Every finding on record at Wexford House

Based on review of facility policy, medical record review, review of facility investigation and interview, the facility failed to report an allegation of abuse to the State Survey Agency for 1 resident (Resident #1) of 5 residents reviewed for abuse. The findings include: Review of the facility's undated policy titled Abuse, Neglect, and Exploitation revealed .it is the policy of this facility to provide .procedures that prohibit and prevent abuse .Abuse .includes .mental abuse including abuse facilitated or enabled through the use of technology .The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse .to the state survey agency .The facility Abuse Coordinator will be the Administrator . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Lumbar Spina Bifida, Neuromuscular Dysfunction of Bladder, and Artificial Opening of Urinary Tract, the resident discharged to a hospital on [DATE]. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's Brief Interview of Mental Status (BIMS) score was 14 indicating the resident was cognitively intact. The resident required assistance of one or more persons with activities of daily living (ADL's).Review of the facility's investigation revealed several statements dated 10/23/2025 revealed Certified Nurse Assistants (CNA's) B, C, D, and License Practical Nurse (LPN) A stated CNA E had photos of Resident #1's back/wounds on her phone, and she sent the photos to the ombudsman. A statement signed by Resident #1 revealed the resident did not give permission to CNA E to take any photos of her. Another statement signed by the Director of Nursing (DON) revealed Resident #1 stated to her .she took pictures without me knowing . Another statement by the Administrator revealed CNA E denied she had photos of the resident and .stated she did not ever use her phone in the facility . None of the statements revealed anyone saw any photos of the resident on CNA E's or any other employee's phone.During an interview on 11/12/2025 at 8:40 AM, the Administrator stated .normally I do report to the state but this one I did not . During an interview by phone on 11/13/2025 at 10:15 AM, the Ombudsman stated .I have not received any pictures, and I have not talked to CNA E or anybody else about [Resident #1] .

Based on review of facility documentation, observation, and interview, the facility failed to employ staff with the appropriate competencies to maintain and ensure manufacturers guidelines were followed for testing of chemical sanitation for dishwasher use. The findings include: Review of the facility's Dishmachine Temperature Record (Low Temperature Machine) for the month of 6/2025, revealed chlorine rinse recordings of 50 were documented each day, 6/1/2025 - 6/13/2025 for the breakfast, lunch and dinner meals. During an observation on 6/16/2025 at 10:43 AM, the Certified Dietary Manager (CDM), was observed having difficulty reading the strips. The CDM asked this surveyor how to read the strip, then asked .what is it supposed to read .? The CDM asked Dietary Aide A, to test the chemical results in the rinse cycle and instructed Dietary Aide A to place on water spots on the pan. During an observation on 6/16/2025 at 10:44 AM of the QT-10 Hydrion container guide for testing strips for the parts per million (ppm), revealed 0, 100, 200, 300 and 400 however, a reading of 50 was not revealed as a test result with the testing strips (50 was recorded on the Dishmachine Temperature Record Log). During an interview on 6/16/2025 at 10:46 AM, Dietary Aide A and the CDM were asked how results of 50 was obtained and recorded on the Dishmachine Temperature Record (Low Temperature Machine) for the month of 6/2025, related to the chlorine rinse results when 50 was not available as a result on the testing guide, there was no response from either the Dietary Aide A or CDM.

Based on facility policy review, observation, and interview, the facility failed to ensure kitchen cooking equipment was maintained in a clean and sanitary condition and food was stored, prepared, and served under sanitary conditions which had the potential to affect 80 of 81 residents. The findings include: Review of the facility's undated policy titled, Pots and Pans-Sanitizing, revealed .scrape food particles form [from] pots and pans .scrub pots and pans .rinse pots and pans free .store in proper storage area . Review of the facility's work order for ice machine maintenance revealed the ice machine was cleaned 2 times per year. During an observation of the ice machine on 6/16/2025 at 9:56 AM, revealed a black substance on the rim of a white panel above and touching the ice contained in the ice machine. During an observation of the hand washing area on 6/16/2025 at 9:58 AM, revealed no paper towels in the dispenser. During an observation and tour of the kitchen with the Certified Dietary Manager (CDM) on 6/16/2025 at 10:00 AM, revealed the following: 1. Large barrel trash can with no cover in the food preparation area 2. Large barrel trash with center opening with trash above the rim and the trash barrel touching a clean stacked storage container. 3. Large barrel trash can with no lid and overflowing with a bag of trash. 4. Ice scoop container with ice scoop and no lid. 5. Can opener blade with dried food debris. 6. Mixer stand with dried food debris. 7. Microwave oven with dried food debris on inside hood and bottom. 8. Food preparation area sink with wet cloth laying on bottom surface of sink. 9. 10 baking pans were observed nested wet. 10. 3 baking pans were observed with dried food debris. 11. Oven doors with dried food debris and grease. 12. Deep fryer with dried food crumbs and the grease was noted to be blackened. 13. (3) Serving bowls sitting upward with 1 serving bowl wet nested. 14. Dried food debris on 4 plates located in the clean dish warming rack 15. Dried food debris on the warming rack. 16. Fried food debris on 2 bowls located on serving table. 17. (3) baking pans with large amounts of dried food debris and grease. 18. Warming oven with dried food debris on door and rubber gasket. 19. (18) serving bowls with food with no dates on the lids. 20. Water pitcher stained with brown substance. 21. 7 of 8 cooking pots with dried food debris. 22. Preparation table with dried food debris. 23. 1 gallon jug of milk located in milk cooler with no lid. 24. Door of milk cooler broken with exposed Styrofoam with dried brown substance. 25. Rubber spatula with torn and jagged edges. 26. The air vent over the food preparation area and pots and pans was noted to have black, powdery debris. 27. Container of tea in reach in cooler with no date. 28. 15 glasses of milk with lids and with no date. 29. 9 serving bowls of cottage cheese with lids and no date. 30. Walk in freezer with frozen spillage on lower rack and floor of freezer. 31. (1) 4-ounce container of chocolate ice cream on freezer floor. During an observation of the kitchen on 6/17/2025 at 9:51 AM, revealed the following: 1. (1) Large barrel trash can with no lid and overflowing bag of trash. 2. (1) Large barrel trash can trash with center opening with trash overflowing the rim of the trash barrel. 3. (1) 5 pound can of whole kernel corn dented located in the dry storage area. During an observation of the ice machine on 6/18/2025 at 12:10 PM, revealed a brown/black debris substance was noted on cotton tipped applicator when applied to the black substance on rim of a white panel above that touched the ice contained in the ice machine. During an interview on 6/16/2025 at 10:02 AM, the CDM stated the staff wash their hands in the 3 compartment sink [sink designated for washing, rinsing and disinfecting pots and pans] . During an interview 6/16/2025 at 10:04 AM, Dietary Aide A stated the deep fryer, .is cleaned about every 6 months . During an interview on 6/17/2025 at 11:00 AM, the Registered Dietician stated, the dietary staff did not have a cleaning schedule for the kitchen and confirmed the kitchen was not maintained in a clean and sanitary condition. During an interview on 6/18/2025 at 12:30 PM, the Maintenance Director confirmed the ice machine was cleaned every 6 months and confirmed the last cleaning for the ice machine was 1/28/2025.

