Every finding on record at Wayne Healthcare Center

Based on observations, staff interviews and resident interviews, the facility failed to ensure resident's call lights were within reach, and to ensure residents did not have long waits for call lights to be answered. This failed practice had the potential to affect a limited number of residents. Resident Identifiers #6, #21, and #27. Facility Census: 59Findings Included: a) Resident #21 On 05/19/26 at12:00 PM, it was observed that Rsident #21 was laying in her bed trying to reach her call bell on the floor beside her bed causing her to almost roll out of the bed. Registered Nurse #34 was alerted, came into the room, and confirmed she was unable to get her call light and began to assist her. b) Resident # 27 On 05/20/26 at 11:59 AM Resident #27 was heard calling out for help. She was observed sitting in her wheelchair, near the foot of her bed, while her call bell was clipped to her pillow at the head of the bed and out of her reach. Registered Nurse #34 was alerted and came into the room, confirmed her call light was not within reach, then assisted putting her back into bed. c) Resident #6: During Enteral tube care, it was observed Resident #6's call light was on her left side. This resident suffered a stroke with left sided weakness and when asked to hit the call light button, the resident could not reach across body to use the call light. This was confirmed by staff member RN #34. This event took place on 05/21/2026 at 10:58 AM. This was discussed with Nursing Home Administrator on 05/21/26 at 11:08 AM. Resident #6s care plan was edited after this conversation to reflect call bell be placed on the right side of the resident.

Based on resident interview, observation and staff interview facility failed to ensure meals are prepared and served in methods to conserve nutritive value, flavor, appearance and in a pleasing, palatable presentation. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #49, #28, #39, #18, #24,#12, #9 , #47 and #15. Facility census: 59. Findings includeA) Regulation review for 483.60 (d) reads in part.-Food prepared by methods that conserve nutritive value, flavor, and appearance.-Food and drink that is palatable, attractive, and at a safe and appetizing temperature.B) During dining observations on 05/19/2026 at around 12:45 PM Resident (49) reports, the vegetables would be better if it wasn't mushy., Resident (28) diet slip shows resident is to have double portions however did not receive double portion of lasagna nor cauliflower. Resident (39) reports this cauliflower is too mushy and brown, Resident (18) diet slip shows dysphagia puree, to receive puree breaded chicken patty for meal however received puree lasagna. Resident (24) feeding assistant/activity director reports She will not touch the cauliflower, it is too discolored. Dining room observation. Cauliflower brown in color, very soft for regular and dysphagia advanced diets. Resident number nine (9) did not receive the ordered magic cup for the lunch tray. District Manager for Food and Nutrition verified the cauliflower was over cooked, Resident (18) did not receive the puree breaded chicken, Resident (28) and the resident did not receive double portions. Resident nine (9) did not receive the magic cup with her meal. Review of the production sheet showed needing puree chicken for one (1) serving. During a staff interview with cook (13) verified it was prepared but not served, reporting I must have missed it.-On 05/19/2026 at around 1:30 PM During an interview with resident (15), reporting, The food, especially the vegetables are mushy when we get them. Pointed at cauliflower on plate reporting this is not supposed to be brown and mushy.- On 5/19/26 at around 2:00pm during a follow up interview with resident (47), reporting they cook the vegetables to death, this is supposed to be cauliflower but it is brown mush-On 05/19/26 at around 1:30PM. During follow up interview with resident (34), reporting this meal today would have been better if they did not cook the cauliflower to death, it is brown and mushy. - On 05/19/2026 at around 10:26 AM. During an interview with resident (47), reporting The vegetables are usually cooked way too much. Sometimes you can not tell what they are supposed to be.- On 05/19/26 at around 2:00PM. During a follow up interview with resident (47), reporting this is what I am talking about, my diet card says it is cauliflower but I am not sure, this is brown mush.

Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to the resident's personal products and unsanitary practices. Resident Identifier: #27. Facility census: 59Findings Included: During a facility walk-through on 05/20/26 at 12:10 PM, we observed 1 wheelchair (w/c) in the A hallway with holes in the seat, exposing the inner padding near the front left screw and 1 Geri-Chair located outside the Central Shower Room with rips and tears down both sides of the back rest and on the right armrest, exposing the inner padding. On 5/20/26 at 2:00 PM, during an interview/walk-through with the Infection Preventionist, the B Hall Nurse manager was present. She confirmed the wheel chair and Geri-Chair had tears and holes exposing inner padding and stated the facility would remove and repair them.

Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record for Resident #23's date of an acute care transfer, the indication of a medication for Resident #3 and pressure ulcer staging for Resident #12. This was true for three (3) of 23 residents reviewed during the survey process. Resident Identifiers: #23, #3 and #12. Facility Census: 59. Findings Include: a) Resident #23 On 03/26/25 at 10:22 AM, an initial interview was held with Resident #23. Resident #23 stated, I had to go to the hospital .I was so sick. The record review found the resident had been transferred to an acute care facility on 12/04/24 due to an abnormal abdominal x-ray. The date documented on the transfer form was 08/14/24. Upon further review, the fax confirmation sheet had the date circled with a notation stating wrong date. (Typed as written.) On 03/26/25 at 6:05 PM, the Administrator confirmed the date on the transfer form was incorrect. b) Resident #3 On 03/27/25 at 10:00 AM, a record review was completed for Resident #3. The review found the resident was prescribed Melatonin 3 (three) mg (milligram) 2 (two) tablets by mouth at bedtime for inability to fall asleep. (Typed as written.) On 03/27/25 at 10:20 AM, the Unit Manager (UM) #55 was notified of the incorrect indication for the medication. The UM #55 confirmed the indication for the medication was incorrect. 49467 c) Resident #12 Upon review of Resident #12's nursing admission assessment, the resident was noted to have a stage three (3) pressure wound upon admission to the facility. However, upon review of the dietary nutritional assessment, completed by the Registered Dietitian (RD), the wound was noted to be stage one (1). In a subsequent progress note, the RD noted the wound was a stage three (3). This inaccuracy was acknowledged by Electronic Health Records Coordinator Licensed Practical Nurse (EHCLPN) #55 at approximately 2:50 PM on 03/27/25.

