 06/04/24 at 1:55 PM found the residents bed alarm was in place however the pressure sensing pad was not plugged into the alarm. Therefore it would not have alarmed had the resident attempted to get out of bed this was confirmed with Nurse Aide #44 at the time of the observation. She stated, I just came out of there and did not notice that because I was on the other side of the bed. A final observation of Resident #65 at 9:15 am on 06/05/24 found Resident #65 was again in bed. The alarm pad was on the residents bed and the alarm was hanging on the assist rail. However upon a closer observation it was discovered the pad was once again not connected to the alarm and would not have alarmed had the resident attempted to get out of bed. This was confirmed with Licensed Practical Nurse (LPN) # 121 at the time of the observation . 49465 49467

Based on observation and staff interview, the facility failed to safeguard the privacy of the back hall of the [NAME] wing resident's medical record. This was a random opportunity for discovery. Resident #83, #108, #97, #65, #60, #35, #98, #44, #45, #66, #68, #94, #66, #69, #30, #19, #58, #18, #3, #35, #96, #86, #80, #57, #10, #79, #53, #512, and #24. Facility Census: 111. Findings Include: a) [NAME] Wing Medication Computer On 05/29/24 at 9:45 PM, a tour of the facility was completed. Upon approaching the [NAME] wing medication computer on the back hall, the computer screen was visible with the resident's pictures and names. On 05/29/24 at 9:48 PM, Licensed Practical Nurse (LPN) #125 approached the cart and stated, I thought I locked the screen. On 06/04/24 at 1:00 PM, Registered Nurse (RN) #4 was notified of the computer screen being visible to anyone passing by the medication cart. RN #4 confirmed the computer screen should have been locked. RN # 4 stated, they told me what happened.

Based on observation and staff interview the facility failed to treat residents with respect and dignity during the dining experience and by pulling a resident down the hall backwards. These failed practices were random oppurtunities for discovery and had the potential to affect more than an limited number of residents currently resding in the facility. Resident Identifier # 36 Facility Census 111. Findings Include: a) Resident #36 An observation on 06/04/24 at 11:25 AM, of hall 400, revealed Nurse Aide (NA) # 58 pulling Resident #36 down the hallway backwards in a Geri chair about 30 feet. During an interview on 04/04/24 at 11:26 AM, NA #58 stated, This is the way I always do it. During an interview on 04/04/24 at 1:45 PM, registered Nurse (RN) #4 confirmed, staff should not be pulling residents backwards. b) Main Dining on 05/28/24 An observation of the main dining room for the evening meal on 05/28/24 found there was 24 residents seated in the dining room waiting for their meal at 6:00 PM. At 6:05 PM, Resident #70, #4, # 73, #6, and #59 were all served their meal. The remaining 19 residents were not immediately served their meal. At 6:20 PM the remaining 19 residents were served their meal. For 15 minutes 19 residents were watching the first five (5) residents eat their meal. One (1) resident was observed asking staff on multiple occasions where her food was. An interview with the activities staff who was working in the dining room indicated there is not usually a delay in the service of the meal. She stated, I don't know what is going on today. C) East Wing Dinner Service At approximately 5:37 PM on 05/28/24, during meal service on the East Wing of the facility, observations were made of staff serving different rooms instead of both residents in the same room, at the same time. Resident #99 was served at 5:37 PM while Resident #361 did not receive a tray. Staff continued to pull trays off of the delivery cart and take them to rooms without ensuring that both residents were served in the same room together. After the first delivery cart was empty, at 5:43 PM, Resident #361 still did not have a tray. At approximately 5:43 PM on 05/28/24, an interview was conducted with Licensed Practical Nurse (LPN) #26 regarding Resident #361 and why they had not received their tray yet, in which they stated We are just waiting on her tray, it should be on the next cart. Resident #361 received her tray at 5:50 PM, thirteen minutes after her roommate received their tray. At approximately 5:45 PM on 05/28/24, there were seven (7) residents prepared to eat in the lounge area on the East Wing of the facility. Five (5) residents were at one table while two residents sat at tables by themselves. At the table with 5 residents, two (2) residents were served their dinner trays, while three (3) of the residents did not receive their trays. The remaining 3 residents did not receive their trays until approximately 5:53 PM. At approximately 5:49 PM on 05/28/24, an interview was conducted with the Nurse Practitioner (NP) regarding the dinner service, as she was helping to pass trays. The NP stated This is not how this should go and it isn't how it usually goes. They all know the residents are to be served room by room and table by table. We will get it corrected. 49465 49467

Based on record review and staff interview, the facility failed to ensure each resident was free from chemical restraint. Resident #27 was given an antipsychotic injection before showers, to prevent the resident from becoming combative during the shower. This was true for one (1) of one (1) residents reviewed for chemical restraints during the survey process. Resident identifier: 27. Facility census: 111. Findings include: A) Record review At approximately 2:22 PM on 05/30/24, a record review was conducted of medication regimen reviews for Resident #27. During this review, the recommendation made on the review for May of 2023 was for Ziprasidone. The recommendation stated the diagnosis of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance should be changed to be more specific, or the medication should be discontinued. The order for the medication read: Geodon Intramuscular Solution Reconstituted (Ziprasidone Mesylate) Inject 10 mg intramuscularly every day shift every Tue, Thu, Sat for Dementia with psychotic features administer 10mg injection IM x 1 20 min prior to shower. A review of the MAR for Resident #27 revealed she received the injection on the following days: -05/20/23 -05/23/23 -05/25/23 -05/27/23 -05/30/23 -06/01/23 -06/03/23 -06/06/23 -06/08/23 -06/10/23 -06/13/23 -06/15/23 -06/20/23 -06/22/23 -06/24/23 -06/27/23 -06/29/23 -07/01/23 -07/04/23 -07/06/23 -07/08/23 -07/11/23 -07/13/23 -07/15/23 -07/18/23 B) Staff interviews At approximately 3:43 PM on 06/03/24 an interview was conducted with the Director of Nursing (DON) regarding the order for Ziprasidone to be given to Resident #27 before her showers. The DON stated That is the only way we could get her in the shower. She was combative, she would hit and scratch the staff, she was going to hurt herself or someone else if we didn't give it to her.

Based on record review and staff interview the facility failed to thoroughly investigate an allegation of sexual abuse involving Resident #91 and Resident #61. This was true for two (2) of six (6) residents reviewed for the care area of abuse during the long term care survey process. Resident Identifiers: 91 and 61. Facility Census: 111. Findings Include: a) Resident #91 and #61 incident date 04/07/24 A review of a Facility Reported Incident which was received by the state agency on 04/07/24 found the following: Type of Incident was a resident to resident incident. The type of abuse was specified as Sexual. The incident form indicated the the staff became aware of the abuse at 9:00 AM on 04/07/24. Resident #91 was listed as the alleged victim. The perpetrator was listed as Resident #61. The reportable listed four (4) staff members as witnesses to the incident. The staff were identified as QA #66, Licensed Practical Nurse (LPN) #105. Restorative Aide #102, and Prior Employee # 1 (Position unknown), The incident report indicated the residents were witnessed in lying in bed in a sexual position. The place was indicated it was Resident #61' bed. A review of the facility's five day follow up report found the following information: .2. steps taken to investigate the allegation: Provide a detailed summary of ALL steps taken to investigate the allegation. Summary of Interviews with the alleged victim and/or the victims responsible party, if applicable. Indicate any visual cues from the resident of psychosocial distress. (The facility's response) No suspicion of abuse or neglect. Resident to Resident No Harm. Summary of Interviews with witnesses including but not limited to, what the individual observed or knowledge of the alleged incident or injury: (Facility Response) None. Summary of Interviews with the alleged perpetrators identifying whether they are staff, resident, visitor, contractor, etc. (facility response) None. Summary of Interviews with other residents who may have had contact with the alleged perpetrators: (Facility Response): None. Summary of Interviews with staff responsible for oversight and supervision of the location where the alleged victim resides (Facility Response) Residents were separated, and educated about sexual contact with other residents. Summary of the interviews with staff responsible for oversight and supervision of the alleged perpetrator if the perpetrators staff or a resident: (Facility Response) see above. Provide Summary information from the investigation related to the incident from the residents clinical record as relevant portions of the RAI, the residents care plan, nurses' notes. social service note, lab reports, x-ray reports, physician or other practitioner reports, or reports from other disciplines that are related to the incident. If a resident to resident altercation occurred provide any relevant details that may have caused the alleged perpetrators behavior, such as habits, routines, medications, diagnosis, how long he/she may have lived at the building, or BIMS score. (facility response): none. If available within the five working day timeframe provide summary of information of other documents obtained, such as hospital/medical progress notes/orders and discharge summaries, law enforcement reports and death reports if applicable. (facility Response) None. 3. Conclusion Provide a brief description of the conclusion of the investigation and indicate if findings were: (For incidents reported as injuries of unknown source indicate if the injury resulted from abuse or neglect, based on evidence from the investigation) Verified: The allegation was verified by evidence collected during the investigation. Indicate how the allegation was verified by evidence collected during the investigation and describe the evidence. (Facility Response) No abuse or neglect. Not Verified: The allegation was refuted by evidence collected during the investigation. Indicate and describe why the allegation was unable to be verified during the investigation. (Facility Response ) No Abuse or neglect Inconclusive: The allegation could not be verified or refuted because there was insufficient information to determine whether or not the allegation had occurred. If this incident was identified as inconclusive, indicate and describe how this was determined. (Facility Response) No abuse or neglect. 4. Corrective action taken: Provide in detail a summary of all corrective action taken. Describe any actions taken as a result of the investigation or allegation. (Facility Response) Residents were separated and educated about sexual contact with other residents. Describe the plan for oversight of the implementation of the corrective action, if the allegation is verified (Facility Response) Staff will provide oversight and monitor the residents for further contact. As a result of of a verified finding of abuse such as physical, sexual, or mental abuse, identify counseling or other intervention planned and implemented to assist the resident (Facility Response) None . An interview with the Social Worker on 05/29/24 regarding the incident that took place on 04/07/24 found she did not take statements from any of the staff because they had contacted the healthcare decision maker, and she basically said it was okay as long as the resident wanted to do it. She stated, she went to his room and sought him out. The social worker continued to state, She wanders in and out of rooms every day, but she always seems to go to his room. She then stated, she must like him. When asked if Resident #91 was able to give consent to sexual contact she said, Well she wanders into his room and gets in his bed so I guess that means she wants it. She stated, It was not abuse or neglect because the healthcare decision make said as long as both people want it then to let it happen. An Additional interview with the social worker in the afternoon of 06/04/24 found she did not take witness statements because the Licensed practical Nurse is the one who filled out the report. When asked about the three (3) additional employees she stated, they just heard about what happened and was not actual witnesses. She stated, they are hear I will get their statements now. The social worker then exited the room. Later in the afternoon on 06/04/24 the social worker provided two (2) hand written statements from QA #66, and Restorative Aide #102. The statements were as follows: QA #66 wrote: '(Typed as written including misspellings) (Name of Resident #91) was wondering and no one knew were she was I went into (First Name of Resident #61)'s room to get his tray and seen (First Name of Resident #61) on top of (First Name of Resident #91) I couldn't leave the residents so I stood by the door and hollered for the closest person which was (First Name of Restorative Aide #102) and (First Name of Licensed Practical Nurse # 105) came they got their clothes back on and directed (First name of Resident #91) to her room. Restorative Aide #102 wrote: (Typed as Written including misspellings) I witnessed (First Name and Last Initial of Resident #91) and Mr. (Last name of Resident #61) trying to engage in sexual activity. I requested the nurses to come and assist and we got them separated and back to their respected rooms and beds. Mr, (Last Name of Resident #61) did have his pants and underwear down and Mrs. (First name of Resident #91) too, but I didn't see if he had made it inside. I helped separate them then reported it. When separating Miss (First name of Resident #91) tried to fight against us due to confusion, but we got her dressed and no problems after that. Mr. (Last Name of Resident #61) co-op completely during it. The surveyor completed an interview with LPN #135 on 05/29/24 at 12:47 PM, she confirmed she had witnessed the residents in bed together on 04/07/24. She stated, Resident #91 was in the male resident's room and they were laying on the bed beside each and were interlocked in a sexual position. She stated that she separated them and called the NH and SW. When asked how Resident #91 was acting she stated she had no emotion on her face which is normal due to her dementia. She stated Restorative aide #102 and QA #66 was the nurse aides that told her about the incident. All three (3) of the witnesses demonstrated they had witnessed the incident on 04/07/24, but the Social Worker failed to obtain statements from them until after surveyor intervention.

Based on record review, staff interview and resident interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. On 01/15/21 Resident #84 was involved in an accident involving a vape (electronic smoking device) in which Resident #84 sustained facial and respiratory burns. In addition Resident #13, #40, #61, #72, #24, #80, #11, #10, #15 and #77 were all provided electronic cigarettes by the facility to use in their room during the COVID-19 outbreak. The state agency determined these failures placed all residents currently residing in an immediate jeopardy situation due to the risk of fire. The state agency notified the Nursing Home Administrator, the Director of Nursing, and the clinical coordinator of the immediate jeopardy at 1:21 PM on 01/27/21. The facility submitted a plan of correction (POC) at 3:40 PM the state agency requested changes and an additional POC was submitted at 3:58 PM at this time the POC was accepted by the state agency. The state agency verified the POC was implemented by conducting staff interviews and record reviews and the immediate jeopardy was abated at 4:55 PM on 01/27/21. Resident Identifiers: Resident #84, Resident #13, Resident #40, Resident #61, Resident #72, Resident #24, Resident #80, Resident #11, Resident #10, Resident #15 and Resident #77. Facility Census: 83. Findings Included: a) A review of Resident #84's medical record on 01/26/21 found the following nursing progress notes: -- Heard staff in hall yelling fire. This nurse ran to residents room. Resident noted to be sitting in bed. Oxygen tubing in floor sparking. This nurse grabbed tubing and pulled away from concentrator and stomped out sparks. Another nurse ran into room and starting providing care for resident. Resident stated that he was going to use his vape when it popped. Vape found in floor. Staff removed room mate, Fire alarm was pulled, 911 called. Resident noted to have singed hair, Beard and mustache. This nurse pulled hair away from face and put in pony tail. Resident was joking that he needed a cigarettes after this. Burns noted to face and (L) ear and hand. Staff cleaned area with NSS( normal saline solution). Resident gave 20$ bill and his key to staff to hold until he gets back from hospital. This note was written on 01/15/21 at 2:15 PM by the Minimum Data Set (MDS) coordinator. -- This nurse was called to residents room by staff. Residents face and hair was in flames. RN on duty extinguished fire. Residents room mate was immediately removed from room, room mates vitals taken and WNL. Resident stated that his vape pen caught fire. Resident was wearing oxygen 4L/M via NC, and had burns to face, nostrils and left hand. Unable to obtain vitals on resident d/t first aid being performed. Oxygen was removed and turned off. Residents face was cleaned with NSS. Oxygen tubing replaced and another source of oxygen was used Resident was alert and oriented. EMS arrived on scene with two attendees, city fire marshal (name of city fire marshal) arrived on scene. Fire marshal obtained vape and oxygen tubing. ER contacted and awaiting arrival. Resident stated: I was puffing my vape and I heard a loud pop. Fire was extinguished by RN on duty. 911 was called and oxygen tubing replaced and another source of oxygen was used. Facial burns cleaned with NSS. EMS arrived. This note was written by Licensed Practical Nurse (LPN) #124 at 2:39 PM on 01/15/21. -- This nurse was on East Wing when the fire alarm went off. A staff member alerted that a resident was on fire. This nurse immediately went to the resident's room. Staff was present. Resident was sitting up in bed alert and oriented. Resident was even making jokes of wanting to go smoke a cigarette. This nurse examined residents nostrils and they were scorched bilaterally, face was burnt on forehead, eye lids, cheeks, nose, his hairline along with beard and mustache were burnt. Scant amount of suet was in the back of throat and on his tongue. When this nurse ask resident what happened he stated: I was sitting here puffing on my vape and I heard a loud boom. The next thing I know I'm on fire. This note was written on 01/15/21 at 2:35 PM by RN #42. Further review of the medical record found Resident #84 was discharged to a local hospital and was later transferred to a burn unit at a second hospital. As of 01/26/21 Resident #84 had not returned to the facility. Review of Resident #84's physicians orders found an order for oxygen (O2) at four (4) liters per minute via nasal cannula (NC) as needed for dyspnea, and shortness of breath. An interview with the Director of Nursing (DON) at 1:26 PM on 01/26/21 confirmed the facility had provided multiple residents who smoke cigarettes with electronic cigarettes to use during the COVID - 19 outbreak at the facility. She indicated since the residents could not leave their rooms to smoke outside they (the facility) purchased the residents electronic cigarettes to use in their room. She stated, they first purchased electronic cigarettes in Late August to early September 2020 during the COVID-19 outbreak at the facility. The DON further explained Resident #84 was using a vaping device that had not been purchased by the facility. However, additional interviews with the staff confirmed that at least two (2) staff members were aware Resident #84 had a different type of vaping device not the one provided by the facility. On the afternoon of 01/27/21, anonymous interviews with two (2) staff confirmed they knew the resident had his own vaping device in his room. The resident had his own because he did not like the ones provided by the facility. The resident would say, I have my own. The DON was asked to provide a list of all residents who were provided electronic cigarettes to use in their rooms during the COVID - 19 outbreak. She provided a list containing the following residents: Resident #13, Resident #40, Resident #61, Resident #72, Resident #24, Resident #80, and Resident #11. However, the survey team identified through interviews with residents three (3) additional residents who were provided Electronic Cigarettes to use during the COVID - 19 outbreak. Resident #10 in an interview on 01/26/21 at 1:00 PM, stated he used an electronic cigarette and kept it in his night stand in a drawer. He pointed to the drawer. He further stated, We can't do that no more because the guy down the hall burnt himself up. They took it a week ago. His care plan was reviewed and verified he had an electronic cigarette. Resident #15 in an interview on 01/26/21 at 2:45 PM, indicated he was upset with the current smoking situation. He confirmed he had used an electronic cigarette he was able to smoke in his room. Resident #77 in an interview on 01/27/21 at 12:50 PM confirmed the facility provided her with an electronic cigarette to use in her room during the COVID - 19 outbreak. She was allowed to smoke it in her room and it recently went away. An interview with Resident #24 on 01/26/21 at 12:41 PM confirmed the facility provided him with an electronic cigarette to use during the COVID-19 outbreak. He stated, they took those a week ago when that man set himself on fire. He indicated that he kept his electronic cigarette in his room and would use it whenever he wanted to. He further stated, when it runs out the nurses or the front office will give you a new one. Resident #24 stated he had an electronic cigarette for several months before they took them and there were at least five (5) or six (6) other residents who had them and used them in their rooms. A review of Resident #61's medical record on 01/26/21 found a progress note dated 09/04/20 at 7:55 AM, Employee #87 documented, Visited with resident (Resident #61) in her room [ROOM NUMBER]/02/20 and also provided her with a case of soda and a electronic cigarette at her request. Resident does become upset easily and staff does provide her with her wants and needs to assist in decreasing her stress. Additionally, Employee #87 documented on 11/23/20 at 7:50 AM, She (Resident #61) does prefer to go outside to smoke but at this time d/t (due to) precautions in place she has use of a E-cigarette. During an interview with the Social Worker on 01/26/21 at 3:10 PM, she stated the e-cigarettes were offered as an alternative to smoking outside during the facility's COVID-19 outbreak. She further reported that the facility had kept them well-stocked and had paid for them. Social Worker also confirmed that Resident #61 had kept her e-cigarette in her room and had access to smoking at any time. An interview with Resident #72 on 01/26/21 at 2:10 PM, revealed the resident was a smoker. The resident stated we usually go out and smoke outside but now we can't go outside. When asked if he used an electronic cigarette. Resident #72 responded Yes. Resident #72 further explained the facility gave him an electronic cigarette when residents were not able to smoke outside because of Covid-19 outbreak. When asked if the resident was able to use the electronic cigarette in his room, Resident #72 stated Yes. An interview with Resident #40, on 01/26/21 at 12:50 PM, concerning the cigarette schedule which was posted in his room. Resident #40 stated, they stopped smoking now. Resident # 40 stated, smokers were not told why smoking was not allowed at this time. Resident #40 stated, Smokers could use electronic cigarettes in their room when ever they wanted to. Smokers needed to get their cigarettes or electronic cigarettes from the nursing station or business office. A review of Resident #13's medical record on 01/27/21 found a physician's order for O2 at two (2) liters per minute via NC as needed. A review of Resident #40's medical record on 01/27/21 found a physician's order for O2 at two (2) liters per minute via NC as needed. A review of Resident #72's medical record on 01/27/21 found a physician's order for O2 at two (2) liters per minute via NC as needed for shortness of breath. In summary of the seven (7) residents provided electronic cigarettes on the list provided by the facility and the three (3) residents identified by the survey team as having electronic cigarettes for use in their room, three (3) had physician's order for as needed oxygen. In addition, Resident #84 also had physician's orders for as needed oxygen. The staff were aware he had a vaping device in his room which he utilized. Review of information from the Centers for Disease Control (CDC) in regards to electronic cigarettes obtained from the world wide web at the following address: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/Electronic-Cigarettes-Infographic-p.pdf found the following: .E-Cigarettes can cause unintended injuries. Defective e-cigarette batteries have caused fires and explosion's, some of which have resulted in serious injuries. In addition, acute nicotine exposure can be toxic. Children and adults have been poisoned swallowing, breathing, or absorbing e - cigarette liquid. Review of the Fire Marshal reports regarding the incident on 01/15/21 found the following, .The cause of the fire appears to be the result of the patient attempting to use his Vape while wearing supplemental oxygen. Staff was advised that vaping is considered smoking and is not permitted inside of the facility. At time of the visit the staff had collected the vapes from the other patients in the facility and will only allow the patients to utilize the devices outside in the designated smoking areas . A review of the facility's policy titled, Smoking with the effective date of 10/24/17 found the following: Policy: (Name of Facility) recognizes the health risks associated with tobacco use, both for the smokers and for those exposed to secondhand smoke. We recognize; however, smoking is prevalent among our resident population and because of this, smoking will only be allowed in designated areas. This policy applies to all residents, employees, families, and visitors. This policy includes the use of electronic cigarettes and vaping devices. Procedure: -- Smoking is prohibited inside the facility. -- Smoking will only be allowed in designated areas and at designated smoking times. - An area designated as a smoking area will be environmentally separate from all patient care areas and will be well ventilated or if outdoors, will protect residents from weather conditions. - A primary gathering place for residents will not be designated as a smoking area that non-smokers are not subject to second had smoke. - Oxygen is not permitted in smoking areas . -- Smoking supplies will be maintained by staff (including cigarettes, matches, lighters, etc.) and will be stored in a suitable location. b) Plan of Correction The facility provided the following POC to abate the immediate jeopardy situation: 1.) On, 1/15/2021 all electronic vaping devices were relinquished to the MDS Coordinator and Assistant Administrator. On 1/15/2021 staff members were educated on safety, prohibited vaping devices, and fire protocol by the MDS Coordinator, maintenance director and the State Fire Marshall. 2.) Because this had the potential to affect all residents, on 1/15/2021 all residents were asked to relinquish their (Specific Name of Vaping device) vaping devices. All residents were asked if they had any other forms of vaping devices, and all resident's stated they had no vaping devices. Resident's agreed to allow MDS Coordinator and Assistant Administrator to search their items. These devices were discarded of appropriately with any corrective action immediately upon discovery. 3.) The MDS coordinator has begun in-servicing all staff on 1/27/2021 educating staff about maintaining an environment free of accidents, hazards, and risks. All staff will be inserviced as of 1/27/2021 prior to their next shift, and virtually if need be. All social distancing regulations will be maintained during inservicing. 4.) The Director of Nursing will ensure adherence to Smoking Policy and Procedure and prohibited vaping devices to ensure continued compliance. The monitoring log attached will be completed daily by the activities staff that the residents are complying with the smoking policies and procedures and no prohibited smoking devices are being used. The monitoring log will be completed daily for a time frame of thirty days, then every other day for two weeks. An individual resident council meeting for all resident's in room will be held today to ensure resident's understanding of electronic vaping devices being prohibited. On 1/26/2021 all residents who utilize tobacco were offered nicotine patches. To ensure continued compliance, audits and will be re-evaluated at the Quarterly, Quality Assurance meeting.

