. Based on observation and staff interview, the facility failed to secure and keep confidential residents personal and medical information. A restorative note was visible on a rolling workstation desk in the 400 hallway for Resident #47. The form identified Parkinson's as a diagnosis for the resident. This was a random opportunity for discovery and was true for only Resident #47. Resident #47. Facility census: 77. Findings include: a) Resident #47 On 05/01/24 at 7:54 AM, a paper restorative note was sitting on top of a rolling workstation desk in the 400 Hallway. The restorative note indicated that Resident #47 was at risk for decline in range of motion related to a diagnosis of Parkinson's. During an interview on 05/01/24 at 8:00 AM, Registered Nurse (RN) #5 verified the restorative note was visible for any passerby and should not have been left out and unattended. On 05/01/24 at 8:15 AM, the Director of Nursing confirmed the practice of leaving a restorative note on a rolling workstation desk failed to protect the privacy of the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents admitted to the facility diagnosed with possible serious mental disorders. This was true for one (1) of six (6) residents reviewed for PASARRs during the survey process. Resident Identifier: 23 . Facility census: 77. Findings include: A) Resident #23 At approximately 11:30 AM on 04/30/24, a record review was conducted for Resident #23. During the record review, it was noted Resident #23 had been admitted to the facility on [DATE]. A diagnosis of cerebral palsy was entered into the system for Resident #23 on 02/06/23 as the principal/admitting diagnosis. Upon review of Resident #23's PASARR, it was noted there was no diagnosis of cerebral palsy present on the PASARR. At approximately 8:40 AM on 05/01/24, an interview was conducted with the Director of Nursing (DON) concerning the PASARR for Resident #23. The DON confirmed the absence of cerebral palsy on the PASARR. At approximately 9:45 AM on 05/01/24, an interview was conducted with Social Worker (SW) #45 regarding the PASARR for Resident #23. SW #45 confirmed the missing cerebral palsy diagnosis and that there has been no new PASARR completed for Resident #23 to reflect the diagnosis.

. Based on medical record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to collaborate with Hospices services. This was true for one (1) of one (1) residents reviewed for hospice services during the long term care survey. Resident Identifier: Resident # 63. Facility Census: 77. Findings Include: a) Resident #63 A medical record review revealed Resident #63 was receiving Hospice Services starting on 03/27/24. A continued record review of physician's orders showed an order for: -- Admit to Hospice, DX dementia. Review of Resident # 63's Hospice documentation notebook showed it did not contain an active care plan or collaborating documentation from Hospice Services. During an interview with the Director of Nursing on 05/01/24 at 2:13 PM, She verified Resident #63 was receiving Hospice Services and had no current coordinated plan of care with the Hospice provider identifying the provider responsible for performing each or any specific services/functions that had been agreed upon. She stated, she had to call hospices services today and have documentation faxed to the facility.

. Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. Physician Orders for Scope of Treatment (POST) forms were incomplete and/or inaccurate for two (2) of three (3) records reviewed for accurate POST forms. Resident identifiers: #176 and #9. Facility census: 77. Findings include: a) Review of Using the POST Form Guidance for Health Care Professionals, 2021 Edition The 2021 POST form guidance states: -The patient or incapacitated patient's Medical Power of Attorney (MPOA) or Health Care Surrogate (HCS) must sign and date for the form to be legally valid. -The health care provider / physician completing this form must print their name, sign, and date for the form to be legally valid. b) Resident #176 An electronic medical record review, completed on 04/29/24 at 2:34 PM, found: -A POST form signed by resident's legal representative but not dated -The POST form was signed and dated by the physician on 04/16/24 A subsequent review of the original POST form at the nurses' station revealed it had also not been dated by Resident #176's legal representative. During an interview on 04/30/24 at 2:50 PM, Social Worker #71 acknowledged the form was not legally valid. c) Resident #9 An electronic medical record review, completed on 04/30/24 at 10:11 AM, found: -A POST form signed and dated by resident's legal representative on 03/20/24 -The POST form was not signed and dated by Resident #9's physician. A subsequent review of the original POST form at the nurses' station revealed it had also not been signed and dated by the physician. During an interview on 04/30/24 at 2:53 PM, Social Worker #71 acknowledged the form was not legally valid.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with newly evident and possible serious mental disorders. This was true for three (3) of six (6) residents reviewed for PASARRs during the survey process. Resident Identifier: #11, #28, and #49. Facility census: 77. Findings include: A) Resident #11 At approximately 11:00 AM on 04/30/24, a record review was conducted for Resident #11. During record review, it was noted Resident #11 had been admitted to the facility on [DATE]. On 07/25/23, Resident #11 was diagnosed with Major Depressive Disorder. Resident #11 had a new PASARR submitted on 01/29/2024, which did not include the new diagnosis of Major Depressive Disorder. At approximately 8:40 AM on 05/01/24, an interview was conducted with the Director of Nursing (DON) concerning the PASARR for Resident #11. The DON confirmed the absence of major depressive disorder on the PASARR. At approximately 9:45 AM on 05/01/24, an interview was conducted with Social Worker (SW) #45 regarding the PASARR for Resident #11. SW #45 confirmed the missing major depressive disorder diagnosis and that there has been no new PASARR completed for Resident #11 to reflect the diagnosis. B) Resident #28 At approximately 1:20 PM on 04/30/24, a record review was conducted for Resident #28. During the record review, it was noted Resident #28 had been admitted to the facility on [DATE]. A diagnosis of major depressive disorder was entered into the system for Resident #28 on 06/28/23, classified as during stay. Upon review of Resident #28's PASARR, it was noted there was no diagnosis of major depressive disorder present on the PASARR. At approximately 8:40 AM on 05/01/24, an interview was conducted with the Director of Nursing (DON) concerning the PASARR for Resident #28. The DON confirmed the absence of major depressive disorder on the PASARR. At approximately 9:45 AM on 05/01/24, an interview was conducted with Social Worker (SW) #45 regarding the PASARR for Resident #28. SW #45 confirmed the missing major depressive disorder diagnosis and that there has been no new PASARR completed for Resident #28 to reflect the diagnosis. c) Resident #49 A record review, completed on 04/30/24 at 3:46 PM, revealed Resident #49 was admitted to the facility on [DATE]. Review of the 02/21/20 PASARR revealed Section III. MI/MR Assessment Question #30 Current Diagnosis was answered NONE. No other PASARR was on file. On 07/22/21 Resident #49 was given a new diagnosis of Major Depressive Disorder, Recurrent. During an interview on 05/01/24 at 8:50 AM, Social Worker #71 confirmed a new PASARR had never been completed to capture the Major Depressive Disorder diagnosis.