Based on document review and staff interview, the facility failed to notify the family of one (1) of seven (7) residents that the resident had sustained a fall and was transferred to the hospital. Resident identifier: #111. Facility census: 59. Findings include: a) Resident #111 On 03/26/25 at approximately 3:55 p.m., upon review of the resident's change of condition form, it is documented resident own poa (power of attorney). The surveyor could not locate in the electronic medical record where family emergency contact was contacted regarding the resident's serious accident and transfer to the hospital. b) On 03/27/25 at approximately 11:02 a.m., interview with employee #55 the employee verified that there was no documentation that family was notified regarding the significant change in the resident's condition. This was also acknowledged by the facility's Administrator upon exit on 03/27/25 at approximately 4:15 p.m.

Based on record review and staff interview, the facility failed to notify the State Ombudsman of an acute care transfer for Resident #23. This was true for one (1) of three (3) residents reviewed under the care area of hospitalizations. Resident Identifier: #23. Facility Census: 59. Findings Include: a) Resident #23 On 03/26/25 at 10:22 AM, an initial interview was held with Resident #23. Resident #23 stated, I've had to go to the hospital, I was pretty sick. A record review was completed on 03/26/25 at 1:30 PM. The review found the resident had been sent to an acute care facility on 08/14/24 for an abnormal abdominal x-ray. On 03/26/25 at 6:05 PM, an interview was held with the Administrator. The Administrator confirmed the State Ombudsman was not notified of the resident's transfer. The Administrator stated, we don't have the Ombudsman notification for 08/14/24.

Based on record review and staff interview, the facility failed to develop the care plan, which included all diagnoses for Resident #57. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident identifier: #57. Facility census: 59. Findings include: a) Resident #57 On 03/26/25 at 2:52 PM, a record review was completed for Resident #57. The resident was admitted to the facility on [DATE]. The review found the care plan did not include all diagnoses for Resident #57. The following diagnoses were not included: --generalized muscle weakness --difficulty in walking, not elsewhere classified --dysphagia, oral phase --personal history of transient ischemic attach (TIA) --cerebral infarction without residual deficits (CVA) --essential (primary) hypertension (HTN) --hyperlipidemia, unspecified (HLD) --type 2 diabetes mellitus with diabetic neuropathy, unspecified (DM) --hypothyroidism, unspecified --benign prostatic hyperplasia without lower urinary tract symptoms (BPH) --generalized anxiety disorder (GAD) --gastro-esophageal reflux disease without esophagitis (GERD) --acquired absence of the left leg above the knee (AKA) On 03/27/25 at 9:20 AM, an interview was held with Minimum Data Set (MDS) Registered Nurse (RN) #14. The MDS RN #14 stated, the care plan is in progress .I haven't updated it yet.

b) Resident #13 Review of Resident #13's comprehensive care plan showed the following focus, The resident is at risk for pain/discomfort r/t [related to] history of left femur fracture repair s/p [status post] ORIF [open reduction internal fixation], rheumatoid arthritis, muscle spasms, diabetic neuropathy, restless leg syndrome, edema, PVD [peripheral vascular disease]. The following intervention was initiated on 09/26/24, Provide medication, Ultram, per orders. Monitor for s/sx [signs and symptoms] of side effects. Evaluate effectiveness of medication. Review of Resident #13's physicians' orders showed the resident was currently receiving gabapentin twice a day for nerve pain and Tylenol three (3) times a day for pain. The resident had received Ultram as needed from 09/25/24 through 10/09/24 and Ultram two (2) times a day from 02/03/25 through 02/17/25. On 03/26/25 at 5:04 PM, Registered Nurse (RN) #14 confirmed Resident #13's comprehensive care plan had not been revised when the resident's Ultram for pain had been discontinued. No further information was provided through the completion of the survey. 49467 Based on record review and staff interview, the facility failed to revise care plans for Resident #12, related to isolation precautions and Resident #13, related to pain medication. This was true for two (2) of 23 resident care plans reviewed during the survey process. Resident identifiers: #12, #13. Facility census: 59. Findings include: A) Resident #12 During review of Resident #12's care plan on 03/26/25, it was noted the resident was recently discharged from the hospital on IV vancomycin, after being diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) and a Urinary Tract Infection due to Extended Spectrum Beta-Lactamases (ESBL). The resident was placed on isolation precautions upon return from the hospital, however, the resident's care plan was not revised to reflect those isolation precautions. At approximately 2:50 PM on 3/27/2025, the isolation precautions omission was acknowledged by Electronic Health Records Coordinator Licensed Practical Nurse (EHCLPN) #55 and MDS Registered Nurse (MDSRN) #14. MDS RN #14 stated, I guess it just hadn't found its way into the care plan yet, but I will put it in there now.

Based on record Review and Staff interview, the facility failed to ensure treatment and care was provided in a timely manner for a resident with a fall with major injury for 1 out of 7 residents reviewed for falls. Resident identifier: #27. Facility Census: 59. Findings included: a) Resident #27 On 12/30/24, the resident had an unwitnessed fall. The incident note on 12/30/24 at 10:20 AM stated, This UCN (Unit Charge Nurse) noted resident laying on the floor in hallway by window sitting on bottom with leg extended in front of him. Resident stated, I think I broke my hip. Assess resident no signs of injury at this time. After getting resident back into wheelchair, resident denies pain with ROM. The Progress Note stated, the Nurse Practitioner was contacted and new orders were obtained for x-ray of the right hip and pelvis. No complaints of pain at this time were documented and the Power of Attorney was notified. On 12/31/2024 at 6:07 PM, x-ray of right hip and pelvis was completed. On 01/01/2025 at 5:36 AM, the nurse's progress note stated that x-ray results were not obtained on this shift. On 01/01/2025 at 2:20 PM, Lab/Radiology results were obtained per the nurse's progress note. On 01/01/2025 at 3:58 PM, the nursing progress report stated an x-ray was completed with a diagnosis of right hip fracture and possible right occult fracture. Physician recommendation was to transfer to the emergency room for evaluation. On 03/26/25 at 05:56 PM the Director of Nursing (DON) was interviewed concerning the amount of time it usually takes for an x-ray to be ordered, and results obtained. The DON reported that the physician was contacted for an unwitnessed fall. If a stat x-ray is ordered, it usually takes between eight (8) to twelve (12) hours to get the x-ray completed and they call the doctor to see if they want the resident to be sent out. The DON reported it usually takes about an hour to obtain the results. On 03/27/25 at 09:55 AM, the surveyor reviewed and confirmed a delay in treatment with the DON concerning Resident #27. The DON stated, I think he was one that didn't complain of pain.

