Every finding on record at Arkansas Veterans Home at Fayetteville

Based on observation, interview, and facility policy review, the facility failed to ensure opened food items in the freezer and the storage areas were covered and sealed; expired food items were promptly removed from stock to maintain freshness; dietary staff practiced good hand hygiene before handling clean equipment or food items; and hot food items were maintained at or above 135 degrees Fahrenheit on the steam table for 2 of 2 meals observed. The findings are: 1. On [DATE] at 10:17 AM, the following observations were made on top of the food preparation counter in the kitchen: a. An opened half gallon of soy sauce that was partially used was on top of the food preparation counter in the kitchen. The manufacture specification on the gallon specified to refrigerate after opening. The District Manager stated it should have been in the refrigerator and not out. b. An opened box of corn starch. The box was not covered or sealed. c. An opened box of salt. The box was not covered or sealed. The District Manager confirmed the boxes were open and she would place them in zip sealed bags d. An opened bag of sugar. The bag was not sealed. The District Manger confirmed that the bag was not sealed and started to bag it. e. The Dietary Manager verified none of the items observed were being used for meal preparation at the time of observation. 2. On [DATE] at 10:26 AM, two boxes of cookies were on a shelf in the walk-in freezer. The boxes were not covered or sealed, exposing the cookies to air. The Dietary Manger confirmed the cookies were not covered or sealed. 3. On [DATE] at 10:31 AM, the following observations were made on a shelf in the dry goods storage room: a. Three of 3 bags of butter fingers were on a shelf in the storage room and had an expiration date of [DATE]. The Dietary Manager confirmed the expiration dates on the bags. b. Three of 3 bags of [chocolate cream filled] cookies were on a shelf in the storage room and had an expiration date of [DATE]. The Dietary Manager confirmed the cookies were dead . c. A box of spice cake mix was on a shelf in the storage room. The box documented, Best used by ,d+[DATE] 2024. The Dietary Manager stated he would remove it from the stock. d. The Dietary Manager verified this area of storage was not used to store dented cans or outdated food items that would be intended for disposal. 4. On [DATE] at 11:13 AM, eight cartons of strawberry pudding were on a shelf in the refrigerator with an expiration date of [DATE]. The Dietary Manager stated they were expired. 5. On [DATE] at 11:17 AM, the following observations were made in the freezer in the Hydration Room on the 600 Hall: a. An opened box of taquitos that contained loose taquitos was in the freezer. The box was not covered, exposing the taquitos to possible freezer burn. b. An opened carton of vanilla ice cream was in the freezer. The ice cream was discolored. The Dietary Manager was asked to describe the appearance of the ice cream. He stated it was a little frost bit. It looks like it was melted and refrozen. 6. On [DATE] at 12:09 PM, the temperature of the corn beef when taken and read by Dietary [NAME] (DC) #4 on the steam table in the dining room kitchen on the 500 Hall was 126.8 degrees Fahrenheit. The meat item was not reheated before serving to the residents. The Dietary Manager stated the meat should have been reheated before serving. 7. On [DATE] 11:22 AM, the following observations were made during the noon meal service in the Kitchenette on the 500 Hall: a. DC#4, who was serving the lunch meal, wore gloves on her hands when she received bags of bread and bags of chips from the Dietary Manager and placed them on the counter by the steam table, untied the bags, picked up tray cards and placed them on the meal trays. Without changing gloves and washing her hands, she picked up plates from the plate warmer and placed them on the trays with her contaminated gloved fingers touching the inside of the plates. b. DC #4 still had not changed gloves or washed her hands before, using the same contaminated gloves, removing slices of bread from the bag. DC #4 placed the slices of bread on a plate and used tongs to place corn beef on one side of the bread, positioned the corn beef on top of the bread with her contaminated, gloved hand, then topped the corn beef with sauerkraut and remaining bread with her contaminated gloved hand to create a corn beef sandwich to be served to the residents for lunch. c. On [DATE] at 12:26 PM, DC #4 stated she should have washed her hands (before touching food intended to be served to residents). 8. On [DATE] at 2: 40 PM, DC #5 was wearing gloves on her hands when she opened the refrigerator and removed a log of cheese and placed it on the counter, contaminating the gloves. Without changing gloves and washing her hands, she started to remove cheese from the original packet and place it in a container to be used when serving the supper meal. DC #5 was asked during an interview what she should have done after touching dirty objects, before handling clean equipment. DC # 5 stated, changed gloves and washed his hands 9. On [DATE] 4:05 PM, DC #5 was wearing gloves on her hands when she picked up a box of clear plastic film and placed it on the counter. Without changing gloves and washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents for who required pureed diets. DC #5 was asked during an interview what she should have done after touching dirty objects before handling clean equipment. DC # 5 stated, changed gloves and washed his hands. 10. A review of facility policy titled, Proper Hand Hygiene initiated 2017, provided by the Dietary Manager on [DATE] indicated, staff should wash their hands with soap and water in between gloves changes, when changing tasks, and after removing gloves and before putting in a fresh pair of gloves. 11. A review of facility policy titled, Food Storage: Dry Goods initiated 2023 provided by the District Manager on [DATE] indicated all food items will be stored in a manner appropriate and timely utilization based on the principle of first in first out inventory management.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. The findings are: 1. The 03/17/2025, the supper menu documented the residents on regular diets were to receive 3 ounces of fried fish. The residents on mechanical soft diets were to receive a #10 scoop (3 ounces or 3/8 cup) of ground fish and 1/2 cup of chopped okra and tomatoes. The residents who received pureed diets were to receive a #8 scoop (4 ounces or 1/2 cup of pureed fish and a #16 scoop (2 ounces or 1/4 cup) of pureed dinner roll. On 3/17/2025 at 5:48 PM, the following observations were made during the supper meal service: a. Dietary [NAME] (DC) #5 used a #30 scoop (1.25 ounces or 1/8 cup) to serve a single portion of pureed bread, instead of a #16 scoop (2 ounces or 1/4 cup) as specified on the menu. b. DC #5 used a 2 ounce (1/4 cup) spoon to serve a single portion of pureed fish, instead of a #8 scoop (4 ounces or 1/2 cup) as specified on the menu. c. DC #5 used a 2-ounce (1/4 cup) spoon to serve a single portion of ground fish, instead of a 10 scoop (3 ounces or 3/8 cup) as specified on the menu. d. DC #5 used a 2-ounce (1/4 cup) spoon to serve a single portion of chopped okra and tomatoes, instead of 1/2 cup as specified on the menu. d. DC #5 served a small fried patty to the residents on regular diets, instead of 3 ounces as specified on the menu. On 3/17/25 at 6:37 PM, the Dietary Manager was asked if he could weigh the same amount of breaded fried fish served to the residents who received regular diets. He did and stated it was 2.5 ounces. He was asked if he could weigh the same hamburger meat served to 8 residents who received hamburger patties due to disliking fish. He did and stated it was 2.7 ounces. 3. On 3/17/25 at 6:45 PM, DC #5 was asked what size of scoop she used when serving pureed food items and mechanical soft diets and she stated she used the blue scoops (2 ounces or 1/4 cup). DC #5 was asked how many servings she gave to each resident. She stated, she gave one (1) serving each. DC #5 was asked if she reviewed the supper menu before meal service. She stated she did not. 4. 03/18/25 at 2:28 PM, during an interview the Distract Manager was asked for the policy on how to follow the menu when preparing and serving food. She stated the kitchen staff used the production sheet.