Based on record review and staff interview, the facility failed to ensure Resident #18's environment over which it had control of was as free from accident hazards as possible. The facility failed to communicate to Nurse Aides the safest way to transfer and or provide incontinence care for Resident #18. The resident subsequently had an accident in which she fractured her left shoulder. This was true for one (1) of four (4) residents reviewed for the care area of accidents during the long term care survey process. Resident identifier: #18. Facility census: 108. Findings included: a) Resident #18 A review of Resident #18's medical record found her [DIAGNOSES REDACTED].>-- Cerebral Infarction with an onset date of 01/27/11. -- Contractures of the left ankle, left elbow, left wrist, and left shoulder all with an onset date of 10/01/13. -- Contractures of the left hand with an onset date of 01/21/11. -- [MEDICAL CONDITION] and Hemipaesis following Cerebral Infraction affecting left side with an onset date of 01/27/11. -- Other non displaced fracture of upper end of left humerus with an onset date of 07/17/19. Further review of Resident #18's medical record found the following nursing progress notes (all notes typed as written), -- 07/15/19 at 5:39 p.m., Notified via staff the resident had to be lowered to the floor during pericare following this resident legs becoming weak and the resident began to fall when staff placed his forearm under her left arm pit and assisted her to the floor resident was assessed no complaints of pain noted resident denies falling states he lowered me to the floor resident denies any pain at this time resident placed back in w/c at this time via staff. resident gave her personal items to smoke and resident proceeded down the cor adore . -- 07/15/19 at 5:43 p.m., Resident presents to the nurses station. Self propelled in w.c (wheelchair) with complaints voiced that her shoulder hurts states she almost fell and the CNA that was helping her caught her and laided her down in the floor . resident denies falling but is very upset yelling and repeating that he laid me down in the dirty floor but does state that her arm is hurting Dr (Last Name of Attending Physician) aware with new orders in place to obtain a xray to left shoulder d/t complaints of painResident is notable upset repeating staff laid her in thedirty floor . resident assessed with [REDACTED]. Resident and staff both deny this resident hitting her head. -- 07/15/19 at5:43 p.m., Resident presents to the nurses station. Self propelled in w.c with complaints voiced that her shoulder hurts states she almost fell and the CNA that was helping her caught her and laided her down in the floor . resident denies falling but is very upset yelling and repeating that he laid me down in the dirty floor but does state that her arm is hurting Dr (Last Name of Attending Physician) aware with new orders in place to obtain a xray to left shoulder d/t complaints of painResident is notable upset repeating staff laid her in thedirty floor . resident assessed with [REDACTED].Resident and staff both deny this resident hitting her head. -- 07/15/19 at 10:00 p.m., xray results received with no acute osseous abnormality [MEDICAL CONDITION] changes -- 07/17/19 at 5:30 p.m., called to resident's room by staff, bruise noted to 5th digit on left hand and lateral left upper arm, c/o pain, resident states It hurts so bad, contacted physician, new orders written -- 07/17/19 at 5:24 p.m., Note: results of x-ray left hand-no acute fracture or dislocation, the osseous structures appear intact. Joint spaces are narrowed. Soft tissues are unremarkable. Conclusion: No acute osseous abnormality, [MEDICAL CONDITION] changes, nondiagnostic views of the phalanges. Humerus-[MEDICAL CONDITION] neck with impaction. No dislocation of the head. Joint space narrowing. Mild soft tissue swelling. Conclusion: Acute [MEDICAL CONDITION] neck as noted. This is better seen on the current exam but retrospectively present but obscured by overlying summation artifact. Addendum report of shoulder complete 7/15/19: follow up examination shows a subtle neck fracture which is only seen retrospectively on this exam done previously 2 days prior. The fracture is obscured by soft tissue lucency. A review of the incident and accident report for Resident #18 dated 07/15/19 found the following information: Incident Description: Resident presents to the nurses station. Self Propelled in w.c. (wheel chair) with compliant voiced that her shoulder hurts states she almost fell and the CNA that was helping her caught her and laid her down in the floor. The residents floor in her room is noted to have popcorn present to most of the floor. Resident denies falling but is very upset and repeating that he laid me down in the dirty floor but does state that her arm is hurting Dr. (Last name of attending Physician) aware with new orders in place to obtain X-ray to left shoulder d/t (due to) complaints of pain. Under the section titled witnesses the following statement was present from Nurse Aide (NA) #147, The resident was gripping the sink in the resident room while standing to be changed at which time the resident started swaying and let go at which time I caught this resident and assisted her to the floor. (First Name of Resident #18) denied being hurt and was very upset that I had laid her in the floor and demanded I get her up. I then assisted her back to her chair with the assistance of other staff X1. Another statement written by NA #147 on 07/22/19 regarding this incident read as follows, Resident (First and Last Name of Resident #18) came to me and informed me she was wet. She and I proceeded to her room to change her. (First Name of Resident #18 ) as always stood at sink with my assistance. After completing claiming her up and changing her clothes (First Name of Resident #18) began to get shaky, almost immediately she buckled and almost fell . I under hooked her left arm and lowered her to the floor without apparent injury. (First Name of Resident #18) stated at the time she wasn't injured or hurting. I stepped into hallway to get assistance (First and Last Name of NA #17) came in and assisted me in picking (First Name of Resident #18) up and putting her back into her wheelchair. Nurse notified of situation and that I caught her and had lowered her to the floor. A review of Resident #18's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/19 found the resident required extensive assistance of two (2) staff members to complete the following activities of daily living (ADLs): Bed Mobility, Transferring, and Dressing, A review of Resident #18's care plan including the revision history found the following: Focus Statement: The resident is at risk for falls R/t -- Unaware of safety needs, -- Confusion, --Psychoactive drug use, -- Gait/balance problems, -- Incontinence, -- left sided weakness, --slides down in chair, --attempts to get up unassisted, -- Vitamin D deficiency, -- Left Humeral surgical neck fracture. This focus statement was initiated on 07/24/13 and most recently revised on 08/01/19. The goals associated with this focus statement included: The resident will be free of signficant injuries related to falls through the review date. This goal was first initiated on 03/01/19 with the most recent revision date being 08/08/19. The interventions related to this focus statement and goals included: -- Requires extensive assistance with transfers. Staff (MONTH) use mechanical lift when resident is tired or unable to stand PRN (As Needed). This intervention was added to the care plan on 05/30/19 and was a current intervention at the time of this review. The care plan was not specific for Resident #18's level of care and left it up to the NA to determine if the resident was a one (1) person assist, a two (2) assist, or a total lift. An interview with the Director of Nursing (DON) and Registered Nurse MDS Coordinator (RN-MDS) at 1:00 p.m. on 10/22/19 confirmed Resident #18 fell on [DATE] while being assisted by NA #147. They confirmed he was the only one assisting the resident at the time of the fall and further confirmed the residents left shoulder was fractured during this incident. The RN-MDS Coordinator when asked where NA's look to determine what type of assistance a resident needs for ADLs she indicated they would look at the Kardex which is derived from the care plan. When asked what Resident #18's Kardex would have said on 07/15/19 she stated it would have been the following, Requires extensive assistance with transfers. Staff (MONTH) use mechanical lift when resident is tired or unable to stand PRN (As Needed). She stated, this was the current intervention at that time and would have been on the Kardex. When asked how long the resident had required an extensive assistance of two (2) people for transfers the RN - MDS coordinator replied, she has needed that level of assistance for a long time now. When asked why the care plan was not specific to direct the NAs on how to transfer Resident #18 the RN- MDS Coordinator indicated, Resident #18 was difficult because sometimes she would stand and other times she would not. She indicated if Resident #18 did not want to wait on help she would just try to do it herself and had multiple behaviors including becoming combative with staff. She further stated if she does not want to be in the lift she will refuse to get out of bed or will try to do it by herself. An interview with the Assistant Nursing Home Administrator (NHA) at 3:37 p.m. on 10/22/19 confirmed this instance was reported to the state agency as an unusual occurrence. The Assistant NHA indicated she had reeducated NA #147 about ensuring to ask for help and providing the correct level of assistance to each resident. When asked to provide any information to show NA #147 was directed that Resident #18 was an extensive assistance with the help of two (2) staff members the assistant NHA was unable to do so.