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow accepted procedures for transmission-based precautions. These were random opportunities for discovery. Resident identifiers: #26 and #22. Facility census: 59. Findings included: a) Resident #26 The facility's policy titled, Enhanced Barrier Precautions, with approval effective date 04/01/25, stated that, for residents in enhanced barrier precautions, a sign would be posted on the resident's door to indicate enhanced barrier precautions were required. Review of Resident #26's physicians' orders showed the resident had the following order written on 03/18/25, Enhanced barrier precautions related to: dressing. When dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting. The resident also had an order written on 03/14/25 to cleanse pressure wound to outer great left toe with wound cleanser, dry, and apply calcium alginate to wound bed and cover with bordered gauze dressing daily. During an observation on 03/26/25 at 10:54 AM, there were no indications the resident required enhanced barrier precautions. The resident's door did not have a sign to indicate enhanced barrier precautions were required for the resident. On 03/26/25 at 12:02 PM, the Assistant Director of Nursing confirmed Resident #26 was in enhanced barrier precautions due to a dressing but did not have signage to indicate she required enhanced barrier precautions on her door. The facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. 45173 b) Resident #22 On 03/26/25 at 12:31 PM, Registered Nurse (RN) #68 was observed taking a meal tray into Resident #22, who was under contact precautions for Extended Spectrum Beta-Lactamese (ESBL) in the urine. ESBL is a multi-drug resistant organism (MDRO). Contact precautions are implemented to prevent the spread of infections that can be transmitted through direct and indirect contact with a resident and their environment. The Signage, provided by the Centers for Disease Control and Prevention (CDC), is to indicate the resident is on contact precautions. The signage was hanging on the door to the resident's room. The signage states, STOP CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. (Typed as written.) On 03/26/25 at 1:41 PM, Unit Manager (UM) #55 was notified and confirmed the resident was on contact precautions and RN #68 should have worn PPE upon entering the resident's room.

Based on observation, policy review, and staff interview the facility failed to store, and serve food in accordance with professional standards by keeping chocolate milk beyond its expiration date, and by not ensuring all staff were wearing hairnets during the Long-Term Care Survey Process. This failed practice had the potential to affect all resident currently resding in the facility. Facility Census 60. Findings Include: a) Chocolate milk During the initial tour of the kitchen on 04/29/24 at 11:00 AM, ia gallon of chocolate milk was found in the reach-in-refrigerator with approximately 1/4th of the gallon of chocolate milk left in the jug. The expiration on the jug of chocolate milk was 04/26/24. A review of the facilities policy number 019, titled, { Food Storage: Cold Foods}, under policy statements reads as follows: Typed as written All time/temperature control for safety (TCS) foods, frozen, and refrigerated, will be appropriately stored in accordance with guidelines of the FDA food code. The Dietary Corporate Manager (DCM), confirmed that the chocolate milk was out of date. b) Employee #61 During the initial tour of the facility's kitchen on 04/29/24 at 11:00 AM, it was found Employee # 61 was washing and putting up dishes and did not have a hairnet on. The DCM confirmed that employee # 61 was not wearing a hairnet.

Based on observation, record review, and staff interview the facility failed to ensure a clean, sanitary environment by leaving a bedpan in the floor on the A-Hall room [ROOM NUMBER] restroom, and following policy to test yearly for Legionellosis. This failed practice had the potential to affect more than a minimal number of residents in the facility. Facility Census: 60 Findings Include: a) Bepan left in floor Observation on 04/29/24 at 11:28 AM, revealed an uncovered bedpan in bathroom floor. A second observation on 04/29/24 at 1:17 PM showed the bedpan remained on the floor in the bathroom. On 04/30/24 at 9:00 AM, a third observation with the facility Administrator who confirmed the bedpan still remained in the bathroom floor in room A13. b) Water Management/Legionella Plan Legionellosis refers to two clinically and epidemiologically distinct illnesses: Legionnaires disease, which is typically characterized by fever, myalgia, cough, and clinical or radiographic pneumonia and Pontiac fever, a milder illness without pneumonia (e.g., fever and muscle aches). Legionellosis is caused by Legionella bacteria Review of the facility Water Management plan/Legionella Plan on 05/01/24 at 12:35 PM, revealed the last Legionellosis test was done on 9/14/22. Further record review of the Policies and standard procedures showed in Policy #: IC:- on page 8 to read Water testing will be performed on an Annual basis and the results of the test to be recorded in the facilities Water Management/Legionella Plan. During a staff interview on 05/01/24 at 1:00 PM with the Administrator confirmed the policy for water testing was not followed and the facility had not had a Lefionella test since 09/14/22.

Based on observation and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and current with the actual direct care hours and the identified direct care staff. This was true for four (4) of five (5) Daily Staffing Posting forms reviewed during the long term care survey process. This had the potential to affect more than a limited number of residents. Days Identified: 04/04/24; 04/05/24; 04/12/24 and 04/18/24. Facility Census: 60. Findings include: a) Inaccuracy of actual direct care hours. On 04/30/24 at 9:30 PM, during a review of 04/04/24, 04/05/24, 04/12/24 and 04/18/24 the total direct care hours posted were compared to the Actual Hours for Direct Care Staff Report document for 04/01/24- 04/30/24 calculations. The following inaccuracies were identified. * 04/04/24 - the Daily Staffing Posting form identified the direct care hours to be 176 hours. The Actual Hours for Direct Care Staff document identified the direct care hours to be 147.50. An inaccuracy of 28.5 hours. *04/05/24 - the Daily Staffing Posting form identified the direct care hours to be 172 hours. The Actual Hours for Direct Care Staff document identified the direct care hours to be 152.25. An inaccuracy of 19.75 hours. *04/12/24 - the Daily Staffing Posting form identified the direct care hours to be 172.5 hours. The Actual Hours for Direct Care Staff document identified the direct care hours to be 169.75. An inaccuracy of 2.75 hours. *04/18/24 - the Daily Staffing Posting form identified the direct care hours to be 183.5 hours. The Actual Hours for Direct Care Staff document identified the direct care hours to be 174.50. An inaccuracy of 8.75 hours. On 05/01/24 at approximately 11:15 AM during an interview with the Administrator, he agreed the hours identified on the Daily Staffing Posting were more than the actual reported hours worked. b) Inaccuracy of direct care staffing hours. On 04/30/24 at 09:30 PM, during a review of 04/04/24, 04/05/24, 04/12/24 and 04/18/24 the staff category and total direct care hours posted were reviewed. The following inaccuracies were identified. * 04/04/24 - the Daily Staffing Posting of direct care staffing care hours identified the Registered Nurse Director of Nursing (RN DON) eight (8) hours and two (2) Registered Nurse (RN) with Administrative Duties 16 hours as direct care hours. * 04/05/24 - the Daily Staffing Posting of direct care staffing care hours identified the Registered Nurse Director of Nursing (RN DON) eight (8) hours and two (2) Registered Nurse (RN) with Administrative Duties 16 hours as direct care hours. * 04/12/24 - the Daily Staffing Posting of direct care staffing care hours identified the Registered Nurse Director of Nursing (RN DON) eight (8) hours and two (2) Registered Nurse (RN) with Administrative Duties eight 16 as direct care hours. * 04/18/24 - the Daily Staffing Posting of direct care staffing care hours identified the Registered Nurse Director of Nursing (RN DON) eight (8) hours and two (2) Registered Nurse (RN) with Administrative Duties 16 hours as direct care hours. On 05/01/24 at approximately 11:15 AM during an interview with the Administrator, he stated the RN DON hours and the RN's with Administrative hours were on the Daily Staffing Posting form because they do sometimes assist throughout their shift with the daily care of the residents. With a review of the Labor Classification/ Job Title section of the Centers for Medicare & Medicaid Services- Electronic Staffing Data Submission- Payroll-Based Journal- Long-Term Care Facility- Policy Manual Version 2.6 with the Administrator. This section defines that the Labor Classification/Job Title Reporting shall be based on the employee's primary role and their official categorical title. It is understood that most roles have a variety of non-primary duties that are conducted throughout the day (e.g., helping out others when needed). Facilities shall still report just the total hours of that employee based on their primary role. CMS recognizes that staff may completely shift primary roles in a given day. For example, a nurse who spends the first four hours of a shift as the unit manager, and the last four hours of a shift as a floor nurse. In these cases, facilities can change the designated job title and report four hours as a nurse with administrative duties, and four hours as a nurse (without administrative duties). The Administrator acknowledged the RN DON hours and the RN's with administrative duties hours should not had been included on the Daily Staffing Posting for direct care staff. .

