Every finding on record at Wood-Lawn Heights

Based on observation, interview, and facility policy review, the facility failed to ensure food items stored in the refrigerator, freezer, and the dry food storage area were covered or sealed to prevent potential food born illnesses; expired food items were promptly removed and discarded on or before the expiration date; and dietary staff washed their hands, before handling clean equipment or food items for one of one meal observed. The findings include: During a concurrent observation and interview on 08/11/2025 at 10:12 AM, this surveyor observed the following in the walk-in refrigerator: a. An opened and unsealed bag of burritos was on a shelf, which exposed it to cross contamination. The Dietary Manager (DM) confirmed the bag was not sealed, so she would throw it away. b. A box that contained 10 packages of bologna was on a shelf, with an expiration date of 07/10/2025. The DM acknowledged the expired meat items, so she would throw them away. c. Two containers of tuna salad were on a shelf, with an expiration date of 08/09/2025. The DM acknowledged the expired tuna salads and confirmed they should have been discarded During a concurrent observation and interview on 08/11/2025 at 10:35 AM, this surveyor observed an opened box of biscuits on a shelf in the walk-in freezer. The box was not covered or sealed, which exposed it to cross contamination. The DM confirmed the box should have been covered and sealed, once opened. During a concurrent observation and interview on 08/11/2025 at 10:37 AM, this surveyor observed the following on a shelf above the food preparation counter: a. An opened and uncovered container of salt, which exposed it to air, moisture, and potential pests. b. An opened and uncovered container of sugar cane, which exposed it to air, moisture, and potential pests. c. An opened and unsealed bag of brown sugar, which exposed it to air, moisture, and potential pests. During a concurrent observation and interview on 08/11/2025 at 10:41 AM, this surveyor observed the following in the storage room: a. An opened and unsealed box of breadcrumbs, which exposed them to air, moisture, and potential pests. The DM confirmed that bugs could crawl into the box. b. A box with a 3-gallon bag of lemonade on a shelf, with an expiration date of 03/09/2025. During a concurrent observation and interview on 08/11/2025 at 3:59 PM, this surveyor observed Dietary Aide (DA) #4 wash and sanitize the blender bowl, lid, and the blade in the three- compartment sink. After sanitizing the food processor equipment, DA # 4 turned off faucet with their bare hand, contaminating her hand. Without washing her hands, DA #4 picked up a clean blade and attached it to the base of the blender to be used in pureeing food items for lunch. When DA #4 was ready to use the blender, this surveyor immediately asked DA #4 what she should have done after touching dirty objects and before handling clean equipment. DA #4 stated she should have washed her hands. A review of the facility policy titled, Handwashing Guidelines for Dietary Employees, indicated dietary employees should wash their hands after engaging in any activity that may contaminate the hands.

Based on observation, interview, and facility policy review, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for one meal observed. The findings include: During an observation on 08/11/2025 at 5:55 PM, Certified Nursing Assistant (CNA) #5 used a #8 scoop, which was equal to 1/2 cup, to serve a single portion of regular shepherd's pie to the residents who received regular diets, and the residents who received mechanical soft diets, instead of 3/4 cup as per the menu. CNA #5 confirmed she should have used a 6-ounce scoop, which would have been equal to 3/4 cup, to serve the shepherd's pie to the residents on regular and mechanical diets. During a concurrent observation and interview on 08/11/2025 at 5:56 PM, CNA #5 used a #8 scoop, which was equal to 1/2 cup, to serve a single portion of pureed shepherd's pie to the residents who received pureed diets, instead of two #10 scoops, to equal to 2/3 cup as per the menu. CNA #5 stated that she should have served two #10 scoops of shepherd's pie to the residents on pureed diets. During an observation on 08/11/2025 at 6:00 PM, CNA #6 used a #8 scoop, which was equal to 1/2 cup to serve a single portion of shepherd's pie to the residents who received regular diets, and the residents who received mechanical soft diets, instead of 3/4 cup as per the menu. During an observation and interview on 08/11/2025 at 6:07 PM, CNA #3 used a #8 scoop, which was equal to 1/2 cup to serve a single portion of pureed shepherd's pie to the residents who received pureed diets, instead of two #10 scoops, to equal 2/3 cup as per the menu. In addition, no pureed bread was served to the residents on pureed diets. CNA #6 stated she did not use the right scoop to serve the shepherd's pie. During an interview on 08/11/2025 at 6:15 PM, this surveyor asked CNA #6 the reason dinner rolls were not served to the residents on pureed diets, as per the menu. CNA #6 stated the temperature on the pureed dinner rolls was above 41 degrees Fahrenheit. Therefore, she decided not to serve it to the residents because it was a cold food item. CNA #6 stated when she asked the Director of Nursing (DON) what she should have done. The DON stated it should have been sent back to the kitchen to be reheated. A review of the supper meal menu on 08/11/2025 indicated that the residents on regular diets were to receive a 3/4 cup of shepherd's pie which was equal to 6 ounces. During an interview with the Dietary Manager on 08/11/2025 at 6:25 PM, she stated that each unit had a menu specifying each food item and the scoop size to use when serving meals. A review of the supper meal menu on 08/11/2025 indicated that the residents on pureed diets were to receive a #16 scoop, which was equal to 1/4 cup, of pureed dinner roll.

Based on observations, record review, interviews, and facility policy review, the facility failed to investigate to determine the causative factors of falls to facilitate development of effective interventions to prevent further falls and minimize the risk of fall-related injuries and failed to ensure current fall documentation and interventions were accessible to all direct care staff for 2 (Resident #85 and Resident #90) of 3 residents reviewed for falls. These failures led to falls resulting in a laceration to the head and bruising to the eyes for Resident #85 and a fractured back and a hematoma to the forehead for Resident #90. The facility also failed to ensure interventions were developed and implemented to decrease the risk of skin tears and/or skin discolorations for 1 (Resident #81) of 3 residents reviewed for falls. Findings include: A review of a facility policy titled, Fall Procedure, with an effective date of 03/08/2022, indicated, Purpose: 1. To assess residents at risk for falls. 2. To follow up and evaluate all falls. 3. To identify the reason for the fall. 4. To prepare a plan of care to reduce the potential for injury related to falls. A review of a facility policy titled, Accidents and Supervision, with a reviewed date of 02/02/2024, indicated, Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary . Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed d. Evaluating the effectiveness of new interventions. 1. A review of the Admission Record, indicated the facility admitted Resident #85 with diagnoses that included Parkinson's disease, cognitive communication deficit, muscle weakness, difficulty walking, and cellulitis. The Signification Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/27/2024, revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severe cognitive impairment. Further review of the MDS indicated the resident had two falls with no injury and one fall with major injury. A review of Resident #85's Care Plan, initiated on 01/15/2024, revealed the resident was at risk for falls related to impaired balance and incontinence. Interventions included the following: padded floor mat to closed side of bed; document all behaviors which are not usual and report to nurse/doctor; keep call light, water, and frequently used items in reach; monitor for changes in condition that may warrant increased supervision/assistance and notify the doctor; review information on falls and attempt to determine cause of falls; staff to assist resident with performing activities of daily living (ADL) care as requested/needed; acute illness (with no context); medication review, obtain labs, staff education (with no context); pull tab alarm to wheelchair, Lap Buddy; family reports that resident gets out of bed and puts self on floor; attempt to take the resident out of the dining room after meals; behavior related (with no context); change cushion to wheelchair; numerous intervention successful (with no context); changed alarm clip (with no indication of which alarm); pressure pad alarm to bed; attempt nonskid shoes; changed wheelchair cushion, therapy; padded floor pad to open side of bed; attempt to adjust bed height to mark (with no context); and monitor sleep pattern. A review of Resident #85's Progress Notes from 01/10/2024 through 05/21/2024 did not include any notes directly related to any falls. On 01/16/2024 at 1:54 PM, Registered Nurse (RN) #7 indicated the resident had a self-reported fall on 01/14/2024. There were no additional notes related to the fall. On 02/01/2024 at 3:00 P.M., the Director of Nursing (DON) indicated on a Skin only note that the resident did not have an injury from a fall. There were no additional notes related to the fall. On 02/15/2024 at 10:19 PM, Licensed Practical Nurse (LPN) #6 indicated there was no acute fracture on an x-ray that was complete. On 02/16/2024 at 9:38 AM, LPN #8 indicated the x-ray was ordered for the resident's left shoulder related to pain from a fall. At 10:29 AM, RN #11 indicated on a Long Term Care Evaluation the resident had an unwitnessed fall on 02/13/2024 in the resident's room. On 02/20/2024 at 2:42 P.M., LPN #8 indicated the resident lowered themselves to the floor from their wheelchair and was assisted back into their wheelchair. On 02/27/2024 at 9:22 A.M., the MDS Coordinator indicated the resident was reviewed for the upcoming interdisciplinary meeting, but no other information was provided. On 04/15/2024 at 12:57 AM, RN #7 indicated in a Long Term Care Evaluation that on 04/11/2024, the resident had a witnessed fall with no injury. There were no additional notes related to the fall. On 04/18/2024 at 6:07 PM, LPN #12 indicated the resident was sent to the hospital to be evaluated. At 10:51 PM, the resident returned to the facility with a glued laceration with no indication of where the laceration was. Based on the review of the progress notes, the resident had four falls. A review of Resident #85's Incident and Accident Reports since admission indicated the resident had a fall on 01/26/2024, 01/27/2024, two on 01/28/2024, two on 01/31/2024, 02/13/2024, 02/15/2024, two on 02/20/2024, two on 02/24/2024, 03/04/2024, 03/19/2024, 04/05/2024, 04/09/2024, 04/11/2024, 04/18/2024, 04/29/2024, 04/30/2024, two on 05/01/2024, 05/02/2024, 05/04/2024, 05/07/2024. The total number of incident reports indicated the resident had 25 falls since admission, one that resulted in a laceration above the resident's eyebrow and bruising to the face. These reports are not part of the resident's medical record. A review of Fall Risk Evaluation indicated Resident #85 was evaluated for falls 22 times since the resident was admitted . Thirteen of the evaluations indicated the type as Post Fall and all 22 evaluations indicated the resident was At Risk for falls. Each Fall Risk Evaluation included level of consciousness, history of falls, ambulation status, vision status, balance, blood pressure, medication, change in mental status, and predisposing disease. A review of Family Care Plan Meeting Summary, dated 05/02/2024 indicated staff discussed the resident's two falls with the resident's spouse. There was nothing else documented about the falls. At the time of the meeting, the resident had 22 falls. During an observation on 05/21/2024 at 9:23 AM, Resident #85 was sitting in their wheelchair near the nurse's desk with a cushion underneath the resident. The resident did not have a wheelchair alarm or a lap buddy present. During an observation on 05/22/2024 at 7:21 AM, Resident #85 was sitting in their wheelchair in the dining room with a cushion underneath the resident. The resident did not have a wheelchair alarm or a lap buddy present and was wearing regular socks, not non-skid socks, and no shoes. During an interview on 05/21/2024 at 6:05 PM, Resident #85's family member stated, they were only aware of three to four falls that the resident had since admission. The family member stated she was only aware of fall interventions of a monitor to the resident's bed and chair. During an interview on 05/21/2024 at 10:53 PM, LPN #2 stated she was familiar with Resident #85 and that the resident thinks they can stand up and walk but could not. She stated she was unaware of how many falls the resident had but has fallen quite a bit at night though. LPN #2 stated the resident would roll out of bed and onto the fall mat and one of the falls resulted in a gash above the resident's eyebrow and was sent to the hospital. LPN #2 stated the resident had another fall in which the resident hit their head and was sent to the hospital for that fall. LPN #2 stated the resident's fall interventions included a mat on either side of the bed, a bed alarm but not a chair alarm, and to keep the resident close to the nurse's desk for observation. LPN #2 stated in order to know what interventions are in place, she would review the Incident and Accident (I&A) reports or call their supervisor and ask. LPN #2 stated the resident has a care plan, but the interventions are not listed there and are only located on the I&A. LPN #2 stated the interventions are in the LPN Guideline book, located at the nurse's desk. LPN #2 stated after a resident falls, they complete an I&A and the supervisor and/or DON tells the staff what intervention needs to be put into place. LPN #2 stated they only document on the I&A for the fall and do not document anything in the resident's progress notes and that is how she was trained. During an interview on 05/22/2024 at 7:25 AM, Certified Nursing Assistant (CNA) #4 stated she was familiar with Resident #90 and the resident had numeral falls that she was aware of. CNA #4 stated the last couple of falls have occurred during the night and one fall resulted in the resident hitting their head. CNA #4 stated fall interventions for Resident #85 included a bed alarm and fall mats to both sides of the bed. CNA #4 stated the resident used to have a lap buddy and a chair alarm, but those were no longer in place. CNA #4 stated all fall interventions should be in the resident's care plan. During an interview on 05/22/2024 at 7:28 AM, CNA #5 stated she was familiar with Resident #85 and the resident had fallen before because the resident will try to stand up and walk but the resident did not have any balance. CNA #5 stated she thought the resident may have had an injury from a fall, but it was a while ago. CNA #5 stated the resident's fall interventions included an alarm on the resident's bed and chair and to just keep an eye on the resident. CNA #5 stated those interventions would be in the resident's care plan, but she had not reviewed Resident #85's care plan in a long time. When asked how she would know if fall interventions were changed, she stated the facility would place in-services at the nurse's station for updates. During an interview on 05/22/2024 at 7:32 AM, LPN #6 stated she was familiar with Resident #85 and that the resident had numerous falls, one including where the resident hit their head and one that resulted in the resident receiving a laceration above the resident's eyebrow. LPN #6 stated she had walked in on the resident on their knees on the fall mat. LPN #6 stated fall interventions for Resident #85 included fall mats and a pressure pad to the resident's bed and that's all she was aware of. LPN #6 stated fall interventions should be included in the resident's care plan. LPN #6 stated when a resident falls, the nurse has to complete an I&A and the MDS Coordinator will place the interventions on the I&A and then update the resident's care plan. LPN #6 stated that all information related to the fall goes on the I&A form and not in the resident's progress notes. When asked if the interventions are listed on the I&A but not in the care plan, how staff would know what interventions were put into place and LPN #6 stated the nursing staff charts on the I&A for three days, in the note's sections, which is not part of the resident's medical record. LPN #6 stated there was an LPN Guideline book, as referenced by LPN #2, and at this time, she reviewed the Guideline book three times with the Surveyor present and was unable to locate current information related to falls. The documentation within the binder was how to complete a fall investigation based on the previous electronic health record system. When asked how she was aware of the process related to falls if the LPN Guideline book was not up to date, she stated she was trained on how to complete an I&A by another staff member. During an interview on 05/22/2024 at 8:12 AM, Registered Nurse (RN) #7 stated she was familiar with Resident #85 and that the resident had numerous falls and for most of their falls, the resident would reach down like they were getting something off of the floor or the resident would throw their legs off the side of the bed and slide down and sit on the floor mat and that was how most of the falls happened. RN #7 was not aware of any injuries related to falls for Resident #85. RN #7 stated fall interventions for Resident #85 was a bed alarm and wedge cushion for the wheelchair. Previous interventions included therapy evaluation, a lap body, and another seat cushion. RN #7 stated those interventions were listed on the I&As, which are not part of the resident's medical record, but should also be included on the resident's care plan. RN #7 when completing an I&A for a fall, nursing staff have to document on the resident for three days in the notes section of the I&A and then the management team can discuss every fall and what intervention could be put into place. RN #7 stated nursing staff only document in the notes section within the I&A, which is not part of the resident's medical record and CNAs cannot access I&As. RN #7 stated the MDS Coordinator was responsible for updating the resident's care plan and she was made aware of the I&A during the daily morning meeting. RN #7 stated she reviewed care plans to ensure care plan interventions were transcribed appropriately based on the I&A. RN #7 stated CNAs are made aware of the interventions by having access to the resident's care plan, but most of the time, CNAs are made aware via in-services. When asked about if the facility has completed a root cause analysis of Resident #85, RN #7 stated the facility looks at each fall and comes up with interventions, however, she is not aware of the facility completing a root cause analysis because the facility just looks at each individual fall and not falls as a whole. RN #7 stated the DON was responsible for keeping the LPN Guideline book up to date. When providing the guidelines for falls that were pulled from the guideline book, RN #7 verified the binder was not accurate and the documentation was based on the facilities previous electronic health record system. At this time, RN #7 reviewed Resident #85's current care plan and stated based on the care plan, the resident should have a lap buddy and a wheelchair alarm. RN #7 stated an acute illness was not an appropriate intervention for a fall, nor was behavior. RN #7 stated that Staff educated was not enough information to indicate what staff were educated on related to falls. At this time, RN #7 stated she should not have said that she had reviewed the resident's care plan because it was not up to date. During an interview on 05/22/2024 at 9:06 AM, LPN #8 stated she was familiar with Resident #85 and that the resident had some falls and that the resident liked to kneel in the floor in the resident's room. LPN #8 stated she would have to look up fall interventions for the resident and could not recall any off the top of her head, but the facility had tried a pressure pad alarm and fall mats and current interventions should be on the resident's care plan. Per LPN #8, the MDS Coordinator was responsible for updating the resident's care plan and was not aware of anyone else that had access to editing the resident's care plan. LPN #8 stated after a resident falls, the nursing staff completes an I&A and the resident's fall intervention for that fall is placed on the I&A. LPN #8 stated the MDS Coordinator is either emailed or the I&A is discussed during the morning meeting and that is how she is made aware of what intervention needs to be added to the resident's care plan. LPN #8 stated they only document on the resident's fall within the I&A, which is not part of the resident's medical record and the only time the staff chart in the resident's medical record would be an instance if the resident's family member refused to send the resident to the hospital related to the fall. LPN #8 stated she frequently checked the resident's care plan for accuracy and discussed interventions during the morning meeting. LPN #8 was not aware of what a root cause analysis for falls was and had not been part of a root cause analysis. LPN #8 stated that the RN Supervisor was responsible for going through the LPN Guideline book to ensure everything was up to date. At this time, LPN #8 was shown the guidance for incidents and stated it was the facility's previous electronic health record system guidance. At this time, LPN #8 also reviewed the resident's current care plan and stated the resident has a current intervention of a lap buddy, but it thought it had been revised to a different intervention and it should not be on the resident's care plan. LPN #8 stated that acute illness was not an intervention and that staff education listed as an intervention did not provide was education was provided. When asked if intervention successful with no context was an appropriate intervention, she stated she would have to look at the IA& to see what the intervention was because it was not listed on the care plan. LPN #8 stated that per the resident's care plan, an alarm should be on the resident's wheelchair but was unaware if one was in place. During an interview on 05/22/2024 at 11:03 AM, LPN #9 stated she was familiar with Resident #85 has had many falls and one of the resident's falls resulted in a bruised face, was sent to the hospital, and had to have a laceration to their face glued. LPN #9 stated the resident had previous fall interventions that included a lap buddy, alarms, and a wedge cushion for the resident's wheelchair. LPN #9 stated that the resident would repeatedly get down on the floor to fix their airplane. LPN #9 stated the resident's falls resulted in numerous skin tears and though the resident may have had a fracture but could not remember when. LPN #9 stated that fall interventions would be included on the resident's care plan and that she did not complete any I&As because she only dealt with wounds. During an interview on 05/22/2024 at 1:07 PM, the MDS Coordinator reviewed Resident #85's I&As and stated the resident had 24 falls since admission. At this time, the MDS Coordinator reviewed the resident's care plan and stated that she had discontinued the intervention of the lap buddy and the wheelchair alarm for resident #85 because she was instructed to do so by RN #7 that morning. The MDS Coordinator stated that based on the care plan, the resident should have had the lap buddy and the wheelchair alarm. The MDS Coordinator stated that acute illness that was listed as an intervention should not be considered an intervention, as well as staff education. The MDS Coordinator stated, behavior related and interventions successful listed as an intervention was not appropriate because it did not provide any details. The MDS Coordinator stated she only put the interventions on the resident's care plan based on the interdisciplinary team's decision during the morning meetings and that she does not review the actual I&A and is only verbally told about the resident's fall. The MDS Coordinator stated the resident's care plan did not clearly define interventions listed for the nursing staff to follow and the DON was responsible for oversight of the care plan process. During an interview on 05/22/2024 at 2:12 PM, the DON stated that the facility had determined Resident #85, per the resident's family, would place themselves on the floor. The DON stated she was not aware of how many falls the resident had since they had been admitted to the facility. The DON stated she had printed off the I&As for the survey team and at this time, she was provided with the I&As and stated the resident had 24 falls since admission. The DON stated Resident #85 had an injury that included a laceration to their eyebrow but was not sure if the resident had a major injury. The DON stated she was only aware of fall interventions of floor mats and non-skid socks and would have to review the I&As for other interventions. The DON stated fall interventions should be in the resident's care plan and LPNs could review the I&A report. The DON stated that when a resident falls, nursing staff are to document everything related to the fall within the IA& report, which is not part of the medical record, and nothing related to the fall should be within the medical record. The DON stated that I&As are reviewed by the interdisciplinary team (IDT) every Monday through Friday during the morning meeting. The IDT team included the DON, the Assistant Director of Nursing (ADON), Hall Supervisors, MDS Coordinator, Social Worker, CNA, and Dietary. When asked where the IDT discussion is documented, the DON stated the discussion is only documented on a regular notebook that only the DON and ADON have access to. The DON stated that nursing staff, not including CNAs, have access to the I&A reports. The DON stated the MDS Coordinator was responsible for updating the resident's care plan, that she was on the IDT team, and was verbally told how to update the resident's care plan and was not provided with the actual I&A report to review. The DON stated she reviewed the resident's care plan weekly to ensure interventions were transcribed accurately and there was no auditing process for accuracy of the care plan, and she was responsible for oversight of the accuracy of the care plans. The DON stated that CNAs were made aware of fall interventions by reviewing the resident's care plan. The DON stated the intervention of the lap buddy should have been removed from the resident's care plan on 04/16/2024 but was not due to an oversight. The DON also stated that she had just completed training and was made aware that acute illness could not be used as an intervention and the facility had stopped using that intervention, however, the facility did not go back and correct current care plans to discontinue acute illness as an intervention. The DON stated that behavior should not have been listed as an intervention because it was the cause of the fall and not an intervention. The DON stated staff educated was an appropriate intervention, however the care plan did not indicate what education was provided. The DON also verified that the resident did not have a wheelchair alarm and it should have been discontinued from the resident's care plan. The DON stated all falls are documented within Risk Management, which was not part of the resident's medical record and staff were instructed to put all notes related to the fall within the I&A in Risk Management. The DON stated staff should update the resident's care plan when an intervention needs to be discontinued. During an interview on 05/22/2024 at 3:32 PM, the Assistant Administrator (AA) stated the facility had a Falls Program that had not been put into place yet, which included for staff to complete a root cause analysis for falls. The AA stated that when a nurse completes an I&A within the electronic health record (EHR), there is a progress note section that should be copied over to the progress notes that is accessible within the EHR. When advised that the notes are only retained within the I&A and not transferred over to the EHR, the AA stated she was not aware the notes were not transferred over, however, they should be. During an interview on 05/22/2024 at 4:46 PM, the Administrator stated she was aware that falls were an issue within the facility, and she expected her staff to update the resident's care plan timely and accurately and interventions should be removed from the care plan if they were no longer effective. The Administrator stated that all fall documentation should be on the I&A, which is not part of the resident's medical record, but should also be in the resident's progress notes to reflect why the facility was doing certain things, such as sending the resident to the hospital. The Administrator stated that the previous administration did not want any of the I&A information within the residents' progress notes. 2. A review of the Admission Record, indicated the facility admitted Resident #90 with diagnoses that included age related cognitive decline, muscle weakness, cognitive communication deficit, difficulty walking, dementia, and vertigo. The Signification Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/17/2024, revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident had severe cognitive impairment. Further review of the MDS indicated the resident had two falls with no injury and one fall with major injury. A review of Resident #90's care plan, initiated on 11/07/2023, revealed the resident was at risk for falls related to impaired balance, incontinence, and poor awareness of safety needs. Interventions included4 acute illness (with no context); family education (with no context); padded floor pad to open side of bed; grip around bathroom bar; staff education (with no context); staff changed intervention after requesting I&As (with no context); attempt grip socks at bedtime; anti-rollbacks to wheelchair, document all behaviors which are not usual for the resident and report to nurse/doctor; keep call light, water, and frequently used items in reach; monitor for changes in condition that may warrant increased supervision/assistance and notify the doctor; review information on falls and attempt to determine cause of falls; and staff to assist with performing ADL care as requested/needed. A review of Resident #90's Progress Notes from 09/18/2023 to 05/21/2024 did not include any notes directly related to any falls. On 01/30/2024 at 12:25 PM, the Director of Nursing (DON) indicated on a Skin only note that the resident had a fall resulting in an abrasion to their nose and first finger on the left hand. There was no additional information related to the fall. On 03/02/2024 at 11:04 AM, LPN #13 indicated on a Skin only note that the resident had a fall resulting in an abrasion to their nose and first finger on the left hand. This note was written verbatim to the DON's note on 01/30/2024 that included the same injury. On 03/28/2024 at 1:38 AM, RN #11 indicated the resident had a fall on 03/07/2024 at 2:20 AM in the resident's bathroom. There were no progress notes on or around the date of the actual fall. On 04/11/2024 at 5:45 PM, LPN #14 indicated she received a report from the local hospital stating the resident was being discharged back to the facility with the diagnosis of a compression fracture. There were no progress notes prior to the fracture to indicate the resident had a fall or was sent to the hospital. On 04/15/2024 at 5:57 AM, LPN #13 indicated on a Long Term Care Evaluation that the resident had a fall on 04/11/2024 while folding a blanket. On 04/17/2024 at 9:49 AM, the MDS Coordinator indicated the interdisciplinary team met related to the resident's falls and due to a decline in the resident's health from the falls, a significant change MDS had to be completed. By completing this, the facility believes that the decline will not resolve within a two-week period. On 04/26/2024 at 4:56 PM, the DON indicated on a Skin only note that the resident had a fall that resulted in a hematoma to the left side of the resident's forehead and the resident complained of pain when the area was touched. There were no other progress notes related to the fall or interventions put into place. On 05/12/2024 at 6:24 AM, RN #11 indicated on a monthly Long Term Care Evaluation that the resident had a fall on 04/24/2024. No other information was provided. Based on review of the progress notes, the resident had five falls. A review of Resident #90's Incident and Accident reports since admission indicated the resident had a fall on 11/26/2024 (outside of the facility), 12/07/2024, 01/28/2024, 03/04/2024, 03/07/2024, 04/11/2024, 04/19/2024, and 04/24/2024. The total number of incident reports indicated the resident had eight falls since admission, one that resulted in a fractured back, and one resulted in a hematoma to the left side of their forehead. A review of Fall Risk Evaluation indicated Resident #90 was evaluated for falls nine times since the resident was admitted . Seven of the evaluations indicated the type as Post Fall and all nine evaluations indicated the resident was At Risk for falls. Each Fall Risk Evaluation included level of consciousness, history of falls, ambulation status, vision status, balance, blood pressure, medication, change in mental status, and predisposing disease. The evaluations did not include any other information, such as interventions. During an interview on 05/21/2024 at 11:16 PM, the LPN #3 stated she was familiar with Resident #90 and was aware the resident had a fall that resulted in a fractured back. LPN #3 stated the resident does not use their call light because they forget to use it. LPN #3 stated after the resident had the fall that fractured the resident's back, the resident had an additional fall in the resident's bathroom. LPN #13 stated she was aware of the falls that occurred on 04/11/2024, 04/19/2024, and 04/24/2024. LPN #13 stated the resident had fall interventions that included non-skid strips in the resident's bathroom and then stated she needed to look at the resident's I&As to see what other fall interventions the resident had. LPN #13 stated she was trained to put the fall interventions in the I&A and that was the only place she knew to look for fall interventions. LPN #13 stated that CNAs do not have access to view the I&A and only nurses do. When asked how CNAs are made aware of the interventions, since they do not have access to the I&As, she stated the nurses verbally tell the CNAs in report and sometimes there are in-services completed. When asked if the interventions should also be in the resident's care plan, LPN #3 stated they should, but nurses do not do anything with the care plan and just review the I&As. LPN #3 verified that the MDS Coordinator updates the resident's care plan. LPN #3 stated when completing an I&A, the DON would typically tell the nurse what intervention to include, but if the previous intervention was successful, the nurse would just document interventions successful. LPN #3 stated the nurses only document within the I&A related to the resident's fall and not in the resident's progress notes. During an interview on 05/22/2024 at 11:03 AM, LPN #9 stated she was familiar with Resident #90, that the resident had fallen a few times, was unfamiliar with the resident's fall interventions but would look in the resident's care plan for those. During an interview on 05/22/2024 at 11:19 AM, LPN #15 stated she was familiar with Resident #90, that the resident had numerous falls in which one fall resulted in the resident fracturing their back and another resulted in bruising to the resident's face because the resident was unsteady on their feet. LPN #15 stated the resident had fall interventions of fall mats to the side of the resident's bed, non-skid socks, and shoes, and had been placed in a wheelchair after the fall resulting in the fractured back. LPN #15 stated the interventions should be in the resident's care plan. LPN #15 stated after a resident falls, the nurse completes an I&A, and the DON assists the nurse with putting a fall intervention on the I&A. Per LPN #15, all notes are to be completed within the I&A and not within the resident's progress notes. LPN #15 stated the MDS Coordinator was responsible for updating the resident's care plan and LPN #15 does not review the care plan for accuracy. At this time, LPN #15 reviewed Resident #90's care plan and stated the interventions of family and staff education should include what the family and staff were educated on. LPN #15 stated the care plan did not identify all interventions clearly in order for a certified nursing assistant (CNA) to understand. During an interview on 05/22/2024 at 11:50 AM, CNA #10 stated she was familiar with Resident #90 and was aware the resident had a fall that resulted in a fractured back and one that resulted in a bruise to the resident's forehead. CNA #10 stated the resident needed a walker to ambulate [TRUNCATED]

