Every finding on record at Arkansas State Veterans Home at North Little Rock

Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure the resident's right to be free from abuse from anyone while they reside in the facility, 5 of 8 residents sampled. This sample includes Resident #40, Resident #48, Resident # 93, Resident # 73, and Resident # 20 were all affected by the deficient practice. Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure the resident's right to be free from abuse for four (Residents #20, #40, #48, and #93) of eight residents reviewed. These findings include: Resident #93 Review of a Care Plan revealed a focus point that indicated Resident #93 wandered aimlessly in and out of other veteran's rooms, causing physical altercation (initiated 5/28/2026, revised on 6/04/2026) Review of an annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/01/2026 revealed Resident #93 had received a Brief Interview for Mental Status score of 6, indicating severe cognitive impairment. Review of an admission Record revealed Resident #93 was admitted on [DATE] with diagnoses that included dementia, urinary tract infection (UTI), hypotension, malignant neoplasm of prostate, depression, and conductive hearing loss. Resident #93 and Resident #20 Review of an Incident Report dated 05/28/2026 revealed Resident #93 wandered into the room of Resident #20. An altercation ensued in which Resident #20 struck Resident #93 in the head, and Resident #93 scratched Resident #20 on the neck. A review of an admission Record revealed Resident #20 was admitted on [DATE] with diagnoses that included anxiety disorder, depression, and dementia. Review of a MDS with an ARD of 04/30/2026 revealed Resident #20 had a BIMS score of 13, indicating intact cognition. A review of a Care Plan revealed that Resident #20 had suffered a scratch on the right side of their neck, initiated on 05/28/2026, with interventions of providing wound care per provider's orders using aseptic technique. A review of Resident #20's Order Summary revealed an order started on 05/29/2026 to cleanse scratch on right side of neck with wound cleanser, pat area dry, apply bacitracin ointment and cover with a dressing every dayshift, Monday and Thursday. During an interview on 08/10/2026 at 1:05 PM, Resident #20 revealed that on 05/28/2026 Resident #93 wandered into their room and stared at them while they were asleep. Resident #20 stated Resident #93's presence woke them up because Resident #93 was close to their bed. Resident #20 revealed they tapped Resident #93 on the back of the head with two fingers and yelled at Resident #93 to get out and even started to push Resident #93 out of the room. Resident #93 proceeded to reach backwards and scratched Resident #20 on the right side of their neck under their ear. During an interview on 08/12/2026 at 9:09 AM, Resident #20's family representative confirmed being informed Resident #93 had wandered into Resident #20's room, and that Resident #20 tapped Resident #93 on the head with two fingers. The family representative also confirmed Resident #20 was scratched deeply underneath the ear on the right side of their neck by Resident #93. The family representative revealed that Resident #93 had wandered into Resident #20's room and stared at them while they slept several times previously. The family representative stated they had witnessed Resident #93 trying to enter Resident #20's room while they were visiting and had reported it to staff every time it occurred. The family representative stated stop signs were put across Resident #20's doorway, but it did not help. The family representative denied Resident #20 having any aggressive tendencies or behaviors. During a follow-up interview on 08/12/2026 at 10:44 AM, Resident #20 confirmed Resident #93 had wandered into their room and would sit in their wheelchair and stare at them while they slept several times before the incident on 05/28/2026. Resident #20 stated every time they woke to find Resident #93 had wandered into their room and was staring at them, they would be, scared to death. During an interview on 08/12/2026 at 1:52 PM, Licensed Practical Nurse (LPN) # 3 confirmed Resident #93 had a history of wandering into other residents' rooms, particularly Resident #20's. LPN #3 stated stop signs were put across Resident #20's door before the incident occurred, but despite the stop signs, Resident #93 would enter Resident #20's room anyway. LPN #3 revealed Resident #93 would become aggressive when anyone tried to remove them from another resident's room. A review of a Police Report, dated 05/28/2026, revealed Resident #93 wandered into Resident #20's room and Resident #20 tapped Resident #93 on the back of the head and Resident #20 was scratched by Resident #93. Resident #93 and Resident #40 Review of an Incident Report dated 6/01/2026 revealed Resident #93 entered the room where Resident #40 resided. Resident #93 threatened to harm Resident #40, causing Resident #40 to strike Resident #93. Review of an admission Record revealed Resident #40 was admitted on [DATE] with diagnoses that included chronic systolic heart failure, schizophrenia, auditory hallucinations, visual hallucinations, major depressive disorder, restlessness and agitation, unspecified atrial flutter, pain, heredity and idiopathic neuropathy, transient cerebral ischemic attack, and pain in unspecified shoulder. Review of an MDS with an ARD of 05/20/2026 reveal a BIMS score of 15, indicating Resident #40 was cognitively intact. The MDS indicated Resident #40 utilized a wheelchair and required substantial assistance for transfers. Resident #93 and Resident #48 Review of an Incident Report, dated 06/25/2026, revealed Resident #93 went into Resident #48's room and attempted to take Resident #48's wheelchair, causing the resident to fall. Resident #48 complained of pain to their back following the fall. Review of an admission Record revealed Resident #48 was admitted on [DATE] with diagnoses that included repeated falls, dementia, immunodeficiency, hypertension, heart disease, and depression. Review of an MDS with an ARD of 07/24/2026 revealed Resident #48 had a BIMS score of 6, indicating severe cognitive impairment. During an interview on 08/13/2026 at 12:18 PM, Universal Worker/Certified Nursing Assistant (UW/CNA) #6 indicated Resident #93 was not redirectable. Resident #93 was the reason for the stop signs on the other resident's doors. We put a stop sign on every door except [Resident #93's] door but stop did not register for [Resident #93.] When ask about the incident involving Resident #93 and Resident #48, UW/CNA #6 stated, I heard the shouting and hurried back to [Resident #48's] room. [Resident #48] was on the floor and [Resident #93] was sitting in [Resident #48's] wheelchair. [Resident #48] told us they were trying to transfer from the chair to the bed when [Resident #93] shoved [Resident #48] causing a fall. [Resident #48] does not have the ability to recall a memory if it just happened. I have worked with [Resident #48] for a while in two different units and the resident's memory has always been this way. During an interview on 08/13/2026 at 12:50 PM, Licensed Practical Nurse (LPN) #8 stated other staff made her aware of a resident-to-resident altercation and she had alerted the supervisor and wound care nurse because Resident #48 and Resident #93 were bleeding following the altercation. Resident #48 had skin tears to their left arm and a back abrasion, an x-ray was done and a fracture was ruled out. A Review of the undated facility policy titled Abuse, Neglect and Misappropriation of Resident Property indicated To ensure the resident is free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion.

Based on interviews, record review, and facility document and policy review, the facility failed to have evidence that a thorough investigation was conducted for 5 (Resident # 8 Resident #93, Resident # 20, Resident # 40, Resident # 48) of 8 residents reviewed for abuse and accidents. Based on interviews, record review, and policy review, the facility failed to maintain and submit to the State Agency evidence that a thorough investigation was conducted for four of four incidents reviewed that occurred in the facility, affecting Residents #8, #20, #40, #48, and #93. The findings include: A review of an Incident and Accident (I&A) report for Resident #20, dated 05/28/26, revealed an incident involving a physical altercation between Resident #20 and Resident #93 that resulted in an injury had been reported to the State Agency (SA). No investigation report had been submitted to the SA for this incident. A review of an I&A report for Resident # 8, dated 05/29/26, revealed the incident of a fall with injury had been submitted to the SA. No investigation into the incident was submitted to the SA. A review of an I&A report for Resident #40, dated 06/01/26, revealed an incident involving a verbal and physical altercation between Resident #40 and Resident #93 had been reported to the SA. No investigation report had been submitted to the SA for this incident. A review of an I&A report for Resident #48, dated 06/25/26, revealed an incident involving a physical altercation between Resident #48 and Resident #93 that resulted in a fall and reported pain by Resident #48 had been reported to the SA. No investigation report had been submitted to the SA for this incident. On 08/12/26 at 8:00 AM, the Complaints Supervisor for The Office of Long-Term Care at the Department of Human Services confirmed there were no full investigation reports (DMS-672) submitted by the facility to the SA for the reported incidents referenced above. During an interview on 08/13/26 at 5:33 PM, the Director of Nursing (DON) revealed it was the Administrator's responsibility to ensure completion of the I&A reports. During an interview on 08/13/26 at 6:09 PM, the Administrator revealed the I&A report for Resident #8, dated 5/29/2026, was incomplete; the I&A did not have a full investigation, and a complete investigation was not submitted to the SA. The Administrator confirmed that the reports for the incidents dated 05/28/26, 06/01/26, and 06/25/26 were also not complete. -The Administrator indicated that the following documents should be included in the I&A FRI report in this order: 1. The face sheet 2. Body audits 3. A pain assessment 4. The care plan 5. The Minimum Data Set (MDS) with Brief Interview for Mental Status (BIMS) score from the latest quarterly MDS6. In-services provided to staff7. Witness statements 8. A printout of the DMS- 7734 (Arkansas DHS Form DMS-7734 is the Incident and Accident Next Day Reporting Form used by long-term care facilities to report events like resident abuse, neglect, or unknown injuries to the state) and DMS 672 (Arkansas DHS Form DMS-762 is the official Investigation Report used by long-term care facilities to standardize how facilities investigate and record incidents involving vulnerable residents.) 9. The police report with the case card from the police officer if applicable. -The Administrator indicated the DMS-7734 form would list those contacted including family in the order they were contacted. It would state what was seen as the root cause analysis on this abuse and what was causing this. This would include the I&A, and the administrator, the Director of Nursing (DON), the attending Licensed Practical Nurse (LPN), and Registered Nurse (RN) signatures. The Administrator stated the Administrator was the last one to sign the reports, and it should be a red flag to their attention if it had not been completed. On 08/14/2026 at 10:05 AM, the Administrator stated the facility did not have a policy for Incidents and Accidents.

Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure residents had a safe, clean, sanitary, comfortable, and homelike environment including (but not limited to) the residents' rooms, lobby, outdoor patio, and activity areas. Specifically, the facility failed to dispose of soiled personal protective equipment (PPE) in a safe trash receptacle instead of on the ground outside the front door of one (Home 1) of eight homes reviewed to prevent the spread of disease-causing organisms. The findings include: During an observation while exiting Home 1 on 08/13/2026 at 3:19 PM, this surveyor observed soiled PPE lying on the ground next to the porch exit from the front door. A picture image was obtained and shown to the Administrator and Director of Nursing (DON). During an interview on 08/13/2026 at 5:31 PM, the DON stated it was not appropriate for staff to walk out of a home and throw their PPE on the ground. She stated, It doesn't look good for [staff] to throw PPE on the ground outside a home and not in a trash can. She continued that the residents could be exposed to something [referring to disease causing organisms]. The DON stated, by gloves being thrown down on the ground, it could make the residents feel like we don't take care of their home. You want it to be pretty on the outside like it is on the inside. And it could spread germs. During an interview on 08/13/2026 at 6:12 PM, the Administrator stated when staff removed gloves, they should dispose of them in a proper trash can and it was not appropriate for them to be thrown down on the ground outside the resident's home. She stated, A resident could come outside, touch it, and anything could be inside it or contaminated with anything. The Administrator stated, I'm sure it makes the residents feel degraded and unkept to see dirty PPE on the ground outside their home, and it doesn't look nice. A review of an in-service over the top of Gloves dated 02/08/2026, indicated staff were to remove gloves after each use, and before going into the hallway from a resident's room, or leaving the kitchen. The in-service also indicated staff were not to have gloves on in the hallways. A review of an in-service over the topic of Infection Control Policy, dated 03/14/2026, indicated staff must comply with the attached infection control policy. The undated infection control policy referred to indicated PPE would be doffed [removed] correctly while in the room and hand hygiene would be performed after glove removal.

Based on observations, interviews, and record review, the facility failed to review and revise the comprehensive person-centered care plan for one (Resident #2) of one resident reviewed for comprehensive care plan revision. Specifically, the facility did not develop Resident #2 did not have develop and implement a care plan that included revisions for care of a suprapubic catheter with interventions added for the catheter's care.The findings include:A review of policy titled Care Plan Comprehensive revision date December 2016, indicated the comprehensive, person-centered care plan will incorporate identified problem areas, risk factors associated with identified problems, identify the professional services that are responsible for each element of care, and reflect currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition. A review of an admission Record, revealed Resident #2 was admitted by the facility on 11/25/2025 with diagnoses that included depression, acute kidney failure, and essential hypertension.A review of Resident #2's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/21/2026, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #2 required partial/moderate assistance with toileting. Urinary Continence was not rated due to having a catheter.A review of Resident #2's Order Summary dated August 2026, indicated this resident had a suprapubic catheter with start date of 5/01/2026, with instructions to change catheter as needed for leakage/obstruction, to cleanse the suprapubic catheter with soap and water, pat dry, apply a topical antibiotic ointment and cover with split gauze/secure with tape every evening shift, and record output from the catheter every shift.A review of a Care Plan date initiated 11/25/2025 with revision date 4/06/2026, indicated Resident #2 had a condom catheter with interventions to monitor for signs and symptoms of discomfort on urination and frequency and pain/discomfort. The care plan was not revised on 5/1/2026 when the suprapubic catheter was placed with orders to change catheter as needed for leakage/obstruction, to cleanse the suprapubic catheter with soap and water, pat dry, apply a topical antibiotic ointment and cover with split gauze/secure with tape every evening shift, and output from the catheter every shift. During an interview on 08/13/2026 at 5:31 PM, the Director of Nursing (DON) revealed Licensed Practical Nurses (LPNs), Registered Nurse (RN) Supervisors, and Certified Nursing Assistants (CNAs) look at the care plans to know what to do to take care of residents. She stated if the care plan was not updated, the staff would not be able to meet the needs of the resident. The DON stated, We are noticing care plans are not being revised timely and they should be revised right then. The DON indicated that with the care plans not being revised, it could be considered neglectful to the residents.During an interview on 08/13/2026 at 6:12 PM, the Administrator stated the DON, RN Supervisors, MDS Coordinator, Medical Director, Treatment Nurse, and the Administrator look at the care plans. She stated, If there was a status change of a resident, and the care plan was not updated, and something happened, it would be bad. The care plan should immediately be revised when there is a change to the order. The Administrator stated, It absolutely could be neglectful of the facility toward a resident if all care plans and physician orders are not carried out. She stated it could change everything if a care plan was not read or updated.

Based on interview and facility document review, the facility failed to post completed nurse staffing information, including but not limited to: facility name, the current date, resident census, the total number and the actual hours worked by the following categories of Registered Nurses (RN), Licensed Practical Nurse (LPN), and Certified Nurses Assistants (CNA) and/or Universal Workers (UW) staff directly responsible for resident care per shift and maintain the daily staffing logs for a period of 18 months. The findings include: A review of the facility form Daily Staffing Log, for home 3 dated 07/09/2026, revealed the document was not completely filled out, and it did not have the actual hours worked per staff. A review of a note titled No Daily Staffing Logs, received from the Administrator on 08/13/2026, revealed the facility failed to maintain the daily staffing logs for Homes 1, 2, and 6. This document was signed by the Interim Administrator. During an interview on 08/13/2026 at 5:31 PM, the Director of Nursing (DON) stated it was the responsibility of the RN Supervisors and herself to make sure the daily staffing logs were completed correctly. She stated, I see there are many daily staffing logs that do not have any staff written on them, no times and actual hours worked. The DON stated it was important to keep the daily staffing logs for 18 months, and they (the facility) had not done that. She stated filling out the logs accurately would give an accurate count of who is in the homes working. During an interview on 08/13/2026 at 6:12 PM, the Administrator revealed they had not kept the daily staffing logs, and/or was unable to locate them. The Administrator stated that by looking at the daily staffing log she had in front of her, it appeared the documents were not accurately completed. She stated, it did not have the total hours worked, some did not have any staff for some shifts, others did not have the actual hours worked. The Administrator stated, the DON and RN supervisors will make sure these are accurately filled out, and they will be checked weekly. She stated she would make sure the DON and RN Supervisors maintain them for the required 18 months, which would start immediately. Upon arrival at the facility on 08/14/2026 at 9:30 AM, the Administrator and the Corporate Division Director came in and stated they did not have, and would be unable to provide, daily staffing logs for homes 1, 2, and 6 as the note the Administrator provided indicated. The Administrator and Corporate Division Director indicated the logs they did have were not accurately completed.

Based on observations, interviews, and facility document review, it was determined the facility failed to ensure staff appropriately dispensed insulin after drawing the medication up for administration. Specifically, the nurse placed the insulin filled syringe over her right ear then came to interview during the survey without administering it to a resident. The findings include: A review of policy titled, Administering Medications revision dated April 2019, indicated if a drug was withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR) space provided for that drug and dose. Staff follows established facility infection control procedures (handwashing, antiseptic technique, gloves, isolation precautions) for the administration of medications. During a concurrent observation and interview on 08/12/2026 at 1:50 PM, Licensed Practical Nurse (LPN #2) came to the community center from Cottage 1 and was observed with a syringe hanging above her right ear. When questioned of the contents, LPN #2 stated it was insulin that she had drawn up to administer to a resident in Cottage 1, but had to come do this interview, so she put it above her ear and forgot about it. LPN #2 stated she did not normally put them [insulin syringes] above her ear. She stated she guessed she would not administer the insulin, and she would throw it in that box thingy. When asked if the LPN was referencing a sharps container, LPN #2 said yes. LPN #2 stated the syringe seen tucked behind her ear and alleged to contain insulin was not labeled. On 08/12/2026 at 2:00 PM, the Administrator and Director of Nursing (DON) were informed of the concern of LPN #2 having the unlabeled insulin syringe above her ear and that LPN #2 had reported she guessed she would dispose of the syringe. The Administrator and DON stated it would be witnessed as being disposed of. A review of an in-service titled Needle Safety dated 08/12/2026 and signed by LPN #2 revealed needle safety involves proper handling, use and disposal to prevent injuries and exposure to bloodborne pathogens. Always handle needles safely, which includes not placing them behind one's ear. This is not safe practice. Whoever observes incorrect disposal or handling of contaminated sharps should report the information to the infection preventionist (IP). the document was signed by the DON and LPN #2. During an interview on 08/13/2026 at 5:31 PM, the DON stated it was not appropriate for LPN #2 to have the syringe of insulin above her ear. She stated, the nurse said she placed it in the sharps container, but I did not ask her if (the disposal) was witnessed. The DON stated LPN #2 had been in-serviced over this incident. She stated it shouldn't be common for staff to draw up medications and not immediately administer them. The DON stated if medications are not immediately administered, the medications should be wasted and redrawn when ready to administer. She stated all medications should be labeled. During an interview on 08/13/2026 at 6:12 PM, the Administrator stated LPN#2 should not have had an insulin syringe above her right ear, it was not appropriate, and the syringe of insulin was wasted and placed in the sharps container. She stated medications should be administered immediately to a resident and if not administered immediately the medication should be discarded.

Number of residents sampled: Number of residents cited: Based on observation, interviews, and facility document review, the facility failed to ensure food had not been kept past the expiration and storage date, food was labeled and dated, and refrigerators will be kept clean and free of food particles for 2 (Cottages #3, #4) of 8 cottage kitchens reviewed for food storage, preparation, and sanitation process. The findings include: During the initial tour of Cottage 4's kitchen with Universal Worker (UW #1), on 08/10/2026 at 10:18 AM,, the following were observed stored in the refrigerator, freezer and spice storage area: Ground mustard seasoning spice with an expiration date of 04/2025. Basil leaves seasoning spice with an expiration date of 08/31/2024. Ground ginger seasoning spice with an expiration date of 04/06/2026. 14 count of frozen raisin cookies in a gallon freezer bag with an expiration date of 07/31/2026. Three count frozen chicken patties in a gallon freezer bag with an expiration date of 08/07/2026. Eight count frozen fish patties in a gallon freezer bag with an expiration date of 08/05/2026. 10 count frozen riblets in a gallon freezer bag with an expiration date of 08/03/2026. Approximately 14 Count frozen chicken breast in a gallon freezer bag, no identifier of meat, no date of opening or expiration date. A plastic tray of blueberries with no expiration date on the container had a fuzzy white substance all over the bottom of the blueberries. Sliced turkey stored in the refrigerator had no expiration date and the meat was slimy. The compartment of the refrigerator freezer had frozen brown liquid debris and food particles. During a concurrent observation and interview in Cottage 4 on 08/10/2026 at 10:20 AM, UW #1 stated she threw food away when the item had expired. UW #1 stated the blueberries had mold all over them and the turkey was ruined, slimy and expired. She stated, the frozen brown substance was probably a soda that had busted in there and hadn't been cleaned. On 8/10/2026 at 10:42 AM, UW #1 discarded the expired frozen food items and spices in Cottage 4. During an initial kitchen tour with UW #4 on 08/10/2026 at 11:14 AM, in Cottage 3's kitchen the following were observed stored in the refrigerator, refrigerator freezer and dry storage: a) A box of cream of wheat with an expiration date of 08/04/2026. b) An unopened pack of lunchmeat with an expiration date of 05/30/2026. c) Two lemon juice bottles with expiration dates of 08/01/2026. d) An unopened plastic bag of frozen corn with an expiration date of 06/2026. UW #4 discarded the expired items from Cottage 3's in the facility trash can. During an interview on 08/11/2026 at 2:29 PM, the Food and Beverage Manager stated she ordered the bulk foods and once delivered she divided them up by placing the item in gallon freezer bags. She stated, I write the item name, opened date and expiration date on the outside of the freezer bag. The Food and Beverage Manager stated she or her staff must have failed to write on some of the bags. She stated either herself or the kitchen expert goes around to the cottages to check the expiration dates. The Food and Beverage Manager stated the UW's were under the supervision of the Director of Nursing (DON). She stated it was not just her responsibility to check the expiration dates; it was everyone's. During an interview on 08/13/2026 at 5:31 PM, the DON stated the DON and Registered Nurses (RNs) were responsible for in-servicing and educating the UWs. She stated they monitor the UWs to make sure they followed the policies for food disposal. The DON stated the Food and Beverage Manager made sure to check expiration dates. The DON indicated if a resident ate or consumed expired foods they could get sick so it should be thrown out. During an interview on 08/13/2026 at 6:12 PM, the Administrator stated if the UWs failed to throw out expired foods the DON and RN supervisors would educate and monitor them to make sure it was being done. She stated the Food and Beverage Manager goes in each cottage weekly to check expiration dates. The Administrator stated if a resident ate expired food, they could get sick. A review of an undated facility policy [Company Name] Produce Storage, indicated opened luncheon meats stored in a refrigerator at 40 degrees Fahrenheit (*F) should be kept for 3-5 days; other fresh fruit (blueberries) should be stored in a refrigerator at 40 degrees Fahrenheit (*F) should be kept for 3-5 days. A review of facility policy Food Storage, dated 2019, indicated all refrigerator units will be kept clean and in good working condition at all times, all foods should be covered, labeled, and dated and all foods will be checked to assure that foods will be consumed by their safe use by dates, or discarded. All frozen food items should be labeled and dated. All frozen foods will be checked to ensure that foods will be consumed by their safe use by dates or discarded. A review of facility in-service titled Storage of Food, dated 06/24/2026, indicated all food and dry storage must be labeled and dated before putting away. Once the food expires, it must be thrown out. All food items, whether refrigerated, frozen, or kept in dry storage must include date received or opened, use by or discarded date, following facility policy. The policy indicated moving forward [the facility] would be incorporating weekly fridge and pantry checks.