. Based on observation and staff interview, the facility failed to provide an environment which was free from accident hazards over which they had control. The facility did not identify a toaster that was plugged in and operable in the Kitchenette on the 500 Hall as a hazard. This had the potential to affect every resident residing on the 500 hall. Resident identifiers: #64, #7, #30, #56, #26, #3, #6, #39, #19, #65, #42, #8, #28. Facility census: 77 Findings include: a) Toaster in the 500 Hall Kitchenette An observation, made on 04/30/24 at 10:25 AM, found the 500 hall kitchenette had a toaster plugged in and accessible to any passerby. Further investigation confirmed when the handle/lever was pushed down, the coils began to glow red which indicated the toaster was fully operable. During an interview on 04/30/24 at 10:35 AM, the Director of Nursing (DON) verified the plugged in toaster was an accident hazard, unplugged it, and removed the toaster from the area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections including Covid-19 in regard to, precaution signage on the entrance, positive Covid-19 precaution signage on resident doors, water management and expired Sani Wipes. This has to potential to affect all residents that reside in the facility. Identifier: room [ROOM NUMBER]. Facility Census: 77. Findings Include: a) Precaution Signage on Entrance Door An observation on [DATE] at 12:00PM of the facility's front entrance revealed no precautionary signage located on the door informing visitors of Covid-19 in the building. During an interview on [DATE] at 4:02 PM, the Director of Nursing verified there was no precautionary signage for visitors on the front entrance. b) Precaution Signage room [ROOM NUMBER] Observations during the initial tour on [DATE] at 12 noon revealed no signs near the door frames of room [ROOM NUMBER]. Continued review revealed Resident # 65's clinical record revealed the resident was admitted to the facility on [DATE], and was on precautions for Covid-19. Subsequent review revealed Resident # 128 was admitted to the facility on [DATE], and was on precautions for Covid-19. During an interview on [DATE] at 4:02 PM the Director of Nursing verified there was no precautionary signage for Covid-19 on room [ROOM NUMBER] where resident's #65 and #128 is residing. She stated there should be precaution signs on the door. c) Water Management During facility record review of the water management plan revealed, the documentation was not maintained to prevent growth of water borne pathogens including the description of the building water system. The facility did not have a flow diagram or text that Identified the buildings water systems for which Legionella control measures are needed. Subsequent review found there was no documentation in regard to flushing the water system in dead leg areas. On [DATE] at 11:43 AM the Maintenance Director verified the facility did not maintain documentation describing the building water systems using text, flushing, or testing protocols. d) 100 Hall Medication Room An observation on [DATE] at 2:30 PM during the medication storage task revealed Sani wipes Large Canister (160 Count) in the 100-hall medication room that expired 02/2017. During an interview on [DATE] at 2:31 PM Licensed Practical Nurse #109 confirmed the Sani wipes were expired and should not be in the medication room.

. Based on Resident interview, staff interview, and record review the facility failed to ensure all residents were able to have their choices honored in regard to bathing and bedtime. This was a random opportunity for discovery discovered during the resident council meeting held on 08/30/22. Resident identifier: #35. Facility census 64. Findings included: a) Resident #35 During a resident council meeting on 08/30/22 at 10:00 AM, Resident #35 stated she gets told because it takes longer to assist her to bed, she must be the last person to get help to go to bed. Resident #35 said she would like to go to bed around 7-7:30 PM, but now it is around 9-9:30 PM, before she can go to bed. A review of medical records in the electronic chart revealed Resident #35 prefers three (3) whirlpool baths a week before bed. The following is the dates and times Resident #35 received her whirlpool; baths: *08/01/22 at 10:30 PM. *08/03/22 at 8:44 PM. *08/05/22 at 7:47 PM. *08/08/22 at 10:36 PM. *08/10/22 at 8:50 PM. *08/12/22 at 9:06 PM. *08/15/22 at 10:09 PM. *08/17/22 at 7:57 PM. *08/19/22 at 9:56 PM. *08/22/22 at 10:35 PM. *08/24/22 at 9:17 PM. *08/26/22 at 9:51 PM. *08/29/22 at 8:10 PM. During an interview with Charge Nurse (CN) #120 in the afternoon of 08/30/22 confirmed the times documented above are the times the NA's give the resident her bath and get her ready for bed. She stated, the Nurse Aides I talked to indicated the try to get Resident #35 to bed between 9:00 pm and 9:30 pm. CN #120 was also asked if it takes longer to help Resident #35 to bed. CN #120 confirmed Resident #35's care would take longer than others. CN #120 went on to say hearing Resident #35 is being told she must be last and has to wait so long to go to bed makes her sad. .