Based on facility policy review, observations, and interviews, the facility failed to ensure resident personal refrigerator logs were kept up to date and temperatures were within facility policy recommendations, and failed to ensure expired foods were not available for resident use for 5 residents (Resident #17, #39, #51, #58, and #64) of 11 resident refrigerators observe. The findings include: Review of the facility's undated policy titled, Resident Refrigerators, revealed .refrigerators are allowed in a resident's room under the following conditions: refrigerator maintains proper temperatures .facility staff shall record refrigerator temperatures daily on a temperature log .temperatures will be below 41 [degrees] [Fahrenheit] [(F)] .foods with use-by dates shall be discarded accordingly . Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Hemiplegia, Muscle Weakness, Diabetes, and Chronic Kidney Disease. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 scored 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation on 6/16/2025 at 11:20 AM, in Resident #17's room, revealed a piece of paper on the side of the refrigerator titled, Temperature Log .June 2025 .Location 209 B . The temperature log revealed no temperature recording on days 6/14/2025 and 6/15/2025 Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Cerebral Vascular Accident, Hemiplegia, and Obstructive Sleep Apnea. Review of a significant change MDS assessment dated [DATE], revealed Resident #39 scored a 15 the BIMS assessment which indicated the resident was cognitively intact. During an observation on 6/18/2025 at 9:35 AM, Resident #39's room, revealed a piece of paper on the side of the refrigerator titled, Temperature Log .June 2025 .Location 210 B . The temperature noted on 6/18/2025 was 44 degrees (F). Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Hemiplegia, Muscle Wasting, Vascular Dementia, and Epilepsy. Review of a quarterly MDS assessment for dated 4/11/2025, revealed Resident #51 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an observation on 6/16/2025 at 12:39 PM, in Resident #51's room, revealed a piece of paper on the side of the refrigerator titled, Temperature Log .June 2025 .Location 204-B . The temperature noted on 6/14/2025 and 6/15/2025 were recorded as 42 degrees (F) and the temperature noted on 6/16/2025 was recorded at 44 degrees (F). Further observation revealed a 5.3-ounce container of strawberry yogurt with an expiration date of 6/12/2025. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including Dementia, Hypertensive Heart Disease, Congestive Heart Failure, Chronic Kidney Disease, and Obstructive Sleep Apnea. Review of a significant change MDS assessment dated [DATE], revealed Resident #58 scored a 12 on the BIMS assessment which indicated moderate cognitive impairment. During an observation on 6/16/2025 at 12:40 PM, in Resident #58's room, revealed a piece of paper on the side of the refrigerator titled, Temperature Log .June 2025 .Location 204 A . The temperature noted on 6/11/2025, 6/12/2025, 6/13/2025, and 6/14/2025 was recorded as 42 degrees (F) and the temperature noted on 6/15/2025 and 6/16/2025 was recorded as 60 degrees (F). Review of the thermometer temperature inside the refrigerator revealed the temperature was 73 degrees (F). There were 2 unopened containers of cranberry juice stored in the refrigerator. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident, Hemiplegia, Muscle Weakness, and Hypertensive Chronic Kidney Disease. Review of a significant change MDS assessment dated [DATE], revealed Resident #64 scored a 10 on the BIMS assessment which indicated moderate cognitive impairment. During an observation on 6/18/2025 at 9:30 AM, in Resident #64's room, revealed a plastic container of yogurt with an expiration date of 6/10/2025. During an observation and interview on 6/18/2025 at 8:25 AM, the Director of Nursing (DON) confirmed the facility failed to ensure resident refrigerators temperatures were monitored and documented daily, failed to ensure the resident's personal refrigerators maintained a temperature below 41 degrees (F), and failed to ensure expired foods were discarded per facility policy.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to provide a homelike environment for 1 resident (Resident #19) of 81 residents reviewed for a homelike environment. The findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Hemiplegia, Dysphagia, and Intracranial injury. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 was severely impaired of cognitively skills of daily decision making. During an observation on 6/16/2025 at 11:28 AM, in Resident #19's room, revealed a large piece of wallpaper was missing from the wall beside Resident #19's bed. Further observation revealed a large area of missing paint from the wall beside the head of the resident's bed. Continued observation revealed the wallpaper was peeling away from the baseboard on the wall by the window. During an observation and interview in Resident #19's room on 6/18/2025 at 10:37 AM, the Maintenance Director stated he was not aware of the areas of missing wallpaper and paint with the area of peeling wallpaper next to the window in Resident #19's room. The Maintenance Director confirmed Resident #19's room was not consistent with a homelike environment and needed repairs.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to develop a person-centered care plan related to tobacco use for 1 resident (Resident #14) of 21 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Care Plan/ Comprehensive Assessment, dated 4/4/2025, revealed .residents will have a comprehensive assessment that determines their functional status, strengths, weaknesses, needs/ preferences .care plan must .includes .initial goals .any services and treatments to be administered . Review of the medical record revealed Resident #14 was admitted to facility on 5/9/2023 with diagnoses including Diabetes, Chronic Kidney Disease, and Hypertension. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #14 used tobacco products. Review of the Physician Encounter Visit dated 5/9/2025, revealed Resident #14 was assessed for current smokeless (chewing) tobacco use. Review of the comprehensive care plan for Resident #14 revised 6/9/2025, revealed Resident #14's current smokeless (chewing) tobacco use was not developed on the care plan. During an observation on 6/16/2025 at 11:24 AM, in Resident #14's room, revealed one can of smokeless (chewing) tobacco (opened with lid in place) stored on the bedside table with Resident #14 lying in bed. During an observation and interview on 6/17/2025 at 9:29 AM, in Resident #14's room, revealed one can of smokeless (chewing) tobacco on his bedside table. Resident #14 stated he used chewing tobacco daily. Further observation revealed Resident #14 was using the smokeless (chewing) tobacco. During an interview on 6/18/2025 at 8:57 AM, Licensed Practical Nurse (LPN) E stated Resident #14 used smokeless (chewing) tobacco daily. LPN E stated the information regarding the resident's smokeless tobacco use should be located on the resident's care plan. During an interview on 6/18/2025 at 9:34 AM, the Director of Nursing (DON) stated the use of tobacco products should be part of a person centered care plan. The DON confirmed Resident #14's smokeless (chewing) tobacco use was not developed on the comprehensive care plan.

Based on review of the facility policy, review of the facility's Narcotic (a category of perception-altering or sensory-dulling drugs that are regulated in schedules according to their abuse risk with schedule 1 being the highest abuse risk and 5 being the lowest abuse risk) Destruction Logs (form containing the name of a resident and the name of a controlled medication with the number of tablets remaining), and interview, the facility failed to follow the facility policy regarding the disposition and destruction of narcotics. The findings include: Review of the facility policy titled, Destruction of Unused Drugs, undated, revealed .The actual destruction of drugs conducted by our facility must be witnessed by the consultant pharmacist and one of the following individuals: a. An agent of the State Board of Pharmacy; b. The facility administrator; or c. The director of nursing services . Review of Narcotic Destruction Logs dated [DATE] to [DATE], revealed the Narcotic Destruction Log provided a listing of the Residents' names, medication, amount of the recorded narcotics remaining, nurses' initials, and reason for destruction, but did not include the actual destruction of the narcotics. During an interview on [DATE] at 9:58 AM, the Assistant Director of Nurses (ADON) stated the destruction of the narcotics once a resident has expired or has been discharged from the facility, were not destroyed on premises. The ADON further stated she was unaware of the facility's policy for destroying narcotics and was not aware the facility was not following the policy for the destruction of narcotics. During an interview on [DATE] at 10:15 AM, the Administrator stated the destruction of the narcotics once a resident had expired or had been discharged from the facility, were not destroyed on the facility's premises. Further interview revealed the Administrator was not aware the facility's policy and the process for the disposition and destruction of narcotics were incongruent. During an interview on [DATE] at 12:19 PM, the facility Consultant Pharmacist stated the facility, and pharmacy utilized a collection process, and the narcotics once a resident had expired or had been discharged from the facility, were processed but not destroyed on the facility's premises. Further interview revealed the Consultant Pharmacist was not aware the facility's policy and the facility's process for the disposition and destruction of narcotics were incongruent.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure proper infection control practices related to hand hygiene were followed during meal service when the staff failed to offer hand hygiene assistance to 3 residents (Resident #178, Resident #34, and Resident #16) of 10 residents observed during meal tray distribution on 1 of 4 hallways. The findings include: Review of the facility's undated policy titled, Hand Hygiene, revealed .all staff will perform proper hand hygiene procedures to prevent the spread of infection .hand hygiene is indicated and will be performed under the conditions listed in .the attached hand hygiene table .[hand hygiene table] condition .before and after eating . Review of the medical record revealed Resident #178 was admitted to the facility on [DATE] with diagnoses including Pelvis Fracture, Chronic Kidney Disease, and Anemia. Review of the comprehensive care plan for Resident #178 revised 5/26/2025, revealed .self-care deficit .assist with ADLs [activities of daily living] . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #178 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident was dependent upon staff assistance with personal hygiene. During an observation on 6/16/2025 at 12:54 PM, in Resident #178's room, revealed Certified Nursing Assistant (CNA) C brought Resident #178's meal tray into the room and placed the meal tray in front of the resident. CNA C opened the resident's silverware and the clamshell food container. Resident #178 picked up her fork and began eating the meal. Continued observation revealed CNA C failed to offer Resident #178 hand hygiene assistance prior to the resident eating the lunch meal. During an interview on 6/16/2025 at 12:56 PM, Resident #178 stated the staff did not offer hand hygiene assistance prior to the lunch meal service. During an interview on 6/16/2025 at 12:59 PM, CNA C confirmed she failed to offer hand hygiene assistance to Resident #178 prior to serving the lunch meal. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Diabetes, Anxiety, and Weakness. Review of a quarterly MDS assessment dated [DATE], revealed Resident #34 scored a 7 on the BIMS assessment which indicated severe cognitive impairment. Further review revealed the resident required substantial or maximal assistance with personal hygiene. Review of the comprehensive care plan for Resident #34 revised 4/2/2025, revealed .self care deficit .assist with ADLs as needed . During an observation on 6/16/2025 at 12:55 PM, in Resident #34's room, revealed CNA D brought Resident #34's meal tray into the room and placed the meal tray in front of her. CNA D opened the resident's silverware. Resident #34 picked up her fork and began eating the meal. Continued observation revealed CNA D failed to offer Resident #34 hand hygiene assistance prior to the resident eating the lunch meal. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Chronic Respiratory Failure, and Heart Failure. Review of a significant change MDS assessment dated [DATE], revealed Resident #16 scored a 9 on the BIMS assessment which indicated moderate cognitive impairment. Further review revealed the resident required substantial or maximal assistance with personal hygiene. Review of the comprehensive care plan for Resident #16 revised 4/30/2025, revealed .self-care deficit .assist with ADLs as needed . During an observation on 6/16/2025 at 12:59 PM, in Resident #16's room, revealed CNA D brought Resident #16's meal tray into the room and placed the meal tray in front of the resident. CNA D opened the resident's silverware. Resident #16 picked up her fork and began eating the meal. Continued observation revealed CNA D failed to offer Resident #16 hand hygiene assistance prior to the resident eating the lunch meal. During an interview on 6/16/2025 at 1:00 PM, CNA D confirmed she failed to offer hand hygiene assistance to Resident #34 and Resident #16 prior to serving the lunch meal. During an interview on 6/18/2025 at 9:35 AM, the Director of Nursing (DON) stated the staff were to offer hand hygiene assistance to all residents before meal service. The DON confirmed infection prevention and control practices were not maintained during the lunch meal service on 6/16/2025 when the staff failed to offer hand hygiene assistance to the residents prior to the lunch meal service.