Based on observations, interviews, facility document review, and policy review, it was determined that the facility did not ensure that Enhanced Barrier Precautions (EBP) were carried out for 1 (Resident #31) of 4 sampled residents reviewed for Enhanced Barrier Precautions (EBP). The findings include: The significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/09/2025 indicated Resident #31 had a Staff Assessment for Mental Status (SAMS) score of 5 (indicating severely impaired cognitive skills). The MDS indicated that the resident had diagnoses of cerebrovascular accident (stroke), non-Alzheimer's dementia (a decline in the function of the brain), aphasia (the inability to speak), and a gastrostomy [PEG] (feeding tube going directly to the stomach). A) On 03/19/25 at 08:41 AM, Registered Nurse (RN) #3 was observed attempting medication administration via the PEG tube for Resident #31. Resident #31's room was observed to have signage to the right of the door, indicating the resident was on Enhanced Barrier Precautions (EBP). The EBP signage indicated the need for staff to put on Personal Protective Equipment (PPE), that included both a gown and gloves, when performing care for the Resident. PPE was observed to be available inside the room in plastic containers. Steps observed in the process performed by RN #3 were as follows: 1) Performed hand hygiene. 2) Prepped four medications 3) Performed hand hygiene 4) Put on gloves 5) Began the process to give the medications by pausing the tube feeding and manipulating the PEG, attempting to flush the tube with a syringe and/or pull back on the plunger. No gown was observed to have been put on by the nurse in this process. B) On 03/19/25 at 02:45 PM, RN #3 was observed performing a PEG tube residual check (the process of ensuring the Resident's stomach is not too full) for Resident #31. EBP signage was at the door and PPE was available in the resident's room in plastic containers. Steps observed in the process performed by RN #3 were as follows: 1) Performed hand hygeine 2) Put on gloves 3) Obtained syringe for checking residual 4) Began the process to check for residual by pausing the tube feeding and manipulating the PEG and the syringe to check for residual. No gown was observed to have been put on by the nurse in this process. C) On 03/19/2025 at 02:49 PM an interview with RN #3 was conducted after care was completed. RN#3 was asked about the EBP signage for the resident. RN #3 immediately acknowledged they did not follow EBP by putting on a gown. RN #3 was asked why it is important for staff to carry out EBP for the resident. RN #3 answered that it was important because it [PEG] was an open portal into a body cavity. D) On 03/20/2025 at 10:07 AM the Medical Director (MD) was interviewed via telephone. The MD indicated that a resident with a PEG tube would be expected to have EBP. Also, the MD indicated that it was important for EBP to be followed to avoid infection and protect the resident. E) On 03/20/25 at 11:20 AM the Assistant Administrator was interviewed regarding EBP. The Assistant Administrator stated that it was expected for a resident with a PEG to have EBP because the purpose was dual fold - to prevent staff from transmitting microbes to the resident and vice versa. The Assistant Administrator was notified that observations were made of EBP not being carried out as directed by the signage posted at the resident's room. F) On 03/20/25 at 03:50 PM the Infection Preventionist (IP) was interviewed. The IP stated that it was expected for a resident with a PEG to have EBP because it was important to protect the resident when they had an indwelling device. G) The facility policy titled Enhanced Barrier Precautions, with a revised date of 06/01/2024, was reviewed and stated gloves and gowns should be used during high contact resident care activities done in a resident's room. In addition, a high contact activity list was provided within the policy that included Device care: feeding tube. H) The educational document titled In-Service Training on the topic Enhanced Barrier Precautions with a date of 01/13/2025 was reviewed. A phrase in the body of the document attached to the training stated EBP includes the use of gown and gloves during high-contact resident care activities. In the list of high-contact resident care activities was listed device care and use of feeding tubes. 50924

Based on interviews, record review, and facility document review, it was determined the facility failed to monitor and notify the resident ' s representative of high trust balances prior to reaching the Social Security resource limit for 1 (Resident #12) for 3 residents reviewed for resident trust fund accounting. As a result, Resident #12 lost their Medicaid benefits and was required to private pay for room and board at a personal cost of $7,817.56. The findings include: A review of a facility document titled, Resident Informational Handbook, dated April 2024 indicated, The facility must manage your deposited funds with your best interest in mind. A review of Resident #12's Admission Recorded, revealed the facility admitted the resident on 07/15/2015 with diagnoses of mood disorder and schizoaffective disorder. A review of Resident #12's Medical Diagnoses, revealed the principal diagnosis was schizophrenia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment. A review of Resident #12's account ledger #1532, from 03/01/2024 to the current date of 03/17/2025 revealed, Resident #12's balance on 07/03/2024 was $2,721.82, $721.82 above the allowed limit. The balance reached $9,177.24 on 10/09/2024 and remained above the allowed limit through 10/17/2024 when the balance was $7,817.56. During an interview on 03/18/2025 at 8:38 AM, the Financial Analyst stated she was unaware notices were to be sent out regarding Medicaid limits. The previous business office manager stated we had always handled [Resident #12's] financials and she never had me send any notices out either. After the previous business office manager left abruptly, the Administrator and I started looking at the balance in Resident #12's trust and we switched the resident to private pay until they were eligible for Medicaid again, then they were switched back. A review of a facility statement with a date of 10/01/2024 revealed, Resident #12 was privately charged for room and board starting on 09/27/2024 through 10/31/2024. The charges totaled $7,817.56. The payment was due by 10/10/2024. A review of check #8058 written from the facility to itself on 10/21/20024 indicated that the facility was paid $7,817.56 from trust account #1532. During an interview on 03/18/2025 at 9:35 AM, the Administrator stated there had been no notices sent out for any balance issues. The facility usually issues monthly statements. We do not have any outstanding balance issues right now. The Administrator stated the facility was supposed to let residents or their representatives know before accounts reach $2,000 so they can do a spin down. I believe we are notifying people for spin downs; I have not personally done that. Regarding Resident #12 someone signed the resident in, and later no one wanted to handle the money. The facility did a rep payee to take over money management. I didn't know the resident had that much of a balance. The Financial Analyst reached out to Medicaid and the resident no longer qualified for benefits, so we had to switch the account to private pay and re-apply for benefits later. I was notified of the high balance when the previous business office manager left, and the Financial Analyst told me. I was like, Oh God. I was never aware of a paper given to me for high balance notifications and the risk of losing Medicaid benefits. It would appear in this situation where the facility was the rep payee I should have been notified. It should have been something internal which should have been dealt with well before a balance of $7,000. A review of the Trust Current Account Balance dated 03/17/2025 revealed, Resident #12 had a balance of $2,362.79.

Based on observation, interview and record review, the facility failed to ensure a sufficient number of competent staff were employed to safely and effectively carry out the functions of 1 of 1 kitchen in the facility which fed 45 residents. The findings are: On 1/24/24, the Certified Dietary Manager served lasagna, lettuce salad and chilled dessert to residents on the 500 and 600 halls. The lasagna did not temp to the required temp of 135.0 degrees, and the lettuce salad temp was 103.0 degrees which it should be 41 degrees or below. The chilled dessert temp was at 62.0 degrees instead of under 41.0 degrees. On 1/24/24 at 2:1, surveyor interviewed the Certified Dietary Manager (CDM), What can happen if food is served above 41 degrees for cold food, or below 135 degree temperature for hot food. CDM confirmed, well bacteria could grow. What type of bacteria, CDM confirmed, I don't know, I was not very good at food born illnesses. On 1/24/24 at 4:1, policy was provided by the Administrator titled Food Receiving and Storage . Policy Interpretation and Implementation .2. Danger Zone, means temperature above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients in ambient temperature) or 6 hours ( if cooked and cooled) may cause a foodborne illness outbreak if consumed. 3. Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation.) .