Based on observations, interviews, record review, and the facility failed to develop, implement, and update a comprehensive person-centered care plan for 4 (Resident #85, Resident #90, Resident #31, and Resident #81) of 10 residents whose comprehensive care plans were reviewed. Specifically, the facility failed to ensure resident's falls were addressed appropriately in the care plan to prevent any further accidents and failed to follow the care plan related to falls. Findings include: A review of a facility policy titled, Comprehensive Care Plans, implemented on 04/2023, indicated, The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed . Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 1. A review of the Admission Record, indicated the facility admitted Resident #85 with diagnoses that included Parkinson's disease, cognitive communication deficit, muscle weakness, difficulty walking, and cellulitis. The Signification Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/27/2024, revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severe cognitive impairment. Further review of the MDS indicated the resident had two falls with no injury and one fall with major injury. A review of Resident #85's Care Plan, initiated on 01/15/2024, revealed the resident was at risk for falls related to impaired balance and incontinence. Interventions included the following: padded floor mat to closed side of bed; document all behaviors which are not usual and report to nurse/doctor; keep call light, water, and frequently used items in reach; monitor for changes in condition that may warrant increased supervision/assistance and notify the doctor; review information on falls and attempt to determine cause of falls; staff to assist resident with performing activities of daily living (ADL) care as requested/needed; acute illness (with no context); medication review, obtain labs, staff education (with no context); pull tab alarm to wheelchair, Lap Buddy; family reports that resident gets out of bed and puts self on floor; attempt to take the resident out of the dining room after meals; behavior related (with no context); change cushion to wheelchair; numerous intervention successful (with no context); changed alarm clip (with no indication of which alarm); pressure pad alarm to bed; attempt nonskid shoes; changed wheelchair cushion, therapy; padded floor pad to open side of bed; attempt to adjust bed height to mark (with no context); and monitor sleep pattern. A review of Resident #85's Incident and Accident (I&A) Reports since admission indicated the resident had a fall on 01/26/2024, 01/27/2024, two on 01/28/2024, two on 01/31/2024, 02/13/2024, 02/15/2024, two on 02/20/2024, two on 02/24/2024, 03/04/2024, 03/19/2024, 04/05/2024, 04/09/2024, 04/11/2024, 04/18/2024, 04/29/2024, 04/30/2024, two on 05/01/2024, 05/02/2024, 05/04/2024, 05/07/2024. The total number of incident reports indicated the resident had 25 falls since admission, one that resulted in a laceration above the resident's eyebrow and bruising to the face. These reports are not part of the resident's medical record. A review of Family Care Plan Meeting Summary, dated 05/02/2024 indicated staff discussed the resident's two falls with the resident's spouse. There was nothing else documented about the falls. At the time of the meeting, the resident had 22 falls. During an observation on 05/21/2024 at 9:23 AM, Resident #85 was sitting in their wheelchair near the nurse's desk with a cushion underneath the resident. The resident did not have a wheelchair alarm or a lap buddy present. During an observation on 05/22/2024 at 7:21 AM, Resident #85 was sitting in their wheelchair in the dining room with a cushion underneath the resident. The resident did not have a wheelchair alarm or a lap buddy present and was wearing regular socks, not non-skid socks, and no shoes. During an interview on 05/21/2024 at 6:05 PM, Resident #85's family member stated they were only aware of three to four falls that the resident had since admission. The family member stated she was only aware of fall interventions of a monitor to the resident's bed and chair. During an interview on 05/21/2024 at 10:53 PM, Licensed Practical Nurse (LPN) #2 stated she was familiar with Resident #85 and that the resident thinks they can stand up and walk but could not. LPN #2 stated the resident's fall interventions included a mat on either side of the bed, a bed alarm but not a chair alarm, and to keep the resident close to the nurse's desk for observation. LPN #2 stated in order to know what interventions are in place, she would review the Incident and Accident (I&A) reports or call their supervisor and ask. LPN #2 stated the resident has a care plan, but the interventions are not listed there and are only located on the I&A. LPN #2 stated after a resident falls, they complete an I&A and the supervisor and/or Director of Nursing (DON) tells the staff what intervention needs to be put into place. LPN #2 stated they only document on the I&A for the fall and do not document anything in the resident's progress notes and that is how she was trained. During an interview on 05/22/2024 at 7:25 AM, Certified Nursing Assistant (CNA) #4 stated she was familiar with Resident #90 and the resident had numeral falls that she was aware of. CNA #4 stated fall interventions for Resident #85 included a bed alarm and fall mats to both sides of the bed. CNA #4 stated the resident used to have a lap buddy and a chair alarm, but those were no longer in place. CNA #4 stated all fall interventions should be in the resident's care plan. During an interview on 05/22/2024 at 7:28 AM, CNA #5 stated she was familiar with Resident #85 and the resident had fallen before because the resident will try to stand up and walk but the resident did not have any balance. CNA #5 stated the resident's fall interventions included an alarm on the resident's bed and chair and to just keep an eye on the resident. CNA #5 stated those interventions would be in the resident's care plan, but she had not reviewed Resident #85's care plan in a long time. When asked how she would know if fall interventions were changed, she stated the facility would place in-services at the nurse's station for updates. During an interview on 05/22/2024 at 7:32 AM, LPN #6 stated she was familiar with Resident #85. LPN #6 stated fall interventions for Resident #85 included fall mats and a pressure pad to the resident's bed and that's all she was aware of. LPN #6 stated fall interventions should be included in the resident's care plan. LPN #6 stated when a resident falls, the nurse has to complete an I&A and the MDS Coordinator will place the interventions on the I&A and then update the resident's care plan. When asked if the interventions are listed on the I&A but not in the care plan, how staff would know what interventions were put into place and LPN #6 stated the nursing staff charts on the I&A for three days, in the note's sections, which is not part of the resident's medical record. During an interview on 05/22/2024 at 8:12 AM, RN #7 stated she was familiar with Resident #85 and that the resident had numerous falls and for most of their falls, the resident would reach down like they were getting something off of the floor or the resident would throw their legs off the side of the bed and slide down and sit on the floor mat and that was how most of the falls happened. Registered Nurse (RN) #7 stated fall interventions for Resident #85 were a bed alarm and wedge cushion for the wheelchair. Previous interventions included therapy evaluation, a lap body, and another seat cushion. RN #7 stated those interventions were listed on the I&As, which are not part of the resident's medical record, but should also be included on the resident's care plan. RN #7 when completing an I&A for a fall, nursing staff have to document on the resident for three days in the notes section of the I&A and then the management team can discuss every fall and what intervention could be put into place. RN #7 stated nursing staff only document in the notes section within the I&A, which is not part of the resident's medical record and CNAs cannot access I&As. RN #7 stated the MDS Coordinator was responsible for updating the resident's care plan and she was made aware of the I&A during the daily morning meeting. RN #7 stated she reviewed care plans to ensure care plan interventions were transcribed appropriately based on the I&A. RN #7 stated CNAs are made aware of the interventions by having access to the resident's care plan, but most of the time, CNAs are made aware via in-services. At this time, RN #7 reviewed Resident #85's current care plan and stated based on the care plan, the resident should have a lap buddy and a wheelchair alarm. RN #7 stated an acute illness was not an appropriate intervention for a fall, nor was behavior. RN #7 stated that Staff educated was not enough information to indicate what staff were educated on related to falls. At this time, RN #7 stated she should not have said that she had reviewed the resident's care plan because it was not up to date. During an interview on 05/22/2024 at 9:06 AM, LPN #8 stated she was familiar with Resident #85 and that the resident had some falls and that the resident liked to kneel in the floor in the resident's room. LPN #8 stated she would have to look up fall interventions for the resident and could not recall any off the top of her head, but the facility had tried a pressure pad alarm and fall mats and current interventions should be on the resident's care plan. Per LPN #8, the MDS Coordinator was responsible for updating the resident's care plan and was not aware of anyone else that had access to editing the resident's care plan. LPN #8 stated after a resident falls, the nursing staff completes an I&A and the resident's fall intervention for that fall is placed on the I&A. LPN #8 stated the MDS Coordinator is either emailed or the I&A is discussed during the morning meeting and that is how she is made aware of what intervention needs to be added to the resident's care plan. LPN #8 stated they only document on the resident's fall within the I&A, which is not part of the resident's medical record. LPN #8 stated she frequently checked the resident's care plan for accuracy and discussed interventions during the morning meeting. At this time, LPN #8 also reviewed the resident's current care plan and stated the resident had a current intervention of a lap buddy, but it thought it had been revised to a different intervention and it should not be on the resident's care plan. LPN #8 stated that acute illness was not an intervention and that staff education listed as an intervention did not provide was education was provided. When asked if intervention successful with no context was an appropriate intervention, she stated she would have to look at the IA& to see what the intervention was because it was not listed on the care plan. LPN #8 stated that per the resident's care plan, an alarm should be on the resident's wheelchair but was unaware if one was in place. During an interview on 05/22/2024 at 11:03 AM, LPN #9 stated she was familiar with Resident #85 has had many falls and one of the resident's falls resulted in a bruised face, was sent to the hospital, and had to have a laceration to their face glued. LPN #9 stated the resident had previous fall interventions that included a lap buddy, alarms, and a wedge cushion for the resident's wheelchair. LPN #9 stated that fall interventions would be included on the resident's care plan and that she did not complete any I&As because she only dealt with wounds. During an interview on 05/22/2024 at 1:07 PM, the MDS Coordinator reviewed Resident #85's I&As and stated the resident had 24 falls since admission. At this time, the MDS Coordinator reviewed the resident's care plan and stated that she had discontinued the intervention of the lap buddy and the wheelchair alarm for resident #85 because she was instructed to do so by RN #7 that morning. The MDS Coordinator stated that based on the care plan, the resident should have had a lap buddy and a wheelchair alarm. The MDS Coordinator stated that acute illness that was listed as an intervention should not be considered an intervention, as well as staff education. The MDS Coordinator stated, behavior related and interventions successful listed as an intervention was not appropriate because it did not provide any details. The MDS Coordinator stated she only put the interventions on the resident's care plan based on the interdisciplinary team's decision during the morning meetings and that she does not review the actual I&A and is only verbally told about the resident's fall. The MDS Coordinator stated the resident's care plan did not clearly define interventions listed for the nursing staff to follow and the DON was responsible for oversight of the care plan process. During an interview on 05/22/2024 at 2:12 PM, the DON stated she was only aware of fall interventions of floor mats and non-skid socks and would have to review the I&As for other interventions for Resident #85. The DON stated fall interventions should be in the resident's care plan and LPNs could review the I&A report. The DON stated that when a resident falls, nursing staff are to document everything related to the fall within the I&A report, which is not part of the medical record. The DON stated that nursing staff, not including CNAs, have access to the I&A reports. The DON stated the MDS Coordinator was responsible for updating the resident's care plan, that she was on the Interdisciplinary Team (IDT), and was verbally told how to update the resident's care plan and was not provided with the actual I&A report to review. The DON stated she reviewed the resident's care plan weekly to ensure interventions were transcribed accurately and there was no auditing process for accuracy of the care plan, and she was responsible for oversight of the accuracy of the care plans. The DON stated that CNAs were made aware of fall interventions by reviewing the resident's care plan. The DON stated the intervention of the lap buddy should have been removed from the resident's care plan on 04/16/2024 but was not due to an oversight. The DON also stated that she had just completed training and was made aware that acute illness could not be used as an intervention and the facility had stopped using that intervention, however, the facility did not go back and correct current care plans to discontinue acute illness as an intervention. The DON stated that behavior should not have been listed as an intervention because it was the cause of the fall and not an intervention. The DON stated staff educated was an appropriate intervention, however the care plan did not indicate what education was provided. The DON also verified that the resident did not have a wheelchair alarm and it should have been discontinued from the resident's care plan. The DON stated staff should update the resident's care plan when an intervention needs to be discontinued. During an interview on 05/22/2024 at 4:46 PM, the Administrator stated she was aware that falls were an issue within the facility, and she expected her staff to update the resident's care plan timely and accurately and interventions should be removed from the care plan if they were no longer effective. 2. A review of the Admission Record, indicated the facility admitted Resident #90 with diagnoses that included age related cognitive decline, muscle weakness, cognitive communication deficit, difficulty walking, dementia, and vertigo. The Signification Change MDS, with an ARD of 04/17/2024, revealed Resident #90 had a BIMS score of 5 which indicated the resident had severe cognitive impairment. Further review of the MDS indicated the resident had two falls with no injury and one fall with major injury. A review of Resident #90's Care Plan, initiated on 11/07/2023, revealed the resident was at risk for falls related to impaired balance, incontinence, and poor awareness of safety needs. Interventions included4 acute illness (with no context); family education (with no context); padded floor pad to open side of bed; grip around bathroom bar; staff education (with no context); staff changed intervention after requesting I&As (with no context); attempt grip socks at bedtime; anti-rollbacks to wheelchair, document all behaviors which are not usual for the resident and report to nurse/doctor; keep call light, water, and frequently used items in reach; monitor for changes in condition that may warrant increased supervision/assistance and notify the doctor; review information on falls and attempt to determine cause of falls; and staff to assist with performing ADL care as requested/needed. A review of Resident #90's Incident and Accident reports since admission indicated the resident had a fall on 11/26/2024 (outside of the facility), 12/07/2024, 01/28/2024, 03/04/2024, 03/07/2024, 04/11/2024, 04/19/2024, and 04/24/2024. The total number of incident reports indicated the resident had eight falls since admission, one that resulted in a fractured back, and one resulted in a hematoma to the left side of their forehead. A review of Fall Risk Evaluation indicated Resident #90 was evaluated for falls nine times since the resident was admitted . Seven of the evaluations indicated the type as Post Fall and all nine evaluations indicated the resident was At Risk for falls. Each Fall Risk Evaluation included level of consciousness, history of falls, ambulation status, vision status, balance, blood pressure, medication, change in mental status, and predisposing disease. The evaluations did not include any other information, such as interventions. During an interview on 05/21/2024 at 11:16 PM, the LPN #3 stated she was familiar with Resident #90 and was aware the resident had a fall that resulted in a fractured back. LPN #13 stated the resident had fall interventions that included non-skid strips in the resident's bathroom and then stated she needed to look at the resident's I&As to see what other fall interventions the resident had. LPN #13 stated she was trained to put the fall interventions in the I&A and that was the only place she knew to look for fall interventions. LPN #13 stated that CNAs do not have access to view the I&A and only nurses do. When asked how CNAs are made aware of the interventions, since they do not have access to the I&As, she stated the nurses verbally tell the CNAs in report and sometimes there are in-services completed. When asked if the interventions should also be in the resident's care plan, LPN #3 stated they should, but nurses do not do anything with the care plan and just review the I&As. LPN #3 verified that the MDS Coordinator updates the resident's care plan. LPN #3 stated when completing an I&A, the DON would typically tell the nurse what intervention to include, but if the previous intervention was successful, the nurse would just document interventions successful. During an interview on 05/22/2024 at 11:19 AM, LPN #15 stated she was familiar with Resident #90, that the resident had numerous falls in which one fall resulted in the resident fracturing their back and another resulted in bruising to the resident's face because the resident was unsteady on their feet. LPN #15 stated the resident had fall interventions of fall mats to the side of the resident's bed, non-skid socks, and shoes, and had been placed in a wheelchair after the fall resulting in the fractured back. LPN #15 stated the interventions should be in the resident's care plan. LPN #15 stated after a resident falls, the nurse completes an I&A, and the DON assists the nurse with putting a fall intervention on the I&A. LPN #15 stated the MDS Coordinator was responsible for updating the resident's care plan and LPN #15 did not review the care plan for accuracy. At this time, LPN #15 reviewed Resident #90's care plan and stated the interventions of family and staff education should include what the family and staff were educated on. LPN #15 stated the care plan did not identify all interventions clearly in order for a certified nursing assistant (CNA) to understand. During an interview on 05/22/2024 at 11:50 AM, CNA #10 stated she was familiar with Resident #90 and was aware the resident had a fall that resulted in a fractured back and one that resulted in a bruise to the resident's forehead. CNA #10 stated fall interventions included the resident was now in a wheelchair, making sure the resident had shoes on, and redirecting the resident. CNA #10 stated she would have to ask what other interventions the resident had. CNA #10 stated acute illness and family education listed as an intervention on the resident's care plan was not enough information for her to know what the actual intervention was. During an interview on 05/22/204 at 12:03 PM, LPN #1 stated she was familiar with Resident #90 and the resident was always looking for something to do, such as folding clothes. LPN #1 stated she was aware of the fall interventions of floor mats but could not recall any other interventions and she would have to look at the resident's care plan. At this time, LPN #1 reviewed the resident's care plan and stated the care plan did not identify the interventions clearly, however, the older CNAs would know but the newer CNAs might not know what the interventions were. When asked how acute illness was an intervention, LPN #1 stated the DON would have to answer that question. LPN #1 stated the intervention regarding family education did not state what the actual intervention was and should include what the family was educated on. LPN #1 stated staff should know what those interventions mean and when the LPN was asked how, LPN #1 stated, I don't know. LPN #1 stated the MDS Coordinator was responsible for updating the resident's care plan and the DON or Assistant Director of Nursing (ADON) should monitor the care plan for accuracy. During an interview on 05/22/2024 at 12:51 PM, the MDS Coordinator reviewed Resident #90's I&As and stated the resident had 8 falls since admission with some resulting in injury. At this time, the MDS Coordinator reviewed the resident's care plan and stated she updated the intervention of staff education yesterday as instructed to do so by the DON. The MDS Coordinator stated every morning during the morning meeting, the IDT verbally tells her what interventions to put in the resident's care plan and was told to include acute illness as an intervention. The MDS Coordinator stated the intervention of family education did not provide enough detail. The MDS Coordinator stated either a nurse or the IDT team notifies her if an intervention should be discontinued. The MDS Coordinator stated she was part of the IDT team and when she was asked about completing a root cause analysis, the MDS Coordinator stated the team reviews the previous fall interventions but was not sure if this meeting was documented anywhere. During an interview on 05/22/2024 at 2:12 PM, the DON stated fall interventions should be in the resident's care plan and LPNs could review the I&A report. The DON stated that when a resident falls, nursing staff are to document everything related to the fall within the I&A report, which is not part of the medical record, and nothing related to the fall should be within the medical record. The DON stated that nursing staff, not including CNAs, have access to the I&A reports. The DON stated the MDS Coordinator was responsible for updating the resident's care plan, that she was on the IDT team, and was verbally told how to update the resident's care plan and was not provided with the actual I&A report to review. The DON stated she reviewed the resident's care plan weekly to ensure interventions were transcribed accurately and there was no auditing process for accuracy of the care plan, and she was responsible for oversight of the accuracy of the care plans. The DON stated that CNAs were made aware of fall interventions by reviewing the resident's care plan. The DON also stated that she had just completed training and was made aware that acute illness could not be used as an intervention and the facility had stopped using that intervention, however, the facility did not go back and correct current care plans to discontinue acute illness as an intervention. The DON stated that behavior should not have been listed as an intervention because it was the cause of the fall and not an intervention. The DON stated staff educated was an appropriate intervention, however the care plan did not indicate what education was provided. The DON stated all falls are documented within Risk Management, which was not part of the resident's medical record and staff were instructed to put all notes related to the fall within the I&A in Risk Management. The DON stated staff should update the resident's care plan when an intervention needs to be discontinued. 37878 3. A review of the Admission Record, indicated Resident #81 with diagnoses of Alzheimer's disease, Parkinsonism, dementia with behavioral disturbance, repeated falls, anemia, and type 2 diabetes mellitus. The Signification Change MDS, with an ARD of 04/02/2024, revealed Resident #81 had a BIMS score of 6 which indicated the resident had severe cognitive impairment. A review of Resident #81's Comprehensive Care Plan revealed the resident was at risk for bleeding date initiated 10/24/2024, interventions included to administer antiplatelet medication as ordered; at risk for easily bruising or skin tears. Nurse to notify doctor of any new skin issues. The care plan did not include any intervention to protect skin. During an observation on 05/22/2024 at 8:36 AM, Resident #81 was sitting in a common area in a wheelchair, wearing a short sleeve shirt. Multiple reddened to purple discolorations to both forearms and tops of hands were observed. During a concurrent observation and interview on 05/22/2024 at 8:40 AM, CNA #16 confirmed Resident #81 had discolorations to both arms and tops of hands and had no interventions in place to protect the skin. During a concurrent observation and interview on 05/22/2024 at 8:52 AM, LPN #17 confirmed Resident #81 had discolorations to both arms and tops of hands and had no interventions in place to protect the skin. During a concurrent observation and interview on 05/22/2024 at 12:34 PM, LPN #9, Treatment Nurse, confirmed Resident #81 had discolorations to both arms and tops of hands and had no interventions in place to protect the skin. During a concurrent observation and interview on 05/22/2024 at 12:52 PM, LPN Supervisor #8 confirmed Resident #81 had discolorations to both arms and tops of hands and had no interventions in place to protect the skin. On 05/22/24 at 3:50 PM LPN, Hall Supervisor #8 provided a policy titled, 'Skin Audits by Nursing Assistants' date implemented 3/13/23, date reviewed/revised 01/03/2024. Nursing assistants shall inspect all skin surfaces during bath/shower and report any concerns to the resident's nurse immediately after the task. Nursing assistants shall report changes in skin condition that are noted during any care procedure. Skin conditions that shall be reported include but are not limited to: redness bruising swelling rashes, hives, blisters, skin tears, open areas, ulcers, lesions.' 39839 4. A record review revealed Resident #31 had a fall on 03/31/2024, with no injuries noted. Resident #31's Care Plan titled, I am at risk for falls related to history of falls, impaired balance, and incontinence listed a new intervention for padded floor pads to the open and closed side of bed that was initiated on 04/01/2024. Further record review revealed Resident #31 had another fall on 04/02/2024 and was transferred to the acute hospital for evaluation. Review of Resident #31's care plan for risk for falls listed acute illness as a new intervention that was initiated on 04/03/2024. Additional record review revealed Resident #31 had another fall on 04/27/2024 with no injuries noted. Review of Resident #31's fall risk care plan revealed a new intervention to place a grip around the toilet handrail that was initiated on 04/29/2024. On 05/21/2024 at 1:45PM, Surveyor observation revealed that Resident #31's bed was in the low position and included fall mats to both sides of the bed. On 5/22/24 at 2:15PM, an interview with the DON revealed acute illness was listed as an intervention because if you treat the illness, the main cause of the fall would be taken care of. However, the DON further stated that she was recently educated at a nursing conference not to use acute illness as an intervention and the facility stopped this practice. The DON confirmed that acute illness is not really a fall prevention intervention, and the facility has not discontinued the intervention from Resident #31's care plan. 46004

Based on observation, interview and record review, it was determined the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days, for two (Resident #9 and #70) of three residents reviewed for psychotropic medications. Specifically, the facility failed to include a duration for an as-needed (PRN) psychotropic medication. These failures affected residents who received psychotropic medications and increased the risk of unnecessary medication administration, adverse reactions, and unwanted side effects of the medications. Findings included: 1. Review of an Admission Record dated [DATE] for Resident #9 reflected a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including dementia, and anxiety disorder. Observation on [DATE] during initial rounds between 9:00 AM and 11:30 AM revealed Resident #9 in bed, sleeping. Observation on [DATE] at approximately 9:00 am, when interviewed, Resident #9 did not answer questions appropriate to the conversation. Review of an Annual MDS assessment dated [DATE] for Resident #9, Section I indicated a diagnosis of anxiety disorder. Review of a Quarterly MDS assessment dated [DATE] for Resident #9 Section I indicated a diagnosis of anxiety disorder. Section C indicated Resident #9 had a BIMS of 3, indicating impaired cognitive function. Review of a care plan for Resident #9 initiated on [DATE], and last revised on [DATE], reflected a focus of a risk of 'I have anti-anxiety medication use. Interventions included to .Administer anti-anxiety medications as ordered by physician . Review of [DATE] Order Summary Report for Resident #9 reflected, Ativan tablet 0.5 mg one tablet every 4 hours as needed for anxiety, ordered on [DATE], and a start date of [DATE]. Review of the [DATE] MAR for Resident #9 reflected an order for Ativan 0.5 mg one tablet by mouth every four hours as needed for anxiety. The start date was [DATE]. Review of a Consultant Pharmacist Communication for Resident #9 dated [DATE] reflected, PRN Ativan 0.5mg po q4H prn for Anxiety is prescribed for this resident. CMS Regulations require periodic re-evaluation of PRN Psychotropic Medications for possible discontinuation. Please review the use of PRN Ativan 0.5mg po q4H prn in this resident and consider discontinuation of therapy. If PRN Ativan prn is still Medically Necessary, please document the Clinical Rationale for continued use .[physician] Response. Do not discontinue medication. Patient continues to have episodes of packing up room & belongings to go back home looks for deceased husband gets distressed There was no duration indicated for the continued use of the psychotropic medication in the response. 2. Review of an Admission Record dated [DATE] for Resident #70 reflected a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including major depressive disorder. Observation on [DATE] during initial rounds between 9:00 AM and 11:30 AM revealed Resident #70 was resting in bed, with eyes closed. Observation on [DATE] at 10:54 AM revealed Resident #70 was in bed, sleeping. Review of a Significant Change MDS assessment dated [DATE] for Resident #70, Section I indicated the box for a diagnosis of anxiety disorder, was not checked. Review of a Quarterly MDS assessment dated [DATE] for Resident #70, Section I indicated the box for a diagnosis of anxiety disorder, was not checked. Review of a care plan for Resident #70 revealed he was receiving Hospice Care, that initiated on [DATE]. An additional focus was 'I have psychotropic medication use, initiated on [DATE] and last revised on [DATE]. There was a focus of, I have anti-anxiety medication use, that was initiated on [DATE]. Review of [DATE] Order Summary Report for Resident #70 reflected, Admit to [hospice agency], dated [DATE]. There was an order for Buspirone 10 mg one tablet every 6 hours as needed for anxiety, ordered on [DATE]. Review of the [DATE] MAR for Resident #70 reflected an order for Buspirone 10 mg by mouth every 6 hours as needed for anxiety, ordered on [DATE]. There was no duration in the order. Review of a Consultant Pharmacist Communication for Resident #70 dated [DATE] reflected, This resident has orders for Hospice. PRN Buspirone (Buspar) 10 mg po q6H prn for Anxiety is prescribed for this resident, which was ordered on [DATE]. PRN orders for Psychotropic Medications should be limited to 14 days unless Medically Necessary, per CMS Regulations. If PRN Psychotropic Medications are medically necessary beyond 14 days, the Clinical Rationale for continued use and Duration of use must be documented. Please review the use of PRN Buspirone 10mg po q6H prn in this resident and consider discontinuation of therapy. If PRN Buspirone prn is Medically Necessary, please document the Clinical Rationale for continued use and indicate the Duration of use .Response: Patient is on Hospice and Hospice did prescribe PRN med in the event it is needed for end-of-life support to help with anxiety & keep comfortable There was no duration indicated for the continued use of the psychotropic medication in the response. During an interview on [DATE] at 2:12 PM the DON was asked about PRN psychotropic medications for Resident #9 and Resident #70. She stated all PRN psychotropic medications should be discontinued after 14 days. She added Resident #70's PRN Buspar, for anxiety, was a hospice order. Review of a policy titled, Pharmacy Services, dated ,d+[DATE] provided by the ADM as the current policy, reflected, .Compliance Guidelines: 1. The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice .

Based on interviews, record review, it was determined the facility failed to notify the resident and the resident's representative in writing of a transfer to the hospital and failed to ensure the transfer notice had all required information regarding the transfer for 4 (Resident #31, Resident #26, Resident #85, and Resident #90) of 5 sampled resident reviewed for hospitalization . Findings include: A review of a facility policy titled, Transfer and Discharge (including AMA), implemented on01/2024, indicated, The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer and discharge. b. The effective date of transfer or discharge. c. The specific location .to which the resident is to be transferred or discharged . d. An explanation of the right to appeal the transfer or discharge to the State. e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests. f. information on how to obtain an appeal form. g. Information on obtaining assistance in completing and submitting the appeal hearing request. h. The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. 1. A review of the Census tab within Resident #85's electronic health record indicated the resident was sent to the hospital three times from 01/10/2024 through 05/21/2024. A review of a transfer letter for Resident #85 included the resident's representative name, date, resident #85's name, the location in which the resident was sent, the facility phone number, and Registered Nurse (RN) #7's name. No other information was listed on the document. During an interview on 05/21/2024 at 6:05 PM, Resident #85's family member stated she had never received a letter from the facility stating the resident had been sent to the hospital and the facility only notified her by phone. During an interview on 05/21/2024 at 10:53 PM, LPN #2 stated when a resident is sent to the hospital, she contacts the resident representative via phone and stated she had never sent a transfer letter before. During an interview on 05/21/2024 at 11:16 PM, LPN #3 stated when a resident is sent to the hospital, she contacts the resident representative via phone and the facility was not required to send out a transfer letter. During an interview on 05/22/2024 at 7:32 AM, LPN #6 stated when a resident is sent to the hospital, she contacts the resident representative via phone and has never sent out a transfer letter. During an interview on 05/22/2024 at 8:12 AM, RN #7 stated when a resident is sent to the hospital, she completes a transfer letter that is given to the MDS Coordinator. RN #7 stated the MDS Coordinator then mailed the letter to the resident's representative. During an interview on 05/22/2024 at 9:06 AM, LPN #8 stated when a resident is sent to the hospital, the nursing staff calls the family to notify them of the transfer and completes a transfer letter that is given to the MDS Coordinator. LPN #8 stated she did not know what the MDS Coordinator did with the letters but LPN #8 did not mail the letter. During an interview on 05/22/2024 at 1:07 PM, the MDS Coordinator stated when a resident is sent out to the hospital, she receives a copy of the transfer letter from the nursing staff but did not mail anything to the resident's responsible party. During an interview on 05/22/2024 at 2:12 PM, the DON stated the hall nursing supervisors were responsible for completing the hospital transfer letters and mailing them to the resident's responsible party, then the supervisor provides the MDS Coordinator with a copy. The DON stated the only information provided on the transfer letter was the date the resident was sent out, where they were sent, and the reason for the transfer. During an interview on 05/22/2024 at 4:46 PM, the Administrator stated the hall nursing supervisors were responsible for completing the hospital transfer letters and mailing them to the resident's responsible party, then the supervisor provides the MDS Coordinator with a copy. The Administrator stated she was just made aware that the transfer letters do not include information about the State Agency, Ombudsman, or the resident's right to appeal and their transfer form did not have all of the correct information. At this time, the Administrator was made aware that the MDS Coordinator, nor the nursing staff, had been mailing the transfer letters. 2. A review of the transfer letters for Resident #90 included the resident's representative name, date, resident #90's name, the location, in which the resident was sent, the facility phone number, and Registered Nurse (RN) #7's name. No other information was listed on the document. A total of five letters were provided indicating the number of times the resident was sent to the hospital. During an interview on 05/21/2024 at 11:16 PM, LPN #3 stated when a resident is sent to the hospital, she contacts the resident representative via phone and the facility was not required to send out a transfer letter. During an interview on 05/22/2024 at 11:03 AM, LPN #9 stated when a resident is sent to the hospital, the facility calls the resident representative and does not send out a letter. During an interview on 05/22/204 at 12:03 PM, LPN #1 stated when a resident is sent to the hospital, the facility calls the resident representative and LPN #1 will fill out a letter and give it to upper management for them to mail out. During an interview on 05/22/2024 at 1:07 PM, the MDS Coordinator stated when a resident is sent out to the hospital, she receives a copy of the transfer letter from the nursing staff but did not mail anything to the resident's responsible party. During an interview on 05/22/2024 at 2:12 PM, the DON stated the hall nursing supervisors were responsible for completing the hospital transfer letters and mailing them to the resident's responsible party, then the supervisor provides the MDS Coordinator with a copy. The DON stated the only information provided on the transfer letter was the date the resident was sent out, where they were sent, and the reason for the transfer. During an interview on 05/22/2024 at 4:46 PM, the Administrator stated the hall nursing supervisors were responsible for completing the hospital transfer letters and mailing them to the resident's responsible party, then the supervisor provides the MDS Coordinator with a copy. The Administrator stated she was just made aware that the transfer letters do not include information about the State Agency, Ombudsman, or the resident's right to appeal and their transfer form did not have all of the correct information. At this time, the Administrator was made aware that the MDS Coordinator, nor the nursing staff, had been mailing the transfer letters. 39839 3. On 05/22/2024 at 9:00 AM, Surveyor record review revealed Resident #31 was transferred to the hospital on 03/04/2024, 04/02/2024, 04/15/2024, and 05/16/2024. Further record review revealed the transfer notices sent with Resident #31 did not include the required contents such as a statement of the resident's appeal rights and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. On 05/22/2024 at 1:15PM, interview with the administrator confirmed that the facility's transfer notices did not include the required contents. 46004 4. Review of an Admission Record dated 05/22/2024 for Resident #26 reflected an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including essential hypertension, heart failure, unspecified dementia, dislocation of right hip, muscle weakness, cognitive communication deficit, and history of transient ischemic attack. Review of an Un-Witnessed Fall Incident report dated 04/18/2024 at 19:40 (7:40 PM) for Resident #26 reflected the resident was 'assessed resident for injuries and pain .send to ED [emergency department] for eval [evaluation]' after a fall. Review of the written notification of transfer for the transfer to the hospital on 04/18/24 reflected, On 04/18/24, [Resident #26] was sent to [hospital name] in Batesville, Arkansas for a change of condition. If you have any questions or concerns, please call [telephone number]. The form did not include a notice to the Office of the State Long-Term Care Ombudsman, or the address/email/telephone number to the Office of the State Long-Term Care Ombudsman.

Based on observation, interview, and record review, it was determined the facility failed to ensure each resident received treatment and care in accordance with the comprehensive person-centered care plan for one (Resident #6) of three residents reviewed. Specifically, the facility did not document blood pressures before administration of a blood pressure lowering medication with hold parameters. These failures had the potential to cause residents to experience unwanted side effects of medications such as lightheadedness, dizziness, and falls causing major injuries. Findings included: Review of Resident #6's Admission Record dated 05/22/2024 reflected an admitted [DATE] with diagnoses including essential hypertension, history of transient ischemic attack (mini-stroke), muscle weakness and unsteadiness on feet. Observation on 05/21/2024 at 1:00 PM revealed Resident #6 was in bed, sleeping. Resident #6 did not speak to the Surveyor. Review of Resident #6's Significant Change Minimum Data Set (MDS) assessment dated [DATE] reflected an active diagnosis of hypertension. Review of Resident #6's Quarterly MDS assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 5, suggesting a severe cognitive impairment (lots of difficulty in making daily decisions about care). In addition, there was an active diagnosis of hypertension. Review of Resident #6's Care Plan initiated on 05/10/2023 and last revised on 10/20/2023 reflected a focus area of being at risk for complications r/t (related to) hypertension. Interventions included, .Obtain blood pressure readings as ordered (at least weekly) notify MD [Medical Doctor] of significant readings . Review of Resident #6's May 2024 Order Summary Report reflected an order dated 05/10/2023 for, Losartan Potassium oral tablet 25 mg [milligrams] .give 1 tablet by mouth one time a day related to Essential (primary) hypertension .Hold if SBP <110 [systolic blood pressure less than 110], and/or DBP <50 [diastolic less than 50] . Review of Resident #6's May 2024 Medication Administration Record (MAR) reflected Losartan Potassium 25 mg give one tablet by mouth one time a day, ordered on 05/11/2023, with instructions to, Hold if SBP <110, and/or DBP <50. Further review reflected the medication was administered 05/01/2024 through 05/15/2024, and 05/18/2024 through 05/21/2024, and no documented blood pressures with the administration of the blood pressure lowering medications. Interview on 05/22/2024 at 1:07 PM with Licensed Practical Nurse (LPN) A revealed the blood pressures for the administration of Resident #6's Losartan were not documented in the EMR (electronic medical record). Interview on 05/22/2024 at 2:12 PM with the Director of Nursing (DON) revealed the expectation was staff followed physician's orders, if blood pressure parameters were ordered then the residents' blood pressure should be assessed. Review of the facility's policy titled, Medication Administration dated April 2024, provided by the Administrator (ADM) as the current policy, reflected, .4. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .15. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR . Review of the facility's policy titled, Pharmacy Services,' dated 02/2024 provided by the ADM as the current policy, reflected, .7. The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs, goals and quality of life that are consistent with current standards of practice and meet state and federal requirements .

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for one (Resident #9) of four residents reviewed for assessment. Specifically, Resident #9's Quarterly MDS assessment indicated the resident had an ostomy. The resident did not have an ostomy. Findings included: Review of an Admission Record dated 05/22/2024 for Resident #9 reflected a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including dementia, constipation, and essential hypertension. Review of an Annual MDS Assessment with an Assessment Reference Date (ARD) of 09/14/2023 for Resident #9, Section H indicated there was no ostomy. Review of a Quarterly MDS Assessment with an ARD of 03/12/2024 for Resident #9, Section H indicated there was an ostomy. Section C indicated Resident #9 had a BIMS of 3, indicating impaired cognitive function. Interview on 05/22/2024 at 8:10 AM with Licensed practical Nurse (LPN) #1, revealed Resident #9 did not have an ostomy. Interview on 05/22/2024 at 12:31 PM with the Registered Nurse (RN) MDS Coordinator, revealed Resident #9 did not have an ostomy. She stated she would do a correction to the MDS assessment. Review of a policy titled, MDS 3.0 Completion,' dated 02/2024, provided by the Administrator (ADM) as the current policy, reflected, .1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity .

Based on observation, and interview, the facility failed to ensure food stored in the freezer was covered and/or sealed to prevent potential contamination or freezer burn and failed to ensure dietary staff washed their hands between dirty and clean tasks and before handling clean equipment to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 100 residents who received meals from the kitchen (total census: 103), as documented on a list provided by the Dietary Supervisor on 04/04/23. The findings are: 1. On 4/03/23 at 12:50 PM the following food items were on a shelf in the walk-in freezer: a. One opened box of corn dogs was not covered or sealed. b. One opened box of polish sausage was not covered or sealed. c. One opened box of beef steak fingers was not covered or sealed. d. One opened box of sopapillas dough was not covered or sealed. 2. On 04/03/23 at 3:39 PM, Dietary Employee (DE) #1 turned on the 3 compartment sink and washed the blender bowl, the blade and the lid. He sanitized each and placed them on a dish rack on the clean side of the 3 compartment sink and turned the water and the sanitizer button off with his bare hand. Without washing his hands, he picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who received a pureed diet. 3. On 04/03/23 at 3:56 PM, DE #1 turned off the sink faucet with his bare hand after washing and sanitizing food preparation equipment to be used in pureeing food items to be served to the residents. Without washing his hands, he picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents. 4. On 04/03/23 at 4:17 PM, DE #1 wore mittens on his hands. He picked a pot of refried beans from the stove and emptied it into 3 pans on the utility cart. He removed the mittens from his hands and placed them on the counter. He picked up 2 bags of bread from the bread rack and placed them on the counter. Without washing his hands, he picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents. 5. On 04/03/23 at 4:19 PM, DE #1 untied a bread bag with gloved hands, contaminating the gloves. With the same gloves on his hands, he reached into the bag to remove slices of bread. The Surveyor immediately stopped him and asked, What should you have done after touching dirty objects and before handling clean objects and/or food items? He stated, I should have rewashed my hands. 6. The facility policy titled, Hand Washing, provided by the Dietary Supervisor on 04/05/23 at 7:42 AM documented, .Procedure: Clean hands and exposed portions of arms . immediately before engaging in food preparation including working with exposed food. 1. When to Wash Hands: .After handling soiled equipment or utensils. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks . Before donning gloves for working with food. After engaging in other activities that contaminate the hands . 46032

Based on observation, record review, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 2 meals observed. This failed practice had the potential to affect 12 residents who received a pureed diet as documented on a list provided by the Dietary Supervisor on 04/04/23. The findings are: 1. On 04/03/23 at 12:14 PM, and at 12:20 PM, the following were on the steam table in the Magnolia Hall kitchen and in Aspen Hall kitchen: a. 3 pans of pureed ham, the meat was gritty with ground pieces of the burnt ham visible. b. A pan of pureed great northern beans, the consistency was lumpy and was not smooth. c. A pan of pureed spinach, the consistency of the pureed spinach was runny. d. A pan of pureed bread, the consistency of the pureed bread was lumpy and was not smooth, e. On 04/03/23 at 12:16 PM, the Surveyor asked Homemaker #1 to describe the consistency of the pureed food items on the steam table. She stated, Pureed ham was gritty. It has burnt particles of ham. Pureed spinach was runny. Pureed bread was lumpy. 2. On 04/03/23 at 3:22 PM, Dietary Employee (DE) #1 used a 4-ounce spoon to place 17 servings of cut green beans into a blender. He poured approximately 3 1/2 cups of the juice from the green beans into the blender, added 6 tablespoon of thickener and pureed. At 3:25 PM, he poured the pureed cut green beans into 3 pans. He covered each pan with foil and placed them in a warmer. The consistency of the pureed mixture was runny. 3. On 04/03/23 at 3:40 PM, DE #1 pureed refried beans for the supper meal. The consistency of the pureed mixture was not smooth. It was lumpy and had pieces of intact thickener in it. 4. On 04/03/23 at 4:28 PM, DE #1 pureed bread, the consistency of the pureed bread was runny. 5. On 04/03/23 at 5:24 PM, the Surveyor asked Homemaker #1 to describe the consistency of the pureed food items served to the residents. She stated, Pureed enchilada was lumpy and was not smooth. Pureed bread and pureed cut green beans were runny. 6. On 04/03/23 at 5:35 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 on Magnolia Hall to describe the consistency of the pureed food items served to the residents. She stated, Pureed enchilada was lumpy. Pureed cut green beans was too soupy. 7. On 04/03/23 a 5:58 PM, the Surveyor asked CNA #2 on Magnolia Hall to describe the consistency of the pureed food items served to the residents. She stated, Pureed enchilada had chunks in it. 46032

Based on observation, record review, and interview, the facility failed to ensure the pureed and regular diets were prepared and served as per the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 12 residents who received a pureed diet and 78 residents who received a regular diet according to the list provided by the Dietary Supervisor 04/04/23 at 7:55 AM. The findings are: 1. On 04/03/23, the lunch menu provided by the Dietary Supervisor documented residents on a regular diet were to receive 3 ounces of baked ham. 2. On 04/03/23 at 12:57 PM, 22 residents on Aspen Hall, 30 residents on Magnolia Hall and 26 residents on Willow Hall were served a small piece of sliced ham each. At 1:17 PM, the Surveyor asked the Dietary Supervisor to weigh the same amount of ham served to the residents who received regular diets on the Aspen Hall, Magnolia Hall, and Willow Hall. She did and it weighed 1.5 ounces, instead of 3 ounces. 3. On 04/03/23, the supper menu documented 2 enchiladas were to be served to each resident on a regular diet and residents on a pureed diet were to receive a #6 scoop (6 ounces) of pureed enchilada during the supper meal service. 4. On 04/03/23 at 3:58 PM, Dietary Employee (DE) #1 placed 10 servings of beef enchiladas into a blender, added beef broth and pureed. At 6:18 PM, the Surveyor asked DE #1 How many servings of enchilada did you use for the pureed diets? He stated, I put 10 servings. The Surveyor asked, How many residents do you have on pureed diets? He stated, We have 12 residents. It was my mistake 5. On 04/03/23 at 5:13 PM, on Aspen Hall, Homemaker #2 used a #8 scoop (4 ounces) to serve a single portion of pureed beef enchilada to the residents on pureed diets, instead of a #6 scoop Homemaker #2 served one enchilada to all the residents on regular diets, instead of 2 each. 6. On 04/03/23 at 5:26 PM, on Magnolia Hall, Homemaker #1 used a #8 scoop to serve a single portion of pureed beef enchilada to the residents on pureed diets, instead of a #6 scoop Homemaker #1 served one enchilada to all the residents on regular diets, instead of 2 each. 7. On 04/03/23 at 6:00 PM, the Surveyor asked Homemaker #1, What was the reason residents on a regular diet received one enchilada each? She stated, To make sure I have enough. I know they were supposed to get 2 each. I used a gray scoop [#8 scoop] to serve a single serving of pureed enchilada. 8. On 04/03/23 at 6:03 PM, the Surveyor asked Homemaker #2, What was the reason residents on a regular diet received one enchilada each? She stated, I thought they were supposed to have one each. I was told that the gray scoop was the right scoop to use, and I gave a serving of pureed beef enchilada to the residents on pureed diets. 46032

Based on observation, interview, and record review, the facility failed to ensure a Continuous Positive Airway Pressure (CPAP) and Nebulizer/Updraft supplies were properly stored to prevent contamination while not in use for 3 (Residents #65, #70 and #78) of 14 (Residents #1, #4, #10, #11, #17, #31, #33, #40, #48, #65, #70, #75, #78 and #82) sampled residents and failed to ensure oxygen usage was properly documented on the Medication Administration Record (MAR) for 1 (Resident #1) of 30 (Residents #1, #2, #3, #4, #10, #11, #16, #17, #22, #29, #31, #33, #37, #40, #44, #48, #52, #59, #63, #65, #70, #75, #78, #80, #82, #87, #90, #97, #252, and #302) sampled residents who had Physician Orders for oxygen therapy. The findings are: 1. Resident #1 had diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease (COPD) with (Acute) Exacerbation and Acute and Chronic Respiratory Failure with Hypoxia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy. a. A Physician's Order dated 07/01/22 documented, .Oxygen at 2-4 liters via nasal canula as needed for shortness of breath or O2 [oxygen] sat [saturation] < [less than] 90. Notify MD [Medical Doctor] if applied and monitor spo2 [oxygen saturation] every shift every 24 hours as needed for shortness of breath . b. The April 2023 Medication Administration Record (MAR) documented, Oxygen at 2-4 liters via nasal canula as needed for shortness of breath OR O2 sat<90. Notify MD if applied and monitor spo2 every shift every 24 hours as needed for shortness of breath -Start Date- 07/01/2022 . There was no documentation on the MAR that the oxygen had been utilized. c. On 04/03/23 at 12:42 PM, Resident #1 was lying in bed with a nasal cannula in place with tubing connected. Resident #1 informed the Surveyor she was having difficulty breathing. The end of the nasal cannula tubing was lying on floor and not connected to the oxygen concentrator. The Surveyor asked the Infection Control Preventionist (ICP) to accompany her into Resident #1's room. The ICP stated, [Resident #1] takes off her cannula. d. On 04/04/23 at 2:10 PM, Resident #1 was lying in bed with a nasal cannula in place. The Surveyor asked how often she used the oxygen. Resident #1 stated, Every day, but not all day. I don't like how it is on my face sometimes. e. On 04/05/23 at 11:30 AM, Resident #1 was lying in bed with a nasal cannula in place. f. On 04/05/23 at 3:44 PM, the Surveyor asked the Director of Nursing (DON) if Resident #1's MAR should be marked on the days the resident received oxygen therapy. The DON stated, It is marked if she has shortness of breath or if her sats are low. The Surveyor asked if the MAR should have been marked on 04/03/23 when Resident #1 reported shortness of breath and had utilized her oxygen. The DON stated, Yes, it should have. All of the residents have a PRN [as needed] order for oxygen. g. The facility policy titled, Oxygen Administration, provided by the Assistant Director of Nursing (ADON) on 04/05/2023 at 4:20 PM documented, .10. Oxygen tubing, nasal cannula/face mask must be changed weekly. When not in use the tubing, cannula, and facemask must be stored in a clear plastic bag to keep it free from contamination . The policy did not address documentation of oxygen therapy usage. 2. Resident #65 had diagnoses of Atherosclerotic Heart Disease, Acute Cough, and Intermittent Asthma Acute Execration. The Quarterly MDS with an ARD of 01/20/23 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a BIMS and did not receive oxygen therapy. a. A Physicians Order dated 06/22/22 documented, Oxygen at 2-4 liters via nasal cannula as needed for SOB [shortness of breath] or O2 SAT< 90 . every 24 hours as needed for shortness of breath . b. A Physicians Order dated 07/06/22 documented, .Ipratropium-Albuterol Sol. [solution] 0.5-2.5 (3) mg [milligrams]\ 3 ml [milliliters] 3 ml inhale orally every 4 hours as needed for SOB or wheezing via nebulizer . c. On 04/03/23 at 12:59 PM, Resident #65 was lying in bed eating breakfast. An updraft (nebulizer) was lying in the second drawer of the bedside dresser with no date and was not in a bag. The Surveyor asked Resident #65 if she used the nebulizer. She stated, Sometimes. The inside of the nebulizer had dry crystalized residue in it. d. The facility policy titled, Administration of Aerosol Medications, provided by the ADON on 04/05/23 at 4:20 PM documented, .The following steps are used in the delivery of aerosol medications, commonly called updraft therapy . It is the responsibility of each charge nurse to ensure that: .c. tubing/nebulizer will be stored in a clean plastic bag when not in use . 3. Resident #70 had diagnoses of Heart Failure, Multiple Sclerosis, and Obstructive Sleep Apnea. The Annual MDS with an ARD of 01/11/23 documented the resident scored 13 (13-15 indicates cognitively intact) on a BIMS and used a Continuous Positive Airway Pressure (CPAP). a. A Physician's Order dated 06/21/22 documented, .CPAP with home settings at bedtime. Nurse to place on resident at HS [hour of sleep] and to remove in the morning every shift . b. On 04/03/23 at 1:11 PM, Resident #70 was sitting up in bed. A CPAP mask with tubing was lying on the bedside dresser not in protective bag. The Surveyor asked, How often do you use your CPAP machine? Resident #70 stated, I use it whenever I am sleeping. c. On 04/04/23 at 8:48 AM, Resident #70 was sitting up in bed. A CPAP mask was sitting on top of the CPAP machine on the bedside dresser not in a protective bag. d. On 04/05/23at 4:10 PM Resident #70 was not in his room. His CPAP mask and tubing was lying on his bedside table not in a protective bag. e. On 04/05/23 at 4:10 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2, Are you the nurse caring for [Resident #70]? LPN #2 stated, Yes. I am taking care of that resident. The Surveyor asked LPN #2 to accompany her to Residents #70 room. The Surveyor asked, Do you see anything wrong with the placement of [Resident #70 ' s] C-PAP mask and tubing? LPN #2 looked at Resident #70's CPAP equipment that was lying on his bedside dresser and stated, It should be in a bag with the date and the residents name written on it. The Surveyor asked, Who is responsible for placing the CPAP mask in a protective bag? LPN #2 stated, The nurse is. The Surveyor asked, Why is it important that the resident ' s CPAP mask is placed in a protective bag when not in use? LPN #2 stated, Putting it in the bag keeps it from getting dirty. Labeling the bag makes sure you know who the mask belongs to. If it is not kept bagged, it becomes an infection control issue. I am going to take care of that right now and get a bag to put it in. 4. Resident #78 had diagnoses of Sleep Apnea and Parkinson's. The Admission MDS with an ARD of 01/22/23 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a BIMS and used a CPAP. a. a Physicians Order dated 01/19/23 documented, .CPAP with home settings at bedtime. Nurse to place on resident at bedtime and remove in the morning. Every day and Evening shift for sleep apnea . b. The Care Plan with an initiated date of 01/31/23 documented, .I use a continuous positive airway pressure (CPAP) at night. Staff to assist me as needed with use and care of CPAP . c. On 04/03/23 at 12:16 PM, Resident #78 was not in his room. A CPAP mask was lying on the bedside table not in a bag. There was no date on the CPAP. d. On 04/04/23 at 8:01 AM, Resident #78 was sitting on the side of the bed eating breakfast. The CPAP tubing and mask were draped over the bedside rail. The Surveyor asked if he wore the CPAP mask. He stated, Every night. e. On 04/05/23 at 8:30 AM, Resident #78 was sitting in his wheelchair eating breakfast. The CPAP tubing was wrapped around the rail of the bed. f. On 04/05/23 at 2:20 PM, the Surveyor accompanied LPN #1 to Resident #78's room and upon entering the room the Surveyor asked LPN #1 to look at the CPAP and asked if there was anything wrong. She stated, The cords are lying around, and it's not hooked up. I took the hose off and cleaned it. She pointed to the sink. The tubing and mask were lying on the sink not in an enclosed bag. The Surveyor asked what should be done with the tubing when not in use. She stated, It should be in a bag. g. On 04/05/23 at 3:25 PM, the Surveyor asked the DON when a CPAP, updraft, or oxygen was not in use, what should happen to the tubing and masks/mouthpiece. She stated, It should be stored in a bag. The Surveyor asked, Why should it be stored in a bag? She stated, It could be on the floor and get bacteria in it. h. On 04/05/23 at 4:10 PM, the Surveyor asked the ICP why it is important that the CPAP be stored in a bag. She stated, For cross contamination purposes. The Surveyor asked what could happen to the resident if cross contamination occurred. She stated, Respiratory Infections. i. The facility policy titled, Noninvasive Ventilation (CPAP, BiPAP (Bi-level Positive Airway Pressure), Trilogy), provided by the Assistant DON on 04/05/23 at 4:20 PM, does not address storage of tubing/mask when not in use. 42965 46868