. Based on medical record review, observation, resident, and staff interview; the facility failed to notify Resident #65's physician and family of resident's traumatic laceration on the resident's left lower leg. This was true for one (1) of one (1) residents reviewed for the care area of notification of change. Resident identifier: #65. Facility census: 64. Findings include: a) Resident #65 On 08/29/22 at 9:46 am, during an interview with Resident #65, this surveyor observed a bandage covering the resident's left lower leg. Resident was asked about her left lower leg, and she said, One of the nursing assistants (NA) was helping me and her watch caused a laceration on my left lower leg and now the area hurts, and is red and swollen, and I am worried about it healing. I have not been seen by a doctor yet. Review of Resident #65's nurses notes found a note written by Employee #96, Registered Nurse (RN) on 08/23/21 at 10:06 am which read: Resident has an open wound on the front of her left lower leg. She states this happened when one of the aides' watch caught her leg. the area is open and reddened with some bleeding noted. area cleansed with wound cleanser, xeroform gauze applied and then covered with border gauze. This is to be done daily and prn until healed. Review of physician orders for Resident #65 found on 08/24/22 at 7:45 am, an order which read: Cleanse left lower front leg with wound cleanser, apply xeroform gauze, cover with border gauze daily and prn to unspecified open wound to left lower leg. Wound RN assessment on 08/23/22 at 10:11 am by RN #96, found the type of wound listed as traumatic with a partial thickness loss. Physician notification and care plan were left blank. Wound data collection found the laceration measured three (3) centimeters (cm) in length and two (2) cm in width and 0.1 cm in depth. Additional review of nurses note had a note written on 08/28/22 at 10:42 am which read: Cleaned wound on residents left lower leg, area slightly reddened and leg has some edema noted and resident reports that it is sore. Some drainage noted to the area. Interview with the Director of Nursing (DON) on 08/29/22 at 2:00 pm, found no incident report had been filed, no indication on what had happened to cause the traumatic injury to Resident #65's left lower leg, and no indication the family and physician had been notified. .

. b) Resident #36 On 08/30/22 12:30 PM, an incident report dated 07/14/22 was reviewed for Resident #36. The incident was regarding a fall with a major injury, which resulted in a closed torus fracture of the distal end of the left femur. The following progress note dated 07/14/22 at 1:30 PM stated the following: Called to room by CNA (certified nursing assistant) , sitting in upright position on floor mat, right leg crossed under left at window side, back against bed frame, bed bolster behind resident back, alarm sounding, CNA reports while providing care for roommate, she heard this resident screaming. Not sure what I was doing, just slid down there, got to get home (Typed as written.) An additional progress dated 07/14/22 at 7:23 PM stated the following: Resident returned from (Name of acute care facility) ER (emergency room) via (Name of transport service). She is A&OX3 (alert and oriented times three) and able to make her needs known. She has closed Torus fracture of the distal end of left femur. She is in a knee immobilizer at this time. She is very painful when moving. ER sent script (prescription) for Oxycodone 5mg 1 tab Q6H (every six hours) PRN (as needed) pain. She is to follow up with Ortho (orthopedics) ASAP (as soon as possible). No orders to remove knee immobilizer at this time. Resident resting in bed at this time with no complaints (Typed as written.) On 08/30/22 at 12:57 PM, Social Worker (SW) #142 confirmed the fall with a major injury was not reported to the appropriate state agencies. She stated, If it's not there .there isn't one, as she gestured toward a stack of reportable incidents on the table. Based on record review and staff interview the facility failed to report all allegations of abuse and neglect to appropriate state agencies as required. This was found to be true for Resident #52 and #36 and was a random opportunity for discovery. Resident Identifiers: #52 and #36. Facility Census: 64. Findings included: a) Resident #52 A review of the facility's reportable incidents on 08/30/22 found a reportable dated 07/19/22 concerning an incident which took place on 07/17/22. Contained in this reportable was a statement from Resident #52 which read as follows: Were you shown any pictures on Sunday? (First Name of Resident #52) reports she was shown a picture of a woman's butt and that it wasn't the best picture. (First name of Resident #52) reports that the girls look to her as a mother figure and come to her about things. (First Name of Nurse Aide (NA) #23) came to her for advice because her boyfriend was paying money to look at these pictures on a website. An interview with Social Worker (SW) #142 on 08/30/22 at 2:34 pm found the allegation reported on 07/19/22 did not involve Resident #52 and was reported in regard to an incident that took place with Resident # 49. When asked if the incident where Resident #52 was shown inappropriate pictures by NA #23 was reported and/or investigated she stated, No it was not. She indicated it was statement obtained during another investigation and she did not think to report it as a separate allegation, but agreed it should have been reported and investigated once the statement from Resident #52 was obtained. .

. Based on record review and staff interview, the facility failed to notify the State Ombudsman of transfers to an acute care facility for Resident #36 and #58. This was true for two (2) of two (2) residents reviewed under the care area of hospitalizations during the long-term survey. Resident Identifiers: #36 and #58. Facility Census: 64. Findings Included: a) Resident #36 On 08/29/22 at 11:25 AM, a record review was completed for Resident #36. This review found Resident #36 was transferred to an acute care facility after a fall on 07/14/22. The fall resulted in a major injury of a closed torus fracture of the distal end of the left femur. On 08/30/22 at 1:30 PM, Registered Nurse Manager (RN) #121 confirmed the State Ombudsman was not notified of the transfer. b) Resident #58 On 08/30/22 at 11:00 AM, a record review was completed for Resident #58. This review found Resident #58 was transferred to an acute care facility due to altered mental status, fever and possible seizure activity on 07/22/22. A progress note dated 07/23/22 at 4:53 AM stated the following: Spoke to (Name of the acute facility staff member), states resident will be admitted to room (number) for septic shock and DVT (deep vein thrombosis), lower extremity. (Typed as written.) On 08/30/22 at 1:30 PM, Registered Nurse Manager (RN) #121 confirmed the State Ombudsman was not notified of the transfer. .