Based on interviews and facility document review, the facility failed to ensure the facility assessment was utilized to inform staffing decisions to ensure sufficient staffing to meet resident needs, evidenced by not following the facility assessment staffing guidelines for 49 of 93 shifts reviewed from 07/09/2026 day shift through 08/08/2026 night shift.The findings include:Review of a facility policy titled, Facility Assessment, dated 1/15/2026, indicated the facility had an average daily census of 76- . Common diagnoses of the facility's residents included:Mental and Behavioral Health- Psychosis, impaired cognition, mental disorder, Depression, Bipolar disorder, schizophrenia, post-traumatic stress disorder, anxiety disorder, behavior that needs interventions, behavioral and psychological symptoms of dementia, substance use disorder.Heart/Circulatory System- Congestive heart failure, coronary artery disease, angina, dysrhythmias, hypertension, orthostatic hypotension, peripheral vascular disease, risk for bleeding or blood clots, deep venous thrombosis, pulmonary thrombo-embolism.Neurological System- Parkinson's disease, hemiparesis, hemiplegia, paraplegia, multiple sclerosis, Alzheimer's disease, non-Alzheimer's dementia, seizure disorders, cerebral vascular accident, stroke, traumatic brain injuries, neuropathy, autism, Huntington's Disease, Tourette's Syndrome, aphasia, cerebral palsy, progressive neurological conditions.Vision- Visual loss, cataracts, glaucoma, macular degenerationHearing- Hearing loss.Musculoskeletal System- Fractures, osteoarthritis, hip/knee replacement, osteoporosis, amputation.Neoplasm- Prostate cancer, breast cancer, lung cancer, colon cancer.Metabolic Disorders- Diabetes, thyroid disorders, hyponatremia, hyperkalemia, hyperlipidemia, obesity, morbid obesity.Respiratory System- Chronic obstructive pulmonary disease, pneumonia, asthma, chronic lung disease.Genitourinary System- Renal insufficiency, nephropathy, neurogenic bowel or bladder, renal failure, end stage renal disease, benign prostatic hyperplasia, obstructive uropathy, urinary incontinence.Diseases of Blood- Anemia.Digestive System- Gastroenteritis, cirrhosis, peptic ulcers, gastroesophageal reflux, Crohn's disease, inflammatory bowel disease, bowel incontinence.Integumentary System- Skin ulcers, injuries.Infection Diseases- Skin and soft tissue infections, respiratory infections, urinary tract infections, infections with multi-drug-resistant organisms, septicemia, viral hepatitis, clostridium difficile, influenza, scabies, legionellosis, Covid-19.The facility assessed acuity affecting licensed nurses was 20 residents on intermittent respiratory treatments, 20 residents on as needed respiratory treatments, two residents on Bilevel Positive Airway Pressure (BIPAP), four on Continuous Positive Airway Pressure (CPAP), two on antibiotics, 13 residents that require setup or clean-up assistance with eating, two residents that required supervision or touching assistance with eating, two residents that require partial/moderate assistance with eating, two residents that was dependent with eating, 64 residents required supervision or touching assistance for dressing, two residents dependent for dressing, 53 residents required partial/moderate assistance for transfer (chair/bed to chair, toilet, tube/shower), 15 residents dependent for transfer (chair/bed to chair, toilet, tube/shower), 64 residents required supervision or touching assistance for toileting hygiene, 6 dependent for toileting hygiene, 53 required partial/moderate assistance sit to stand, and 15 require substantial/maximal assistance sit to stand.The facility assessed their coverage needs to adequately meet the residents' daily needs per shift such as:Day Shift: Licensed nurses (Registered Nurse (RN), Licensed Practical Nurse (LPN) providing direct care- 4 per shift. Nurse Aides- 24 for day shiftEvening Shift: RN/LPN- 4 per shift. Nurse Aides- 16 for evening shiftNight Shift: RN/LPN- 4 per shift. Nurse Aides- 16 for night shiftA review of document Midnight Census Report dated 8/09/2026 revealed the facility had 89 current residents, with three beds on hold.A review of document Staffing Numbers Per Shift received on 8/14/2026 from the Administrator sent to the Office of Long-Term Care as additional information. The was reviewed for total staff of each designation starting with the day shift on 7/09/2026 through the end of the night shift on 8/08/2026. The following revealed the facility did not have the required staffing for the residents per their facility assessment:07/09/2026- Evening shift revealed, Nurses' Aides had 15; Night shift Nurses' Aides had 15.07/10/2026- Night shift revealed, Nurses' Aides had 13.07/11/2026- Day shift revealed, Nurses' Aides had 19; Evening shift revealed, no LPN or Nurses' Aide worked.07/12/2026- Day shift revealed, Nurses' Aides had 22; Evening shift revealed, no LPN or Nurses' Aide worked.07/13/2026- Evening shift revealed, Nurses' Aides had 15; Night shift revealed, Nurses' Aides had 12.07/14/2026- Night shift revealed, Nurses' Aides had 14.07/15/2026- Evening shift revealed, Nurses' Aides had 14; Night shift revealed, Nurses' Aides had 13.07/16/2026- Night shift revealed, Nurses' Aides had 13.07/17/2026- Evening shift revealed, Nurses' Aides had 14; Night shift revealed, Nurses' Aides had 14.07/18/2026- Evening shift revealed, no LPN or Nurses' Aide worked.07/19/2026- Evening shift revealed, no LPN or Nurses' Aide worked07/20/2026- Evening shift revealed, Nurses' Aides had 15; Night shift revealed, Nurses' Aides had 11.07/21/2026- Night shift revealed, Nurses' Aides had 14.07/22/2026- Evening shift revealed, Nurses' Aides had 14; Night shift revealed, Nurses' Aides had 14.07/23/2026- Night shift revealed, Nurses' Aides had 15.07/24/2026- Evening shift revealed, Nurses' Aides had 15; Night shift revealed, Nurses' Aides had 15.07/25/2026- Evening shift revealed, no LPN or Nurses' Aide worked. 07/26/2026- Day shift revealed, Nurses' Aides had 21; Evening shift revealed, no LPN or Nurses' Aides worked. 07/27/2026- Evening shift revealed, no LPN worked; Night shift revealed, Nurses' Aides had 12.07/29/2026- Evening shift revealed, Nurses' Aides had 12; Night shift revealed, Nurses' Aides had 15.07/30/2026- Evening shift revealed, Nurses' Aides had 15; Night shift revealed, Nurses' Aides had 15.07/31/2026- Evening shift revealed, Nurses' Aides had 15; Night shift revealed, Nurses' Aides had 13.08/01/2026- Day shift revealed, Nurses' Aides had 23; Evening shift revealed, no LPN or Nurses' Aides worked. 08/02/2026- Evening shift revealed, no LPN worked; Night shift revealed, Nurses' Aides had 12; Night shift Nurses' Aides had 14.08/03/2026- Evening shift revealed, Nurses' Aides had 15; Night shift revealed, Nurses' Aides had 12.08/4/2026- Night shift revealed, Nurses' Aides had 14.08/5/2026- Evening shift revealed, Nurses' Aides had 14; Night shift revealed, Nurses' Aides had 13.08/06/2026- Night shift revealed, Nurses' Aides had 13.08/07/2026- Evening shift revealed, Nurses' Aides had 13; Night shift revealed, Nurses' Aides had 12.08/08/2026- Evening shift revealed, no LPN or Nurses' Aides worked During an interview on 08/13/2026 at 5:31 PM, Universal Worker (UW), UW #11 stated, We always work short staffed and most nights there is only one other person in this cottage other than me. She stated, There is always only the [UW] and a [Certified Nurse's Assistant (CNA)], and the nurses do not help at all. UW #11 stated People will not come to work at night.During an interview on 08/13/2026 at 5:31 PM, the Director of Nursing (DON) stated, It was important for the daily staffing logs to be completed so they know how many and who worked in a specific home.During an interview on 08/13/2026 at 6:12 PM, the Administrator stated the daily staffing logs were not filled out, it did not show who was working, time in and out with actual hours worked, and her goal as the Interim Administrator was to be more accurate with staffing.Upon arrival at the facility on 08/14/2026 at 9:30 AM, the Administrator and the Corporate Division Director came in and stated, They did not have daily staffing logs and was not able to provide logs to show licensed staff per shift each day for the past 30 days.

49596 49866 Based on observation, record review and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed and dated to minimize contamination for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed / discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or contamination; meals from 8 of 8 kitchens; Hot food items were maintained at above 135 degrees Fahrenheit on the counter while awaiting service to prevent potential food borne illness for residents who received meals from the kitchen in Heroes Home #1, Heroes Home #2, Heroes Home #3, Heroes Home #4, Heroes Home #5 Heroes Home #6 Heroes Home #7 and #8, and hand hygiene was maintained during food service to minimize the risk of food borne illness in Heroes #4 and #6. These failed practices had the potential to affect 12 residents Heroes Home #1, 11 residents on Heroes Home #2, 12 residents on Heroes Home #3, 12 residents on Heroes Home #4, 12 residents on Heroes Home #5, 6 residents on Heroes Home #6 11 Residents on Heroes Home #7, 7 residents on Heroes Home #8, who received meal trays from the Heroes Homes kitchens, (Total census: 88), as documented on a list provided Dietary Supervisor on [DATE] 04:00 PM. The findings are: On [DATE] at 04:09 AM, the following was observed: a. A bag of hamburger buns that contained 12 counts of buns was on the counter in the kitchen. There was no received date on the bag. b. A spout to the pitcher in the refrigerator that contained strawberry lemonade was not covered. c. A zip lock in that contained slices of ham was in the refrigerator compartment. There was no date on the bag to indicate when it was stored. d. A bag of tortilla chips in the snack rack on the counter had expiration date of [DATE]. e. A container of parsley flakes in the cabinet above the counter had expiration date of [DATE]. f. An opened soy sauce was in the cabinet above the counter. The manufacturer specification on the bottle documented, Refrigerator after opening. On [DATE] 04:22 PM, The following observations were made in the storage room: a. A bag of community coffee was on a shelf in the storage room. There was no received date on the bag. b. An opened bag of cornflakes was on a shelf in the storage room. The bag was not sealed. c. An opened bag of bite site tortilla chips was on a shelf in the storage room. The bag was not sealed. d. An opened box of baking soda was in the cabinet. The box was not covered. On [DATE] at 04:42 PM, the following observations were made in the refrigerator in Heros Home #2: a. Two cartons of liquid eggs on a shelf in the refrigerator had expiration date of [DATE]. b. An opened box of salt was in the cabinet. The box was not covered. On [DATE] 04:46 PM, the following observations were made in the storage room. a. A cup of Greek yogurt in the refrigerator has no received date on it. b. A bag of hamburger bun on the rack in the storage room with 5 counts of bun had expiration date of [DATE]. c. A bag of hot dog buns on a rack in the storage room with 12 counts of buns had expiration date of [DATE]. d. Four bags of tortilla chips on a shelf in the storage room with an expiration date of [DATE]. e. One bag of tortilla chips on a shelf in the storage room has expiration date of [DATE]. f. [DATE] 04:59 PM, an opened and of brown sugar was on a shelf. The bag was not sealed. On [DATE] at 04:59 PM, the following observations were made in the refrigerator in Heros Home #3. a. A pitcher that contained sweet tea was dated [DATE] on a shelf. The spout to the pitcher was not covered, exposing tea for cross contamination. b. An opened plastic bag that contained slices of cheese was in an opened bag on a shelf. Neither bag was sealed. c. An opened garlic powered container was in the cabinet. The container was not covered, exposing the garlic to air. d. An opened container of lemon pepper season salt in the cabinet above the counter. The container was not sealed. 2. On [DATE] at 05:06 PM, the following observation was made in the storage room. a. An open box of cereal had an open inside bag, that contained raisin that was placed inside an open plastic bag, exposing it to air. The surveyor asked Dietary Employee (DE) #14, the Universal worker (UW), if there were pests, would they be able to crawl into the cereal bag? (DE) #14 stated, yes. On [DATE] at 05:17 PM, the following observations were made in in freezer in the kitchen of Heroes Home #4. a. An opened plastic bag of dinner roll was in freezer compartment. The bag was not sealed. b. An opened bag of hamburger buns was on a shelf. The bag was not sealed. c. There were 3 individual packets of French dressing on a shelf in the storage room with an expiration date of [DATE]. 3. On [DATE] at 11:16 AM, Certified Nursing Assistant (CNA) #15 touched the cabinet with her gloves on then went to handle food. The Surveyor asked what should you have done after touching the dirty objects and before handling food items? She stated, Washed my hands. 4. On [DATE] at 11:20 AM, CNA #15 was wearing mittens on her hands when she opened the oven, she picked up a bowl; from the cabinet with her mitten thumb inside the bowl while she placed 2 servings of fried fish inside the bowl to be ground and served to the residents who required mechanical soft diets. She was asked what should have been done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. The following observations were in Heroes Home #7 On [DATE] at 08:12 AM A carton of French vanilla yogurt on a shelf in the refrigerator has expiration date [DATE]. a. An opened container of black pepper was in the cabinet. The container was not covered. On [DATE] at 08:25 AM, the following observations were made in the storage room: a. An opened bag of coffee filter with coffee was on a shelf in the storage room. The bag was not sealed. There was no opened date on the bag. The following observations were made in Heroes Home #6. On [DATE] at 12:16 PM, the Food items on a plate to be served to the residents when checked and read by the CNA #11. was a Chopped chicken 109 degrees Fahrenheit. On [DATE] at 12:25 PM, CNA #11 was wearing gloves on her hands when she turned on the faucet and washed the blender bowl, with hot water and no soap. She did not sanitize the equipment. then used tissue paper to the inside of the blender bowl and the blade and blade with hot water and did not sanitize the process. She turned off the faucet with her gloved hand. She used the same glove to attach the blade at the base of the blender to be used in pureeing food items to be served to the resident on a puree diet. When CNA #11 was ready to use the blender, the surveyor asked was soap used to wash the pureed equipment. She stated, No soap was used. The Surveyor asked how dishes are supposed to be dried. CNA #11 stated, Dishes are to be air dried. The Surveyor asked how equipment should have been washed. She stated, The equipment needed to be re-washed. She then placed the equipment in the dishwasher between each food item that required to be pureed. On [DATE] PM at 12:30 PM, CNA was picking up food plates to serve to the residents with her thumb inside the plates. On [DATE] 12:51 PM, CNA #5 was wearing gloves on her hands when she opened the cabinet. Without changing gloves and washing her hands, she removed plates from the cabinet and placed them on the counter to be used in portioning desserts for lunch with her contaminated gloves finger touching inside the plates. At 1:59 PM, Surveyor asked CNA # 5 what should you have done after touching dirty objects and before handling clean equipment? CNA #5 stated, I should have washed my hands. On [DATE] 12:52 PM, CNA #11 with gloves on her hands, opened the oven and removed a pan of chicken and placed it on the counter. Without changing gloves and washing her hands, she deboned and placed the chicken into a blender, added gravy and pureed. On [DATE] 12:54 PM, CNA #6 with gloves on her hands, removed a spatula from the drawer. She held on to the foil pan as she cut the cheesecake and contaminated the glove. Without changing gloves and washing her hands, she used her contaminated gloved hand to push slices of cheesecake into individual plates to be served to the residents for lunch. On [DATE] at 08:50 AM, the following observations were made in the refrigerator and the kitchen area of Heros Home #5. a. The temperature of the refrigerator was 48 degrees. The surveyor asked the UW #17, cook aide, to check the internal temperature of the milk in the refrigerator. She did so and it was 51 degrees Fahrenheit, and she threw it away. b. A gallon of whole milk on a shelf in the refrigerator had an expiration date of [DATE]. c. An opened plastic bag that contained 25 counts of biscuits in the freezer compartment. The bag was not sealed. On [DATE] 09:05 AM, the following observations were made in the storage room. a. An opened box that contained 10 counts of tea bags was on a shelf. The box was not covered. b. A packet of powder cheese sauce was on a shelf in the storage room. The packet was not fully sealed. c. A bag of bread was on a shelf in the storage room with no received date on the bag. d. An opened hamburger bun was on a shelf in the storage room with no opening date on the bag. e. An opened box of cream of wheat. The box was not covered. f. An opened bottle of soy sauce in the cabinet. The manufacture' specification on the bottle documented, Refrigerate after opening for quality. The following observations were made in Heroes Home #8. On [DATE] at 09:37 AM, the refrigerator temperature was 47 degrees Fahrenheit. The surveyor asked the Certified Nursing Assistant CNA # 8, cook aide to check the internal temperature of the milk. The milk was 46-degree Fahrenheit. The surveyor asked CNA, cook aide do you consider milk to be a cold food item? CNA #8, cook aide stated, Yes, the temperature was too high. The Surveyor asked CNA #8 do you think the milk temperature was ok? CNA#8 stated, No, I have to discard it. A pitcher of cranberry Juice was on a shelf in the refrigerator. The spout to the pitcher was not covered, there was no date on the pitcher to indicate when it was stored. An opened packet of Salami was in the refrigerator compartment with an expiration date of [DATE]. The bag was not sealed. An opened plastic bag that contained 27 Frozen Dinner Rolls was in the refrigerator compartment. The bag was not sealed. The following observations were made in the storage room. a. An opened 2.5 pounds bag of cookies was on a shelf in the storage room with an expiration date of [DATE]. b. An opened 24 ounces bag of fried onions was on a shelf in the storage room. The bag was not sealed. c. An opened gallon of white distilled vinegar on a shelf in the storage room has no date when opened. d. An opened gallon of imitation vanilla extract was on a shelf in the storage room with no date on the gallon to indicate when it was stored. e. An opened gallon of sweet and BBQ sauce was on a shelf in the storage room with no date when opened on the gallon. A facility Dietary Checklist documented, All items in the refrigerator and freezer is dated and labeled (Identify what it is) Hands are washed before and after using gloves. Hands are washed when going from one task and after finishing a task. Hands are washed when going from on task to another. The following observations were made on [DATE] at10:50 AM in Cottage 8: Refrigerator in storage area:5 -4oz cups of yogurt expired as of [DATE] (3 peach & 2 raspberry). Opened can of lemon lime can open with straw in it not labeled or dated. Large jar of Maraschino Cherries opened [DATE]. No expiration date, open bag of plain potato chips not labeled. Bag of 10 - 1 oz containers of cream cheese dated [DATE]. Pantry - bag of hamburger buns - 12 count - expired [DATE], 2 packages of 2 count buns expired [DATE]. 18 count of Italian dressing pouches and 1 French dressing expired [DATE]. Cabinets: Toaster stored on shelf in pantry covered with breadcrumbs. Slow cooker dusty. Slow cooker dried substance running down cooker - stored in pantry. Dried orange colored substance on blade of hand chopper stored on shelf in pantry. Outside of refrigerator door, rust areas noted. Utensil drawer - Dark brown spots in scoop and in bottom of drawer. 3 other scoops with dried particles in them. Cheese shredder blade has a rusty color substance dried on it. The coating inside 3 pots were noted to be peeling off. Refrigerator in kitchen area of home rolls not dated in freezer. Garlic bread expired; Potato wedges expired. Sweet corn batter not sealed. Pie crust expired ,d+[DATE], Okra expired ,d+[DATE], Eggs noted stored on 2nd shelf above refrigerator drawer where bags of cheese is stored. Coleslaw expired; skips were noted on the temp log for the refrigerators. 8 residents live in this home. Lunch today was Pork loin, greens, cornbread, and sweet potato casserole. On [DATE], dressing no dates, bacon and turkey stored in same drawer as eggs. Toaster covered in breadcrumbs. kitchen cabinets covered in tacky substance running down them. Upon entering kitchen surveyor in cottage 1 noted in dried pantry no open date on curry vegetables, unsealed fruit punch powder not dated or sealed. Also noted large flour tub without date on it. Dried storage area's refrigerator and freezer: refrigerator temperature - 44 degrees and freezer temperature-5 degrees Kitchen refrigerator and freezer: In the storage area of refrigerator noted shredded brown, mushy lettuce dated [DATE] also large head of lettuce that was brown dated [DATE]. Noted also in storage area of refrigerator two mushy tomatoes date received [DATE]. Shredded cheese with no receive date. Refrigerator temperature- 44 degrees and freezer temperature- 5 degrees

Based on observation, interview and record review, the facility to ensure a call light was in reach for 1 Resident #49. The findings are: Resident #49 diagnoses showed Dementia and Macular degeneration. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/15/24 showed a Staff Assessment of Mental Status (SAMS) documenting short- and long-term memory problems. The Resident requires substantial/maximum assistance with toileting and personal hygiene. The Resident is dependent on staff to put on or take off footwear. The care plan showed Resident #49 had an ADL (Activities of Daily Living) self-care performance deficit related to dementia. Staff are to encourage the resident to use the bell to call for assistance. On 02/20/24 at 11:26 AM, the Surveyor observed no call light in Resident #49's room. On 02/20/24 at 2:41 PM, the Surveyor observed no call light in Resident #49's room. On 02/21/24 at 11:09 AM, the Surveyor observed no call light in Resident #49's room. On 02/21/24 at 11:10 AM, the Surveyor asked Certified Nursing Assistant (CNA) #13 where is the resident's call light? CNA #13 said, they are all demented and can't use a call light. We keep all the residents up front and keep an eye on them. The Surveyor asked, what about when they are in bed or laying down? CNA #13 said, they don't know to use a call light, so why would they need one? On 02/23/24 at 12:47 PM, the Surveyor asked the Director of Nursing (DON) should every resident have a call light within reach? The DON said yes, but Hero House 8 is special because these veterans are wanderers and elopement risks. They tend to pick things up and set them down where they are. The home workers make rounds more often and they tend to stay up in the day area together. We also use pendant lights instead of regular call lights, so we find the pendants everywhere. A document titled provided by the DON on 2/23/24 at 4:03 PM titled, Answering the Call Light showed, .be sure the call light is within easy reach of the resident .