Based on medical record, Incident/Accident reports, Complaints/Grievances and Reportable reports, staff interview, resident interview and review of the facility's abuse policy, the facility failed to ensure each resident was free from abuse and neglect. Additionally, the facility failed to not use verbal, mental, sexual or physical abuse, or involuntary seclusion. This deficient practice caused actual harm for Residents #89, #99, #26 and #5. This deficient practice had the potential to affect more than an isolated number. Resident identifiers: #89, #99, #26, #11, #71, #5, #44, #58, #4, #212, #114. Facility census: 107. Findings included: a) Resident #89 1) Review of Resident #89's medical records found an annual Minimum Data Set (MDS) with an Assessment reference date (ARD) of 11/07/17. This MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 for severe cognitive impairment. Resident # 89's [DIAGNOSES REDACTED]. Severe confusion was noted with poor safety awareness with a history of falls. Resident #89 required the physical assistance of one person with bathing/showering. Resident #89 was noted as always continent of bowel and bladder functions. Requiring only supervision with most Activities of Daily living except bathing and personal hygiene. 2) A review of the Incident/Accident reports found on 02/01/18 at 10:20 AM found an incident occurred in the shower room. The incident description was as follows: Called to shower room per staff. Resident sitting in floor in shower room. Resident noted to have a complaint of pain in left wrist. Left wrist noted to be swollen at this time. Resident has no other complaints of pain. No redness or bruising noted at this time. Resident was unable to give description states, My wrist is really hurting me. Resident noted to be holding left wrist at this time. Resident was transferred to nearby hospital and was diagnosed with [REDACTED]. A review of statements by the two (2) nurse aides (NA) present in the shower room found: --Statement by Employee #56, NA read: I was showering (Resident #89's name) with another staff member in the shower room. As I turned to get a piece of clothing the resident got up and tried to walk by herself and lost her footing and fall the other staff member (Employee #43, NA) tried to catch her but wasn't quick enough then got (Employee #32, licensed practical nurse (LPN) name. --Statement by Employee #43, NA read: I was assisting another staff member in showering resident (Resident #89). As the other staff member turned to get a piece of the resident's clothing. Resident got up unassisted. She lost her footing. I tried to catch her but I was too late. 3) Review of the significant change MDS with an ARD of 05/09/18 found the resident has had a decline in her activities of daily living (ADL) and has more episodes of incontinence. Resident remains alert to person only and continues to have poor safety awareness secondary to impaired cognitive status. This indicates following the incident on 02/01/18 resulting in a fractured left wrist, Resident #89 has experienced a decline in her ADL status and incontinence status. 4) On 02/02/18 at 11:00 AM an in-service was provided on Proper showering techniques the following was included, Maintain a face-to-face contact when possible, stay with resident during the entire process . do not leave residents alone while bathing or showering . This indicates actual harm for Resident #89 due to leaving the resident unsupervised and out of reach while in the shower resulting in a fall acquired fracture and pain. b) Resident #99 1) Review of the reportable allegation of abuse found a report for Resident #99, dated 05/23/18 at 1:34 AM, this report read Resident told reporter (Employee #6, Social Worker (SW) that she was trying to get out the door to smoke. She tried to get a lighter out of the alleged perpetrator's pocket. While trying to get the resident back into the building, it was alleged that (Employee #59, licensed practical nurse (LPN) grabbed Resident #99's right hand and squeezed her fingers hard causing pain. Resident #99 stated, It hurt real bad. I thought she had broken it. Review of statements found: --Statement by the alleged perpetrator, Employee #59, LPN read: On 05/23/18 at 11:34 AM, Resident #99 was trying to exit through the back door, as I was trying to redirect the resident. The resident was moving wheelchair back into facility the resident grabbed the door frame. I slid my hand under her wrist to guide it backwards. The resident started putting her hand in my pockets, when I asked her not to. At which time resident became agitated and stated, She was going out and we couldn't stop her. then she turned her wheelchair and propelled her self-down the hallway muttering and cursing. --Statement by the nurse whom examined the resident, Employee #23, RN read: This nurse was on East wing, approached by SW and asked to assess (Resident #99's) hand. Resident sitting in her room in her wheelchair at bedside with remote in hand. This nurse asked her if something occurred, she stated, Yes, I don't remember if it was yesterday or today. I was going outside to smoke. I opened the door, I know all the codes. Somebody grabbed my chair, it jerked me backwards. I couldn't go forward or backwards. I saw the girl's lighter in her pocket and I grabbed it. She grabbed my hand and squeezed it real hard. It hurt bad. I thought she broke it. I continued to assess the resident's right hand, this is the hand that was squeezed . 2) Only statements obtained was the perpetrator, Employee #59, LPN and Resident #99. Employee #23, registered nurse (RN) provided a statement with her assessment of Resident 99's injuries (she did not observe the incident). 3) Interview with Resident #99, on 06/05/18 at 9:15 AM, she stated, The staff punishes me with not letting me smoke with the other residents due to I feed the cats my leftover food and cat food that I have bought. They say all kinds of stuff to me, they mock me and they take the food I have for the cats and throws it in the trash can in front of me and says, Ha,Ha. They grab my wheelchair and prevent me from moving and jerks my chair backwards at times. Employee #59 squeezed my hand/fingers one time so hard I thought she broke it. The resident appeared distraught and upset as she recalled these incidents. This deficient practice has caused Resident #99 actual psychosocial and physical harm which caused mental anguish, pain, intimidation, punishment, and humiliation. c) Resident #11 1) Review of Complaint/Concern log found a complaint for Resident #11 dated 03/14/18 and made by the resident's family. The concern stated, (DON's name) received a call from (Name of resident's family) on 03/14/18. Also, another family member was also on the call. The family stated, I want to report abuse. Nurse Aide (NA) #46, is pulling out resident's hair. The family member stated, I have reported this to Employee #23, RN and nothing is been done. The family goes on to say they do not want NA #46 taking care of her as they feel mistreatment by NA #46 is a retaliation due to some criminal activity by residents and NA #46's family. A review of the statements found: --Statement by Director of Nursing (DON) #18, NA #7 and Registered Nurse (RN) dated at 2:00 PM on 03/14/18, statement read: Employee #23, NA #7 and myself (DON) went to the residents room. I asked her if she was happy here and she stated, No, I want to go to Williamson. I asked her if everyone is good to her and she stated, They take my stuff. I asked her if anyone has done anything mean to her and she stated, No. I asked her if anyone had smacked her or hit her she stated, No. I asked her if NA #7, RN #23 or myself (DON) had ever pulled her hair and she stated, No. She denied anyone being mean to her and stated they take care of her. --Statement by Employee #46, NA, the alleged perpetrator read: I was putting the resident (Resident #11) to bed after the last smoke break. The resident became combative and I asked the nurse (No name mentioned) to assist me with the resident. She continued hitting and scratching me. We got her in bed and I was removing her jewelry and the necklace pulled her hair. I told her, I was sorry and she said, She was fine and told me to put her stuff on the table. d) Resident #71 1) A review of the Complaint log found a complaint dated 03/28/18. This complaint was from Resident #71 and was made to the DON. This complaint read: (Resident's name) made a complaint that the staff got her up at 4 am to take a shower. 2) No statements or investigation could be found. After this surveyors intervention it was determined by the staff this was an allegation of neglect/abuse. e) Resident #44 Review of the grievance/concern forms for the last year found three (3) concern/allegations: 1) Allegation #1: On 06/08/17, Resident #44 reported that Licensed Practical Nurse (LPN) #36 did not give her medication to her. The resident reported this to RN #123, who informed the DON. Social Worker (SW) #124 and DON spoke with the resident separately concerning her allegation. Resident denies the allegation of abuse, neglect or anyone treating her in a mean manner. She stated she does not like her nurse because she crushes her medicine. On 06/22/17, resident is no longer receiving medication crushed. Review of the statements found: I explained that I could not give a medication without an order from the physician and again I explained I would contact the physician regarding residents request. I attempted to explain the parameters for Tylenol toxicity due to the resident currently had an order for [REDACTED]. At this time, RN #123 states well you are well within your limits and what could Tylenol hurt? This writer attempted to let Rn #123 know of resident's drug seeking behaviors but that again one of us would contact the physician and let her know the residents request. Statement by Employee #16, LPN on 06/01/17 at 17:40 (5:40 pm): A resident went up to (Employee #123's name) and told her she had a temperature of 99 degrees. The RN came out and told the nurse to give her two (2) Tylenol. Staff attempted to explain to the RN we could not give medication without a physician's orders [REDACTED].#116 two (2) Tylenol. Resident stated she had a temperature of 99 degrees. Staff again attempted that we could not give it. This nurse took RN into the office and attempted to give some of the resident's history with being told I was just an LPN and that she had been a nurse for [AGE] years. Rn became loud to the point that it was almost a scream cutting this nurse off. Statement by Employee #36, LPN on 06/06/17 at approximately 15:10 (3:10 pm) While sitting at nurse's station attempting to complete paperwork to send a resident to hospital. RN #123 is noted to approach the nurse's station and state, I need drugs this writer informed her that I would be with her in just a minute as I was on the telephone attempting to transfer a resident to the hospital. RN #123 states, I wasn't speaking to you, I was speaking to Employee #57, nurse assistant (NA). This writer explained if you are referring to Resident #214's antibiotic then I am his nurse and Employee #57, NA cannot help you. Then Rn #123 stated, I apparently, I didn't make myself clear I was speaking to Employee #57, NA. Again, this writer explained I was the resident's nurse and would get the medication for her in a minute that I am in the process of sending someone to the hospital. RN #123 stated, Obviously, you don't seem to understand that I am not speaking to you. At this time, this writer went into the med room and got the said antibiotic and handed it to the RN #123. RN #123 walks off. Statement by Employee #36, LPN on 06/08/17 at approximately 18:45 (6:45 pm) Front door alarm sounds and this writer proceeds up to the front to check for safety and reset the alarm. I proceeded out to the parking lot to be sure that no residents were in the parking lot unattended. For further safety, this writer walked around building to be sure the parking lot and surrounding areas were clear. This writer then proceeded to the west wing to check with nursing staff to be sure all residents were accounted for. Upon entering front hall of the east wing (Employee #123, RN name) was noted to be standing at the nurses station with the Medication Administration Report (MAR) for the A section opened. This writer enters the nurses station to begin charting on the computer when Employee #123, RN states, You did not give (Resident #44' name) her meds today. At this time this writer states, yes I did. Employee #123, RN then states, Well, I don't think you did. She told me you didn't. I explained to the RN that the resident has hoarding behaviors, refusal of medications and false accusations. The RN then states, Well if she says you didn't give the medication, as far as I concerned you didn't. RN proceeds to state, There are no initials in the box (referring to the MAR). Then asked, Is 0900 9am or pm. At this time, I stated 0900 is 9am and I have been checking my MAR to be sure all of my finger sticks and etc. has been documented. RN then states, Well, apparently you did not learn anything in nursing school, you are to sign medication out when you give them, therefore, as far as I am concerned you did not give her medication and that is abuse. At no time did the RN allow me to see which area of MAR that she was referring to and nor did she know the resident had been found with a [MEDICATION NAME] (pain medication) in her bra. While attempting to explain this resident's behavior the RN became loud and she pointed her finger in this writers face and saying, Where were you when I was looking for you. I explained I was assessing the situation with the door alarm going off and being sure there was no elopement, while she sat in the office not responding. She (RN) continued to point finger in this writer's face. This writer states, please get your finger out of my face. RN states, you need to get in the office to continue this conversation. This writer informed the RN , I will not go to a private area to hold a conversation with you alone. You are pointing your finger in my face and approached me here in front of my peers and other residents. So, I will not go to a private area with you if you want to speak to me I will do it in front of the DON only. At this time, the RN looks to her right where several staff as well as residents in the hallway. The RN then states, (Employee #57, NA name) go to the office. At this time this writer explained that the NA was a union representative but as a union employee I did not wish to have her present to speak with the RN without the DON in the building due to her aggressive tone with me. RN states, Well, we will see about this I am calling the DON. At no time during this shift did this RN look at any other MAR located on the east wing or any other resident's MAR regarding medications or administration. But the RN stated, Well she is my family and I will take care of this. Statement by Employee #125, SW read, On 06/09/17, I spoke with resident, (Resident #44's Name), regarding allegations a nurse made that the resident was not getting her medications. (Resident #44's name) came to my office in private and I asked her if any nurse failed to give her medications to her. The resident stated, No, I get my medication but she makes me take them crushed and I don't like that. I then looked in the resident's chart to verify that the resident had an physician's orders [REDACTED]. There was a fact an order stating that the resident was to receive crushed meds. I explained this to the resident and she stated her understanding. Statement by Employee #60. LPN read, On 06/11/17, I worked the A hallway on the west wing and (Employee #39, LPN name) worked B hallway. She came to me with a [MEDICATION NAME] (pain medication) in a cup and asked me to waste it with her. She stated she had popped it out in error when pulling a residents medicine, Medication was wasted. We counted at the end of shift and a [MEDICATION NAME](pain med) was signed out by Employee #39 for 06/11/17 at 9 pm and count was correct. 2) Allegation #2: Resident #44 reported an allegation of neglect on 06/12/17 to RN #123. RN #123 reported teh allgeation to the Nursing Home Administrator and DON. The allegation made by the resident was not given her medication by LPN #123. LPN #123 went to the resident's room to confront the resident by reportedly saying, Since you told on me now your medication will be crushed and I will give them to you in the hallway. Employee #124, social worker (SW) talked with resident regarding the allegations and resident denies the allegation. The resident continues to deny any issues with staff being mean to her. She continues to be upset about her medications being crushed. A review of the statements found: --Statement by Employee #44, RN, made on 06/12/17 at 5:35 p.m.: While doing skin assessments, patient in room [ROOM NUMBER]- (Resident #112, Name) called me into her room. She asked me if I was a nurse and I told her yes. Resident stated she did not receive her 9 pm meds last night. I asked her did she know what med, she stated little blue pill (pain pill- [MEDICATION NAME]). I told her I would check the MAR (Medication Administration Record), it may have been not available. I checked the MAR and the medication ([MEDICATION NAME]) had been signed out with the initials of (Employee #39, LPN). I went back into Resident #112's room with Employee #125, Graduate Nurse (GN). What month is it? she stated, June. I asked the year, she stated, (YEAR). I asked her who was the President, she said, Trump. I asked her if she was mistaken, she said, No, I check my pills, my pain pill is the little blue pill and it wasn't there. And I asked the nurse (Employee #39) about it and she told she didn't have it and that they would give it at 12:00 a.m. She went on to tell me several nurses about it and nobody came to see her. --Statement by Employee #49, NA read: On (MONTH) 12, (YEAR) (time ineligible) I was putting (Name of Resident #76) in bed. The wife of Resident #76 was in the room. Employee #124, RN came in the room to do an assessment on the resident. The RN #124 started talking to the resident's wife about an incident that happened on east hallway. She told the wife it involved Resident #44 and Employee #36, LPN. She said she was in the bathroom and heard everything between Resident #44 and LPN #36. She told the wife she had took it to the Administrator and the DON. She told the wife she had screen shot all the nurses whom had been notified. She said they were that the facility was trying to get rid of her and that she reported it to the state. On (MONTH) 20, (YEAR) the wife of Resident #76 was told by RN #124 this morning she had received her letter from the state and they were investigated. --Statement by Employee #41, NA, written on 06/12/17 read: I witnessed a resident come up to the RN and asked about her medicine, The RN came up to the nurse's station and asked where the nurse was at. The RN started looking through the medicine book and when the LPN came back to the nurse's station the RN asked the LPN about the resident's medicine and the MAR book. The RN was telling the LPN she must have not learned anything or she would have signed the book when she gave the resident meds. RN points at LPN and asked her to come to the office. LPN asked the RN to stop pointing her finger in her face. The RN said I'm not pointing in your face. --Statement by Employee #125, SW, written on 06/12/17 read: On 06/12/17, SW spoke with (Resident #44's name), regarding allegations the LPN #36 had not gave her medications and that she came into her room and stated, Since you told on me now your meds will be crushed and I will give it to you in the hall. Resident #44 denies that this was said and also says, Nobody has been mean to me here but I don't like that nurse (LPN #36) because she crushes my meds. --Statement by Employee #127, NA written on 06/12/17 read; I witnessed Resident #44 go into the DON's office and told RN #124 she had not had any of her medicine all day. The RN looked at the MAR and the book had holes in it where the LPN had not signed the MAR. The LPN assured the RN she had gave the meds but had not signed the MAR. The RN's and the LPN's voices kept getting louder. 3) Allegation #3: A review of the concern/grievance log found a statement on 06/20/17 at approximately 9:00 AM, NA #58 entered Resident #44's room to find her roommate some clothes, this resident had her roommates pants on. I came out and got my nurse (LPN #36) to assist me. The housekeeper and I was standing in the closet doorway and Resident #44 exited the bathroom holding the clothes. The resident threw the pants and hit LPN #36 in the side of head and then openly smacked her across the face knocking her glasses off. I attempted to get the resident away from the nurse and calm her down. The resident started yelling at the nurse stating, I am going to have your job [***] . I dare you to hit me queer. --Statement by Employee #36, LPN dated 06/20/17 at 9:15 am read: Upon entering Resident #44's room I found the resident had her roommates pants on. This writer, NA and Housekeeper were standing in the doorway of this resident's room when she exited the bathroom striking this nurse in left side of face multiple times screaming, (RN #124) and I are going to have your job [***] . I dare you to hit me I'm calling RN #124 and she will beat your face in. This writer exited the room and notified the supervisor of this resident's behaviors and notified the physician with new orders to administer [MEDICATION NAME] 20 milligrams (mg) intramuscularly (IM) now for agitation. Power of attorney (POA) notified and made aware of residents room change from east to west wing. --Statement by Employee #125, SW read: On 06/20/17, I talked with Resident #44, to discuss her recent behaviors against LPN #36. I asked (Resident #44) why she hit LPN#36 and the resident stated the nurse was discrimating against her. I then asked her why she felt LPN #36 was discriminating against her and she stated, She crushes my medicine and RN #124 told me it was discrimation. I then asked the resident why she called the LPN #36 a queer. She at first denied calling her a queer but later she said, RN #124 told me that she was married to a girl so what would you call her. I told the resident that she could not act that way toward a staff member regardless of her personal opinion. The resident states understanding. f) Residents in room [ROOM NUMBER] on 06/19/17 1) A review of grievance/concern book found an incident, in which, occurred between RN #124 and Employee NA #54 on 06/19/17 at 9:30 PM. Review of the statements found: --Statement by Employee #124, RN read, On 06/19/17 at around 9:30 pm I went to find who had Resident #117 to do a skin assessment. The NAs stated that NA #54 had Resident #117. I went into room [ROOM NUMBER]and pecked on the door, when I entered the room I said, Good I need to do (Resident #118's skin assessment and you have her undressed. NA #54 said, Why you want to look at her ass. I asked him what he meant by that and he said, I don't have time for this. I told him I needed him to help me turn Resident #117 on her side for a skin assessment that I had already did everything but her buttock and back. NA #54 stated, I have more patients to do and you treat NAs and nurses like were dirt under her feet. I told him that wasn't true and I hadn't even talked to him before, that I was told to get help turning the patients and he kept saying you never asked. I asked again for help and he refused. I told him I was going to write him up for insubordination and he stated, I am getting a union representative. As I came down the hall I stated, I hate it when people are smart asses. Statement by Employee #54, NA read: I was on west wing and was in room [ROOM NUMBER] assisting the residents in getting ready for bed, when RN #124 came into the room and told me that I was to come to room [ROOM NUMBER]. I asked her to give me a minute, she then told me that she needed me to do it now. I told her she needed to give me a minute. I asked her if she needed to look at their butt. She then told me I was getting wrote up for insubordination. I never refused to help. I told her to give me a minute. Then she yelled at me and called me a smartass. She stated she was the RN and that meant I would do as I am told and not question her. She pulled her name badge at my face and said that is what this means. g) Resident #58 1) A review of the Complaint/Grievance book found a concern by Resident #58. This allegation was reported to Employee #125, SW on 01/23/18. Concern: Resident reports that she doesn't know how to take the Employee #43, NA on evening shift. NA sometimes. She takes good care of me but she likes to joke and sometimes doesn't know how to take her. She makes me anxious. Interventions: NA #43 received a written warning. The resident no longer has the NA as her caregiver. 