Based on facility policy review, observations, and interview, the facility failed to ensure kitchen cooking equipment was maintained in a sanitary condition which had the potential to affect 82 of 86 residents. The findings include: Review of the facility's undated policy titled, Pots and Pans-Sanitizing, showed .scrape food particles form [from] pots and pans .scrub pots and pans .rinse pots and pans free .store in proper storage area . Review of the facility's undated policy titled, Sanitization of Equipment, showed .wipe up spills .using clean sanitizing solution .wash .inside and outside and front .scrub interior and exterior .door frames .hinge areas . During an observation of the clean dish storage area on 3/18/2024 at 10:15 AM, with the Food Service Manager (FSM), showed one large sheet pan with crusty, greenish-brown food debris present to outer edge of the pan. During an observation of the cooking area on 3/18/2024 at 10:25 AM, with the FSM, showed the following: -Hot food holding cabinet had dried, black, greasy food debris present around the door handle and on the bottom, outer edge of the cabinet -Plate warmer had dried, brownish-yellow residue present on the sides of the inner wells During an interview on 3/18/2024 at 10:30 AM, the FSM confirmed the kitchen equipment (large sheet pan, plate warmer, and hot food holding cabinet) had not been maintained in a sanitary condition.

Based on facility policy review, observations, and interviews, the facility failed to ensure staff maintained residents' dignity when residents were served milk products in disposable cartons for 9 residents (Residents #20, #84, #6, #18, #19, #23, #33, #43, and #85) on 3 of 5 hallways observed for meal tray distribution and failed to maintain resident's dignity during feeding for 1 resident (Resident #29) of 3 residents observed for feeding. The findings include: Review of the facility's policy titled, PATIENT/RESIDENT RIGHTS, revised on 7/14/2023, showed .All persons involved in the care of a patient/resident shall respect and support the patient/resident's right to competent, considerate, and courteous treatment or service within our capacity . Review of the facility's policy titled, Dining, revised on 12/2023, showed .The dining experience will be safe and satisfying for the resident .Seating promotes sociable, friendly dining .Residents are assisted in a dignified and timely manner . Review of the facility's undated policy titled, RESIDENT RIGHTS -Dignity Policy & Procedures, showed .ensure resident has the right to a dignified existence and to communicate with individuals and representatives of choice. The facility will protect and promote resident rights and dignity as designated below .Dignity .The facility will treat Resident with dignity and respect in full recognition of Resident individuality in a dignified existence that promotes quality of life . Resident #20 was admitted to the facility on [DATE] with diagnoses including Anemia, Early Onset Alzheimer's Dementia, and Encephalomalacia (softening or loss of brain tissue). Review of Resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact. Review of Resident #20's medical record showed no evidence the resident had requested to receive his milk products in disposable milk cartons. During an observation on 3/18/2024 at 11:44 AM, Certified Nursing Assistant (CNA) #1 delivered the lunch meal tray to Resident #20. The lunch tray contained a chocolate mighty shake (milk based nutritional shake) in a disposable carton. CNA #1 set up the resident's tray and opened the mighty shake for the resident and exited the room without offering the resident a glass for the mighty shake. During an interview on 3/18/2024 at 11:46 AM, this surveyor asked CNA #1 if Resident #20 had requested to receive his mighty shake in the disposable carton and CNA #1 stated .No .we always serve them [mighty shakes] and milk in cartons . The CNA confirmed Resident #20 had not been offered a glass for his mighty shake. During an interview on 3/18/2024 at 11:48 AM, Resident #20 stated he had not requested to receive his mighty shake in a disposable carton and had not been offered a glass for the shake. Resident #20 shrugged his shoulders and did not verbally answer when asked if he minded drinking his mighty shake from the disposable carton. Resident #84 was admitted to the facility on [DATE] with diagnoses including Expressive Aphasia, Anxiety Disorder, and Hemiparesis Affecting the Right Side. Review of Resident #84's quarterly MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. Review of Resident #84's medical record showed no evidence the resident had requested to receive milk products in disposable milk cartons. During an observation on 3/18/2024 at 11:49 AM, Resident #84 was seated in a wheelchair beside her bed eating her lunch tray. Resident #84 was drinking the milk from her tray from a disposable milk carton. The resident stated she had not been offered a glass for her milk carton and had not requested to have her milk products served in a disposable carton. Resident #84 stated milk was always served to her in the disposable carton. Resident #84 stated .it doesn't matter to me if it's in a glass or a carton . Resident #6 was admitted to the facility on [DATE] with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction. Review of Resident #6's quarterly MDS assessment dated [DATE], showed the resident was cognitvely intact. Review of Resident #6's medical record showed no evidence the resident had requested to receive milk or shake products in disposable cartons. During an observation and interview on 3/18/2024 at 11:54 AM, Resident #6 was observed eating independently from the lunch tray that contained a carton of milk and a mighty shake in disposable cartons. The resident stated he had not requested for either the milk or the shake to be served in a disposable carton and was not offered a glass. Resident # 18 was admitted to the facility on [DATE] with a diagnosis of Pulmonary Fibrosis. Review of a Resident #18's quarterly MDS assessment dated [DATE], showed the resident was was moderately cognitively impaired. Review of Resident #18's medical record showed no evidence the resident had requested to receive milk products in disposable milk cartons. During an observation and interview with CNA #2 on 3/18/2024 at 4:52 PM, in Resident #18's room, showed the resident was served the dinner meal tray that included a carton of milk in a disposable carton. CNA #2 stated Resident #18's milk was served in a disposable carton because that was how the kitchen sent it to the floor to be served. CNA #2 confirmed Resident #18 had not been offered a glass for the milk. During an interview on 3/18/2024 at 4:54 PM, Resident #18 stated she had not requested for her milk to be served in a disposable carton and was not offered a glass. The resident also stated the disposable carton did not upset her. Resident #19 was admitted to the facility on [DATE] with a diagnosis of Congestive Heart Failure. Review of Resident #19's quarterly MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident #19's medical record showed no evidence the resident had requested to receive milk products in disposable milk cartons. During an observation and interview on 3/18/2024 at 12:01 PM, Resident #19 was observed eating lunch independently with a disposable carton of milk on her tray. The resident stated she had not requested for her milk to be served in a disposable carton, but the carton did not bother her. During an interview on 3/18/2024 at 12:20 PM, CNA #1 stated residents were always served milk in disposable milk cartons. Resident #23 was admitted to the facility on [DATE] with diagnoses including History of Cerebrovascular Accident (CVA or stroke) and Major Depression. Review of Resident #23's quarterly MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident #23's medical record showed no evidence the resident had requested to receive milk products in disposable milk cartons. During an observation and interview on 3/18/2024 at 4:48 PM, Resident #23 was served her dinner with milk in a disposable carton. The resident stated she had not requested for her milk to be served in a disposable carton and had not been offered a glass. She stated the carton did not bother her. Resident #33 was admitted to the facility on [DATE] with diagnoses including Coronary Artery Disease and Type 2 Diabetes Mellitus. Review of Resident #33's significant change MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident #33's medical record showed no evidence the resident had requested to receive milk products in disposable milk cartons. During an observation and interview on 3/18/2024 at 12:01 PM, Resident #33 was observed drinking out of a disposable milk carton. The resident stated they usually deliver her meal with the disposable milk carton, but she had not requested for milk to be delivered in the disposable carton and had not been offered a glass from which to drink. The resident stated the carton did not bother her. Resident #43 was admitted to the facility on [DATE] with a diagnosis of Chronic Anoxic Encephalopathy (disease affecting brain brain function caused by lack of oxygen). Review of a Resident #43's annual MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident #43's medical record showed no evidence the resident had requested to receive milk products in disposable milk cartons. During an observation and interview on 3/18/2024 at 11:54 AM, Resident #43 was observed eating lunch with milk in a disposable carton. The resident stated he had not requested to receive his milk in a disposable carton and had not been offered a glass. During an observation on 3/18/2024 at 5:02 PM, Resident #43 was observed with milk on his dinner tray in a disposable carton. Resident #85 was admitted to the facility on [DATE] with diagnoses including Generalized Anxiety Disorder and History of CVA. Review of Resident #85's quarterly MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident #85's medical record showed no evidence the resident had requested to receive milk products in disposable milk cartons. During an observation and interview on 3/18/2024 at 4:57 PM, Resident #85 was observed drinking milk out of a disposable milk carton. The resident stated she had not requested for her milk to be served out of the disposable carton and had not been offered a glass. Resident #85 stated the disposable carton did not bother her. Resident #29 was admitted to the facility on [DATE] with diagnoses including Seizure Disorder, Essential Hypertension and Traumatic Brain Injury. Review of Resident #29's care plan dated 7/22/2022 showed the resident had a self care deficit related to weakness with an intervention to provide feeding assistance. Review of Resident #29's quarterly MDS assessment dated [DATE], showed the resident had severe cognitive impairment. The resident had upper and lower extremity impairment on both sides. The resident was totally dependent on staff for eating. During an observation and interview on 3/18/2024 at 12:15 PM, CNA #3 was feeding Resident #29 by standing over him beside the bed. CNA #3 stated she stood over the resident to feed him because .It works better for me this way . During an interview on 3/19/2024 at 5:00 PM, the Administrator stated milk and mighty shakes were served to residents in milk cartons, and glasses would be provided upon resident request. The Administrator stated she was unaware of the regulations related to providing residents with non-disposable cutlery and dishware including cups and glasses. The Administrator confirmed it was her expectation that residents that required feeding assistance from staff were to be fed with the staff member seated and at eye level to the resident being fed. During an interview on 3/19/2024 at 5:05 PM, the Evening Dietary Supervisor stated milk and mighty shakes were sent to residents in disposable cartons, and glasses were not sent on the trays unless requested by the resident. During an interview on 3/19/2024 at 5:22 PM, the Director of Nursing (DON) confirmed .it is our normal procedure to serve milk and mighty shakes in cartons . The DON stated the resident would be provided a glass if they requested one. The DON was unaware of the regulations related to providing residents with non-disposable cutlery and dishware including cups and glasses. The DON confirmed staff feeding residents should be seated while feeding the resident. During an interview on 3/20/2024 at 1:18 PM, with the Dietary Clinical Manager and the Registered Dietician, the Dietary Clinical Manager stated she had worked at the facility for [AGE] years and confirmed milk products had always been served in cartons and stated .we have always done it that way . The Dietary Clinical Manager and the Registered Dietician confirmed glasses were only provided for residents for milk and mighty shakes if requested by the resident. The Dietary Clinical Manager and Registered Dietician confirmed that milk cartons were considered disposable containers. The Dietary Clinical Manager and Registered Dietician confirmed it was their expectation that long term care regulations were followed and were unaware of the regulations related to providing residents with non-disposable cutlery and dishware including cups and glasses. During an interview on 3/20/2024 at 4:56 PM, the Director of Nursing confirmed there was no evidence in the medical record that Residents #20, #84, #6, #18, #19, #23, #33, #43, and #85 had requested to receive their milk or mighty shake in the disposable cartons.