Based on observation and interview, the facility failed to ensure the 2023 survey results were located in the State Survey Binder, if. This failed practice had the potential to affect all sampled residents who chose to read the State Survey Binder. The findings are: On 02/20/24 at 02:07 PM, the Surveyor observed the State Survey Binder in Hero House #7 with the most recent survey in the book being a complaint on 9/22/2022. The most recent recertification survey was dated 12/09/2022. On 12/20/24 at 02:43 PM, the Surveyor did not observe a State Survey Binder in Hero House #8 readily available to residents and visitors. On 02/21/24 at 04:32 PM, the Surveyor asked the Administrator should each Hero House have a State Survey Binder readily available, and with the most current survey information, for residents and visitors to read? The Administrator said yes. The Administrator confirmed the most recent copy of the survey was not in the binder for Hero House #7 and the survey binder in Hero House #8 was not readily available. A document provided by the Director of Nurses on 2/22/24 at 11:15 a.m. titled, Resident Rights showed, .Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to .examine survey results .

49866 Based on observation, interview, and record review the facility failed to ensure that 4 Resident's # 3, #26, #30, #75) of 19 sample mix residents had their nails cleaned and trimmed to promote good hygiene, cleanliness, and a sense of wellbeing. The findings are: On 02/20/2024 at 10:04 AM, surveyor observed Resident (#3) in room with 1/4 inch nails on both hands with dark brown substance under jagged nails. On 2/20/2024 at 11:28 AM, surveyor observed Resident (#3) in room. Resident had long 1/4 inch nails on both hands with brown substance under jagged nails on both hands. On 2/21/2024 at 10:04 AM, surveyor observed Resident (#3) in room. Resident had long 1/4 inch nails on both hands with brown substance under jagged nails on both hands. On 2/21/2024 at 3:45 PM, surveyor interviewed Certified Nursing Assistant (CNA) (#3) and asked how often is nail care performed. CNA #3 confirmed, on their shower days if needed. Who is responsible for making sure nail care is completed. CNA #3 confirmed, the CNAs are. The surveyor asked what negative outcome can occur from nails being left with brown substance under them and jagged. CNA #3 confirmed infection, the resident could cut themselves. On 2/21/24 at 3:48 PM, surveyor interviewed CNA (#4), asked how often is nailcare provided. CNA #4 confirmed, on their shower days. Who is responsible for making sure nailcare is completed. CNA#4 confirmed, the CNAs are. The surveyor asked what negative outcome can happen if nails are left with brown substance and jagged. CNA#4 confirmed infection or a skin tear. On 2/21/24 at 3:52 PM, surveyor interviewed Director of Nursing (DON), How often is nail care provided. DON confirmed, on the residents scheduled bath day or as needed. Who is responsible for making sure nailcare is completed. DON confirmed, for non- diabetic residents the CAN ' s are and for diabetic residents the licensed nurses are responsible. What negative outcome could occur if nails are left with brown substance and jagged. Infection or they could hang them on something and tear their nail off. Resident #26 had diagnoses of: legal blindness, ABNORMALITIES OF GAIT AND MOBILITY, , HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBROVASCULAR DISEASE AFFECTING RIGHT DOMINANT SIDE. A Quarterly MDS with target date 1-22-24 notes Brief Interview for Mental Status (BIMs) is 15. A Care Plan with a revision on 11-28-23 showed: .Has an alteration in ADL functions due to (d/t) Right (R) hemiparesis & legally blind r/t history/of cerebrovascular disease; poor muscle tone; limited Range of Motion (ROM) to (R) arm and leg; occasional episodes of bowel and bladder incontinence. Offer and assist as indicated with showers or baths (every) shift and prn, reporting to his nurse of any changes in his skin integrity. Staff will file nails and clean as needed and as allowed by resident. Staff will encourage residents to allow staff to help with care when needed. LPN (Licensed Practical Nurse)/RN (Registered Nurse) will trim nails as needed and allowed by resident . On 02/20/24 at 10:19 AM, the surveyor observed Resident #26 ' s nails were jagged and had dark brown substance underneath nails on both hands. Interviewed CNA #3 on 2/21/24 at 3:00 PM; How often is nail care performed? After showers. Who performs nail care? CNAs. What is the negative outcome of having dirty or jagged nails? Infection or could cut themselves. Interviewed CNA #4 on 2/21/24 at 3:45 PM; How often is nail care performed? After showers. Who performs nail care? The CNAs do unless they are diabetic then the nurses do them. What is the negative outcome of having dirty or jagged nails? Infections or skin tears. Interviewed DON on 2/21/24 at 3:52 PM How often is nail care performed? During baths and as needed. Who performs nail care? non-diabetic- CNAs and diabetics-nurses. What is the negative outcome of having dirty or jagged nails? Hanging on something or rip their nails off. Resident # 30 diagnoses showed type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side. The MDS with an ARD of 1/10/24 showed a BIMS of 15 (13 to 15 points indicates cognitive intactness). The resident required supervision or touch assistance with personal hygiene. Physician's Order Summary showed a start date of 6/21/22 to provide diabetic nail care every day shift every Tuesday for nail care. The care plan showed the Resident has an Activities of Daily Living (ADL) self-care performance deficit related to (r/t) generalized weakness and unsteady gait at times. Staff will file nails and clean as needed and as allowed by the resident. LPN/ RN will trim nails as needed and allowed by resident. Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Diabetic nail care to be provided weekly by licensed staff. Review of Progress Notes dated 1/22/24 through 2/22/24 showed no nail care or refusals of nail care from resident. On 02/20/24 at 02:09 PM, the Surveyor observed Resident # 30 fingernails 1/4-inch past the nail bed with dark matter under the nail. On 02/21/24 at 04:21 PM, the Surveyor observed Resident's fingernails with dark matter under the nail which was 1/4 inch past the nail. On 02/22/24 at 11:23 AM, the Surveyor observed Resident's fingernails 1/4-inch past the nail bed with dark matter under the nail. On 02/22/24 at 2:25 PM, the Surveyor asked Resident #30 Do you like your nails the way they are? Resident #30 said no, I would like them to be clean and cut down. On 02/22/24 at 02:27 PM, the Surveyor asked the CNA #7 Who is responsible for trimming and cleaning the resident's fingernails? CNA #7 stated the resident is diabetic and it is up to the nurses. On 02/22/24 at 02:31 PM, the Surveyor asked LPN #5 who is responsible for trimming and cleaning Resident #30 ' s fingernails? LPN #5 said the resident is diabetic, so the nurses are. The Surveyor asked, can you describe the Resident's fingernails? LPN #5 said they are long and dirty underneath. The Surveyor asked, can you show me the Resident's order for diabetic nail care? LPN #5 said they don't have one. The Surveyor asked, Can you show me the order for diabetic nail care? LPN #5 said diabetic nail care every Tuesday on dayshift. The Surveyor asked where do you chart that nail care is complete? LPN #5 s said we don't. On 02/22/24 at 02:37 PM, the DON confirmed the Resident's nails were long and dirty and there is an order for diabetic nail care every Tuesday on dayshift. A document provided by the DON on 2/23/24 at 11:30 a.m. titled, Care of Fingernails/Toenails showed, .review the resident's care plan to assess for any special needs of the resident . On 02/20/2024 at 10:04 AM, surveyor observed Resident #75 in room with 1/4-inch nails on both hands with dark brown substance under jagged nails. On 2/20/2024 at 11:28 AM, surveyor observed Resident (#75) in room. Resident had long 1/4 inch nails on both hands with brown substance under jagged nails on both hands. On 2/21/2024 at 10:04 AM, surveyor observed Resident #75 in room. Resident had long 1/4 inch nails on both hands with brown substance under jagged nails on both hands. On 2/21/24 at 3:48 PM, surveyor interviewed CNA #4, and asked how often is nailcare provided. CNA #4 confirmed, on their shower days. The surveyor asked who is responsible for making sure nailcare is completed. CNA #4 confirmed, the CNAs are. The surveyor asked what negative outcome can happen if nails are left with brown substance and jagged. CNA #4 confirmed. Infection or a skin tear. On 2/21/24 at 3:52 PM, surveyor interviewed DON, how often is nail care provided. DON confirmed, on the residents scheduled bath day or as needed. Who is responsible for making sure nailcare is completed. DON confirmed, for non- diabetic residents the CNAs are and for diabetic residents the licensed nurses are responsible. What negative outcome could occur if nails are left with brown substance and jagged. Infection or they could hang them on something and tear their nail off.

Based on record review, interview, and observation, the facility failed to ensure an accident/hazard free environment was provided for 3 (#8, #45 and #56) residents in the case mix. This failed practice had the potential to affect 3 (#8, #49, #47) sampled ambulatory residents who resided in Unit 8. The facility also failed to ensure the residents were free of potential accidents and hazards, as evidenced by failure to ensure that all the end clips were in place on the Hoyer lift. This failed practice had the potential to affect 2 residents, (#26, and #59), of 2 sampled residents who reside in Cottage 1 and are dependent on a Hoyer Lift to transfer. The findings are: Resident (#8) had Diagnoses: Unspecified dementia, severe, with other behavioral disturbance, Dementia in other diseases classified elsewhere, severe, with agitation. On the Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of December 21, 2023, the resident is identified as (Moderately Impaired) on the Staff Assessment for Mental Status. On 2/20/24 at 12:15 AM, the light fixture in Resident #8 ' s room is noted to be hanging from wires, with a glass globe and exposed wires. This fixture is on the wall directly in front of you as you enter the room. On 2/20/24 at 12:15 AM, the toilet tissue holder in Resident #8 ' s bathroom with the broken bracket protruding out into the room. The towel bar in the bathroom was broken with the broken bracket protruding out into the room. On 02/21/24 11:57 AM, the light fixture in resident #8 ' s room is noted to be hanging from wires, with a glass globe and exposed wires. This fixture is on the wall directly in front of you as you enter the room. On 2/21/24 at 11:57 AM, the toilet tissue holder in Resident #8 ' s bathrooms with the broken bracket protruding out into the room. The towel bar in the bathroom is broken with the broken bracket protruding out into the room. On 2/22/24 at 11:00 AM, the light fixture in Resident #8 ' s room is noted to be hanging from wires, with a glass globe and exposed wires. This fixture is on the wall directly in front of you as you enter the room. On 2/22/24 at 11:00 AM, the toilet tissue holder in Resident #8 ' s bathroom with the broken bracket protruding out into the room. The towel bar in the bathroom is broken with the broken bracket protruding out into the room. On 2/21/24 at @ 11:03 AM, the surveyor observed 2 Certified Nursing Assistants (CNA), #1 and #2, use a Hoyer lift to transfer Resident #26 from the wheelchair to the bed using a Hoyer lift that had a missing clip on the ends on both sides of the lift on opposite ends. a. On 2/21/24 at @11:18 AM, the surveyor interviewed certified nursing assistant, #1, CNA #1 and asked what should you look at on this lift before you use it on a resident. CNA #1 confirmed, you should make sure everything is working properly on the lift and the battery is charged, also make sure the lift pad is in good shape. The Surveyor asked should you use the lift with missing clips? CNA #1 confirmed, said no ma'am you shouldn't. What negative outcome could happen. CNA #1 confirmed, staff or resident could be hurt from it. b. On 2/21/24 @ at 11:23 AM, surveyor interviewed CNA #2, and asked what should you look at on the lift before you begin to use it on a resident? CNA#2 confirmed, make sure it is locked and the battery is charged. Should you use the lift if it has missing clips. CNA #2 confirmed, no, we should not ever use it with missing clips. What negative outcome could occur is you use a lift with clips missing. CNA#2 confirmed, it wouldn't hold the resident correctly and the resident could fall. c. On 2/21/24 @ at 12:52 PM, the Manufactures Guidelines for Hoyer Lift 600 was provided to surveyor by the Administrator . Page 29 . Resident (#45) had diagnoses of Unspecified dementia, unspecified severity, without behavioral disturbance, Psychotic disturbance, Mood disturbance, and Anxiety. The MDS with an ARD of 1/18/24 documented the resident scored a 1 on the Brief Interview for Mental Status (BIMS) which is severe cognitive impairment. 02/20/24 11:46 AM, Surveyor found the following items in Resident #45 ' s bathroom, sitting on his vanity: Zinc Oxide Paste Skin Protectant, with instructions for accidental ingestion, get medical help or contact a Poison Control Center right away. Shave gel with directions to keep away from children. Shave Foam regular, with warning that intentional misuse by deliberately inhaling the contents can be harmful or fatal. Keep away from children. contents . Propane. Full-body wash and Peri-cleanser, with caution may cause eye irritation. Avoid contact with eyes. Keep away from children. Foot repair cream, with caution to keep out of reach of children, avoid contact with eyes. In case of accidental ingestion, get medical help or contact Poison Control. On 02/21/24 at 1:00 AM, items still sitting on vanity in resident #45 ' s bathroom. On 2/21/24 at 9:30 AM, items listed above are still sitting on vanity in resident #45 ' s bathroom. On 2/22/24 at 11:00 AM Items listed above are still in resident #45 ' s bathroom. 4. On 02/20/24 at 10:45 AM, the Surveyor note observed 1 knife with pointed end and 2 pairs of sharp pointed scissors in container on bedside table that belonged to Resident #56. a. On 02/20/24 at 11:14 AM, the Surveyor observed 1 knife with pointed end and two 2 sharp pointed scissors on bedside table of Resident #56. b. On 02/21/24 at 10:00 AM, the Surveyor observed 1 knife with pointed end and two 2 sharp pointed scissors on bedside table of Resident #56. c. On 2/22/24 at 10:50 AM, the surveyor observed 1 knife with pointed end on bedside table of Resident #56. d. Resident #56 had a diagnosis of DEMENTIA, SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY. e. A Quarterly Minimum Data Set (MDS) Target Date: with an ARD OF 01-18-24 notes a Brief Interview for Mental Status (BIMs) is 13. f. A Care Plan with a revision date of 3/01/23 documented, . Has potential for impaired cognitive function or impaired thought processes related to DEMENTIA, SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY. 1. Cue, reorient and supervise as needed. 2. Keep resident routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion . Has depression, mood problem, and PTSD. 1. Administer medications as ordered. Monitor/document for side effects and effectiveness. 2. Monitor/document/report PRN any signs and symptoms of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. On 2/22/24 at 3:19 PM, the Surveyor interviewed the DON. Surveyor interviewed Director of Nursing (DON). The DON was asked where the e-cylinders should be stored. She stated, In the O2 room in the garage. When asked if the supply closet containing razors, zinc and cleaning-cloths should be locked. She stated Yes, so the resident doesn't get one and try to shave themselves or someone else or cut themselves or someone else. When asked if the residents with dementia or Alzheimer's should have shaving cream/gel items in their rooms. The DON stated, Not if it says keep away from children. On 2/23/24 at 10:54 PM, the DON provided the Storage of Medication policy which states The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

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 1 of 1 meal observed. This failed practice had the potential to affect 1 resident who received a puree diet. The findings are: 1. On 02/22/24 12:37 PM, Certified Nursing Assistant (CNA) #11 placed a serving of corn into a blender, added milk and pureed. At 12:42 PM, she poured the pureed corn on a divided plate on the counter. The consistency of the corn was runny, not formed and not smooth. There were pieces of corn skin visible in the mixture. 2. On 02/22/24 at 12:52 PM, CNA #11 deboned servings of fried chicken and placed them into a blender, added gravy and pureed. At 12:56 PM, CNA #11 poured the pureed chicken in a divided plate. The consistency of the purees chicken was gritty and not smooth. There were pieces of chicken visible in the mixture. 3. On 02/22/24 at 01:03 PM, CNA #11 placed one serving of cornbread into a blender, added milk and pureed. At 01:06 PM, she poured the pureed cornbread onto a divided plate. The consistency of the pureed cornbread was gritty and not smooth. 4. On 02/22/24 at 01:33 PM, the Surveyor asked Certified Nursing Assistant (CNA) #11 to describe the consistency of the pureed food items served to the resident on a pureed diet. She stated, Pureed fried chicken was gritty. Pureed beans were lumpy. Pureed corn has skin in it and pureed corn bread was lumpy.

Based on observation and interview, the facility failed to ensure a safe environment for 7 residents (#8, #11, 30, #32, #45, #47, #49) sampled residents living in Units 7&8. The findings are: 1) On 02/22/24 11:51 AM, the Surveyor surveyed cottages 7 and 8: a) Cottage 7 laundry room - chemical cabinet unlocked: a large amount of lint buildup was behind dryer, the lint pipe was not connected, releasing lint into the area behind the washer and dryer. Dirt, large white items, and a purple cigarette lighter were behind the washer, which sits beside the dryer. b) Cottage 8 laundry room - A significant amount of lint build-up was found on the floor and up the wall behind the dryer and washer. A camouflaged 912 bag was hanging over the back of the dryer. A magnifying screen was lying on the dryer. A broomlike handle, dirty mop head, brown cloth, brown stick were found behind the washer and dryer. 2) On 2/20/24 11:46 AM, Cottage 8 - Storage area unlocked with an e-cylinder sitting in just inside the doorway of the room with boxes, walkers, IV (intravenous) poles, accessible to all residents. 3) On 2/21/24 12:15 AM, Cottage 8 - Storage area unlocked with e-cylinder sitting in just inside the doorway of the room with boxes, IV poles, accessible to all residents. 4) On 02/22/24 11:00 AM, Surveyor asked CNA #7 who cleans behind the washer and dryer, CNA #7 stated, The night shift. The surveyor asked CNA #7 why it is important to keep that area clean. CNA #7 stated, To keep it from starting a fire. 5) On 2/23/24 at 2:00 PM, the Surveyor interviewed the Administrator. The Surveyor asked who should clean behind the washer and dryers. The administrator stated, The home staff. The Surveyor asked why is it important to clean behind these. The Administrator stated, To remove the lint and it is a fire hazard. The Surveyor asked how often it was cleaned. The Administrator stated, Weekly, or as needed. 6) On 2/23/24 at 2:46 PM, received a policy from Director of Nursing titled Safety and Supervision of Residents , The policy states that Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview and record review, the facility failed to ensure that 1 Resident #3 in Cottage 1 had a change of condition or a e- interact completed when the resident was sent to the hospital. The findings are: 1. On 2/20/24 at 10:03 AM, surveyor noted a large hematoma to head with staples and dried blood on back of Resident #3's head. The Resident was unable to inform the nurse what happened. 2. On 2/21/24 at 11:28 AM, surveyor noted a large hematoma with staples to back of Resident #3's head. 3. On 2/21/24 at 1:56 PM, surveyor noted while performing record review resident had no change of condition or e-interact form completed only a note that triggered off the incident and accident form that had been done. 4. On 2/21/24 at 3:48 PM, surveyor interviewed Licensed Practical Nurse (LPN)#1, what should be completed when a resident has a change in their health. LPN#1 confirmed, a change of condition form or an e-interact form. Why is it important to fill this form out. LPN#1 confirmed, to let upper management and family know and the patient could get worse and suffer more from complications. 5. On 2/21/24 at 3:58 PM, surveyor interviewed Director of Nursing (DON), what should be completed if a resident has a change in their health, or needs to go to the hospital? The DON confirmed, get an order from doctor, notify the family, and do a nurses note. The surveyor asked what negative outcome can happen if documentation or change of condition form not done. The DON confirmed, lack of communication to the family and the next shift. They need to know what is going on with the resident. 6. On 2/21/24 at 4:54 PM, surveyor asked Administrator for a policy on change of condition and was informed they do not have a policy.