. Based on medical record review, observation, resident, and staff interview; the facility failed to follow Resident #5's physician order for daily weights and notification of the physcian. This was a random opputunity for discovery. Resident identifiers: #5. Facility census: 64. Findings included: a) Resident #5 Review of Resident #5's medication regimen review found an order dated 12/09/21 which read: Daily weight related to congestive heart failure (CHF). Notify the physician if greater than three (3) pounds weight gain in 24 hours or greater than five (5) pounds in one week. Review of Resident #5's Medication Administration Record for August 2022 found on the following dates the resident gained greater than three-pounds ofweight gain in 24 hours: --08/09/22 weight was 210 pounds and on 08/10/22 weight was 216 pounds which was a gain of 6 pounds. --08/13/22 weight was 208 pounds and on 08/14/22 weight was 213.5 pounds which was a gain of 5.5 pounds. --08/19/22 weight was 214 pounds and on 08/20/22 weight was 218 pounds which was a gain of 4 pounds. --08/25/22 weight was 206.1 pounds and on 08/26/22 weight was 214.3 pounds which was a gain of 8.2 pounds. Review of Resident #5's nurses' notes found no indication the physician was notified of the above-mentioned weight gains of three (3) pounds in 2 hours as directed by the physcian order. Review of Resident #5's medical records with the acting Director of Nursins (DON) on 08/30/22 at 11:00 am, revealed the physician was not notified on the above-mentioned dates. She confirmed the physician should have been notified. .

. Based on resident council concerns and staff interview, the facility failed to ensure the food was palatable, attractive, and at a safe and appetizing temperature for all residents. This was a random opportunity for discovery. Resident Identifier: #14. Facility census: 64. Findings included: a) Resident Council meeting: During the Resident council meeting on 08/30/22 at 11:00 AM, the group complained about receiving cold food often. This was voiced by three (3) residents that reside on the 500 unit. b) Resident #14 On 08/30/22 at lunch the last tray on the 500 unit, which belonged to Resident #14 was tested to ensure it was at the proper temperature. The Certified Dietary Manager (CDM) took the temperature with this surveyor observing and found the temperature of the lunch meal was pureed mash potatoes which was 110 degrees and the pureed meat loaf was 100 degrees, and the pureed green beans was 90 degrees. The CDM agreed the tray for Resident #14's lunch tray was cold and not at the proper temperature. .

Based on Resident council meeting, record review and staff interview, the facility failed to resolve a group grievance concerning call lights in a timely manner. This was discovered during the resident council meeting and had a potential to affect more than a limited number of residents. Facility census 64. Findings included: a) Resident council minutes A review of the past Resident council meeting minutes revealed that there were complaints about staff turning off the call lights and saying they will be right back, but not coming back. The dates these complaints were found from the resident council meeting minutes on the following dates: *12/06/21 *There was not another meeting until March due to COVID-19 outbreak. *03/15/22 *04/05/22, problem with turning off call lights continue. *08/02/22, again the group complained about the call lights being turned off without having their needs met. b) Facility grievance/concern forms A review of the facility forms titled, Suggestion or Concern, found the following: *12/06/21 a Suggestion or Concern Person making report: Resident Council Report of concern: Staff turn off their call light before their need is met. States staff do not come back to take care of needs. *Residents were encouraged to tell charge nurse at time of concern. Completed by: Director of Social Services (DSS) #143. *03/15/22 a Suggestion or Concern, Person making report: Resident Council group Report of Concern: Resident state staff are turning off call light before need is met. States also waited 45 minutes. Reviewed the previous concern forms from January Resident Council minutes: follow-up states call light issue still a problem at times. Informed will place on concern form for nursing to address. Completed by: DSS #143. *04/05/22 a Suggestion or Concern, from 03/15/22, was still attached to the minutes still unresolved. *05/03/22 a Suggestion or Concern from 03/05/22, was attached without any improvements or resolution, to the resident council minutes. *08/02/22 a Suggestion or Concern form was attached to the August resident group meeting. Report of concern: Named Resident #35, 1. turning call lights off and then not coming back. 2. On Sunday evening the staff told Resident #35 that if she wanted to be put to bed that she had better come now when she was visiting with the roommate. Completed by: Social Worker #142. A form titled, For Center/Campus Use Only Investigation: Updated team in morning meeting Staff development Coordinator states there was scheduled nursing and nurse aide meetings soon. She will address issues during meeting. Meetings for Nurses will be on 03/23/22 and 03/24/22. Nurse aides will have meetings on 03/28/22 and 03/29/22. Completed by SW #142 on 03/18/22. Resolution: Met with residents and they state they still turn off call light at times. Residents were updated that on one of the monthly meetings for nurses and nurse aides, the staff development coordinator discussed the concerns with them. Resident voiced having to wait too long. Completed by: DSS #143 on 04/05/22. Follow-up comments/reviewed with concerned party: Met with Resident about concern. Completed by: DSS #143 on 04/25/22. A note at bottom of form read: Updated Residents noting issue with call light still occurs at times. Completed by: DSS #143 on 05/03/22. *08/18/22 a Suggestion or Concern Reported by: Residents Report of concern: Resident asked, Do staff treat you with respect and dignity? Resident stated Nurse Aide #137 turns off call lights and walks out. States when she comes in room and Resident tells her she needs to use bathroom, NA #137 looks at her - turns off light and walks out. Resident states she turns the light back on and hopes a different NA will come. c) Resident Council with Surveyor During an in-person meeting with the Resident Council Group, on 08/30/22 at 11:00 AM it was asked if the staff answer the call lights timely? As a group the residents said no and were shaking their heads to indicate no. The group said the staff turn the light off and say they will be back. Resident #35 stated she waits 15 minutes and pushes the call light again She was asked how many times they must do this. She indicated three (3) to four (4) times before her need is met. Two (2) other residents stated they also do this and have had to wait 45 minutes or more. d) Staff interview On 08/30/22 at 12:00 PM, SW #142 was asked about the ongoing problem with the call lights, and she stated she was aware of it. SW #142 stated it was being handled by Health Information Coordinator (HIC) #139. On 08/30/22 at 12:10 PM, HIC #139 was asked if the facility had any documentation on call light audits. HIC #139 could not provide any type of audits which had been done by the close of the survey. HIC #139 was unable to provide proof the facility had worked to resolve this repetitive grievance voiced by the resident council. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . e) Resident #36 On 08/30/22 12:30 PM, an incident report dated 07/14/22 was reviewed for Resident #36. The incident was regarding a fall with a major injury, which resulted in a closed torus fracture of the distal end of the left femur. The following progress note dated 07/14/22 at 1:30 PM stated the following: Called to room by CNA (certified nursing assistant) , sitting in upright position on floor mat, right leg crossed under left at window side, back against bed frame, bed bolster behind resident back, alarm sounding, CNA reports while providing care for roommate, she heard this resident screaming. Not sure what I was doing, just slid down there, got to get home (Typed as written.) An additional progress dated 07/14/22 at 7:23 PM stated the following: Resident returned from (Name of acute care facility) ER (emergency room) via (Name of transport service). She is A&OX3 (alert and oriented times three) and able to make her needs known. She has closed Torus fracture of the distal end of left femur. She is in a knee immobilizer at this time. She is very painful when moving. ER sent script (prescription) for Oxycodone 5mg 1 tab Q6H (every six hours) PRN (as needed) pain. She is to follow up with Ortho (orthopedics) ASAP (as soon as possible). No orders to remove knee immobilizer at this time. Resident resting in bed at this time with no complaints (Typed as written.) A review of the Facility Abuse and Neglect policy under section 4c found the following: --Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency . --i. If there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and/or there is serious bodily injury, then it will be reported immediately, but not later than two hours after the allegation is made. On 08/30/22 at 12:57 PM, Social Worker (SW) #142 confirmed the fall with a major injury was not reported to the appropriate state agencies. If it's not there .there isn't one. Based on record review, policy review and staff interview the facility failed to implement their abuse and neglect policy in regard to reporting allegations of abuse and neglect for Resident #52 and #36. In addition the facility failed to thoroughly investigate all allegations of abuse and neglect for Resident #51, #62, #37, and #49. This was a random opportunity for discovery found during the long term care survey process. Facility Census: 64. Findings Included: a) Allegations against Former Nurse Aide (NA) #148 involving Resident #51, #62, and #37. A review of the facility's reportable incidents found a reportable incident dated 07/21/22. The allegation contained on this report read as follows: Allegedly (First and last Name of Former Nurse Aide #148) was making sexually inappropriate comments to the male residents on the 200 hall. A review of the investigation found the following statements: -- Statement from Nurse Aide #75. Typed as written: I want to report at 200 CNA (certified nursing assistant) for having sexual conversations with male 200 residents. The 200 CNA is (first and last name of former NA #148). I have witnessed her talking with Residents (First and Last Name of Resident #62), (First and Last Name of Resident #51), (First and Last Name of Resident # 37). I have told her to stop multiple times. (Conversation between (first name of Resident #62), (First name of Former NA #148) and me). (First name of Former NA #148) asked me to help lay (First name of Resident #62 down). (First name of Resident #62 asked why it taked 2 to lay him down. I said I wasn't sure, (First name of Resident #62) asked me if she (First name of Former NA #148) was the one with 20 some boyfriends? I looked at (First name of Former NA #148) and (First name of Former NA #148) said no (first name of Resident #62) I don't have that many (First name of Resident #62 ) said well if there not all boyfriends than what are they (First name of Former NA #148) then said well haven't you had friends you just have fun with (First name of Resident #62) said, No I haven't had sex since my wife put me in here and that's been three years (First name of Former NA #148) said you haven't had sex with anybody else but your wife. (First name of Resident #62) said no (First name of Former NA #148) said well. [Please note the remainder of this conversation was written on the back of the sheet and the facility failed to copy the back of the page when requested therefore it can not be quoted by the surveyor] She's (First name of Former NA #148) had made comments to (Resident #51) such as: (First name of Former NA #148) :You want her to climb in bed with you? (First Name of Resident #51): Yes I don't care she can if she wants (First name of Former NA #148) : Oh what would you do if she did? (First name of Resident #51: Climb in here and find out what this (grabs him self) can do. (I walked out after saying that gross to (First name of Former NA #148)). (First name of Former NA #148) has also said to me something about bouncing on (First name of Resident #51's) area 'penis'. I told her that was disgusting. There are more conversations like these also. Its an everyday she works thing. She can turn anything sexual also with her coworkers. The only other statements contained in the investigation was from two (2) female residents who reside on the 200 hall both of which denied any inappropriate comments. There was also two (2) additional statements from NA's who reported NA #75 had told them the same thing she wrote in her statement. There were not statements obtained from NA #148 who was the alleged perpetrator. There was also no statements from Resident #51, #62 and #37 who were named as the alleged victims. A review of the most recent Minimum Data sets for Resident #51, #62 and #37 found the following in regards to their cognitive status: Resident #51 had a Brief interview for mental status (BIMS) score of a 12 which indicates a moderate impairment but not severe. Resident #62 did not have a BIMS score but the MDS did indicate his long term and short term memory was not impaired. Resident #37 had a BIMS score of 15 which indicated he was cognitively intact. A list of all male residents residing on the 200 hall at the time of the allegation was requested. On the list was 5 additional males. The following information is the BIMS scores for the remaining males on the 200 hall: Resident #55 had a BIMS of 15 indicating he was cognitively intact. Resident #38 had a BIMS of 14 indicating her was cognitively intact. Former Resident #1 had a BIMS