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to address the care and monitoring required related to respiratory therapy for 3 (Residents #1, #65 and #70) of 30 (Residents #1, #2, #3, #4, #10, #11, #16, #17, #22, #29, #31, #33, #37, #40, #44, #48, #52, #59, #63, #65, #70, #75, #78, #80, #82, #87, #90, #97, #252 and #302) sampled residents who received respiratory therapy. This failed practice had the potential to affect 102 residents with physician's orders for oxygen. The findings are: 1. Resident #1 had diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease (COPD) with (Acute) Exacerbation and Acute and Chronic Respiratory Failure with Hypoxia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy. a. A Physician's Order dated 07/01/22 documented, .Oxygen at 2-4 liters via nasal canula as needed for shortness of breath or O2 [oxygen] sat [saturation] < [less than] 90. Notify MD [Medical Doctor] if applied and monitor spo2 [oxygen saturation] every shift every 24 hours as needed for shortness of breath . b. The Care Plan with a revision date of 03/30/23 documented, .I am at risk for complications related to Chronic respiratory disease/COPD . The Care Plan does not address oxygen therapy. c. On 04/03/23 at 12:42 PM, Resident #1 was lying in bed with a nasal cannula in place with tubing connected. Resident #1 informed the Surveyor she was having difficulty breathing. The end of the nasal cannula tubing was lying on floor and not connected to the oxygen concentrator. The Surveyor asked the Infection Control Preventionist (ICP) to accompany her into Resident #1 ' s room. The ICP stated, [Resident #1] takes off her cannula. The Surveyor asked if Resident #1 was care planned for removing her nasal cannula. The ICP stated, Yes, I'm sure she is. The Surveyor asked how often oxygen is checked. The ICP stated, Each shift. d. On 04/04/23 at 2:10 PM, Resident #1 was lying in bed with a nasal cannula in place. The Surveyor asked how often she used the oxygen. Resident #1 stated, Every day, but not all day. I don't like how it is on my face sometimes. e. On 04/05/23 at 11:30 AM, Resident #1 was lying in bed with a nasal cannula in place. f. On 04/05/23 at 3:39 PM, the Surveyor asked the MDS Coordinator if a resident receiving oxygen therapy should be care planned and have interventions in place for oxygen therapy. The MDS Coordinator stated, Yes. g. On 04/05/23 at 3:44 PM, the Surveyor asked the Director of Nursing (DON) if Resident #1 had oxygen therapy on her Care Plan. The DON stated, I'm gonna say no since you're asking me. The Surveyor asked if a resident receiving oxygen therapy should be care planned and have interventions for oxygen therapy. The DON stated, Yes. Surveyor: [NAME], [NAME] L 2. Resident #65 had diagnoses of Atherosclerotic Heart Disease, Acute Cough, and Intermittent Asthma Acute Execration. The Quarterly MDS with an ARD of 01/20/23 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a BIMS and did not receive oxygen therapy. a. A Physicians Order dated 06/22/22 documented, Oxygen at 2-4 liters via nasal cannula as needed for S.O.B or O2 SAT [saturation]< [less than] 90 q [every] 24 hours as needed. b. A Physicians Order dated 07/06/22 documented, .Ipratropium-Albuterol Sol. [solution] 0.5-2.5 (3) mg [milligrams]\ 3 ml [milliliter] 3 ml inhale orally every 4 hours as needed for SOB [shortness of breath] or wheezing via nebulizer . c. The Care Plan with a revision date of 03/30/23, did not address oxygen therapy and/or nebulizer treatments. d. On 04/03/23 at 12:59 PM, Resident #65 was lying in bed eating breakfast. An updraft (nebulizer) was lying in the second drawer of the bedside dresser with no date and was not in a bag. The Surveyor asked Resident #65 if she used the nebulizer. She stated, Sometimes. The inside of the nebulizer had dry crystalized residue in it. e. On 04/06/23 at 8:25 AM, the Surveyor asked the MDS Coordinator to look at Resident #65 ' s Care Plan for oxygen therapy and nebulizer use. She stated, It's not there. I'm already working on a plan to capture things better. f. On 04/06/23 at 8:33 AM, the Surveyor asked the DON if physician ordered oxygen and nebulizer treatments should be in the Care Plan. She stated, Yes. 3. Resident #70 had diagnoses of Heart Failure, Multiple Sclerosis, and Obstructive Sleep Apnea. The Annual MDS with an ARD of 01/11/23 documented the resident scored 13 (13-15 indicates cognitively intact) on a BIMS and used a Continuous Positive Airway Pressure (CPAP). a. A Physician's Order dated 06/21/22 documented, .CPAP with home settings at bedtime. Nurse to place on resident at HS [hour of sleep] and to remove in the morning every shift . b. The Care Plan with a revision date of 01/24/23, did not address the resident used a CPAP machine. c. On 04/03/23 at 1:11 PM, Resident #70 was sitting up in bed. A CPAP mask with tubing was lying on the bed side chest not in protective bag. The Surveyor asked, How often do you use your CPAP machine? Resident #70 stated, I use it whenever I am sleeping. d. On 04/04/23 at 8:48 AM, Resident #70 was sitting up in bed. A CPAP mask was sitting on top of the CPAP machine on the bed side chest not in a protective bag. e. On 04/05/23 at 4:20 PM, the Surveyor asked the MDS Coordinator, Does [Resident #70] use a CPAP machine? The MDS Coordinator stated, Yes, he does. The Surveyor asked, Does [Resident #70] have a Care Plan addressing his CPAP? The MDS Coordinator stated, I will have to look in his record. The MDS Coordinator looked in Resident #70's electronic record and stated, I do not have it in the Care Plan. The Surveyor asked, Should [Resident #70] have a Care Plan that addresses the use of his CPAP machine? The MDS Coordinator stated, Usually, yes ma'am, they should. The Surveyor asked, Why is it important that the Care Plan addresses the residents CPAP machine? The MDS Coordinator stated, The Care Plan is a guide to assist the nurses with the care for the resident as are the Physicians Orders. 4. The facility policy titled, Comprehensive Care Plans, provided by the Assistant DON on 04/05/23 at 4:20 PM documented, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . 42965 46868

Based on record review and interview the facility failed to ensure an injury of unknown origin was thoroughly investigated and protective measures were immediately implemented to prevent further potential abuse/neglect for 1 of 1 (Resident #1) sampled resident who had an injury of unknown origin. These failed practices had the potential to affect all 98 residents who resided in the facility, according to the Daily Census dated 2/28/2022. The findings are: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set with an Assessment Reference Date of 7/5/2021 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required one-person physical assist with transfers and toileting needs. a. The Facility Investigation Report for Resident abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities DMS (Division of Medical Services) form 762 documented, .Date and Time of Discovery .2/7/2022 .Time 0630 AM . Type of Incident: Abuse: Physical . On 2/7/2022 Administrator received notification from LPN [Licensed Practical Nurse] that resident had been transferred to hospital due to complaining of pain and bruising to right hip area hospital notified the LPN that resident was being admitted for right femur, pelvis and tailbone fracture . Administrator interviewed day shift nurse, she stated that resident had been fine all day moving about room going to bathroom nothing unusual, around 2:30 pm nurse and CNA [Certified Nursing Assistant] found resident laying in floor beside her bed. When nurse asked her if she had fallen resident stated, 'Well no I just wanted to lay down here'. Resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrator and DON [Director of Nursing] reviewed camera system .These injuries may have been related to said incident or to unreported fall in resident's room. There is nothing to indicate the injuries are due to any type of abuse from staff or visitors in the facility . b. The OLTC (Office of Long-Term Care) Witness Statement form dated 2/6/2022 documented, .Witness Full Name [LPN #1] . This nurse was called into resident's room at 11:00 PM by [CNA's] with resident complaining of severe pain. Upon assessment resident had major bruising and swelling to right hip and some bruising on right clavicle. This nurse notified [Advanced Practice Nurse] related to condition of resident and received order to send resident to [Hospital] for evaluation and treatment. Received call from [Hospital Nurse] at approximately 2:30 AM with resident being admitted for right femur, pelvis, and tailbone fracture. I &A [Incident & Accident Report] completed at 11:00 PM . c. The Nursing Progress Notes documented, .2/6/2022 11:29 PM . This nurse was called into resident room by CNA [Certified Nursing Assistant] staff at approximately 2300 [11:00 p.m.]. CNA staff were toileting resident when they noticed a tender, bruised mass to resident right hip and significant bruising to site and resident right clavicle area. Resident was c/o [complaining of] severe pain upon palpitation and when attempting to bear weight on right leg. Notified [Advanced Practice Registered Nurse] at 2303 [11:03 p.m.] with orders to send resident to [Hospital] for evaluation and treatment. Notified residents daughter at 2304 [11:04 a.m.] and agreeable with sending resident to [Hospital] for treatment and evaluation . d. The Hospital Records documented, .2/7/2022 .Clinical Impression: Traumatic retroperitoneal hematoma, Multiple fractures of pelvis, Closed fracture of greater trochanter of left femur, Traumatic hematoma of right hip, Closed fracture of right clavicle . e. On 2/28/2022 at 3:53 p.m., the DON was asked, When did [LPN #1] notify you regarding [Resident #1] multiple fractures of unknown origin? The DON stated, [LPN #1] did not tell me until 5:00-6:00 a.m. on 2/7/2022. I told [LPN #1] to hang up and call the Administrator. f. On 2/28/2022 at 3:08 p.m., the Administrator was asked, When did [LPN #1] call you regarding [Resident #1] multiple fractures? The Administrator stated, [LPN #1] called me at 06:30 a.m. on 2/7/2022. I think he called the DON when [LPN #1] sent her out. The Administrator was asked, Did you do body audits and interview cognitively intact residents that resided on the same floor as [Resident #1]? The ADM stated, No, I haven't done any body audits. I didn't necessarily have an abuse allegation. It wasn't someone calling me with an allegation of abuse. g. On 3/1/2022 at 9:35 a.m., LPN #1 was asked, Did you get a report about [Resident #1] being found in the floor around 2:30 p.m.? LPN #1 stated, I remember her telling me about a resident crawling on the floor, don't remember her mentioning a name. LPN #1 was asked, When did you first observe [Resident #1] injuries of unknown source? LPN #1 stated, The CNA came and got me. This was around 10:30-11:00 p.m. The CNA told me that [Resident #1] had some bruising on her hip and shoulder that was not there the previous day. [Resident #1] was complaining of severe pain. I asked her what had happened. [Resident #1] said she did not fall and that she didn't remember getting on the floor or crawling on the floor. [Resident #1's] hip looked completely disformed. It was very swollen. I called the Doctor and got orders to send her out. I called the DON [Director of Nursing] and the family. LPN #1 was asked, When were you alerted about [Resident #1] having multiple fractures? LPN #1 stated, The Hospital called back around 3:00-4:00 a.m. LPN #1 was asked, When did you alert the Administrator about [Resident #1] multiple fractures? LPN #1 stated, I notified the DON around 6:00 a.m.

Based on record review and interview the facility failed to ensure an injury of unknown origin was reported to the Administrator within 2 hours of discovery resulting in delays in initiating an investigation to rule out possible abuse/neglect for 1 of 1 (Resident #1) sampled resident who had injuries of unknown origin. The findings are: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set with an Assessment Reference Date of 7/5/2021 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required one-person physical assist with transfers and toileting needs. a. The Facility Investigation Report for Resident abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term Care Facilities DMS (Division of Medical Services) form 762 documented, .Date and Time of Discovery . 2/7/2022 . Time 0630 AM . Type of Incident: Abuse: Physical . On 2/7/2022 Administrator received notification from LPN [Licensed Practical Nurse] that resident had been transferred to hospital due to complaining of pain and bruising to right hip area hospital notified the LPN that resident was being admitted for right femur, pelvis and tailbone fracture . Administrator interviewed day shift nurse, she stated that resident had been fine all day moving about room going to bathroom nothing unusual, around 2:30 pm nurse and CNA [Certified Nursing Assistant] found resident laying in floor beside her bed. When nurse asked her if she had fallen resident stated, 'Well no I just wanted to lay down here'. Resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrator and DON [Director of Nursing] reviewed camera system . These injuries may have been related to said incident or to unreported fall in resident's room. There is nothing to indicate the injuries are due to any type of abuse from staff or visitors in the facility . b. The OLTC (Office of Long-Term Care) Witness Statement form dated 2/6/2022 documented, .Witness Full Name [LPN #1] . This nurse was called into resident's room at 11:00 PM by [CNA's] with resident complaining of severe pain. Upon assessment resident had major bruising and swelling to right hip and some bruising on right clavicle. This nurse notified [Advanced Practice Nurse] related to condition of resident and received order to send resident to [Hospital] for evaluation and treatment. Received call from [Hospital Nurse] at approximately 2:30 AM with resident being admitted for right femur, pelvis, and tailbone fracture. I &A [Incident & Accident Report] completed at 11:00 PM . c. The Nursing Progress Notes documented, .2/6/2022 11:29 PM . This nurse was called into resident room by CNA (Certified Nursing Assistant) staff at approximately 2300 [11:00 p.m.]. CNA staff were toileting resident when they noticed a tender, bruised mass to resident right hip and significant bruising to site and resident right clavicle area. Resident was c/o [complaining of] severe pain upon palpitation and when attempting to bear weight on right leg. Notified [Advanced Practice Registered Nurse] at 2303 [11:03 p.m.] with orders to send resident to [Hospital] for evaluation and treatment. Notified residents daughter at 2304 [11:04 a.m.] and agreeable with sending resident to [Hospital] for treatment and evaluation . d. The Hospital Records documented, .2/7/2022 .Clinical Impression: Traumatic retroperitoneal hematoma, Multiple fractures of pelvis, Closed fracture of greater trochanter of left femur, Traumatic hematoma of right hip, Closed fracture of right clavicle . e. On 2/28/2022 at 3:53 p.m., the DON was asked, When did [LPN #1] notify you regarding [Resident #1] multiple fractures of unknown origin? The DON stated, [LPN #1] did not tell me until 5:00-6:00 a.m. on 2/7/2022. I told [LPN #1] to hang up and call the Administrator. f. On 2/28/2022 at 3:08 p.m., the Administrator was asked, When did [LPN #1] call you regarding [Resident #1] multiple fractures? The Administrator stated, [LPN #1] called me at 06:30 a.m. on 2/7/2022. I think he called the DON when [LPN #1] sent her out. The Administrator was asked, Did you do body audits and interview cognitively intact residents that resided on the same floor as [Resident #1]? The ADM stated, No, I haven't done any body audits. I didn't necessarily have an abuse allegation. It wasn't someone calling me with an allegation of abuse. g. On 3/1/2022 at 9:35 a.m., LPN #1 was asked, Did you get a report about [Resident #1] being found in the floor around 2:30 p.m.? LPN #1 stated, I remember her telling me about a resident crawling on the floor, don't remember her mentioning a name. LPN #1 was asked, When did you first observe [Resident #1's] injuries of unknown source? LPN #1 stated, The CNA came and got me. This was around 10:30-11:00 p.m. The CNA told me that [Resident #1] had some bruising on her hip and shoulder that was not there the previous day. [Resident #1] was complaining of severe pain. I asked her what had happened. [Resident #1] said she did not fall and that she didn't remember getting on the floor or crawling on the floor. [Resident #1] hip looked completely disformed. It was very swollen. I called the Doctor and got orders to send her out. I called the DON [Director of Nursing] and the family. LPN #1 was asked, When were you alerted about [Resident #1] having multiple fractures? LPN #1 stated, The Hospital called back around 3:00-4:00 a.m. LPN #1 was asked, When did you alert the Administrator about [Resident #1] multiple fractures? LPN #1 stated, I notified the DON around 6:00 a.m.

Based on observation, record review and interview, the facility failed to ensure food items stored in the refrigerator, freezer and storage area were covered and sealed; dietary staff washed their hands before handling clean equipment or food items; and hot foods were maintained at or above 135 degrees Fahrenheit (F.) on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 main kitchen and 4 (Willow, Aspen, Magnolia and Orange Blossom kitchenettes) of 4 kitchenettes. These failed practices had the potential to affect 31 residents on Willow Hall, 33 residents on Aspen Hall, 5 residents on Orange Blossom Hall, and 30 residents on Magnolia Hall for a total of 99 residents (total census: 103), as documented on a list provided by the Dietary Supervisor on 10/27/2021. The findings are: 1. On 10/25/21 at 10:33 AM, the following observations were made in the walk-in refrigerator in the main kitchen. a. An open box of bacon was stored on a shelf in the walk-in refrigerator. The box was not covered or sealed. b. An open box of chocolate choy was stored on a shelf in the refrigerator. The box was not covered or sealed. 2. On 10/25/21 at 10:39 AM, the following observations were made in the walk-in freezer in the main kitchen. a. An open box of biscuits was stored on a shelf in the walk-in freezer. The box was not covered or sealed. b. An open bag of chicken breasts was stored on a shelf in the walk-in freezer. The bag was not sealed. c. An open box of beef patties was stored on a shelf in the walk- in freezer. The box was not covered or sealed. d. An open box of garlic bread was stored on a shelf in the walk- in freezer. The box was not covered or sealed. 3. On 10/25/21 at 10:46 AM, an open box of baking soda was stored on a shelf above the food preparation counter. The box was not covered. 4. On 10/25/21 at 11:02 AM, in the main kitchen, Dietary Employee #1 washed her hands. After she finished washing her hands, she dried her hands with paper towels. She then used the same paper towels to dry around the sink and inside the sink, contaminating her hands in the process. Dietary Employee #1 did not re-wash her hands before she picked up clean bowls and placed them on the counter with her fingers touching the insides of the bowls. Dietary Employee #1 was asked, What should you have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 5. On 10/25/21 at 11:12 AM, in the main kitchen, Dietary Employee #2 pushed a food cart that contained a pan of chocolate cake into a walk-in refrigerator. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who required pureed diets for the lunch meal. Dietary Employee #2 was asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Wash my hands. 6. On 10/25/21 at 12:01 PM, an open box of baking soda was stored in the kitchenette cabinet on Magnolia Hall. The box was not covered. 7. On 10/25/2021 at 12:10 PM, in the kitchenette on Willow Hall, the temperature of the food on the steam table was checked by Certified Nursing Assistant (CNA) #1. The hamburger patties registered 125.9 degrees Fahrenheit. 8. On 10/25/21 at 12:23 PM, in the kitchenette on Aspen Hall the temperatures of the food items on the steam table when tested and read by CNA #2 were: a. Hamburger patties 132 degrees Fahrenheit. b. Pureed bread 127 degrees Fahrenheit. 9. On 10/25/21 at :30 PM, in the kitchenette on Orange Blossom Hall, the temperatures of the food items on the steam table, were tested and read by CNA #3 as follows: a. Hamburger patties 126.9 degrees Fahrenheit. b. Pork chops 122.5 degrees Fahrenheit. 10. The facility's policy on handwashing, received from the Dietary Manager on 10/28/21 at 2:02 PM, documented, Procedure: Clean hands and exposed portions of arms . after engaging in other activities that contaminate the hands.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 8 residents who received a pureed diet from Willow Hall kitchenette and one resident who received a pureed diet from Aspen Hall kitchenette, according to a list provided by the Dietary Supervisor on 10/27/2021 at 8:40 AM. The findings are: 1. On 10/25/2021 at 12:10 PM, the following observations were made during the noon meal: A pan of pureed rice was on the steam table in the kitchenette on Willow Hall. The consistency of the pureed rice was thick and not smooth. Pieces of rice were visible in the mixture. 2. On 10/25/21 at 4:43 PM Dietary Employee #3 placed 2 slices of garlic bread into a blender, added warm milk and pureed. At 4:48 PM, she poured the pureed bread into a pan. The consistency of the pureed bread was not smooth. There were pieces of bread visible in the mixture. At 4:50 PM, Dietary Employee #3 placed 3 servings of garlic bread into a blender, added warm milk and pureed. At 4:52 PM, she poured the pureed bread into another pan. The consistency of the pureed bread was not smooth. Pieces of bread were visible in the mixture. At 4:53 PM, Dietary Employee #4 placed 5 servings of garlic bread into a blender, added warm milk, pureed, and added another carton of warm milk. She pureed and poured the mixture into the same pan. The consistency of the pureed bread was not smooth; pieces of bread were still visible in the mixture. a. On 10/25/21 at 5:12 PM, Assistant Dietary Supervisor was asked to describe the consistency of the pureed bread. She stated, It has spikes of bread in it and needs to be pureed longer. b. On 10/26/21 at 1:15 PM, the Dietary Supervisor was asked to describe the consistency of the pureed rice served to the residents on pureed diets at the lunch meal on 10/25/21. She stated, Pureed rice was thick. It was not pureed like it should. 3. On 10/26/21 at 8:00 AM, the following observations were made during the breakfast meal: a. A pan of pureed sausage was on the steam table in the kitchenette on Willow Hall. The consistency was not smooth. Pieces of sausage were visible in the mixture. b. A pan of pureed bread was on the steam table. The consistency of the pureed bread was not smooth and was thick. c. A pan of pureed oatmeal was on the steam table in the kitchenette on Willow Hall. The consistency was thick and not smooth. 4. On 10/26/21 at 1:15 PM, the Assistant Dietary Supervisor was asked to describe the consistency of the pureed sausage, pureed oatmeal and pureed bread served to the residents who required pureed diets at the breakfast meal. She stated, Pureed sausage was gritty. Pureed oatmeal and pureed bread were thick.

Based on observation, record review and interview, the facility failed to ensure vials of insulin stored in 1(2000 Hall medication cart) of 4 medication carts and 1 (2000 Hall medication storage refrigerator) of 2 medication storage refrigerators were disposed of in accordance with the manufacturer's instructions to prevent potential administration of insulin that had been opened and stored beyond the manufacturer's specified timeframes. This failed practice had the potential to affect 13 residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: 1. On 10/27/21 at 2:05 p.m., the 2000 Hall medication storage room refrigerator and medication cart were inspected with Licensed Practical Nurse (LPN) #1 in attendance. The refrigerator contained the following: Two vials of [MEDICATION(S)] insulin with an opened date of 9/16/21 were stored in the refrigerator. One vial of [MEDICATION(S)] dated as opened on 9/23/21 was stored in the 2000 Hall medication cart. a. On 10/27/21 at 2:10 p.m., Licensed Practical Nurse (LPN) #1 was asked, What does the handwritten date on these insulin bottles represent? The LPN stated, The date they were opened. The LPN was asked, How many days is an open bottle of insulin used before it is supposed to be discarded? She stated, [MEDICATION(S)] is thirty days and [MEDICATION(S)] is twenty-eight days. They should have been pulled . The nurse was asked, Who is responsible for removing expired medications from the refrigerator and the medication cart? The nurse stated, The three to eleven shift is supposed to check it, but all of the nurses I guess . b. On 10/28/21 at 8:29 a.m., the Director of Nursing (DON) was asked, What is a potential complication of administering insulin after the manufacturer's recommended discard date? She stated, It possibly not effective. She was asked, Who is responsible for ensuring the expired medications are no longer being administered and removed from the cart? The DON stated, The charge nurse. c. On 10/28/21 at 9:09 a.m., the storage of medication policy and procedure provided by the Assistant Director of Nursing documented, .The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications . These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. d. A [MEDICATION(S)] package insert documented the manufacturer's recommended timeframe for storage as follows: Storage . multiple-dose vial . 28 days refrigerated or room temperature . e. A [MEDICATION(S)] package insert documented, .Storage and Handling . Do not use after the expiration date . In-use [MEDICATION(S)] vials . should be stored at room temperature . and must be used within 28 days or be discarded .

Based on observations, and interview, the facility failed to ensure proper infection prevention and control practices were implemented to prevent the development and transmission of COVID-19 and other communicable diseases and infections as evidence by wearing a face mask and wearing a face mask to cover the nose for the residents residing; failed to implement proper signage upon entrance to isolation unit; failed to maintain safety of other residents of possible exposure; failed to ensure doors were closed from the resident isolation rooms to prevent potential exposure to other and or other residents; and failed to maintain all residents who were admitted or readmitted from the hospital were placed in the isolation unit in 1 of 1 facility. This failed practice had the potential to affect 123 residents who resided in the facility according to the Resident Census and Condition of Residents form provided by the Assistant Director of Nursing (ADON) on 8/6/2020. The findings are: a. On 8/6/2020 at 9:22 a.m., the double doors on the 2nd floor were closed with no signage on doors. The surveyor took a picture at 9:40 a.m. There were 10 rooms on the isolation unit, 6 rooms not on isolation and 4 rooms on isolation precautions. Resident #6 self-propelled herself through the double doors into the isolation unit. She then went through the other doors of the exit from the unit into the facility. The Surveyors then went to the 1st floor and observed 2 rooms with isolation precaution for re-admit or admit. b. On 8/6/2020 at 9:24 a.m., Rooms #2057 and #2055 were on droplet isolation per a sign on the door. Both of the doors were open completely with reusable gowns in a plastic holder on the door. Photographs were taken of the doors at this time. Certified Nursing Assistant (CNA) #1 was asked, What kind of isolation is this resident in? The CNA #1 stated, I don't know. CNA #1 was asked, How do you know how to take care of this resident? CNA #1 stated, I don't know, and I can go get the nurse. c. On 8/6/2020 at 9:28 a.m., Registered Nurse (RN) #1 placed a sign on the resident door stating resident was in droplet isolation. Registered Nurse (RN) #1 was asked, What is this resident on isolation for? RN #1 stated, Droplet isolation. RN #1 was asked, Why are you putting a sign up there now? RN #1 stated, It had fallen down, so I was putting it back up. RN #1 was asked, Should the residents' door be closed to the hallway? She stated, It's not airborne. d. On 8/6/2020 at 9:43 a.m., the Director of Nursing (DON) was asked, What is droplet precautions? The DON stated, Coughing, sneezing or bodily fluids. It is not airborne. Resident #6 self- propelled herself through the double doors into the isolation unit. She then went through the other doors of the exit from the unit into the facility. e. On 8/6/2020 at 10:12 a.m., there were dirty gloves on the floor around the trash can rooms and #2051 & (and) #2057. A photograph was taken of the dirty gloves and trash cans at this time. f. On 8/6/2020 at 10:17a.m., RN #2 was asked, Why is this resident in isolation? RN #2 stated, It is a new admit from the community. RN #2 was asked, Was this resident tested for COVID prior to admission? RN #2 stated, Yes. We have to have 2 negative tests. RN #2 was asked, Should the doors be closed? RN #2 stated, It's not airborne. g. On 8/6/2020 at 11:07 a.m., Housekeeper #1 had her mask down below her nose. When she saw this surveyor, she pulled her mask up onto the bridge of her nose.