49071 Based on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents, to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The failed practice had the potential to affect 45 residents who received meal trays in their rooms and in dining rooms on 500 and 600 Hall. The findings are: 1. On 1/24/24 at 12:13 PM the surveyor observed the first tray being served on the kitchen line. The Certified Dietary Manager took the temperature of the food on the steam table with the following results; lasagna 173.3, lettuce salad 39.0, and the chilled dessert 36 degrees. 2. On 1/24/24 at 12:43 PM, the surveyor observed the food cart be delivered to the 500 hall by the kitchen staff member. The first tray was served at 12:45 PM and the final test tray was delivered at 1:12 PM. 3. On 1/24/24 at 1:04 PM, the CDM took the temperature of Resident #37 ' s tray with the following results; lasagna 129.7, lettuce salad 95.9 and chilled dessert 59.0. 4. On 1/24/24 at 1:09 PM, the CDM took the temperature of the food of Resident #30 ' s tray with the following results; lasagna 129.2, lettuce salad 103.0, and chilled dessert 62 degrees. 5. On 1/24/24 at 1:12 PM the surveyor requested the CDM take the temperature of the last tray, test tray that was in the cart with the following results; Lasagna 139.0, lettuce salad in a bowl 55.9, chilled dessert 66.5. On 1/24/24 at 2:13 PM, surveyor interviewed the CDM, and asked, should the hot food be served to residents at 129.0 degrees? The CDM said no it should be at least 135.0-140.0 degrees. The surveyor asked, should the cold lettuce salad be served to residents at a temperature of 103.0? The CDM confirmed, no, I should have served it in bowls. The surveyor asked, what should the temperature be for cold food to be served at? The CDM replied, 40 degrees or lower. The surveyor asked, should chilled dessert be served at 62.0 to residents? The CDM confirmed, no it shouldn't. The surveyor asked, what should the temperature be. CDM confirmed, 40 degrees or less. On 1/24/24 at 4:10 PM, the Administrator provided a Policy titled Food Receiving and Storage . Policy Interpretation and Implementation .3. Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (YCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial, or viral organisms capable of causing a disease or toxin formation). A. A review of an Admission Record indicated the facility admitted Resident #37 with a diagnosis of Alzheimer ' s. The quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident was cognitively intact. The resident required set-up help for eating. On 01/23/24 9:52 AM, during an interview, Resident # 37 stated, The food was cold and it did not start until they started moving in those hall carts. On 01/24/24 1:04 PM, a meal tray was delivered to Resident #37. The Dietary Manager (DM) used a thermometer to check the food temperature with a reading of lasagna at 129.7 degrees, lettuce with tomato with a reading of 95.9, garlic bread with a reading of 114 degrees, and a sundae brownie dessert with a reading of 59.0 degrees.

Based on observation, record review and interview the facility failed to ensure that hot food was maintained at or above 135 degrees before serving and failed to ensure that cold food maintained at or below 41 degrees before serving, to minimize the potential for food borne illnesses for residents who received meals from 1 of 1 kitchen, and facility failed to ensure food was covered during transport. These failed practices had the potential to affect 45 residents who received meals from the kitchen. the findings are: 1. On 1/24/24 at 12:13 PM, surveyor observed the first tray being served on the kitchen line. The Certified Dietary Manager took the temperature of the food on the steam table with the following results; lasagna 173.3, lettuce salad 39.0, and the chilled dessert 36 degrees. 2. On 1/24/24 at 12:43 PM, the surveyor observed the food cart be delivered to the 500 hall by the kitchen staff member. The first tray was served at 12:45 PM and the final test tray was delivered at 1:12 PM. 3. On 1/24/24 at 1:04 PM, the CDM took the temperature of Resident #37 ' s tray, lasagna 129.7, lettuce salad 95.9 and chilled dessert 59.0. 4. On 1/24/24 at 1:09 PM, the CDM took the temperature of Resident #30 ' s, food tray with the following results; lasagna 129.2, lettuce salad 103.0 and chilled dessert 62 degrees. 5. On 1/24/24 at 1:12 PM, the surveyor requested the CDM to take the temperature of the last tray, test tray that was in the cart. The temperatures were the following: Lasagna 139.0, lettuce salad 55.9 that was in a bowl, chilled dessert 66.5. On 1/24/24 at 2:1, surveyor interviewed the CDM and asked should the hot food be served to residents at 129.0 degrees? The CDM said no it should be at least 135.0-140.0 degrees. Should the cold lettuce salad be served to residents at a temperature of 103.0. CDM said no, I should have served it in bowls. The Surveyor asked, what should the temperature be for cold food to be served? The CDM replied, 40 degrees or lower. The surveyor asked should chilled dessert be served at 62.0 to residents. The CDM confirmed, no it shouldn't. The surveyor asked what should the temperature be? CDM confirmed, 40 degrees or less. On 1/24/24 at 4:10 PM, the Administrator provided a Policy titled Food Receiving and Storage . Policy Interpretation and Implementation .3. Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (YCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial, or viral organisms capable of causing a disease or toxin formation). On 01/22/24 at 5:35 PM Certified Nursing Assistant (CNA) #1 and CNA #3 were observed pushing a meal tray cart down the 500 hall to the dining room. The meal trays on top were in Styrofoam containers. The bowls of dessert salad, and beans were not covered. A tray card for Resident #6 contained a Styrofoam bowel of salad and beans was not covered and was open to air. A review of the facility policy, Food Preparation and Service, dated November 2022, specified, Food and nutrition services employees prepare, distribute and service food in a manner that complies with safe food handling practices. Food Service means the processes involved in actively serving food to the resident. When actively serving residents in a dining room or outside a resident's room where trained staff are serving food/beverage choices directly from a mobile food cart or steam table, there is no need for food to be covered. However, food should be covered when traveling a distance) i.e., down a hallway, to a different unit or floor). On 1/24/2024 at 10:55 AM The Infection Control Preventionist (ICP) was asked why should food be covered during transportation? The ICP stated, So that germs and stuff doesn't get into it.

Surveyor: [NAME], [NAME] Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with a. Infection control procedures, b. with distributing and serving food in a sanitary manner, c. with the resident's being free of accidents/supervision/devices, d. with meeting Pre-admission screening and Resident Review (PASRR) requirements, e. with respiratory care and f. with Quality Assurance and Assessment (QAA) and Quality Assessment and Performance Improvement (QAPI) requirements. These failed practices had the potential to affect all 49 residents who resided in the facility. The findings are: 1. A Recertification and Complaint survey was conducted on 01/26/24 at the facility. During this survey, the team identified concerns with laundry, preparing, and serving food in a safe/sanitary manner, residents being free of accident hazards/supervision/devices, PASRR requirements, providing respiratory care and QAA/QAPI program, infection control precautions. a. A review of the facility's Plan of Correction, with a completion date of 10/21/2022 indicated the Housekeeping Supervisor/Designee would monitor proper laundry infection control protocols through observations and documenting on Monitoring worksheet, weekly for 4 weeks, then monthly thereafter or until compliance is verified. The Housekeeping Supervisor/Designee will present all findings to QA committee for further review and recommendations. b. The Plan of Correction for serving in a sanitary manner, with a completion date of 10/21/2022 indicated staff were provided with in-service training on proper temperatures, observing meal service temperatures. The Food and Beverage Director/designee will ensure proper food storage are followed by observation and documenting on monitoring log 2 days a week for 6 weeks, until compliance is met, then to routinely monitor 1 time per week until compliance is verified. Monitoring will be documented on printed log; any negative finding will be corrected immediately, and Administrator/designee notified. c. The Plan of Correction for resident's being free of accident hazards/supervision, with a completion date of 10/21/2022 indicated the DON/designee will monitor weekly by observe resident rooms to ensure they are free of hazards before and/or after showers 3 times weekly for 4 weeks or until compliance is verified. Any negative findings will be corrected immediately, and the DON/designee notified. The DON/designee will present all findings to the quarterly QA committee for further review and recommendations. d. The Plan of Correction for PASRR screenings, with a completion date of 10/21/2022 indicated that weekly, the Social Worker/designee will review admissions for the past week to ensure PASRR complete for 4 weeks or until compliance is verified. Any negative findings will be corrected immediately, and the Administrator/designee notified. The DON/designee will present all findings to the quarterly QA committee for further review and recommendations. e. The Plan of Correction for Respiratory Care, with a completion date of 10/21/2022 indicated that daily, proper storage of oxygen tubing to prevent cross contamination and the potential for respiratory infections will be part of RN Supervisor/designee routine rounds every shift daily for 4 weeks or until compliance is verified. Any negative findings will be corrected immediately, and the DON/designee notified. The DON/designee will present all findings to the quarterly QA committee for further review and recommendations. f. The Plan of Correction for QAPI Program/Plan, with a completion date of 10/21/22 indicated that the Administrator/designee reviewed QAPI meeting agenda to ensure survey results were included as a topic of discussion by the Interdisciplinary Team. The Administrator/designee to in-service QAPI members regarding importance of monitoring programs for deficient practices through next survey to ensure no repeat findings. The Administrator/designee will monitor through quarterly QAPI meeting monitoring worksheets for 15 months or until compliance is verified. Any negative findings will be corrected immediately, and Administrator/designee notified. Administrator/designee will present all findings to the quarterly QA committee for further review and recommendations. 2. A Recertification survey was conducted on 1/26/24. During the survey the team identified concerns with infection control procedures, with the provision of nail care, with distributing and serving food in a sanitary manner, with the resident's being free of accidents/supervision/devices, with meeting PASRR requirements, with respiratory care and with QAA and QAPI requirements. Cross Reference F 880, F812, F695 F689, F645, 3. Review of the facility policy, Quality Assurance/Quality Assurance Performance Improvement (QAPI), specified, QAPI plan provides guidance for the overall quality improvement program. Quality assurance performance principles will drive the decision-making process within our organization. Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transition. Focus areas will include all systems that affect resident and family satisfaction, quality of care and services provided and all areas that affect the quality of life for personal living and working in or supporting our facilities. 4. On 1/26/2024 at 9:32 AM, the Administrator was asked, is there a mechanism for staff to report quality concerns to the QAA committee? The Administrator stated, Yes, we have hired and started a position for QA Analyst, and her function is to be out on the floor and talking to staff on any issues that we are having or that is preventing us from delivering care or meeting residents needs anyway, whether that be issues with supplies or processes or staffing. She gathers that information, and we incorporate that into our monthly QAPI meetings. The Administrator was asked how does the facility decide which issues to work on? The Administrator stated, We meet and discuss all of the things that have come up in our daily meetings and we set priorities based on that, if we have a process failure, that could potentially cause an issue for the residents we usually do an immediate plan of corrections even if it's in be-tween QAPI meeting dates. The Administrator was asked how does the facility know that corrective action has been implemented, is effective, and improvement is occurring? The Administrator stated, We review whatever the issue was, when we set a goal, we make it to where its measurable and so if wheat we are measuring doesn't improve, then we have to revise our plan to improve whatever the subject or the issue was.