Based on observations, interview and record reviews, the facility failed to accurately complete weekly nursing assessment (body audit) by failing to document redness to the buttock of 1 sampled Resident (#44) of 8 Residents in Homes 5 and 6 who skin audit completed by Licensed Practical Nurse (LPN) #2. This failed practice had the potential to cause further skin breakdown to Resident 44. The Findings are: According to Quarterly Minimum Data Set with Assessment Reference Date of 12/19/23 documented Resident #44 had a Brief Interview of Mental Status of 15 (13-15 cognitively intact) and was frequently incontinent of bowel and bladder. Care plan document that Resident #44 had Activity of Daily Living self-care performance deficit related to Amputation right below knee and required limited assistance with personal hygiene and oral care. On 02/22/24 10:00 AM, Surveyor observed Resident #44 lying on right and Certified Nursing Assistants (CNA) #5 and #6 pulling up the Resident's pants. The Surveyor observed intact redden skin to Resident #44 bilateral buttock cheeks, seam of buttock, and back of both upper thighs. On 02/22/24 at 10:33 AM, the Surveyor asked CNA #5 when the brief was removed from Resident #44 what did you see? CNA #5 stated, Red bottom, look like he had went again he does that sometime. The Surveyor asked CNA #5 how long has Resident #44 had redness to his buttock? CNA #5 stated, Three months it got pretty bad then it got better. The Surveyor asked CNA #5 has the redness ever gone away? CNA #5 stated, no. The Surveyor asked CNA #5 have you reported it to the nurse? CNA #5 stated, oh yeah. On 02/22/24 at 10:55 AM, the Surveyor asked LPN #2 who does Resident #44 skin audit? LPN stated Me. The Surveyor asked LPN #2 has any of the aides reported that Resident #44 had redness to his buttock? LPN stated, Yes but if it's not a wound I just tell them to put cream on them. Surveyor asked LPN #2 to read the definition of stage 1 on the weekly progress notes. The Surveyor asked do you think the redness should have been addressed on the skin assessment? LPN #2 stated Yes ma'am it should have, thank you for bringing that to my attention. On 02/22/24 at 04:26 PM, the Surveyor asked the Director of Nursing (DON) should redden intact skin be addressed on skin assessments? The DON stated, yes. The Surveyor asked the DON, what could be a negative outcome? The DON stated, further skin breakdown. On 02/23/24 at 12:37 PM, a policy was provided to the Surveyor titled Pressure Ulcer Risk Assessment documented Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps define those care approaches. Documentation the following information should be recorded in the resident's medical record: 6. The condition of the resident's skin (i.e., the size and location of any red or tender areas).

Based on observations, interviews, and record review the facility failed to ensure that 1 sampled (Resident #44) of 5 Residents receiving incontinence care in Home 6 received proper incontinence care . This failed practice had the potential to cause skin breakdown, poor hygiene, and/or infection. The Findings are: According to Quarterly Minimum Data Set with Assessment Reference Date of 12/19/23 documented Resident 44 had a Brief Interview of Mental Status of 15 (13-15 indicates cognitively intact) and was frequently incontinent of bowel and bladder. Care plan document that Resident 44 had Activity of Daily Living self-care performance deficit related to Amputation right below knee and required limited assistance with personal hygiene and oral care. On 02/22/24 10:00 AM, Surveyor observed Resident 44 lying on right and Certified Nursing Assistants (CNA) #5 and #6 pulling up the Resident's pants. The Surveyor received consent from Resident 44 to see his buttock and requested the 2 CNAs to expose the Resident's buttock. The Surveyor observed stool in the seam of buttock and between left and scrotum. The Surveyor observed CNA #5 wipe remaining stool with right hand and reach to grab a wipe from the pack with right hand until complete. On 02/22/24 at 10:33 AM, the Surveyor asked CNA #5, When I entered Resident 44's room where were you all in the perineal care process? CNA #5 stated, We were finished. The Surveyor asked CNA #5 when the brief was removed what did you see? CNA #5 stated, Red bottom, look like he had went again he does that sometime. The Surveyor asked CNA #5, what about the stool that is between his left leg and scrotum? CNA #5 stated, We did miss that. The Surveyor asked CNA #5 is it standard practice to grab wipes from the pack with dirty gloves? CNA #5 stated No. The Surveyor asked CNA #5, what is standard practice? CNA stated, To reach with the clean hand or change gloves if they have something on them. The Surveyor asked CNA #5, did you use standard practice? CNA #5 stated, No ma'am. On 02/22/24 at 04:26 PM, the Surveyor asked the Director of Nursing (DON) after perineal care is complete should the Resident have stool remaining on the anus and scrotum? The DON stated No. The Surveyor asked the DON, what issue could that cause? The DON stated infection, skin breakdown. On 02/23/24 at 10:55 AM, the Surveyor was provided with a policy titled Perineal Care that documented Purpose: the purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. h. wash and rinse the rectal thoroughly, including the area under the scrotum, the anus, and the buttocks.

Based on observation, interviews and record review, the facility failed to ensure an order for 1 (Resident #56) of 5 sampled residents who had physician orders for nebulizers received medication as ordered, and the facility failed to ensure supervision of nebulizer treatments for 1 ( Resident #56) who had nebulizer treatments and the facility failed to ensure inhaler was put in storage bag when not in use for 1 ( Resident #56) who had physician orders for inhalers. On 02/20/24 at 10:45 AM, Licensed Practical Nurse LPN #6 was standing outside of room [ROOM NUMBER] with door shut. The surveyor entered the room and Resident (#56 had a nebulizer mask on face and nebulizer machine running. After Resident #56 completed nebulizer treatment they took mask off and laid it down on table. Surveyor observed inhaler laying on bedside table. Resident #56 stated I keep that there in case I need it. On 02/21/24 at 11:08 AM, the surveyor asked Resident #56 if an updraft treatment was given this morning. Resident #56 stated no. The surveyor noted inhaler laying on bedside table next to Resident #56. The surveyor asked LPN #6 if updraft had been administered? LPN #6 stated' no. The Surveyor asked to see the Medication Administration Record (MAR). Review of the Medication Administration Record (MAR) showed LPN #6 had initialed that she had administered updraft to resident. The surveyor asked LPN (#6), did you give this updraft, LP N (#6) confirmed No I did not give it. Resident (#56) had a diagnosis of ACUTE RESPIRATORY FAILURE WITH HYPERCAPNIA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION. A Quarterly Quarterly Minimum Data Set (MDS) Target Date: 01-18-24 notes Brief Interview for Mental Status (BIMs) is 13 An February 2024 physician order documented, . Ventolin HFA Aerosol Solution 108 MCG/ACT (Albuterol Sulfate HFA) 2 puff inhale orally every 6 hours as needed for SOB related to OBSTRUCTIVE SLEEP APNEA (WAIT AT LEAST 1 MINUTE BETWEEN PUFFS) .Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 2 puffs every 6 hours for SOB) as ordered. Monitor for effectiveness and side effects .Has CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION . A Care Plan with a revision on 3/01/23 documented, . Has altered respiratory status/difficulty breathing r/t SLEEP APNEA, UNSPECIFIED, CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION. 1.Administer medication/puffers (1.Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML PRN every 6 hours for wheezing, 2. Budesonide-Formoterol Fumarate Aerosol 160-4.5 MCG/ACT 2 puffs BID,3. Tiotropium Bromide Monohydrate Aerosol Solution 2.5 MCG/ACT 2 puffs @ bedtime, 4.Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 2 puffs every 6 hours for SOB) as ordered. Monitor for effectiveness and side effects.Has CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION. 1.Give aerosol or bronchodilators (1 Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML PRN every 6 hours for wheezing, 2. Budesonide-Formoterol Fumarate Aerosol 160-4.5 MCG/ACT 2 puffs BID,3. Tiotropium Bromide Monohydrate Aerosol Solution 2.5 MCG/ACT 2 puffs @ bedtime, 4.Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 2 puffs every 6 hours for SOB) as ordered. On 2/23/24 at 12:17 PM during interview, the surveyor asked LPN# 7 should a resident be left alone to administer a nebulizer? LPN #6 said no. The surveyor asked should a resident have a self-administration assessment to administer their own nebulizer treatments? LPN #6 said no. The surveyor asked are inhalers supposed to be left in a resident's room? LPN #6 said no. 2 On 2/23/24 at 9:47 AM during interview, the surveyor asked the director of Nursing (DON) should a resident be left alone to administer a nebulizer? The DON said no. The surveyor asked should a resident have a self-administration assessment to administer their own medication? The DON said they should have an assessment done. The surveyor asked can you show me if this resident has a self-administration assessment? The DON said no he doesn't. The survey asked should inhalers be left at bedside? The DON said no. .

Based on interview, and record review, the facility failed to ensure resident safety by failing to initiate and implement measures to prevent elopement after at risk behaviors were identified for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents who were reviewed for elopement risk. The findings are: Resident #1 had a diagnosis of Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/09/23 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and had no recent behaviors or wandering. a. A Comprehensive Plan of Care with a revision date of 12/29/22 documented, .has potential to be verbally and physically aggressive towards staff r/t [related to] Anger, Dementia, poor impulse control . also calls 911 occasionally, stating that the facility was keeping him against his will . The Care Plan did not address/contain interventions and/or problem areas related to elopement. b. A Wandering Risk assessment dated [DATE] indicated Resident #1 was at moderate risk for wandering with no known history of wandering. c. A Provider Progress Note by the Advanced Practice Registered Nurse (APRN) dated 05/16/23 at 1:03 PM documented, .Note Text: 5/16/23 Veteran reports contacting his attorney today. Reports his attorney will be active attempting to get a hearing while utilizing letters from [local medical facility] and [primary physician] attempting to go home. Veteran indicates he will let [primary physician] or / & I know if we are needed. Emotional support provided and reiterated to follow policies while he is a resident at [Facility]. Veteran agrees to follow policies. 05/15/23 Veteran has reportedly had behavioral disturbances demanding to go home over the weekend. [Name], son has chosen not to allow Veteran to leave [Facility]. Veteran agrees to mental health consult as well as indicates no further outburst while attempting elopement. [Primary Physician], DON [Director of Nursing] and I have met and agree on current treatments. 05/09/23 Veteran reports seeing [Physician] @ [at] [local medical facility] Neuro-Psych. Reports this MD [Medical Doctor] will be writing a letter stating Veteran is safe to go home and encouraged another psychiatric evaluation if need. d. On 06/01/23 at 10:22 AM, Resident #1 stated his son has guardianship over him which he has been trying to revoke and that he has letters from 2 different doctors saying he does not have dementia and he can go home. He reported he left the facility because he wanted to go home and take pictures of damage that has occurred to his house so he can present it to the court. He stated he had asked multiple times to be taken there but no one would take him. He also stated he had asked his son to go back to his home and he [his son] said No. e. On 06/01/23 at 12:36 PM, and at 2:34 PM, the DON stated Resident #1 had a BIMS of 15, but his son has guardianship of him, and he has been trying to go to court to remove his son from guardian. She reported that residents can move freely about the campus if they are not in Home 8. Home 8 is secured for the residents that are at risk of wandering. The DON reported on May 27, 2023, Resident #1 was attending a memorial picnic and activities the facility had on the campus and upon conclusion of the activities, Resident #1 had not returned to his [facility] home. She reported he walked to the [Veterans Home/medical facility] campus, got on a VA [Veterans Administration] bus and was found at a local bus station by local police and was returned to the facility. She stated that since he had letters from [Physician] and [local medical facility], he understood he could go home. The APRN had explained to him that he would have to go to court to get the guardianship removed before he could leave. At 3:55 PM, the DON was asked if any intervention was put in place after Resident #1 was demanding to go home over the weekend prior to 05/15/23, on 05/13-14/23, to prevent him from eloping or trying to leave the facility to go home. She stated that the staff did watch him that night and he did not try to leave the facility. She did not provide any documentation of elopement interventions put in place prior to 05/27/23 after he had left the facility. f. On 06/01/23 at 4:18 PM, the Surveyor asked the Administrator if an intervention was put in place to prevent the resident from leaving the facility after he had verbalized on 05/13/23 that he was going home. The Administrator stated, We just explained to him that he couldn't leave because of the guardianship. He was fine after that. He didn't mention it again. g. On 06/01/23 at 4:23 PM, Registered Nurse (RN) Supervisor who was on duty the weekend of 05/13/23 and 05/27/23 stated on 05/13/23 Resident #1 had stated he was going to leave the facility to go home since he had letters from a doctor. He was upset after she told him he could not just leave the facility. The RN Supervisor stated she had staff watch him to make sure he was ok and did not leave. The Surveyor asked if any interventions were put in place to prevent him from leaving the facility. The RN Supervisor stated they had watched him for a couple of hours, after that he was ok and didn't try to leave, so they stopped watching. On 05/27/23, the RN Supervisor reported Resident #1 had attended the Memorial Day activities, and after all the residents had gone back to their homes, it was discovered that Resident #1 was not in his home. The staff looked around the VA campus for him, while she notified his son and administration. h. A facility policy titled, Wandering, Unsafe Resident, provided by the Administrator on 06/01/23 at 4:04 PM documented, Policy Statement The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Policy Interpretation and Implementation . 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) . 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included .