Based on observation and interview, the facility failed to ensure foods stored in the refrigerator were maintained to prevent potential for cross contamination to prevent food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure cold salad was maintained at or below a temperature of 41 degrees Fahrenheit (F); failed to ensure hot food items on the steam table were maintained at a temperature at or above 135 degrees Fahrenheit while awaiting service, to prevent food borne illness for residents who received meals from 5 of 5 dining room with steam tables; failed to ensure dietary staff changed gloves and washed their hands between dirty and clean tasks and before handling clean equipment or food items to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; and failed to ensure expired food items were promptly removed /discarded on or before the expiration or use by dates to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 116 residents who received meals from the kitchen (Total census 120), as documented on a list provided by the Dietary Supervisor on [DATE]. The findings are: 1. On [DATE] at 10:46 a.m., the following observations were made in the walk-in refrigerator in the main kitchen: a. An open zip lock bag of slices of turkey was on a shelf in the walk-in refrigerator. b. There were 2 containers of chicken salad on a shelf in the walk-in refrigerator with used by date of [DATE]. One container has been opened with some of the chicken salad eaten out of it. 2. On [DATE] at 10:54 a.m., there were 4 bags of hotdog buns on the bread rack with an expiration date of [DATE]. The bun had mold on it. There were 2 hamburger buns on the bread rack with an expiration date of [DATE]. 3. On [DATE] at 11:07 a.m., the following observation was made on Willow Hall Kitchenette. There was a 46 Fl oz carton of thickened lemon-flavored water on a shelf in the refrigerator with no lid on it. 4. On [DATE] at 11:17 a.m., the following observation were made on Magnolia Hall Kitchenette refrigerator and storage area: a. There was an open bag of cheese slices in a compartment in the refrigerator. b. There was a bag of hamburger bun in a cabinet with an expiration date of [DATE]. 5. On [DATE] at 11:21 AM, the following observations were made in Orange Blossom Hall kitchenette: a. An open bag of cheese slices was on a shelf in the refrigerator. The bag was not sealed. b. An open container of pure sugar was in the cabinet. The container was not covered. 5. 0n [DATE] at11:23 AM, the following observations were made on Aspen Hall kitchenette: a. There was a zip lock bag with slices of cheese in it on a shelf in the refrigerator. The zip lock bag was not sealed. b. There were 2 - 5 pound (lb). boxes of baker source golden butter milk pancake and waffle mix in a cabinet with an expiration date of [DATE]. One of the boxes had been opened some of the pancake or waffle mix has been and used. 6. On [DATE] at 02:41 p.m., Dietary Employee #2 turned the faucet of the sink on and washed her hands. She then turned off the sink faucet with her bare hand. She removed a paper towel from the dispenser and used it to dry her hands. She then picked up clean dishes and stacked them on the carts to be used in serving supper meal with fingers touching the interior surfaces of the dishes. She picked glasses by the rims and stacked them on a clean cart to be used in serving beverages to the resident at supper meal. 7. On [DATE] at 3:59 p.m., Dietary Employee #3 picked up a bag of bread from the bread rack and placed it on the counter, took out 4 cartons of whole milk from the refrigerator and placed them on the counter. She washed her hands and placed gloves on her hands. She removed 9 slices of white bread from the bag and placed them into a blender, she opened 2 cartons of milk and poured them on the slices of bread in the blender and pureed. She removed 9 more slices of bread from the bag and placed them in the blender, opened 2 more cartons of milk and poured them in the blender. Dietary Employee #3 did not wash her hands, before she removed slices of bread from the bag and placed them into a blender to be pureed and served to the residents on pureed diets. 8. On [DATE] at 11:44 a.m., the temperature of the food items when tested and read by the Dietary Supervisor on the steam table on willow kitchenette were: a. Salad with cheese 51 degrees Fahrenheit. b. Broccoli 101 degrees Fahrenheit. 9. On [DATE] at 11:51 a.m., the temperature of the food item when tested and read by the Dietary Supervisor on the steam table on Magnolia kitchenette was pureed broccoli 99.1 degrees Fahrenheit. 10. On [DATE] at 11:56 a.m., the temperature of the food items when tested and read by the Dietary Supervisor on the steam table in Orange Blossom kitchenette were: a. Salad with cheese 58 degrees Fahrenheit. b. Puree broccoli 103 degrees Fahrenheit. 11. On [DATE] at 02:41 p.m., Dietary Employee #2 turned the faucet of the sink on and washed her hands. She then turned off the sink faucet with her bare hand. She removed a paper towel from the dispenser and used it to dry her hands. She then picked up clean dishes and stacked them on the carts to be used in serving supper meal with fingers touching the interior surfaces of the dishes. She picked glasses by the rims and stacked them on a clean cart to be used in serving beverages to the resident at supper meal. 12. On [DATE] at 3:59 p.m., Dietary Employee #3 picked up a bag of bread from the bread rack and placed it on the counter, took out 4 cartons of whole milk from the refrigerator and placed them on the counter. She washed her hands and placed gloves on her hands. She removed 9 slices of white bread from the bag and placed them into a blender. She opened 2 cartons of milk and poured them on the slices of bread in the blender and pureed. She removed 9 more slices of bread from the bag and placed them in the blender and opened 2 more cartons of milk and poured them in the blender. Dietary Employee #3 did not wash her hands, before she removed slices of bread from the bag, placed them into a blender to be pureed, and served to the residents on pureed diets. 13. On [DATE] at 11:47 a.m., the temperature of the food item when tested and read by the Dietary Supervisor on the steam table on Aspen kitchenette was: Pureed cut green beans, 129 degrees Fahrenheit.

Complaint # (AR 396) was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure staff immediately reported an allegation of staff (facility Administrator) to resident abuse to the appropriate facility person; to ensure the prompt initiation of an investigation; and to ensure residents were protected from the potential of further abuse for 1 (Resident #1) of 1 case mix residents who reported the Administrator had physically hit him. The facility also failed to ensure staff did not use intimidation tactics when interviewing 1 (Resident #1) of 1 case mix residents who reported the Administrator had physically hit him and who temporarily recanted his statement regarding the allegation of physical abuse involving the Administrator. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Residents #1 who reported an allegation of staff to resident physical abuse and had the potential to cause more than minimal harm for 42 residents in the facility, according to a list provided by the Social Director on 8/15/14 at 5:45 p.m. The facility was informed of the Immediate Jeopardy on 8/15/14 at 1:04 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of 6/19/14 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive assistance of 1 person for transfers; and was independent via wheelchair for mobility. a. A hand-written statement dated and signed by Licensed Practical Nurse (LPN) #3 on 8/6/14 at 10:25 a.m. documented, "On 8/5/14 at approx. (approximately) 1430 (2:30 p.m.), (Resident #1) approach this nurse stating that (Administrator) had hurt his paralyzed arm by tapping it with her pointer finger as she was passing by in the hallway to discuss with him the importance of his oral care. This nurse immediately notified (Social Services Director) of facility whom was unavailable upstairs at the time stating she would be with him later for discussion or he could propel w/c (wheelchair) upstairs via elevator. Upon observation of residents left arm, no bruising nor redness nor swelling was noted. He stated that he was going outside to smoke ..." b. The Office of Long Term Care (OLTC) statement dated 8/5/14 (no time given) and signed by the Social Services Director on 8/14/14 (not timed) documented, "(LPN #3) called me and I was in the activity office working on the newsletter. I can't remember what (LPN #3) said to me but it involved something happening between (Resident #1) and (Administrator). I then responded to (LPN #3) that I was busy upstairs in the activity office and for him to come up there to speak with me. (Resident #1) never did come upstairs nor did I see him to talk to him." On 8/14/14 at 6:15 p.m., the Social Services Director (SSD) was asked to describe what occurred on 8/5/14 with (Resident #1). She stated, "I was upstairs in the activity office (8/5/14), mid-afternoon. (LPN #3) paged me. I called to Willow and she picked up the phone." The SSD was asked, "What did (LPN #3) say to you?" The SSD stated, "I can't remember what she said, I really didn't pay attention. I told her to send him (Resident #1) up to activity room. (Resident #1) he never came up. I just thought it wasn't a big deal." The SSD was asked, "What wasn't a big deal?" The SSD stated, "About whatever she (LPN #3) had said on the phone." Staff calls me all the time about him, because of things - his behaviors. He (Resident #1) will cuss staff because he was angry. He will go up to family members asking for cokes, cigarettes, money - he has manipulated them. Usually if it's a serious situation, he will come tell me. So he never showed. I didn't think it was important. So I left." c. A Facility Investigation Report for Resident Incident and Accident statement dated 8/6/14 at (12:30 a.m.) and signed by LPN #1 documented, "(Resident #1) came to the desk and asked if an employee hit a resident would you help the resident or employee? I told (Resident #1) I would help the resident and (Resident #1) then said that (Administrator) had hit him many times on his arm and that he told his nurse (LPN #3) twice and she told him to go tell (Social) and (LPN#3) wouldn't help him. (Resident #1) then said so will you help me. I said lets tell your nurse I called (LPN #2) and he told her the same story. We then called the ADON because the DON was on vacation no answer so we then called the hall supervisor no answer so then we called the DON and she answered I explained." A second Facility Investigation Report for Resident Incident and Accident statement dated 8/6/14 at (12:40 a.m.) and signed by LPN #1 documented, "On 8/6/14 (Administrator) called facility and I answered the phone. (Administrator) stated that the DON had called her because of (Resident #1) had stated that (Administrator) had hit him. The DON had stated to write his statement to me and (Administrator) asked me when she called if he wrote a statement. I told her yes he did and she asked why I or (LPN #2) the 100 nurse had not called her and I told her because she was the one he was saying hit him and I felt like me calling her was wrong I followed my chain. I called ADON because the DON was on vacation then called Hall supervisor when I couldn't get them. I called the DON who answered. She (Administrator) stated, "You tell him I did not hit him and that if he would have fixed his teeth like he should have we wouldn't be having to spend all this damn money now. He is just mad because he isn't seeing the doctor he wants." I stated "Ok" to (Administrator) then she said 'tell him' and I told her ok again she then said is he near you and I said yes and she said tell him he knows I did not hit him and I told her no I wasn't telling him that. She (Administrator) said well tell him I might have tapped his arm to get his attention but it was not a hit and it's on camera so I'm covered. I again stated Ok she asked if he reported it to the nurse when it happened and I told her yes he said he did but she "blew me off" and (Administrator) said tell him he doesn't know she blew him off she could have told someone and he doesn't know it. "Hell we could be already looking into it and he just doesn't know it." I again stated ok to (Administrator) and she stated, "Well if he keeps saying it I guess ok because I'm covered it's on camera. I'll deal with it when I get back. My husband is having surgery in the morning." I said ok she then said tell him I said to knock it off and shut up. I said "ok" again. I and (LPN #2) then finished his statement. I then called my DON again and told her about the phone call she said you do your job and protect the resident. I told her we were but (Administrator) was mad when she called. DON said it doesn't matter if she's mad ...." On 8/15/14 at 7:55 a.m., LPN #1 was asked to describe what occurred on 8/6/14 with (Resident #1). LPN #1 stated, "...to be honest, he (Resident #1) didn't act right, he was sorta subdued. He asked me if an employee hit a resident would you believe them. Would you take up for the employee or the resident? I said, the resident, did something happen? Is the resident hurt? (Resident #1) said, 'Then will you help me because (Administrator) hit me yesterday and nobody will help me' I asked him, when?' (Resident #1) said, 'Day shift. I told (LPN #3) twice, but she blew me off.' I asked (Resident #1), what do you mean? He said, the first time she blew me off, the second time she said ok (Resident #1) just go tell (Social Director). (Resident #1) said he went to (Social's office), she wasn't there. He said he went to smoke at that time and came back the social's office door was shut. I (LPN #1) called over to Willow because (LPN #2) was his direct charge nurse. (LPN #2) came over. We went into the charting area and I told (Resident #1) to tell (LPN #2) what he told me. He told (LPN #2) the same story. I called Assistant Director of Nursing (ADON) 10-15 minutes later. I left a message on her voice mail that I've got a big problem when you call, she (ADON) didn't respond. Then I text her the same thing. Then when she didn't respond, I called Registered Nurse (RN #1). I left a message again with her. She didn't call. Then I text the Director of Nursing (DON). She answered immediately. She was on vacation. I wasn't sure about the procedure myself. She said you protect the resident and get a blank abuse form and you write it up." LPN #1 stated, "Do I think she maliciously tried to hurt him? No. Do I think he honestly believes she did? Yes. Honestly on purpose, no." LPN #1 stated, "He repeatedly reported it two times. She blew him off. He said this happened on day shift. He didn't tell anyone until 3/11 shift. He told me around midnight on 11/7 shift. His demeanor that night was not his demeanor. I was completely shocked when he said it. I never heard him say that anybody had abuse him that I'm aware of." d. A Facility Investigation Report for Resident Incident and Accident statement dated 8/6/14 at (12:30 a.m.) and signed by (LPN #2) documented, " ...was called by (LPN #1) to come over to Magnolia Hall, when I got there she had me and (Resident #1) go into the chart room. When we go in there, resident then said that (Administrator) hit his arm repeatedly and his arm fell off the chair and she continued to hit his arm with her finger, and that he told his nurse (LPN #3) twice and she blew him off and told him to go tell (Social) and wouldn't help him. We then called the ADON because the DON was on vacation, no answer. We then called the hall supervisor with no answer. So then called DON, she answered and (LPN #1) told her why she did not call the Administrator. She (LPN #1) said she was unsure if she should call (Administrator) because she was the one (Resident #1) was accusing. The DON had us get (Resident #1's) statement and turn it into the ADON or HR (Human Resource) in the morning." On 8/15/14 at 8:40 a.m., LPN #2 was asked to describe what occurred on 8/6/14 with (Resident #1). LPN #2 stated, "He told us on 8/6/14. But it happened on 8/5/14. I was charting on hall when (LPN #1) called me to come to Magnolia Hall about 12:30 midnight, when I got there (Resident #1) was at the desk, we had to go into the charting room for privacy. (LPN #1) told (Resident #1) 'to tell (LPN #2) what you just told me. What would you do if an employee hit you?' He's always oriented times three, he's with it. (Resident #1) said (Administrator) hit him on his arm. He said she was tapping him on his arm. '(saying) If you had been going to Dr. (Dentist), you wouldn't have this problem with your teeth.' Then he said his arm fell off the wheelchair armrest. He said he had to pick it back up. She did it again and he said it hurt. He said he told (LPN #3). I guess he told her twice and she said to go tell (Social). He said he never found (Social). Apparently, he waited the entire shift. (Resident #1) said it hurt. His pain is different from anyone else. His pain is his pain. You can't tell somebody if it hurts or not. When I came back that night (8/6/14), he said (Administrator) said to him 'you know it didn't happen that way.' He said they had him in the office watching the video. I feel like they gained up on him. (RN #1) was in his room first thing the next morning. LPN #1 tried (ADON and RN #1) no answer, we didn't want to call the Administrator she was the accused. (Administrator) called that night, she was mad, says why you didn't call me." e. A hand-written statement dated 8/6/14 at (12:30 a.m.) and signed by Resident #1 documented, "In front of DON's office coming from ADON's office, (Administrator) was walking beside me and kept hitting my arm with her finger. My arm fell off the w/c (wheelchair) and I put it back up, thinking she wouldn't hit it any more but she kept hitting it because I haven't been seeing the (Dentist). I told (LPN #3) my nurse twice and she said for me to tell (Social) but I couldn't find her. She was hitting my arm hard enough it hurt." A hand-written statement dated 8/6/14 (not timed) and signed by Resident #1 documented, "We were down by (ADON) office and was arguing about the dentist appointment. We started walking toward the hall. (Administrator) was on my left side and she hit my arm with her index finger, telling me that if I had been seeing the dentist that we could have prevented the toothache. At that time my arm fell and I picked it up and put it back up on the armrest. I think she was hitting me trying to get my attention." On 8/15/14 at 11:25 a.m., Resident #1 was asked about the conversation he had with the Administrator in front lobby next to the elevator. He stated, "I honestly don't know what happened to her. She was hitting my arm. She was hitting it hard enough to it fell off the wheelchair armrest. (RN/Hall Supervisor) had to pick my arm up and put it back on the armrest. (Administrator) was getting on to me pretty much about the dentist. I didn't want to go to that dentist because he didn't approach me the right way one time. He just came up to me and put his fingers in my mouth - said 'yep, all them need to be pulled.' Then later I agree to see him again and the first thing he did was put his fingers in my mouth with no gloves on." Resident #1 was asked about the incident on 8/5/14. He stated, "As I was going down hall, (Administrator) said - if I had seen (dentist) the whole time - I wouldn't be in this situation." Since the incident, Resident #1) stated he has not seen the Administrator. Resident #1 was asked, "Are you fearful - afraid of the Administrator?" He stated, "No, but it made me not want to be around her." He was asked, "Are you afraid to be around her?" Resident #1 stated, "No, not really. I just prefer not to be around her. But as long as I live here, I'm sure I've got to run into her." Resident #1 stated, "It embarrassed me out in front of the God and everybody. If she wanted to talk to me about the dentist or anything she should have taken me to an office where we could have privacy and tell me. There was no need to yell at me." Resident #1 was asked, "Right now do you feel safe, secure in this facility?" He stated, "Well, she could throw me out." f. An OLTC Witness Statement dated 8/5/14 and signed by a family member (non case-mix) documented, "I was at the elevator waiting to go up to see my mother. (Resident #1) and (Administrator) were right next to the elevator. She was telling him either to go to the dentist here or get another one and pay for it himself. She did not touch him that I saw. I was not there before that time so I do not know what led up to her speaking in a voice that sounded condescending. I was embarrassed and tried to not look at them." On 8/15/14 at 9:25 a.m., the family member (non case-mix) was interviewed. She stated, "I went to visit my mother, I came in the front door waiting on the elevator. I could hear her (Administrator) voice. It wasn't pleasant. I didn't even know who she was at first. I knew she was the big blonde lady. It was her (Administrator) tone. I can't tell you why. It was enough to make me feel uncomfortable. I heard them discussing something about going to the dentist. It was loud enough, I was trying to hear and not stare. I felt like she lost her temper." Family member stated, "Sometimes you should think before you speak." g. On 8/14/14 at 4:35 p.m., RN #1 was asked to describe what occurred on 8/5/14 and 8/6/14 with (Resident #1). RN #1 stated, "that morning 8/5/14, Thursday approximately 8:30 a.m. I saw (Resident #1). He told me about his toothache. I checked on it, looked at his mouth. I told him, I think you need to see a dentist. After this I went to the morning meeting and reported the tooth in the meeting. The (ADON, Administrator) and myself, we decided to get an appointment with the dentist. (Resident #1) mentioned he wanted to see (Dentist #2)." The RN/Hall Supervisor stated the facility has the services within the nursing home and (Dentist #1), who comes to the facility routinely. The RN/Hall Supervisor stated, "I asked (ADON) to tell (Resident #1) about the appointment with (Dentist #1), but (Resident #1) refused. That started the day with (Resident #1). Time went by later on in the day, I waited, (Resident #1) went to smoke. I went out there. It was just me and him. We had an adult conversation, shared my concerns about his toothache. (Resident #1) agreed to see (Dentist #1). We shook hands on it. I went to (ADON's) office. I was telling her about what me an (Resident #1) had discussed. So we actually made (Resident #1) an appointment for the next morning at 9:30 a.m. It was about 2:30 p.m. - 2:35 p.m., I was in the office when I heard the conversation. I heard the loud conversation. It was very loud, loud enough to get my attention. It was in the hall. I recognized the voices. I heard the argument." The RN was asked if they were being argumentative. The RN stated, "Yes, their voices were loud. It prompted me to go straight out of the office. It was (Administrator and Resident #1) arguing about seeing the dentist. I was trying to stop the argument. I told (Administrator) that we got him an appointment at 9:30 a.m. in the morning. A little bit more arguing went on. The only thing I saw was (Administrator) put her hand on his shoulder. I did not see her actually hit him. I'm not saying she didn't, I just didn't see it. His arm did fall off the chair. I pulled it up and put it back on the armrest. She (Administrator) very well could've hit him. But I wasn't focused on that. I felt it was a public area (lobby), if they wanted to have the conversation, they needed to in another area." The RN #1 was asked if the Administrator was shaking her finger at him. She stated, "Yes, there was finger shaking going on. I felt the approach was fast on the Administrator's part. The Administrator did not have any knowledge we had settled the dentist appointment. The Administrator said to (Resident #1) at the time, if he would use the services, see the dentist the facility provided that his teeth wouldn't get to this point." The RN was asked was the Administrator scolding him (Resident #1). The RN stated, "Yes." The RN was asked, "How did the argument between the resident and the Administrator make you feel?" The RN stated, "It made me feel uncomfortable. It was loud, kinda like two adult people yelling in the hallway. I felt like (Resident #1) should not be there." The RN then stated, "Somehow over the weekend. I had the weekend to think about it. I played it over and over in my mind. I got a text that (Resident #1) said (Administrator) hit his arm. That's how I actually learned about what (Resident #1) had said. I got here as fast as I could 8/6/14. I went straight to (Resident #1's) room. It was just me and him, we had a [MEDICATION NAME] conversation so I asked him what was going on? I wrote down his statement. I read it back to him. He signed it. I took the statement and went straight to (Assistant Adm.). I gave her that and I told her we needed to report it to OLTC now, do it today. She (Assistant Administrator) said, 'we are going to turn this over to (ADON).' Me and (ADON) talked, (ADON) said we needed to interview (Resident #1), I wasn't sure what to do." The RN stated, "There was (ADON, me, Resident #1 and Human Resource (HR)), all in the office. (ADON) sat there she was not meaning to be rude. She asked him about it (Administrator hitting him). She asked (Resident #1) what the extent of the allegation was. (Resident #1) watched the video. (ADON) ran the video three times for him. I'm her witness. (Resident #1) said, 'Maybe she (Administrator) was treating me like a child." The RN was asked, "Did anyone talk to him in such a way that persuaded him to change his statement?" The RN stated, "No. I do think he was persuaded, but it wasn't intentional to manipulate by me or (ADON). We explained to him that there will be an investigation, it was serious. I think it concerned him." The RN stated, "The Office of Long Term Care (OLTC) was not notified based on his recanted statement. I told (ADON) we should've never done that. We should've never pulled (Resident #1) back in here and had him sign that statement. We just should've reported it to OLTC. We made a mistake. We all make mistakes. I do think we went one step too far. It was intimidating. If that had been me, I would have recanted too. That was wrong. I told the DON that statement is bullshit. I want the state called. I don't want this mess to come up 6 months from now and they think we are trying to hide something. I was a part of that interview. It was wrong." The RN was asked, "Do you think yelling at a resident is verbal abuse?" She stated, "Yes, I do." The RN was asked, "Do you consider the argument between the resident and the Administrator was verbal abuse on the Administrator's part?" The RN stated, "I don't know, they have had loud conversations before in the office. (Administrator) was not herself that day. She had a shot of [MEDICATION NAME] and [MEDICATION NAME]. She was wound that day. She was not herself, not her normal pattern." h. On 8/14/14/ at 5:35 p.m., the ADON was asked to describe what occurred on 8/6/14 with (Resident #1). The ADON stated she had received a phone call from (LPN #1). The ADON stated, "I called her (LPN#1) back and I talked to the DON. She told me (Resident #1) said (Administrator) hit him. I got here a little after 8:00 a.m., I reviewed the camera. I left to go to a doctor's appointment at 8:45 a.m. I got back around 10:30 a.m. on 8/6/14. I went to talk to (RN/Hall Supervisor), she had talked to (Resident #1). He did report it to her. I felt it would be a good idea to look at the footage, to let him point out to me what he felt his allegation was. We put him in front of the computer and he looked at it three times. I felt like he needed to see it as many times as he needed. He never pointed anything out on camera. I asked him, (Resident #1) this is serious, do you feel like (Administrator) was maliciously hitting you or being mean. He paused a minute and he said, no. He said she was tapping; it was more like a mother getting on to her child. I asked him well will you write that in a statement for me." ADON stated, "I don't know what she (Administrator) did. Maybe she went too far. Now should she have done that? No. My concern was did she really hit him, lay her hand on him?" The ADON stated, "After that it pretty much was dropped." The ADON stated she felt they should have not taken (Resident #1) into the office and had him change his statement. The ADON stated, "I take responsibility for that." i. On 8/14/14 at 6:00 p.m., HR was asked to describe what occurred on 8/6/14 with (Resident #1). She stated, "When I came in that morning (8/6/14), two nurses gave me statements. I got here at 7:00 a.m. and the (ADON) was usually here at 8:00 a.m., (DON) was on vacation." She stated, "My intent when I walked into the room was to give the ADON the statements. When I walked into the office, they (ADON), (RN/Hall Supervisor) and (Resident #1) were in there. I kinda felt awkward. I didn't know whether I should leave or stay. I didn't say anything. I just observed. (Resident #1) was pushed up to the computer. (ADON) was reaching over him manipulating the mouse to run the computer. I'm pretty sure (Resident #1) had already seen it once. (ADON) backed away from him. She did get down on her knees, got down on his level. Some discussion, then (RN/Hall Supervisor) commented to (Resident #1) that this was a serious allegation. 'Are you sure you want to make this?' Then next thing I remember was that (ADON) was writing out a statement. (Resident #1) had recanted his accusation. (Resident #1) signed the statement. (Resident #1) was asked did he feel he was intimidated made to feel bad. He stated, 'Yes, (ADON) is very tall for someone being in a w/c.' (Administrator) can speak loudly. I think if that were me in that situation, I would feel intimidated. As far as intent goes, I really don't feel that is what was intended." She was asked if she questioned (Administrator) actions toward him (Resident #1). She stated, "No, (Resident #1) is very difficult. I've never heard her do other residents that way." An OLTC Witness Statement dated 8/6/14 (not timed) and signed by Resident #1 documented, "I do not believe (Administrator) was in no way physically abusive to me on 8/5/14." j. The DON's written statement dated 8/12/14 at 7:00 p.m. documented, "...(Resident #1) stated, 'She (Administrator) was hitting my arm in the hall and it hurt because it's my paralyzed arm, and nobody believes me.' I asked (Resident #1) if he was telling me the truth why he changed his story he said, 'because they took me in the office and I was afraid if I didn't change my story I would have to leave the facility. I know (Administrator) makes the decision she has threatened to make me leave before. I was scared not to change my story.' I observed residents left arm and observed small bruises to his forearm. Resident stated to me, 'don't worry about me, if you say anything to anyone they will be mad at you.' I explained to resident not to worry about me, and no employee has the right to place their hands on you, yell or mistreat you or any other resident in the facility. Resident verbalized, '(Administrator) was cruel to me that day because I didn't want to see her dentist, and she did hit my arm and hurt it.' Resident was assisted back to his hall. Acting Asst. Adm. and Administrator were notified of my conversation with resident related original allegation of abuse and new allegation of intimidation." On 8/15/14 at 3:35 p.m., the DON was asked to describe what occurred on 8/6/14 with Resident #1. She stated, "On 8/6/14 at 12:04 a.m. (LPN #1) called me. She said (Resident #1) was making an allegation that the administrator hit him. She (LPN #1) stated that (Resident #1) had reported to the day shift nurse (LPN #3), she blew him off and (Social) she blew him off. (LPN #1) was very anxious because the allegation was against the Administrator. I told her no matter who the allegation is against even if it's me you have to protect the resident. Take their statement for face value. I instructed her to take his written statement and (LPN #2's) statement as it would be a reportable and turn into (ADON) or (HR) to ensure it got to (ADON). (LPN #1) asked if she had to call (Administrator). I said I would call her. I called (Administrator), I told her we had a reportable it was an allegation of abuse, against you. (Resident #1) said you hit him. Her (Administrator) exact words were 'I didn't hit him. I just smacked his arm to get his attention'. At 12:35 a.m., I received a second call from (LPN #1), she stated (Administrator) called and she was mad. She told then to go down there and tell him to shut up and knock it off. So I told (LPN #1) she still had to report it. It didn't matter how (Administrator) felt. She still needed to report it. Wednesday, 8/6/14 at 8:45 p.m., I received a text from (Administrator) that stated, "Meant to tell you they showed camera to (Resident #1) and he recanted his claim on me. I didn't respond to the text because even if he recanted his statement, it was still a reportable. I believe it is up to OLTC (Office of Long Term Care) to decide if it was abuse. On 8/12/14, I'm at lunch with (RN/Hall Supervisor), (ADON), and (RN/Care plan Coordinator). (RN/Hall Supervisor) tells me she believes they did something wrong, that they didn't report it. That she has known in the past something like that needed to be reported. She knew taking him (Resident #1) into the office like that she knew was wrong. I asked them to explain it to me and (ADON) said she got a phone call from (Administrator). She said (Administrator) told her to treat her like any other staff and report it. The next thing she knew she was at the doctor's office. (Administrator) called her screaming at her so loud the doctor could hear her screaming that she better get back to the building, get a handle on it and get control. (ADON) received a text message from (Administrator) that said 'if he doesn't recant his statement, I will walk you through how to do a reportable by noon.' We got back to building spoke with (Asst. Adm.) and (HR). I always have a witness. I asked (Asst. Adm.) why it wasn't reported. She said she called (Administrator) to let her know she was going to report it. (Administrator) said, 'No, let (ADON) handle it.' (Asst. Adm.) and (HR) asked me what I was going to do. I told them it was a reportable and it should've been reported. Either way I'm going to get my building in trouble no matter what I do. I'm going to lose my job that I have to pray about it. So I went to review the camera footage and the statements. (Asst. Adm.) had told me the statements had been shredded, but they had not been. They were in her top right hand door of her desk. The camera footage showed the resident in hall next to elevator. The Administrator approached him in an abrupt manner, shaking her finger at him. He backed away from her she approached him a second time. (RN/Hall Supervisor) walked up to try to take him down the hall. (Administrator) appears to be tapping him on his left arm with her right index finger. At 6:30 p.m., I talked to the resident. The resident was not his typical self. I asked him if he had anything he wanted to tell me. He said no. I said are you sure? He said, 'Can I tell you about me and the administrator?' I told him he could tell me anything. He said she was hitting him last week on the arm. It was hurting because it was his paralyzed arm. He explained his arm hurts when you hit it. He told me that he told her (Administrator) it was hurting, but it didn't do any good. He told me he didn't want me to do anything because people would be mad at me because he had already caused problems. I asked him if he was telling the truth, why did he change his story? He said they took him in the office and started asking him questions and showed him a video tape and demanded he show them where she (Administrator) hit him. He said, 'you know me, I get confused. I couldn't show them. I was scared if I didn't change my story, I'd have to leave here.' He told me (Administrator) made the decisions around here and threatened to make him leave before. He asked me if I saw it on the camera because nobody believes him. On 8/13/14, she (Administrator) came barreling in here, demanded a meeting with the DON, Asst. Adm., HR, RN/Hall Supervisor, and ADON to discuss our facility failures." k. On 8/15/14 at 1:35 p.m., the Assistant Administrator (Asst. Adm.) was asked to describe what occurred on 8/5/14 with Resident #1. She stated, "...(Resident #1) is more challenging, we were concerned about his teeth, he needed to get fixed. I saw (Administrator) approach him. I can't tell you exact words. I did hear her say she was concerned about his teeth. She was encouraging him to trust the facility dentist. I saw her when she first went up to resident. ...Her voice was raised. He has a loud voice ... I didn't really take it as yelling. I would say with the traffic in the room her voice was raised. It was loud enough to catch my attention to make me look while I was inside the office, to see what was going on. I didn't find out (about the allegation until the next morning 8/6/14). The Administrator was gone, the DON was gone. That morning, the ADON and RN/Hall Supervisor came into the office. They said we have a problem. They told me an allegation of abuse was made and asked what we are supposed to do. I immediately notified the DON and Administrator. I immediately turned to my computer and stated, 'We have until 11 a.m. to report it to OLTC'. When I dropped the ball, (Administrator) had been communicating with them. I got a text back from (Administrator) that told me to know I was not to handle it, let (ADON) take care of it. I knew in my heart th