Based on observation, interview, and record review, the facility failed to ensure resident individualized care plan was updated to ensure appropriate care was received for 1 (Resident #2) of 1 sampled resident who had a new service or level of care ordered or provided. The findings are: 1. On 01/22/24 at 4:49 PM, surveyor observed R (#2) had oxygen at 3 liters via nasal cannula being administered while resident was lying in his bed. 2. On 01/23/24 at 10:24 AM, surveyor observed R (#2) with oxygen being administered at 3 liters nasal cannula while resident was up in his chair. 3. On 01/23/23 at 2:50 PM, surveyor did a record review of care plan for R (#2) and noted there was no entry in care plan for resident to have oxygen administered. 4. On 01/25/24 at 8:50 AM, surveyor interviewed Minimum Data Set (MDS) coordinator, how do you know when to care plan something when it is added to a resident care. MDS confirmed, in our morning meetings we discuss it also I print out new orders, fall summary and risk data sheet each day. Who is responsible for care planning new interventions, MDS confirmed, I am. If a resident has a new intervention/order related to care put in place, should it be care planned. MDS confirmed, yes it should. 5. On 01/25/24 at 10:55 AM, the administrator provided policy titled Care Plans, Comprehensive Person-Centered . Policy Interpretation and Implementation .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

Based on observations, record reviews, and interviews, the facility failed to ensure Certified Nursing Assistants (CNA's) and Licensed Practical Nurses (LPN's) were able to demonstrate competency in identifying, reporting, and investigating injuries of unknown sources for 1 (Resident #27) of 1 sampled residents; and failure to report injury to residents during care for 1 (Resident #11) of 1 sampled residents, to prevent possible further injury or harm, and to rule out possible abuse. This failed practice had the potential to affect 49 residents. The findings are: Review of a facility policy titled, Change in a Resident's Condition or Status, dated February 2021, specified, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's attending physician on call when there has been a (an): accident or incident involving the resident. Review of a facility policy titled, Identifying Types of Abuse, dated September 2022, specified, As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. Abuse of any kind against residents is strictly prohibited. Physical abuse includes, but is not limited to hitting, slapping, biting, punching, or kicking. Examples of injuries that could indicate physical abuse include but are not limited to: injuries that are non-accidental or unexplained; bruises, including those found in unusual locations such as the head, neck, lateral locations on the arms, or posterior torso and trunk, or bruises in shapes (e.g., finger imprints). Staff are trained on abuse reporting and investigation, as well as on requirements to report reasonable suspicion of crime. Review of a facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, specified, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review of a facility in-service titled, Abuse & Neglect of a Resident, dated 9/28, indicated by signing staff acknowledge receipt of training/guidelines and agree to abide by the training/guidelines as instructed. Review of a facility check off for Licensed Practical Nurse (LPN) #5, dated 9/8/2023, documented LPN #5 received training / orientation related to Incidents and Accidents, and reporting alleged or suspected abuse/neglect. Review of a facility CNA Proficiency Check Off, dated 9/4/2023, for CNA #1, revealed CNA #1 met standards for abuse and infection control. Review of a facility, In-Service Training, dated 12/5/2023, documented, Complete all I & A's, also we need an immediate intervention put in on the Notes section when you are filling out your I & A, but it also needs to be updated in the resident's care plan also. 1. A review of an Admission Record indicated the facility admitted Resident #11 with a diagnosis of rheumatoid arthritis and diabetes mellitus. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The resident required maximum assist for most all activities of daily living (ADL). Review of Resident #11 Care Plan, revised on 12/6/2023, revealed the resident had an ADL self-care performance deficit related to (r/t) activity intolerance, fatigue, impaired balance. Interventions included a revision date on 12/6/2023; transfer: I require assistance by 1-2 staff to move between surfaces and as necessary. On 01/22/24 5:11 PM, Certified Nursing Assistant (CNA) #4 was observed pushing Resident #11 in a wheelchair down the hall of the 500 hall. CNA #4 ran over Resident # 11 ' s left foot with the wheelchair wheel. Resident # 11 was observed to make a face and yelled out. CNA #4 was overheard to ask Resident #11 if he was ok. Resident #11 stated his left foot hurt. CNA #4 told Resident #11 he needed foot pedals for his wheelchair. CNA #4 asked Resident #11 if he wanted to go take a shower. CNA #4 and Resident # 11 then disappeared behind the wall of the hall. On 01/23/24 02:34 PM, the Surveyor asked Resident #11 how is his foot, the one that got ran over yesterday. Resident # 11 said it was ok. A review of Resident #11 Progress Notes, dated 12/24/2023 through 1/22/2024 revealed no documentation related to injury of Resident #11 ' s left foot. A review of the Incident Report, dated 1/4/2024 through 10/23/2024 did not reveal any incident report documented for Resident #11. On 1/24/2024 at 9:05 AM, Certified Nursing Assistant (CNA) #1 was asked, what are you supposed to do if a staff runs over a resident ' s foot with a wheelchair? CNA #1 stated, Tell the nurse. CNA #1 was asked, have you been trained on abuse and reporting of injuries of unknown sources? CNA #1 stated, Yes, we go over it every time there is an issue. On 1/24/2024 at 9:15 AM, Licensed Practical Nurse (LPN) #4 was asked what are staff supposed to do if they run over a resident ' s foot with a wheelchair? LPN #4 stated, Tell the nurse, we assess, and do an incident report. LPN #4 was asked, when is an incident and accident report performed? LPN #4 stated, When there is a fall, skin tears, bruises like that, when they elope, any abuse, pressure ulcers, and any injuries. LPN #4 confirmed the facility had provided abuse and reporting of abuse training to staff. On 1/24/2024 at 9:29 AM LPN #1 was asked what are staff supposed to do if they run over a resident ' s foot with a wheelchair? LPN #1 stated, Notify the nurse, we assess it and notify the doctor, fill out an I & A (incident and accident) report. LPN #1 was asked do you have an I & A on Resident #11? LPN #1 stated, I haven't done one on named Resident #11 (him). LPN #1 checked the computer and stated, There is no I & A. LPN #1 was asked, has it been reported to you that a CNA ran over Resident #11 ' s left foot? LPN #1 stated, no. LPN #1 was asked have you been trained / in-serviced over reporting abuse and injuries to residents during care? LPN #1 stated, yes. On 1/24/2024 at 9:45 AM The Administrator was asked what are staff supposed to do if they run over a resident ' s foot with a wheelchair while providing care? The Administrator stated, Report to the nurse. The Administrator was asked when is an I & A performed? The Administrator stated, When there is an Incident & Accident, for skin tears, any changes, anything they don't know the cause of, or resident to resident. The Administrator was asked do you have an I & A on Resident #11? The Administrator stated, Not off the top of my head. The Administrator was asked has anyone reported to you that a CNA ran over Resident #11 ' s foot? The Administrator stated, no. The Administrator was asked, how are you notified of any incidents? The Administrator stated, They call immediately if it's abuse, and they will send texts, usually in morning