Complaint # (AR 780) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure a resident with a history of a recent elopement attempt was provided with adequate supervision during a period of exit-seeking and / or verbalizing the desire to leave the facility to prevent elopement for 1 (Resident #1) of 2 (Residents #1 and #2) case mix residents who were at risk for elopement. This failed practice resulted in past non-compliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #1, who eloped from the facility and was found near the campus exit gate, and had the potential to cause more than minimal harm to 11 residents who were at risk for elopement, as documented on a list provided by the Interim Administrator on 11/6/19 at 5:28 p.m. The Interim Administrator was informed of the past Immediate Jeopardy situation on 11/6/19 at 4:49 p.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An Admission Minimum Data Set with an Assessment Reference date of 10/18/2019 documented the resident scored 6 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required supervision with setup help only for bed mobility, supervision with setup help only for transfers, walking in room and in corridor, locomotion on unit and off the unit, dressing, eating, toilet use and personal hygiene, was independent for bathing with setup help only, was always continent of bowel and bladder and exhibited wandering behavior which occurred on 1 to 3 of the past 7 days. a. A Wandering Risk assessment dated [DATE] documented, .Category: Low Risk for Wandering . Score: 4.0. b. An Arkansas Department of Health and Human Services Division of Medical Services (DMS) Office of Long Term Care form DMS 762 dated 10/12/2019 documented, .Complete description of Incident . (Resident #1) was admitted on [DATE]. He slept all night and awakened confused at 4:30 a.m. He walked out on the porch with a Universal Worker. The staff could not get him to return inside. He stated he needed to go home. The charge nurse and RN (Registered Nurse) supervisor walked with him up the sidewalk towards (Name) hospital. He refused to return to the home, he refused to get into the RN supervisor's truck, when the RN supervisor got out to open the door for the veteran to try to get him into the truck the Veteran ran into the tall weeds next to the Community Center. He tried to hide in those weeds until the NLR PD (North Little Rock Police Department) came and assisted. (Resident #1) stated to the PD that he was just going home, and these people came out of the woodwork and were chasing him. (Resident #1) was sent to (Name of hospital) via ambulance and checked out in the emergency room . He had no injuries or trauma and returned to the facility where he was immediately placed into Hero Home #8 which has keypad locks and wanderguard system for our Veterans to be secure who attempt exit seeking. He had no injuries upon body assessment and seems calm and happy at this time . Findings and Actions Taken .The police were notified and assisted staff to get (Resident #1) to get into the vehicle. Administrator, DON (Director of Nursing), Physician and family were notified. All staff interviewed with no one who worked with him during his first 24 hours identified any indication he would try to exit his home. Veterans in HH 1(Hero Home #1) were interviewed and none had even had time to meet (Resident #)1 before he left and was moved. Body audit was completed when Veteran returned from the ER and he had no injuries. Conclusion: Since the Veteran was attended by staff the entire incident and no harm was done - he was only confused and 'going home' to the hospital campus which adjoins our campus. He did not give any indication verbally or in his admission elopement assessment that he would try to leave. He was examined by a physician for injuries then immediately placed into a safe environment upon return, we do not feel any neglect occurred. The veteran's medical condition remains the same as before the incident. Only his location on campus has changed . c. A Care Plan dated 10/13/19 documented, .(Resident #1) is an elopement risk/wanderer r/t (related to) history of wandering and exit seeking and confusion . Document wandering behavior and attempted diversional interventions in behavior section . Identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? . Monitor for fatigue and weight loss . Provide structured activities; toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes . d. A Wandering Risk assessment dated [DATE] documented, . Category: High Risk for Wandering . Score: 11.0 . e. A physician's orders [REDACTED].Transfer out to hospital for Geri-psych evaluation . f. A Wandering Risk assessment dated [DATE] documented, . Category: High Risk for Wandering . Score: 12.0. g. An Incident: Elopement Note dated 10/31/2019 at 15:30 (3:30 p.m.) documented, . RN Supervisor was notified by Float LPN (Licensed Practical Nurse) from Dayshift that she picked up Veteran up from walking outside. The LPN said that he got in her car with no resistance and she was able to bring back inside the home with no incident. I notified Administrator and Administrator notified DON (Director of Nursing) and APN (Advanced Practice Nurse) about the incident. Order was given to send out to the LR (Little Rock)-VA to be admitted through the ER (emergency room ) to the Geri-Psych Unit for evaluation. Resident returned eval (evaluation) no med changes, one on one, staff education on redirecting if exit seeking. Pendant working no issues .11/1/2019 - Resident out to (hospital) . 11/1/2019 - Resident out of facility at hospital . 11/1/2019 - Veteran assessed in room with family. No sign or symptoms of distress noted. Veterans pendant on patient. Will continue to monitor and follow P[NAME] (Plan of Care) . 2100 (9:00 p.m.) Veteran in room sitting up in recliner watching TV voiced no c/o (complaints) and has no pain or discomfort at this time, UW (Universal Worker) present for 1:1 monitoring, will continue monitoring Q (every) shift PRN (as needed) . 11/2/2019 - Veteran observed lying in bed, eyes closed, no signs or symptoms of pain or distress. Will continue to monitor . 11/2/2019 - Lying on Lt (left) side in bed resting with eyes closed, 1:1 sitter at side of bed . 11/3/2019 - Sitting in chair in living room with UW at side . 11/4/2019 0230 (2:30 a.m.) Resident resting in bed with eyes closed, respiration regular and unlabored, no s/s (signs/symptoms) pain/discomfort/distress noted. 1:1 sitter in room, will continue P[NAME] and monitoring . h. A Communication with Family / NOK (Next of Kin) / POA (Power of Attorney) Note dated 10/31/2019 at 16:50 (4:50 p.m.) documented, .Note Text: . P[NAME] (Point of Care) for Veteran was contacted by this RN Supervisor that due to veteran eloping from facility on this campus, While veteran never left the actual campus, due to safety concerns there was an order given to have him transported to the (Hospital) ER, and to have an admission to the Geri-psych unit for evaluation . i. A Health Status Note dated 10/31/2019 at 17:11 (5:11 p.m.) documented, .Note Text: Resident wandered from lock facility and was discovered by another worker from another home report given to this nurse by RN House (Supervisor #1). This contact (Hospital) ER for report to admit to Geripysch for intervention due to second attempt by resident reported of living home. This nurse spoke with RN (Charge #2) report given also informed that resident was not allowed to return per Administrator due to resident continued attempts of leaving building. MEM (Metropolitan Emergency Medical Services) ambulance service notified for transfer. House Supervisor informed she notified family . j. A Discharge Summary dated 10/31/2019 at 17:55 (5:55 p.m.) documented, .Note Text: Patient left facility via stretcher accompanied by EMS for transfer to hospital for a mental evaluation. patient talking and in good spirits . k. An Incident Note dated 10/31/2019 at 19:01 (7:01 p.m.) documented, .Note Text: RN Supervisor was notified by Float LPN from Dayshift that she picked up Veteran up from walking outside. The LPN said that he got in her car with no resistance and she was able to bring him back inside the home with no incident. I notified Administrator and administrator notified DON, and APN about the incident. Order was given to send out to the (Hospital) to be admitted through the ER to the Geri-Psych Unit for evaluation. Veteran was assessed by Float LPN on Evening shift with body audit complete with no injuries or distress or pain noted prior to being picked up by MEMS at 71:42 for transport to (Name) Hospital for admission to Geri-Psych unit. Report was called in to (Hospital) ER by Staff LPN in home . l. A DMS form 762 dated 11/01/19 for Resident #1 documented, .On 10/31/19 a Universal Worker (UW) who had never worked Hero Home 8 before opened the door to go into the home. (Resident #1) walked out of the home. The Universal Worker did not know he lived there. He is ambulatory very steady and fast, he doesn't look his chronological age. (Resident #1) was picked up by an LPN (Licensed Practical Nurse) outside walking on the sidewalk. He got into her car with no resistance and was returned to his home without incident. He was very confused and did not know where he was going per the LPN. He ate cookies and drank punch with the LPN until an ambulance arrived to transport him to (Hospital Name) for a psych admission/medication review. A body audit was completed, and ambulance was called . Findings and Actions Taken . A body audit was completed with no injuries. Administrator, DON, family, police, and APN (Advanced Practice Nurse) were notified. Witness statements were obtained from those in the home which indicated at times this veteran will speak of leaving and is confused and doesn't know where he is often. Veteran was transported to (name of hospital) hospital for psych admission/medication review. The VA ED (emergency department) attempted to return the Veteran without any assessment or treatment but the nurse in Hero Home 8 refused to take the Veteran until he had been evaluated and medications reviewed, and we had staff present and assigned one on one supervision. Veteran was placed on one on one supervision immediately upon return on 11/1/19 until placement in a more secure facility can be obtained. Family has been notified that under the circumstance of this being cottages, and (Resident #1) exit seeking behavior plus his ability to move independently and quickly will likely make it impossible for us to keep him safe. The hospital documents 'he was evaluated by psych no changes to his medication' is at risk for repeating this again. (Resident #1) will continue to have one on one supervision indefinitely until a physically safer placement can be obtained. In conclusion neglect was not confirmed - appropriate placement is questioned. Veterans current medical condition remains the same. 1.) An OLTC (Office of Long Term Care) witness statement dated 10/31/19 at 3:00 p.m. and signed by LPN #1, documented, .Just got off, was in my car headed to the back gate, I saw resident walking down the sidewalk just past the yield sign headed towards the gated entry. I pulled over and talked with him. I put him in my car and drove him back around to home 8. When I walked up to walkway, (UW #1) was coming out the door, she stood in the doorway talking to the other (UW), I had to excuse myself for people to move out of the doorway so I could bring him in. An agency (UW) stated she had opened the door and he stepped out. Activity Director came in with cookies, I took the resident to the dining area and gave him punch and cookies and talked with him for a few minutes. Then I left . 2.) An OLTC witness statement dated 10/31/19 at 4:54 p.m. and signed by Certified Nurse Assistant (CNA) #2, documented, .I was walking in at shift change and when I opened the door he walked out. I don't know the residents in this home and wasn't aware that he was a resident when he walked out of the building . 3.) An OLTC Witness Statement dated 11/1/19 at 2:45 p.m. and signed by UW #3, documented, .It was 2:50 p.m., the 6:30-2:30 nurse drove up with (Resident #1) in the car. I asked the nurse where he was? She stated she said he was walking in the community. I couldn't figure out how he got out. The agency worker said he walked out as she was walking in. She said she didn't know he wasn't supposed to leave, he had been asking for his niece and trying to get out. I told him the doors were locked and he couldn't get out. He had settled down at that time . 4.) An OLTC Witness Statement dated 11/1/19 and signed by UW #1 documented, . When I left home 8 to go to HR (human resources), the Vet (Veteran) (Resident #)1 was sitting at back table and (UW #3) was also sitting on the other side of table . m. Care Plan revisions dated 10/31/19 documented, .sent to ER (emergency room ) for evaluation. admitted to (Hospital) for observation. 11/1/19 Return 1:1 supervision . (Resident #1) to reside in secured home with wander alarm/pendent to alert staff of elopement attempts . (Resident #1) triggers for wandering/eloping are wanting to go home and drive truck. (Resident #1) behaviors is de-escalated by redirection and distraction . n. A Social Worker History dated 11/1/2019 documented, .Comments: Resident was congenial and cooperative. He was somewhat apprehensive regarding the assessment/history process and asked several questions. He was disoriented to time & (and) place. Stepdaughter was present and was preparing to assist resident with ADL (activities of daily living). She provided known social history but did not know about resident's childhood. Resident does not appear to comprehend purpose or plan regarding admission to (Nursing Home). He has reportedly fled from the home twice with no clear destination or reason in mind. BIMS score is 6 . n. A hospital Brief Course of Stay Note dated 11/1/19 documented, .Earlier today veteran was referred from (facility) for evaluation for wandering, and after evaluated by ED (Emergency Department) physician and Emergency Psychiatrist consult . Patient was admitted overnight and was evaluated by psychiatry whom made no changes to his medication regimen as he appears to be at baseline status. Patient denies any complaints today and appears to be doing well. Social worker was able to contact the nursing home and arrange for his transport back and safety needs to be taken lot more seriously as the patient is at risk for repeating this again . o. A Health Status Note dated 11/1/2019 at 1:30 p.m. documented, .Note Text: Resident returned from (Hospital Name) hospital, Resident was evaluated by Psychiatry who made no changes to his medication regimen reported he appears to be at baseline status. Stepdaughter aware of resident's return, resident will remain on one on one supervision while he is in the home, staff will monitor and engage in activity and redirect if there is any exit seeking behavior . p. A Provider Progress Note dated 11/4/2019 at 3:49 p.m. documented, .Note Text: Vet seen today for follow-up on mood and behavior. Sent to ED last week following incident where he exited secured unit. No changes were made by psych and vet has been on one on one monitoring since that time. Vet currently sitting at dining table with UW at side. He is profoundly confused. Unable to tell me where he is or how he got here. He keeps telling me he wants to go back home, which is (City). He has poor understanding of his ability to manage his own care independently and keeps telling me, 'I'm not sick, I just need to get home.' Vet is calm and cooperative during exam. Staff report he has been eating well and no overt behavior noted. Will continue to monitor . q. A Provider Progress Note dated 11/5/2019 at 3:47 p.m. documented, .Note Text: Vet seen today for evaluation of mood and behavior. Remains on 1-1 monitoring due to exit seeking behavior . r. A Health Status Note dated 11/5/2019 at (8:28 p.m.) documented, .Note Text: Resident continues on one on one. No behaviors reported or observed this shift. Resident displayed pleasant affect and mood each time nurse interacted with him . s. On 11/5/19 at 11:22 a.m., the resident was sitting at a dining room table playing dominoes with Universal Worker (UW) #8 at his side. The staff member was asked about the pendant the resident was wearing and she turned the pendant on. The light outside of the resident's room lit up and the pager of an employee standing by the kitchen sounded and displayed the resident's name. UW #9 stated when a resident turns his pendant on, it turns on the light above the resident's door, and her pager will also beep and light up with the resident's name. If a resident approaches an exit door, the alarm will also sound from the resident's pendant. t. On 11/6/19 at 8:37 a.m., the resident was sitting at a dining room table drinking a cup of coffee with a staff member (not identified) sitting next to him. u. On 11/6/19 at 10:53 a.m., the resident was seated in the living room watching TV. The pendant was around the resident neck, and UW #4 was sitting with the resident. v. On 11/6/19 at 8:32 a.m., LPN #2 was asked how the pendent necklaces alerted staff and stated when a resident pushes his pendent necklace, the light outside of the room comes on and sounds to the CNA's pager with the resident's name and room number. Two minutes later it will go the LPN's pager and two minutes after that it will go to the RN supervisor's pager. She further stated if a resident gets close to an exit door or window in Cottage 8, all pagers will sound. She stated this only applied for Cottage 8, where residents at risk for elopement resided. She stated the residents' pendants were checked every morning to make sure they were functioning. w. On 11/6/19 at 1:29 p.m., UW #3 was asked about the incident with (Resident #1) in Home 8 and stated, I work in Home 1 right now. I started Home 1 this week I worked Home 8 prior to this. I am familiar with Resident #1. I was working on the day of the incident with the resident. I stayed late that day. Two employees stayed late. The girl that was working with me had to go over to Human Resources to do some paperwork. This left me alone in the Home. This was approximately at around 2:45 p.m. to 3:05 p.m. In home 8 the call lights are constantly going off. Residents can just be walking around, and the alarms go off. I was walking around trying to make the call lights go off, I was checking on residents. I used my magnet to deactivate the pendants on residents that did not need help. As I was doing this, a girl from an Agency came in at around 3:00 p.m. She came to the kitchen counter and asked who it was. I looked at my pager and told her the name on my pager who was walking around the hallways. It was not (Resident #1). A couple of minutes later the nurse drove up and had (Resident #1) in her car, I thought to myself 'how'd he get out?' The agency girl said he walked out when she walked in. She said, 'I asked you who it was'. The way she was talking she had never worked in that building before . I did not know that (Resident #1) had left the building. I had seen (Resident #1) just a few minutes, maybe ten minutes, before the agency girl came. I had seen (Resident #1) at the door. He was pushing on the door. I approached the resident; he said he was looking for his niece. I told him that we could not go outside, the doors are locked. I assisted the resident away from the door and he sat at the table. When I asked the nurse where she found him, she told me that he was close to the gate trying to get out . In Home 8, I would say all residents are at risk for elopement. (Resident #1) has been on one on one since the incident. Usually the agency girls come to relieve us when we have someone that does not show . Since the incident we check the pendants every day to make sure that they are all working properly. We also check the doors and pagers. x. On 11/6/19 at 1:54 p.m., UW #6 was asked about the incident with (Resident #1) in Home 8 and, who stated, I work all over the place. I am working in Home 4 today. I have worked in Home 8. I had worked on the day that (Resident #1) was found outside. I had gotten sick and had gone home earlier that morning. I was not here at the time of the incident. I have worked in Home 8 since the incident. The resident is now on one/one supervision. We have had an in-service, anyone in Home 8 is not to go outside unless someone is with them. We have been checking the resident's pendants, now we check them three times a day. Every resident in Home 8 we must keep eyes on due to residents being at risk for elopement. Home 8 is a lock down unit this indicates that residents are at risk for elopement . y. On 11/6/19 at 3:15 p.m., UW #7 was asked about a sign on the door to Cottage #8 which documented, Please be aware of secured unit. Do not allow any residents to leave unattended. Please check with staff immediately. The UW stated the sign was placed there, about a week ago. z. On 11/6/19 at 3:28 p.m., LPN #1 was asked about the 10/31/19 incident with (Resident #1) and stated, On the day of the incident with (Resident #1), I had just gotten off my shift, approximately a little bit after 3:00 p.m. I had worked Homes 7 and 8 that day. I had gotten in my vehicle. I came to turn left and leave out of the non-gated entrance. Just across from the main office, the stop signs right by the main office, I had come to the stop sign to turn left. I saw the resident walking on the sidewalk past the stop sign. I saw the resident and turned around in the parking lot, turned to the right and pulled up to the resident. I asked the resident where he was going. He said hello. I had worked with the resident all day. He told me that he was going to find his daughter. I got out of the car, approached the resident and said to the resident, let me take you home. The resident got into the car, I drove him around the campus and then to Home 8. We came back around, I opened the car door and walked with the resident to the front door. He asked what this was. Before I left that day, the resident was sitting at the dining table. When we arrived at the door of Home 8, a UW came to the doorway to assist me. I took the resident inside. I took the resident to the dining room area and got the resident some punch and sat and talked to resident for a while. The activity director came in with cookies and I gave one to the resident. One of the UW said to me that it may have been her fault because she had let the resident out of the door. She stated that she did not know the resident lived there. I notified the RN supervisor. I sat in my car texting for 8-10 minutes before I drove to leave the campus and when I saw the resident . aa. On 11/6/19 at 3:51 p.m., the Interim Administrator was asked if agency staff had been trained regarding Home #8 being a secure unit and stated, We have contracted agency staff that are on the schedule and they receive the same training as every other employee. We also have Per Diem agency staff and it would be impossible to train them. We do not know who is coming. The agency will put out a needs call and whomever responds is who works to fill the spot of someone that has not shown for work. It is the responsibility of the agency to train the Per Diem staff. The Per Diem CNA that worked on the evening of the incident has not worked since that time. At 4:10 p.m., the Interim Administrator was asked if any per diem staff still worked in Home 8 and stated, There have been no Per Diem staff that have worked in Home 8 since the incident with (Resident #1); this is part of the intervention to prevent reoccurrence of the incident. aa. On 11/6/19 at 4:08 p.m., the Maintenance Coordinator was asked about the monitoring of the locks and alarms for Hero Home #8 and stated, .I check Home 8 and all the other homes. Home 8 has a wander vision system, with locks and a punch code. We check weekly, the doors to make sure the locking mechanism is working, the key pads for functionality, and do spot checks on the pendants. I have a team viewer system on the computer, it allows me to access the computers everywhere. There is a computer in each home; it constantly sends out a test signal to check pendants, doors, everything connected to the system. It tests itself and reports any faults, I then check to see if there are any faults. As soon as I heard about the elopement, I went to check resident's pendant to make sure it was working properly. I have been asked since the incident to go check the system in Home 8, which I did and there were no problems. bb. On 11/6/19 at 5:08 p.m., the Interim Administrator stated, .When the resident returned from the hospital, he was placed on one/one supervision and has been ever since. We immediately started education with all staff to include not opening door and letting anyone out of that home, checking of pendants. No agency staff work now in Home 8. A sign was placed on the door to alert everyone that the home is secured. We have started conversations with the resident's daughter about placing the resident in a secure unit within a building. cc. The facility removed the immediate jeopardy and corrected the failed practice on 10/31/19 when the resident was sent to the hospital and subsequently placed on 1:1 supervision, and the following additional corrective actions were implemented: 1.) An Inservice dated 10/31/19 documented, . ABUSE NEGLECT and MISAPPROPRIATION OF RESIDENT PROPERTY. All residents have the right to be free from all types of abuse this includes verbal, physical, and mental abuse as well as corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Neglect is failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Any allegation of mistreatment of [REDACTED]. Any employee who suspect and alleged violation must immediately notify the Administrator/Director of Nursing/RN on duty . 2.) An In-Service dated 11/1/19 documented, .Do not let any resident out of Home 8 without approval . 3.) An In-Service dated 11/1/19 documented, .Elopement procedure: Staff is to immediately respond to door alarms. Go to door and assess situation. If a resident is trying to open the door or is too close, move the veteran to a safe location. If there is no Veteran in the immediate area, survey the area outside. Immediately do a head count inside the home. If a veteran is missing, determine the resident is on leave or pass. If not authorized to leave announce CODE ORANGE and initiate a search immediately . Notify the DON and Administrator immediately . See Elopement Policy and Procedure attached . 4.) An In-Service dated 11/1/19 documented, .Attention Staff: (Resident #1): Resident is to be 1:1 at all times. Resident is to be in hands reach at all times Resident will be 1:1 until further notice due to exit seeking. Monitoring sheets needs to be completed Q (every) shift with your initial. Any issues with respect notify charge nurse immediately . 5.) There is a sign posted on the door of Home 8 that reads . Please be aware of secured unit. Do not allow any residents to leave unattended. Please check with staff immediately. 6.) Throughout the complaint investigation survey, the resident was accompanied and being supervised 1:1 during all observations.

Complaint # (AR 467) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure residents were free of abuse, as evidenced by Certified Nursing Assistant (CNA) #2 who allegedly raised her voice and argued with 1 of 1 (Resident #7 case mix resident who was the alleged victim of verbal abuse. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #7 who was allegedly verbally abused by CNA #2, and had the potential to cause more than minimal harm to 11 residents who resided in Home 4, and received care from CNA #2 as documented on a list provided by the Administrator on 1/17/19. The Administrator was notified of Immediate Jeopardy condition on 1/15/19 at 4:20 p.m. The findings are: 1. Resident #7 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 11/2/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, had the ability to make self understood and had the ability to understand others, exhibited no physical or verbal behaviors directed toward others, and required supervision and set up help only with bed mobility and eating, required supervision only with transfer, dressing, toilet use, and personal hygiene, had functional limitation in range of motion of one side in lower extremity, and required a walker for mobility. a. The Plan of Care with a revised date of 11/8/18 documented, .(Resident #7) has an alteration in his behavioral function AEB (As evidenced by) yelling at staff in a threatening manner, using racial slurs . speaking in very loud tone, cursing at staff . Assist him to develop more appropriate methods of coping and interacting with his nurse and UW's (Universal Workers (Certified Nursing Assistants)) . His behavioral episode was triggered by his c/o (complaint of) pain and lack of understanding of his medications and their actions. His behavior is de-escalated by alleviating his pain and anxiety . Use a calm approach when explaining medications to him . Walk away and re-approach in an appropriate amount of time, ensuring his and other's safety . b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term care Facilities Office of Long Term Care (OLTC), Division of Medical Services (DMS) form 762 dated 10/2/18, page 2 of 9 documented, .Facility Staff Member Completing DMS-762 . Administrator #1 .Title . Administrator . Date Incident Reported to OLTC . 10/2/18 . Time . 10:55 a.m. Date and Time of Incident (if known) . 9/20/18 . Time . 23:15 (11:15) p.m. Date and Time of Discovery . 10/1/18 . Time . 15:00 (3:00) p.m. Type of Incident . Verbal (checked) . Emotional / Mental (checked) . Name of Involved Resident . (Resident #7) . Physical Functional Level / Impairment . Mobile with limited assistance . Mental Functional Level . BIMS 14 (a score of 13-15 indicates cognitively intact) . Primary [DIAGNOSES REDACTED]. (page 3) .On [DATE]st (10/1/18) at or around 3:30 (p.m.) UW (Universadl Worker (CNA)) #1 reported to DON (Director of Nursing) that the previous night there was a verbal altercation possibly between a fell ow (CNA #2) and male veteran (Resident #7) at the beginning of the night shift. (CNA #1) reported that the tension was very high between (Resident #7) and (CNA #2). It was reported that (Resident #7) and (CNA #2) were communicating in a very loud manner back and forth about (CNA #2) discharge status in the Army, and at one point had to be separated by the Nurse (Licensed Practical Nurse (LPN #1)). It was reported by (CNA #1) that the communication that (CNA #2) was using towards (Resident #7) seemed threatening . Page 4 .(Facility Name ) conducted investigation led by the Administrator starting on [DATE]nd (YEAR) (10/2/18). Upon interview of (Resident #7), stated verbally to the Administrator that he felt (CNA #2) wanted to fight him and at one point (CNA #2) had her fist raised upwards to indicate she was serious that he not ever ask her about her Military Service again. Upon interviewing the fell ow UW (CNA) worker in the house and the Nurse (LPN #1) in the house at the time, there is no proof that (CNA #2) raised her fist at (Resident #7). All evidence according to witness of (LPN #1) indicates there was a verbal altercation between (Resident #7) and (CNA #2) with the LPN (#1) having to get between the two of them to separate them. The LPN (#1) stated in her opinion that (CNA #2) was verbally abusive to (Resident #7) . Based on the evidence obtained during the investigation, (Facility Name) substantiates the allegation of Verbal and or Mental abuse by (CNA #2) towards (Resident #7) . (CNA #2) has not been allowed to work since the incident . In-service given on Abuse and Neglect on Oct. 3, (YEAR) (10/3/18) . All residents were interviewed with no other reports of verbal abuse . (signed by (Administrator #1) . Date .10/5/18) . c. A facility email dated Monday, 10/1/18 at 7:40 p.m., sent by the Deputy Director to the Assistant Director for Veteran Services, and provided by the Administrator on 1/15/19, documented, .Per our conversation earlier today about the incident at the (Facility Name), I would like you to perform a disciplinary investigation in accordance with ADVA 2-1 (Facility Policy). This is a separate investigation from the OLTC (Office of Long Term Care) Investigation being conducted by (Administrator #1) . d. The investigation conducted by the Assistant Director for Veteran Services documented, .1. On (MONTH) 1, (YEAR) I was asked to look into an alleged altercation between a Universal Worker (Certified Nursing Assistant) and a resident at the (Facility). I was provided statements from all parties and a witness list. Arrangements were made for me to speak to all parties on (MONTH) 3rd, 4th and 5th (10/3/18, 10/4/18, 10/5/18) . 2. During the investigation I spoke with (CNA #2), the accused Universal Worker (Certified Nursing Assistant), (LPN #1), UW (CNA) #1 and witness, (RN Supervisor) and (Resident #7) . 3. The first person that I spoke with was (LPN #1), Supervisor on (MONTH) 3, (YEAR). She provided a written statement that is attached. During our interview (recorded interview is attached) as we were going through the incident again and making clarifications, I asked (LPN #1) if when (CNA #2) raised her voice to (Resident #7), if in her professional opinion it rose the level of verbal abuse or was she simply trying to speak in a manner to be heard over his 'yelling'. (LPN #1) said that (CNA #2) and (Resident #7) were not speaking or yelling simultaneously to each other, so she was not trying to speak over (Resident #7). In her professional opinion when (CNA #2) raised her voice to (Resident #7) it did rise to the level of verbal abuse . 4. The second person I spoke to was (CNA #2), the accused UW (CNA)} on (MONTH) 3, (YEAR). She provided a written statement that is attached. During our interview (recorded interview is attached), she described her account of the incident . (CNA #2) states she never raised her voice to (Resident #7) or spoke to him after that point . (CNA #2) says that she did not raise her voice or make a gesture towards (Resident #7) . 5. The third person I spoke with was (CNA #1) and witness on (MONTH) 3, (YEAR). She provided a written statement that is attached. During our interview (recorded interview is attached) (CNA #1) stated .as she was walking to (Resident #7's) room, she saw (CNA #2) walk into (Resident #7's) room and she could hear him yell that he did not want (CNA #2) in his room and to send (CNA #1). (CNA #2) then left the room as (CNA #1) entered and (CNA #2) continued to 'talk' as she was leaving the room. (Resident #7) told (CNA #1) that his neck and shoulder were hurting so she proceeded to massage his neck and shoulder. They could hear (CNA #2) talking out in the hallway . directly across from (Resident #7's) room . (LPN #1) asked (CNA #1) to step out of his room . (CNA #1) said that (CNA #2) kept going 'to go off' She (CNA #1) went to care for another resident . (CNA #1) continued to hear loud talking, and when she came back around the corner and (LPN #1) was at the Nurse's Station and (CNA #2) was in (Resident #7's) with the door closed. (CNA #1) could hear them talking loudly but could not make out the conversation . About that time (LPN #1) was getting up to go back into (Resident #7's) room, (CNA #2) walked out and both (Resident #7) and (CNA #2) continued to talk loudly toward each other and (Resident #7) started heading toward the smoking area. I asked if the reason that (CNA #2) went back into the room could have been to answer a call light, and she said 'no, there was not a call light on and there was no reason for her to go back into his room'. As (Resident #7) was walking toward the Smoking Area, (CNA #2) started following him and was continuing to talk to him. (CNA #2) said, 'You keep talking, I'm gonna keep talking' . I asked (CNA #1) if, in her opinion, if (CNA #2) actions rose to the level of verbal abuse, and she said 'yes, it did because she should not have put herself in that situation and the common practice in a nursing home is that if a resident is agitated it is best to walk away and not provoke the situation' . 6. The fourth person I spoke to was (RN Supervisor #1) on (MONTH) 4, (YEAR). He did not have a written statement, but was interviewed and the recorded interview is attached . When (RN (Registered Nurse) Supervisor #1) arrived, (Resident #7) was on the smoking patio, and (LPN #1) stopped him to brief him on what had happened since she had called him. (LPN #1) told him that (Resident #7) was on the smoking patio and that he had made a comment that, 'if (CNA #2) came in there again, he was going to attack her and that (CNA #2) had threatened him'. He stated from what he could tell that was not valid based on other statements. He then approached (Resident #7) on the smoking patio and .he told him that if (CNA #2) was not removed from the home he would strike her. He told him that he could not remove her immediately because there was a process, but that he would have her avoid him . It was 6 a.m. (6:00 a.m.) and everyone was going off shift in less than an hour. He wanted to avoid further contact between (Resident #7) and (CNA #2) and talk to HR (Human Resources) on how to proceed. He said that he had been made aware of tension between (Resident #7) and (CNA #2) and (CNA #1) in the past 3 weeks, so this was a preexisting issue with (Resident #7's) perception of (CNA #2) . (RN Supervisor) told (Resident #7) to relax for the time being and he would ask (LPN #1) and (CNA #2) to avoid him for the next hour so that he could talk to HR. He reported the incident later that morning to HR and told them the situation had escalated and needed to be resolved now. I asked what specific claims (Resident #7) made when he talked to him on the smoking patio, and he said that (CNA #2) came into his room and threatened him . 7. The fifth person I interviewed was (Resident #7), the resident on (MONTH) 5, (YEAR). He did not have a written statement, but was interviewed and the recorded interview is attached. According to him, . (CNA #2) .came in and started talking about something he had said about her Army career two weeks earlier . Then (CNA #2) came in by herself and put her fists up and said that he did not know what she can do to him. He took this as a threat. (Resident #7) stated that she left his room and came back in and just stared at him but did not do anything to help with his pain and just left again . When I asked him if he wanted anyone removed from the home, he said that he wanted (CNA #2) removed . 8. Summary of my findings . a. (CNA #2) should have avoided contact with (Resident #7) once he told her to leave his room . b. When (CNA #2) raised her voice to argue with (Resident #7) it rose to the level of verbal abuse of a resident . e. A Letter of Recommendation regarding Universal Worker (CNA) #2 dated 10/17/19, which accused and later substantiated an allegation of verbal abuse on 9/30/18, and completed by Administrator #1 documented, .Conclusion after Investigation(s) . It is my recommendation that (CNA #2) receive a Class A infraction for Verbal Abuse of a veteran which would result in Termination of her employment as of (MONTH) 17th (YEAR) . f. The Arkansas Department of Veterans Affairs Notice of Disciplinary Action Form dated 10/17/18 and completed by Administrator #1 documented, .Name of Employee . (CNA #2) . Date . (MONTH) 17, (YEAR) . Action Taken . Termination (checked) . Reason for Disciplinary Action . After investigation by (Facility Name), it has been determined that on (MONTH) 30th (9/30/18) you verbally abused a resident which is a Class A infraction (Not signed by Employee or Supervisor) . g. On 1/16/19 at 1:20 p.m., Certified Nursing Assistant (CNA) #2 was asked about the incident with Resident #1. She denied knowledge of ever knowing why she was put on paid Administrative Leave, and eventually was placed on Unpaid Leave for three days. She stated she was allowed to return to work without any disciplinary measures and / or training on abuse / neglect after the 3 days of unpaid leave and without continuous direct supervision. She stated she was not told why she was recently placed on paid Administrative Leave as well. h. The facility Time Ticket for the timeframe of 9/30/18 through 10/30/18 for CNA #2, provided by the Administrator on 1/16/19, documented the following dates / hours worked: .Worked 8.100 hours 9/30/18 (day of incident) . on Administrative Paid Leave from 10/1/18 through 10/20/18 . 3 days (unpaid) suspension from 10/22/18 through 10/24/18 and worked 8 plus hours on 10/26/18 through 10/30/18 . i. On 1/16/19 at 1:25 p.m., the Administrator, Deputy Director, and Director of Nursing were asked about CNA #2's schedule since the incident / investigation. They stated Certified Nursing Assistant #2 had worked all scheduled days since the incident of verbal abuse to Resident #7 on 9/30/18 from 10/30/18 until she was placed on Administrative Leave again for another allegation of abuse on 1/11/19. 2. The Immediate Jeopardy was removed and the scope / severity reduced to H on 1/16/19 at 12:30 p.m., when the facility implemented the following Plan of Removal: .Plan of Removal . Abuse and Neglect a. Effective immediately on 1/15/19, the following items are to be initiated for All facility employees on (Facility Name) roster, new hires and agency contract (direct care) staff. b. Immediately remove any employee with suspected allegations from the schedule to conduct abuse and neglect investigations. (Alleged employee (CNA #2) placed on Administrative Leave 1/11/2019). c. Ensure any resident who has been involved in an abuse / neglect allegation is interviewed, and a body audit is performed by licensed staff. (Body audit and interview conducted on alleged victim Resident #6 on 1/9/19). d. Initial Abuse and Neglect in-service defining the Abuse, Neglect, Misappropriation, and Procedure / Policy for all scheduled employees, any new hires, and any employees returning from leave prior to their next scheduled shift. (Initiated on 1/14/9 upon Administration awareness, to be completed by 1/24/19). e. Administrator's contact information posted by all employee time clocks to report allegations of abuse / neglect immediately as needed. (Completed 1/15/19). f. Obtain witness statements from all employees who were on shift at the time of the alleged abuse or neglect. (Completed on 1/16/19). g. Ensure all residents in the home who have been in direct contact with alleged employee (CNA #2) are interviewed to verify if there are further investigations that should be conducted involving other any other residents. (Initiated on 1/15/19 and completed on 1/17/19). h. All direct care and non-direct care staff, upon arrival to shift starting on 1/15/19, will be re-educated by the Administrator / Designee to ensure the following topics are given: In-service: 'Abuse and Neglect' in-service defining Abuse, Neglect, Misappropriation, and Policy and Procedure. In-service: 'Reporting Abuse & (and) Process - RN Supervisors.' Video In-service: 'Your Legal Duty - Reporting Elder and Dependent Adult Abuse'. i. All residents who have cognitive impairments will have a body audit performed and documented, to ensure there are no residents with unknown injuries. (Initiated on 1/16/19 and to be completed by 1/18/19, and will be done 3 x (times) week on Monday's, Wednesday's and Saturday's for the next month or until substantial compliance is achieved). Any negative findings will be immediately reported to the Administrator /DON / RN Supervisor for further investigation. j. All cognitively intact residents will have an interview conducted by (DON / designees) to determine if there are any reports of abuse and neglect. All resident interviews will be completed by 1/18/18. Any negative findings during interviews will be documented, immediately reviewed for further investigations. These interviews will be conducted until substantial compliance is achieved.