Based on observations, family interview and staff interview the facility failed to ensure the residents were provided a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The facility failed to place chairs in the residents rooms for the resident and/or visitors to utilize. This was a random opportunity of discovery during the long term care survey process and had the potential to affect a limited number of residents. Resident Identifier: Resident #12. Census: 60. Findings Include: a) Resident #12 On 04/29/24 at 12:56 PM, during an interview with Resident #12, his brother was observed to be sitting half way on the rooms packaged terminal air conditioner (PTAC) unit beside Resident #12's bedside. Resident #12's brother stated, the room never had a chair in it but sometimes he is able to get a fold-up chair if there are any available. On 04/30/24 at 4:10 PM, during an interview with the Administrator, he stated, many rooms does not have chairs and he will replace them. He further acknowledged the rooms should have chairs for residents and visitors to have a functional comfortable homelike environment.

Based on resident observation, resident interview, and staff interview the facility failed to ensure Resident #54 was treated with dignity and respect. This was true for one (1) of seven (7) residents reviewed for the care area of dignity during the long term care survey process. Resident identifier: #54. Facility census: 60. Findings include : A) Resident #54 On 4/29/24 at 1:44 PM, Resident #54 was observed with long chin hairs which needed to be removed. An interview with Resident #54 on 4/30/24 at 4:10 PM, confirmed she did not like having chin hair and she would like it removed. The Director of Nursing was present during the resident interview and agreed her chin hair needed removed. She stated she would do that now.

Based on record review and staff interview the facility failed to inform the resident or resident representative, in advance, by the physician or other practitioner or professional, of the risks and benefits of the proposed use of an antipsychotic medication. This was true for one (1) of five (5) sampled residents in the long term survey process. Resident identifier: #36. Facility census: 60 Findings include: a) Resident #36 On 05/01/24 at 12:42 PM, a review of Resident #36's medical record noted Resident #36 was receiving an antipsychotic medication Rispirdone which was ordered 03/07/24. Upon further review it was noted there was no documentation education related to the risks and benefits of the antipsychotic medication was provided to Resident #36's healthcare decision maker prior to the resident being started on the medication. On 05/01/24 at approximately 2:00 PM, an interview was conducted with the Director of Nursing who acknowledged the education related to the risks and benefits of the use of the antipsychotic medication was not completed prior to the medication being started.

Based on record review and staff interview the facility failed to issue a beneficiary notification within appropriate time frames. This was true for one (1) of three (3) residents reviewed for beneficiary notifications during the long term care survey process. Resident identifier # 111. Facility Census 60. Findings include: A) Resident #111 A review of Resident #111's medical record on 05/01/24 found her last covered day of Medicare services was 12/14/23. A review of her notice of medicare non-coverage (nomnc) Centers for Medicare and Medicaid Services (CMS) form 10123 found it was issued to the responsible party on 12/14/23. The form indicated the appeal needed to be filed on 12/13/23 which was one day before the responsible party was notified. This made the appeal process inaccessible to the residents responsible party. An interview with the Nursing Home Administrator on 05/01/24 at 10:30 AM, confirmed Resident # 111's NOMNC was not issued two (2) days prior to her last covered day as required.

Based on observations and staff interviews the facility failed to ensure the residents were provided a safe, functional, sanitary, and comfortable homelike environment. This was evident by soiled equipment, holes in walls and a dirty bathroom. These were random opportunities of discovery during the long term care survey process and had the potential to affect a limited number of residents. Resident Room Identifiers: room [ROOM NUMBER]A, Room # A14B, and Room #B14. Census: 60. Findings Include: a) room [ROOM NUMBER]A On 04/29/24 at 12:37 PM, during a tour of the facility, room [ROOM NUMBER]A was identified to have a piece of equipment in the bathroom which appeared to be soiled on the platform where you would place your feet to stand. On 04/29/24 at 12:40 PM, during an interview with Licensed Practical Nurse (LPN) # 45 and LPN #65, the equipment was identified to be a turn and positioning device the resident stands on to be assisted to turn. LPN #45 stated the platform to stand on was filthy. Neither LPN #45 nor LPN #65 were aware of what the cleaning requirements were for this equipment. On 04/30/24 at 11:50 AM, during an interview with the Administrator, the Policies and Standard Procedures for Infection Control Practices for Maintenance Department, Category noted to be Nursing, was provided. It was identified under the Procedures outlined in Section V. Maintenance and repair of equipment used for resident care that the equipment will be cleaned by staff or housekeeping for visible contaminated blood or other body fluids. The Administrator acknowledged the equipment was not properly cleaned and sanitary for the residents use. b) Room A14-B During an observation on 04/29/24 at 11:23 AM, two holes in the wall were observed behind the B bed in room [ROOM NUMBER] on the A-wing, The holes were observed on each side of the over the bead light. A Staff interview on 04/30/24 at 4:20 PM, with the Administrator confirmed the over head light had been replaced and the holes from the previous light remained in the wall. I will have these fixed as soon as possible, thank you. c) B14 On 04/29/24 at 12:24 PM, the bathroom for room B14 was observed and a brown substance was smeared on the floor by the toilet. An additional observation of the bathroom for room B14 was made on 04/29/24 at 11:30 AM, found the same brown substance on the floor. On 04/30/24 at 11:40 AM, the director of plant maintenance confirmed the floor needed cleaned. He indicated the room should be cleaned daily. 49751 50801