meeting I'm updated, and I have to sign off in point click care on the incidents and accidents. The Administrator verbally confirmed staff had been trained on reporting abuse and reporting of injuries to residents. On 1/24/2024 at 11:27 AM The Administrator stated, I spoke with CNA #4 and CNA #4 admitted to bumping and rolling over named Resident #11 foot. I spoke with CNA #4 about reporting and that it should have been reported, but CNA #4 didn't realize it at the time. We are going to be doing one on one with CNA #4. On 1/24/2024 at 12:04 PM CNA #4 was interviewed via telephone. CNA #4 was asked to describe what happened with R#11 and the wheelchair on 1/22/2024. CNA #4 stated, I was on showers that day, and was pushing named Resident #11 to the shower. Named Resident #11 usually propels in the wheelchair so we can't use foot pedals, as I was pushing named Resident #11, named Resident #11 did not lift his feet. His foot got caught on the wheel and came to a stop. We stopped and then went to the shower room. I was unaware I needed to fill out an I & A report. The Administrator told me. I did to my knowledge, what I was supposed to do. CNA #4 was asked have you been trained on reporting resident injury during care? CNA #4 stated, I don't work for the home named facility (VA), I didn't see it as an accident. 2. A review of an Admission Record indicated the facility admitted Resident #27 with diagnosis that included dementia. The annual Minimum Data Set (MDS), dated [DATE], revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The resident required maximum assist for personal hygiene and toileting; and was dependent on staff for bathing. A review of Resident #27 Care Plan, initiated on 12/7/2023, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to(r/t) dementia, fatigue, impaired balance, musculoskeletal impairment. Interventions included skin inspection: the resident requires skin inspection. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse; initiated on 7/12/2022. On 01/22/24 at 5:06 PM, Resident #27 observed sitting in the dining room. A large dark purple in color, area observed to the top of Resident #27 ' s left hand. On 01/22/24 at 5:41 PM, Resident #27 observed sitting in the dining room. A large dark purple in color, area covering the top of the left hand. On 1/23/2024 at 2:27 PM, Resident #27 observed with a large dark purple in color area covering the top of the left hand. Resident #27 was asked how it happened and Resident #27 stated I don't know. A review of the Incident Report, dated 1/4/2024 through 10/23/2024 did not reveal any incident report documented for Resident #27. A review of Resident #27 ' s Progress Note, dated 12/1/2023 through 1/23/2024 did not document any skin issues related to Resident #27 left hand. A review of Resident #27 ' s Skin Assessment, dated 1/19/2024, 1/12/2024, and 1/10/2024, did not document any skin issues related to R#27 left hand. On 1/24/2024 at 9:05 AM, Certified Nursing Assistant (CNA) #1 was asked, what are you supposed to do if you notice any new skin issues with the residents? CNA #1 stated, Notify the nurse. Resident #27 has a big bruise on the back of the hand. I reported it to LPN #5 yesterday. CNA #1 was asked what happened to Resident #27 ' s hand. CNA #1 stated, I don't know, and Resident #27 can't tell you. CNA #1 was asked, have you been trained on abuse and reporting of injuries of unknown sources? CNA #1 stated, yes, we go over it every time there is an issue. On 1/24/2024 at 9:12 AM, CNA #5 was asked, what are you supposed to do if you notice any new skin issues with the residents. CNA #5 stated Report to the nurse. CNA #5 was asked what happened to Resident #27 ' s left hand and did you report it to anyone? CNA #5 stated, It wasn't there last Thursday, the last day I worked. I mentioned it to LPN #5 on 1/23/2024 and she was off and didn't know how it happened. CNA #5 verbally confirmed the facility had provided training on abuse and reporting of unknown origins. On 1/24/2024 at 9:15 AM Licensed Practical Nurse (LPN) #4 was asked what are staff supposed to do if you notice any new skin issues with the residents? LPN #4 stated, Notify the nurse. LPN #4 was asked, what happened to the top of Resident #27 ' s left hand? LPN #4 stated, That's the first time knowing about it. LPN #4 was asked if there was an incident report for Resident #27 ' s left hand. LPN #4 looked in the computer and stated, I don't see any notes for the hand, and I don't see an incident report, I can make one. LPN #4 was asked, when is an incident and accident report performed? LPN #4 stated, When there is a fall, skin tears, bruises like that, when they elope, any abuse, pressure ulcers, and any injuries. LPN #4 was asked, has anyone reported Resident #27 ' s left hand to you? LPN #4 stated, Not that I'm aware of. LPN #4 confirmed the facility had provided abuse and reporting of abuse training to staff. On 1/24/2024 at 9:45 AM, the Administrator was asked what are staff supposed to do if you notice any new skin issues with the residents. The Administrator stated, Report to the nurse. The Administrator was asked, what happened to Resident #27 ' s left hand? The Administrator stated, I believe named Resident #27 had a blood draw. The Administrator was asked, should that be documented somewhere? The Administrator stated, It should be documented somewhere, we should notice changes. The Administrator was asked if Resident #27 ' s left hand had been reported. The Administrator stated, Not specifically. The Administrator was asked, how are you notified of any incidents? The Administrator stated, They call immediately if it's abuse, and they will send texts, usually in morning meeting I'm updated, and I have to sign off in point click care on the incidents and accidents. The Administrator confirmed the facility provides staff with abuse and reporting of abuse training.

Based on interview and record review the facility failed to ensure 1 (Resident #3) of 1 resident that was reviewed for unnecessary medication did not receive a PRN (as needed) medication pass 14 days without justification, and an evaluation revision by the doctor. The findings are: 1. On 1/25/24 at 10:38 AM, a review of Resident #3 records indicated he had a diagnosis of hypertensive heart disease, diastolic congestive heart failure, Post Traumatic Stress Disorder, and anxiety disorder. A significant change Minimum Data Set (MDS) with an Assessment Reference Date of 1/16/24 indicated she had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact.) A review of the December 2023 physician order documented Haloperidol every 6 hours as needed for agitation, and Lorazepam 0.5mg every 2 hours as needed for anxiety both ordered on 12/28/23. A review of January 2024 Medication Administration Record revealed that Resident # 3 still had order for Haloperidol Lactate 0.5mg every 6 hours as needed for agitation, and Lorazepam 0.5mg every 2 hours as needed for anxiety. A review of the medical records, and the monthly pharmacy reviews did not indicate a justification of why Resident #3should continue 0.5mg Haloperidol 0.5mg as needed past 14 days, or Lorazepam 0.5mg every 2 hours for anxiety as needed. Resident #3 is not taking it on a regular basis therefore it should be discontinued , or scheduled per regulation. On 1/25/24 at 3:00 PM, the surveyor asked the Director of Nurse (DON), If the resident is receiving a PRN (as needed) psychotropic or antipsychotic medication(s): How is this medication monitored and how does the Interdisciplinary Team determine if the PRN medication is clinically indicated and ensure the PRN orders are consistent with PRN requirements for psychotropic and antipsychotic medications? Don stated, It should be clinically documented by the nurses why they still need the medication then followed up with the MD as to why they are still on it and his discretion if they stay on it or if the doctor needs to try something else.