2) No further statements, investigation or intervention could be located. h) Resident #4 1) A review of the complaint/grievance book found a concern by Resident #4. This allegation was reported to SW #6 on 06/01/18. Concerns noted by Resident #4's family read: Still not getting coffee at all meals. Staff were mocking the resident Help at the west wing nurses' station. One NA would not give the NA caring for Resident #4 the proper size of diapers. Wednesday, pm shift. The resident was lying angled in her bed. She couldn't get to her tray to eat. She had a bowl of peaches in her bed with her. She needs pulled up to the tray to eat her meals. Residents name is not over her bed it is a different residents' name. Interventions: Coffee is being served at all meals. Diaper issue is resolved. Resident will eat in day lounge (sitting upward). 2) No further statements could be located. i) Complaint made by the Ombudsman 1) A review of the complaint/grievance book found a concern by the Ombudsman. This allegation was reported to SW #6 on 05/15/18. Concern: I had more complaints of staff being rude to residents. One employee (NA) was huffing and puffing and complaining because they were short staffed and everyone was acting crazy. After the visitor reported this a resident spoke up and reported a nurse who is mean and hateful and this nurse had to shut up and quit talking so much. The NA said that is her personality. There is one employee that is hateful as the devil; when one resident asked for a drink and another asked if there was church tonight; she yelled and was hateful to both residents. Please address this issue with your staff. 2) This surveyor was provided a copy of an in-service for Ethical behavior and Unethical behavior conducted on 05/16/18 by the Administrator. 3) No further statements could be located. j) Resident #114 1) Review of Resident #114's medical records found the resident was admitted on [DATE]. Care Plan initiated; Resident is a 53yr. old female-Diagnosis: [REDACTED]. Staff supervises meals, assists as needed. She is noted to take food from other resident's trays. Easily agitated. Diet Regular NAS with lidded cups for safety. Weight 102# --below IBW range (123#-149#) She feeds herself meals--often uses her fingers to eat --likes sweets and snack foods. No teeth or dentures. 2) Progress notes found the following incident/altercations involving resident-to-resident: --10/18/2017 at 08:28 - Resident noted to be up walking around day lounge throwing food on the floor and taking food from other resident's trays. --10/19/2017 at 18:00 - Resident up and ambulating in day lounge throwing her shoes across room pushing furniture against resident's wheelchairs. staff sits down with resident to assist with meal resident then gets up and proceeds to remove food from her brother's tray. when attempting to redirect resident begins hitting self in head and slamming fists on wall, offered activities, fluids and snacks with staff to monitor for safety. --11/6/2017 at 18:00 - Another resident was calling out to resident and calling her names. Resident became agitated and grabbed other resident's hair and pulled hard. Residents were separated by staff. Vital signs unable to be obtained due to resident was agitated. --11/9/2017 at 21:46 - Late Entry: Note: resident has been noted to be up wandering in other resident's rooms, taking food and drinks off resident's dinner trays this shift requiring redirection numerous times. --11/27/2017 at 07:59 - Resident up ambulating in day lounge removing food from other resident's trays requiring redirection numerous times. resident becomes agitated and begins hitting self in head. attempts to take resident to room for self-soothing. --12/7/2017 at 13:20 - Resident in day lounge at this time alert and nonverbal skin clean dry warm to touch resident noted to hit her head on the walls and glass numerous times this shift , staff makes attempts to redirect this resident , with no positive results noted , this resident noted to be grabbing other residents chairs in the day lounge and halls x 4 this shift staff attempts to redirect this resident to the day lounge resident placed in chair at which time resident proceeds to kick and hit staff numerous times along with attempting to hit her head on tables and chairs in the day lounge , staff remains with resident at this time. --12/7/2017 at 17:40 - Resident continues to be aggressive to staff along with continues to hit her head on the walls and windows, with each attempt to redirect this resident from getting upset and pushing another resident's wheelchair. --12/12/2017 at 09:35- Resident is noted to be standing at the nurse's station grabbing other resident w/c as they pass x 1 this shift along with getting notably agitated x 1 at nurse station then enters the day lounge door and began to push and shake another residents merri walker resident assisted to room via staff now to self-soothing. --2/14/2018 at 15:21 - Resident was agitated and shoving tray tables and tables in dining area. when this nurse enters dining area to calm her down another resident stated that you smashed my hand remover other resident near nurse's station for further evaluations. --2/27/2018 at 10:30 - RNA states that Resident was in DL and ran over and grabbed another female resident by the hair and got ahold of her left breast. No injuries were noted to either resident. The residents were separated. --3/16/2018 at 16:40 - Nurse called to day lounge this resident grabbed another resident by arm and struck him on his chest. staff separated residents and redirected this resident verbally and assisted to sit on couch to watch the television. vital signs refused now. --3/26/2018 at 15:56 - Reported via staff that resident has been noted to get in bed with roommate now, resident removed from roommate's bed. Will continue to monitor resident --3/26/2018 at 16:30 - Resident has been noted to run up and grab another resident's mobile device now. Resident's separated now. Both residents assessed, no injuries to either resident. Will continue to monitor. --3/26/2018 at 17:00 - Called to resident's room via staff, resident is lying in roommate's bed, with roommate in the floor bedside bed. Tries to re-direct resident to correct bed now. Resident cooperated with success of redirection. --3/26/2018 at 17:30 - Reported via staff that resident went up to another resident that was in a w/c, grabbed his arms and put her head down as if she was (TRUNCATED)

Based on medical record, Incident/Accident reports, Complaints/Grievances and Reportable reports, staff interview, resident interview and review of the facility's abuse policy, the facility failed to ensure each allegation of alleged or acutal abuse and neglect to the State Survey Agency and Adult Protective Services. This deficient practice caused actual harm for Residents #89, #99, #26 and #5. This deficient practice had the potential to affect more than an isolated number. Resident identifiers: #89, #99, #26, #11, #71, #5, #44, #58, #4, #212, #114. Facility census: 107. Findings included: a) Resident #89 1) Review of Resident #89's medical records found an annual Minimum Data Set (MDS) with an Assessment reference date (ARD) of 11/07/18. This MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 for severe cognitive impairment. Resident # 89's [DIAGNOSES REDACTED]. Severe confusion was noted with poor safety awareness with a history of falls. Resident #89 required the physical assistance of one person with bathing/showering. Resident #89 was noted as always continent of bowel and bladder functions. Requiring only supervision with most Activities of Daily living except bathing and personal hygiene. 2) A review of the Incident/Accident reports found on 02/01/18 at 10:20 AM found an incident occurred in the shower room. The incident description was as follows: Called to shower room per staff. Resident sitting in floor in shower room. Resident noted to have a complaint of pain in left wrist. Left wrist noted to be swollen at this time. Resident has no other complaints of pain. No redness or bruising noted at this time. Resident was unable to give description states, My wrist is really hurting me. Resident noted to be holding left wrist at this time. Resident was transferred to nearby hospital and was diagnosed with [REDACTED]. A review of statements by the two (2) nurse aides (NA) present in the shower room found: --Statement by Employee #56, NA read: I was showering (Resident #89's name) with another staff member in the shower room. As I turned to get a piece of clothing the resident got up and tried to walk by herself and lost her footing and fall the other staff member (Employee #43, NA) tried to catch her but wasn't quick enough then got (Employee #32, licensed practical nurse (LPN) name. --Statement by Employee #43, NA read: I was assisting another staff member in showering resident (Resident #89). As the other staff member turned to get a piece of the resident's clothing. Resident got up unassisted. She lost her footing. I tried to catch her but I was too late. 3) Review of the significant change MDS with an ARD of 05/09/18 found the resident has had a decline in her activities of daily living (ADL) and has more episodes of incontinence. Resident remains alert to person only and continues to have poor safety awareness secondary to impaired cognitive status. This indicates following the incident on 02/01/18 resulting in a fractured left wrist, Resident #89 has experienced a decline in her ADL status and incontinence status. 4) On 02/02/18 at 11:00 AM an in-service was provided on Proper showering techniques the following was included, Maintain a face-to-face contact when possible, stay with resident during the entire process . do not leave residents alone while bathing or showering . 5) This incident was not reported as potential neglect until 06/12/18 (after surveyor intervention). The Social Worker (SW) and the Director of Nursing (DON) agreed the NAs were neglectful by stepping away from the resident, whom has poor safety awareness due to impaired short term and long term memory. This indicates actual harm for Resident #89 due to leaving the resident unsupervised and out of reach while in the shower resulting in a fall acquired fracture and pain. b) Resident #99 1) Review of the reportable allegation of abuse found a report for Resident #99, dated 05/23/18 at 1:34 AM, this report read Resident told reporter (Employee #6, Social Worker (SW) that she was trying to get out the door to smoke. She tried to get a lighter out of the alleged perpetrator's pocket. While trying to get the resident back into the building, it was alleged that (Employee #59, licensed practical nurse (LPN) grabbed Resident #99's right hand and squeezed her fingers hard causing pain. Resident #99 stated, It hurt real bad. I thought she had broken it. Review of statements found: --Statement by the alleged perpetrator, Employee #59, LPN read: On 05/23/18 at 11:34 AM, Resident #99 was trying to exit through the back door, as I was trying to redirect the resident. The resident was moving wheelchair back into facility the resident grabbed the door frame. I slid my hand under her wrist to guide it backwards. The resident started putting her hand in my pockets, when I asked her not to. At which time resident became agitated and stated, She was going out and we couldn't stop her. then she turned her wheelchair and propelled her self-down the hallway muttering and cursing. --Statement by the nurse whom examined the resident, Employee #23, RN read: This nurse was on East wing, approached by SW and asked to assess (Resident #99's) hand. Resident sitting in her room in her wheelchair at bedside with remote in hand. This nurse asked her if something occurred, she stated, Yes, I don't remember if it was yesterday or today. I was going outside to smoke. I opened the door, I know all the codes. Somebody grabbed my chair, it jerked me backwards. I couldn't go forward or backwards. I saw the girl's lighter in her pocket and I grabbed it. She grabbed my hand and squeezed it real hard. It hurt bad. I thought she broke it. I continued to assess the resident's right hand, this is the hand that was squeezed . 2) This allegation was submitted to Adult Protective Service (APS) on 05/24/18 only. Was not faxed to all of the other required agencies until 05/30/18. Only statements obtained was the perpetrator, Employee #59, LPN and Resident #99. Employee #23, registered nurse (RN) provided a statement with her assessment of Resident 99's injuries (she did not observe the incident). 3) Interview with Resident #99, on 06/05/18 at 9:15 AM, she stated, The staff punishes me with not letting me smoke with the other residents due to I feed the cats my leftover food and cat food that I have bought. They say all kinds of stuff to me, they mock me and they take the food I have for the cats and throws it in the trash can in front of me and says, Ha,Ha. They grab my wheelchair and prevent me from moving and jerks my chair backwards at times. Employee #59 squeezed my hand/fingers one time so hard I thought she broke it. The resident appeared distraught and upset as she recalled these incidents. This deficient practice has caused Resident #99 actual psychosocial and physical harm which caused mental anguish, pain, intimidation, punishment, and humiliation. c) Resident #11 1) Review of Complaint/Concern log found a complaint for Resident #11 dated 03/14/18 and made by the resident's family. The concern stated, (DON's name) received a call from (Name of resident's family) on 03/14/18. Also, another family member was also on the call. The family stated, I want to report abuse. Nurse Aide (NA) #46, is pulling out resident's hair. The family member stated, I have reported this to Employee #23, RN and nothing is been done. The family goes on to say they do not want NA #46 taking care of her as they feel mistreatment by NA #46 is a retaliation due to some criminal activity by residents and NA #46's family. A review of the statements found: --Statement by Director of Nursing (DON) #18, NA #7 and Registered Nurse (RN) dated at 2:00 PM on 03/14/18, statement read: Employee #23, NA #7 and myself (DON) went to the residents room. I asked her if she was happy here and she stated, No, I want to go to Williamson. I asked her if everyone is good to her and she stated, They take my stuff. I asked her if anyone has done anything mean to her and she stated, No. I asked her if anyone had smacked her or hit her she stated, No. I asked her if NA #7, RN #23 or myself (DON) had ever pulled her hair and she stated, No. She denied anyone being mean to her and stated they take care of her. --Statement by Employee #46, NA, the alleged perpetrator read: I was putting the resident (Resident #11) to bed after the last smoke break. The resident became combative and I asked the nurse (No name mentioned) to assist me with the resident. She continued hitting and scratching me. We got her in bed and I was removing her jewelry and the necklace pulled her hair. I told her, I was sorry and she said, She was fine and told me to put her stuff on the table. 2) This alleged allegation of abuse/neglect was not reported till 06/15/18 after this Surveyor's inquiry. d) Resident #71 1) A review of the Complaint log found a complaint dated 03/28/18. This complaint was from Resident #71 and was made to the DON. This complaint read: (Resident's name) made a complaint that the staff got her up at 4 am to take a shower. 2) No statements or investigation could be found. After this surveyors intervention it was determined by the staff this was an allegation of neglect/abuse. This was submitted on 06/05/18 to the proper agencies. e) Resident #44 Review of the grievance/concern forms for the last year found three (3) concern/allegations: 1) Allegation #1: On 06/08/17, Resident #44 reported that Licensed Practical Nurse (LPN) #36 did not give her medication to her. The resident reported this to RN #123, who informed the DON. Social Worker (SW) #124 and DON spoke with the resident separately concerning her allegation. Resident denies the allegation of abuse, neglect or anyone treating her in a mean manner. She stated she does not like her nurse because she crushes her medicine. On 06/22/17, resident is no longer receiving medication crushed. Review of the statements found: Statement by Employee #36, LPN, made on 06/01/17 at approximately 1700 (5pm): (Employee #123, RN's name) approached nurse's station and stated, who is (Resident #116's name) nurse? Myself as well as another LPN were sitting at desk when RN #123 states, she needs Tylenol, I explained to RN #123 that this resident did not have a current RX (prescription) for Tylenol. RN #123 states, well you need to give her some Tylenol again I explained, we can call the doctor and ask but most generally she doesn't give Tylenol for a temperature of 99 degrees. Rn #123 states, well I said to give it to her. I explained that I could not give a medication without an order from the physician and again I explained I would contact the physician regarding residents request. I attempted to explain the parameters for Tylenol toxicity due to the resident currently had an order for [REDACTED]. At this time, RN #123 states well you are well within your limits and what could Tylenol hurt? This writer attempted to let Rn #123 know of resident's drug seeking behaviors but that again one of us would contact the physician and let her know the residents request. Statement by Employee #16, LPN on 06/01/17 at 17:40 (5:40 pm): A resident went up to (Employee #123's name) and told her she had a temperature of 99 degrees. The RN came out and told the nurse to give her two (2) Tylenol. Staff attempted to explain to the RN we could not give medication without a physician's orders [REDACTED].#116 two (2) Tylenol. Resident stated she had a temperature of 99 degrees. Staff again attempted that we could not give it. This nurse took RN into the office and attempted to give some of the resident's history with being told I was just an LPN and that she had been a nurse for [AGE] years. Rn became loud to the point that it was almost a scream cutting this nurse off. Statement by Employee #36, LPN on 06/06/17 at approximately 15:10 (3:10 pm) While sitting at nurse's station attempting to complete paperwork to send a resident to hospital. RN #123 is noted to approach the nurse's station and state, I need drugs this writer informed her that I would be with her in just a minute as I was on the telephone attempting to transfer a resident to the hospital. RN #123 states, I wasn't speaking to you, I was speaking to Employee #57, nurse assistant (NA). This writer explained if you are referring to Resident #214's antibiotic then I am his nurse and Employee #57, NA cannot help you. Then Rn #123 stated, I apparently, I didn't make myself clear I was speaking to Employee #57, NA. Again, this writer explained I was the resident's nurse and would get the medication for her in a minute that I am in the process of sending someone to the hospital. RN #123 stated, Obviously, you don't seem to understand that I am not speaking to you. At this time, this writer went into the med room and got the said antibiotic and handed it to the RN #123. RN #123 walks off. Statement by Employee #36, LPN on 06/08/17 at approximately 18:45 (6:45 pm) Front door alarm sounds and this writer proceeds up to the front to check for safety and reset the alarm. I proceeded out to the parking lot to be sure that no residents were in the parking lot unattended. For further safety, this writer walked around building to be sure the parking lot and surrounding areas were clear. This writer then proceeded to the west wing to check with nursing staff to be sure all residents were accounted for. Upon entering front hall of the east wing (Employee #123, RN name) was noted to be standing at the nurses station with the Medication Administration Report (MAR) for the A section opened. This writer enters the nurses station to begin charting on the computer when Employee #123, RN states, You did not give (Resident #44' name) her meds today. At this time this writer states, yes I did. Employee #123, RN then states, Well, I don't think you did. She told me you didn't. I explained to the RN that the resident has hoarding behaviors, refusal of medications and false accusations. The RN then states, Well if she says you didn't give the medication, as far as I concerned you didn't. RN proceeds to state, There are no initials in the box (referring to the MAR). Then asked, Is 0900 9am or pm. At this time, I stated 0900 is 9am and I have been checking my MAR to be sure all of my finger sticks and etc. has been documented. RN then states, Well, apparently you did not learn anything in nursing school, you are to sign medication out when you give them, therefore, as far as I am concerned you did not give her medication and that is abuse. At no time did the RN allow me to see which area of MAR that she was referring to and nor did she know the resident had been found with a [MEDICATION NAME] (pain medication) in her bra. While attempting to explain this resident's behavior the RN became loud and she pointed her finger in this writers face and saying, Where were you when I was looking for you. I explained I was assessing the situation with the door alarm going off and being sure there was no elopement, while she sat in the office not responding. She (RN) continued to point finger in this writer's face. This writer states, please get your finger out of my face. RN states, you need to get in the office to continue this conversation. This writer informed the RN , I will not go to a private area to hold a conversation with you alone. You are pointing your finger in my face and approached me here in front of my peers and other residents. So, I will not go to a private area with you if you want to speak to me I will do it in front of the DON only. At this time, the RN looks to her right where several staff as well as residents in the hallway. The RN then states, (Employee #57, NA name) go to the office. At this time this writer explained that the NA was a union representative but as a union employee I did not wish to have her present to speak with the RN without the DON in the building due to her aggressive tone with me. RN states, Well, we will see about this I am calling the DON. At no time during this shift did this RN look at any other MAR located on the east wing or any other resident's MAR regarding medications or administration. But the RN stated, Well she is my family and I will take care of this. Statement by Employee #125, SW read, On 06/09/17, I spoke with resident, (Resident #44's Name), regarding allegations a nurse made that the resident was not getting her medications. (Resident #44's name) came to my office in private and I asked her if any nurse failed to give her medications to her. The resident stated, No, I get my medication but she makes me take them crushed and I don't like that. I then looked in the resident's chart to verify that the resident had an physician's orders [REDACTED]. There was a fact an order stating that the resident was to receive crushed meds. I explained this to the resident and she stated her understanding. Statement by Employee #60. LPN read, On 06/11/17, I worked the A hallway on the west wing and (Employee #39, LPN name) worked B hallway. She came to me with a [MEDICATION NAME] (pain medication) in a cup and asked me to waste it with her. She stated she had popped it out in error when pulling a residents medicine, Medication was wasted. We counted at the end of shift and a [MEDICATION NAME](pain med) was signed out by Employee #39 for 06/11/17 at 9 pm and count was correct. This allegation of abuse/neglect was never reported to the required state agencies. 