Based on facility policy review, review of the Resident Assessment Instrument (RAI) Manual 3.0, medical record review, observations, and interviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 residents (Residents #78 and #56) of 20 residents reviewed for MDS assessments. The findings include: Review of the RAI Manual 3.0 dated 10/1/2023 showed . primary purpose as an assessment instrument is to identify resident care problems that are addressed in an individualized care plan .the assessment [MDS] accurately reflects the resident's status .registered nurse conducts or coordinates each assessment .One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status .Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, mood or behavior status, medical treatments, nursing monitoring .during the 7-day look-back period .Check the following information sources in the medical record for the last 7 days to identify 'active' diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports . Resident #78 was admitted to the facility on [DATE] with diagnoses including Amyotrophic Lateral Sclerosis (ALS) (nervous system disease that impacts physical functioning), Quadriplegia, and Adjustment Disorder. Review of a General History and Physical note dated 12/12/2023, showed .[Resident #78] communicates w/ [with] eye movement computer .patient active problem list .Quadriplegia . Review of Resident #78's admission MDS dated [DATE], showed the resident was cognitively intact, had impairment to the upper and lower extremities, and was dependent upon staff assistance with personal hygiene, dressing, transfers, and bed mobility. Continued review showed Quadriplegia was not listed as an active diagnosis. Review of Resident #78's comprehensive care plan dated 2/29/2024, showed .risk for limitations in ROM [range of motion] r/t [related to] .quadriplegia . During an observation and interview on 3/18/2024 at 11:25 AM, Resident #78 was seated upright in a specialized wheelchair and could not move her neck or upper and lower extremities. Resident #78 stated via communication device she could not move her neck or extremities without staff assistance. During an interview on 3/20/2024 at 5:01 PM, the Director of Nursing confirmed the admission MDS assessment for Resident #78 was not accurate and did not reflect the resident's active diagnosis of Quadriplegia upon admission. 41782 Resident #56 was admitted to the facility on [DATE] with diagnoses including Adult Failure to Thrive, Hypothyroidism, Alzheimer's Dementia, and Major Depressive Disorder. Review of Resident #56's physician's orders dated 8/1/2022, showed an order for Levothyroxine (medication to treat hypothyroidism) 75 micrograms (mcg) by mouth daily before breakfast. Review of Resident #56's comprehensive care plan dated 9/21/2022, showed .Risk for complications r/t [related to] .Hypothyroidism . Review of the Medication Administration Record (MAR) dated 1/1/2024 - 1/31/2024, showed Resident #56 received Levothyroxine daily. Review of Resident #56's quarterly MDS assessment dated [DATE], showed the resident had severe cognitive impairement. Continued review showed Hypothyroidism was not listed as an active diagnosis. During an interview on 3/20/2024 at 4:07 PM, the MDS Coordinator stated she reviewed physician and nurse practitioner progress notes and medication orders to determine active diagnoses to code on the resident MDS assessments. The MDS Coordinator confirmed Resident #56 had received the medication of Levothyroxine daily during the 7 day look back period prior to the 1/5/2024 quarterly MDS assessment. The MDS Coordinator confirmed Resident #56's quarterly MDS assessment was coded incorrectly and did not include the active diagnosis of Hypothyroidism.

Based on facility policy review, medical record review, and interviews, the facility failed to include 1 resident (Resident #31) in the care planning process of 20 residents reviewed for care planning. The findings include: Review of the facility's policy titled, Interdisciplinary Care Conference Guidelines, dated 2/2024, showed .Interdisciplinary Care Conference is held to develop/review the plan of care based upon the comprehensive assessment .includes .Resident and family concerns .Care Conference .may be held whenever the team feels it is necessary to review the plan of care .the following should have representation at the meeting .resident .is informed and invitations are sent to resident .as appropriate prior to the conference date . Social Services documents the attempt to include or set up meeting in the resident's record .Social Services will schedule .care conference . Resident #31 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Arthritis, and Diabetes Mellitus. Review of a letter dated 1/24/2024 showed Resident #31's representative was sent a letter inviting him to a care plan meeting, but he did not attend. Review of a quarterly care plan review dated 2/2/2024, showed Resident #31 was not a participant of the meeting. Those attending the meeting were representatives from dietary, nursing, social services, and activities. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #31 was cognitively intact and required substantial assistance with showers and upper body dressing. During an interview on 3/18/2024 at 3:09 PM, Resident #31stated she had not received invitations to the quarterly care plan meetings and stated she did not remember anyone providing her a copy of the latest care plan. During an interview on 3/19/2024 at 9:27 AM, the Social Services Director (SSD) stated she set up meetings for the quarterly review of the plans of care. The SSD stated if the resident wanted to attend, and were cognitively intact, they were invited to all the care plan meetings. The SSD stated the meetings could be held on a phone conference or in the resident's room, if that was what was convenient for the resident or the resident's representative. She stated a letter was sent to the son, who was the POA, but he had not responded. The SSD stated she had no documentation to show Resident #31 did not want to participate in the care plan meetings. When asked why the resident, who was cognitively intact, was not asked to join, the SSD stated I don't know. I can see that we are missing that on her. We should've [invited the resident], it just got missed. The SSD confirmed the resident had never received an invitation to or attended the quarterly care plan meetings and had not received a copy of the care plan from the last quarterly meeting. During an interview on 3/20/2024 at 4:01 PM, the Director of Nursing (DON) stated it was her expectation that a resident who was cognitively intact would receive an invitation to the quarterly care plan meetings, and Resident #31 should be involved in her care plan meetings.