Complaint # (AR 396) was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure residents were consistently treated with respect and dignity in order to enhance and promote a sense of well-being for 1 of 1 (Resident #1) case mix residents, who alleged verbal/physical abuse involving the facility Administrator and who had 3 staff members take him into a room in an attempt to ensure he was aware how serious his allegations were. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Residents #1 who reported an allegation of staff to resident physical abuse and had the potential to cause more than minimal harm for 42 residents in the facility, according to a list provided by the Social Director on 8/15/14 at 5:45 p.m. The facility was informed of the Immediate Jeopardy on 8/15/14 at 1:04 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of 6/19/14 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive assistance of 1 persons for transfers; and was independent via wheelchair for mobility. a. A hand-written statement dated and signed by Licensed Practical Nurse (LPN) #3 on 8/6/14 at 10:25 a.m. documented, "On 8/5/14 at approx. (approximately) 1430 (2:30 p.m.), (Resident #1) approach this nurse stating that (Administrator) had hurt his paralyzed arm by tapping it with her pointer finger as she was passing by in the hallway to discuss with him the importance of his oral care. This nurse immediately notified (Social Services Director) of facility whom was unavailable upstairs at the time stating she would be with him later for discussion or he could propel w/c (wheelchair) upstairs via elevator. Upon observation of residents left arm, no bruising nor redness nor swelling was noted. He stated that he was going outside to smoke ..." The Office of Long Term Care (OLTC) statement dated 8/5/14 (no time given) and signed by the Social Services Director on 8/14/14 (not timed) documented,, "(LPN #3) called me and I was in the activity office working on the newsletter. I can't remember what (LPN #3) said to me but it involved something happening between (Resident #1) and (Administrator). I then responded to (LPN #3) that I was busy upstairs in the activity office and for him to come up there to speak with me. (Resident #1) never did come upstairs nor did I see him to talk to him." b. A Facility Investigation Report for Resident Incident and Accident statement dated 8/6/14 at (12:30 a.m.) and signed by LPN #1 documented, "(Resident #1) came to the desk and asked if an employee hit a resident would you help the resident or employee? I told (Resident #1) I would help the resident and (Resident #1) then said that (Administrator) had hit him many times on his arm and that he told his nurse (LPN #3) twice and she told him to go tell (Social) and (LPN#3) wouldn't help him. (Resident #1) then said so will you help me. I said lets tell your nurse I called (LPN #2) and he told her the same story. We then called the ADON because the DON was on vacation no answer so we then called the hall supervisor no answer so then we called the DON and she answered I explained." A second Facility Investigation Report for Resident Incident and Accident statement dated 8/6/14 at (12:40 a.m.) and signed by LPN #1 documented, "On 8/6/14 (Administrator) called facility and I answered the phone. (Administrator) stated that the DON had called her because of (Resident #1) had stated that (Administrator) had hit him. The DON had stated to write his statement to me and (Administrator) asked me when she called if he wrote a statement. I told her yes he did and she asked why I or (LPN #2) the 100 nurse had not called her and I told her because she was the one he was saying hit him and I felt like me calling her was wrong I followed my chain. I called ADON because the DON was on vacation then called Hall supervisor when I couldn't get them. I called the DON who answered. She (Administrator) stated, "You tell him I did not hit him and that if he would have fixed his teeth like he should have we wouldn't be having to spend all this damn money now. He is just mad because he isn't seeing the doctor he wants." I stated "Ok" to (Administrator) then she said 'tell him' and I told her ok again she then said is he near you and I said yes and she said tell him he knows I did not hit him and I told her no I wasn't telling him that. She (Administrator) said well tell him I might have tapped his arm to get his attention but it was not a hit and it's on camera so I'm covered. I again stated Ok she asked if he reported it to the nurse when it happened and I told her yes he said he did but she "blew me off" and (Administrator) said tell him he doesn't know she blew him off she could have told someone and he doesn't know it. "Hell we could be already looking into it and he just doesn't know it." I again stated ok to (Administrator) and she stated, "Well if he keeps saying it I guess ok because I'm covered it's on camera. I'll deal with it when I get back. My husband is having surgery in the morning." I said ok she then said tell him I said to knock it off and shut up. I said "ok" again. I and (LPN #2) then finished his statement. I then called my DON again and told her about the phone call she said you do your job and protect the resident. I told her we were but (Administrator) was mad when she called. DON said it doesn't matter if she's mad ...." On 8/15/14 at 7:55 a.m., LPN #1 was asked to describe what occurred on 8/6/14 with (Resident #1). LPN #1 stated, "...to be honest, he (Resident #1) didn't act right, he was sorta subdued. He asked me if an employee hit a resident would you believe them. Would you take up for the employee or the resident? I said, the resident, did something happen? Is the resident hurt? (Resident #1) said, 'Then will you help me because (Administrator) hit me yesterday and nobody will help me' I asked him, when?' (Resident #1) said, 'Day shift. I told (LPN #3) twice, but she blew me off.' I asked (Resident #1), what do you mean? He said, the first time she blew me off, the second time she said ok (Resident #1) just go tell (Social Director). (Resident #1) said he went to (Social's office), she wasn't there. He said he went to smoke at that time and came back the social's office door was shut. I (LPN #1) called over to Willow because (LPN #2) was his direct charge nurse. (LPN #2) came over. We went into the charting area and I told (Resident #1) to tell (LPN #2) what he told me. He told (LPN #2) the same story. I called Assistant Director of Nursing (ADON) 10-15 minutes later. I left a message on her voice mail that I've got a big problem when you call, she (ADON) didn't respond. Then I text her the same thing. Then when she didn't respond, I called Registered Nurse (RN #1). I left a message again with her. She didn't call. Then, I text the Director of Nursing (DON). She answered immediately. She was on vacation. I wasn't sure about the procedure myself. She said you protect the resident and get a blank abuse form and you write it up." LPN #1 stated, "Do I think she maliciously tried to hurt him? No. Do I think he honestly believes she did? Yes. Honestly on purpose, no." LPN #1 stated, "He repeatedly reported it two times. She blew him off. He said this happened on day shift. He didn't tell anyone until 3/11 shift. He told me around midnight on 11/7 shift. His demeanor that night was not his demeanor. I was completely shocked when he said it. I never heard him say that anybody had abuse him that I'm aware of." c. A Facility Investigation Report for Resident Incident and Accident statement dated 8/6/14 at (12:30 a.m.) and signed by (LPN #2) documented, " ...was called by (LPN #1) to come over to Magnolia Hall, when I got there she had me and (Resident #1) go into the chart room. When we go in there, resident then said that (Administrator) hit his arm repeatedly and his arm fell off the chair and she continued to hit his arm with her finger, and that he told his nurse (LPN #3) twice and she blew him off and told him to go tell (Social) and wouldn't help him. We then called the ADON because the DON was on vacation, no answer. We then called the hall supervisor with no answer. So then called DON, she answered and (LPN #1) told her why she did not call the Administrator. She (LPN #1) said she was unsure if she should call (Administrator) because she was the one (Resident #1) was accusing. The DON had us get (Resident #1's) statement and turn it into the ADON or HR (Human Resource) in the morning." On 8/15/14 at 8:40 a.m., LPN #2 was asked to describe what occurred on 8/6/14 with (Resident #1). LPN #2 stated, "He told us on 8/6/14. But it happened on 8/5/14. I was charting on hall when (LPN #1) called me to come to Magnolia Hall about 12:30 midnight, when I got there (Resident #1) was at the desk, we had to go into the charting room for privacy. (LPN #1) told (Resident #1) 'to tell (LPN #2) what you just told me. What would you do if an employee hit you?' He's always oriented times three, he's with it. (Resident #1) said (Administrator) hit him on his arm. He said she was tapping him on his arm. '(saying) If you had been going to Dr. (Dentist), you wouldn't have this problem with your teeth.' Then he said his arm fell off the wheelchair armrest. He said he had to pick it back up. She did it again and he said it hurt. He said he told (LPN #3). I guess he told her twice and she said to go tell (Social). He said he never found (Social). Apparently, he waited the entire shift. (Resident #1) said it hurt. His pain is different from anyone else. His pain is his pain. You can't tell somebody if it hurts or not. When I came back that night (8/6/14), he said (Administrator) said to him 'you know it didn't happen that way.' He said they had him in the office watching the video. I feel like they gained up on him. (RN #1) was in his room first thing the next morning. LPN #1 tried (ADON and RN #1) no answer, we didn't want to call the Administrator she was the accused. (Administrator) called that night, she was mad, says why you didn't call me." d. A hand-written statement dated 8/6/14 at (12:30 a.m.) and signed by Resident #1 documented, "In front of DON's office coming from ADON's office, (Administrator) was walking beside me and kept hitting my arm with her finger. My arm fell off the w/c (wheelchair) and I put it back up, thinking she wouldn't hit it any more but she kept hitting it because I haven't been seeing the (Dentist). I told (LPN #3) my nurse twice and she said for me to tell (Social) but I couldn't find her. She was hitting my arm hard enough it hurt." A hand-written statement dated 8/6/14 (not timed) and signed by Resident #1 documented, "We were down by (ADON) office and was arguing about the dentist appointment. We started walking toward the hall. (Administrator) was on my left side and she hit my arm with her index finger, telling me that if I had been seeing the dentist that we could have prevented the toothache. At that time my arm fell and I picked it up and put it back up on the armrest. I think she was hitting me trying to get my attention." On 8/15/14 at 11:25 a.m., Resident #1 was asked about the conversation he had with the Administrator in front lobby next to the elevator. He stated, "I honestly don't know what happened to her. She was hitting my arm. She was hitting it hard enough to it fell off the wheelchair armrest. (RN/Hall Supervisor) had to pick my arm up and put it back on the armrest. (Administrator) was getting on to me pretty much about the dentist. I didn't want to go to that dentist because he didn't approach me the right way one time. He just came up to me and put his fingers in my mouth - said 'yep, all them need to be pulled.' Then later I agree to see him again and the first thing he did was put his fingers in my mouth with no gloves on." Resident #1 was asked about the incident on 8/5/14. He stated, "As I was going down hall, (Administrator) said - if I had seen (dentist) the whole time - I wouldn't be in this situation." Since the incident, Resident #1) stated he has not seen the Administrator. Resident #1 was asked, "Are you fearful - afraid of the Administrator?" He stated, "No, but it made me not want to be around her." He was asked, "Are you afraid to be around her?" Resident #1 stated, "No, not really. I just prefer not to be around her. But as long as I live here, I'm sure I've got to run into her." Resident #1 stated, "It embarrassed me out in front of the God and everybody. If she wanted to talk to me about the dentist or anything she should have taken me to an office where we could have privacy and tell me. There was no need to yell at me." Resident #1 was asked, "Right now do you feel safe, secure in this facility?" He stated, "Well, she could throw me out." e. An OLTC Witness Statement dated 8/5/14 and signed by a family member (non case-mix) documented, "I was at the elevator waiting to go up to see my mother. (Resident #1) and (Administrator) were right next to the elevator. She was telling him either to go to the dentist here or get another one and pay for it himself. She did not touch him that I saw. I was not there before that time so I do not know what led up to her speaking in a voice that sounded condescending. I was embarrassed and tried to not look at them." On 8/15/14 at 9:25 a.m., the family member (non case-mix) was interviewed. She stated, "I went to visit my mother, I came in the front door waiting on the elevator. I could hear her (Administrator) voice. It wasn't pleasant. I didn't even know who she was at first. I knew she was the big blonde lady. It was her (Administrator) tone. I can't tell you why. It was enough to make me feel uncomfortable. I heard them discussing something about going to the dentist. It was loud enough, I was trying to hear and not stare. I felt like she lost her temper." Family member stated, "Sometimes you should think before you speak." f. On 8/14/14 at 4:35 p.m., RN #1 was asked to describe what occurred on 8/5/14 and 8/6/14 with (Resident #1). RN #1 stated, "that morning 8/5/14, Thursday approximately 8:30 a.m. I saw (Resident #1). He told me about his toothache. I checked on it, looked at his mouth. I told him, I think you need to see a dentist. After this I went to the morning meeting and reported the tooth in the meeting. The (ADON, Administrator) and myself, we decided to get an appointment with the dentist. (Resident #1) mentioned he wanted to see (Dentist #2)." The RN/Hall Supervisor stated the facility has the services within the nursing home and (Dentist #1), who comes to the facility routinely. The RN/Hall Supervisor stated, "I asked (ADON) to tell (Resident #1) about the appointment with (Dentist #1), but (Resident #1) refused. That started the day with (Resident #1). Time went by later on in the day, I waited, (Resident #1) went to smoke. I went out there. It was just me and him. We had an adult conversation, shared my concerns about his toothache. (Resident #1) agreed to see (Dentist #1). We shook hands on it. I went to (ADON's) office. I was telling her about what me an (Resident #1) had discussed. So we actually made (Resident #1) an appointment for the next morning at 9:30 a.m. It was about 2:30 p.m.- 2:35 p.m., I was in the office when I heard the conversation. I heard the loud conversation. It was very loud, loud enough to get my attention. It was in the hall. I recognized the voices. I heard the argument." The RN was asked if they were being argumentative. The RN stated, "Yes, their voices were loud. It prompted me to go straight out of the office. It was (Administrator and Resident #1) arguing about seeing the dentist. I was trying to stop the argument. I told (Administrator) that we got him an appointment at 9:30 a.m. in the morning. A little bit more arguing went on. The only thing I saw was (Administrator) put her hand on his shoulder. I did not see her actually hit him. I'm not saying she didn't, I just didn't see it. His arm did fall off the chair. I pulled it up and put it back on the armrest. She (Administrator) very well could've hit him. But I wasn't focused on that. I felt it was a public area (lobby), if they wanted to have the conversation, they needed to in another area." The RN #1 was asked if the Administrator was shaking her finger at him. She stated, "Yes, there was finger shaking going on. I felt the approach was fast on the Administrator's part. The Administrator did not have any knowledge we had settled the dentist appointment. The Administrator said to (Resident #1) at the time, if he would use the services, see the dentist the facility provided that his teeth wouldn't get to this point." The RN was asked was the Administrator scolding him (Resident #1). The RN stated, "Yes." The RN was asked, "How did the argument between the resident and the Administrator make you feel?" The RN stated, "It made me feel uncomfortable. It was loud, kinda like two adult people yelling in the hallway. I felt like (Resident #1) should not be there." The RN then stated, "Somehow over the weekend. I had the weekend to think about it. I played it over and over in my mind. I got a text that (Resident #1) said (Administrator) hit his arm. That's how I actually learned about what (Resident #1) had said. I got here as fast as I could 8/6/14. I went straight to (Resident #1's) room. It was just me and him, we had a [MEDICATION NAME] conversation so I asked him what was going on? I wrote down his statement. I read it back to him. He signed it. I took the statement and went straight to (Assistant Adm.). I gave her that and I told her we needed to report it to OLTC now, do it today. She (Assistant Administrator) said, 'we are going to turn this over to (ADON).' Me and (ADON) talked, (ADON) said we needed to interview (Resident #1), I wasn't sure what to do." The RN stated, "There was (ADON, me, Resident #1 and Human Resource (HR)), all in the office. (ADON) sat there, she was not meaning to be rude. She asked him about it (Administrator hitting him). She asked (Resident #1) what the extent of the allegation was. (Resident #1) watched the video. (ADON) ran the video three times for him. I'm her witness. (Resident #1) said, 'Maybe she (Administrator) was treating me like a child." The RN was asked, "Did anyone talk to him in such a way that persuaded him to change his statement?" The RN stated, "No. I do think he was persuaded, but it wasn't intentional to manipulate by me or (ADON). We explained to him that there will be an investigation, it was serious. I think it concerned him." The RN stated, "The Office of Long Term Care (OLTC) was not notified based on his recanted statement. I told (ADON) we should've never done that. We should've never pulled (Resident #1) back in here and had him sign that statement. We just should've reported it to OLTC. We made a mistake. We all make mistakes. I do think we went one step too far. It was intimidating. If that had been me, I would have recanted too. That was wrong. I told the DON that statement is bullshit. I want the state called. I don't want this mess to come up 6 months from now and they think we are trying to hide something. I was a part of that interview. It was wrong." The RN was asked, "Do you think yelling at a resident is verbal abuse?" She stated, "Yes, I do." The RN was asked, "Do you consider the argument between the resident and the Administrator was verbal abuse on the Administrator's part?" The RN stated, "I don't know, they have had loud conversations before in the office. (Administrator) was not herself that day. She had a shot of [MEDICATION NAME] and [MEDICATION NAME]. She was wound that day. She was not herself, not her normal pattern." g. On 8/14/14/ at 5:35 p.m., the ADON was asked to describe what occurred on 8/6/14 with (Resident #1). The ADON stated she had received a phone call from (LPN #1). The ADON stated, "I called her (LPN#1) back and I talked to the DON. She told me (Resident #1) said (Administrator) hit him. I got here a little after 8:00 a.m., I reviewed the camera. I left to go to a doctor's appointment at 8:45 a.m. I got back around 10:30 a.m. on 8/6/14. I went to talk to (RN/Hall Supervisor), she had talked to (Resident #1). He did report it to her. I felt it would be a good idea to look at the footage, to let him point out to me what he felt his allegation was. We put him in front of the computer and he looked at it three times. I felt like he needed to see it as many times as he needed. He never pointed anything out on camera. I asked him, (Resident #1) this is serious, do you feel like (Administrator) was maliciously hitting you or being mean. He paused a minute and he said, no. He said she was tapping; it was more like a mother getting on to her child. I asked him well will you write that in a statement for me." ADON stated, "I don't know what she (Administrator) did. Maybe she went too far. Now should she have done that? No. My concern was did she really hit him, lay her hand on him?" The ADON stated, "After that it pretty much was dropped." The ADON stated she felt they should have not taken (Resident #1) into the office and had him change his statement. The ADON stated, "I take responsibility for that." An OLTC Witness Statement dated 8/6/14 (not timed) and signed by Resident #1 documented, "I do not believe (Administrator) was in no way physically abusive to me on 8/5/14." h. The DON's written statement dated 8/12/14 at 7:00 p.m. documented, "...(Resident #1) stated, 'She (Administrator) was hitting my arm in the hall and it hurt because it's my paralyzed arm, and nobody believes me.' I asked (Resident #1) if he was telling me the truth why he changed his story he said, 'because they took me in the office and I was afraid if I didn't change my story I would have to leave the facility. I know (Administrator) makes the decision she has threatened to make me leave before. I was scared not to change my story.' I observed residents left arm and observed small bruises to his forearm. Resident stated to me, 'don't worry about me, if you say anything to anyone they will be mad at you.' I explained to resident not to worry about me, and no employee has the right to place their hands on you, yell or mistreat you or any other resident in the facility. Resident verbalized, '(Administrator) was cruel to me that day because I didn't want to see her dentist, and she did hit my arm and hurt it.' Resident was assisted back to his hall. Acting Asst. Adm. and Administrator were notified of my conversation with resident related original allegation of abuse and new allegation of intimidation." On 8/15/14 at 3:35 p.m., the DON was asked to describe what occurred on 8/6/14 with Resident #1. She stated, "On 8/6/14 at 12:04 a.m. (LPN #1) called me. She said (Resident #1) was making an allegation that the administrator hit him. She (LPN #1) stated that (Resident #1) had reported to the day shift nurse (LPN #3), she blew him off and (Social) she blew him off. (LPN #1) was very anxious because the allegation was against the Administrator. I told her no matter who the allegation is against even if it's me you have to protect the resident. Take their statement for face value. I instructed her to take his written statement and (LPN #2's) statement as it would be a reportable and turn into (ADON) or (HR) to ensure it got to (ADON). (LPN #1) asked if she had to call (Administrator). I said I would call her. I called (Administrator), I told her we had a reportable it was an allegation of abuse, against you. (Resident #1) said you hit him. Her (Administrator) exact words were 'I didn't hit him. I just smacked his arm to get his attention'. At 12:35 a.m., I received a second call from (LPN #1), she stated (Administrator) called and she was mad. She told then to go down there and tell him to shut up and knock it off. So I told (LPN #1) she still had to report it. It didn't matter how (Administrator) felt. She still needed to report it. Wednesday, 8/6/14 at 8:45 p.m., I received a text from (Administrator) that stated, "Meant to tell you they showed camera to (Resident #1) and he recanted his claim on me. I didn't respond to the text because even if he recanted his statement, it was still a reportable. I believe it is up to OLTC (Office of Long Term Care) to decide if it was abuse. On 8/12/14, I'm at lunch with (RN/Hall Supervisor), (ADON), and (RN/Care plan Coordinator). (RN/Hall Supervisor) tells me she believes they did something wrong, that they didn't report it. That she has known in the past something like that needed to be reported. She knew taking him (Resident #1) into the office like that she knew was wrong. I asked them to explain it to me and (ADON) said she got a phone call from (Administrator). She said (Administrator) told her to treat her like any other staff and report it. The next thing she knew she was at the doctor's office. (Administrator) called her screaming at her so loud the doctor could hear her screaming that she better get back to the building, get a handle on it and get control. (ADON) received a text message from (Administrator) that said 'if he doesn't recant his statement, I will walk you through how to do a reportable by noon.' We got back to building spoke with (Asst. Adm.) and (HR). I always have a witness. I asked (Asst. Adm.) why it wasn't reported. She said she called (Administrator) to let her know she was going to report it. (Administrator) said, 'No, let (ADON) handle it.' (Asst. Adm.) and (HR) asked me what I was going to do. I told them it was a reportable and it should've been reported. Either way I'm going to get my building in trouble no matter what I do. I'm going to lose my job that I have to pray about it. So I went to review the camera footage and the statements. (Asst. Adm.) had told me the statements had been shredded, but they had not been. They were in her top right hand door of her desk. The camera footage showed the resident in hall next to elevator. The Administrator approached him in an abrupt manner, shaking her finger at him. He backed away from her she approached him a second time. (RN/Hall Supervisor) walked up to try to take him down the hall. (Administrator) appears to be tapping him on his left arm with her right index finger. At 6:30 p.m., I talked to the resident. The resident was not his typical self. I asked him if he had anything he wanted to tell me. He said no. I said are you sure? He said, 'Can I tell you about me and the administrator?' I told him he could tell me anything. He said she was hitting him last week on the arm. It was hurting because it was his paralyzed arm. He explained his arm hurts when you hit it. He told me that he told her (Administrator) it was hurting, but it didn't do any good. He told me he didn't want me to do anything because people would be mad at me because he had already caused problems. I asked him if he was telling the truth, why did he change his story? He said they took him in the office and started asking him questions and showed him a video tape and demanded he show them where she (Administrator) hit him. He said, 'you know me, I get confused. I couldn't show them. I was scared if I didn't change my story, I'd have to leave here.' He told me (Administrator) made the decisions around here and threatened to make him leave before. He asked me if I saw it on the camera because nobody believes him. On 8/13/14, she (Administrator) came barreling in here, demanded a meeting with the DON, Asst. Adm., HR, RN/Hall Supervisor, and ADON to discuss our facility failures." i. The Administrator's written statement received 8/15/14 documented, "...8/5/14 this was going to be my last day at work for the rest of the week as I was taking off... I was walking out into lobby and saw (Resident #1), sitting there, and crossed my mind that he was having tooth pain and was refusing dental care. So I approached him and said something to the effect of "(Resident #1) you know you are going to have to go see a dentist?" At that point, he hollered at me very loudly 'I don't have to do anything I don't want to do.' I looked up and saw a visitor at the elevator door and thought no telling what she thinks is going on. I remember saying to (Resident #1) you don't have to holler. This is serious that you need to see the dentist. At that time the RN, came out of the office and stood beside his wheelchair. I continued to talk to him telling him the facility can provide him dental services and the need for him to see a dentist; he could get poisoned from the infection. ...My voice is loud on a normal basis, as well as having severe [MEDICAL CONDITION] that affected my voice sounding I am sure different somewhat different. The lobby is 2 stories and there is echoing also. I took my index finger and tapped on the top of his hand and said something to the effect. (Resident #1), listen to me on how serious this is. We have a contract with a dentist and he can see you every month and prevent any other teeth from becoming involved so that it won't get to this point in the future. This is what happens when you refuse care and it can be prevented. I also told him that we were paying for him to see the dentist and he should see our facility dentist since he comes every month, and we have these dental facilities and it would be so easy. (I relay this tapping motion on his hand to seeing a baby in a seat and tapping on his little hand to get the baby to smile or look at you.) This same motion is not classified as abuse to a child and certainly was not abuse to (Resident #1). I did not hit him in any manner ...nor was I yelling at him. I deny that ...I hit him. I do remember that I barely touched him... but it was not a hit. ...I may have been loud, I don't know. I am often a loud personality... August 6 Wednesday I received a phone call from DON... She informed me (Resident #1) had made an allegation on me that I hit him. I called the 11/7 nurse to reassure to her that I wanted her to feel comfortable on calling me on any allegation including myself and not feel bad or uncomfortable. ...It was a call to relieve her anxiety of having to deal with this. I gave her no instructions or any innuendos. Sometime the next morning I called (ADON) and told her to handle all this. The DON had received the allegation and they should have proceeded. I sent a text to both her and (RN/Hall Supervisor) to take care of the allegation. ADON was in charge, and (RN/Hall Supervisor) was his hall RN. (ADON) sent me a text that they had interviewed (Resident #1) and he had recanted, so in my mind it was a simple reportable. I talked no further to any staff regarding the allegation. I stayed out of it, not even reviewing the camera assuming while I was out they were all handling it. I certainly did not want any influence on their investigation. ...The DON had notified me of the allegation, has done many reportable and I assumed they were communicating with her on the process as well. August 7, 8, 9, and 10 Thursday, Friday, Saturday and Sunday, the facility ran as usual as far as my knowledge. I was not present in the building and therefore had no contact with (Resident #1). ...On August 11, Monday, afternoon DON returned to work. I had no conversation with her. She did not call me to inform the reportable had not been filed. I later learned that (RN/Hall Supervisor) had felt that maybe taking him in the office and interviewing was not a good situation; they should have just filed it and moved on. DON learns the report had not been filed. At this point, I am still under the impression everything was fine. On August 12, Tuesday, about 9:30 p.m. (Asst. Adm.) calls me tell me that she was seeing that the DON was trying to turn the issue into something and that the reportable still had not been filed. That was my first knowledge t