of 15 indicating he was cognitively intact. Resident #5 had a BIMS of 5 which indicated a severe impairment. Resident #54 had a BIMS of 15 which indicated he was cognitively intact. Of the eight (8) men who resided on the 200 hall only one (1) Resident #5 had a cognitive impairment which would have made it difficult to obtain a statement from regarding Former NA #148's behavior. However; the facility obtained no statements from any male resident residing on the 200 hall. At 4:00 PM on 08/30/22 Social Worker (SW) #142 was interviewed regarding the investigation for these allegations. When asked why she only obtained statements from Females when the allegation was Former NA #148 was talking inappropriately to males, she stated, I tried to ask people who were cognitively able to answer questions. When the BIMS scores of Resident #55, #38, #51, Former Resident #1, #37, #62, and #54 were reviewed with her she stated, Your right I should have interviewed the males. She agreed she did not obtain statement from Former NA #148, nor any of the males residing on the 200 hall including the three (3) named victims. The allegation was unsubstantiated without conducting a through investigation. b) Resident #49 A review of the facility reportable incidents found a Reportable dated 07/19/22 concerning an incident which took place on 07/17/22. A review of the Immediate Fax reporting of allegations found the following allegation: (First Name of Nurse Aide (NA) #23) allegedly placed her hand over (First Name of Resident #49's) mouth while changing her to make her stop yelling and informed the aide helping her that she does it all the time when she change's (First Name of Resident #49) by herself. The statements gathered during the investigation were reviewed and contained the following pertinent statements: --Statement from former NA # 148 regarding the incident typed as written: Interview conducted via phone with (First and Last Name of NA #148) on 07/19/22 at 3:40 PM with (First and Last Name of Registered Nurse (RN) #121), (First and Last Name of the Director of Nursing (DON), and (First and Last name of Licensed Practical Nurse (LP) #120) present. (First Name of former NA #148) stated that she did not witness any abusive activity towards (First and Last Name of Resident #49) on 07/17/22. She stated that she never has seen anyone put a hand over (First Name of Resident #49)'S mouth. She stated she did not provide care to (First name of Resident #49) on 07/17/22 and that (First and Last Name of NA #35) and (First and last Name of NA #23) provided care to (First name of Resident #49). -- Statement provided by NA #35 statement is hand written by NA #35. Statement typed as written with multiple misspelled words. (First name of NA #23) always puts her hand over (First name of Resident #49)'S mouth when yells to make her stop. She also showed (First name of Resident #52) a picture of girls viginia. She will come up behind me and smack me with briefs. She put pictures of her viginia and boobs in my face when I tell her not to. She pulled her pants down in the tub room and told me to look at her hairy monkey. (First Name of former NA #142) an I went to change (first name of Resident #28) got half way through and (First name of NA #23) came in an yelled at both of because it does not take two people to change (first name of Resident #28). She buts in and told us to get out of her way and finished changing (first name of Resident #28) by herself even though (first name of Resident #28) is a total. Every time she has to do the vitals she [NAME] them. She always chooses who does totals and singles and makes us do like 6 sets of rounds. After she got at me for the (first name of Resident #28) thing she almost fit me in the head with the vital machine. The first time I saw (First Name of NA #23) put her hand over (First Name of Resident #49)'s mouth was Sunday. She told me that she does it all the time when she changes her by herself. --Statement Provided by NA #23. Typed as written: As we were doing rounds after supper, I went to help (First Name of NA #35) change (First name of Resident #49), and she told me to go on and start changing (First Name of Resident Resident #52). I went on over and changed (First name of Resident #52), and waited for her to come help me pull her up. She never came, so I said (First name of NA #35) three times, and got no answer. I then went to find her, and found (First name of Resident #28)'s door closed. So I went in and asked her to come help me pull her up. She said she would, so I went back to (first name of Resident #52)'s room and waited, she never came so I went back again, she and (First Name of former NA #148) were in there and when they were done she came back and met me in (first name of Resident #52's) room. As for (First name of Resident #49) I didn't have any part in her care for that evening. After reviewing the above statements the Documentation Survey Report was requested for Resident #49 for the date of 07/17/22. This report was reviewed to determine who documented they provided care for Resident #49 on the evening of 07/17/22. A review of the report found NA #23 documented providing the following care for Resident #49 on the evening of 07/17/22: -- Bed mobility ar 3:26 pm. -- Dressing at 3:26 pm. -- Locomotion off Unit at 3:26 pm. -- Locomotion on unit at 3:26 pm. -- Oral care at 3:27 pm. -- Personal Hygiene at 3:26 pm. -- Toileting at 3:29 pm, 4:56 pm, 6:07 pm, and 8:46 pm. -- Transferring at 3:26 pm. During an interview on 08/30/22 at 4:07 pm the review of the survey documentation report was shared with Social Worker (SW) #142. When asked if she had reviewed the report to confirm NA #23's statement that she did not provide care to Resident #49 on 07/17/22. She indicated she had not. When she reviewed the report and saw NA #23 had in fact provided care to Resident #49 on 07/17/22 she stated, This was poorly investigated. She agreed, the allegations needed to be looked into further. The allegation was unsubstantiated without conducting a through investigation. c) Resident #52 A review of the facility's reportable incidents on 08/30/22 found a reportable dated 07/19/22 concerning an incident which took place on 07/17/22. Contained in this reportable was a statement from Resident #52 which read as follows: Were you shown any pictures on Sunday? (First Name of Resident #52) reports she was shown a picture of a woman's butt and that it wasn't the best picture. (First name of Resident #52) reports that the girls look to her as a mother figure and come to her about things. (First Name of Nurse Aide (NA) #23) came to her for advice because her boyfriend was paying money to look at these pictures on a website. An interview with Social Worker (SW) #142 on 08/30/22 at 2:34 pm found the allegation reported on 07/19/22 did not involve Resident #52 and was reported in regard to incident that took place with Resident # 49. When asked if the incident where Resident #52 was shown inappropriate