2) Allegation #2: Resident #44 reported an allegation of neglect on 06/12/17 to RN #123. RN #123 reported teh allgeation to the Nursing Home Administrator and DON. The allegation made by the resident was not given her medication by LPN #123. LPN #123 went to the resident's room to confront the resident by reportedly saying, Since you told on me now your medication will be crushed and I will give them to you in the hallway. Employee #124, social worker (SW) talked with resident regarding the allegations and resident denies the allegation. The resident continues to deny any issues with staff being mean to her. She continues to be upset about her medications being crushed. A review of the statements found: --Statement by Employee #44, RN, made on 06/12/17 at 5:35 p.m.: While doing skin assessments, patient in room [ROOM NUMBER]- (Resident #112, Name) called me into her room. She asked me if I was a nurse and I told her yes. Resident stated she did not receive her 9 pm meds last night. I asked her did she know what med, she stated little blue pill (pain pill- [MEDICATION NAME]). I told her I would check the MAR (Medication Administration Record), it may have been not available. I checked the MAR and the medication ([MEDICATION NAME]) had been signed out with the initials of (Employee #39, LPN). I went back into Resident #112's room with Employee #125, Graduate Nurse (GN). What month is it? she stated, June. I asked the year, she stated, (YEAR). I asked her who was the President, she said, Trump. I asked her if she was mistaken, she said, No, I check my pills, my pain pill is the little blue pill and it wasn't there. And I asked the nurse (Employee #39) about it and she told she didn't have it and that they would give it at 12:00 a.m. She went on to tell me several nurses about it and nobody came to see her. --Statement by Employee #49, NA read: On (MONTH) 12, (YEAR) (time ineligible) I was putting (Name of Resident #76) in bed. The wife of Resident #76 was in the room. Employee #124, RN came in the room to do an assessment on the resident. The RN #124 started talking to the resident's wife about an incident that happened on east hallway. She told the wife it involved Resident #44 and Employee #36, LPN. She said she was in the bathroom and heard everything between Resident #44 and LPN #36. She told the wife she had took it to the Administrator and the DON. She told the wife she had screen shot all the nurses whom had been notified. She said they were that the facility was trying to get rid of her and that she reported it to the state. On (MONTH) 20, (YEAR) the wife of Resident #76 was told by RN #124 this morning she had received her letter from the state and they were investigated. --Statement by Employee #41, NA, written on 06/12/17 read: I witnessed a resident come up to the RN and asked about her medicine, The RN came up to the nurse's station and asked where the nurse was at. The RN started looking through the medicine book and when the LPN came back to the nurse's station the RN asked the LPN about the resident's medicine and the MAR book. The RN was telling the LPN she must have not learned anything or she would have signed the book when she gave the resident meds. RN points at LPN and asked her to come to the office. LPN asked the RN to stop pointing her finger in her face. The RN said I'm not pointing in your face. --Statement by Employee #125, SW, written on 06/12/17 read: On 06/12/17, SW spoke with (Resident #44's name), regarding allegations the LPN #36 had not gave her medications and that she came into her room and stated, Since you told on me now your meds will be crushed and I will give it to you in the hall. Resident #44 denies that this was said and also says, Nobody has been mean to me here but I don't like that nurse (LPN #36) because she crushes my meds. --Statement by Employee #127, NA written on 06/12/17 read; I witnessed Resident #44 go into the DON's office and told RN #124 she had not had any of her medicine all day. The RN looked at the MAR and the book had holes in it where the LPN had not signed the MAR. The LPN assured the RN she had gave the meds but had not signed the MAR. The RN's and the LPN's voices kept getting louder. This allegation of abuse/neglect was never reported to the required agencies. 3) Allegation #3: A review of the concern/grievance log found a statement on 06/20/17 at approximately 9:00 AM, NA #58 entered Resident #44's room to find her roommate some clothes, this resident had her roommates pants on. I came out and got my nurse (LPN #36) to assist me. The housekeeper and I was standing in the closet doorway and Resident #44 exited the bathroom holding the clothes. The resident threw the pants and hit LPN #36 in the side of head and then openly smacked her across the face knocking her glasses off. I attempted to get the resident away from the nurse and calm her down. The resident started yelling at the nurse stating, I am going to have your job [***] . I dare you to hit me queer. --Statement by Employee #36, LPN dated 06/20/17 at 9:15 am read: Upon entering Resident #44's room I found the resident had her roommates pants on. This writer, NA and Housekeeper were standing in the doorway of this resident's room when she exited the bathroom striking this nurse in left side of face multiple times screaming, (RN #124) and I are going to have your job [***] . I dare you to hit me I'm calling RN #124 and she will beat your face in. This writer exited the room and notified the supervisor of this resident's behaviors and notified the physician with new orders to administer [MEDICATION NAME] 20 milligrams (mg) intramuscularly (IM) now for agitation. Power of attorney (POA) notified and made aware of residents room change from east to west wing. --Statement by Employee #125, SW read: On 06/20/17, I talked with Resident #44, to discuss her recent behaviors against LPN #36. I asked (Resident #44) why she hit LPN#36 and the resident stated the nurse was discrimating against her. I then asked her why she felt LPN #36 was discriminating against her and she stated, She crushes my medicine and RN #124 told me it was discrimation. I then asked the resident why she called the LPN #36 a queer. She at first denied calling her a queer but later she said, RN #124 told me that she was married to a girl so what would you call her. I told the resident that she could not act that way toward a staff member regardless of her personal opinion. The resident states understanding. This incident of alleged abuse/neglect was never entered on a Complaint/Grievance form and was never reported to the appropriate agencies. f) Residents in room [ROOM NUMBER] on 06/19/17 1) A review of grievance/concern book found an incident, in which, occurred between RN #124 and Employee NA #54 on 06/19/17 at 9:30 PM. Review of the statements found: --Statement by Employee #124, RN read, On 06/19/17 at around 9:30 pm I went to find who had Resident #117 to do a skin assessment. The NAs stated that NA #54 had Resident #117. I went into room [ROOM NUMBER]and pecked on the door, when I entered the room I said, Good I need to do (Resident #118's skin assessment and you have her undressed. NA #54 said, Why you want to look at her ass. I asked him what he meant by that and he said, I don't have time for this. I told him I needed him to help me turn Resident #117 on her side for a skin assessment that I had already did everything but her buttock and back. NA #54 stated, I have more patients to do and you treat NAs and nurses like were dirt under her feet. I told him that wasn't true and I hadn't even talked to him before, that I was told to get help turning the patients and he kept saying you never asked. I asked again for help and he refused. I told him I was going to write him up for insubordination and he stated, I am getting a union representative. As I came down the hall I stated, I hate it when people are smart asses. Statement by Employee #54, NA read: I was on west wing and was in room [ROOM NUMBER] assisting the residents in getting ready for bed, when RN #124 came into the room and told me that I was to come to room [ROOM NUMBER]. I asked her to give me a minute, she then told me that she needed me to do it now. I told her she needed to give me a minute. I asked her if she needed to look at their butt. She then told me I was getting wrote up for insubordination. I never refused to help. I told her to give me a minute. Then she yelled at me and called me a smartass. She stated she was the RN and that meant I would do as I am told and not question her. She pulled her name badge at my face and said that is what this means. 2) This allegation of abuse and neglect was not reported till after this Surveyor's inquiry of situation. It was reported on 06/08/18 (a year after the occurrence). g) Resident #58 1) A review of the Complaint/Grievance book found a concern by Resident #58. This allegation was reported to Employee #125, SW on 01/23/18. Concern: Resident reports that she doesn't know how to take the Employee #43, NA on evening shift. NA sometimes. She takes good care of me but she likes to joke and sometimes doesn't know how to take her. She makes me anxious. Interventions: NA #43 received a written warning. The resident no longer has the NA as her caregiver. 2) No further statements could be located. This allegation of abuse/neglect was not reported until after this Surveyors inquiry. Reported on 06/05/18 to the required agencies. h) Resident #4 1) A review of the complaint/grievance book found a concern by Resident #4. This allegation was reported to SW #6 on 06/01/18. Concerns noted by Resident #4's family read: Still not getting coffee at all meals. Staff were mocking the resident Help at the west wing nurses' station. One NA would not give the NA caring for Resident #4 the proper size of diapers. Wednesday, pm shift. The resident was lying angled in her bed. She couldn't get to her tray to eat. She had a bowl of peaches in her bed with her. She needs pulled up to the tray to eat her meals. Residents name is not over her bed it is a different residents' name. Interventions: Coffee is being served at all meals. Diaper issue is resolved. Resident will eat in day lounge (sitting upward). 2) No further statements could be located. This allegation of abuse/neglect was not reported until after this Surveyors inquiry. Reported on 06/05/18 to the required agencies. i) Complaint made by the Ombudsman 1) A review of the complaint/grievance book found a concern by the Ombudsman. This allegation was reported to SW #6 on 05/15/18. Concern: I had more complaints of staff being rude to residents. One employee (NA) was huffing and puffing and complaining because they were short staffed and everyone was acting crazy. After the visitor reported this a resident spoke up and reported a nurse who is mean and hateful and this nurse had to shut up and quit talking so much. The NA said that is her personality. There is one employee that is hateful as the devil; when one resident asked for a drink and another asked if there was church tonight; she yelled and was hateful to both residents. Please address this issue with your staff. 2) This surveyor was provided a copy of an in-service for Ethical behavior and Unethical behavior conducted on 05/16/18 by the Administrator. 3) No further statements could be located. This allegation of abuse/neglect was not reported until after this Surveyors inquiry. Reported on 06/06/18 to the required agencies. j) Resident #114 1) Review of Resident #114's medical records found the resident was admitted on [DATE]. Care Plan initiated; Resident is a 53yr. old female-Diagnosis: [REDACTED]. Staff supervises meals, assists as needed. She is noted to take food from other resident's trays. Easily agitated. Diet Regular NAS with lidded cups for safety. Weight 102# --below IBW range (123#-149#) She feeds herself meals--often uses her fingers to eat --likes sweets and snack foods. No teeth or dentures. 2) Progress notes found the following incident/altercations involving resident-to-resident: --10/18/2017 at 08:28 - Resident noted to be up walking around day lounge throwing food on the floor and taking food from other resident's trays. --10/19/2017 at 18:00 - Resident up and ambulating in day lounge throwing her shoes across room pushing furniture against resident's wheelchairs. staff sits down with resident to assist with meal resident then gets up and proceeds to remove food from her brother's tray. when attempting to redirect resident begins hitting self in head and slamming fists on wall, offered activities, fluids and snacks with staff to monitor for safety. --11/6/2017 at 18:00 - Another resident was calling out to resident and calling her names. Resident became agitated and grabbed other resident's hair and pulled hard. Residents were separated by staff. Vital signs unable to be obtained due to resident was agitated. --11/9/2017 at 21:46 - Late Entry: Note: resident has been noted to be up wandering in other resident's rooms, taking food and drinks off resident's dinner trays this shift requiring redirection numerous times. --11/27/2017 at 07:59 - Resident up ambulating in day lounge removing food from other resident's trays requiring redirection numerous times. resident becomes agitated and begins hitting self in head. attempts to take resident to room for self-soothing. --12/7/2017 at 13:20 - Resident in day lounge at this time alert and nonverbal skin clean dry warm to touch resident noted to hit her head on the walls and glass numerous times this shift , staff makes attempts to redirect this resident , with no positive results noted , this resident noted to be grabbing other residents chairs in the day lounge and halls x 4 this shift staff attempts to redirect this resident to the day lounge resident placed in chair at which time resident proceeds to kick and hit staff numerous times along with attempting to hit her head on tables and chairs in the day lounge , staff remains with resident at this time. --12/7/2017 at 17:40 - Resident continues to be aggressive to staff along with continues to hit her head on the walls and windows, with each attempt to redirect (TRUNCATED)

Based on medical record, Incident/Accident reports, Complaints/Grievances and Reportable reports, staff interview, and resident interview, the facility failed to ensure each allegation of abuse and/or neglect were thoroughly investigated to prevent further potential abuse, neglect and mistreatment. This deficient practice caused actual harm for Residents #89, #99, #26 and #5. This deficient practice had the potential to affect more than an isolated number. Resident identifiers: #89, #99, #26, #11, #71, #5, #44, #58, #4, #212, #114. Facility census: 107. Findings included: a) Resident #89 1) Review of Resident #89's medical records found an annual Minimum Data Set (MDS) with an Assessment reference date (ARD) of 11/07/18. This MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 for severe cognitive impairment. Resident # 89's [DIAGNOSES REDACTED]. Severe confusion was noted with poor safety awareness with a history of falls. Resident #89 required the physical assistance of one person with bathing/showering. Resident #89 was noted as always continent of bowel and bladder functions. Requiring only supervision with most Activities of Daily living except bathing and personal hygiene. 2) A review of the Incident/Accident reports found on 02/01/18 at 10:20 AM found an incident occurred in the shower room. The incident description was as follows: Called to shower room per staff. Resident sitting in floor in shower room. Resident noted to have a complaint of pain in left wrist. Left wrist noted to be swollen at this time. Resident has no other complaints of pain. No redness or bruising noted at this time. Resident was unable to give description states, My wrist is really hurting me. Resident noted to be holding left wrist at this time. Resident was transferred to nearby hospital and was diagnosed with [REDACTED]. A review of statements by the two (2) nurse aides (NA) present in the shower room found: --Statement by Employee #56, NA read: I was showering (Resident #89's name) with another staff member in the shower room. As I turned to get a piece of clothing the resident got up and tried to walk by herself and lost her footing and fall the other staff member (Employee #43, NA) tried to catch her but wasn't quick enough then got (Employee #32, licensed practical nurse (LPN) name. --Statement by Employee #43, NA read: I was assisting another staff member in showering resident (Resident #89). As the other staff member turned to get a piece of the resident's clothing. Resident got up unassisted. She lost her footing. I tried to catch her but I was too late. 3) Review of the significant change MDS with an ARD of 05/09/18 found the resident has had a decline in her activities of daily living (ADL) and has more episodes of incontinence. Resident remains alert to person only and continues to have poor safety awareness secondary to impaired cognitive status. This indicates following the incident on 02/01/18 resulting in a fractured left wrist, Resident #89 has experienced a decline in her ADL status and incontinence status. 4) On 02/02/18 at 11:00 AM an in-service was provided on Proper showering techniques the following was included, Maintain a face-to-face contact when possible, stay with resident during the entire process . do not leave residents alone while bathing or showering . 5) This incident was not reported as potential neglect until 06/12/18 (after surveyor intervention). The Social Worker (SW) and the Director of Nursing (DON) agreed the NAs were neglectful by stepping away from the resident, whom has poor safety awareness due to impaired short term and long term memory. This indicates actual harm for Resident #89 due to leaving the resident unsupervised and out of reach while in the shower resulting in a fall acquired fracture and pain. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. b) Resident #99 1) Review of the reportable allegation of abuse found a report for Resident #99, dated 05/23/18 at 1:34 AM, this report read Resident told reporter (Employee #6, Social Worker (SW) that she was trying to get out the door to smoke. She tried to get a lighter out of the alleged perpetrator's pocket. While trying to get the resident back into the building, it was alleged that (Employee #59, licensed practical nurse (LPN) grabbed Resident #99's right hand and squeezed her fingers hard causing pain. Resident #99 stated, It hurt real bad. I thought she had broken it. Review of statements found: --Statement by the alleged perpetrator, Employee #59, LPN read: On 05/23/18 at 11:34 AM, Resident #99 was trying to exit through the back door, as I was trying to redirect the resident. The resident was moving wheelchair back into facility the resident grabbed the door frame. I slid my hand under her wrist to guide it backwards. The resident started putting her hand in my pockets, when I asked her not to. At which time resident became agitated and stated, She was going out and we couldn't stop her. then she turned her wheelchair and propelled her self-down the hallway muttering and cursing. --Statement by the nurse whom examined the resident, Employee #23, RN read: This nurse was on East wing, approached by SW and asked to assess (Resident #99's) hand. Resident sitting in her room in her wheelchair at bedside with remote in hand. This nurse asked her if something occurred, she stated, Yes, I don't remember if it was yesterday or today. I was going outside to smoke. I opened the door, I know all the codes. Somebody grabbed my chair, it jerked me backwards. I couldn't go forward or backwards. I saw the girl's lighter in her pocket and I grabbed it. She grabbed my hand and squeezed it real hard. It hurt bad. I thought she broke it. I continued to assess the resident's right hand, this is the hand that was squeezed . 2) This allegation was submitted to Adult Protective Service (APS) on 05/24/18 only. Was not faxed to all of the other required agencies until 05/30/18. Only statements obtained was the perpetrator, Employee #59, LPN and Resident #99. Employee #23, registered nurse (RN) provided a statement with her assessment of Resident 99's injuries (she did not observe the incident). 3) Interview with Resident #99, on 06/05/18 at 9:15 AM, she stated, The staff punishes me with not letting me smoke with the other residents due to I feed the cats my leftover food and cat food that I have bought. They say all kinds of stuff to me, they mock me and they take the food I have for the cats and throws it in the trash can in front of me and says, Ha,Ha. They grab my wheelchair and prevent me from moving and jerks my chair backwards at times. Employee #59 squeezed my hand/fingers one time so hard I thought she broke it. The resident appeared distraught and upset as she recalled these incidents. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. This deficient practice has caused Resident #99 actual psychosocial and physical harm which caused mental anguish, pain, intimidation, punishment, and humiliation. c) Resident #11 1) Review of Complaint/Concern log found a complaint for Resident #11 dated 03/14/18 and made by the resident's family. The concern stated, (DON's name) received a call from (Name of resident's family) on 03/14/18. Also, another family member was also on the call. The family stated, I want to report abuse. Nurse Aide (NA) #46, is pulling out resident's hair. The family member stated, I have reported this to Employee #23, RN and nothing is been done. The family goes on to say they do not want NA #46 taking care of her as they feel mistreatment by NA #46 is a retaliation due to some criminal activity by residents and NA #46's family. A review of the statements found: --Statement by Director of Nursing (DON) #18, NA #7 and Registered Nurse (RN) dated at 2:00 PM on 03/14/18, statement read: Employee #23, NA #7 and myself (DON) went to the residents room. I asked her if she was happy here and she stated, No, I want to go to Williamson. I asked her if everyone is good to her and she stated, They take my stuff. I asked her if anyone has done anything mean to her and she stated, No. I asked her if anyone had smacked her or hit her she stated, No. I asked her if NA #7, RN #23 or myself (DON) had ever pulled her hair and she stated, No. She denied anyone being mean to her and stated they take care of her. --Statement by Employee #46, NA, the alleged perpetrator read: I was putting the resident (Resident #11) to bed after the last smoke break. The resident became combative and I asked the nurse (No name mentioned) to assist me with the resident. She continued hitting and scratching me. We got her in bed and I was removing her jewelry and the necklace pulled her hair. I told her, I was sorry and she said, She was fine and told me to put her stuff on the table. 2) This alleged allegation of abuse/neglect was not reported till 06/15/18 after this Surveyor's inquiry. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. d) Resident #71 1) A review of the Complaint log found a complaint dated 03/28/18. This complaint was from Resident #71 and was made to the DON. This complaint read: (Resident's name) made a complaint that the staff got her up at 4 am to take a shower. 2) No statements or investigation could be found. After this surveyors intervention it was determined by the staff this was an allegation of neglect/abuse. This was submitted on 06/05/18 to the proper agencies. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. e) Resident #44 Review of the grievance/concern forms for the last year found three (3) concern/allegations: 1) Allegation #1: On 06/08/17, Resident #44 reported that Licensed Practical Nurse (LPN) #36 did not give her medication to her. The resident reported this to RN #123, who informed the DON. Social Worker (SW) #124 and DON spoke with the resident separately concerning her allegation. Resident denies the allegation of abuse, neglect or anyone treating her in a mean manner. She stated she does not like her nurse because she crushes her medicine. On 06/22/17, resident is no longer receiving medication crushed. Review of the statements found: Statement by Employee #36, LPN, made on 06/01/17 at approximately 1700 (5pm): (Employee #123, RN's name) approached nurse's station and stated, who is (Resident #116's name) nurse? Myself as well as another LPN were sitting at desk when RN #123 states, she needs Tylenol, I explained to RN #123 that this resident did not have a current RX (prescription) for Tylenol. RN #123 states, well you need to give her some Tylenol again I explained, we can call the doctor and ask but most generally she doesn't give Tylenol for a temperature of 99 degrees. Rn #123 states, well I said to give it to her. I explained that I could not give a medication without an order from the physician and again I explained I would contact the physician regarding residents request. I attempted to explain the parameters for Tylenol toxicity due to the resident currently had an order for [REDACTED]. At this time, RN #123 states well you are well within your limits and what could Tylenol hurt? This writer attempted to let Rn #123 know of resident's drug seeking behaviors but that again one of us would contact the physician and let her know the residents request. Statement by Employee #16, LPN on 06/01/17 at 17:40 (5:40 pm): A resident went up to (Employee #123's name) and told her she had a temperature of 99 degrees. The RN came out and told the nurse to give her two (2) Tylenol. Staff attempted to explain to the RN we could not give medication without a physician's orders [REDACTED].