Based on record review and staff interview, the facility failed to ensure Resident #30 was free from abuse which includes freedom from resident to resident altercations and #16 was free from inappropriate language from a staff member. This is true for two (2) of two (2) residents reviewed during the survey. This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the of plan of correction were completed prior to this survey beginning. This did occur and because Resident #30 did not have the cognitive ability to indicate how this affected her the reasonable person standard was applied. A reasonable person would suffer psychosocial harm from being hit by another resident residing in the same facility as her therefore this will be cited as actual harm at past non compliance for Resident #30. Resident #16 voiced to staff that hearing the nurse aide using profanity about caring for her made her upset also resulting in actual harm for Resident #16. Resident Identifier: #30 and #16. Facility Census: 195. Findings Include: a) Resident #30 On 04/30/24 at 11:00 AM, a record review was completed for Resident #30. The record review found a documented incident which occurred on 03/28/24 at 3:00 PM. A witnessed allegation of Resident #57 hitting Resident #30 in the left eye was reported by the Activities Director #54. This was also witnessed by two (2) guests. Resident #30 was admitted to the facility on [DATE]. The resident had the following diagnoses: - Alzheimer's disease with late onset - Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbances - Hypertensive chronic kidney disease with Stage 1 through stage 4 chronic kidney disease or unspecified kidney disease - Chronic kidney disease, Stage 4 (Severe) - Anemia in Chronic Kidney disease - Primary generalize osteoarthritis - Essential primary hypertension - Atherosclerotic heart disease of native coronary artery without angina pextoris - Type 2 diabetes mellitus with diabetic chronic kidney disease - Iron deficiency anemia secondary to blood loss (chronic) - Other seasonal allergic rhinitis - Vitamin D deficiency, unspecified - Major Depressive Disorder, Recurrent, moderate. - Insomnia due to medical condition - Generalize anxiety disorder. - Muscle weakness (generalized) - History of falling - Type 2 diabetes mellitus with hyperglycemia - Dysphagia, oral phase - Personal history of COVID-19 - Hypotension, unspecified - Personal history of (healed traumatic fracture of the right hip - Slow transit constipation The Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed on 04/30/24 at 12:30 PM. The Brief Interview of Mental Status (BIMS), found under section C, a score of -04- (four), which indicates moderate cognitive impairment. The resident does not have capacity according to the Physicians Determination of Capacity form dated 03/02/23 and has a resident representative in place. On 04/30/24 at 01:45 PM, a review of the facility reportable was completed. The review found a reportable dated 03/28/24. The incident took place on 03/28/24 at approximately 3:00 PM. The allegation was Resident #57 hit Resident #30 in the left eye. The incident was reported to the Physician by the Activities Director #54 who witnessed the incident. The reportable was faxed to all appropriate state agencies. The investigation started immediately on 03/28/24. A written statement was obtained from the Activity Director #54 who states she was talking to (Resident #57) concerning his eye and (Resident #30) pointed at him and he hit her in the left eye. There were two (2) guest that also witnessed the incident. Their statements were #1 he was talking and just hit her in the face, witness #2 it looked like an accident, he went to push away her hand and accidentally hit her in the face. The Activities Director #54 immediately separated the residents and summoned the Physician which was in house and was instructed to place a cold compress on her eye. Resident #57 was placed on one on one (1:1) until he was able to be transferred to a local hospital for evaluation. He has since been discharged from the facility. The alleged perpetrator, Resident #57 has the following medical diagnosis: - Epilepsy, unspecified, not intractable, without status epileptics. - Anoxic brain damage, not elsewhere classified. - Difficulty walking - Muscle weakness (generalized) - Unspecified mood (affective) disorder - Impulse disorder - Intermittent explosive disorder - Asthma - Non surgical orthopedic/musculoskeltal - Essential hypertension - Unilateral primary osteoarthritis, right hip - Type 2 diabetes without complications - Bipolar disorder - Moderate intellectual disabilities - Unspecified hearing loss, bilateral - Mixed hyperlipidenia - Presence of artificial right eye - Pain in right knee Resident #57's Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed on 04/30/24 at 12:40 PM. The Brief Interview of Mental Status (BIMS), found under section C, a score of 12 (twelve), which indicates moderately cognitive impairment. The resident does not have capacity according to the Physicians Determination of Capacity form dated 02/20/23 and has a resident representative in place. On 04/30/24 at approximately 3:30 PM, the Administrator provided a copy of the Abuse Abatement Plan dated 03/2/24. The Abatement Plan states the following: Resident's Head to toe assessment completed 03/28/24 Resident's Pain assessment complete. 03/28/24 Resident's MD (medical doctor) and RP (resident representative) notification of incident. 03/28/24 Resident Social services referral. 03/28/24 Care plan reviewed- 04/30/24 All agencies and police notified of incident. 03/28/24 Identification of Others: All competent residents in the facility were interviewed for any concerns of being safe or if their needs were being met. No residents voiced any concerns of their safety or of their needs not being met. Head to toe skin assessments were conducted on residents residing in the facility who are unable to be interviewed. No additional residents were identified to have any unknown skin issues. A further review of Resident #30's record indicated a head to toe assessment and a pain assessment were completed on 03/28/24. Based on the residents mental status the facility was able to confirm the witnessed incident at the time of the incident. The completed assessments by nursing staff documented no indication the resident had any physical injuries and the resident did not have any signs or symptoms to indicate pain. There were continued skin assessments completed weekly since the incident. The Resident is scheduled Tylenol 650 mg twice a day for osteoarthritis pain. She has denied pain since the incident. Pain assessments are completed twice a day and a pain observation tool was completed on 03/28/24 based on the incident. An interview was conducted on 05/02/24 at 11:15 AM with the Administrator and the Director of Nursing (DON). Both the Administrator and the DON confirmed the incident which involved Resident #30 did happen as reported. The Administrator, also stated Resident #57 has been discharged from this facility to a more suitable facility for his mental capacity. b) Resident #16 On 04/29/24 at 11:00 AM, a record review was completed for Resident #16. The record review found an allegation of the resident hearing a Certified Nursing Assistant (CNA) use profanity in front of Resident #16 and stating CNA #83 doesn't want to care for Resident #16. On 04/29/24 at 10:30 AM, a review of the facility reportable's was completed. The review found a reportable dated 02/19/24 by the administrator. The incident took place on 02/18/24 . The allegation was CNA #83 stated, , If I knew how much fucking work (he) had to do, he wouldn't have taken this fucking job. Resident #16 heard the statement be made in the doorway of Resident #16's room. Resident #16 reported this to staff stating CNA #83 uses profanity often and I don't care for it and do not want him caring for her. The report was faxed to all appropriate state agencies and investigation started. The CNA #83 was placed on unpaid suspension following the incident on 02/18/24. Multiple witness statements were obtained by other staff members regarding the incident from 02/18/2024 through 02/21/24. The witness statements reviewed stated CNA #83 did say what he said in front of Resident #16. The five (5) day follow up investigation was submitted by SSD #84 on 02/23/24 Allegation of abuse (verbal and psychosocial) made by the resident to the nurse Conclusion it was determined the resident overheard CNA using profanity, which was validated by staff members who also heard the profanity. The statement made by CNA #83 left the resident upset and no longer wanting CNA #83 caring for them. CNA #83 agreed making the statement, however stated he did not use profanity. CNA #83 states he knew this interview was coming and he would no longer be working at the facility he resigned. SSD #84 concluded an investigation stating Resident #16 was not continuing to be in psychological distress knowing CNA #83 no longer works at this Long-Term Care Facility. On 02/21/24 CNA #83 resigned during investigation of verbal abuse by using profanity in front of Resident #16 when contacted about the investigation his response was I have been waiting for this call and didn't come into work anyway because I am quitting down there. Upon being hired to this facility CNA #83 had completed Elder Abuse: The Elder Justice Act training, Preventing, Recognizing, and Reporting Abuse training on 02/07/24. 49751