Surveyor: [NAME], [NAME] Based on Observation, Interview, and Record Review the facility failed to assure the two medication carts were free from expired medications and that the controlled substances were separately locked in a permanently affixed compartment. The findings are: On 1/24/2024 at 8:50 AM Med Cart 1, LPN #2: Biscadyl sup.10 mg filled 5/17/23 # 6 APAP sup. 650 mg filled 5/17/23 exp. 11/16/23 # 9 Biscadyl sup. 10 mg filled 9/8/22 expired 3/7/23 #5 On 1/24/2024 at 9:01 AM, the medicine room on the 6th floor the narcotic box is behind two locks, but the narcotic containers are not attached to the refrigerator shelf. The Surveyor was able to pick the narcotic boxes up and remove them from the refrigerator. On 1/25/2024 at 9:05 AM, the Surveyor handed the narcotic box to the LPN #2 asked her, what can you do with the narcotic box? The LPN #2 said, I could carry it off. Surveyor asked her if the narcotic box should be attached to the refrigerator shelf. The LPN #2 said, The narcotics are behind two locks, is it supposed to be attached to the refrigerator, if so, I did not know. On 01/25/2024 at 9:19 AM, LPN #3, Med Cart 2 there was Instant Food Thick with an expiration date of 9/2/2022. On 1/25/2024 at 9:23 AM, the Surveyor asked the LPN #3 who keeps track of the medications and gets rid of the expired medication in the medication carts. The LPN #3 said, the nurse using the cart. The Surveyor asked the LPN #3 what do you do with the expired medications. LPN #3 said we take them to the medication room and dispose of them. The Surveyor asked, what do you do with the expired narcotics. The LPN #3 said, we call the Director of Nursing (DON) and she comes to get them from us. On 1-26-2024 at 9:01 A.M. the Surveyor asked the DON who is responsible for assuring expired medications are disposed of off the medication carts. The DON said, I go through and a pharmacist goes through monthly. Medications are put in a bio-hazard bag and melted down. The Surveyor asked the DON how should the narcotic boxes be stored. The DON said, They should be behind two locked doors. On 1/25/24 at 1:48 PM A policy on, Medication Labeling and Storage was provided for us. Policy Interpretation and Implementation, Medication Storage .7. Controlled substances (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately .

Based on Observation, interview and record review, the facility failed to provide mandatory in-services for the year to all staff. This failed practice had the potential to affect all 49 residents in the facility. The findings are: On 1-25-2024 at 3:03 PM, the Administrator provided proof of the in services that were completed by the staff. It lacked the 12 hours of training in a year that is needed to care for residents. On 1-26-2024 at 9:07 AM, the Surveyor asked the Director of Nursing (DON) how many hours are staff required for in-services yearly. The DON said, twelve hours. The Surveyor asked the DON why are in-services important for the staff. The DON said, Because it is repetitive and helps the staff to remember. On 1-26-2024 at 9:28 AM, the Surveyor asked the Administrator how often in-services should be performed in a facility. The Administrator said, twelve hours for Certified Nursing Assistants, maybe the other staff too. The Surveyor asked the Administrator, why do the staff need in services. The Administrator said, for continuing education and get the new information out that changes often.

Based on observations, record review and interviews, the facility failed to ensure residents with injuries of unknown source, received care and treatment according to practical nursing standards, for 1 (Resident #27) of 1 sampled residents. The findings are: A review of an Admission Record indicated the facility admitted R#27 with diagnosis that included dementia. The annual Minimum Data Set (MDS), dated [DATE], revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The resident required maximum assistance for personal hygiene and toileting; and was dependent on staff for bathing. A review of Resident #27 Care Plan, initiated on 12/7/2023, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to(r/t) dementia, fatigue, impaired balance, musculoskeletal impairment. Interventions included skin inspection: the resident requires skin inspection. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse; initiated on 7/12/2022. Review of a facility policy titled, Identifying Types of Abuse, dated September 2022, specified, As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. Abuse of any kind against residents is strictly prohibited. Physical abuse includes, but is not limited to hitting, slapping, biting, punching, or kicking. Examples of injuries that could indicate physical abuse include but are not limited to: injuries that are non-accidental or unexplained; bruises, including those found in unusual locations such as the head, neck, lateral locations on the arms, or posterior torso and trunk, or bruises in shapes (e.g., finger imprints). Staff are trained on abuse reporting and investigation, as well as on requirements to report reasonable suspicion of crime. Review of a facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, specified, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review of a facility policy titled, Change in a Resident's Condition or Status, dated February 2021, specified, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's attending physician on call when there has been a (an): accident or incident involving the resident. Discovery of injuries of an unknown source. On 01/22/24 at 05:06 PM, Resident #27 observed sitting in the dining room. A large dark purple in color, area observed to the top of Resident #27 ' s left hand. On 01/22/24 at 5:41 PM, Resident #27 observed sitting in the dining room. A large dark purple in color, area covering the top of the left hand. On 1/23/2024 at 2:27 PM, Resident #27 observed with a large dark purple in color area covering the top of the left hand. Resident #27 was asked how it happened and Resident #27 stated I don't know. A review of the Incident Report, dated 1/4/2024 through 10/23/2024 did not reveal any incident report documented for Resident #27. A review of Resident #27 Progress Note, dated 12/1/2023 through 1/23/2024 did not document any skin issues related to Resident #27 left hand. A review of Resident #27 Skin Assessment, dated 1/19/2024, 1/12/2024, and 1/10/2024, did not document any skin issues related to Resident #27 ' s left hand. On 1/24/2024 at 9:05 AM, Certified Nursing Assistant (CNA) #1 was asked, what are you supposed to do if you notice any new skin issues with the residents? CNA #1 stated, Notify the nurse. Resident #27 has a big bruise on the back of the hand. I reported it to (named) Licensed Practical Nure (LPN) #5 yesterday. CNA #1 was asked what happened to Resident #27 ' s hand. CNA #1 stated, I don't know, and Resident #27 can't tell you. CNA #1 was asked, have you been trained on abuse and reporting of injuries of unknown sources? CNA #1 stated, Yes, we go over it every time there is an issue. On 1/24/2024 at 9:12 AM, CNA #5 was asked, what are you supposed to do if you notice any new skin issues with the residents. CNA #5 stated Report to the nurse. CNA #5 was asked what happened to Resident #27 ' s left hand and did you report it to anyone? CNA #5 stated, It wasn't there last Thursday, the last day I worked. I mentioned it to LPN #5 on 1/23/2024 and she was off and didn't know how it happened. CNA #5 verbally confirmed the facility had provided training on abuse and reporting of unknown origins. On 1/24/2024 at 9:15 AM, Licensed Practical Nurse (LPN) #4 was asked what are staff supposed to do if you notice any new skin issues with the residents. LPN #4 stated, Notify the nurse. LPN #4 was asked, what happened to the top of Resident #27 ' s left hand? LPN #4 stated, That's the first time knowing about it. LPN #4 was asked if there was an incident report for Resident #27 left hand. LPN #4 looked in the computer and stated, I don't see any notes for the hand, and I don't see an incident report, I can make one. LPN #4 was asked, when is an incident and accident report performed? LPN #4 stated, When there is a fall, skin tears, bruises like that, when they elope, any abuse, pressure ulcers, and any injuries. LPN #4 was asked, has anyone reported Resident #27 ' s left hand to you? LPN #4 stated, Not that I'm aware of. LPN #4 confirmed the facility had provided abuse and reporting of abuse training to staff. On 1/24/2024 at 9:45 AM, the Administrator was asked what are staff supposed to do if you notice any new skin issues with the residents. The Administrator stated, Report to the nurse. The Administrator was asked, what happened to Resident #27 ' s left hand? The Administrator stated, I believe Resident #27 had a blood draw. The Administrator was asked, should that be documented somewhere? The Administrator stated, It should be documented somewhere, we should notice changes. The Administrator was asked if Resident #27 ' s left hand had been reported. The Administrator stated, Not specifically. The Administrator was asked, how are you notified of any incidents? The Administrator stated, They call immediately if it's abuse, and they will send texts, usually in morning meeting I'm updated, and I have to sign off in point click care on the incidents and accidents. The Administrator confirmed the facility provides staff with abuse and reporting of abuse training.