#116 two (2) Tylenol. Resident stated she had a temperature of 99 degrees. Staff again attempted that we could not give it. This nurse took RN into the office and attempted to give some of the resident's history with being told I was just an LPN and that she had been a nurse for [AGE] years. Rn became loud to the point that it was almost a scream cutting this nurse off. Statement by Employee #36, LPN on 06/06/17 at approximately 15:10 (3:10 pm) While sitting at nurse's station attempting to complete paperwork to send a resident to hospital. RN #123 is noted to approach the nurse's station and state, I need drugs this writer informed her that I would be with her in just a minute as I was on the telephone attempting to transfer a resident to the hospital. RN #123 states, I wasn't speaking to you, I was speaking to Employee #57, nurse assistant (NA). This writer explained if you are referring to Resident #214's antibiotic then I am his nurse and Employee #57, NA cannot help you. Then Rn #123 stated, I apparently, I didn't make myself clear I was speaking to Employee #57, NA. Again, this writer explained I was the resident's nurse and would get the medication for her in a minute that I am in the process of sending someone to the hospital. RN #123 stated, Obviously, you don't seem to understand that I am not speaking to you. At this time, this writer went into the med room and got the said antibiotic and handed it to the RN #123. RN #123 walks off. Statement by Employee #36, LPN on 06/08/17 at approximately 18:45 (6:45 pm) Front door alarm sounds and this writer proceeds up to the front to check for safety and reset the alarm. I proceeded out to the parking lot to be sure that no residents were in the parking lot unattended. For further safety, this writer walked around building to be sure the parking lot and surrounding areas were clear. This writer then proceeded to the west wing to check with nursing staff to be sure all residents were accounted for. Upon entering front hall of the east wing (Employee #123, RN name) was noted to be standing at the nurses station with the Medication Administration Report (MAR) for the A section opened. This writer enters the nurses station to begin charting on the computer when Employee #123, RN states, You did not give (Resident #44' name) her meds today. At this time this writer states, yes I did. Employee #123, RN then states, Well, I don't think you did. She told me you didn't. I explained to the RN that the resident has hoarding behaviors, refusal of medications and false accusations. The RN then states, Well if she says you didn't give the medication, as far as I concerned you didn't. RN proceeds to state, There are no initials in the box (referring to the MAR). Then asked, Is 0900 9am or pm. At this time, I stated 0900 is 9am and I have been checking my MAR to be sure all of my finger sticks and etc. has been documented. RN then states, Well, apparently you did not learn anything in nursing school, you are to sign medication out when you give them, therefore, as far as I am concerned you did not give her medication and that is abuse. At no time did the RN allow me to see which area of MAR that she was referring to and nor did she know the resident had been found with a [MEDICATION NAME] (pain medication) in her bra. While attempting to explain this resident's behavior the RN became loud and she pointed her finger in this writers face and saying, Where were you when I was looking for you. I explained I was assessing the situation with the door alarm going off and being sure there was no elopement, while she sat in the office not responding. She (RN) continued to point finger in this writer's face. This writer states, please get your finger out of my face. RN states, you need to get in the office to continue this conversation. This writer informed the RN , I will not go to a private area to hold a conversation with you alone. You are pointing your finger in my face and approached me here in front of my peers and other residents. So, I will not go to a private area with you if you want to speak to me I will do it in front of the DON only. At this time, the RN looks to her right where several staff as well as residents in the hallway. The RN then states, (Employee #57, NA name) go to the office. At this time this writer explained that the NA was a union representative but as a union employee I did not wish to have her present to speak with the RN without the DON in the building due to her aggressive tone with me. RN states, Well, we will see about this I am calling the DON. At no time during this shift did this RN look at any other MAR located on the east wing or any other resident's MAR regarding medications or administration. But the RN stated, Well she is my family and I will take care of this. Statement by Employee #125, SW read, On 06/09/17, I spoke with resident, (Resident #44's Name), regarding allegations a nurse made that the resident was not getting her medications. (Resident #44's name) came to my office in private and I asked her if any nurse failed to give her medications to her. The resident stated, No, I get my medication but she makes me take them crushed and I don't like that. I then looked in the resident's chart to verify that the resident had an physician's orders [REDACTED]. There was a fact an order stating that the resident was to receive crushed meds. I explained this to the resident and she stated her understanding. Statement by Employee #60. LPN read, On 06/11/17, I worked the A hallway on the west wing and (Employee #39, LPN name) worked B hallway. She came to me with a [MEDICATION NAME] (pain medication) in a cup and asked me to waste it with her. She stated she had popped it out in error when pulling a residents medicine, Medication was wasted. We counted at the end of shift and a [MEDICATION NAME](pain med) was signed out by Employee #39 for 06/11/17 at 9 pm and count was correct. This allegation of abuse/neglect was never reported to the required state agencies. 2) Allegation #2: Resident #44 reported an allegation of neglect on 06/12/17 to RN #123. RN #123 reported teh allgeation to the Nursing Home Administrator and DON. The allegation made by the resident was not given her medication by LPN #123. LPN #123 went to the resident's room to confront the resident by reportedly saying, Since you told on me now your medication will be crushed and I will give them to you in the hallway. Employee #124, social worker (SW) talked with resident regarding the allegations and resident denies the allegation. The resident continues to deny any issues with staff being mean to her. She continues to be upset about her medications being crushed. A review of the statements found: --Statement by Employee #44, RN, made on 06/12/17 at 5:35 p.m.: While doing skin assessments, patient in room [ROOM NUMBER]- (Resident #112, Name) called me into her room. She asked me if I was a nurse and I told her yes. Resident stated she did not receive her 9 pm meds last night. I asked her did she know what med, she stated little blue pill (pain pill- [MEDICATION NAME]). I told her I would check the MAR (Medication Administration Record), it may have been not available. I checked the MAR and the medication ([MEDICATION NAME]) had been signed out with the initials of (Employee #39, LPN). I went back into Resident #112's room with Employee #125, Graduate Nurse (GN). What month is it? she stated, June. I asked the year, she stated, (YEAR). I asked her who was the President, she said, Trump. I asked her if she was mistaken, she said, No, I check my pills, my pain pill is the little blue pill and it wasn't there. And I asked the nurse (Employee #39) about it and she told she didn't have it and that they would give it at 12:00 a.m. She went on to tell me several nurses about it and nobody came to see her. --Statement by Employee #49, NA read: On (MONTH) 12, (YEAR) (time ineligible) I was putting (Name of Resident #76) in bed. The wife of Resident #76 was in the room. Employee #124, RN came in the room to do an assessment on the resident. The RN #124 started talking to the resident's wife about an incident that happened on east hallway. She told the wife it involved Resident #44 and Employee #36, LPN. She said she was in the bathroom and heard everything between Resident #44 and LPN #36. She told the wife she had took it to the Administrator and the DON. She told the wife she had screen shot all the nurses whom had been notified. She said they were that the facility was trying to get rid of her and that she reported it to the state. On (MONTH) 20, (YEAR) the wife of Resident #76 was told by RN #124 this morning she had received her letter from the state and they were investigated. --Statement by Employee #41, NA, written on 06/12/17 read: I witnessed a resident come up to the RN and asked about her medicine, The RN came up to the nurse's station and asked where the nurse was at. The RN started looking through the medicine book and when the LPN came back to the nurse's station the RN asked the LPN about the resident's medicine and the MAR book. The RN was telling the LPN she must have not learned anything or she would have signed the book when she gave the resident meds. RN points at LPN and asked her to come to the office. LPN asked the RN to stop pointing her finger in her face. The RN said I'm not pointing in your face. --Statement by Employee #125, SW, written on 06/12/17 read: On 06/12/17, SW spoke with (Resident #44's name), regarding allegations the LPN #36 had not gave her medications and that she came into her room and stated, Since you told on me now your meds will be crushed and I will give it to you in the hall. Resident #44 denies that this was said and also says, Nobody has been mean to me here but I don't like that nurse (LPN #36) because she crushes my meds. --Statement by Employee #127, NA written on 06/12/17 read; I witnessed Resident #44 go into the DON's office and told RN #124 she had not had any of her medicine all day. The RN looked at the MAR and the book had holes in it where the LPN had not signed the MAR. The LPN assured the RN she had gave the meds but had not signed the MAR. The RN's and the LPN's voices kept getting louder. This allegation of abuse/neglect was never reported to the required agencies. 3) Allegation #3: A review of the concern/grievance log found a statement on 06/20/17 at approximately 9:00 AM, NA #58 entered Resident #44's room to find her roommate some clothes, this resident had her roommates pants on. I came out and got my nurse (LPN #36) to assist me. The housekeeper and I was standing in the closet doorway and Resident #44 exited the bathroom holding the clothes. The resident threw the pants and hit LPN #36 in the side of head and then openly smacked her across the face knocking her glasses off. I attempted to get the resident away from the nurse and calm her down. The resident started yelling at the nurse stating, I am going to have your job [***] . I dare you to hit me queer. --Statement by Employee #36, LPN dated 06/20/17 at 9:15 am read: Upon entering Resident #44's room I found the resident had her roommates pants on. This writer, NA and Housekeeper were standing in the doorway of this resident's room when she exited the bathroom striking this nurse in left side of face multiple times screaming, (RN #124) and I are going to have your job [***] . I dare you to hit me I'm calling RN #124 and she will beat your face in. This writer exited the room and notified the supervisor of this resident's behaviors and notified the physician with new orders to administer [MEDICATION NAME] 20 milligrams (mg) intramuscularly (IM) now for agitation. Power of attorney (POA) notified and made aware of residents room change from east to west wing. --Statement by Employee #125, SW read: On 06/20/17, I talked with Resident #44, to discuss her recent behaviors against LPN #36. I asked (Resident #44) why she hit LPN#36 and the resident stated the nurse was discrimating against her. I then asked her why she felt LPN #36 was discriminating against her and she stated, She crushes my medicine and RN #124 told me it was discrimation. I then asked the resident why she called the LPN #36 a queer. She at first denied calling her a queer but later she said, RN #124 told me that she was married to a girl so what would you call her. I told the resident that she could not act that way toward a staff member regardless of her personal opinion. The resident states understanding. This incident of alleged abuse/neglect was never entered on a Complaint/Grievance form and was never reported to the appropriate agencies. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. f) Residents in room [ROOM NUMBER] on 06/19/17 1) A review of grievance/concern book found an incident, in which, occurred between RN #124 and Employee NA #54 on 06/19/17 at 9:30 PM. Review of the statements found: --Statement by Employee #124, RN read, On 06/19/17 at around 9:30 pm I went to find who had Resident #117 to do a skin assessment. The NAs stated that NA #54 had Resident #117. I went into room [ROOM NUMBER]and pecked on the door, when I entered the room I said, Good I need to do (Resident #118's skin assessment and you have her undressed. NA #54 said, Why you want to look at her ass. I asked him what he meant by that and he said, I don't have time for this. I told him I needed him to help me turn Resident #117 on her side for a skin assessment that I had already did everything but her buttock and back. NA #54 stated, I have more patients to do and you treat NAs and nurses like were dirt under her feet. I told him that wasn't true and I hadn't even talked to him before, that I was told to get help turning the patients and he kept saying you never asked. I asked again for help and he refused. I told him I was going to write him up for insubordination and he stated, I am getting a union representative. As I came down the hall I stated, I hate it when people are smart asses. Statement by Employee #54, NA read: I was on west wing and was in room [ROOM NUMBER] assisting the residents in getting ready for bed, when RN #124 came into the room and told me that I was to come to room [ROOM NUMBER]. I asked her to give me a minute, she then told me that she needed me to do it now. I told her she needed to give me a minute. I asked her if she needed to look at their butt. She then told me I was getting wrote up for insubordination. I never refused to help. I told her to give me a minute. Then she yelled at me and called me a smartass. She stated she was the RN and that meant I would do as I am told and not question her. She pulled her name badge at my face and said that is what this means. 2) This allegation of abuse and neglect was not reported till after this Surveyor's inquiry of situation. It was reported on 06/08/18 (a year after the occurrence). No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. g) Resident #58 1) A review of the Complaint/Grievance book found a concern by Resident #58. This allegation was reported to Employee #125, SW on 01/23/18. Concern: Resident reports that she doesn't know how to take the Employee #43, NA on evening shift. NA sometimes. She takes good care of me but she likes to joke and sometimes doesn't know how to take her. She makes me anxious. Interventions: NA #43 received a written warning. The resident no longer has the NA as her caregiver. 2) No further statements could be located. This allegation of abuse/neglect was not reported until after this Surveyors inquiry. Reported on 06/05/18 to the required agencies. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. h) Resident #4 1) A review of the complaint/grievance book found a concern by Resident #4. This allegation was reported to SW #6 on 06/01/18. Concerns noted by Resident #4's family read: Still not getting coffee at all meals. Staff were mocking the resident Help at the west wing nurses' station. One NA would not give the NA caring for Resident #4 the proper size of diapers. Wednesday, pm shift. The resident was lying angled in her bed. She couldn't get to her tray to eat. She had a bowl of peaches in her bed with her. She needs pulled up to the tray to eat her meals. Residents name is not over her bed it is a different residents' name. Interventions: Coffee is being served at all meals. Diaper issue is resolved. Resident will eat in day lounge (sitting upward). 2) No further statements could be located. This allegation of abuse/neglect was not reported until after this Surveyors inquiry. Reported on 06/05/18 to the required agencies. i) Complaint made by the Ombudsman 1) A review of the complaint/grievance book found a concern by the Ombudsman. This allegation was reported to SW #6 on 05/15/18. Concern: I had more complaints of staff being rude to residents. One employee (NA) was huffing and puffing and complaining because they were short staffed and everyone was acting crazy. After the visitor reported this a resident spoke up and reported a nurse who is mean and hateful and this nurse had to shut up and quit talking so much. The NA said that is her personality. There is one employee that is hateful as the devil; when one resident asked for a drink and another asked if there was church tonight; she yelled and was hateful to both residents. Please address this issue with your staff. 2) This surveyor was provided a copy of an in-service for Ethical behavior and Unethical behavior conducted on 05/16/18 by the Administrator. 3) No further statements could be located. This allegation of abuse/neglect was not reported until after this Surveyors inquiry. Reported on 06/06/18 to the required agencies. No evidence was found or provided to support the facility conducted a thorough investigation or put interventions in place to protect the resident. j) Resident #114 1) Review of Resident #114's medical records found the resident was admitted on [DATE]. Care Plan initiated; Resident is a 53yr. old female-Diagnosis: [REDACTED]. Staff supervises meals, assists as needed. She is noted to take food from other resident's trays. Easily agitated. Diet Regular NAS with lidded cups for safety. Weight 102# --below IBW range (123#-149#) She feeds herself meals--often uses her fingers to eat --likes sweets and snack foods. No teeth or dentures. 2) Progress notes found the following incident/altercations involving resident-to-resident: --10/18/2017 at 08:28 - Resident noted to be up walking around day lounge throwing food on the floor and taking food from other resident's trays. --10/19/2017 at 18:00 - Resident up and ambulating in day lounge throwing her shoes across room pushing furniture against resident's wheelchairs. staff sits down with resident to assist with meal resident then gets up and proceeds to remove food from her brother's tray. when attempting to redirect resident begins hitting self in head and slamming fists on wall, offered activities, fluids and snacks with staff to monitor for safety. --11/6/2017 at 18:00 - Another resident was calling out to resident and calling her names. Resident became agitated and grabbed other resident's hair and pulled hard. Residents were separated by staff. Vital signs unable to be obtained due to resident was agitated. --11/9/2017 at 21:46 - Late Entry: Note: resident has been noted to be u (TRUNCATED)

Based on record review, staff interview, and physician interviews, the facility failed to ensure Resident #53 received [MEDICATION NAME], an anticoagulant (blood thinner) upon return from a stay at an acute care hospital. After initiating [MEDICATION NAME] therapy, the facility failed to ensure prompt notification of the resident's physician of the results of ordered [MEDICATION NAME]/International Ratio (PT/INR) laboratory (lab) tests. Additionally, on two (2) separate occasions, the physician gave orders to increase Resident #53's [MEDICATION NAME], but the facility failed to administer the increased dose until the next day despite the fact it was available in the emergency medication box. These significant medication errors placed Resident #53 at an immediate risk for serious harm and/or death, resulting in a determination of immediate jeopardy. The Nursing Home Administrator (NHA) and the Director of Nursing (NHA) were notified of the immediate jeopardy at 3:05 p.m. on 04/06/16. The facility provided a plan of correction (POC) to the State agency at 4:13 p.m. on 04/06/17, which the State agency reviewed and accepted at 4:17 p.m. on 04/06/17. The State agency representatives onsite ascertained implementation of the POC and abated the immediacy at 4:50 p.m. on 04/06/17. After removal of the immediate jeopardy, no deficient practice for this requirement remained. Resident identifier: #53. Facility Census: 113 Findings include: a) Resident #53 Resident #53 was readmitted from an acute care facility on 03/21/17 at 9:00 a.m. Review of the resident's medical record found the hospital discharge summary noted [DIAGNOSES REDACTED]. An echocardiogram completed during her hospitalization showed an ejection fraction of 40-45%, apical hypokinesis (abnormally decreased muscle function) and left ventricular apical thrombus (clot). Her target INR (international ratio) was 3.0. The discharge summary included an instruction for the resident to receive [MEDICATION NAME] 2 mg by mouth every evening. Review of Resident #53's Medication Administration Record [REDACTED]. The medication was started after the attending physician visited and ordered [MEDICATION NAME] 2 mg and a PT/INR on 03/23/17. During an interview at 11:15 a.m. on 04/06/17, when asked about the resident not receiving [MEDICATION NAME] after her readmission, the resident's attending physician stated she would not have discontinued the resident's [MEDICATION NAME] unless she had hematuria or some other bleeding condition. (The medical contained no evidence Resident #53 had these conditions). The facility did not obtain the PT/INR ordered on [DATE] until 03/27/17. Facility staff reviewed, printed, and notified the physician of the results of this PT/INR on 03/28/17. The physician ordered the dose of [MEDICATION NAME] increased to 3 mg. However, the facility did not increase Resident #53's [MEDICATION NAME] dose until the evening of 03/29/17, despite the fact it was available in the emergency medication box. The facility did not notify the physician of the PT/INR results obtained on 04/03/17, until 04/04/17 of the result of 1.39 (low). The physician then gave orders to increase the resident's [MEDICATION NAME] to 4 mg. She did not get the first dose of this increased dosage until 04/05/17, despite the fact it was available in the emergency medication box. An interview with the DON on 04/06/17 at 11:25 a.m., found the facility has an emergency medication box that contains [MEDICATION NAME]. She confirmed Resident #53 did not receive the [MEDICATION NAME] as ordered. These significant medication errors placed Resident #53 at an immediate risk for serious harm and/or death, resulting in a determination of immediate jeopardy. The Nursing Home Administrator (NHA) and the Director of Nursing (NHA) were notified of the immediate jeopardy at 3:05 p.m. on 04/06/16. The facility provided a plan of correction (POC) to the State agency at 4:13 p.m. on 04/06/17, which the State agency reviewed and accepted at 4:17 p.m. on 04/06/17. The State agency representatives onsite ascertained implementation of the POC and abated the immediacy at 4:50 p.m. on 04/06/17. After removal of the immediate jeopardy, no deficient practice for this requirement remained. b) The Facility's Plan of Correction: On 04/06/17 Medical Director and Director of Nursing (DON) implemented the following plan: -- The DON and LPN immediately evaluated the resident number 53. Vital signs were B/P 108/58, SPO2 97% on 2L O2, RR 20, Temp 98.6, and Pulse 87. The resident assessment revealed resident without s/s of distress. No bleeding or new bruising noted to skin. Old ecchymosis areas in various shades were noted on her arm, abdomen, and around her right knee. The DON notified the physician of the resident condition and re-notified the physician of a PT/INR that was not obtained on 3/23/17 as ordered following a med error/lab error from a readmission on 3/21/17. The DON also re-reported the PT/INR values for the labs collected on 3/27/17 and 4/3/17 and the subsequent orders given by the physician. The DON reported to the physician the dates and times which ordered [MEDICATION NAME] therapy was instituted. The physician requested the resident be sent to the emergency room for further evaluation. During the emergency room evaluation. Nursing staff present were immediately in-serviced and all other nurses will be in-serviced prior to their next scheduled shift by the DON or designee on [MEDICATION NAME] therapy, collecting labs and reporting lab findings, starting medications within a reasonable time following order, and utilization of the ER box if medications are needed. -- The DON and nursing staff will review the medical records for all other resident's receiving [MEDICATION NAME]. All residents receiving [MEDICATION NAME] will be assessed by nursing staff and documentation will be provided in the medical record. All residents receiving [MEDICATION NAME] will be ordered a stat PT/INR to ensure therapeutic levels. Once the levels are received they will be reported promptly to the physician for orders as indicated and any medication changes will be addressed promptly. -- Because this had the potential to effect all residents receiving [MEDICATION NAME], nursing staff present were immediately in-serviced and all other nurses will be in-serviced prior to their next scheduled shift by the DON or designee on [MEDICATION NAME] therapy, collecting labs and reporting lab findings, starting medications within a reasonable time following order, and utilization of the ER box if medications are needed. The facility also ordered a finger stick PT/INR monitor to perform in house monitoring of levels to avoid a delay in care. PT/INR levels will be recorded on a monitoring log for each resident on [MEDICATION NAME] and will be promptly reported for the physician and medications will be started promptly following orders received. The ER Box will be utilized as needed to provide timely medication. A [MEDICATION NAME] review monitor will be utilized to ensure that as results are obtained and orders are given, medications are started in a timely manner. -- The interdisciplinary team will review the aforementioned monitoring forms at the weekly team meeting for quality improvement x 8 weeks or until the committee determines satisfactory resolution has been achieved to ensure compliance. -- All nurses will be in-serviced prior to working their next shift. All resident charts will be reviewed by 4-14-17.