Complaint # (AR 467) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure allegations of abuse were reported to the Administrator, Office of Long Term Care (OLTC) and other state agencies within 2 hours of the alleged abuse to assure an investigation was immediately initiated and protective measures were put in place to prevent further potential abuse for 1 of 1 (Resident #7) case mix resident who was the alleged victim of verbal abuse and 1 of 1 (Resident #6) case mix resident who was an alleged victim of physical abuse. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious, harm, injury, or death to Resident #7, who was allegedly yelled at and threatened and Resident #6 who was allegedly physically abused resulting in bruising to the facial area and had the potential to affect all 11 residents who resided in Home 4 and 10 residents who resided in Home 1, and received care from Certified Nursing Assistant #2, according to the list provided by the Administrator on 1/17/19. The Administrator was notified of the Immediate Jeopardy condition on 1/15/19 at 4:20 p.m. The findings are: 1. Resident #7 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 11/2/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, had the ability to make self understood and had the ability to understand others, exhibited no physical or verbal behaviors directed toward others, and required supervision and set up help only with bed mobility and eating, required supervision only with transfer, dressing, toilet use, and personal hygiene, had functional limitation in range of motion of one side in lower extremity, and required a walker for mobility. a. The Plan of Care with a revised date of 11/8/18 documented, .(Resident #7) has an alteration in his behavioral function AEB (As evidenced by) yelling at staff in a threatening manner, using racial slurs .speaking in very loud tone, cursing at staff .Interventions .Assist him to develop more appropriate methods of coping and interacting with his nurse and UW's (Universal Workers (Certified Nursing Assistants)) . His behavioral episode was triggered by his c/o (complaint of) pain and lack of understanding of his medications and their actions. His behavior is de-escalated by alleviating his pain and anxiety . Use a calm approach when explaining medications to him . Walk away and re-approach in an appropriate amount of time, ensuring his and other's safety . b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term care Facilities Office of Long Term Care (OLTC), Division of Medical Services (DMS) form 762 dated 10/2/18, page 2 of 9 documented, .Facility Staff Member Completing DMS-762 . Administrator #1 .Title . Administrator . Date Incident Reported to OLTC . 10/2/18 . Time . 10:55 a.m. Date and Time of Incident (if known) . 9/20/18 . Time . 23:15 (11:15) p.m. Date and Time of Discovery . 10/1/18 . Time . 15:00 (3:00) p.m. Type of Incident . Verbal (checked) . Emotional / Mental (checked) . Name of Involved Resident . (Resident #7) . Physical Functional Level / Impairment . Mobile with limited assistance . Mental Functional Level . BIMS 14 (a score of 13-15 indicates cognitively intact) . Primary [DIAGNOSES REDACTED]. (page 3) .On [DATE]st (10/1/18) at or around 3:30 (p.m.) UW (Universal Worker (CNA)) #1 reported to DON (Director of Nursing) that the previous night there was a verbal altercation possibly between a fell ow (CNA #2) and male veteran (Resident #7) at the beginning of the night shift. (CNA #1) reported that the tension was very high between (Resident #7) and (CNA #2). It was reported that (Resident #7) and (CNA #2) were communicating in a very loud manner back and forth about (CNA #2) discharge status in the Army, and at one point had to be separated by the Nurse (Licensed Practical Nurse (LPN #1)). It was reported by (CNA #1) that the communication that (CNA #2) was using towards (Resident #7) seemed threatening . Page 4 .(Facility Name ) conducted investigation led by the Administrator starting on [DATE]nd (YEAR) (10/2/18). Upon interview of (Resident #7), stated verbally to the Administrator that he felt (CNA #2) wanted to fight him and at one point (CNA #2) had her fist raised upwards to indicate she was serious that he not ever ask her about her Military Service again. Upon interviewing the fell ow UW (CNA) worker in the house and the Nurse (LPN #1) in the house at the time, there is no proof that (CNA #2) raised her fist at (Resident #7). All evidence according to witness of (LPN #1) indicates there was a verbal altercation between (Resident #7) and (CNA #2) with the LPN (#1) having to get between the two of them to separate them. The LPN (#1) stated in her opinion that (CNA #2) was verbally abusive to (Resident #7) . Based on the evidence obtained during the investigation, (Facility Name) substantiates the allegation of Verbal and or Mental abuse by (CNA #2) towards (Resident #7) . (CNA #2) has not been allowed to work since the incident . In-service given on Abuse and Neglect on Oct. 3, (YEAR) (10/3/18) . All residents were interviewed with no other reports of verbal abuse . (signed by (Administrator #1) . Date .10/5/18) . c. A facility email dated Monday, 10/1/18 at 7:40 p.m., sent by the Deputy Director to the Assistant Director for Veteran Services, and provided by the Administrator on 1/15/19, documented, .Per our conversation earlier today about the incident at the (Facility Name), I would like you to perform a disciplinary investigation in accordance with ADVA 2-1 (Facility Policy). This is a separate investigation from the OLTC (Office of Long Term Care) Investigation being conducted by (Administrator #1) . d. The investigation conducted by the Assistant Director for Veteran Services documented, .1. On (MONTH) 1, (YEAR) I was asked to look into an alleged altercation between a Universal Worker (Certified Nursing Assistant) and a resident at the (Facility). I was provided statements from all parties and a witness list. Arrangements were made for me to speak to all parties on (MONTH) 3rd, 4th and 5th (10/3/18, 10/4/18, 10/5/18) . 2. During the investigation I spoke with (CNA #2), the accused Universal Worker (Certified Nursing Assistant), (LPN #1), UW (CNA) #1 and witness, (RN Supervisor) and (Resident #7) . 3. The first person that I spoke with was (LPN #1), Supervisor on (MONTH) 3, (YEAR). She provided a written statement that is attached. During our interview (recorded interview is attached) as we were going through the incident again and making clarifications, I asked (LPN #1) if when (CNA #2) raised her voice to (Resident #7), if in her professional opinion it rose the level of verbal abuse or was she simply trying to speak in a manner to be heard over his 'yelling'. (LPN #1) said that (CNA #2) and (Resident #7) were not speaking or yelling simultaneously to each other, so she was not trying to speak over (Resident #7). In her professional opinion when (CNA #2) raised her voice to (Resident #7) it did rise to the level of verbal abuse . 4. The second person I spoke to was (CNA #2), the accused UW (CNA)} on (MONTH) 3, (YEAR). She provided a written statement that is attached. During our interview (recorded interview is attached), she described her account of the incident . (CNA #2) states she never raised her voice to (Resident #7) or spoke to him after that point . (CNA #2) says that she did not raise her voice or make a gesture towards (Resident #7) . 5. The third person I spoke with was (CNA #1) and witness on (MONTH) 3, (YEAR). She provided a written statement that is attached. During our interview (recorded interview is attached) (CNA #1) stated .as she was walking to (Resident #7's) room, she saw (CNA #2) walk into (Resident #7's) room and she could hear him yell that he did not want (CNA #2) in his room and to send (CNA #1). (CNA #2) then left the room as (CNA #1) entered and (CNA #2) continued to 'talk' as she was leaving the room. (Resident #7) told (CNA #1) that his neck and shoulder were hurting so she proceeded to massage his neck and shoulder. They could hear (CNA #2) talking out in the hallway . directly across from (Resident #7's) room . (LPN #1) asked (CNA #1) to step out of his room . (CNA #1) said that (CNA #2) kept going 'to go off' She (CNA #1) went to care for another resident . (CNA #1) continued to hear loud talking, and when she came back around the corner and (LPN #1) was at the Nurse's Station and (CNA #2) was in (Resident #7's) with the door closed. (CNA #1) could hear them talking loudly but could not make out the conversation . About that time (LPN #1) was getting up to go back into (Resident #7's) room, (CNA #2) walked out and both (Resident #7) and (CNA #2) continued to talk loudly toward each other and (Resident #7) started heading toward the smoking area. I asked if the reason that (CNA #2) went back into the room could have been to answer a call light, and she said 'no, there was not a call light on and there was no reason for her to go back into his room'. As (Resident #7) was walking toward the Smoking Area, (CNA #2) started following him and was continuing to talk to him. (CNA #2) said, 'You keep talking, I'm gonna keep talking' . I asked (CNA #1) if, in her opinion, if (CNA #2) actions rose to the level of verbal abuse, and she said 'yes, it did because she should not have put herself in that situation and the common practice in a nursing home is that if a resident is agitated it is best to walk away and not provoke the situation' . 6. The fourth person I spoke to was (RN Supervisor #1) on (MONTH) 4, (YEAR). He did not have a written statement, but was interviewed and the recorded interview is attached . When (RN (Registered Nurse) Supervisor #1) arrived, (Resident #7) was on the smoking patio, and (LPN #1) stopped him to brief him on what had happened since she had called him. (LPN #1) told him that (Resident #7) was on the smoking patio and that he had made a comment that, 'if (CNA #2) came in there again, he was going to attack her and that (CNA #2) had threatened him'. He stated from what he could tell that was not valid based on other statements. He then approached (Resident #7) on the smoking patio and .he told him that if (CNA #2) was not removed from the home he would strike her. He told him that he could not remove her immediately because there was a process, but that he would have her avoid him . It was 6 a.m. (6:00 a.m.) and everyone was going off shift in less than an hour. He wanted to avoid further contact between (Resident #7) and (CNA #2) and talk to HR (Human Resources) on how to proceed. He said that he had been made aware of tension between (Resident #7) and (CNA #2) and (CNA #1) in the past 3 weeks, so this was a preexisting issue with (Resident #7's) perception of (CNA #2) . (RN Supervisor) told (Resident #7) to relax for the time being and he would ask (LPN #1) and (CNA #2) to avoid him for the next hour so that he could talk to HR. He reported the incident later that morning to HR and told them the situation had escalated and needed to be resolved now. I asked what specific claims (Resident #7) made when he talked to him on the smoking patio, and he said that (CNA #2) came into his room and threatened him . 7. The fifth person I interviewed was (Resident #7), the resident on (MONTH) 5, (YEAR). He did not have a written statement, but was interviewed and the recorded interview is attached. According to him, . (CNA #2) .came in and started talking about something he had said about her Army career two weeks earlier . Then (CNA #2) came in by herself and put her fists up and said that he did not know what she can do to him. He took this as a threat. (Resident #7) stated that she left his room and came back in and just stared at him but did not do anything to help with his pain and just left again . When I asked him if he wanted anyone removed from the home, he said that he wanted (CNA #2) removed . 8. Summary of my findings . a. (CNA #2) should have avoided contact with (Resident #7) once he told her to leave his room . b. When (CNA #2) raised her voice to argue with (Resident #7) it rose to the level of verbal abuse of a resident . e. A Letter of Recommendation regarding Universal Worker (CNA) #2 dated 10/17/19, which accused and later substantiated an allegation of verbal abuse on 9/30/18, and completed by Administrator #1 documented, .Conclusion after Investigation(s) . It is my recommendation that (CNA #2) receive a Class A infraction for Verbal Abuse of a veteran which would result in Termination of her employment as of (MONTH) 17th (YEAR) . f. The Arkansas Department of Veterans Affairs Notice of Disciplinary Action Form dated 10/17/18 and completed by Administrator #1 documented, .Name of Employee . (CNA #2) . Date . (MONTH) 17, (YEAR) . Action Taken . Termination (checked) . Reason for Disciplinary Action . After investigation by (Facility Name), it has been determined that on (MONTH) 30th (9/30/18) you verbally abused a resident which is a Class A infraction (Not signed by Employee or Supervisor) . g. On 1/16/19 at 1:20 p.m., Certified Nursing Assistant (CNA) #2 was asked about the incident with Resident #1. She denied knowledge of ever knowing why she was put on paid Administrative Leave, and eventually was placed on Unpaid Leave for three days. She stated she was allowed to return to work without any disciplinary measures and / or training on abuse / neglect after the 3 days of unpaid leave and without continuous direct supervision. She stated she was not told why she was recently placed on paid Administrative Leave as well. h. The facility Time Ticket for the timeframe of 9/30/18 through 10/30/18 for CNA #2, provided by the Administrator on 1/16/19, documented the following dates / hours worked: .Worked 8.100 hours 9/30/18 (day of incident) . on Administrative Paid Leave from 10/1/18 through 10/20/18 . 3 days (unpaid) suspension from 10/22/18 through 10/24/18 and worked 8 plus hours on 10/26/18 through 10/30/18 . i. On 1/16/19 at 1:25 p.m., the Administrator, Deputy Director, and Director of Nursing were asked about CNA #2's schedule since the incident / investigation. They stated Certified Nursing Assistant #2 had worked all scheduled days since the incident of verbal abuse to Resident #7 on 9/30/18 from 10/30/18 until she was placed on Administrative Leave again for another allegation of abuse on 1/11/19. 2. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 12/6/18 documented the resident scored 6 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status, exhibited no behaviors, required extensive two plus person physical assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene, required a wheelchair for mobility, and was frequently incontinent of bladder and of bowel. a. The Plan of Care with a revised date of 6/8/18 documented, .(Resident #6) has an alteration in his behavioral function AEB (as evidenced by) verbally aggressive towards staff and attempts to physically strike staff . not easily redirected . 6/1/18 . persistently agitated and demonstrates verbal aggression towards other Veteran . no immediate physical harm . Interventions . Always ensure the safety of (Resident #6) . attempt to redirect . When the Veteran becomes agitated . Engage calmly in conversation . If response is aggressive, staff to walk calmly away and approach later . b. On 1/13/19 at 10:52 p.m., Resident #6 was lying in a low bed on his right side. The resident had a fading bruise circling his left eye, a purple fading bruise in the mustache area going around his entire mouth and chin area, and a large area of bruising on the left side of his lower chin area. c. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated 1/14/19 at 5:25 p.m. documented, .Date and Time submitted .1/14/19 at 5:25 p.m. Date and Time of Discovery .1/6/19 at 6:20 a.m. Staff Reporting I and A (Incident and Accident) . (Administrator #2) . Status of Alleged Perpetrator . Facility Employee . Type of Incident . Physical (checked) . On the morning of 14 (MONTH) 2019 (1/14/19) I was notified by an OLTC (Office of Long Term Care) surveyor that there was an accusation of abuse filed regarding an incident that occurred on 6 (MONTH) 2019 (1/6/19). The incident was originally reported on 6 (MONTH) 2019 (1/6/19), but was deemed a witnessed self-inflicted accident (I&A) (Incident and Accident) at the time. (See Note Below) On 6 (MONTH) 2019 (1/6/19), a Universal Worker in Hero Home 1 reported that a resident became combative while they were performing a peri-care procedure and struck himself in the lip. RN (Registered Nurse) assessment of the resident indicated minor bruising of the upper lip. The incident was documented as an I&A (Incident and Accident) in the resident records . Family Member notified on 6 [DATE] (1/6/19) (at) 12:02 p.m. APRN (Advanced Practice Registered Nurse) notified on 6 (MONTH) 2019 (1/6/19) (at) 12:00 p.m. DON (Director of Nursing) notified on 6 (MONTH) 2019 (1/6/19) (at) 12:02 p.m.Interim Administrator notified 6 (MONTH) 2019 (1/6/19( (at) 6:30 p.m.Police notified on 14 (MONTH) 2019 (1/14/19) (at) 4:30 p.m.Resident was on visual supervision monitoring his bruise .Obtained witness statements . Placed accused employee on suspension pending investigation (MONTH) 11, 2019 (1/11/19) . Note . On 11 (MONTH) 2019 (1/11/19), I was contacted by OLTC (the Office of Long Term Care) regarding this incident. However, because there was another allegation of the same employee similar in nature that was being investigated and reported to OLTC, there was confusion . The incident was not reported to the Office of Long Term Care (OLTC) until 1/14/19, 3 days after the facility was notified by OLTC, and 8 days after the incident occurred. d. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities, DMS form 762, dated 1/14/19 documented, .Date and Time Submitted to OLTC .1/14/29 at 5:25 p.m.Date and Time of Discovery . 1/6/19 at 6:20 a.m.Staff Reporting I&A (Incident and Accident) . (Administrator #2) . Status of Alleged Perpetrator . Facility Employee (checked) . Type of Incident . Physical (checked) . e. On 1/15/19 at 10:48 a.m., Resident #6 was sitting up in his wheelchair. The resident had fading bruising (black) to his left eye, bruising around his entire mouth with a larger area on his left outer lower chin area. There were no bruises visible on the resident's forearms. The resident was asked about the bruising to his eye and face. The resident only looked at the surveyor and smiled. The resident was unable to verbalize what had happened. f. On 1/15/19 at 11:00 a.m., Administrator #2 was asked about the incident involving Resident #6 on 1/6/19. She stated, I was notified by an OLTC employee on 1/11/19 that they had received an allegation of physical abuse involving (Resident #6) and (Certified Nursing Assistant #2); however since I had already been working on another incident involving the same Veteran and UW (CNA), I just assumed that was what they were talking about and continued with that investigation and did not realize until the OLTC Surveyor asked me about that Reportable on 1/14/19, and that's when I began that investigation. Administrator #2 stated the CNA was placed on Paid Administrative Leave on 1/11/19 due to an unwitnessed fall involving (Resident #6), not due to this investigation, but she remains on leave at this time due to this allegation of physical abuse. g. On 1/16/19 at 1:20 p.m., Certified Nursing Assistant #2 (alleged perpetrator) was asked about the incident involving Resident #6 on 1/15/19. She stated, While I was assisting Resident #6 with cleaning his hands after he had smeared them with feces, he grabbed the washcloth with his hands in a praying stance and hit his mouth right under his nose with his hands one time. He (the resident) was not being combative, he was just acting playful. He has never been combative with me while I care for him. I did report this to my LPN and later to the RN Supervisor because I was afraid that he might become combative after this. I did not note the extensive bruising to his face until I came in that night, and asked the RN Supervisor what happened to my guy (Resident #6). She was asked if she had been told that she was under investigation due to an allegation of abuse with this Veteran from his unwitnessed fall on 1/1/19, and again concerning this same Veteran for the allegation of physical abuse on 1/6/19. She stated, No. 3. The facility policy titled Abuse, Neglect and Misappropriation of Resident Property provided by the Director of Nursing (DON) on 1/15/19 at 9:43 a.m., documented, .Policy .To ensure the resident is free of verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion .Procedure .1. Any allegation of mistreatment of [REDACTED]. 4. Prevention, Identification and Protection . The Administrator / Director of Nursing / RN (Registered Nurse) on Duty must identify, intervene and correct situations in which abuse, neglect and / or misappropriation may occur . 5. Reporting . Any employee who suspects an alleged violation must immediately notify the Administrator / Director of Nursing / RN on Duty .The supervisor on duty must notify the State agency and local law enforcement agency as required by law .The Administrator or designee will complete form 7734 and fax to . by 11:00 a.m. the following business day and mail the completed form 762 within 5 business days . 8. Documentation . The final report to the appropriate State agency must be completed as required by (facility), State and federal regulations. This report should include the final determination of the investigation and corrective actions taken . 4. The Immediate Jeopardy was removed and the scope / severity reduced to H on 1/16/19 at 12:30 p.m., when the facility implemented the following Plan of Removal: .Plan of Removal . Abuse and Neglect a. Effective immediately on 1/15/19, the following items are to be initiated for All facility employees on (Facility Name) roster, new hires and agency contract (direct care) staff. b. Immediately remove any employee with suspected allegations from the schedule to conduct abuse and neglect investigations. (Alleged employee (CNA #2) placed on Administrative Leave 1/11/2019). c. Ensure any resident who has been involved in an abuse / neglect allegation is interviewed, and a body audit is performed by licensed staff. (Body audit and interview conducted on alleged victim Resident #6 on 1/9/19). d. Initial Abuse and Neglect in-service defining the Abuse, Neglect, Misappropriation, and Procedure / Policy for all scheduled employees, any new hires, and any employees returning from leave prior to their next scheduled shift. (Initiated on 1/14/9 upon Administration awareness, to be completed by 1/24/19). e. Administrator's contact information posted by all employee time clocks to report allegations of abuse / neglect immediately as needed. (Completed 1/15/19). f. Obtain witness statements from all employees who were on shift at the time of the alleged abuse or neglect. (Completed on 1/16/19). g. Ensure all residents in the home who have been in direct contact with alleged employee (CNA #2) are interviewed to verify if there are further investigations that should be conducted involving other any other residents. (Initiated on 1/15/19 and completed on 1/17/19). h. All direct care and non-direct care staff, upon arrival to shift starting on 1/15/19, will be re-educated by the Administrator / Designee to ensure the following topics are given: In-service: 'Abuse and Neglect' in-service defining Abuse, Neglect, Misappropriation, and Policy and Procedure. In-service: 'Reporting Abuse & (and) Process - RN Supervisors.' Video In-service: 'Your Legal Duty - Reporting Elder and Dependent Adult Abuse'. i. All residents who have cognitive impairments will have a body audit performed and documented, to ensure there are no residents with unknown injuries. (Initiated on 1/16/19 and to be completed by 1/18/19, and will be done 3 x (times) week on Monday's, Wednesday's and Saturday's for the next month or until substantial compliance is achieved). Any negative findings will be immediately reported to the Administrator /DON / RN Supervisor for further investigation. j. All cognitively intact residents will have an interview conducted by (DON / designees) to determine if there are any reports of abuse and neglect. All resident interviews will be completed by 1/18/18. Any negative findings during interviews will be documented, immediately reviewed for further investigations. These interviews will be conducted until substantial compliance is achieved.