Based on medical record review and staff interviews the facility failed to accurately encode the residents Minimum Data Set (MDS) upon discharge. This was true for one (1) of two (2) resident discharges reviewed during the long term care survey process. Resident Identifier: Resident #59. Facility Census: 60. Findings Include: a) Resident #59 On 4/30/24 at 6:45 PM during a medical record review for Resident #59, there were no notes identified for the anticipated discharge of Resident #59 prior to the discharge occuring on 03/21/24. A review of the miscellaneous documents identified the Notice of Medicare Non-Coverage that was verbally reviewed with Resident #59's son on 03/15/24. Upon further review of the residents record, the discharge summary dated 03/21/24 was completed by all required departments. The discharge summary did include but was not limited to the notification of the need to follow up with attending physician in 2 weeks, medication list, and the discharge goals of St Mary's home health. On 04/30/24 at 10:40 AM, during an interview with Unit Manager Licensed Practical Nurse (UM LPN) #65, she stated that the MDS Coordinator was currently off but she remembered that the residents son had worked with the staff on the discharge process but then he had came to get her one day before the date they had originally planned for. She stated she felt it had to do with financial issues. She further stated she felt that because he came before the planned date is why it was marked as unplanned. On 04/30/24 at 11:38 AM, during an interview with Regional Director of Finance # 82, she confirmed the cut letter and provided the letter of determination that Resident #59 had won her appeal dated 03/18/24. She further stated that there was nothing financially in the system that would indicate the discharge to be due to financial reasons. On 04/30/24 at approximately 11:45 AM, during an interview with the Administrator, he agreed that everything identified in regards to this discharge indicates that the discharge was planned and the MDS was not encoded correctly.

Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed to ensure residents were free from abuse. Eight (8) residents were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). Employee #81 physically abused Resident #12 by performing an invasive medical procedure without a physician's order, which resulted in physical discomfort and/or emotional distress as witnessed by multiple employees who reported having heard an audio-recording on Employee #81's cellular phone of Resident #12 screaming and cursing during the procedure. Employee #81 also physically abused a number of unidentified residents by giving them a combination of laxative medications that were not ordered by a physician. Employee #81 threw or squirted water on residents (including a resident known to be afraid of water) and allowed nursing assistants to perform tasks that should not be delegated to unlicensed assistive personnel in a nursing home. Employee #81 subjected residents to involuntary seclusion by restraining them with inappropriate devices and in the absence of a medical necessity. In addition, Employee #81 incited residents to yell and curse. All of the residents identified in the employees' statements had a [DIAGNOSES REDACTED]. The period of time, the extent of harm to others (beyond Resident #12), and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report resulted from a failure of the facility to operationalize the abuse prohibition program outlined in the facility's policy and procedures. Resident identifiers: #12, #15, #30, #59, #60, #61, #62, and "X". Facility census: 58. Findings include: a) Residents #12, #15, #30, #59, #60, #61, #62, and "X" 1. On 06/06/11 at approximately 4:00 p.m., a review of the facility's records of allegations of resident mistreatment / abuse / neglect (which had been self-reported to State agencies by the facility) revealed thirteen (13) allegations against Employee #81 - a licensed practical nurse (LPN) who worked on the night shift - were self-reported by the facility to the State survey agency as follows: - "Employee was alleged to have audiotaped a resident (#12) cursing on her cellular phone." (This was reported to the State survey agency on 01/25/10; date of incident was not known.) - "Employee was alleged to have squirted water on resident (#62). ..." (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - "Employee was alleged to have pushed resident (#15) quickly down the hallway in wheelchair. ..." (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - "It was alleged that employee tied resident's (#30) wheelchair to side rail. ..." (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - "It was alleged that employee encouraged resident (#61) to yell and cuss. ..." (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - "It was alleged that employee encouraged resident (#12) to yell and cuss and allegedly gave medications in an inappropriate manner." (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - "It was alleged that this employee placed cold water on the resident's face (#62). ..." (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - "It was alleged that this employee was verbally inappropriate to residents." (No residents were named.) (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - "It was alleged that the employee put resident (#60) to bed in a rough manner. ..." (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - "It was alleged that this employee cursed in front of a resident and the resident repeated this. Resident unknown at this time. ..." (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - "It was alleged that the employee gave laxatives without physician's order and mixed medications and did not give to residents." (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - "It was alleged that employee used inappropriate restraints (on Resident #30)." (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - "It was alleged that employee used inappropriate restraints (on Resident #12)." (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - Review of the facility's internal investigations into allegations of mistreatment / abuse / neglect by Employee #81 found the facility substantiated five (5) of the thirteen (13) allegations: - Recording on her cellular phone Resident #12 cursing - Administering laxatives without a physician's order - Encouraging Resident #61 to yell and curse - Tying Resident #30's wheelchair to a side rail - Being verbally inappropriate to residents - Encouraging Resident #12 to yell and curse and administering medications in an inappropriate manner -- 2. Upon review of the witness statements obtained during the facility's internal investigation, the following allegations were reported by staff to administrative personnel at the facility regarding Employee #81's actions towards residents (all are quoted as they were written): (Note: The statements were variously dated as having been written by the witnesses on 01/22/10, 01/23/10, and 01/15/10. Additional responses to pre-determined sets of questions were recorded for employees and signed by each witness and co-signed by either the administrator, director of nursing, and/or social worker, but these statements were not dated.) In a statement dated 01/22/10 by Employee #74 (an LPN): "This UCN (unit charge nurse) has witnessed UCN (Employee #81) allowing CNA's (certified nursing assistants), to take blood sugars, give insulin, IV (intravenous) treatment & administer meds. Also witnessed a voice recording on cellular phone of a resident having a fecal impaction removed. Resident screams, curses, and makes several other noises. When allowing CNA's to do med, witnessed CNA pry jaws of resident's mouth open shoved crushed pill in mouth & held mouth shut for approximately 15 seconds." In a separate statement (undated) signed by Employee #74 were the following handwritten responses to a pre-determined set of questions: "Yes. Ive heard her yell @ (at) residents. Ive seen her hold residents noses & pry mouths open to give medications. She goes in residents rooms and slams door and yells. Ive heard her ask residents 'What the hell do you want?' I have seen her give too much laxitives to residents. She calls this a 'Ashlanta'. It is (4 [MEDICATION NAME] - 30ccs [MEDICATION NAME] & 30 ccs MOM (milk of magnesia). I have seen her put H2O in residents when they have called out. Yes. I heard a recording on (Employee #81's first name)'s cell phone of (Resident #12) yelling & cursing while having stool digitally removed. She played this for staff while laughing. Yes. (Employee #81) gave (Employee #78) CNA insulin and had her give the injection. I don't know which resident. (Employee #81's first name) has asked CNAs to do blood sugar sticks. I seen her give (Employee #78) CNA pills to give residents. Note: Ive been scared of her ..." - In a statement dated 01/22/10 by Employee #50 (a CNA): "I have seen (Employee #81) putting (first name of Resident #12) up to singing and getting her to yell an cuss. She has also got (Resident #61) to yell an cuss. ..." In a separate statement (undated) signed by Employee #50 were the following handwritten responses to a pre-determined set of questions: "I have witnessed things I do not think is appropriate from (Employee #81's first name) such as riling them up, encouraging cussing & yelling. (First name of Resident #12) (First name of Resident #61)" - In a statement dated 01/22/10 by Employee #58 (an LPN): "This LPN has had CNA make verbal statements to me regarding (first name / last initial of Employee #81) and her inappropriate remarks made to residents. They state to me that she'll aggravated and yell at them. ... CNAs state to me that she gets some of the residents "rowled" up and laugh about it. ... Some of the CNAs have told me that they have seen her let a couple of the midnite CNAs pass some of her meds and check blood sugars for her. ... I think people are afraid to 'tattle' on her for what she will do to get back at them." - In a statement dated 01/23/10 by Employee #73 (an LPN): "I have heard a recording on a cell phone owned by (first name / last initial of Employee #81) and (first name / last initial of Employee #78) of what I believed to be (first name / last initial of Resident #12). It was the sounds made while she was being dug out from impaction. I have witnessed (first name / last initial of Employee #81) holding (first name of Resident #12)'s nose to give meds when she would not take them. I called her on it and have not seen it since. I have had others come to me and tell me that (first name / last initial of Employee #81) throw ice water in (Resident #59) face to make her be quiet. I went to look and could not prove, but pillow as wet. I witnessed (first name / last initial of Employee #81) tie up (Resident #30)'s wheel chair to a hand rail ... I heard (first name / last initial of Employee #81) got mad at (Resident #62) one night and took her to the shower turned on the cold water and held it in her face. (Resident #62) is scared of water ..." In another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: "Yes. I have seen her (Employee #81) hold a residents nose to get her to swallow. I have heard her be verbally inapprop. i.e. 