Based on record review, staff interview, and physician interviews, the facility failed to ensure Resident #53 received [MEDICATION NAME], an anticoagulant (blood thinner) upon return from a stay at an acute care hospital. After initiating [MEDICATION NAME] therapy, the facility failed to ensure prompt notification of the resident's physician of the results of ordered [MEDICATION NAME]/International Ratio (PT/INR) laboratory (lab) tests. Additionally, on two (2) separate occasions, the physician gave orders to increase Resident #53's [MEDICATION NAME], but the facility failed to administer the increased dose until the next day despite the fact it was available in the emergency medication box. These significant medication errors placed Resident #53 at an immediate risk for serious harm and/or death, resulting in a determination of immediate jeopardy. Additionally, the discharge summary from the hospital included an appointment was scheduled with a cardiologist for 04/04/17. The resident, who had a recent [MEDICAL CONDITION] infarction, did not attend due to the facility's failure to arrange for transportation to and from the appointment. The Nursing Home Administrator (NHA) and the Director of Nursing (NHA) were notified of the immediate jeopardy at 3:05 p.m. on 04/06/16. The facility provided a plan of correction (POC) to the State agency at 4:13 p.m. on 04/06/17, which the State agency reviewed and accepted at 4:17 p.m. on 04/06/17. The State agency representatives onsite ascertained implementation of the POC and abated the immediacy at 4:50 p.m. on 04/06/17. This immediate jeopardy began on 03/21/17, when the facility failed to initiate [MEDICATION NAME] therapy. From 03/21/17, forward the facility continued to make errors in following resident's plan of care. After removal of the immediacy, deficient practices remained for Residents #76 and #79. The scope and severity was decreased from a K to D for the deficient practices that were no a part of the immediate jeopardy. For Resident #76, a scheduled appointment with the wound care center was not kept and Resident # 79 had non-pressure related wounds for which the facility failed to attempt to determine the cause of her wounds. These issues were found for three (3) of twenty-three (23) sampled residents. Resident identifiers: #53, #76, and #79. Facility census: 113. Findings include: a) Resident #53 1. A review of Resident #53's medical record at 12:00 p.m. on 04/05/17, found the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The discharge instructions included, but not limited to: -- [MEDICATION NAME] ([MEDICATION NAME]) two (2) milligrams (mg) by mouth daily at bedtime for treatment of [REDACTED]. -- A scheduled appointment with a Cardiologist on 04/04/17 at 10:20 a.m. for follow-up treatment of [REDACTED]. (Address and phone number included) -- The facility was to call for an appointment with a neurologist within six (6) weeks from date of discharge. (Address and phone number included) Review of Resident #53's Medication Administration Record [REDACTED]. The medication was started after the attending physician visited and ordered [MEDICATION NAME] 2 mg and a PT/INR on 03/23/17. During an interview at 11:15 a.m. on 04/06/17, when asked about the resident not receiving [MEDICATION NAME] after her readmission, the resident's attending physician stated she would not have discontinued the resident's [MEDICATION NAME] unless she had hematuria or some other bleeding condition. (The medical contained no evidence Resident #53 had these conditions). The physician further stated she did not recall if they told her the resident was started on [MEDICATION NAME] while in the hospital. She stated, I don't remember what they found I would have to look at her record. The facility did not obtain the PT/INR ordered on [DATE] until 03/27/17. The results of the PT/INR obtained at 5:00 a.m. on 03/27/17, were available for review by the facility by 1:00 p.m. on 03/27/17. Facility staff did not review or print the results of this PT/INR until 03/28/17. On 03/28/17, the facility reported the PT/INR result of 1.21 to the physician by telephone, at which time the physician increased the dose of [MEDICATION NAME] to 3 mg. However, the facility did not increase Resident #53's [MEDICATION NAME] dose until the evening of 03/29/17, despite the fact it was available in the emergency medication box. The facility obtained the repeat PT/INR 04/03/17 as ordered, but did not notify the physician of the PT/INR results obtained on 04/03/17, until 04/04/17 of the result of 1.39 (low). The physician then gave orders to increase the resident's [MEDICATION NAME] to 4 mg. She did not get the first dose of this increased dosage until 04/05/17, despite the fact it was available in the emergency medication box. An interview with the Director of Nursing (DON) on 04/06/17 at 11:25 a.m., found the facility had an emergency medication box that contained [MEDICATION NAME]. She confirmed Resident #53 did not receive the [MEDICATION NAME] as ordered. 2. The facility failed to arrange transportation for Resident #53 to and from her appointment with the cardiologist scheduled for 10:20 a.m. on 04/04/17. Therefore, the resident was not seen by the cardiologist after her recent [MEDICAL CONDITION] as directed by the discharge summary due to the facility's failure to make arrangements. An interview with the DON on 04/06/17 at 10:30 a.m., found the facility followed the hospital discharge summary when a resident was admitted /readmitted to the facility unless the attending physician specified differently. When the attending physician wished to provide a different medication and/or treatment, it was documented in the nurses' notes. She verified the physician wished to follow the orders as directed by the discharge summary. 3. These failures by the facility placed Resident #53 at an immediate risk for serious harm and/or death. This has resulted in a determination of immediate jeopardy. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified of the immediate jeopardy at 1:30 p.m. on 04/06/16. The facility provided a plan of correction (POC) to the State agency at 4:13 p.m. on 04/06/17, which the State agency reviewed and accepted at 4:17 p.m. on 04/06/17. The State agency representatives onsite, verified implementation of the POC and abated the immediacy at 4:50 p.m. on 04/06/17. This immediate jeopardy began on 03/21/17, when the facility first began to fail to provide appropriate medications and treatments as outlined in the discharge summary from an acute care hospital for treatment of [REDACTED]. From 03/21/17, forward the facility continued to make errors in following the identified resident's plan of care. After removal of the immediate jeopardy, deficient practices. not a part of the immediate jeopardy remained for Residents #76 and #79. The scope and severity was decreased from a K to D 4. The Facility's Plan of Correction contained: On 04/06/17 Medical Director and Director of Nursing implemented the following plan: -- The DON and LPN immediately evaluated the resident number 53. Vital signs were B/P (blood pressure) 108/58, SPO2 (oxygen saturation) 97% on 2L O2 (2 liters of oxygen), RR 20 (respiratory rate), Temp 98.6 (temperature), and Pulse 87. The resident assessment revealed resident without s/s of distress. No bleeding or new bruising noted to skin. Old ecchymosis areas in various shades were noted on her arm, abdomen, and around her right knee. The DON notified the physician of the resident condition and re-notified the physician of a PT/INR that was not obtained on 3/23/17 as ordered following a med error/lab error from a readmission on 3/21/17. The DON also re-reported the PT/INR values for the labs collected on 3/27/17 and 4/3/17 and the subsequent orders given by the physician. The physician was notified of a missed cardiology appointment scheduled for 4-4-17 and discussed previous discharge orders that required the resident to be re-evaluated within 6 weeks. Staff re-scheduled an appointment for the earliest available appointment on April 28th 2017, which falls within the 6 week time period. The physician requested the resident be sent to the emergency room for further evaluation. During the emergency room evaluation, the physician will request a complete cardiac work up. Nursing staff present were immediately in-serviced and all other nurses will be in-serviced prior to their next scheduled shift by the DON or designee on [MEDICATION NAME] therapy, collecting labs, reporting lab findings, reporting [MEDICATION NAME] levels promptly, starting medications within a reasonable time following order, utilization of \the ER box if medications are needed, ordering labs, making follow up appointments, and transcribing admission and readmission orders [REDACTED] -- The DON and nursing staff will review the medical records for all other resident's receiving [MEDICATION NAME]. All residents receiving [MEDICATION NAME] will be assessed by nursing staff and documentation will be provided in the medical record. All residents receiving [MEDICATION NAME] will be ordered a stat PT/INR to ensure therapeutic levels. Once the levels are received they will be reported promptly to the physician for orders as indicated. The DON and nursing staff will review the medical records of all admissions and re-admissions for February of 2017 to ensure all admission/re-admission orders [REDACTED]. If the in house physician does not agree with an order, documentation and rationale for order not being completed will be documented in the medical record. -- Because this had the potential to effect all residents receiving [MEDICATION NAME], nursing staff present were immediately in-serviced and all other nurses will be in-serviced prior to their next scheduled shift by the DON or designee on [MEDICATION NAME] therapy, collecting labs, reporting lab findings, reporting [MEDICATION NAME] levels promptly, starting medications within a reasonable time following order, utilization of the ER box if medications are needed, ordering labs, making follow up appointments, and transcribing admission and readmission orders [REDACTED]. PT/INR levels will be recorded on a monitoring log for each resident on [MEDICATION NAME] and will be promptly reported for the physician. A re-admission/admission monitor will be instituted to ensure that all orders are properly transcribed into the facility system and ordered as directed by the physician. A [MEDICATION NAME] therapy monitoring for will be instituted and to ensure [MEDICATION NAME] levels are obtained as prescribed, results are called to the physician in a timely manner, and medications are started in a timely manner. -- The interdisciplinary team will review the aforementioned monitoring forms at the weekly team meeting for quality improvement x 8 weeks or until the committee determines satisfactory resolution has been achieved to ensure compliance. -- All nurses will be in-serviced prior to working their next shift. All resident charts will be reviewed by 4-14-17. c) After removal of the immediate jeopardy, deficient practices remained for Residents #76 and #79 at a scope and severity of D 1. Resident #76 Review of Resident #76s medical record on 04/10/17 at 9:45 a.m., revealed the resident had a Stage 4 pressure ulcer on right foot Symes amputation (an amputation through the ankle joint) site which occurred following an attempt to wear a prosthesis. An outside wound clinic treated and monitored the pressure ulcer. Review of consultation reports found an outside wound clinic saw and treated Resident #76' pressure ulcer on 03/13/17. This consult specified recommended treatments and a return appointment in three (3) weeks. The facility physician ordered an appointment for the resident to go to the wound clinic on 04/03/17. There was no evidence found in the resident's medical record to indicate the resident went to the wound clinic on the specified date, and if not, why the resident missed the appointment. An interview with the DON on 04/10/17 at 12:30 p.m., found the staff did not know why the appointment with the wound care clinic had been missed. She further confirmed the appointment had been rescheduled. c) Resident #79 At 8:06 a.m. on 04/04/17, observation of the resident found he had numerous areas of discoloration to both forearms and a band-aid on his right elbow. The areas were various shades of red and purple. Review of a monthly summary, dated 03/03/07, found the resident had no skin issues. Further review of the medical record found a nurse's note, dated 04/04/17, New orders received and noted to cleanse open ecchymotic area to right elbow with NNS (normal saline solution), Pat dry, apply [MEDICATION NAME] and cover with band aid daily and PRN (as needed), Left message for A second nurse's note, dated 04/03/17, New orders received and noted to discontinue tx (treatment) to right and left forearm areas resolved. At 1:42 p.m. on 04/05/17, Licensed Practical Nurse (LPN) #31, when asked if she had any information regarding the reddened areas on the resident's forearms and the skin tear, said she did not have an incident report for the skin tear. She said the reddened areas on the resident's forearms were ecchymotic areas due to the use of [MEDICATION NAME] (an anti-platelet). At 1:53 p.m. on 04/05/17, LPN #22 said the area to his elbow was just a scab the resident had picked at. The areas come and go where he just constantly picks, he is on [MEDICATION NAME]. Review of the current care plan found the use of [MEDICATION NAME] and the ecchymotic areas identified by the staff were not currently care planned. She stated, I did not care plan the use of [MEDICATION NAME]. On 04/03/17 at 9:27 a.m., Registered Nurse (RN) #38, the quality assurance coordinator, was asked if the facility had any information regarding the reddened areas to the resident's forearms and the recent skin tear to the resident's elbow. She had no additional information to offer. At 11:05 a.m. on 04/11/17, RN #4 said she had ordered elbow protectors, after surveyor intervention, for the resident because he hits his arms on things. On 04/11/17, at 11:06 a.m., the director of nursing (DON) said she would have expected staff to do an incident report to attempt to determine how the skin tear could have occurred. The DON was unable to provide any evidence to explain what had caused, or may have caused, the discolorations. Prior to the surveyor asking about the resident's skin condition, there was no documentation regarding the areas observed on the resident's forearms and the recent skin tear to the right elbow other than the 04/05/17 order for treatment for [REDACTED].

Based on observation, record review, staff interview, resident interview, and review of facility policies, the facility failed to provide pressure relieving devices to promote the healing of an unstageable sacral wound for one (1) of three (3)residents reviewed for pressure ulcers. The facility failed to provide a pressure relieving/reduction cushion to Resident #128's wheelchair and an appropriate pressure relieving mattress to his bed to promote the healing of an unstageable pressure ulcer to his sacral area. The wound had increased in size from 5 cm x 6 cm x 2 cm on admission to 6 cm x 6.5 cm x .2 cm on 11/19/14. Resident identifier: #128. Facility census: 112. Findings include: a) Resident #128 This resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission nurse's notes, dated 09/24/14, documented a body audit revealed a suspected deep tissue wound measured at 3 centimeter (cm) x 3 cm on the residents left heel, a small red non-opened area to his right heel, a surgical scar to the mid back for a laminectomy with a small amount of light red drainage noted to the dressing, and an unstageable pressure ulcer to his sacrum the measured at 5 cm x 6 cm with 50% red granulation tissue and 50% dark yellow slough and a moderate amount of serosanguinous drainage noted. Review of the 5-day Minimum Data Set (MDS), dated [DATE], found it documented Resident #128 required the extensive assistance of two (2) staff for bed mobility and was dependent on the assistance of two (2) staff for all transfers. He was documented to have an "indwelling" Foley catheter and was frequently incontinent of bowel. This MDS documented Resident #128 was at risk for skin breakdown and was admitted with an unhealed Stage II pressure ulcers on his left heel, and his coccyx was documented as being an unstageable area of pressure. This MDS documented pressure reduction was applied to his bed upon admission, but there was no documentation indicating any type of pressure reduction device was placed into the resident's chair. Review of Resident #128's 14-day MDS assessment dated [DATE], found it documented he required the extensive assistance of two (2) staff for all transfers and bed mobility and was totally dependent of two (2) staff to get out of bed. He was noted to have two (2) Stage II pressure ulcers, one (1) of which was noted to be present on admission, one area of slough that was present on admission, and one unstageable area that was present on admission. There was no documentation indicating the resident had any pressure relieving device to his wheelchair. Review of Resident #128's Braden scale for predicting pressure sore risk from admitted d 09/24/14 revealed Resident #128 was documented to have no impairment in his ability to respond to meaningful pressure related discomfort, was rarely moist, chairfast, and was very limited in his ability to change or control his body positioning. He was also documented as requiring moderate to maximum assistance in moving and he frequently slid down in the bed and the chair requiring frequent repositioning with maximum assistance. Review of the current skin care plan revealed Resident #128 had pressure ulcers and had a potential for further pressure ulcer development related to his decreased mobility and incontinence. The care plan documented he was admitted with a Stage II to LLL (left lower leg - shin), an unstageable area to his sacrum, and a suspected deep wound to his left heel. The interventions noted on the skin/pressure ulcer care plan were for the staff to cleanse the deep suspected tissue injury to residents left heel with normal saline, pat dry, apply santyl, and wrap with a dressing daily. Another order was noted for staff to cleanse the unstageable area to his sacrum with normal saline, pat dry, and apply [MEDICATION NAME] and zinc compound cover with a pad and tape into place. The care plan also documented Resident #128 was to be turned and repositioned every two (2) hours, but there was no mention of the pressure reduction devices to his bed or his chair. The physician's orders [REDACTED]. Review of the skin documentation revealed the following (typed as written): 10/01/14 "Sacrum unstageable 4.8 x 6 cm by .2 100% granulation slough ) undermining/tunneling/sinus tract: document via clock method -: none Exudate: amount/type/odor -: moderate amount of serosanguinous Pain -: none" 10/01/14 left heel "Type - : pressure Stage -: deep suspected tissue injury Where Wound was acquired -: hospital Location -: left heel Size cm: L X W (length times width) -: 2.8x2.9 Depth cm -: unable to obtain Wound bed description: Type of tissue(with color) to = 100% (granulation/[MEDICATION NAME]/slough/eschar) -: brown/black soft and intact undermining/tunneling/sinus tract: document via clock method -: none Exudate: amount/type/odor -: none Pain -: no" 10/08/14 "sacrum L X W -: 6x7 Depth cm -: 0.2 Wound bed description:Type of tissue(with color) to = 100% (granulation/[MEDICATION NAME]/slough/eschar) -: 60% red 20% black 20% yellow undermining/tunneling/sinus tract: document via clock method -: none Exudate: amount/type/odor -: moderate amount of serosanguinous drainage Pain -: no" "Left heel Size cm: L X W -: 2x2.5 Depth cm -: unable to obtain Wound bed description:Type of tissue(with color) to = 100% (granulation/[MEDICATION NAME]/slough/eschar) -: dark purple undermining/tunneling/sinus tract: document via clock method -: none noted Exudate: amount/type/odor -: none noted Pain -: no" 10/15/14 "Sacrum Size cm: L X W -: 8.5 x 9 Depth cm -: Wound bed description:Type of tissue(with color) to = 100% (granulation/[MEDICATION NAME]/slough/eschar): Black and red with slough" "deep suspected wound Stage -: Location -: left heel Size cm: L X W -: 2 x 2 Depth cm -: Wound bed description:Type of tissue(with color) to = 100% (granulation/[MEDICATION NAME]/slough/eschar) dark discolored area" 10/22/14 "pressure Stage -: unstageable Where Wound was acquired -: hospital Location -: sacrum Size cm: L X W -: 5.5cm x 7.5 cm Depth cm -: 0.2 cm Wound bed description:Type of tissue(with color) to = 100% (granulation/[MEDICATION NAME]/slough/eschar) 50% red tissue 50% yellow tissue" "deep suspected tissue injury Where Wound was acquired -: hospital Location -: left heel Size cm: L X W -: 4 cm x 4 cm Depth cm -: UTO (unable to obtain) Wound bed description:Type of tissue(with color) to = 100% (granulation/[MEDICATION NAME]/slough/eschar) 90% dark purple 10% red tissue" 10/29/14 "deep suspected tissue injury Where Wound was acquired -: hospital Location -: left heel Size cm: L X W -: 4 cm x 4 cm Depth cm -: UTO depth over 0.2 cm over 80% beefy red 20% of wound bed d/t necrotic tissue Wound bed description:Type of tissue(with color) to = 100% (granulation/[MEDICATION NAME]/slough/eschar) -: 0.2 cm over 80% beefy red, 20% of wound bed is covered with necrotic tissue " "unstageable Where Wound was acquired -: hospital Location -: sacrum Size cm: L X W -: 7.6 cm x 6.2 cm Depth cm -: 0.2 cm Wound bed description:Type of tissue(with color) to = 100% (granulation/[MEDICATION NAME]/slough/eschar) -: 50% beefy red tissue with yellow slough. white [MEDICATION NAME] tissue noted to center of wound." 