Complaint # (AR 467) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure an allegations of abuse were thoroughly investigated and protective measures immediately implemented to prevent further potential abuse for 1 (Resident #7) case mix resident who was the alleged victim of staff-to-resident verbal abuse, and 1 of 1 (Resident #6) case mix resident who was the alleged victim of physical abuse. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to Resident #7 who was allegedly yelled at and threatened and Resident #6 who was allegedly physically abused resulting in bruising to the facial area, and had the potential to affect all 11 residents who resided in Home 4 and received care from Certified Nursing Assistant #2, according to the list provided by the Administrator on 1/17/19. The Administrator was notified of the Immediate Jeopardy condition on 1/15/19 at 4:20 p.m. The findings are: 1. Resident #7 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date of 11/2/18 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, had the ability to make self understood and had the ability to understand others, exhibited no physical or verbal behaviors directed toward others, and required supervision and set up help only with bed mobility and eating, required supervision only with transfer, dressing, toilet use, and personal hygiene, had functional limitation in range of motion of one side in lower extremity, and required a walker for mobility. a. The Plan of Care with a revised date of 11/8/18 documented, .(Resident #7) has an alteration in his behavioral function AEB (As evidenced by) yelling at staff in a threatening manner, using racial slurs .speaking in very loud tone, cursing at staff .Interventions .Assist him to develop more appropriate methods of coping and interacting with his nurse and UW's (Universal Workers (Certified Nursing Assistants)) . His behavioral episode was triggered by his c/o (complaint of) pain and lack of understanding of his medications and their actions. His behavior is de-escalated by alleviating his pain and anxiety . Use a calm approach when explaining medications to him . Walk away and re-approach in an appropriate amount of time, ensuring his and other's safety . b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long-Term care Facilities Office of Long Term Care (OLTC), Division of Medical Services (DMS) form 762 dated 10/2/18, page 2 of 9 documented, .Facility Staff Member Completing DMS-762 . Administrator #1 .Title . Administrator . Date Incident Reported to OLTC . 10/2/18 . Time . 10:55 a.m. Date and Time of Incident (if known) . 9/20/18 . Time . 23:15 (11:15) p.m. Date and Time of Discovery . 10/1/18 . Time . 15:00 (3:00) p.m. Type of Incident . Verbal (checked) . Emotional / Mental (checked) . Name of Involved Resident . (Resident #7) . Physical Functional Level / Impairment . Mobile with limited assistance . Mental Functional Level . BIMS 14 (a score of 13-15 indicates cognitively intact) . Primary [DIAGNOSES REDACTED]. (page 3) .On [DATE]st (10/1/18) at or around 3:30 (p.m.) UW (Universal Worker (CNA)) #1 reported to DON (Director of Nursing) that the previous night there was a verbal altercation possibly between a fell ow (CNA #2) and male veteran (Resident #7) at the beginning of the night shift. (CNA #1) reported that the tension was very high between (Resident #7) and (CNA #2). It was reported that (Resident #7) and (CNA #2) were communicating in a very loud manner back and forth about (CNA #2) discharge status in the Army, and at one point had to be separated by the Nurse (Licensed Practical Nurse (LPN #1)). It was reported by (CNA #1) that the communication that (CNA #2) was using towards (Resident #7) seemed threatening . Page 4 .(Facility Name ) conducted investigation led by the Administrator starting on [DATE]nd (YEAR) (10/2/18). Upon interview of (Resident #7), stated verbally to the Administrator that he felt (CNA #2) wanted to fight him and at one point (CNA #2) had her fist raised upwards to indicate she was serious that he not ever ask her about her Military Service again. Upon interviewing the fell ow UW (CNA) worker in the house and the Nurse (LPN #1) in the house at the time, there is no proof that (CNA #2) raised her fist at (Resident #7). All evidence according to witness of (LPN #1) indicates there was a verbal altercation between (Resident #7) and (CNA #2) with the LPN (#1) having to get between the two of them to separate them. The LPN (#1) stated in her opinion that (CNA #2) was verbally abusive to (Resident #7) . Based on the evidence obtained during the investigation, (Facility Name) substantiates the allegation of Verbal and or Mental abuse by (CNA #2) towards (Resident #7) . (CNA #2) has not been allowed to work since the incident . In-service given on Abuse and Neglect on Oct. 3, (YEAR) (10/3/18) . All residents were interviewed with no other reports of verbal abuse . (signed by (Administrator #1) . Date .10/5/18) . c. A facility email dated Monday, 10/1/18 at 7:40 p.m., sent by the Deputy Director to the Assistant Director for Veteran Services, and provided by the Administrator on 1/15/19, documented, .Per our conversation earlier today about the incident at the (Facility Name), I would like you to perform a disciplinary investigation in accordance with ADVA 2-1 (Facility Policy). This is a separate investigation from the OLTC (Office of Long Term Care) Investigation being conducted by (Administrator #1) . d. The investigation conducted by the Assistant Director for Veteran Services documented, .1. On (MONTH) 1, (YEAR) I was asked to look into an alleged altercation between a Universal Worker (Certified Nursing Assistant) and a resident at the (Facility). I was provided statements from all parties and a witness list. Arrangements were made for me to speak to all parties on (MONTH) 3rd, 4th and 5th (10/3/18, 10/4/18, 10/5/18) . 2. During the investigation I spoke with (CNA #2), the accused Universal Worker (Certified Nursing Assistant), (LPN #1), UW (CNA) #1 and witness, (RN Supervisor) and (Resident #7) . 3. The first person that I spoke with was (LPN #1), Supervisor on (MONTH) 3, (YEAR). She provided a written statement that is attached. During our interview (recorded interview is attached) as we were going through the incident again and making clarifications, I asked (LPN #1) if when (CNA #2) raised her voice to (Resident #7), if in her professional opinion it rose the level of verbal abuse or was she simply trying to speak in a manner to be heard over his 'yelling'. (LPN #1) said that (CNA #2) and (Resident #7) were not speaking or yelling simultaneously to each other, so she was not trying to speak over (Resident #7). In her professional opinion when (CNA #2) raised her voice to (Resident #7) it did rise to the level of verbal abuse . 4. The second person I spoke to was (CNA #2), the accused UW (CNA)} on (MONTH) 3, (YEAR). She provided a written statement that is attached. During our interview (recorded interview is attached), she described her account of the incident . (CNA #2) states she never raised her voice to (Resident #7) or spoke to him after that point . (CNA #2) says that she did not raise her voice or make a gesture towards (Resident #7) . 5. The third person I spoke with was (CNA #1) and witness on (MONTH) 3, (YEAR). She provided a written statement that is attached. During our interview (recorded interview is attached) (CNA #1) stated .as she was walking to (Resident #7's) room, she saw (CNA #2) walk into (Resident #7's) room and she could hear him yell that he did not want (CNA #2) in his room and to send (CNA #1). (CNA #2) then left the room as (CNA #1) entered and (CNA #2) continued to 'talk' as she was leaving the room. (Resident #7) told (CNA #1) that his neck and shoulder were hurting so she proceeded to massage his neck and shoulder. They could hear (CNA #2) talking out in the hallway . directly across from (Resident #7's) room . (LPN #1) asked (CNA #1) to step out of his room . (CNA #1) said that (CNA #2) kept going 'to go off' She (CNA #1) went to care for another resident . (CNA #1) continued to hear loud talking, and when she came back around the corner and (LPN #1) was at the Nurse's Station and (CNA #2) was in (Resident #7's) with the door closed. (CNA #1) could hear them talking loudly but could not make out the conversation . About that time (LPN #1) was getting up to go back into (Resident #7's) room, (CNA #2) walked out and both (Resident #7) and (CNA #2) continued to talk loudly toward each other and (Resident #7) started heading toward the smoking area. I asked if the reason that (CNA #2) went back into the room could have been to answer a call light, and she said 'no, there was not a call light on and there was no reason for her to go back into his room'. As (Resident #7) was walking toward the Smoking Area, (CNA #2) started following him and was continuing to talk to him. (CNA #2) said, 'You keep talking, I'm gonna keep talking' . I asked (CNA #1) if, in her opinion, if (CNA #2) actions rose to the level of verbal abuse, and she said 'yes, it did because she should not have put herself in that situation and the common practice in a nursing home is that if a resident is agitated it is best to walk away and not provoke the situation' . 6. The fourth person I spoke to was (RN Supervisor #1) on (MONTH) 4, (YEAR). He did not have a written statement, but was interviewed and the recorded interview is attached . When (RN (Registered Nurse) Supervisor #1) arrived, (Resident #7) was on the smoking patio, and (LPN #1) stopped him to brief him on what had happened since she had called him. (LPN #1) told him that (Resident #7) was on the smoking patio and that he had made a comment that, 'if (CNA #2) came in there again, he was going to attack her and that (CNA #2) had threatened him'. He stated from what he could tell that was not valid based on other statements. He then approached (Resident #7) on the smoking patio and .he told him that if (CNA #2) was not removed from the home he would strike her. He told him that he could not remove her immediately because there was a process, but that he would have her avoid him . It was 6 a.m. (6:00 a.m.) and everyone was going off shift in less than an hour. He wanted to avoid further contact between (Resident #7) and (CNA #2) and talk to HR (Human Resources) on how to proceed. He said that he had been made aware of tension between (Resident #7) and (CNA #2) and (CNA #1) in the past 3 weeks, so this was a preexisting issue with (Resident #7's) perception of (CNA #2) . (RN Supervisor) told (Resident #7) to relax for the time being and he would ask (LPN #1) and (CNA #2) to avoid him for the next hour so that he could talk to HR. He reported the incident later that morning to HR and told them the situation had escalated and needed to be resolved now. I asked what specific claims (Resident #7) made when he talked to him on the smoking patio, and he said that (CNA #2) came into his room and threatened him . 7. The fifth person I interviewed was (Resident #7), the resident on (MONTH) 5, (YEAR). He did not have a written statement, but was interviewed and the recorded interview is attached. According to him, . (CNA #2) .came in and started talking about something he had said about her Army career two weeks earlier . Then (CNA #2) came in by herself and put her fists up and said that he did not know what she can do to him. He took this as a threat. (Resident #7) stated that she left his room and came back in and just stared at him but did not do anything to help with his pain and just left again . When I asked him if he wanted anyone removed from the home, he said that he wanted (CNA #2) removed . 8. Summary of my findings . a. (CNA #2) should have avoided contact with (Resident #7) once he told her to leave his room . b. When (CNA #2) raised her voice to argue with (Resident #7) it rose to the level of verbal abuse of a resident . e. A Letter of Recommendation regarding Universal Worker (CNA) #2 dated 10/17/19, which accused and later substantiated an allegation of verbal abuse on 9/30/18, and completed by Administrator #1 documented, .Conclusion after Investigation(s) . It is my recommendation that (CNA #2) receive a Class A infraction for Verbal Abuse of a veteran which would result in Termination of her employment as of (MONTH) 17th (YEAR) . f. The Arkansas Department of Veterans Affairs Notice of Disciplinary Action Form dated 10/17/18 and completed by Administrator #1 documented, .Name of Employee . (CNA #2) . Date . (MONTH) 17, (YEAR) . Action Taken . Termination (checked) . Reason for Disciplinary Action . After investigation by (Facility Name), it has been determined that on (MONTH) 30th (9/30/18) you verbally abused a resident which is a Class A infraction (Not signed by Employee or Supervisor) . g. On 1/16/19 at 1:20 p.m., Certified Nursing Assistant (CNA) #2 was asked about the incident with Resident #1. She denied knowledge of ever knowing why she was put on paid Administrative Leave, and eventually was placed on Unpaid Leave for three days. She stated she was allowed to return to work without any disciplinary measures and / or training on abuse / neglect after the 3 days of unpaid leave and without continuous direct supervision. She stated she was not told why she was recently placed on paid Administrative Leave as well. h. The facility Time Ticket for the timeframe of 9/30/18 through 10/30/18 for CNA #2, provided by the Administrator on 1/16/19, documented the following dates / hours worked: .Worked 8.100 hours 9/30/18 (day of incident) . on Administrative Paid Leave from 10/1/18 through 10/20/18 . 3 days (unpaid) suspension from 10/22/18 through 10/24/18 . and worked 8 plus hours on 10/26/18 through 10/30/18 . i. On 1/16/19 at 1:25 p.m., the Administrator, Deputy Director, and Director of Nursing were asked about CNA #2's schedule since the incident / investigation. They stated Certified Nursing Assistant #2 had worked all scheduled days since the incident of verbal abuse to Resident #7 on 9/30/18 from 10/30/18 until she was placed on Administrative Leave again for another allegation of abuse on 1/11/19. 2. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 12/6/18 documented the resident scored 6 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status, exhibited no behaviors, required extensive two plus person physical assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene, required a wheelchair for mobility, and was frequently incontinent of bladder and of bowel. a. The Plan of Care with a revised date of 6/8/18 documented, .(Resident #6) has an alteration in his behavioral function AEB (as evidenced by) verbally aggressive towards staff and attempts to physically strike staff . not easily redirected . 6/1/18 . persistently agitated and demonstrates verbal aggression towards other Veteran . no immediate physical harm . Interventions . Always ensure the safety of (Resident #6) . attempt to redirect . When the Veteran becomes agitated . Engage calmly in conversation . If response is aggressive, staff to walk calmly away and approach later . b. On 1/13/19 at 10:52 p.m., Resident #6 was lying in a low bed on his right side. The resident had a fading bruise encircling his left eye, a purple fading bruise in the mustache area going around his entire mouth and chin area, and a large area of bruising on the left side of his lower chin area. c. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A), Division of Medical Services (DMS) form 7734 dated 1/14/19 at 5:25 p.m. documented, .Date and Time submitted .1/14/19 at 5:25 p.m. Date and Time of Discovery .1/6/19 at 6:20 a.m. Staff Reporting I and A (Incident and Accident) . (Administrator #2) . Status of Alleged Perpetrator . Facility Employee . Type of Incident . Physical (checked) . On the morning of 14 (MONTH) 2019 (1/14/19) I was notified by an OLTC (Office of Long Term Care) surveyor that there was an accusation of abuse filed regarding an incident that occurred on 6 (MONTH) 2019 (1/6/19). The incident was originally reported on 6 (MONTH) 2019 (1/6/19), but was deemed a witnessed self-inflicted accident (I&A) (Incident and Accident) at the time. (See Note Below) On 6 (MONTH) 2019 (1/6/19), a Universal Worker (Certified Nursing Assistant) in Hero Home 1 reported that a resident became combative while they were performing a peri-care procedure and struck himself in the lip. RN (Registered Nurse) assessment of the resident indicated minor bruising of the upper lip. The incident was documented as an I&A (Incident and Accident) in the resident records . Family Member notified on 6 [DATE] (1/6/19) (at) 12:02 p.m. APRN (Advanced Practice Registered Nurse) notified on 6 (MONTH) 2019 (1/6/19) (at) 12:00 p.m. DON (Director of Nursing) notified on 6 (MONTH) 2019 (1/6/19) (at) 12:02 p.m.Interim Administrator notified 6 (MONTH) 2019 (1/6/19( (at) 6:30 p.m.Police notified on 14 (MONTH) 2019 (1/14/19) (at) 4:30 p.m.Resident was on visual supervision monitoring his bruise .Obtained witness statements . Placed accused employee on suspension pending investigation (MONTH) 11, 2019 (1/11/19) . Note . On 11 (MONTH) 2019 (1/11/19), I was contacted by OLTC (the Office of Long Term Care) regarding this incident. However, because there was another allegation of the same employee similar in nature that was being investigated and reported to OLTC, there was confusion . The incident was not reported to the Office of Long Term Care (OLTC) until 1/14/19, 3 days after the facility was notified by OLTC, and 8 days after the incident occurred. d. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long Term Care Facilities, DMS form 762, dated 1/14/19 documented, .Date and Time Submitted to OLTC .1/14/29 at 5:25 p.m.Date and Time of Discovery . 1/6/19 at 6:20 a.m.Staff Reporting I&A (Incident and Accident) . (Administrator #2) . Status of Alleged Perpetrator . Facility Employee (checked) . Type of Incident . Physical (checked) . e. On 1/15/19 at 10:48 a.m., Resident #6 was sitting up in his wheelchair. The resident had fading bruising (black) to his left eye, bruising around his entire mouth with a larger area on his left outer lower chin area. There were no bruises visible on the resident's forearms. The resident was asked about the bruising to his eye and face. The resident only looked at the surveyor and smiled. The resident was unable to verbalize what had happened. f. On 1/15/19 at 11:00 a.m., Administrator #2 was asked about the incident involving Resident #6 on 1/6/19. She stated, I was notified by an OLTC employee on 1/11/19 that they had received an allegation of physical abuse involving (Resident #6) and (Certified Nursing Assistant #2); however since I had already been working on another incident involving the same Veteran and (CNA), I just assumed that was what they were talking about and continued with that investigation and did not realize until the OLTC Surveyor asked me about that Reportable on 1/14/19, and that's when I began that investigation. Administrator #2 stated the CNA was placed on Paid Administrative Leave on 1/11/19 due to an unwitnessed fall involving (Resident #6), not due to this investigation, but she remains on leave at this time due to this allegation of physical abuse. g. On 1/16/19 at 1:20 p.m., Certified Nursing Assistant #2 (alleged perpetrator) was asked about the incident involving Resident #6 on 1/15/19. She stated, While I was assisting Resident #6 with cleaning his hands after he had smeared them with feces, he grabbed the washcloth with his hands in a praying stance and hit his mouth right under his nose with his hands one time. He (the resident) was not being combative, he was just acting playful. He has never been combative with me while I care for him. I did report this to my LPN and later to the RN Supervisor because I was afraid that he might become combative after this. I did not note the extensive bruising to his face until I came in that night, and asked the RN Supervisor what happened to my guy (Resident #6). She was asked if she had been told that she was under investigation due to an allegation of abuse with this Veteran from his unwitnessed fall on 1/1/19, and again concerning this same Veteran for the allegation of physical abuse on 1/6/19. She stated, No. 3. The Immediate Jeopardy was removed and the scope / severity reduced to H on 1/16/19 at 12:30 p.m., when the facility implemented the following Plan of Removal: .Plan of Removal . Abuse and Neglect a. Effective immediately on 1/15/19, the following items are to be initiated for All facility employees on (Facility Name) roster, new hires and agency contract (direct care) staff. b. Immediately remove any employee with suspected allegations from the schedule to conduct abuse and neglect investigations. (Alleged employee (CNA #2) placed on Administrative Leave 1/11/2019). c. Ensure any resident who has been involved in an abuse / neglect allegation is interviewed, and a body audit is performed by licensed staff. (Body audit and interview conducted on alleged victim Resident #6 on 1/9/19). d. Initial Abuse and Neglect in-service defining the Abuse, Neglect, Misappropriation, and Procedure / Policy for all scheduled employees, any new hires, and any employees returning from leave prior to their next scheduled shift. (Initiated on 1/14/9 upon Administration awareness, to be completed by 1/24/19). e. Administrator's contact information posted by all employee time clocks to report allegations of abuse / neglect immediately as needed. (Completed 1/15/19). f. Obtain witness statements from all employees who were on shift at the time of the alleged abuse or neglect. (Completed on 1/16/19). g. Ensure all residents in the home who have been in direct contact with alleged employee (CNA #2) are interviewed to verify if there are further investigations that should be conducted involving other any other residents. (Initiated on 1/15/19 and completed on 1/17/19). h. All direct care and non-direct care staff, upon arrival to shift starting on 1/15/19, will be re-educated by the Administrator / Designee to ensure the following topics are given: In-service: 'Abuse and Neglect' in-service defining Abuse, Neglect, Misappropriation, and Policy and Procedure. In-service: 'Reporting Abuse & (and) Process - RN Supervisors.' Video In-service: 'Your Legal Duty - Reporting Elder and Dependent Adult Abuse'. i. All residents who have cognitive impairments will have a body audit performed and documented, to ensure there are no residents with unknown injuries. (Initiated on 1/16/19 and to be completed by 1/18/19, and will be done 3 x (times) week on Monday's, Wednesday's and Saturday's for the next month or until substantial compliance is achieved). Any negative findings will be immediately reported to the Administrator /DON / RN Supervisor for further investigation. j. All cognitively intact residents will have an interview conducted by (DON / designees) to determine if there are any reports of abuse and neglect. All resident interviews will be completed by 1/18/18. Any negative findings during interviews will be documented, immediately reviewed for further investigations. These interviews will be conducted until substantial compliance is achieved.