Based on facility policy review, observation, and interview, the facility failed to ensure expired supplies were not available for resident use in 1 medication cart (300 long hall cart) of 3 medication carts observed. The findings include: Review of the facility's policy titled Storage of Medical Supplies and Medication, dated ,d+[DATE], showed . No discontinued, outdated, or deteriorated medical supplies/medications are available for use in the facility. All such .and medical supplies disposed of in accordance to federal, state regulations, and facility policies as well as manufacturer's guidelines. During an observation and interview of the 300 long hall medication cart on [DATE] at 7:55 AM, with Licensed Practical Nurse (LPN) #1, showed 1 package of two cotton swabs expired [DATE], 1 speimen collection swab kit expired [DATE], 3 vacuum blood draw vials expired [DATE], and 1 blood draw vial expired [DATE] were observed in a cardboard box in the drawer of the medication cart. LPN #1 stated .I don't know why those (referring to the vials and cotton swabs) are in there. We have a blood draw kit in the med [medication] room that has everything we need in it . LPN #1 also stated the protocol was to remove expired supplies and medications from the cart and notify the supervisor about the expired supplies. During an interview on [DATE] 08:47 AM, the Director of Nursing (DON) confirmed the blood draw vials and the cotton swabs for lab tests were expired and should not be on the medication cart.

Based on facility policy review, observations, and interviews, the facility failed to ensure garbage and refuse were properly contained in 2 of 2 dumpsters (dumpster #1 and #2). The findings include: Review of the facility's undated policy titled, Garbage and Trash Cans, showed .waste must be placed in covered garbage and trash cans . Review of the facility's policy titled, Home-like Environment, dated 12/2023, showed .refuse containers provided for an area shall have tight-fitting covers . During an observation on 3/18/2024 at 10:35 AM, of the outside dumpster area, with the Food Service Manager (FSM), showed 2 dumpsters were present for waste disposal. The hard, plastic roof covering dumpster #1 was open and dumpster #2's sliding door on the right side of the dumpster was open. Dumpster #1 and #2's contents were open to air, elements, and had the potential exposure to pests. During an interview on 3/18/2024 at 10:40 AM, the FSM stated the dumpster #1's roof and dumpster #2's sliding door should have been tightly closed to prevent the exposure to elements and potential rodents. Further interview showed the FSM confirmed the dumpster contents for dumpsters #1 and #2 were not contained properly.

Based on review of facility policy, medical record review, review of facility investigation and interview the facility failed to ensure an allegation of abuse was reported timely to the State Survey agency for 2 residents (Resident #1 and Resident #3) of 6 residents reviewed for abuse. The findings include: Review of the facility's Policy titled, Abuse Reporting and Investigation undated showed .alleged abuse including mental, physical, verbal .(Administrator, Director of Nursing or designee) shall report to the State Agency .no later than twenty-four (24) hours if the events that cause suspicion do not result in serious bodily injury .The Department of Health will be notified of the alleged event . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 15 indicating the resident was cognitively intact. The resident required assistance of one or more persons with activities of daily living (ADL's). Review of the medical record showed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] showed Resident #3 was severely cognitively impaired and required assistance of one or more persons with ADL's. Review of facility investigation revealed the facility was notified of allegations of abuse which were reported the facility on 4/13/22 by a nursing instructor. Review revealed an investigation was iniated upon notification and the allegations were found to be unsubstantiated. During an interview on 4/26/2022 at 11:15 AM, the Director of Nursing (DON) stated .an instructor [nursing instructor] .came and asked to speak with me on April 13th [4/13/2022] .she did tell me that she had a complaint .she said it was the week before when the students were on the 1 and 200 hall .I talked to the nursing students to get names .they [nursing students] said [Resident #1] was the resident that was put back to bed and bounced and they [Certified Nurse Assistant (CNA) #1 and CNA #3] were rough when they changed him .then they told me there was an incident with a resident who had used her brief and that [CNA #1 and CNA #3] were saying things like this is disgusting you smell bad what did you eat .they said that was [Resident #3] .we did not contact the Department of Health [State Survey Agency] . Interview confirmed the facility had failed to notify the State Survey Agency of the allegations of abuse timely.

Based on facility policy review, medical record review, observation, and interview, the facility failed to prevent the occurrence of verbal abuse to 1 resident (#1) of 4 residents reviewed for abuse. The findings include: Review of the policy titled, Abuse Protection revised 1/2020, showed .The resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone, including but not limited to, facility staff .Abuse .includes verbal abuse .Verbal abuse is defined as the use of oral .disparaging and derogatory terms to residents .regardless of their age, ability to comprehend, or disability .Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation .Includes .insulting, or ridiculing a resident .The facility is committed to protecting our resident from abuse by anyone including .facility staff . Review of the policy titled, Abuse Reporting and Investigation revised 1/2020, showed .This facility will thoroughly investigate all reports of suspected or alleged abuse including mental .verbal .To ensure prompt enforcement of employee disciplinary procedures in the case of alleged or suspected abuse .The following will apply to both alleged and suspected abuse .Anyone who witnesses and incident of suspected resident abuse of any type .is to intervene immediately .If an employee is involved in the suspected violation, the employee will be immediately removed from duty . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #1 scored a 14 on the Brief Interview for Mental Status (BIMS) Assessment which indicated the resident was cognitively intact. The MDS showed Resident #1 required extensive 2 staff assistance for bed mobility and toileting, required extensive 1 staff assistance for dressing and hygiene, and was totally dependent on 2 staff for transfers with the use of a mechanical lift. The MDS showed the resident received antipsychotic and antidepressant medications and received hospice services. Review of the current comprehensive care plan showed Resident #1 was admitted to hospice services due to [MEDICAL CONDITION]. Resident #1 was dependent on staff for activities, cognitive stimulation, and social interaction. The care plan showed Resident #1 was incontinent of bowel and bladder and required staff assistance with incontinence care. Review of a handwritten statement dated 5/24/2020 by CNA #2 showed .I (CNA #2) went into .(Resident #1's room) .I asked .if she was wet .Resident (#1) stated 'that was a dumb question' .(CNA #1) said you don't have to be a (expletive). Resident said wait til tomorrow and I will report you. (CNA #1) then said the next time you can wipe your own (expletive) . Review of an emailed documentation from Licensed Practical Nurse (LPN) #1 to the Director of Nursing (DON) dated 5/26/2020, showed .May 24th I (LPN #1) was on 100 hall on the med (medication) cart, when I heard a loud voice coming from (Resident #1's room) .I can't remember word for word however the CNA (CNA #1) was saying 'you don't have to be a damn (expletive)' that was said a couple of times, then I heard 'you can wipe your own damn (expletive)'. I went to the room and asked what was going on and if they were cutting up, CNA #1 said 'no!' I then told her (CNA #1) she could not talk to the residents like that she went on to say the resident shouldn't talk to them like that I asked what did the resident say she stated that they asked her if she was wet and resident said that's a dumb (question). I then went to the (Registered Nurse) RN supervisor. When I went into the room to give the medicine to resident (Resident #1) she said she wanted to talk with supervisor, that she was talked to terribly (by CNA #1) . Review of an emailed documentation from the Social Services Manager to the DON dated 5/26/2020, showed .(Resident #1) reported to me (Social Services Manager) that on Sunday night (5/24) (5/24/2020) (CNA #2) and another CNA .came into her room to change her. They asked her if she was wet. She (Resident #1) said she proceeded to answer in a joke .and (CNA #2) laughed. The other CNA responded with 'you don't have to be so smart about it' in a loud and rude voice .(Resident #1) felt like .(CNA #1's) behavior toward her was abuse .(Resident #1) reports that after she asked .(CNA #1) .to leave the room the CNA continued to keep 'running her mouth' (to Resident #1) .until she finally left . Review of handwritten documentation dated 5/26/20, regarding the incident on 5/24/2020 with Resident #1, by CNA #1 confirmed .I felt like I verbal (verbally) abuse (abused) the resident (Resident #1) . Review of CNA #1's employee record showed the CNA was terminated from employment with the facility on 5/26/2020. Review of a facility investigation dated 5/27/2020, showed 2 Certified Nurse Assistants (CNA) entered Resident #1's room on 5/24/2020 to provide incontinence care. One of the CNA's asked the resident if she was wet and the resident replied, that was a dumb question to answer. LPN #1 reported she overheard CNA #1 tell the resident you don't have to be a damn smart (expletive) .you can wipe you own damn (expletive) . CNA #2 also reported this was said to Resident #1. Review of the investigation showed a written statement by CNA #1 dated 5/26/2020 which stated .went into room .for a dry round .she (CNA #2) had asked (Resident #1) .if they needed changed. Resident #1 stated that was a stupid question you will get a stupid answer. (CNA #1) turned around and said not to be smart .then (LPN #1) came in and asked .what happen .she (LPN #1) told me not to say anymore because I (CNA #1) can get into trouble .I (CNA #1) felt like I verbal abuse the resident (Resident #1) . During an observation and interview on 9/14/2020 at 2:18 PM, Resident #1 was lying in bed watching TV. Resident #1 stated .a little girl that is real hateful every time she comes in here, it's her tone of voice specifically .one night she told me 'you are going to have to start doing for yourself' and was real mean and hateful . Resident #1 stated she could not remember the date but it had occurred at night.She is just real hateful and that way all the time .I don't think she works here anymore, it seems like they might have got rid of her . Resident #1 stated .I just dreaded the thoughts of her coming in here . During an interview on 9/15/2020 at 2:04 PM, CNA #2 stated on 5/24/2020 around 7:00-8:00 PM, she went into Resident #1's room to put the blinds down and asked Resident #1 if she was wet or needed to be changed. Resident #1 replied, 'I am always wet and I always need to be changed' CNA #1 turned to Resident #1 and stated, you can wipe your own damn (expletive) the next time. CNA #2 stated, CNA #1 and Resident #1 continued to have words back and forth but could not remember exactly what else was said.I was kind of shocked that she (CNA #1) said that . CNA #2 stated LPN #1 walked into Resident #1's room and intervened. CNA #2 stated LPN #1 began talking to CNA #1 and she (CNA #2) left the room. CNA #2 stated LPN #1 reported the incident to the RN supervisor on duty. During a telephone interview on 9/15/2020 at 2:53 PM, LPN #1 stated on 5/24/2020 around 8:00 PM, .I was on the med (medication) cart passing out meds (medications) and I heard somebody say something like, we take care of you, we change you everyday .I don't have to come in here and listen to this .What got me .it was harsh and it was wrong .she (CNA #1) said you can wipe your own (expletive) from now on, she was being ugly . LPN #1 stated, she removed CNA #1 from Resident #1's room and told her not to go back in the room and she could be fired for talking to a resident like that . LPN #1 stated she told CNA #1 .you can't talk to resident's like that it's their home .(CNA #1) said well she's not going to talk to me that way .if they (the facility administration) fires me, it will be their loss . LPN #1 stated she advised the RN supervisor of the situation. LPN #1 stated when she went into Resident #1's room to administer her medicine, Resident #1 complained of being talked to so bad and was upset about the situation. LPN #1 stated she had overheard CNA #1 be rude and hateful to other staff but never to a resident until that night. During a telephone interview on 9/15/2020 at 3:09 PM, RN #1 stated on 5/24/2020, LPN #1 advised her about CNA #1 .getting rude to a resident (Resident #1) . RN #1 stated, LPN #1 advised her she had been standing outside Resident #1's door and overheard a conversation between CNA #1 and Resident #1 .I do believe she (CNA #1) called her a smart (expletive) .got smart or hateful with her .I can't remember all the details .I and (LPN #1) called the DON . and advised her of the incident. RN #1 stated she talked with CNA #1 and asked what happened with Resident #1 and if she had said the things that were overheard by LPN #1 .at first she said no and then she said there was no point in lying and then admitted to it . RN #1 stated she asked CNA #1 to leave the facility and walked her to the time clock. During an interview on 9/15/2020 at 3:27 PM, the DON stated she had received a call on 5/24/2020 from LPN #1 who advised CNA #1 had been verbally abusive to Resident #1. The DON stated she had the RN Supervisor ask CNA #1 to leave the facility and not to return to work until the investigation had been completed. The DON stated she and the Administrator spoke to CNA #1 on 5/26/2020. The DON stated, CNA #1 wrote a statement which admitted to being verbally abusive to Resident #1. The DON stated CNA #1 did not return to work after the incident and confirmed CNA #1 was terminated from employment on 5/26/2020.