Complaint # (AR 396) was substantiated (all or in part) with these findings Based on record review and interview, the facility's Abuse Prohibition Policy and Procedure failed to address steps to instruct employees on who to report abuse to when the allegation involves the Administrator and/or the Director of Nursing. The facility failed to implement the facility's Abuse & Neglect Prohibition & Reporting Policy and Procedure regarding reporting, investigating and protecting as evidenced by the facility failures to ensure staff immediately reported an allegation of staff (facility Administrator) to resident abuse to the appropriate facility person; to ensure the prompt initiation of an investigation; and to ensure residents were protected from the potential of further abuse for 1 (Resident #1) of 1 case mix residents who reported the Administrator had physically hit him. The facility also failed to ensure staff did not use intimidation tactics when interviewing 1 (Resident #1) of 1 case mix residents who reported the Administrator had physically hit him and who temporarily recanted his statement regarding the allegation of physical abuse involving the Administrator. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Residents #1 who reported an allegation of staff to resident physical abuse and had the potential to cause more than minimal harm for 42 residents in the facility, according to a list provided by the Social Director on 8/15/14 at 5:45 p.m. The facility was informed of the Immediate Jeopardy on 8/15/14 at 1:04 p.m. The findings are: 1. The facility's original Abuse & Neglect Prohibition & Reporting policy, last reviewed 6/17/09, provided by the DON documented, "...Employees suspected of any form of abuse must immediately be removed from direct resident care to assure the safety of all residents until an investigation can be completed....Immediate suspension of the employee, placing them in a non-direct care department with full time supervision...The employee must remain on suspension/supervision until the investigation is complete ...Identification and Reporting: All employees are responsible for reporting any and all suspected occurrences of any form of abuse to your supervisor (including abuse, verbal abuse, sexual abuse, physical abuse, involuntary seclusion, mental abuse, neglect and misappropriation of property) IMMEDIATELY ...Investigation and Reporting by the Facility: ...a complete investigation should be made by the Administrator and/or designee ...I & A (incident and accident) reports; witness statements; ...CMS form 7734 completed and faxed to OLTC by 11:00 a.m. next business day ...physician, law enforcement, family/responsible party notified-all parties (excluding law enforcement) notified even for unfounded reports ..." The policy failed to address steps to instruct employees on who to report abuse to when the allegation involves the Administrator and/or the Director of Nursing. 2. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of 6/19/14 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive assistance of 1 persons for transfers; was independent via wheelchair for mobility. a. An hand-written statement dated and signed by Licensed Practical Nurse (LPN) #3 on 8/6/14 at 10:25 a.m. documented, "On 8/5/14 at approx. (approximately) 1430 (2:30 p.m.), (Resident #1) approach this nurse stating that (Administrator) had hurt his paralyzed arm by tapping it with her pointer finger as she was passing by in the hallway to discuss with him the importance of his oral care. This nurse immediately notified (Social Services Director) of facility whom was unavailable upstairs at the time stating she would be with him later for discussion or he could propel w/c (wheelchair) upstairs via elevator. Upon observation of residents left arm, no bruising nor redness nor swelling was noted. He stated that he was going outside to smoke ..." b. The Office of Long Term Care (OLTC) statement dated 8/5/14 (no time given) and signed by the Social Services Director on 8/14/14 (not timed) documented, "(LPN #3) called me and I was in the activity office working on the newsletter. I can't remember what (LPN #3) said to me but it involved something happening between (Resident #1) and (Administrator). I then responded to (LPN #3) that I was busy upstairs in the activity office and for him to come up there to speak with me. (Resident #1) never did come upstairs nor did I see him to talk to him." On 8/14/14 at 6:15 p.m., the Social Services Director (SSD) was asked to describe what occurred on 8/5/14 with (Resident #1). She stated, "I was upstairs in the activity office (8/5/14), mid-afternoon. (LPN #3) paged me. I called to Willow and she picked up the phone." The SSD was asked, "What did (LPN #3) say to you?" The SSD stated, "I can't remember what she said, I really didn't pay attention. I told her to send him (Resident #1) up to activity room. (Resident #1) he never came up. I just thought it wasn't a big deal." The SSD was asked, "What wasn't a big deal?" The SSD stated, "About whatever she (LPN #3) had said on the phone." Staff calls me all the time about him, because of things - his behaviors. He (Resident #1) will cuss staff because he was angry. He will go up to family members asking for cokes, cigarettes, money - he has manipulated them. Usually if it's a serious situation, he will come tell me. So he never showed. I didn't think it was important. So I left." c. A Facility Investigation Report for Resident Incident and Accident statement dated 8/6/14 at 0030 a.m. and signed by LPN #1 documented, "(Resident #1) came to the desk and asked if an employee hit a resident would you help the resident or employee? I told (Resident #1) I would help the resident and (Resident #1) then said that (Administrator) had hit him many times on his arm and that he told his nurse (LPN #3) twice and she told him to go tell (Social) and (LPN#3) wouldn't help him. (Resident #1) then said so will you help me. I said lets tell your nurse I called (LPN #2) and he told her the same story. We then called the ADON because the DON was on vacation no answer so we then called the hall supervisor no answer so then we called the DON and she answered I explained." A second Facility Investigation Report for Resident Incident and Accident statement dated 8/6/14 at 0040 a.m. and signed by LPN #1 documented, "On 8/6/14 (Administrator) called facility and I answered the phone. (Administrator) stated that the DON had called her because of (Resident #1) had stated that (Administrator) had hit him. The DON had stated to write his statement to me and (Administrator) asked me when she called if he wrote a statement. I told her yes he did and she asked why I or (LPN #2) the 100 nurse had not called her and I told her because she was the one he was saying hit him and I felt like me calling her was wrong I followed my chain. I called ADON because the DON was on vacation then called Hall supervisor when I couldn't get them. I called the DON who answered. She (Administrator) stated, "You tell him I did not hit him and that if he would have fixed his teeth like he should have we wouldn't be having to spend all this damn money now. He is just mad because he isn't seeing the doctor he wants." I stated "Ok" to (Administrator) then she said 'tell him' and I told her ok again she then said is he near you and I said yes and she said tell him he knows I did not hit him and I told her no I wasn't telling him that. She (Administrator) said well tell him I might have tapped his arm to get his attention but it was not a hit and it's on camera so I'm covered. I again stated Ok she asked if he reported it to the nurse when it happened and I told her yes he said he did but she "blew me off" and (Administrator) said tell him he doesn't know she blew him off she could have told someone and he doesn't know it. "Hell we could be already looking into it and he just doesn't know it." I again stated ok to (Administrator) and she stated, "Well if he keeps saying it I guess ok because I'm covered it's on camera. I'll deal with it when I get back. My husband is having surgery in the morning." I said ok she then said tell him I said to knock it off and shut up. I said "ok" again. I and (LPN #2) then finished his statement. I then called my DON again and told her about the phone call she said you do your job and protect the resident. I told her we were but (Administrator) was mad when she called. DON said it doesn't matter if she's mad ...." On 8/15/14 at 7:55 a.m., LPN #1 was asked to describe what occurred on 8/6/14 with (Resident #1). LPN #1 stated, "...to be honest, he (Resident #1) didn't act right, he was sorta subdued. He asked me if an employee hit a resident would you believe them. Would you take up for the employee or the resident? I said, the resident, did something happen? Is the resident hurt? (Resident #1) said, 'Then will you help me because (Administrator) hit me yesterday and nobody will help me' I asked him, when?' (Resident #1) said, 'Day shift. I told (LPN #3) twice, but she blew me off.' I asked (Resident #1), what do you mean? He said, the first time she blew me off, the second time she said ok (Resident #1) just go tell (Social Director). (Resident #1) said he went to (Social's office), she wasn't there. He said he went to smoke at that time and came back the social's office door was shut. I (LPN #1) called over to Willow because (LPN #2) was his direct charge nurse. (LPN #2) came over. We went into the charting area and I told (Resident #1) to tell (LPN #2) what he told me. He told (LPN #2) the same story. I called Assistant Director of Nursing (ADON) 10-15 minutes later. I left a message on her voice mail that I've got a big problem when you call, she (ADON) didn't respond. Then I text her the same thing. Then when she didn't respond, I called Registered Nurse (RN #1). I left a message again with her. She didn't call. Then, I text the Director of Nursing (DON). She answered immediately. She was on vacation. I wasn't sure about the procedure myself. She said you protect the resident and get a blank abuse form and you write it up." LPN #1 stated, "Do I think she maliciously tried to hurt him? No. Do I think he honestly believes she did? Yes. Honestly on purpose, no." LPN #1 stated, "He repeatedly reported it two times. She blew him off. He said this happened on day shift. He didn't tell anyone until 3/11 shift. He told me around midnight on 11/7 shift. His demeanor that night was not his demeanor. I was completely shocked when he said it. I never heard him say that anybody had abuse him that I'm aware of." d. A Facility Investigation Report for Resident Incident and Accident statement dated 8/6/14 at 0030 midnight and signed by (LPN #2) documented, " ...was called by (LPN #1) to come over to Magnolia Hall, when I got there she had me and (Resident #1) go into the chart room. When we go in there, resident then said that (Administrator) hit his arm repeatedly and his arm fell off the chair and she continued to hit his arm with her finger, and that he told his nurse (LPN #3) twice and she blew him off and told him to go tell (Social) and wouldn't help him. We then called the ADON because the DON was on vacation, no answer. We then called the hall supervisor with no answer. So then called DON, she answered and (LPN #1) told her why she did not call the Administrator. She (LPN #1) said she was unsure if she should call (Administrator) because she was the one (Resident #1) was accusing. The DON had us get (Resident #1's) statement and turn it into the ADON or HR (Human Resource) in the morning." On 8/15/14 at 8:40 a.m., LPN #2 was asked to describe what occurred on 8/6/14 with (Resident #1). LPN #2 stated, "He told us on 8/6/14. But it happened on 8/5/14. I was charting on hall when (LPN #1) called me to come to Magnolia Hall about 12:30 midnight, when I got there (Resident #1) was at the desk, we had to go into the charting room for privacy. (LPN #1) told (Resident #1) 'to tell (LPN #2) what you just told me. What would you do if an employee hit you?' He's always oriented times three, he's with it. (Resident #1) said (Administrator) hit him on his arm. He said she was tapping him on his arm. '(saying) If you had been going to Dr. (Dentist), you wouldn't have this problem with your teeth.' Then he said his arm fell off the wheelchair armrest. He said he had to pick it back up. She did it again and he said it hurt. He said he told (LPN #3). I guess he told her twice and she said to go tell (Social). He said he never found (Social). Apparently, he waited the entire shift. (Resident #1) said it hurt. His pain is different from anyone else. His pain is his pain. You can't tell somebody if it hurts or not. When I came back that night (8/6/14), he said (Administrator) said to him 'you know it didn't happen that way.' He said they had him in the office watching the video. I feel like they gained up on him. (RN #1) was in his room first thing the next morning. LPN #1 tried (ADON and RN #1) no answer, we didn't want to call the Administrator she was the accused. (Administrator) called that night, she was mad, says why you didn't call me." e. A hand-written statement dated 8/6/14 at 0030 midnight and signed by Resident #1 documented, "In front of DON's office coming from ADON's office, (Administrator) was walking beside me and kept hitting my arm with her finger. My arm fell off the w/c (wheelchair) and I put it back up, thinking she wouldn't hit it any more but she kept hitting it because I haven't been seeing the (Dentist). I told (LPN #3) my nurse twice and she said for me to tell (Social) but I couldn't find her. She was hitting my arm hard enough it hurt." A hand-written statement dated 8/6/14 (not timed) and signed by Resident #1 documented, "We were down by (ADON) office and was arguing about the dentist appointment. We started walking toward the hall. (Administrator) was on my left side and she hit my arm with her index finger, telling me that if I had been seeing the dentist that we could have prevented the toothache. At that time my arm fell and I picked it up and put it back up on the armrest. I think she was hitting me trying to get my attention." On 8/15/14 at 11:25 a.m., Resident #1 was asked about the conversation he had with the Administrator in front lobby next to the elevator. He stated, "I honestly don't know what happened to her. She was hitting my arm. She was hitting it hard enough to it fell off the wheelchair armrest. (RN/Hall Supervisor) had to pick my arm up and put it back on the armrest. (Administrator) was getting on to me pretty much about the dentist. I didn't want to go to that dentist because he didn't approach me the right way one time. He just came up to me and put his fingers in my mouth - said 'yep, all them need to be pulled.' Then later I agree to see him again and the first thing he did was put his fingers in my mouth with no gloves on." Resident #1 was asked about the incident on 8/5/14. He stated, "As I was going down hall, (Administrator) said - if I had seen (dentist) the whole time - I wouldn't be in this situation." Since the incident, Resident #1) stated he has not seen the Administrator. Resident #1 was asked, "Are you fearful - afraid of the Administrator?" He stated, "No, but it made me not want to be around her." He was asked, "Are you afraid to be around her?" Resident #1 stated, "No, not really. I just prefer not to be around her. But as long as I live here, I'm sure I've got to run into her." Resident #1 stated, "It embarrassed me out in front of the God and everybody. If she wanted to talk to me about the dentist or anything she should have taken me to an office where we could have privacy and tell me. There was no need to yell at me." Resident #1 was asked, "Right now do you feel safe, secure in this facility?" He stated, "Well, she could throw me out." f. An OLTC Witness Statement dated 8/5/14 and signed by a family member (non case-mix) documented, "I was at the elevator waiting to go up to see my mother. (Resident #1) and (Administrator) were right next to the elevator. She was telling him either to go to the dentist here or get another one and pay for it himself. She did not touch him that I saw. I was not there before that time so I do not know what led up to her speaking in a voice that sounded condescending. I was embarrassed and tried to not look at them." On 8/15/14 at 9:25 a.m., the family member (non case-mix) was interviewed. She stated, "I went to visit my mother, I came in the front door waiting on the elevator. I could hear her (Administrator) voice. It wasn't pleasant. I didn't even know who she was at first. I knew she was the big blonde lady. It was her (Administrator) tone. I can't tell you why. It was enough to make me feel uncomfortable. I heard them discussing something about going to the dentist. It was loud enough, I was trying to hear and not stare. I felt like she lost her temper." Family member stated, "Sometimes you should think before you speak." g. On 8/14/14 at 4:35 p.m., RN #1 was asked to describe what occurred on 8/5/14 and 8/6/14 with (Resident #1). RN #1 stated, "that morning 8/5/14, Thursday approximately 8:30 a.m. I saw (Resident #1). He told me about his toothache. I checked on it, looked at his mouth. I told him, I think you need to see a dentist. After this I went to the morning meeting and reported the tooth in the meeting. The (ADON, Administrator) and myself, we decided to get an appointment with the dentist. (Resident #1) mentioned he wanted to see (Dentist #2)." The RN/Hall Supervisor stated the facility has the services within the nursing home and (Dentist #1), who comes to the facility routinely. The RN/Hall Supervisor stated, "I asked (ADON) to tell (Resident #1) about the appointment with (Dentist #1), but (Resident #1) refused. That started the day with (Resident #1). Time went by later on in the day, I waited, (Resident #1) went to smoke. I went out there. It was just me and him. We had an adult conversation, shared my concerns about his toothache. (Resident #1) agreed to see (Dentist #1). We shook hands on it. I went to (ADON's) office. I was telling her about what me an (Resident #1) had discussed. So we actually made (Resident #1) an appointment for the next morning at 9:30 a.m. It was about 2:30 p.m.- 2:35 p.m., I was in the office when I heard the conversation. I heard the loud conversation. It was very loud, loud enough to get my attention. It was in the hall. I recognized the voices. I heard the argument." The RN was asked if they were being argumentative. The RN stated, "Yes, their voices were loud. It prompted me to go straight out of the office. It was (Administrator and Resident #1) arguing about seeing the dentist. I was trying to stop the argument. I told (Administrator) that we got him an appointment at 9:30 a.m. in the morning. A little bit more arguing went on. The only thing I saw was (Administrator) put her hand on his shoulder. I did not see her actually hit him. I'm not saying she didn't, I just didn't see it. His arm did fall off the chair. I pulled it up and put it back on the armrest. She (Administrator) very well could've hit him. But I wasn't focused on that. I felt it was a public area (lobby), if they wanted to have the conversation, they needed to in another area." The RN #1 was asked if the Administrator was shaking her finger at him. She stated, "Yes, there was finger shaking going on. I felt the approach was fast on the Administrator's part. The Administrator did not have any knowledge we had settled the dentist appointment. The Administrator said to (Resident #1) at the time, if he would use the services, see the dentist the facility provided that his teeth wouldn't get to this point." The RN was asked was the Administrator scolding him (Resident #1). The RN stated, "Yes." The RN was asked, "How did the argument between the resident and the Administrator make you feel?" The RN stated, "It made me feel uncomfortable. It was loud, kinda like two adult people yelling in the hallway. I felt like (Resident #1) should not be there." The RN then stated, "Somehow over the weekend. I had the weekend to think about it. I played it over and over in my mind. I got a text that (Resident #1) said (Administrator) hit his arm. That's how I actually learned about what (Resident #1) had said. I got here as fast as I could 8/6/14. I went straight to (Resident #1's) room. It was just me and him, we had a [MEDICATION NAME] conversation so I asked him what was going on? I wrote down his statement. I read it back to him. He signed it. I took the statement and went straight to (Assistant Adm.). I gave her that and I told her we needed to report it to OLTC now, do it today. She (Assistant Administrator) said, 'we are going to turn this over to (ADON).' Me and (ADON) talked, (ADON) said we needed to interview (Resident #1), I wasn't sure what to do." The RN stated, "There was (ADON, me, Resident #1 and Human Resource (HR)), all in the office. (ADON) sat there, she was not meaning to be rude. She asked him about it (Administrator hitting him). She asked (Resident #1) what the extent of the allegation was. (Resident #1) watched the video. (ADON) ran the video three times for him. I'm her witness. (Resident #1) said, 'Maybe she (Administrator) was treating me like a child." The RN was asked, "Did anyone talk to him in such a way that persuaded him to change his statement?" The RN stated, "No. I do think he was persuaded, but it wasn't intentional to manipulate by me or (ADON). We explained to him that there will be an investigation, it was serious. I think it concerned him." The RN stated, "The Office of Long Term Care (OLTC) was not notified based on his recanted statement. I told (ADON) we should've never done that. We should've never pulled (Resident #1) back in here and had him sign that statement. We just should've reported it to OLTC. We made a mistake. We all make mistakes. I do think we went one step too far. It was intimidating. If that had been me, I would have recanted too. That was wrong. I told the DON that statement is bullshit. I want the state called. I don't want this mess to come up 6 months from now and they think we are trying to hide something. I was a part of that interview. It was wrong." The RN was asked, "Do you think yelling at a resident is verbal abuse?" She stated, "Yes, I do." The RN was asked, "Do you consider the argument between the resident and the Administrator was verbal abuse on the Administrator's part?" The RN stated, "I don't know, they have had loud conversations before in the office. (Administrator) was not herself that day. She had a shot of [MEDICATION NAME] and [MEDICATION NAME]. She was wound that day. She was not herself, not her normal pattern." h. On 8/14/14/ at 5:35 p.m., the ADON was asked to describe what occurred on 8/6/14 with (Resident #1). The ADON stated she had received a phone call from (LPN #1). The ADON stated, "I called her (LPN#1) back and I talked to the DON. She told me (Resident #1) said (Administrator) hit him. I got here a little after 8:00 a.m., I reviewed the camera. I left to go to a doctor's appointment at 8:45 a.m. I got back around 10:30 a.m. on 8/6/14. I went to talk to (RN/Hall Supervisor), she had talked to (Resident #1). He did report it to her. I felt it would be a good idea to look at the footage, to let him point out to me what he felt his allegation was. We put him in front of the computer and he looked at it three times. I felt like he needed to see it as many times as he needed. He never pointed anything out on camera. I asked him, (Resident #1) this is serious, do you feel like (Administrator) was maliciously hitting you or being mean. He paused a minute and he said, no. He said she was tapping; it was more like a mother getting on to her child. I asked him well will you write that in a statement for me." ADON stated, "I don't know what she (Administrator) did. Maybe she went too far. Now should she have done that? No. My concern was did she really hit him, lay her hand on him?" The ADON stated, "After that it pretty much was dropped." The ADON stated she felt they should have not taken (Resident #1) into the office and had him change his statement. The ADON stated, "I take responsibility for that." i. On 8/14/14 at 6:00 p.m., HR was asked to describe what occurred on 8/6/14 with (Resident #1). She stated, "When I came in that morning (8/6/14), two nurses gave me statements. I got here at 7:00 a.m. and the (ADON) was usually here at 8:00 a.m., (DON) was on vacation." She stated, "My intent when I walked into the room was to give the ADON the statements. When I walked into the office, they (ADON), (RN/Hall Supervisor) and (Resident #1) were in there. I kinda felt awkward. I didn't know whether I should leave or stay. I didn't say anything. I just observed. (Resident #1) was pushed up to the computer. (ADON) was reaching over him manipulating the mouse to run the computer. I'm pretty sure (Resident #1) had already seen it once. (ADON) backed away from him. She did get down on her knees, got down on his level. Some discussion, (RN/Hall Supervisor) commented to (Resident #1) that this was a serious allegation. 'Are you sure you want to make this?' Then next thing I remember was that (ADON) was writing out a statement. (Resident #1) had recanted his accusation. (Resident #1) signed the statement. (Resident #1) was asked did he feel he was intimidated made to feel bad. He stated, 'Yes, (ADON) is very tall for someone being in a w/c.' (Administrator) can speak loudly. I think if that were me in that situation, I would feel intimidated. As far as intent goes, I really don't feel that is what was intended." She was asked if she questioned (Administrator) actions toward him (Resident #1). She stated, "No, (Resident #1) is very difficult. I've never heard her do other residents that way." AN OLTC Witness Statement dated 8/6/14 (not timed) and signed by Resident #1 documented, "I do not believe (Administrator) was in no way physically abusive to me on 8/5/14." j. The DON's written statement dated 8/12/14 at 7:00 p.m. documented, "...(Resident #1) stated, 'She (Administrator) was hitting my arm in the hall and it hurt because it's my paralyzed arm, and nobody believes me.' I asked (Resident #1) if he was telling me the truth why he changed his story he said, 'because they took me in the office and I was afraid if I didn't change my story I would have to leave the facility. I know (Administrator) makes the decision she has threatened to make me leave before. I was scared not to change my story.' I observed residents left arm and observed small bruises to his forearm. Resident stated to me, 'don't worry about me, if you say anything to anyone they will be mad at you.' I explained to resident not to worry about me, and no employee has the right to place their hands on you, yell or mistreat you or any other resident in the facility. Resident verbalized, '(Administrator) was cruel to me that day because I didn't want to see her dentist, and she did hit my arm and hurt it.' Resident was assisted back to his hall. Acting Asst. Adm. and Administrator were notified of my conversation with resident related original allegation of abuse and new allegation of intimidation." On 8/15/14 at 3:35 p.m., the DON was asked to describe what occurred on 8/6/14 with Resident #1. She stated, "On 8/6/14 at 12:04 a.m. (LPN #1) called me. She said (Resident #1) was making an allegation that the administrator hit him. She (LPN #1) stated that (Resident #1) had reported to the day shift nurse (LPN #3), she blew him off and (Social) she blew him off. (LPN #1) was very anxious because the allegation was against the Administrator. I told her no matter who the allegation is against even if it's me you have to protect the resident. Take their statement for face value. I instructed her to take his written statement and (LPN #2's) statement as it would be a reportable and turn into (ADON) or (HR) to ensure it got to (ADON). (LPN #1) asked if she had to call (Administrator). I said I would call her. I called (Administrator), I told her we had a reportable it was an allegation of abuse, against you. (Resident #1) said you hit him. Her (Administrator) exact words were 'I didn't hit him. I just smacked his arm to get his attention'. At 12:35 a.m., I received a second call from (LPN #1), she stated (Administrator) called and she was mad. She told then to go down there and tell him to shut up and knock it off. So I told (LPN #1) she still had to report it. It didn't matter how (Administrator) felt. She still needed to report it. Wednesday, 8/6/14 at 8:45 p.m., I received a text from (Administrator) that stated, "Meant to tell you they showed camera to (Resident #1) and he recanted his claim on me. I didn't respond to the text because even if he recanted his statement, it was still a reportable. I believe it is up to OLTC (Office of Long Term Care) to decide if it was abuse. On 8/12/14, I'm at lunch with (RN/Hall Supervisor), (ADON), and (RN/Care plan Coordinator). (RN/Hall Supervisor) tells me she believes they did something wrong, that they didn't report it. That she has known in the past something like that needed to be reported. She knew taking him (Resident #1) into the office like that she knew was wrong. I asked them to explain it to me and (ADON) said she got a phone call from (Administrator). She said (Administrator) told her to treat her like any other staff and report it. The next thing she knew she was at the doctor's office. (Administrator) called her screaming at her so loud the doctor could hear her screaming that she better get back to the building, get a handle on it and get control. (ADON) received a text message from (Administrator) that said 'if he doesn't recant his statement, I will walk you through how to do a reportable by noon.' We got back to building spoke with (Asst. Adm.) and (HR). I always have a witness. I asked (Asst. Adm.) why it wasn't reported. She said she called (Administrator) to let her know she was going to report it. (Administrator) said, 'No, let (ADON) handle it.' (Asst. Adm.) and (HR) asked me what I was going to do. I told them it was a reportable and it should've been reported. Either way I'm going to get my building in trouble no matter what I do. I'm going to lose my job that I have to pray about it. So I went to review the camera footage and the statements. (Asst. Adm.) had told me the statements had been shredded, but they had not been. They were in her top right hand door of her desk. The camera footage showed the resident in hall next to elevator. The Administrator approached him in an abrupt manner, shaking her finger at him. He backed away from her she approached him a second time. (RN/Hall Supervisor) walked up to try to take him down the hall. (Administrator) appears to be tapping him on his left arm with her right index finger. At 6:30 p.m., I talked to the resident. The resident was not his typical self. I asked him if he had anything he wanted to tell me. He said no. I said are you sure? He said, 'Can I tell you about me and the administrator?' I told him he could tell me anything. He said she was hitting him last week on the arm. It was hurting because it was his paralyzed arm. He explained his arm hurts when you hit it. He told me that he told her (Administrator) it was hurting, but it didn't do any good. He told me he didn't want me to do anything because people would be mad at me because he had already caused problems. I asked him if he was telling the truth, why did he change his story? He said they took him in the office and started asking him questions and showed him a video tape and demanded he show them where she (Administrator) hit him. He said, 'you know me, I get confused. I couldn't show them. I w