49071 Based on observations, record review and interviews, the facility failed to ensure residents environment was free of accidents and hazards as possible, as evidenced by failure to ensure medications were not left at bedside for 1 (Resident #26) of 1 sampled resident; and failed to ensure staff reported the potential injury for 1 (Resident #11) of 1 sampled residents, to prevent further possible injury and delaying possible treatment, for 1 (Resident #11) of 1 sampled resident. The findings are: A review of an Admission Record indicated the facility admitted Resident #11 with a diagnosis of rheumatoid arthritis and diabetes mellitus. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The resident required maximum assist for most all activities of daily living (ADL). Review of Resident #11 Care Plan, revised on 12/6/2023, revealed the resident had an ADL self-care performance deficit related to (r/t) activity intolerance, fatigue, impaired balance. Interventions included a revision date on 12/6/2023; transfer: I requires assistance by 1-2 staff to move between surfaces and as necessary. Review of a facility policy titled, Change in a Resident's Condition or Status, dated February 2021, specified, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's attending physician on call when there has been a (an): accident or incident involving the resident. On 01/22/24 5:11 PM Certified Nursing Assistant (CNA) #4 was observed pushing Resident #11 in a wheelchair down the hall of 500 hall. CNA #4 ran over Resident #11 ' s left foot with the wheelchair wheel. Resident #11 was observed to make a face and yelled out. CNA #4 was overheard to ask R#11 if he was ok. Resident #11 stated his left foot hurt. CNA #4 told Resident #11 he needed foot pedals for his wheelchair. CNA #4 asked Resident # 11 if he wanted to go take a shower. CNA #4 and Resident #11 then disappeared behind the wall of the hall. On 01/23/24 2:34 PM, Resident # 11 observed sitting in a wheelchair in room. Resident # 11 was how his foot was, the one that got ran over yesterday. Resident # 11 stated, it was ok. A review of Resident #11 Progress Notes, dated 12/24/2023 through 1/22/2024 revealed no documentation related to injury of Resident #11 left foot. A review of the Incident Report, dated 1/4/2024 through 10/23/2024 did not reveal any incident report documented for Resident #11. On 1/24/24 at 9:05 AM, Certified Nursing Assistant (CNA) #1 was asked, what are you supposed to do if a staff runs over a resident ' s foot with a wheelchair? CNA #1 stated, Tell the nurse. CNA #1 was asked, have you been trained on abuse and reporting of injuries of unknown sources? CNA #1 stated, Yes, we go over it every time there is an issue. On 1/24/24 at 9:15 AM, Licensed Practical Nurse (LPN) #4 was asked what are staff supposed to do if they run over a resident ' s foot with a wheelchair? LPN #4 stated, Tell the nurse, we assess, and do an incident report. LPN #4 was asked, when is an incident and accident report performed? LPN #4 stated, When there is a fall, skin tears, bruises like that, when they elope, any abuse, pressure ulcers, and any injuries. LPN #4 confirmed the facility had provided abuse and reporting of abuse training to staff. On 1/24/24 at 9:29 AM LPN #1 was asked what are staff supposed to do if they run over a resident ' s foot with a wheelchair? LPN #1 stated, Notify the nurse, we assess it and notify the doctor, fill out an I & A (incident and accident) report. LPN #1 was asked do you have an I & A on Resident #11? LPN #1 stated, I haven't done one on R#11 (him). LPN #1 checked the computer and stated, There is no I & A. LPN #1 was asked, has it been reported to you that a CNA ran over resident #11 ' s left foot? LPN #1 stated, No. LPN #1 was asked, have you been trained / in-serviced over reporting abuse and injuries to residents during care? LPN #1 stated, yes. On 1/24/2024 at 9:45 AM, the Administrator was asked what are staff supposed to do if they run over a resident ' s foot with a wheelchair while providing care? The Administrator stated, Report to the nurse. The Administrator was asked when is an I & A performed? The Administrator stated, When there is an Incident & Accident, for skin tears, any changes, anything they don't know the cause of, or resident to resident. The Administrator was asked, do you have an I & A on Resident #11? The Administrator stated, Not off the top of my head. The Administrator was asked has anyone reported to you that a CNA ran over Resident #11 ' s foot? The Administrator stated, no. The Administrator was asked, how are you notified of any incidents? The Administrator stated, They call immediately if it's abuse, and they will send texts, usually in morning meeting I'm updated, and I have to sign off in point click care on the incidents and accidents. The Administrator verbally confirmed staff had been trained on reporting abuse and reporting of injuries to residents. On 1/24/2024 at 11:27 AM, the Administrator stated, I spoke with CNA #4 and CNA #4 admitted to bumping and rolling over Resident #11 ' s foot. I spoke with CNA #4 about reporting and that it should have been reported, but CNA #4 didn't realize it at the time. We are going to be doing one on one with CNA #4. On 1/24/2024 at 12:04 PM, CNA #4 was interviewed via telephone. CNA #4 was asked to describe what happened with Resident #11 and the wheelchair on 1/22/2024. CNA #4 stated, I was on showers that day, and was pushing named Resident #11 to the shower. Named Resident #11 usually propels in the wheelchair so we can't use foot pedals, as I was pushing named Resident #11, named Resident #11, did not lift his feet. His foot got caught on the wheel and came to a stop. We stopped and then went to the shower room. I was unaware I needed to fill out an I & A report. The Administrator told me. I did to my knowledge, what I was supposed to do. CNA #4 was asked, have you been trained on reporting resident injury during care. CNA #4 stated, I don't work for the home (named)VA), I didn't see it as an accident. On 1/22/24 at 4:32 PM, surveyor observed Resident #26 sitting in his chair having several different medication ointments on bedside table and on his computer table. On 1/23/2 at 9:25 AM, surveyor observed Resident #26 in his room lying on his bed with several medication tubes of different ointments at his bedside. On 1/24/24 at 8:25 AM, observed resident #19 in his recliner with ointment medication tubes beside his bed on table and on his computer table. On 1/24/24 at 9:42 AM, the surveyor reviewed resident medical records to determine if a self- medication assessment had been completed. No assessment was identified. On 1/25/24 at 1:30 PM, the surveyor interviewed Registered Nurse #1 (RN) and asked should medications be left at a resident ' s bedside? RN#1 confirmed, only if they have had a self- medication assessment done and only the medication approved can be in the room locked in the box. On 1/25/24 at 1:36 PM, the surveyor interviewed the Director of Nursing (DON), and asked should medication be left at a resident ' s bedside. Don confirmed, no unless they have been evaluated to self- administer their own medication. On 1/25/24 at 1:48 PM, the Director of Nurses provided a policy titled Medication Labeling and Storage Policy Heading the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access with keys .4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays, or carts used to transport such items are not left unattended if open or otherwise potentially available to others .

Based on observation, record review, and interview, the facility failed to ensure nail care was provided, to maintain good personal hygiene for 1 Resident(#27) of 1 sample mix residents who required assistance with nail care. The findings are: A review of an Admission Record indicated the facility admitted Resident #27 with diagnosis that included dementia. The annual Minimum Data Set (MDS), dated [DATE], revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The resident required maximum assist for personal hygiene and toileting; and was dependent on staff for bathing. Review of Resident #27 ' s Care Plan, revised on 12/7/2023, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to (r/t) dementia. Interventions included, check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse, initiated 7/12/2022; I am totally dependent on 1 staff to provide shower at least twice weekly and as necessary, initiated on 12/7/2023; provide sponge bath when a full bath or shower cannot be tolerated, initiated on 7/12/2022. Review of a facility policy titles, Care of Fingernails/Toenails, dated October 2010, specified, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. On 01/22/24 at 5:41 PM, Resident # 27 observed sitting in the dining room. Resident #27 ' s fingernails are long with a dried black substance under them. 01/22/24 05:06 PM, Resident #27 observed with fingernails long with a dried black substance under them. On 1/23/2024 at 2:27 PM, Resident #27 observed with fingernails are long with a dried black substance under them. On 01/24/24 12:54 PM, Resident #27 observed self-feeding lunch in the dining room. Fingernails are long with a dark black substance under them. On 1/25/2024 at 10:39 AM, Certified Nursing Assistant (CNA) #1 was asked when nail care was done and who does it. CNA #1 stated, The aides can do it, and usually on their shower days or anytime the need to be done. CNA #1 was asked why should residents nails be clean and free of dried black substances. CNA #1 stated, Because it's nasty. CNA #1 was asked to describe Resident #27 ' s nails. CNA #1 stated, Gunk, most likely food, (named Resident #27) likes to spit food out and play in it. CNA #1 was asked when Resident #27 received a shower. CNA #1 stated, yesterday. On 1/25/2024 at 10:45 AM, Registered Nurse (RN) #1 was asked when nail care was performed and who performs it. RN #1 stated, During showers and the CNA's unless they are diabetic, then the nurses. RN #1 was asked why should residents nails be free of dried black substances. RN #1 stated, Because it's disgusting. RN#1 was asked to describe Resident #27 ' s nails. RN#1 stated, I don't know what it is, a dry black substances under the fingernails. RN#1 was asked to measure Resident #27 ' s nails from the edge of the finger to the end of the nail on the last four digits of the left hand. RN#1 stated, 0.6 centimeters. On 1/25/2024 at 10:55 AM The Infection Control Preventionist (ICP) was asked why should residents nails be free of dried black substances? The ICP stated, They should be free of any materials under the nails, we pray it's not food, because we are in Long Term Care (LTC), and for cleanness.