Based on facility policy review, facility documentation review, medical record review, and interview, the facility failed to notify the state survey agency in the required timeframe after an allegation of verbal abuse of 1 resident (#1) of 4 residents reviewed for abuse. The findings include: Review of the policy titled, Abuse Protection revised 1/2020, showed .The resident has the right to be free from abuse .Residents must not be subjected to abuse by anyone, including but not limited to, facility staff .Abuse .includes verbal abuse .Verbal abuse is defined as the use of oral .disparaging and derogatory terms to residents .Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation .Includes .insulting, or ridiculing a resident . Review of the policy titled, Abuse Reporting and Investigation revised 1/2020, showed .The facility .shall report to the State Agency .any reasonable suspicion of a crime against any .resident .shall report .no later than twenty-four (24) hours if the events that cause suspicion do not result in serious bodily injury .The Department of Health will be notified of the alleged event .Notification will include the nature of the allegation, name of the resident and the individual implicated .If there is no serious bodily injury, then a report must be filed within twenty-four (24) hours of the event . Review of the medical record showed, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #1 scored a 14 on the Brief Interview for Mental Status (BIMS) Assessment which indicated the resident was cognitively intact. The MDS showed Resident #1 required extensive 2 staff assistance for bed mobility and toileting, required extensive 1 staff assistance for dressing and hygiene, and was totally dependent on 2 staff for transfers with the use of a mechanical lift. Review of the current comprehensive care plan dated 8/4/2020, showed Resident #1 was admitted to hospice services due to [MEDICAL CONDITION]. Resident #1 was incontinent of bowel and bladder and required staff assistance with incontinence care. During an observation and interview on 9/14/2020 at 2:18 PM, Resident #1 was lying in bed watching TV. Resident #1 stated .a little girl that is real hateful every time she comes in here, it's her tone of voice specifically .one night she told me 'you are going to have to start doing for yourself' and was real mean and hateful . Resident #1 stated she could not remember the date but it had occurred at night. Review of a facility investigation dated 5/27/2020, with the date of occurrence 5/24/2020, showed 2 Certified Nurse Assistants (CNAs) entered Resident #1's room to provide incontinence care. One of the CNA's asked the resident if she was wet and the resident replied, that was a dumb question to answer. LPN #1 reported she overheard CNA #1 tell the resident you don't have to be a damn smart (expletive) .you can wipe you own damn (expletive) . Continued review showed a written statement by CNA #1 dated 5/26/2020 .I (CNA #1) felt like I verbal (verbally) abuse (abused) the resident (Resident #1) . Review of the investigation revealed the allegation of abuse was not reported to the State Survey Agency until 5/27/20 (3 days after the incident). Review of a handwritten statement dated 5/24/2020 by CNA #2 showed .(CNA #1) said you don't have to be a smart (expletive) .(CNA #1) then said the next time you can wipe your own (expletive) . Review of an emailed documentation from LPN #1 to the DON dated 5/26/2020, showed .On the May 24th I (LPN #1) .heard a loud voice coming from (Resident #1's room) .(CNA #1) was saying 'you don't have to be a damn smartass' that was said a couple of times, then I heard 'you can wipe your own damn ass' .I then went to the RN (Registered Nurse) supervisor . Review of an emailed documentation from the Social Services Manager to the DON dated 5/26/2020, showed .(Resident #1) reported to me (Social Services Manager) that on Sunday night (5/24) (5/24/2020) .(CNA #1) .behavior toward her was abuse . During an interview on 9/15/2020 at 2:04 PM, CNA #2 stated on 5/24/2020 around 7:00-8:00 PM, she went into Resident #1's room and asked her if she was wet or needed to be changed. Resident #1 replied, I am always wet and I always need to be changed CNA #1 turned to Resident #1 and stated, you can wipe your own damn (expletive) the next time. During a telephone interview on 9/15/2020 at 2:53 PM, LPN #1 stated on 5/24/2020 around 8:00 PM, .I heard .I don't have to come in here and listen to this .it was harsh and it was wrong .she (CNA #1) said you can wipe your own (expletive) from now on, she was being ugly . LPN #1 stated she advised the RN supervisor of the situation. During a telephone interview on 9/15/2020 at 3:09 PM, RN #1 stated on 5/24/2020, LPN #1 advised her about CNA #1 .getting rude to a resident (Resident #1) . RN #1 stated, LPN #1 advised her she had overheard a conversation between CNA #1 and Resident #1 .I do believe she (CNA #1) called her a smart (expletive) .got smart or hateful with her .I and (LPN #1) called the DON . and advised her of the verbal abuse incident. Review of handwritten documentation, regarding the incident on 5/24/2020 with Resident #1, dated 5/26/2020 by CNA #1 stated .I felt like I verbal (verbally) abuse (abused) the resident (Resident #1) . During an interview on 9/15/2020 at 3:27 PM, the DON stated she had received a call on 5/24/2020 from LPN #1 who advised CNA #1 had been verbally abusive to Resident #1. The DON stated, CNA #1 wrote a statement which admitted she was verbally abusive to Resident #1. During a telephone interview on 9/16/2020 at 1:15 PM, the DON confirmed the verbal abuse which occurred on 5/24/2020 was not reported to the state survey agency until 5/27/2020.