Complaint # substantiated, (all or in part) with these findings at part A. Complaint # substantiated, (all or in part) with these findings at part B. A. Based on record review and interview, the facility failed to ensure Resident #6 received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan. The facility failed to ensure the physician was consulted immediately when changes in the resident's neurological status first developed following a fall with a head injury, failed to obtain neurological checks according to facility protocol and failed to ensure the physician was consulted immediately of a critically high lab result which resulted in the resident receiving an additional dose of an anticoagulation medication, while being monitored for the potential for an intracranial bleed following a fall with a head injury for 1 (Resident #6) of 1 case mix resident who sustained a head injury from a fall and was at risk for abnormal bleeding related to anticoagulation medication. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious injury, harm or death for Resident #6, who required hospitalization for a subdural hematoma and later died from [MEDICAL CONDITION] secondary to massive [MEDICAL CONDITION]. These failed practices was likely to cause more than minimal harm for 6 residents at risk for falls and on anticoagulation medication as identified by a list provided by the Administrator on [DATE]. The facility was informed of the Immediate Jeopardy on [DATE] at 3:27 p.m. The findings are: 1. The facility Policy and Procedure provided by the Assistant Director of Nursing on [DATE] at 3:30 p.m. documented, "Post-Fall Management Minor Head Trauma Protocol. Neuro (Neurological) checks every 2 hours for the first 12 hours, every 3 hours for the next 24 hours and every 4 hours for the following 24 hours. Alert the attending physician for any changes. Alert attending physician for all falls with head trauma in residents receiving anticoagulants." 2. Resident #6 had [DIAGNOSES REDACTED]. and a fall with a major injury since admission. a. The Plan of Care dated [DATE] documented, "I am at risk for falls related to a history of falls, leg weakness, incontinence issues and impaired cognition... I use a wheelchair for mobility at this time. Observe for changes in my condition that may warrant increased supervision/assistance and notify the physician... I have the potential for complications related to the use of anticoagulant medication... Observe for bruising, hematuria." b. The February 2012 Physician order [REDACTED]. c. A "Resident Incident Report" dated [DATE] at 7:50 a.m. documented, "Incident Type: Fall/with injury. Type of Injury: Head injury/minor ... Narrative of incident and Description of injuries: Resident was in therapy and was lifting his legs to stretch the muscles when his (wheelchair) began to tip backwards...staff attempted to catch resident but was unsuccessful and residents (wheelchair) tipped to the floor with resident hitting his head. Received a 8 cm (centimeter) X 5 cm knot to the back of his head and a ,[DATE] cm laceration. Minimal blood noted from laceration. Resident denies any pain to neck or back. Resident was sent to the ER (emergency room ) for eval (evaluation)..." d. A Nurses note dated [DATE] at 10:13 a.m., documented, "Resident returned from ER around 1000 (10:00 a.m.) with no new orders. Resident feeling well and smiling. Neuro (Neurological) checks started and within normal limits. Eating cookie in his room....Will continue neuro checks per facility protocol." e. The "Neurological Flow Sheet" documented neuro checks were done every hour for 4 hours (10:00 a.m. through 1:00 p.m.) then 4 hours later at 5:00 p.m. then every 4 hours after that at 9:00 p.m., 1:00 a.m., 5:00 a.m. and 9:00 a.m. as follows: [DATE] 10:00 a.m. BP (Blood pressure) ,[DATE], Pulse 88, Respirations 20, Temperature 97.0, Pupil size 3 mm (millimeter) 11:00 a.m. BP ,[DATE], Pulse 77, Respirations 20, Temperature 97.0, Pupil size 3 mm 12:00 p.m. BP ,[DATE], Pulse 76, Respirations 20, Temperature 97.0, Pupil size 3 mm 1:00 p.m. BP ,[DATE], Pulse 78, Respirations 20, Temperature 97.0, Pupil size 3 mm 5:00 p.m. BP ,[DATE], Pulse 73, Respirations 20, Temperature 98.9, Pupil size 3 mm (Facility policy stated every 2 hours for first 12 hours - injury occurred at 7:50 a.m.) 9:00 p.m. BP ,[DATE], Pulse 85, Respirations 20, Temperature 99.5, Pupil size 3 mm (Facility policy stated every 3 hours for next 24 hours - injury occurred at 7:50 a.m. every 3 hours should have started at 10:50 p.m. and continued until 10:50 p.m. on [DATE]) [DATE] 1:00 a.m. BP ,[DATE], Pulse 89, Respirations 20, Temperature 100.9, Pupil size 2 mm 5:00 a.m. BP ,[DATE], Pulse 90, Respirations 20, Temperature 99.6, Pupil size 2 mm The "Neurological Flow Sheet" also documented, "Notify MD IMMEDIATELY of signs and symptoms of Intracranial Pressure!!!" The online article titled "Increased Intracranial Pressure" at <http://www.nlm.nih.gov/medlineplus/ency/article/ 3.htm> documented, "...Symptoms- ...Adults: Behavior changes, Decreased consciousness, Headache, Lethargy, Neurological symptoms, including weakness, numbness, eye movement problems, and double vision, [MEDICAL CONDITION], and Vomiting..." f. A Nurses Note dated [DATE] at 1:27 p.m., documented, "...PT/INR scheduled for [DATE] 1:00 p.m. was completed. PT/INR obtained per INRatio Meter and results faxed to (Physician)'s office with current [MEDICATION NAME] dosage of 4 mg daily. PT 43.4/INR 4.3. Reported to charge nurse." 1) The Protocol for the use of the PT ([MEDICATION NAME] Time) /INR (International Normalized Ratio) machine provided by the Assistant Director of Nursing (ADON) on [DATE] documented, "...For ranges of INR (International Normalized Ratio) ... (greater than) 4.0 (equals) critical high (MD (Physician) should be called immediately) for PT ([MEDICATION NAME] Time): ...Critical level is (greater than) 43 seconds (MD should be called immediately)." 2) The facility Policy and Procedure for Monitoring and Reporting PT/INR results provided by the ADON on [DATE] documented, "...Results of abnormal PT/INR with INR (greater than) 3 are to be immediately called to the MD by the PT/INR nurse... PT/INR nurse ...must ensure that the nurse that will be administering the next scheduled dose of [MEDICATION NAME] is aware of the abnormal value and check with the MD prior to administering the medication ..." 3) The Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] at 1:50 p.m., the PT/INR nurse stated, "I thought I had told (LPN #1) about the abnormal lab but (LPN #1) said she did not remember being told anything about the resident's PT/INR that day." g. A Nurses Note dated [DATE] at 1:14 a.m., documented, "Resident continues with neuro checks. Resident with increase in temp (temperature) and PRN (as needed) APAP (Tylenol) given..resident speech is clear and resident denies pain or discomfort.. resident with no signs/symptoms of distress." There was no documentation that the physician was consulted. A Nurses Note dated [DATE] at 1:58 a.m., documented, "Temp is coming down to 100.4 at this time.. resident still denies pain or discomfort." h. A Nurses Note dated [DATE] at 6:42 a.m. and signed by LPN #2, documented, "Resident this early am (morning) is slightly confused...has been incontinent of bladder...and has had increase in temp and increase in BP...BP this am at 0630 ,[DATE], at 445 am BP was ,[DATE]...new order received for cath (catheter) UA (urinalysis) and cath attempted with no urine output ...resident had just 5 mins (minutes) before been changed from incontinent episode..XXX,[DATE] med nurse notified to obtain UA and contact POA (power of attorney)." On [DATE] at 1:40 p.m., LPN #2 stated she had not notified the physician of the changes in the resident's condition. The LPN stated the physician didn't like to be called at night unless it was an emergency so she just called the DON (Director of Nursing) and the DON told her she could get a UA." i. A Nurses Note dated [DATE] at 8:58 a.m., documented, "Neuro checks ongoing BP ,[DATE] Pulse 94 Respirations 24 Temperature 99.8 axillary. Resident is alert but unable to follow commands, slurred speech, c/o (complains of) headache. Contacted (physician) related to change of condition and received order for CT (Computed Tomography) to head. Transport notified to schedule CT of head ASAP (as soon as possible) ... Resident was transported via geri chair, via facility van to outpatient CT scan at 1045 this day." j. A Nurses Note dated [DATE] at 11:16 a.m., documented, "PT/INR obtained per INRatio Meter and results called to (APN) at (Physician's office) with results and current [MEDICATION NAME] dosage of 4 mg daily. PT 46.7/INR 4.7. Received telephone order to hold [MEDICATION NAME] and recheck PT/INR in 2 days. [MEDICATION NAME] removed from med (medication) cart." k. A Nurses Note dated [DATE] at 2:12 p.m., documented, "Resident was taken to (Hospital) for CT of the head related to lethargy and confusion at 11:30 a.m." l. The (Hospital) Discharge Summary dated [DATE] documented, "Date and time of death [DATE] at 12:55 a.m. Preliminary cause of death: [MEDICAL CONDITION] secondary to massive [MEDICAL CONDITION] (Resident) fell at therapy and developed a subdural hematoma ... He did poorly after admission and given his INR level from the [MEDICATION NAME], unfortunately we were unable to do any type of evacuation of the subdural hematoma and he continued to bleed despite multiple units of FFP and Vitamin K. Given the worsening bleeding in his brain and development of [MEDICAL CONDITION] and early signs of herniation, the family elected to transfer him to inpatient Hospice care..." 3. The Immediate Jeopardy was removed on [DATE] at 4:55 p.m. and the Scope and Severity was reduced to a "G", when the facility initiated the following plan of removal: 1) The Director of Nursing Services or Assistant Director of Services or designee will immediately inservice all licensed personnel in the building on the policies of Monitoring of Neuro Checks, Notification of Changes to Physician and Critical Lab Results. 2) The licensed personnel currently in the building are being inserviced beginning at 3:40 p.m. [DATE] to stop what they are doing until inservice completed. The ,[DATE] shift will be inserviced PRIOR to their shift beginning. The oncoming shift of ,[DATE] personnel that has not been inserviced will be inserviced prior to starting of shift. All licensed personnel that has not been inserviced will be called to come in and will be inserviced on [DATE]. All new hires will be educated on the particular policies On Monitoring of Neuro Checks and Changes, and Notification of Changes and on monitoring of those residents on anticoagulant treatment who are at risk for falls and notifying of significant critical lab results to physician. 3) A policy on reporting of PT/INR was revised on [DATE] and licensed personnel educated on change of policy of notifying physician by phone of critical lab results on all head injuries receiving [MEDICATION NAME]. 4) The DON and ADON and/or designee will monitor residents on anticoagulant therapy for those residents who are at risk for falls, lab results to ensure all critical readings will be immediately called to the physician, and establish data to collect for Quality Assurance purposes to assure that all neuro check monitoring with any changes that the nursing staff will notify the physician regarding the change. Any negative findings of nursing staff not notifying the physician of changes will be immediately corrected by the DON/ADON and physician will be called. The monitoring will be all neuro checks monitored for changes for 1 year. The DON/ADON will report monthly to the Quality Assurance meeting of all residents who had checks, findings of any changes, and reporting to physician of such changes. There are no residents in the building that are being assessed regarding neuro checks from a head injury. B. Based on record review and interview, the facility failed to ensure physician ordered laxatives were administered at the frequency and/or the time specified to treat Constipation, failed to ensure signs/symptoms of impaction e.g. (for example) decreased appetite, no bowel movements, increased agitation were recognized and included in nursing assessment and that assessments were performed timely to determine signs/symptoms of impaction for 1 (Resident #1) of 3 (Residents #1, 4, and 5) residents who required PRN (as needed) laxative use for the treatment of [REDACTED]. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident was moderately impaired in cognitive skills for daily decision-making per a Staff Assessment of Mental Status, had signs of [MEDICAL CONDITION] e.g. inattention and disorganized thinking that was continuously present and did not fluctuate, was independently ambulatory, continent of bowel and bladder and required limited assistance with toileting and personal hygiene. a. The Plan of Care dated [DATE] documented, "I have moderate to severe impairment cognitive skills for daily decision-making related to Dementia with short and long term memory loss. I currently reside on the Secured Unit. I toilet myself, but supervise to ensure adequate hygiene. Monitor and record bowel movements q (every) shift." b. The BM (Bowel Movement) Detailed Report Roster for [DATE] through [DATE] documented the following: The resident did not have a BM (bowel movement) on ,[DATE], ,[DATE] or ,[DATE]. The resident self toileted and had a medium BM on ,[DATE]. The resident did not have a bowel movement again until [DATE] when she was incontinent of an extra large watery liquid BM. The resident did not have a BM documented on ,[DATE]. On ,[DATE], the resident self toileted and had a small soft formed BM. The resident did not have a BM documented on ,[DATE], ,[DATE], or ,[DATE]. c. A fax sheet sent to the physician by the facility on [DATE] at 2300 (11:00 p.m.) documented, "Resident has been having Constipation and has no order for this. May we have a order for MOM (Milk of Magnesia) every day PRN (as needed)? Please advise." The physician response on the form dated as faxed on [DATE] at 14:15 (2:15 p.m.) documented, "Prefer [MEDICATION NAME] one dose hs (bedtime) PRN." The order was marked as "N and P" (noted and processed) on [DATE]. d. The February 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] e. The BM (Bowel Movement) Detailed Report Roster documented the resident was incontinent of an extra large watery liquid BM on [DATE]. A Nurse's Note dated [DATE] at 2:17 p.m. documented, "Resident had BM this shift." The BM was not recorded on the BM Detailed Report Roster. The resident did not have a BM documented on ,[DATE], ,[DATE] or ,[DATE]. The February 2012 MAR indicated [REDACTED]. f. A fax sheet sent to the physician by the facility on [DATE] at 11:26 a.m. documented, "Resident continues to appear on the No BM list but only has a PRN order for [MEDICATION NAME] 17 gm (grams) at bedtime. Please advise." The physician response on the form documented, "How many times taken and for how long?" and also documented by the physician at bottom of form was "[DATE] No answer." g. The February 2012 MAR indicated [REDACTED]. The BM Detailed Report Roster did not document the resident had a BM on ,[DATE]. (4 days without a bowel movement) h. A fax sheet sent to the physician on [DATE] at 12:31 p.m. documented, "Resident noted to have decreased appetite. Please review recent meal percentages. Also resident has few BM's and requires prn laxative [MEDICATION NAME] 17 gm with water to promote BM. She has taken prn laxative twice so far since initiated on [DATE]. Please also review BM report." The physician response on the form documented, "Appetite may be related to no BM's. List does not tell me what you did about it. Did you give [MEDICATION NAME] each day no BM noted? ("each day no BM noted" was underlined) What was question about [MEDICATION NAME]? Check for impaction and clear it. Prevent." i. The BM Detailed Report Roster did not document the resident had a BM on ,[DATE]. The February 2012 MAR indicated [REDACTED]. (5 days without a documented bowel movement). A Nurse's note dated [DATE] at 5:10 p.m. documented, "[MEDICATION NAME] 20 mg (milligram) capsule was administered due to increased anxiety telling other resident to shut up." The MAR indicated [REDACTED]. j. The [DATE] physician fax form also documented, "[DATE] Resident has no s/s (signs or symptoms) of impaction. Nurses are not going to digitally check resident. She is ambulatory and goes to bathroom on her own" and was signed by the Director of Nursing. There was no documentation in the nurse's notes of an assessment done on [DATE] to determine signs and/or symptoms of fecal impaction. A nurse's note dated [DATE] at 2:02 p.m. signed by the Director of Nursing documented, "Resident is up in the hallway ambulating ad lib. Resident assisted to the room for assessment of abdomen. Upon assessment resident's abdomen is soft, nontender, flat. Resident denies BM today. She is independently ambulatory and goes to the bathroom on her own without any assistance from staff. Due to her cognition/confusion she is unable to remember if she had a BM or not and therefore it is very difficult to keep up with her BM's. Resident ate 50% of her meal at lunch without any difficulty. Staff did not check this resident for impaction due to she has no s/s of impaction at this time. This was communicated to the MD." k. The BM Detailed Report Roster did not document the resident had a BM on ,[DATE]. (6 days without a documented bowel movement) The February 2012 MAR indicated [REDACTED]. l. The BM Detailed Report Roster documented the resident was incontinent of an extra large BM on ,[DATE]. m. The BM Detailed Report Roster documented the resident did not have a BM on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] or [DATE]. The MAR indicated [REDACTED]. On [DATE], the [MEDICATION NAME] was administered at 4:46 p.m. (not bedtime). n. On [DATE] at 10:30 a.m., CNA #1 stated, "There aren't any toilets in the resident's rooms on the secure unit. Everybody uses the central bathroom/shower room for toileting. It's easier to keep up with everybody's toileting that way. We may miss seeing someone going to the bathroom every once in a while but not usually." o. On [DATE] at 2:30 p.m., the resident's physician stated that when he ordered PRN [MEDICATION NAME] that he wanted the [MEDICATION NAME] given every day a BM is not recorded.

Complaint # was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure the physician was consulted immediately when changes in the resident's neurological status first developed following a fall with a head injury and failed to ensure the physician was consulted immediately of a critically high lab result which resulted in the resident receiving an additional dose of an anticoagulation medication, while being monitored for the potential for an intracranial bleed following a fall with a head injury for 1 (Resident #6) resident who was identified to be at risk for falls and abnormal bleeding related to anticoagulation medication. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious injury, harm or death for Resident #6, who required hospitalization for a subdural hematoma and later died from [MEDICAL CONDITION] secondary to massive [MEDICAL CONDITION]. These failed practices was likely to cause more than minimal harm for 6 residents at risk for falls who received anticoagulation medication as identified by a list provided by the Administrator on [DATE]. The facility was informed of the Immediate Jeopardy on [DATE] at 3:27 p.m. The findings are: 1. The facility Policy and Procedure provided by the Assistant Director of Nursing (ADON) on [DATE] at 3:30 p.m. documented, "Post-Fall Management Minor Head Trauma Protocol. Neuro (neurological) checks every 2 hours for the first 12 hours, every 3 hours for the next 24 hours and every 4 hours for the following 24 hours. Alert the attending physician for any changes. Alert attending physician for all falls with head trauma in residents receiving anticoagulants." 2. The Protocol for the use of the PT ([MEDICATION NAME] Time) /INR (International Normalized Ratio) machine provided by the Assistant Director of Nursing on [DATE] documented, " ...For ranges of INR (International Normalized Ratio) ... (greater than) 4.0 (equals) critical high (MD (Physician) should be called immediately) for PT ([MEDICATION NAME] Time): ...Critical level is (greater than) 43 seconds (MD should be called immediately). The facility Policy and Procedure for Monitoring and Reporting PT/INR results provided by the ADON on [DATE] documented, " ...Results of abnormal PT/INR with INR (greater than) 3 are to be immediately called to the MD by the PT/INR nurse... PT/INR nurse ...must ensure that the nurse that will be administering the next scheduled dose of [MEDICATION NAME] is aware of the abnormal value and check with the MD prior to administering the medication..." 3. Resident #6 had [DIAGNOSES REDACTED]. and a fall with a major injury since admission. a. The Plan of Care dated [DATE] documented, "I am at risk for falls related to a history of falls, leg weakness, incontinence issues and impaired cognition ... I use a wheelchair for mobility at this time. Observe for changes in my condition that may warrant increased supervision/assistance and notify the physician ... I have the potential for complications related to the use of anticoagulant medication ... Observe for bruising, hematuria." b. The February 2012 Physician order [REDACTED]. c. A "Resident Incident Report" dated [DATE] at 7:50 a.m. documented, "Incident Type: Fall/with injury. Type of Injury: Head injury/minor ... Narrative of incident and Description of injuries: Resident was in therapy and was lifting his legs to stretch the muscles when his (wheelchair) began to tip backwards...staff attempted to catch resident but was unsuccessful and residents (wheelchair) tipped to the floor with resident hitting his head. Received a 8 cm (centimeter) X 5 cm knot to the back of his head and a ,[DATE] cm laceration. Minimal blood noted from laceration. Resident denies any pain to neck or back. Resident was sent to the ER (emergency room ) for eval (evaluation)..." d. A Nurses note dated [DATE] at 10:13 a.m., documented, "Resident returned from ER around 1000 (10:00 a.m.) with no new orders. Resident feeling well and smiling. Neuro (Neurological) checks started and within normal limits. Eating cookie in his room....Will continue neuro checks per facility protocol." e. The "Neurological Flow Sheet" documented neuro checks were done every hour for 4 hours (10:00 a.m. through 1:00 p.m.) then 4 hours later at 5:00 p.m. then every 4 hours after that at 9:00 p.m., 1:00 a.m., 5:00 a.m. and 9:00 a.m. as follows: [DATE] 10:00 a.m. BP (Blood pressure) ,[DATE], Pulse 88, Respirations 20, Temperature 97.0, Pupil size 3 mm (millimeter) 11:00 a.m. BP ,[DATE], Pulse 77, Respirations 20, Temperature 97.0, Pupil size 3 mm 12:00 p.m. BP ,[DATE], Pulse 76, Respirations 20, Temperature 97.0, Pupil size 3 mm 1:00 p.m. BP ,[DATE], Pulse 78, Respirations 20, Temperature 97.0, Pupil size 3 mm 5:00 p.m. BP ,[DATE], Pulse 73, Respirations 20, Temperature 98.9, Pupil size 3 mm 9:00 p.m. BP ,[DATE], Pulse 85, Respirations 20, Temperature 99.5, Pupil size 3 mm [DATE] 1:00 a.m. BP ,[DATE], Pulse 89, Respirations 20, Temperature 100.9, Pupil size 2 mm 5:00 a.m. BP ,[DATE], Pulse 90, Respirations 20, Temperature 99.6, Pupil size 2 mm The "Neurological Flow Sheet" also documented, "Notify MD IMMEDIATELY of signs and symptoms of Intracranial Pressure!!!" The online article titled "Increased Intracranial Pressure" at <http://www.nlm.nih.gov/medlineplus/ency/article/ 3.htm> documented, "...Symptoms- ...Adults: Behavior changes, Decreased consciousness, Headache, Lethargy, Neurological symptoms, including weakness, numbness, eye movement problems, and double vision, [MEDICAL CONDITION], and Vomiting..." f. A Nurses Note dated [DATE] at 1:27 p.m., documented, " ...PT/INR scheduled for [DATE] 1:00 p.m. was completed. PT/INR obtained per INRatio Meter and results faxed to (Physician)'s office with current [MEDICATION NAME] dosage of 4 mg daily. PT 43.4/INR 4.3. Reported to charge nurse." g. The Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] at 1:50 p.m., the PT/INR nurse stated, "I thought I had told (LPN #1) about the abnormal lab but (LPN #1) said she did not remember being told anything about the resident's PT/INR that day." h. A Nurses Note dated [DATE] at 1:14 a.m., documented, "Resident continues with neuro checks. Resident with increase in temp (temperature) and PRN (as needed) APAP (Tylenol) given..resident speech is clear and resident denies pain or discomfort.. resident with no signs/symptoms of distress." There was no documentation that the physician was consulted. A Nurses Note dated [DATE] at 1:58 a.m., documented, "Temp is coming down to 100.4 at this time.. resident still denies pain or discomfort." i. A Nurses Note dated [DATE] at 6:42 a.m. and signed by LPN #2, documented, "Resident this early am (morning) is slightly confused...has been incontinent of bladder...and has had increase in temp and increase in BP...BP this am at 0630 ,[DATE], at 445 am BP was ,[DATE]...new order received for cath (catheter) UA (urinalysis) and cath attempted with no urine output ...resident had just 5 mins (minutes) before been changed from incontinent episode..XXX,[DATE] med nurse notified to obtain UA and contact POA (power of attorney)." On [DATE] at 1:40 p.m., LPN #2 stated she had not notified the physician of the changes in the resident's condition. The LPN stated the physician didn't like to be called at night unless it was an emergency so she just called the DON (Director of Nursing) and the DON told her she could get a UA." j. A Nurses Note dated [DATE] at 8:58 a.m., documented, "Neuro checks ongoing BP ,[DATE] Pulse 94 Respirations 24 Temperature 99.8 axillary. Resident is alert but unable to follow commands, slurred speech, c/o (complains of) headache. Contacted (physician) related to change of condition and received order for CT (Computed Tomography) to head. Transport notified to schedule CT of head ASAP (as soon as possible) ... Resident was transported via geri chair, via facility van to outpatient CT scan at 1045 this day." k. A Nurses Note dated [DATE] at 11:16 a.m., documented, "PT/INR obtained per INRatio Meter and results called to (APN) at (Physician's office) with results and current [MEDICATION NAME] dosage of 4 mg daily. PT 46.7/INR 4.7. Received telephone order to hold [MEDICATION NAME] and recheck PT/INR in 2 days. [MEDICATION NAME] removed from med (medication) cart." l. A Nurses Note dated [DATE] at 2:12 p.m., documented, "Resident was taken to (Hospital) for CT of the head related to lethargy and confusion at 11:30 a.m." m. The (Hospital) Discharge Summary dated [DATE] documented, "Date and time of death [DATE] at 12:55 a.m. Preliminary cause of death: [MEDICAL CONDITION] secondary to massive [MEDICAL CONDITION] (Resident) fell at therapy and developed a subdural hematoma ... He did poorly after admission and given his INR level from the [MEDICATION NAME], unfortunately we were unable to do any type of evacuation of the subdural hematoma and he continued to bleed despite multiple units of FFP and Vitamin K. Given the worsening bleeding in his brain and development of [MEDICAL CONDITION] and early signs of herniation, the family elected to transfer him to inpatient Hospice care..." 4. The Immediate Jeopardy was removed on [DATE] at 4:55 p.m. and the Scope and Severity was reduced to a "G", when the facility initiated the following plan of removal: 1) The Director of Nursing Services or Assistant Director of Services or designee will immediately inservice all licensed personnel in the building on the policies of Monitoring of Neuro Checks, Notification of Changes to Physician and Critical Lab Results. 2) The licensed personnel currently in the building are being inserviced beginning at 3:40 p.m. [DATE] to stop what they are doing until inservice completed. The ,[DATE] shift will be inserviced PRIOR to their shift beginning. The oncoming shift of ,[DATE] personnel that has not been inserviced will be inserviced prior to starting of shift. All licensed personnel that has not been inserviced will be called to come in and will be inserviced on [DATE]. All new hires will be educated on the particular policies On Monitoring of Neuro Checks and Changes, and Notification of Changes and on monitoring of those residents on anticoagulant treatment who are at risk for falls and notifying of significant critical lab results to physician. 3) A policy on reporting of PT/INR was revised on [DATE] and licensed personnel educated on change of policy of notifying physician by phone of critical lab results on all head injuries receiving [MEDICATION NAME]. 4) The DON and ADON and/or designee will monitor residents on anticoagulant therapy for those residents who are at risk for falls, lab results to ensure all critical readings will be immediately called to the physician, and establish data to collect for Quality Assurance purposes to assure that all neuro check monitoring with any changes that the nursing staff will notify the physician regarding the change. Any negative findings of nursing staff not notifying the physician of changes will be immediately corrected by the DON/ADON and physician will be called. The monitoring will be all neuro checks monitored for changes for 1 year. The DON/ADON will report monthly to the Quality Assurance meeting of all residents who had checks, findings of any changes, and reporting to physician of such changes. There are no residents in the building that are being assessed regarding neuro checks from a head injury.