Complaint # (AR 461) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure door alarms were activated to prevent the potential for elopement for 1 (Resident #1) of 2 (Residents #1 and #6) case mix residents who were at risk for elopement. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1 who had been assessed for being at risk for elopement, and left the facility unnoticed by staff when the alarm on the front exit door was turned off, and was found approximately 150 to 200 yards from the facility, and had the potential to cause more than minimal harm to 28 residents who were at risk for elopement, according to the list provided by the Administrator on 1/17/19. The Administrator was notified of the Immediate Jeopardy condition on 1/15/19 at 4:20 p.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 11/7/18 documented the resident scored 3 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status, exhibited wandering behavior one to three days out of the last 7 days, wandering behavior placed resident at significant risk of getting to a potentially dangerous place (such as, outside the facility), required supervision with one person assistance for bed mobility, transfer, and dressing, require supervision and set up help only for toilet use and personal hygiene, was occasionally incontinent of bladder and of bowel, had a history of [REDACTED]. a. A Care Plan with a revised date of 11/13/18 documented, .(Resident #1) has a DX (Diagnosis) of Alzheimer's Dementia with decreased safety awareness and impulsive behaviors AEB (as evidenced by) attempts to leave his Hero Home unsupervised, placing him at a HIGH risk for wandering (Resident #1) to have no undetected attempts at elopement through next review date . Encourage (Resident #1) to wear his call-pendant on lanyard . staff to respond immediately to silent alerts prn (as needed) attempts of exiting the building unescorted or unsupervised . Frequent observation by staff for safety and location . b. On 1/14/19 at 12:26 a.m., Licensed Practical Nurse (LPN) #1 was asked if she was aware of any residents eloping from any of the homes. She stated, (Resident #1). He got out of his home (7). He was at the back entrance by the old (Name) facility. It was 7 to 8 (7:00 p.m. to 8:00 p.m.) o'clock at night. A worker brought him back on her lunch break. She didn't know what home he belonged in. She started at Home 8 then went to Home 7. There were 2 (Certified Nursing Assistants (CNAs) and a Nurse assigned to the home. They didn't know he was gone until she brought him back. She was asked if there had been any in-services regarding elopement after this incident. She stated, There were no in-services after this incident. c. An Office of Long Term Care (OLTC) Incident and Accident Report (I&A) documented, . Date and Time Submitted (if known) 1/9/19 at 5:50 p.m. Date and time of Discovery . 1/8/19 at 7:30 p.m. Summary of Incident .On (MONTH) 8, 2019 around 7:15 p.m. (Resident #1) eloped and Universal Worker (CNA) found him on campus . Steps Taken to Prevent Continued Abuse or Neglect during the Investigation . 1/8/19 DON (Director of Nursing) Notified . 1/8/19 Interim Administrator Notified . 1/8/19 Family Attempted to Notify . 1/8/19 MD (Medical Director) Notified . 1/8/19 Police Notified . Q (Every) 15 Min (minute) Monitor . Body Audit Completed by RN (Registered Nurse) . Witness Statements Obtained . The facility performed every 15-minute monitoring for Resident #1 included in the facility's Incident and Accident Report documented the monitoring was initiated on 1/9/19 at 6:45 a.m. The resident eloped from his Home on 1/8/19 at approximately 7:30 p.m. The every 15-minute monitoring for the resident was not initiated until 11 hours and 15 minutes after the elopement of Resident #1. d. An Office of Long Term Care (OLTC) Witness Statement Form dated 1/8/19 at 7:30 p.m., and signed by Certified Nursing Assistant #3, documented, .Witness Full Name . (CNA #3) . Job Title . UW (Certified Nursing Assistant (CNA)) . Shift .2:30 p.m. to 10:30 p.m. I last saw (Resident #1) in living room before I went to lay a resident down into bed and my co-worker (CNA #4) helped me, as well. He (Resident #1) left while we was doing that, and the alarm was off when I got here today and didn't realize it was off . e. An OLTC Witness Statement Form dated 1/8/19 at 7:30 p.m., and signed by Certified Nursing Assistant #4, documented, .Witness Full Name . (CNA #4) . Job Title . UW (CNA) . Shift . 2:30 p.m. to 10:30 p.m. I last saw (Resident #1) in the living room watching TV (television) . (CNA #3) and myself were changing and assisting another veteran when (Resident #1) left Hero Home 7. I don't know why the alarm on the door was off . f. An OLTC Witness Statement Form dated 1/8/19 at 1924 (7:24 p.m.), and signed by Registered Nurse Supervisor #1, documented, .Witness Full Name (RN Supervisor) . The RN Supervisor received a call from a UW (CNA) from Home 8 who was on her lunch break. She noticed (Resident #1) outside the back gate by the nursing home behind the (Facility Name). The (CNA) returned him to the Supervisor to identify that he was actually one of our veterans. The UW (CNA) stated, 'I remember working (with) him once but wasn't really sure if he was one of our veterans.' The RN Supervisor identified him (Resident #1), and returned him to Home 7. The LPN in the home at this time noticed that the door alarm was off and turned it back on. The RN Supervisor notified the DON, Deputy Director and (Administrator #2) the Administrator Designee . g. An OLTC Witness Statement Form dated 1/8/19 at 1939 (7:30 p.m.), and signed by LPN #2, documented, .Witness Full Name (LPN #2) . Job Title . LPN . Shift .7P to 7A (7:00 p.m. to 7:00 a.m.) . Notified by RN Supervisor that Resident had eloped and was found by UW (CNA). Resident last seen by writer at Approx (approximately) 1918 (7:18 p.m.). Resident was standing in kitchen. Both UW's (CNAs) present at that time. Writer proceeded to finish medication pass at the back (Rooms 133 to 135). When writer exited room [ROOM NUMBER] to get water for resident, that's when writer was told about the elopement. Writer went to front door to see why alarm did not work. It was turned off. Alarm currently on and working. Writer is unaware why alarm was off. h. A blank, untitled piece of paper dated 1/8/19 documented, . (CNA #5) Was on my way to lunch. Seen man that was walking almost to the second back gate. So I stopped the car thinking that he could have been a resident. So I let down the window to get a good look at him. He looked familiar, so (I) told him to get in and we came to Home 8. Asked co-worker to come out to see if she knew him, or what Home he belongs to. She did not. We called the Supervisor and took him to Home 7. It was about 7:15 (p.m.), outside back gate by the Nursing Home behind (Facility Name) . i. A Nursing Progress Note dated 1/8/19 at 20:43 (8:43 p.m.), and signed by LPN #2, documented, .Late Entry . Resident was found outside of home by a UW (CNA) . Resident was returned. Remains very confused. DON (Name) and Director (Name) both notified of incident. Resident has no visual injuries noted at this time r/t (related to) leaving home . 1950 (7:50 p.m.) Resident will not follow orders, continues to walk and open door after writer asked resident not to exit. Resident proceeded to exit home. Writer at that time convinced resident to come back inside. j. On 1/15/19 at 10:15 a.m., CNA #3 was asked if he was working the evening of 1/8/19 when (Resident #1) eloped. He stated, Yes. I was working that evening. He was asked to explain the incident. He stated, I was going to lay another resident down with the help of another (CNA) (CNA #4). While we were laying that resident down, that's when he left. I know that's when he left because he was in the living room when we went to lay the other resident down. The alarm wasn't on. Didn't know he had left at that time. CNA #3 was asked if he was aware that (Resident #1) was at risk of elopement prior to the incident. He stated, I was aware he was at risk for elopement prior to him eloping. He was asked what interventions were in place to prevent elopement. He stated, The alarms on the doors now cannot be turned off. He was asked if the alarms on the exit doors could be turned off. He stated, At the time, the alarms on the exit doors could be turned off the front door only. He was asked how long the resident was gone before he was returned to his home. He stated, He was gone approximately 10 minutes before he was returned. He was asked how far the resident had gotten before he was found. He stated, (RN Supervisor #2) said he was past Home 6, near the gate when he was found. He was asked if he was aware the resident was missing before he was returned. He stated, I was not aware he was gone before he was returned. He was asked what interventions had been put in place to prevent further incidents of this nature. He stated, The alarms on the doors now cannot be turned off. He was asked how he was made aware of which residents were at risk for elopement. He stated, The Charge Nurse lets us know which residents are at risk for elopement. He was asked if there were any in-services before or after his (Resident #1's) elopement. He stated, I have not received any in-services about this before or after the incident. k. On 1/15/19 at 10:50 a.m., the DON was asked to explain the incident involving (Resident #1) eloping from the facility. She stated, I did hear that the alarm to Home 7 was turned off. I heard that the next day. That day I made sure each Home's alarm was activated and working, and also that his (Resident #1's) call pendant was on. I don't think his call pendant was on when he eloped, and the alarm (exit door alarm) was not on. The next day I checked it. It was on, but the battery needed to be changed. They started, I believe, Q (every) 15 minute checks early in the morning after his elopement. I did ask who turned it off, but no one admitted to turning it off. The DON was asked if she was aware (Resident #1) was at risk for elopement prior to the incident. She stated, I knew he was at risk for elopement. I don't think he had attempted to leave before. His call pendant was to be on him at all times and the alarms on doors were not to be turned off. I believe the alarm model he has can still be turned off. She was asked if there had been any in-services regarding elopement since the incident. She stated, There was just an initial in-service (1/14/19), but no monitoring of alarms put in place. She was asked if she knew how long the resident was missing prior to staff realizing he was gone. She stated, I haven't got a good answer as to how long he was gone, but I'm saying 30 to 45 minutes. I was told he got to the gates. I'm guessing 150 to 200 yards. She was asked if the resident had been assessed to be at risk for elopement. She stated, There's a Wandering Risk Assessment done on everyone. It's on their profile. We have books at the Nurses Stations. There's nothing in place to make sure the nurses are communicating with the (CNAs). The in-service that was done was only to address not to turn alarms off. I didn't know that he had actually been witnessed exiting his Home and brought back in on 1/8/19 at 1950 (7:50 p.m.) until a day later when I read the note. She was asked if she had asked the nurse about this. She stated, No I did not. She was asked if there had been any other residents who attempted elopement in the last 3 months. She stated, I'm not aware of any other residents exiting any of the Homes in the last 3 months. l. On 1/15/19 at 10:50 a.m., CNA #5 was asked to explain the incident regarding (Resident #1's) elopement). She stated, I was working that evening. Approximately 7:20 p.m., I was leaving for my supper break and the back gate was open. The resident was almost at the (other facility name). I stopped and he banged on my window. It was dark. It scared me so I drove off a little bit, looked in my rear view mirror, and thought I recognized him. I put him in my car and drove to my Home (Home 8). The other (CNA) did not know him, so I called the RN Supervisor. She came approximately 5 minutes after I called. She said she recognized him. I took him to Home 7. She was asked if there had been any additional interventions put in place since the elopement. She stated, I'm not aware of any additional interventions. The doors have loud alarms on them already when they are opened. I don't know if the alarms can be turned off, I've never tried. She was asked if she knew how long (Resident #1) had been gone before she brought him back. She stated, I don't know how long he was gone before I brought him back. He got down to the back gate near that other Nursing Home. She was asked how she is made aware of which residents are at risk for elopement. She stated, I think we are made aware of residents at risk of elopement by bracelets. She was asked if there had been any in-services since the elopement. She stated, I think there was an in-service after this incident. m. On 1/15/19 at 11:10 a.m., LPN #2 was asked if she was working when (Resident #1) eloped. She stated, I was working the night (Resident #1) eloped from Home 7. I only had that home. She was asked if the resident had eloped in the past. She stated, I'm only aware he got out that one time, that night. She was asked if she was aware he was at risk for elopement. She stated, I knew he was at risk for elopement prior to his getting out. She was asked how the staff is made aware of residents who are at risk for elopement. She stated, There is no book. We are just told verbally when residents are at risk for elopement. She was asked what types of interventions were in place to prevent elopement, and to alert staff of attempted elopements. She stated, We have door alarms on all 3 doors and that was the only intervention prior to him getting out. The alarm on the front door can be turned off. She was asked how long (Resident #1) had been gone prior to the staff realizing he had eloped. She stated, I'm not sure how long he had been gone before he was brought back. I was told he got to the back gate. I don't know how far. I never use that gate. I was not aware he was missing. I was in the back doing med (medication) pass. I don't remember hearing an alarm. After he was returned I checked the door, and the alarm was off. All I did was turn it back on. She was asked if there had been any in-services since the elopement. She stated, There were no in-services after the incident. n. On 1/15/19 at 1:37 p.m., CNA #6 in Home 7 was asked if she could turn off the alarm on the front door, side door, and back door. CNA #6 was able to turn each door alarm off. She was asked if she was aware of a book with residents at risk for elopement. She stated, I'm not aware of any book to let us know any resident is at risk for elopement. I knew (Resident #1) was at risk for elopement prior to him getting out. There are 3 (CNAs) and 1 nurse on Day shift Monday thru Thursday, and on Fridays, 2 (CNAs) and 1 nurse. If he gets out, the door will alarm and his wanderguard will set off another alarm if he gets through the threshold. He came here on (MONTH) 31st (YEAR). I wasn't aware he was at risk for elopement until just before Christmas. He started trying to get out. The alarm use to be turned off until he started trying to get out. o. On 1/17/19 at 12:55 p.m., Administrator #2 stated, I was first notified at 8:02 p.m. (MONTH) the 8th (1/8/19) by (RN Supervisor Name) of the elopement. I was told he was found at the back gate by a (CNA). He was returned to his home and had no injuries. She said the alarm was turned off. I know the alarm was off when he got out, but don't know when it was turned off. We did do an in-service afterwards. It was done on 1/10/19. There was no monitoring initiated. p. On 1/17/19 at 2:19 p.m., the Maintenance Director was asked if the gates were usually open or closed. He stated, They are usually open during standard hours of work Monday thru Friday, 8:00 a.m. to 4:30 p.m. I normally close them when I leave at approximately 4:30 p.m. Around the Christmas holidays an ambulance had hit the gate controller on the inside metal gate, and it was not stable. (Deputy Director) and I decided just to leave it open as to not damage vehicles or a person. There is no way for the gate to open by a person, only by vehicles. 2. A facility policy titled Elopement provided by the DON on 1/15/19 at 6:16 p.m. documented, .Policy Statement . Staff shall investigate and report all cases of missing Veterans . Policy Interpretation and Implementation . 1. Staff shall promptly report any Veteran who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing . 2. If an employee observes a Veteran leaving the premises, he / she should . a. Attempt to prevent the departure in a courteous manner . b. Get help from other staff members in the immediate vicinity, if necessary . and, c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a Veteran has left the premises. 3. The Immediate Jeopardy was removed and the scope / severity reduced to D on 1/16/19 at 12:30 p.m. when the facility implemented the following Plan of Removal: a. .Date: 1/15/19 . Plan of removal: Failure to prevent elopement for residents at risk b. Effective immediately at 1800 (6:00 p.m.) on Tuesday, 1/15/19 the following items are to be initiated for all employees on (Facility Name) roster, any new hires, and agency contract (direct care) staff c. Update all Wandering Risk Assessments on all residents to identify who triggers for moderate to high risk. (Done 1/14/19). This will be done on all admissions, re-admissions, quarterly or as needed. d. All moderate / high risk residents will be flagged as an elopement risk in (computer system) . (Done 1/14/19). This will be reviewed and updated quarterly or as needed. e. All elopement binders in each home will be reviewed and updated with a photo of the resident, demographics and policy. (Done 1/15/19). This will be reviewed and updated quarterly or as needed. f. All direct care and non-direct care staff will be in-serviced on the Risk for Elopement / Wandering List and a copy of this list will be available in each UW (CNA) Shift Communication Binder, as well as in the Elopement Binder. (Initiated on 1/15/19 but will be completed by 1/22/19). This list will be updated quarterly or as needed for any changes. g. All direct care and non-direct care staff will be in-serviced on the policy for Elopement (Initiated on 1/15/19 but will be completed by 1/22/19). This list will be updated quarterly or as needed for any changes. h. All direct care and non-direct care staff upon arrival to shift starting on 1/15/19 will be in-serviced by Administration / designee to ensure the process is in place as follows: 1.)* All homes are to have functioning door alarms that alert when anyone exits or enters the home. (3 exits in each home). This will be monitored by the LPN every shift, daily for the next 30 days or until substantial compliance noted. RN supervisor to ensure completion each shift. 2.) * If an alarm is no longer functioning, immediately notify the RN supervisor on duty for immediate replacement. 3.) * All staff to be in-serviced on keeping the garage door locked at all times. This will be monitored by the LPN every shift, daily for the next 30 days or until substantial compliance noted. RN supervisor to ensure completion each shift. 4.)* Call pendants will be verified they are in place for each resident every shift. This will be monitored by the LPN every shift, daily for the next 30 days or until substantial compliance is noted. RN supervisor to ensure completion each shift. 5.)* Pagers / Beepers will be kept on direct care staff in the homes at all times. This will be monitored by the LPN every shift, daily for the next 30 days or until substantial compliance noted. RN supervisor to ensure completion each shift. 6.)* If any pager/beeper issues are noted, notify RN supervisor on duty for immediate repair. i. Plan of Removal will go into effect immediately 1/15/19, and will be monitored daily each shift for the next 30days. **If desired results are noted within 30 day plan, then after 2 weeks on (1/30/19), monitoring will continue 3 times a week each shift on Monday's, Wednesday's, and Saturday's until substantial compliance noted for permanent process. Any negative findings are to be documented and reviewed.