Based on facility policy review, record review, observation, and interview, the facility failed to identify and assess restraint use for 3 of 6 residents (Resident #5, #77, and #115) reviewed for restraints. The findings include: Review of the facility policy titled, Restraints, dated 10/2019, showed .Physical restraints include, but are not limited to .soft ties . the resident cannot remove easily .Using side rails that keep a resident from voluntarily getting out of bed .Using devices in conjunction with a chair, .belts, that the resident cannot remove easily, that prevent the resident from rising .Restraint use will be assessed by the interdisciplinary team at least quarterly for elimination, reduction or continued need based on resident's condition . Review of the medical record, showed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician's orders dated 2/1/2020-2/29/2020 showed .soft belt to be used . Review of the medical record showed no documentation a quarterly restraint assessment had been completed for Resident #5. Observation of Resident #5 on 2/18/2020 at 11:08 AM, showed the resident in the hall, in a wheelchair with a front fastening seat belt in use. Review of the medical record, showed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician's orders dated 2/1/2020-2/29/2020 showed .3/4 SR (side rail) to aid with positioning and mobility . Review of the medical record showed no documentation a quarterly restraint assessment had been completed for Resident #77. Observation of Resident #77 on 2/20/2020 at 9:44 AM and 11:30 AM, showed the resident lying in bed with 2 of the 3/4 side rails in the up position. Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician's order dated 2/1/2020 - 2/29/2020 showed .soft belt while up in high back WC (wheelchair) .and 3/4 side rails pad side rails . Review of the medical record showed no documentation a quarterly restraint assessment had not been completed for Resident #115. Observation of Resident #115 on 2/18/2020 at 10:17 AM, showed resident seated in a high back wheelchair, in the hallway, with a soft belt in use fastened in the back of the chair. Interview with the Director of Nursing (DON) on 2/20/2020 at 12:57 PM, the DON stated she did not consider a soft seat belts or side rails as restraints if the resident was non-ambulatory. If a resident who is non-ambulatory it becomes a safety device and no longer a restraint.

Based on facility policy review, medical record review, observation, and interview, the facility failed to properly assess 1 resident (#60) for self-administration of medications of 45 residents sampled. The findings include: Review of facility policy Self-Administration of Medication, revised 5/2018, revealed .Storage of medications in the resident's room must be such that it will prevent access by other residents .Only the medications permitted for self-administration shall be left at the bedside . Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Medical record review of the physician's recapitulation orders dated 2/1/19-2/28/19 revealed no documentation of an order for [REDACTED]. Observation of Resident #60 on 2/4/19 at 10:40 AM, in the resident's room, revealed a bottle of over the counter eye drops and a bottle of over the counter saline nasal spray on the resident's over bed table. Observation of Resident #60 on 2/5/19 at 8:13 AM, in the resident's room, revealed the bottle of eye drops and the bottle of saline nasal spray remained on the resident's over bed table. Observation and interview of Resident #60 on 2/5/19 at 2:02 PM, in the resident's room, revealed the bottle of eye drops and the bottle of saline nasal spray remained on the resident's over bed table. Interview revealed .I buy those . Interview and interview with Licensed Practical Nurse (LPN) #1 on 2/5/19 at 2:20 PM, at the nurse's station, revealed the bottle of eye drops and the saline nasal spray were on the resident's over bed table. Interview confirmed Resident #60 was not assessed for self-administration of medications or assessed to keep medications at the resident's bedside. Interview with the Director of Nursing (DON) on 2/5/19 at 2:45 PM, in the DON's office, confirmed the facility failed to assess Resident #60 for self-administration of medications.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure respiratory equipment was maintained for 2 residents (#19 and #90) of 14 residents reviewed for respiratory therapy of 45 sampled residents. The findings include: Review of facility policy Equipment Change-Out, revised 7/2017, revealed .The following list of equipment is handled as follows: Changed weekly .Cannula .Humidifier . Medical record review revealed Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Continued review revealed the resident received oxygen (O2) therapy. Medical record review of the Physician Standing Orders dated 2/2/19 revealed .Change O2 .tubing weekly and PRN (as needed) . Observation of Resident #19 on 2/4/19 at 10:24 AM, in the resident's room, revealed the resident was receiving O2 at 2 liters per minute (2l/m) by nasal cannula (BNC) and a prefilled humidifier bottle was attached to the O2. Continued observation at 3:12 PM revealed the prefilled O2 humidifier bottle was empty and dated 1/12/19 (25 days prior). Observation of Resident #19 on 2/5/19 at 7:48 AM, in the resident's room, revealed the resident was on O2 at 2 l/m BNC and the prefilled humidifier bottle was attached to the O2. Continued observation revealed the prefilled O2 humidifier bottle was empty and dated 1/12/19. Medical record review revealed Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #90 scored a 14 on the BIMS indicating the resident was cognitively intact. Continued review revealed the resident received O2 therapy. Medical record review of the physician's recapitulation orders dated 1/17/19 through 1/31/19 revealed .Oxygen @ (at) 2 LPM (liters per minute) change O2 tubing weekly & (and) PRN . Observation of Resident #90 on 2/4/19 at 11:17 AM, in the resident's room, revealed the resident was receiving O2 at 2 l/m BNC and a prefilled humidifier bottle was attached to the O2. Continued observation revealed the O2 nasal cannula tubing was dated 1/22/19 (15 days prior) and the prefilled O2 humidifier was not dated. Observation of Resident #90 on 2/5/19 at 7:50 AM, in the resident's room, revealed the resident was receiving O2 at 2 l/m BNC and a prefilled humidifier bottle was attached to the O2. Continued observation revealed the O2 nasal cannula tubing was dated 1/22/19 and the prefilled O2 humidifier bottle was not dated. Interview with Licensed Practical Nurse (LPN) #2 on 2/5/19 at 4:36 PM, on the 200 hallway, confirmed Resident #19's prefilled humidifier bottle was empty and was not in date. Continued interview confirmed Resident #90's O2 nasal cannula tubing was not in date and the prefilled humidifier bottle was not dated. Interview with the Director of Nursing (DON) on 2/6/19 at 7:39 AM, in the conference room, confirmed the facility failed to follow the facility's policy.