pictures by NA #23 was reported and/or investigated she stated, No it was not. She indicated it was statement obtained during another investigation and she did not think to report it as a separate allegation, but agreed it should have been reported and investigated once the statement from Resident #52 was obtained. d) Facility Policy A review of the facility's policy titled Abuse and Neglect - Rehab/Skilled, therapy and Rehab with a reviewed revised date of 03/31/22 contained the following regarding the reporting and investigation of all allegations of abuse, neglect, and injury of unknown origin: .4. Notification Procedures: a. Alleged or suspected violation involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. b. In case of absence of the administrator, follow the chain of command for notification (director of nursing services, social worker, etc.) If the alleged perpetrator is one's supervisor or department manager, notify his or her supervisor. Document the notification in the Risk management Module of PCC (Point Click Care). c. Designated agencies will be notified in accordance with state law, including the state survey and certification agency. If applicable, Adult Protective Services will be notified where state law provides for jurisdiction in long term care centers 9. The investigation may include interviewing employees, residents or other witnesses to the incident. Interview all involved (employee, resident and family) individually, not as a group so that their descriptions of the incident can be compared to determine inconsistencies. Consider having each person his or her memory of the event. If possible, get signed and dated statements from any witnesses .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to thoroughly investigate all allegations of abuse and or neglect. This was a random opportunity for discovery and was found to be true for Resident #51, #62, #37 and #49. Resident Identifier: #51, #62, #37, and #49. Facility Census: 64. Findings Included: a) Allegations against Former Nurse Aide (NA) #148 involving Resident #51, #62, and #37. A review of the facility's reportable incidents found a reportable incident dated 07/21/22. The allegation contained on this report read as follows: Allegedly (First and last Name of Former Nurse Aide #148) was making sexually inappropriate comments to the male residents on the 200 hall. A review of the investigation found the following statements: -- Statement from Nurse Aide #75. Typed as written: I want to report at 200 CNA (certified nursing assistant) for having sexual conversations with male 200 residents. The 200 CNA is (first and last name of former NA #148). I have witnessed her talking with Residents (First and Last Name of Resident #62), (First and Last Name of Resident #51), (First and Last Name of Resident # 37). I have told her to stop multiple times. (Conversation between (first name of Resident #62), (First name of Former NA #148) and me). (First name of Former NA #148) asked me to help lay (First name of Resident #62 down). (First name of Resident #62 asked why it taked 2 to lay him down. I said I wasn't sure, (First name of Resident #62) asked me if she ((First name of Former NA #148) was the one with 20 some boyfriends? I looked at (First name of Former NA #148) and (First name of Former NA #148) said no (first name of Resident #62) I don't have that many (First name of Resident #62 ) said well if there not all boyfriends than what are they (First name of Former NA #148) then said well haven't you had friends you just have fun with (First name of Resident #62) said, No I haven't had sex since my wife put me in here and that's been three years (First name of Former NA #148) said you haven't had sex with anybody else but your wife. (First name of Resident #62) said no (First name of Former NA #148) said well. [Please note the remainder of this conversation was written on the back of the sheet and the facility failed to copy the back of the page when requested therefore it can not be fully quoted here] She's (First name of Former NA #148) had made comments to (Resident #51) such as: (First name of Former NA #148) :You want her to climb in bed with you? (First Name of Resident #51): Yes I don't care she can if she wants (First name of Former NA #148) : Oh what would you do if she did? (First name of Resident #51: Climb in here and find out what this (grabs him self) can do. (I walked out after saying that gross to (First name of Former NA #148)). (First name of Former NA #148) has also said to me something about bouncing on (First name of Resident #51's) area 'penis'. I told her that was disgusting. There are more conversations like these also. Its an everytime she works thing. She can turn anything sexual also with her coworkers. The only other statements contained in the investigation was from two (2) female residents who reside on the 200 hall both of which denied any inappropriate comments. There was also two (2) additional statements from NA's who reported NA #75 had told them the same thing she wrote in her statement. There were not statements obtained from NA #148 who was the alleged perpetrator. There was also not statement from Resident #51, #62 and #37 who were named as the alleged victims. A review of the most recent Minimum Data sets for Resident #51, #62 and #37 found the following in regards to their cognitive status: Resident #51 had a Brief interview for mental status (BIMS) score of a 12 which indicates a moderate impairment but no severe. Resident #62 did not have a BIMS score but the MDS did indicate his long term and short term memory was not impaired. Resident #37 had a BIMS score of 15 which indicated he was cognitively intact. A list of all residents residing on the 200 hall at the time of the allegation was requested. On the list was 5 additional males. The following information is the BIMS scores for the remaining males on the 200 hall: Resident #55 had a BIMS of 15 indicating he was cognitively intact. Resident #38 had a BIMS of 14 indicating her was cognitively intact. Former Resident #1 had a BIMS of 15 indicating he was cognitively intact. Resident #5 had a BIMS of 5 which indicated a severe impairment. Resident #54 had a BIMS of 15 which indicated he was cognitively intact. Of the eight (8) men who resided on the 200 hall only one (1) Resident #5 had a cognitive impairment which would have made it difficult to obtain a statement from regarding Former NA #148's behavior. At 4:00 PM on 08/30/22 SW #142 was interviewed regarding the investigation for this allegations. When asked why she only obtained statements from Females when the allegation was Former NA #148 was talking inappropriately to males, she stated, I tried to ask people who were cognitively able to answer questions. When the BIMS scores of Resident #55, #38, #51, Former Resident #1, #37, #62, and #54 were reviewed with her she stated, Your right I should have interviewed the males. She agreed she did not obtain statement from Former NA #148, nor any of the males residing on the 200 hall including the three (3) named victims. The allegation was unsubstantiated without conducting a through investigation. b) Resident #49 A review of the facility reportable incidents found a Reportable dated 07/19/22 concerning an incident which took place on 07/17/22. A review of the Immediate Fax reporting of allegations found the following allegation: (First Name of Nurse Aide (NA) #23) allegedly placed her hand over (First Name of Resident #49's) mouth while changing her to make her stop yelling and informed the aide helping her that she does it all the time when she change's (First Name of Resident #49) by herself. The statements gathered during the investigation contained the following pertinent statements: -- Statement from former NA # 148 regarding the incident typed as written: Interview conducted via phone with (First and Last Name of NA #148) on 07/19/22 at 3:40 PM with (First and Last Name of Registered Nurse (RN) #121), (First and Last Name of the Director of Nursing (DON), and (First and Last name of Licensed Practical Nurse (LP) #120) present. (First Name of former NA #148) state that she did not witness any abusive activity towards (First and Last Name of Resident #49) on 07/17/22. She stated that she never has seen anyone put a hand over (First Name of Resident #49)'S mouth. She state she did not provide care to (First name of Resident #49) on 07/17/22 and that (First and Last Name of NA #35) and (First and last Name of NA #23) provided care to (First name of Resident #49). -- Statement provided by NA #35 statement is hand written by NA #35. Statement typed as written with multiple misspelled words. (First name of NA #23) always puts her hand over (First name of Resident #49)'S mouth when yells to make her stop. She also showed (First name of Resident #52) a picture of girls viginia. She will come up behind me and smack me with briefs. She put pictures of her viginia and boobs in my face when I tell her not to. She pulled her pants down in the tub room and told me to look at her hairy monkey. (First Name of former NA #142) an I went to change (first name of Resident #28) got half way through and (First name of NA #23) came in an yelled at both of becuas it does not take two people to change (first name of Resident #28). She buts in and told us to get out of her way and finished changing (first name of Resident #28) by herself even though (first name of Resident #28) is a total. Every time she has to do the vitals she [NAME] them. She always chooses who does totals and singles and makes us do like 6 sets of rounds. After she got at me for the (first name of Resident #28) thing she almost fit me in the head with the vital machine. The first time I saw (First Name of NA #23) put her hand over (First Name of Resident #49)'s mouth was Sunday. She told me that she does it all the time when she changes her by herself. -- Statement Provided by NA #23. Typed as written: As we were doing rounds after supper, I went to help (First Name of NA #35) change (First name of Resident #49), and she told me to go on and start changing (First Name of Resident Resident #52). I went on over and changed (First name of Resident #52), and waited for her to come help me pull her up. She never came, so I said (First name of NA #35) three times, and got no answer. I then went to find her, and found (First name of Resident #28)'s door closed. So I went in and asked her to come help me pull her up. She said she would, so I went back to (first name of Resident #52)'s room and waited, she never came so I went back again, she and (First Name of former NA #148) were in there and when they were done she came back and met me in (first name of Resident #52's) room. As for (First name of Resident #49) I didn't have any part in her care for that evening. After reviewing the above statements the Documentation Survey Report was requested for Resident #49 for the date of 07/17/22. This report was reviewed to determine who documented they provided care for Resident #49 on the evening of 07/17/22. A review of the report found NA #23 documented providing the following care for Resident #49 on the evening of 07/17/22: -- Bed mobility ar 3:26 pm. -- Dressing at 3:26 pm. -- Locomotion off Unit at 3:26 pm. -- Locomotion on unit at 3:26 pm. -- Oral care at 3:27 pm. -- Personal Hygiene at 3:26 pm. -- Toileting at 3:29 pm, 4:56 pm, 6:07 pm, and 8:46 pm. -- Transferring at 3:26 pm. During an interview on 08/30/22 at 4:07 pm the review of the survey documentation report was shared with Social Worker (SW) #142. When asked if she had reviewed the report to confirm NA #23's statement that she did not provide care to Resident #49 on 07/17/22. She indicated she had not. When she reviewed the report and saw NA #23 had in fact provided care to Resident #49 on 07/17/22 she stated, This was poorly investigated. She agreed, the allegations needed to be looked into further. The allegation was unsubstantiated without conducting a through investigation. .

. Based on observation and interview, the facility failed to provide an individualized home like environment. An air mattress on top of the beds original mattress was smaller than the original mattress. This is a random opportunity for discovery. Resident identifier: #167. Facility census: 69. Findings included: a) On 05/10/21 at 12:45 PM Resident #167 was sitting up eating lunch. His bed was made up with an air mattress on top of the original bed mattress. The air mattress was much smaller than the original mattress. The area between the grab bars and the regular mattress was lower than the air mattress. On 05/11/21 at 11:00 AM Resident #167 who is alert and oriented said he has fell into this low spot and had to be assisted to get out. At 11:15 AM on 05/11/2, the above information was explained to the 100 Hall charge nurse. She stated she was not aware of the air mattress being smaller than the original mattress, and immediately fixed the problem. .

. Based on observation and interview, the facility failed to secure all medications in a locked storage area to limit access to unauthorized personnel and residents. This failed practice had the potential to a limited number of residents. Facility census: 69. Findings included: a) Observation On 05/11/21 at 7:35 AM, the medication cart for 400 Hall was found unattended and unlocked. Registered Nurse (RN) #90 returned to medication cart from inside a Resident's room. RN #90 could not see the medication cart from inside the Resident's room and was unaware this surveyor was standing at cart with access to its contents. RN #90 became startled upon return to the unlocked medication cart with the Surveyor present and stated sorry when it was discovered the cart was left unsecured. b) Staff Interview During an interview on 05/11/21 at 7:43 AM, RN #90 confirmed the medication cart was left unlocked and unattended. RN #90 agreed the medication cart should have been locked when left unoccupied and not in use. .