'Youll get your meds when Im ready' 'Youll eat when I eat' I have heard her yell in residents room but done know what she was yelling about. Ive seen her squirt H2O on multiple residents with a syringe just because she thought it was funny. I seen her tie a resident chair to the hand rail to prevent the resident from roaming around. I have seen her give too much [MEDICATION NAME] (laxative) to residents. She calls it a 'Ashlanta' Too many pills w/ liquid [MEDICATION NAME]. She also goes into residents rooms and slams doors. She targets certain residents. I have also witnessed her not giving medication but initialing that she gave them. ... (Employee #81) is inappropriate and we have been afraid to say anything." In yet another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: "... Yes, she held a resident's nose and covered mouth until they took their medications. I have also seen her mix medications and not give them to residents. ..." - In a statement dated 01/23/10 by Employee #59 (an LPN): "I have heard an audio recording of (Resident #12) having an impaction removed. I heard from a CNA that cold water was poured on (Resident #59) one night while she was screaming. I heard that (Resident #60) was picked up and thrown into bed and hit the wall. The above was done by (Employee #81)." In a separate statement (undated) signed by Employee #59 were the following handwritten responses to a pre-determined set of questions: "...Yes. (Resident #12) - yelling while being digitally removed by LPN. (Employee #81) played this for this LPN and other staff. ..." - In a statement dated 01/23/10 by Employee #51 (an LPN): "I have heard audio of (first name of Resident #12) hollering & cursing. (First name of Employee #81) recorded when resident was impacted. Resident was upset. ..." In a separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: "... Yes, she (Employee #81) held a resident's nose to give juice to (illegible) to get sugar up. ... Yes. I saw her (Employee #81) squirt saline at a resident. ..." In yet another separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: "... - Witnessed her (Employee #81) pinching (Resident #12) nose to get her to eat, drink - (residents sugar was low) - Resident was acting out & she (Employee #81) squirted her (Resident #62) w/ (with) syringe ..." - In a statement dated 01/23/10 by Employee #76 (a CNA): "I do not witnessed or heard any miss conduct other than (first name / last initial of Employee #81) cursed in front of a resident and the resident repeated." - In a statement dated 01/23/10 by Employee #5 (a CNA): "I have only heard by another CNA that Nurses was getting a Resident upset." - In a statement dated 01/23/10 by Employee #79 (a CNA): "I am aware of no misconduct in this facility over 6 months ago. I was asked to change out oxygen parts by midnight shift." - In a statement dated 01/25/10 by Employee #75 (a CNA): "(Employee #81) has know to get people started yelling and such things as (Resident #15) in wc (wheelchair) took to showered later driving the w/c up down hallway say whooo like a cris cross pattern. Getting (Resident #12) start yelling by messing with her and recording it on cell phone. Has made residents upset at times just to hear them yell or see how they react." In a separate statement (undated) signed by Employee #75 were the following handwritten responses to a pre-determined set of questions: "I have witnessed her (Employee #81) being inappropriate. Zigzagging her (Resident #15) in wc (wheelchair) quickly down hallway. Yes - (Employee #81's first name) played audio form her phone of (Resident #12's first name) yelling & cussing (Whoo! Oh s***!). Said she taped it the other night w/ a CNA in the room while they were changing her. ..." In an undated statement signed by Employee #80 (a CNA) were the following handwritten responses to a pre-determined set of questions: "... (Employee #81) encourages (Resident #12's first name) to cuss." - In an undated statement signed by Employee #67 (a CNA) were the following handwritten responses to a pre-determined set of questions: "... It's been a couple of months ago - (Employee #81 was) aggrevating (first name of Resident #12). ... she tied a garbage bag & tied it around (first name of Resident X) & first name of Resident #12) to keep them from falling (because they kept falling). ... squirting w/ syringe - aggrevate (first name of Resident #12). ... (first name / last initial of Resident #61) & (first name / last initial of Resident #12) - mocking what they say." -- 3. Failure to Meet Reporting Requirements Although the witness statements did not identify when each of these alleged events occurred, it was evident that these events were not immediately reported after they occurred by the employees to the facility's administrator as required by this regulation. Additionally, the earliest statements containing allegations of resident abuse / neglect by Employee #81 were dated 01/22/10, but the first self-report of an allegation of abuse was not sent to the State survey agency until 01/25/10. The initial reporting of allegations of abuse / neglect against Employee #81 were not made within no more than twenty-four (24) hours after they were received by the facility as required by this regulation. Furthermore, not all of the events alleged by the employees in their witness statements were reported to the State survey agency as required by this regulation, including the following allegations: - Employee #81 pinched Resident #12's nose to get her to take medications, food, and fluids - Employee #81 poured cold water on Resident #59 to get her to quiet down - Employee #81 initialed residents' medical records to indicate medications were administered when they were not given - Employee #81 allowed unqualified non-licensed personnel to perform tasks outside of their "scope of practice", such as administer medications / treatments, perform invasive procedures (to include giving fingersticks and insulin injections), etc. - Employee #81 tied garbage bags around Resident #12 and Resident "X" to keep them from falling -- Review of minimum data set assessments (MDSs) for each of the residents identified in the employees' statements above, all with assessment reference dates (ARDs) prior to 01/22/10 (the date of the first witness statement alleging abuse of residents by Employee #81), revealed the following: - According to her 12/15/09 MDS, Resident #12, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/16/09 MDS, Resident #15, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/02/09 MDS, Resident #30, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/13/09 MDS, Resident #59, at that time, was a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE]; her [DIAGNOSES REDACTED]. - According to his 11/11/09 MDS, Resident #60, at that time, was a [AGE] year old male who was admitted to the facility on [DATE]; his [DIAGNOSES REDACTED]. - According to her 01/14/10 MDS, Resident #61, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/30/09 MDS, Resident #62, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - A review of Resident #12's medical record revealed she have a [DIAGNOSES REDACTED]. Further review of Resident #12's medical record, including nursing notes, medication administration records (MARs), and physician's orders for December 2009 and January 2010, found no physician's order to digitally remove stool from the resident's rectum (an invasive procedure which cannot be performed by an LPN without a physician's order), no nursing note entries by Employee #81 describing the resident's health status necessitating this procedure (including signs / symptoms of the presence of a fecal impaction), and no nursing note entries detailing the performance of this procedure (including the resident's response to the procedure). There was no evidence in the resident's record to indicate digital removal of stool from her rectum was either medically necessary or approved by the physician. The director of nursing and the registered nurse consultant, when interviewed on the afternoon of 06/09/11, agreed the medical record contained no documentation regarding why Employee #81 digitally removed stool from Resident #12. - Employee #81's willful act of digitally removing stool from Resident #12's rectum (causing Resident #12 physical discomfort and/or emotional distress as evidenced by her screaming / cursing during the procedure, which Employee #81 recorded on her cell phone and played for others to hear) constituted abuse. The facility reported to the State survey agency the allegation that Employee #81 audio-recorded Resident #12 screaming and cursing, but the facility failed to report that the cause of the resident's distress was an invasive procedure that was performed by Employee #81 without a physician's order and without evidence of medical necessity. (See also citation at F225.) - Employee #81 physically abused Resident #12 by performing an invasive medical procedure without a physician's order, which resulted in physical discomfort and/or emotional distress as witnessed by multiple employees who reported having heard an audio-recording on Employee #81's cellular phone of Resident #12 screaming and cursing during the procedure. Employee #81 also physically abused a number of unidentified residents by giving them a combination of laxative medications that were not ordered by a physician. Employee #81 threw or squirted water on residents (including a resident known to be afraid of water) and allowed nursing assistants to perform tasks that should not be delegated to unlicensed assistive personnel in a nursing home. Employee #81 subjected three (3) residents to involuntary seclusion by restraining them with inappropriate devices in the absence of a medical necessity. In addition, Employee #81 incited residents to yell and curse. All of the residents identified in the employees' statements had a [DIAGNOSES REDACTED]. The period of time, the extent of harm to others, and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report resulted from a failure of the facility to operationalize the abuse prohibition program outlined in the facility's policy titled "Abuse, Neglect and Misappropriation Of Resident Property: Protection of Residents / Reporting and Investigation" (effective 01/09/09). (See also citations at F225 and F226.) .