11/05/14 "Stage -: unstageable Where Wound was acquired -: hospital Location -: sacrum Size cm: L X W -: 5.5 cm by .5 cm Depth cm -: 0.2 Wound bed description:Type of tissue(with color) to = 100% (granulation/[MEDICATION NAME]/slough/eschar) -: 60% red 40 % purple undermining/tunneling/sinus tract: document via clock method -: none Exudate: amount/type/odor -: moderate amount of serosanguinous" "Stage -: deep suspected tissue injury Where Wound was acquired -: hospital Location -: left heel Size cm: L X W -: 4.5x4.5 Depth cm -: 0.1 Wound bed description:Type of tissue(with color) to = 100% (granulation/[MEDICATION NAME]/slough/eschar) -: 80% red ; 20 % black undermining/tunneling/sinus tract: document via clock method -: none Exudate: amount/type/odor -: moderate amount of serosanguinous Pain -: none" 11/12/14 'Stage -: unstageable Where Wound was acquired -: hospital Location -: sacrum Size cm: L X W -: 6x6 Depth cm -: 0.2 Wound bed description:Type of tissue(with color) to = 100% (granulation/[MEDICATION NAME]/slough/eschar) -: 70% red 30 % yellow undermining/tunneling/sinus tract: document via clock method -: none Exudate: amount/type/odor -: moderate amount of serosanguinous drainage with foul odor noted Pain -: none' 'Stage -: 2 Where Wound was acquired -: hospital Location -: left heel Size cm: L X W -: 4x4 Depth cm -: 0.1 Wound bed description:Type of tissue(with color) to = 100% (granulation/[MEDICATION NAME]/slough/eschar) red' On 11/18/14 at 8:50 a.m. Resident #128 was observed to be seated in his wheelchair in his room and was sitting on some type of cushion. Observation at that time also revealed there was some type of pressure reduction mattress to his bed. This surveyor was unable to determine the the type of cushion or mattress that were being used during this observation. Interview with Resident #128 on 11/18/14 at 8:50 a.m. revealed he came to the facility from another facility a few months ago and he had an open area on his bottom and an area on his left heel when he was admitted . He stated that he did not think he had any type of special cushion in his wheelchair, he stated it was just the normal cushion that came with the chair. Resident #128 was noted to be out of the facility most of the day for a doctor's appointment on 11/18/14 and was unable to be observed. Interview with the Minimum Data Set/Care Plan Nurse Staff #22 on 11/18/14 at 2:00 p.m. revealed she was not aware Resident #128 had any type of special cushion in his wheelchair, but if he did she would make sure to get the use of the cushion to his current pressure ulcer care plan. Interview with Licensed Practical Nurse (LPN) Staff #41 on 11/18/14 at 3:00 p.m. revealed Resident #128 did not have any current orders for any type of special cushion for his wheelchair or any special pressure mattress for his bed. This surveyor advised her that Resident #128 did have some type of cushion in his wheelchair and she stated if he did it would have been placed there by the therapy department. She called the therapy department and they advised her that they had placed a cushion in the residents, wheelchair but it was just a cushion for comfort and not for any type of pressure relief. Interview with Physical Therapy Staff #135 on 11/18/14 at 3:05 p.m. revealed the therapy department did place a cushion in Resident #128's wheelchair and stated the cushion was just for comfort and it was not a special cushion to provide any type pressure relief to the resident's sacral/coccyx area. Interview with LPN #32 on 11/18/14 at 3:20 p.m. revealed he did not have anything to do with the cushions placed into the residents' chairs. He stated the physical therapy department would conduct an evaluation for those devices and then they would apply the pressure reduction cushions as they felt appropriate. He stated he was not sure of the type of cushion that was currently in Resident #128's wheelchair and was unsure if it was a pressure reduction/relieving cushion. He stated there was not a procedure that he used to determine the type of pressure relieving device a resident might need based on their wounds. Interview with Director of Nursing (DON) #19 on 11/18/14 at 3:25 p.m., revealed she thought physical therapy had previously evaluated Resident #128 for a pressure reduction cushion for his wheelchair and thought he currently had some type of pressure reduction cushion in his wheelchair. DON #19 was also unable to verify the type of mattress that was on Resident #128's bed and if it was an appropriate mattress for a resident with an unstageable pressure area to the sacral area. This surveyor requested the manufacturer's recommendations for the type of mattress Resident #128 was currently using. DON #19 was unable to provide information about the pressure reduction qualities of the current mattress, but stated she would obtain this information. Interview with Physical Therapy Staff #133 and #134 on 11/19/14 at 8:30 a.m. revealed the cushion Resident #128 had in his wheelchair was for comfort only and had no type of pressure relieving/reducing properties. Physical Therapy Staff #133 stated he worked with Resident #128 and the resident did a lot of sacral sitting while seated in his wheelchair, but stated he was not aware the resident had any type of wound to his sacrum. He stated the facility staff were to advise the therapy department when a resident needed to be evaluated for any type of pressure reduction/relieving devices to their wheelchairs and he was never told Resident #128 needed to be evaluated. He stated the resident used to have a bed pillow under him in the wheelchair right after he was admitted and therapy placed the current cushion in his wheelchair for comfort, but he did not remember when that was done. He stated he would evaluate the resident immediately for a new cushion. He stated they had added the current comfort cushion because Resident #128 was up his wheelchair all the time and they felt it would be more comfortable for him. Observation on 11/19/14 at 8:50 a.m. revealed Resident #128 was seated in his wheelchair with the same comfort cushion and the lift pad from the mechanical lift was also observed to be under him. Observation of the treatment to Resident #128's left heel and sacrum was conducted on 11/19/14 at 11:30 a.m. with LPN #32. Wound measurements were obtained while he completed the treatments. The left heel was noted to be healing and the wound was clean. The sacral area was noted to measure 6 centimeters (cm) by 6.5 cm by 0.2 cm. There was a large open area in the center and the skin surrounding the open area was noted to be deep purple/black in color. The far outer edges were observed to be deep red in color. There was a foul odor noted to the wound and the dressing when it was removed. Interview with the Minimum Data Set/Care Plan Nurse #22, on 11/19/14 at 8:57 a.m., revealed Resident #128 did have a pressure reduction mattress on his bed. She stated it was the standard mattress that was placed on every residents' bed in the facility. She was unable to identify if the mattress the resident was currently using was an appropriate mattress for a resident with an unstageable area on the sacrum area. DON #19 provided the manufacturer's recommendations for the mattress Resident #128 was currently using. There was no information indicating if the mattress was an appropriate mattress for a resident with an unstageable pressure area to the sacrum area. This surveyor researched and found information on the SPAN America website, which was the mattress manufacturer for the resident's current mattress. The information indicated the current mattress was not providing acceptable pressure relief for a resident with an unstageable area on their sacrum. The manufacturer's information indicated for a resident with an unstageable pressure ulcer with infection noted to the wound, the current foam mattress was not the most appropriate mattress to promote wound healing. DON #19 and the Quality Assurance Nurse #11 both indicated they did not have a system in place to determine which mattress would be acceptable to aid in promoting the healing of wounds for residents. They stated currently the Nurse Aide supervisor ordered the mattress if there was an order for [REDACTED]. Review of the facility's protocol for wound care on 11/19/14 at 12:20 p.m., revealed in the area of skin assessment that the facility should have completed a Braden Scale for predicting pressure ulcer risk upon admission and then weekly for three (3) weeks afterwards. DON #19 verified on 11/19/14 at 12:32 p.m., there was only one (1) Braden Scale completed for Resident #128 and it was completed upon admission. She stated she was not sure why the other assessments were not completed. The facility failed to provide a pressure relieving/reduction cushion to Resident #128's wheelchair and an appropriate pressure relieving mattress to his bed to promote the healing of an unstageable pressure ulcer to his sacral area. The wound had increased in size from 5 cm x 6 cm x 2 cm on admission to 6 cm x 6.5 cm x .2 cm on 11/19/14. .

Based on observation, staff interviews, and clinical record review, the facility failed to ensure each resident had an environment free of accident hazards, and received adequate supervision and/or assistance devices to prevent accidents related to multiple falls with injuries, elevated water temperatures used for resident bathing, and smoking assessment to assure resident safety for 4 of 23 sampled residents (R 25, 80, 99, and 115). Findings include: 1. Review of R115's clinical record revealed the resident was admitted to the facility in 2008 with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. On 09/13/11 the resident was found "laying in floor." Review of falls notes revealed R115 sustained another fall on 12/22/11 when staff witnessed the resident, "sliding to the floor from her wheelchair." Review of the investigation form revealed that staff had marked, "Other" as a predisposing "Environmental Factor" relevant to the fall. However, review of the form revealed no evidence as to what this "other" factor was. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 05/25/12 at 12:55pm revealed no documentation to determine what the "other" predisposing factor related to the fall was. Further interview with the DON and ADON indicated they would not be able to determine a root cause or identify additional actions needed to prevent further accidents without this information. Interview on 05/25/12 at 1:25pm with the DON and ADON revealed that in response to a resident sliding from their wheelchair, they would, "normally ask therapy to look at," and evaluate the resident. Review of the clinical record revealed no evidence R115 was seen by therapy staff between 10/07/11 and 01/07/12, at the time of her regularly scheduled quarterly screens. Further interview with the DON confirmed that therapy staff did not recall screening the resident after the fall on 12/22/11. Review of the facility's "Fall Prevention Program," revealed that the objectives for "Possible Therapy Intervention" included preventing, and decreasing falls and injuries, as well as recommending appropriate positioning and equipment . Review of R115's care plan, initiated on 01/11/12, revealed the resident was at risk for falls due to dizziness, unsteady balance, and poor safety awareness. Although the resident's 12/22/11 fall was noted under the problem statement, review of the care plan revealed it contained no interventions relevant to the resident's use of the wheelchair, other than ensuring the resident was wearing non-skid socks/shoes when out of bed. The care plan included approaches, such as encouraging the resident, who had severe cognitive impairment, to use the call light, and "reposition as needed." The care plan noted the resident required two persons for transfer, as she was very unsteady on her feet. A Minimum Data Set (MDS), dated [DATE], revealed that after hospitalization for pneumonia, the resident was dependent on staff for all her activities of daily living (ADL) including transferring from bed to chair and propelling her wheelchair. This MDS noted that during the look-behind period of the assessment, the resident did not walk in her room, and had been dependent on staff for any locomotion. A brief interview for mental status (BIMS) revealed the resident continued with severe cognitive impairment, with a score of 5 out of a possible 15. Review of the clinical record revealed that on 03/03/12 at 10:07am, R115 fell , face-first from her wheelchair, while sitting in her room. R115 was found "lying on floor on her face beneath the sink. Her wheelchair was behind her." The resident was noted to have a large hematoma on the forehead, the size of an egg. Staff assisted R115 to bed, and vital signs were taken, with blood pressure of 197/111. After being assisted back to bed, the resident started to complain of pain to the neck. The resident also complained of nausea and was, "noted to vomit small amount of emesis." The resident was transported by ambulance to the local hospital where she was diagnosed with [REDACTED]. 2. Review of the clinical record revealed R80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Upon admission, the resident was identified as at high risk for falls. Admission physician orders [REDACTED]. Review of the clinical record revealed R80 sustained his first fall in the facility on 04/26/12 at 1:24am. Review of the "Incident Description" revealed the resident was sitting on the safety mats beside his bed, and stated he was "getting up to get a sandwich." A review of the investigation form revealed that staff had marked multiple items, including "Other" as a predisposing Environmental Factor. However, review of the form revealed no evidence as to what this "other" factor was. Review of the investigation revealed no evidence as to whether the ordered bed alarm had sounded, or been in use at the time of this fall. Interview with the DON and ADON on 05/25/12 at 12:55pm revealed they could not determine whether the bed alarm had been in use or working from reviewing the investigation. They stated they did not know what the "other" predisposing factor related to the fall was, and would not be able to determine a root cause or identify additional actions needed without this information. Review of the clinical record revealed R80 sustained a second fall on 04/26/12, at 10:50am. The resident was found lying on his back in the middle of the hallway. The resident complained, "My back and head are hurting," and was transferred to the local hospital emergency room . Review of the investigation report revealed staff marked "using wheeled walker" as a predisposing factor in the accident. However, interview with the ADON on 05/25/12 at 12:55pm indicated that this information was not accurate, as the fall occurred from the resident sliding out of his wheelchair. Review of the clinical record revealed R80 sustained additional falls. On 05/03/12, the resident was found lying on the floor in the day lounge. The incident description stated, "The resident was trying to move a chair, and pushed it too far, causing resident to lose his balance and fall, hitting his forehead on door, then hitting the back of his head." R80 required evaluation at the hospital. Review of the incident description for a fall on 05/12/12 revealed R80 was found lying on his right side next to the wall below his bed, with his right arm underneath him. The resident's forehead was up against the wall. The resident sustained [REDACTED]. Review of the investigation revealed that staff had again marked "other" as a predisposing situational factor. Interview with the DON and ADON revealed they did not know what other factor was involved in this accident. Although the physician orders [REDACTED]. Observation on 05/24/12 at 11:00am, 2:30pm, and 3:15pm, revealed R80 in bed asleep. During each observation, no falls mats were on the floor. Observation on 05/24/12 at 4:45pm revealed R80 sitting in a recliner in his room. Interview with Licensed Practical Nurse (LPN29), who was present in the room, confirmed there were no mats in the room for use when the resident was in bed. LPN29 revealed she thought that "Maybe Laundry took them to clean." Further interview with LPN29 revealed that the facility had no system in place to notify nursing to obtain additional mats if one was being taken away for cleaning. Review of R80's clinical record also revealed additional accident hazards. Nursing notes of 05/20/12 revealed a nurse "was called to resident's room, resident talking and chewing on something in mouth that sounded like metal. This nurse instructed resident on how to get object out so he didn't get choked. Resident did not understand that he had metal in his mouth - resident confused and thought it was spaghetti ...Object was a metal bracket - the source of the bracket is unknown." Review of the resident's care plan revealed no evidence it had been revised after this incident with actions to prevent further choking hazards. 3. Review of the clinical record of R99 revealed [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Review of the 06/17/11 fall revealed, "The resident stated, "I'm in my sock feet and fell ." Review of the immediate action revealed staff, "encouraged resident to wear shoes when out of bed." However, the notes also stated that the resident's understanding was, "questionable due to Alzheimer's dementia." Further review of this investigation revealed that staff was present in the room performing care for the roommate while the resident, "was going through items in closet and lost balance" while in sock feet. Review of the resident's care plan revealed that, "staff to ensure that resident is wearing shoes when out of bed," had been initiated on 06/01/11, before this fall occurred. Review of R99's care plan, dated 03/21/12, revealed the subsequent two falls were on 09/14/11, when the resident fell , resulting in a hip fracture. However, review of Fall investigations revealed that the resident actually fell on [DATE]. On 09/08/11, a "Health Status Note" reported that the resident was ambulating without assist, and was "found in floor on right side in front of nurse's station." The resident complained of pain to the right hip and leg, and was transported to the hospital. Further review of "Falls Notes" revealed after R99 returned from the hospital on [DATE], the resident sustained [REDACTED]. On 12/04/11, the Falls investigation revealed that R99 fell when, "Residents husband was trying to transfer resident by himself. Residents husband did not alert staff that resident needed assistance." Review of the next fall investigation (12/27/11) revealed R99's husband was transferring her without staff assistance. Interview with ADON on 05/25/12 at 10:20am confirmed the facility did not identify the need for the husband to not assist with transfers until after the 12/27/11 fall. Review of R99's current care plan revealed this intervention had not been added. Review of Falls investigations revealed multiple additional falls, including ones on 01/26/12, 03/20/ 12, 03/24/12, and 05/11/12, Interview with the DON on 05/24/12 at 4:35pm revealed that in response to a fall, staff were required to complete an incident report. The report would be reviewed by the DON, Administrator and physician. Review of the incident reports for each of the above falls revealed there was no documented evidence of assessment as to possible root causes of the accidents. Although each incident report contained multiple items of data, the meaning of the data and how it impacted on the accident was not assessed. All 4 incident reports from 2012 had "confused," "gait imbalance," and "ambulating without assistance" marked in the data collection screens. However, each fall occurred in different circumstances (i.e. from the bed versus ambulating in the day lounge.) There was no review of whether care plan intervention had been in use, and if they had been in use, why they were not effective in preventing the accident. For example, on 05/11/12, staff documented the resident, "got out of wheelchair unattended before staff could get to this resident," and she fell in the hallway. The investigation did not address whether interventions for R99 such as whether the resident's restraint had been in place, or whether the ordered alarm had sounded. Further interview with the DON on 05/24/12 at 4:35pm confirmed there was no system in place where all pertinent data was gathered after each incident, investigated for possible root causes, care planned in response to the findings of the specific investigation, and evaluated in a consistent area as, "the information is in lots of different places. " 4. Interview during initial tour on 05/22/12 at 10:05am with the ADON revealed R25 was identified as a smoker who used both tobacco and electronic cigarettes. Observation revealed R25 out on the deck, smoking a tobacco cigarette under staff supervision at 11:00am on 05/23/12. Review of the clinical record of R25 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Prior to admission, the resident was hospitalized with acute chronic respiratory failure, and chronic obstructive lung disease. Review of a note labeled, "Medicare" for 03/22/12 revealed the resident, "has poor safety awareness and poor decision making. " Review of the facility's "Smoking Policy" revealed, "A smoking assessment will be completed upon admission, quarterly, and with any changes for those residents who choose to smoke." Review of the clinical record revealed that the resident's smoking assessment was not completed until 04/18/12, 55 days after admission. Further review of the smoking assessment revealed it was incomplete for the resident's safety needs. Section C - Dexterity, had not been completed. Review of the form revealed it did not address the resident's use of oxygen, for which she had "as needed" orders relative to safety during smoking. Interview on 05/25/12 at 4:15pm with the Social Services Director (SSD) revealed that upon admission, the resident had been using an electronic cigarette. The SSD stated that she had not identified the need to do a smoking assessment on admission, but should have, since the resident was a smoker. 5. Observation on 05/24/12 at 10:50am with the Maintenance Supervisor using his thermometer revealed water temperatures were elevated in the following rooms: The tub room located on East Wing was 114 degrees Fahrenheit. Room 126 on East Wing was 116 degrees. Interview on 5/24/12 at 1:10pm with the Maintenance Supervisor revealed that he has been checking water temperatures monthly. He acknowledged that the water temperatures were to be no higher than 110? F. Documentation provided by the Maintenance Supervisor revealed that only one room on each wing was tested monthly and no documentation was provided that either of the tubs room was tested during 2012. .