Based on medical record review, review of facility investigations and interview, the facility failed to ensure an alarm was in place and failed to supervise one resident (#4) of ten residents reviewed. The facility's failure resulted in harm to resident #4. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the significant change Minimum Data Set (MDS) dated [DATE] revealed the resident scored 0/15 on the Brief Interview for Mental Status (BIMS) with severe cognitive impairment; had moderately impaired vision; displayed inattention and disorganized thinking; required extensive assistance of two people for bed mobility, transfers, ambulation, dressing, toileting and hygiene; was totally dependent on two people for bathing; required staff assistance with moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfer; had limitation in range of motion in one upper extremity; was incontinent of bowel and bladder and had a fall with no injury and a fall with injury since the prior assessment dated [DATE]. Medical record review of quarterly fall risk assessments dated May 19, 2012, August 9, 2012, November 2, 2012, January 23, 2013 and April 22, 2013 revealed the resident was at high risk for falls. Medical record review of a nurse's note dated October 16, 2012 at 5:00 p.m. revealed the resident was observed by staff on the floor in the resident's bathroom. Continued review revealed the resident had no injuries, and a parameter-defined mattress was placed on the bed. Medical record review of a nurse's note dated October 29, 2012 revealed the resident was observed in the doorway of the room with the back against the door and the legs extended outward and "Resident stated she thought...had a phone call..." The resident received no injuries from the fall. The facility placed the resident in a "high/low" bed. Medical record review of a nurse's note dated November 23, 2012 at 3:00 a.m. revealed the resident was observed on the floor in front of the door to the resident's room. Continued review revealed the resident complained of "arm pain" but denied pain when the wrists were rotated. Medical record review of a nurse's note dated November 23, 2012 at 3:40 a.m. revealed the resident was observed out of the bed (no fall) and complained of "pain in arm...Knot in wrist apparent. MD (Medical Doctor) notified..." Medical record review of the mobile x-ray report dated November 23, 2012 revealed "...Fracture of the distal radius, not clearly visualized, age unknown. An acute fracture cannot be excluded. Images of the left wrist are recommended for further evaluation...Patchy bone demineralization..." Medical record review of a nurse's note dated November 24, 2012 at 1:45 p.m. revealed, "N.O. (New order) received to send to (hospital) for x-ray...(left) wrist (left) hand (left) forearm. Family @ (at) bedside..." Medical record review of a nurse's note dated November 24, 2012 at 3:10 p.m. revealed the resident was returned to the facility. Review of the facility's investigation (received by fax on June 24, 2013) of the fractured wrist revealed the resident returned to the facility with a "sugar tong splint (immobilizes and supports the limb)". Continued review revealed a hard cast was placed on the left wrist on November 27, 2012. Medical record review of a nurse's note dated December 5, 2012 at 6:45 p.m. revealed the resident "...attempted to get out of chair in dayroom...fell , hitting...head on w/c (wheelchair)...c/o (complained of) neck & (and) back pain after fall...called 911 for non-emergency transport...confused...Unsure of events..." Medical record review of nurses' notes dated December 5, 2013 revealed the resident was transferred to the hospital emergency room at 7:00 p.m. and returned to the facility at 11:45 p.m. Medical record review of a hospital CT scan dated December 5, 2012 revealed no acute intracranial abnormalities were observed. Review of the facility's investigation dated December 5, 2012 revealed a soft belt was placed on the resident's wheelchair. Medical record review of a nurse's note dated December 12, 2012 at 8:30 p.m. revealed the resident was observed on the bathroom floor with the back propped against the Certified Nursing Assistant's (CNA) knee. Continued review revealed, "...CNA stated resident began to fall & CNA lowered...to ground, using leg to stabilize resident. No distress apparent. (No) C/O pain...(No) injuries noted..." Review of the facility investigation dated December 12, 2012 revealed two-person assistance for transfers was put in place. Medical record review of a nurse's note dated April 9, 2013 at 11:30 p.m. revealed a CNA entered the resident's room in response to the alarm sounding. The resident "began to fall back and CNA held...& lowered gently to floor per protocol." The resident had no injuries. A step-pad alarm was implemented. Medical record review of a nurse's note dated April 14, 2013 at 11:30 p.m. revealed the resident's alarm sounded; the nurse responded to the alarm; and observed the resident lying on the floor. The resident stated, "rolled out of bed." Continued review revealed the resident had a "small abrasion with slight bruising" on the "back left side." Review of the facility investigation dated April 14, 2013 revealed, "...Instructed CNA assigned to resident to make sure side rails are up when putting resident to bed in future." Medical record review of a mental health note dated April 15, 2013 revealed, "...had a fall a few days ago and has been having increased (falls) trying to get up without assistance...lethargic and does not seem to be aware of...environment...continues to decline in health...risk of falls...Limited insight and judgment..." Medical record review of a nurse's note dated April 24, 2013 at 2:00 a.m. revealed, "Called to lobby et (and) observed resident on floor @ (at) doorway of copy room. Denies pain-denied hitting head. Observed moderate size knot on back of head (after) getting...up in w/c (wheelchair)...had head resting on shelf in copy room. Reddened areas noted on upper back. Sent to (hospital) ER (emergency room )..." Medical record review of the ER report dated April 24, 2013 revealed, "...Struck head and complains of headache but no loss of consciousness...Based on mechanism of injury-low risk for significant head injury...Complains of pain affecting the posterior scalp...has a soft tissue injury/contusion of the posterior scalp. Complains of soft tissue swelling affecting the posterior scalp. No active bleeding. No visual complaints. Complains of...occipital headache...CT head...have reviewed films...No evidence of skull fracture..." Review of the facility's investigation dated April 24, 2013 revealed the resident fell after getting the feet tangled in the soft belt on the wheelchair. Continued review revealed after the resident returned from the hospital, the resident was placed in a Broda chair (recliner chair) with a leg strap when out of bed. Medical record review of a nurse's note dated June 9, 2013 at 8:45 a.m. revealed, "...observed resident on the floor on...(R) side in front of bathroom door...stated...had to go to bathroom...said...face hurt on...cheekbone...hand hurt...EMS (Emergency Medical Service) called, awaiting arrival for transport..." Medical record review of a nurse's note dated June 9, 2013 at 10:30 a.m. revealed, "...(Hospital) called et spoke (with) this nurse, informed this nurse resident had a hip, wrist et elbow fx (fracture), they are keeping resident...possible surgery..." Medical record review of hospital x-ray reports dated June 9, 2013 revealed, "...Hip...transverse fracture of the right femoral neck...superior displacement of the shaft of the femur without rotation of the femoral heal...Wrist...transverse fracture of the distal right radius with mild posterior angulation of the distal fracture fragment..." Medical record review of a hospital operative report dated June 9, 2013 revealed, "...Preoperative diagnosis...Displaced right subcapital femoral neck fracture...Angulated right distal radius fracture...Procedure Performed:...Right hip hemiarthroplasty...Closed reduction of the right distal fracture with application of a long-arm sugar-tong splint...operative fixation was indicated in order to get both fractures treated in the most proper manner that would allow her to get out of bed as soon as possible, begin ambulation, and decrease any complications associated with nonoperative treatment..." Medical record review of a hospital consultation report dated June 17, 2013 revealed, "...Hospital course was complicated...developed shortness of breath...Initially managed as a Pneumonia versus fluid overload...had IV (intravenous) Levaquin (antibiotic) followed by Rocephin (antibiotic). Because of the worsening chest x-ray, Infectious Disease Service was consulted for further management of antibiotic...had a PICC (Peripherally Inserted Central Catheter) line placed on the 11th of June for IV access...Patient in mild respiratory distress...IMPRESSION...Bilateral lung infiltrate with possible healthcare associated Pneumonia with high risk of aspiration versus fluid overload..." Medical record review of a hospital chest x-ray report dated June 18, 2013 revealed, "...Atelectasis (no air in the lung) of the anterior left upper lobe with adjacent mass or airless lung...Bilateral pleural effusions...Biapical pleural thickening and scarring...Right lower lobe and right middle lobe Pneumonia...Partial Atelectasis of the left lower lobe..." Review of the facility investigation dated June 9, 2013 revealed the floor alarm pad did not sound and was "not used properly." Interview on June 20, 2013 at 7:50 a.m. in the conference room with Licensed Practical Nurse (LPN) #1 who identified self as the facility's Incident and Accident Coordinator revealed the following related to resident #4: the resident had a history of [REDACTED]. Continued interview confirmed the resident was "very confused" and often did not sleep during the night. Continued interview confirmed the resident had "dismantled" and removed alarms over the past one-and-one-half years and had unraveled and removed two casts on the arm after the November 23, 2012 fractured wrist. Continued interview confirmed the short-term memory was "almost non-existent." Continued interview confirmed the resident was at high risk for falls. Continued interview with LPN #1 confirmed the facility had never provided one-on-one supervision with the resident because the resident "had no behaviors." Continued interview confirmed the resident was non-compliant and continued to have falls. Continued interview revealed the resident's family had been asked about providing sitters for the resident. Review of the facility's investigations and interview on June 20, 2013 at 8:20 a.m. in the conference room with LPN #1 revealed one side of the resident's bed was positioned against the wall with a half side rail raised when the resident was in bed. Continued interview revealed the resident was to wear non-skid socks. Continued interview confirmed, at the time of the fall on November 23, 2012, the resident was not wearing non-skid socks, and the facility had no knowledge of why the socks were not in place. Continued interview confirmed on December 5, 2012, the resident stood from the wheelchair; fell and hit the head; and was transported to the emergency room . Continued interview confirmed the resident was to have a Velcro belt when up in the wheelchair, and the facility had no knowledge if the belt or non-skid socks were in place at the time of the fall on December 5, 2012. Continued interview confirmed on April 14, 2013 at the time of the fall with injury (abrasion and bruising to the back), the half side rail was in the lowered position. Continued interview confirmed the CNA had left the side rail down and had been instructed to always raise the rail when the resident was in the bed. Continued interview confirmed at the time of the fall on June 9, 2013 when the resident had a fractured hip and fractured right wrist, the step-pad alarm did not sound because it was folded beside the bed. Interview on June 20, 2013 at 10:50 a.m. in the conference room with the resident's physician confirmed the resident had Parkinson's Disease which caused an unsteady gait and made the resident at high risk for falls. Continued interview confirmed the resident had a history of [REDACTED]. Interview on June 20, 2013 at 1:50 p.m. in the conference room with the Administrator revealed on June 9, 2013 the CNA "folded the mat (alarming) beside the bed while feeding (the resident)...when finished took the tray out of the room without replacing the mat" beside the bed. Review of additional information faxed to the surveyor on June 25, 2013 revealed, "...Final note: Upon further investigation it was discovered that housekeeping had been in that room to clean that morning. The housekeeper states that she picks up the mats to clean under them. She folds them up and places them 'out of the way, usually up against the wall.' She leaves the room to allow the floor to dry and starts on another room. When she left the room resident was lying in bed resting, nursing staff was in the hall, and alarms were on bed. When the floor is dry she goes back to put the mat down." Telephone interview on June 25, 2013 at 12:10 p.m. with LPN #2 who was assigned to the 400 unit on June 9, 2013 revealed LPN #2 heard LPN #3 yell, "come quick." Continued interview confirmed LPN #2 entered the resident's room; observed the resident on the floor; and observed the "safety pad folded and slid between the night stand and the bed." Continued interview confirmed the resident "could not have moved" the mat. Continued interview confirmed resident #4 was "one of our high risk residents...go running when we hear the alarm," and the alarm was not sounding. Telephone interview on June 25, 2013 at 12:30 p.m. with LPN #3 confirmed LPN #3 was assigned to the resident's hall on June 9, 2013. Continued interview revealed LPN #3 was doing a medication pass in the room adjacent to the resident's room and "heard" the resident fall; observed the resident in the floor; and yelled for LPN #2. Continued interview confirmed the mat alarm was "folded up beside the bed" and the resident "would not have been able to fold the mat." C/O # , #