49071 Based on observation, interview, and record review the facility failed to ensure staff had on appropriate Personal Protection Equipment (PPE) for 1 (Resident #18) of 4 (Residents #2, #6, #14, #18) sampled residents that were on isolation, and failed to ensure proper signage was posted outside residents rooms to advise or instruct staff and or visitors on appropriate PPE to be worn, and failed to maintain and transport linens properly by staff in the hallway, and failed to ensure clean linen and dirty linen were handled properly in the laundry room to prevent cross contamination. The findings are: 1. On 01/22/24 at 4:04 PM, Resident #18 had red tape on the side of door that had documented, 1/14/24 -1/24/24 Surveyor observed Certified Nurse Aide (CNA) go into Resident #18 ' s room without donning a gown or gloves. Surveyor observed CNA go in and touch resident and ask if he needed changed, and then left the room without washing hands. a. On 01/23/24 at 9:03 AM, the surveyor observed male Certified Nursing Assistant (CNA)#2 enter Resident #18 ' s room without donning or doffing gown or gloves. CNA #2 went into the resident room to see if he was done eating, he assisted him with the rest of his breakfast. On 01/23/24 at 9:09 AM, the surveyor asked Certified Nurse Aide (CNA) #2, If a resident is on isolation what should you wear in the room when you're providing care? He stated, Gloves and the gown, but I was told he was off isolation He was asked, well, then what does this red tape up here with dates on it mean. CNA #2 confirmed, it means he is still on isolation, I just didn't even pay attention. Why is it important that you wear the appropriate PPE when you are providing care to a resident that's on isolation? He confirmed, I don't want to bring germs into them or bring anything out to other residents. On 01/25/24 at 8:29 AM, the surveyor asked Licensed Practical Nurse (LPN) #1, If a resident is on isolation what should you wear in the room when you are providing care? She stated, Gown and gloves. She was asked, how do you know that someone is on isolation. LPN #1 said, there is a piece of red tape on the door and a bin outside door with PPE in it also there is a sign on the door. The surveyor asked, what if there is not a sign on the door how does staff and visitors know that someone is on isolation? LPN #1 said I don't know I can't answer that. The surveyor asked, how would a visitor know that a resident is in isolation? LPN #1 said, I don't know. The surveyor asked why is it important that you wear the appropriate PPE when you are providing care to a resident that's in isolation? She stated, So you won't spread infection to yourself or other residents. On 01/25/24 at 8:34 AM, the surveyor asked the Infection Preventionist (IP), If a resident is on isolation how does your staff know. IP said, there is a piece of red tape on the door and a sign on the door also a bin outside with PPE in it. The surveyor asked If there is no sign on the door just a piece of red tape with dates on it, how would a visitor know that the resident was in isolation. IP said, they would not know. The surveyor asked has staff been trained to know what red tape mean? The IP said, yes, we tell them. The surveyor asked how about the agency staff? The IP said, they are told as well. The surveyor asked can you provide me with an in service that you have trained your staff on the red tape. The IP said, no I cannot, I don't have one. The surveyor asked what should staff/visitors do before entering an isolation room? The IP said, put their PPE on. On 1/24/2024 at 9:00 AM Certified Nursing Assistant (CNA) #1 was observed to exit room [ROOM NUMBER] carrying dirty linens against the body, under both arms, down 500 Hall. CNA #1 was overheard saying I do not have bags big enough for this. CNA #1 was asked, what kind of linens were you carrying down the hall? CNA #1 stated, The residents dirty bedding, dirty linen. CNA #1 was asked, why should linens not be carried against the body? CNA #1 stated, So we don't get no dirtiness on us. CNA #1 was asked, how do you usually protect yourself from dirty linens? CNA #1 stated, We usually use big bags to carry dirty linens in, but we are out. On 1/25/2024 at 9:00 AM, two large white bags, marked soiled, was observed in the floor of the 600 Hall laundry room in the clean linen area. Laundry Aid #1 was asked what was in the 2 white bags on the floor? Laundry Aid #1 stated, It was dirty linens and turned the bag over showing the word soiled written on the outside of the bag. Laundry Aid #1 stated, The bags contained linens, towels, sheets and bedding. On 1/25/2024 at 10:55 AM, the Infection Control Preventionist (ICP) was asked, why should soiled linens not be stored on the floor and with the clean linen? The ICP stated, Dirty laundry should not be on the floor when there is clean laundry out because of contamination. Review of a facility policy titled, Laundry and Bedding, Soiled, dated September 2022, indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. All used laundry is handled as potentially contaminated using standard precautions. Contaminated laundry is bagged or contained at the point of collection. Staff handle soiled textiles/linens with minimum agitation to avoid the contamination of air, surfaces, and persons. Clean linen is stored separately, away from soiled linens, at all times. Clean linen is kept separate from contaminated linen. The use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination.

Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed before a resident was admitted to the facility for 1 (Resident #3) of 1 (Resident #3) sampled residents who required a PASRR before admission to a skilled nursing facility. The failed practice had the potential to affect 49 residents. The findings are: Resident #3 was admitted on [DATE]. He has active diagnoses of Post Traumatic Stress Disorder and anxiety disorder. A Quarterly Minimum Data Set with an Assessment Reference Date of 1/16/2024 documented the resident scored 14 (indicates cognitively intact) on a Brief Interview for Mental Status. a. On 1/24/2024 at 1:21 PM, the resident's electronic clinical record was reviewed and there was no PASRR Level I noted in record at this time. b. On 1/24/2024 at 2:55 PM, the Administrator confirmed he did not have anything on this resident, after being asked to provide a Level I or Level ll PASRR or a letter from [a screening company] for this resident. d. On 2/24/2024 at 3:40 PM, the Administrator was asked, Do you know if [Resident #3] had a Level I PASRR done? He reviewed the the Resident's electronic clinical record and was unable to locate any information. When should a resident have a Level I PASRR done? He stated, Before they come into the facility or if they get a new diagnosis.

Based on interview, observation, and record review, the facility failed to ensure that an order to administer oxygen was written for 1 Resident (R #2) of 1 sampled resident. Who are receiving oxygen to prevent desaturation. The findings are: 1. On 1/22/24 at 4:49 PM, surveyor observed R (#2) with oxygen via nasal canula at 3 liters per minute. 2. On 1/23/24 at 10:24 AM, surveyor observed R(#2) sitting in wheel chair with oxygen at 3liters per minute. 3. On 1/23/24 at 2:57 PM, a review of R#2 medical record, physician orders revealed there was no order for oxygen to be administered. a. On 1/25/24 at 10:41 AM, surveyor interviewed Registered Nurse (RN)#1, When a resident is receiving oxygen should they have an order. RN#1 said yes, they should. The surveyor asked, who is responsible for making sure an order is placed in the computer. RN#1 said the doctor or the nurse or whoever receives the order should put it in. b. On 1/25/24 at 10:48 AM, the surveyor interviewed Director of Nurses (DON), and asked, when a resident is receiving oxygen should they have an order? The DON said, yes, any medication given should have an order. The surveyor asked, who is responsible for making sure an order is placed in the computer. The DON said nurse, RN supervisor, DON, or whoever takes the order. On 1/25/24 at 11:03 AM, administrator provided policy titled Oxygen Safety . Procedure 1. Oxygen therapy is administered to the resident only upon the written order of a licensed physician .

Based on observation, interview, and record review, the facility failed to ensure residents/families had the right to voice grievances and were provided a prompt resolution and failed to ensure the resident/families were apprised of the progress toward resolution for 2 (Residents #1 and #3) of 3 (Residents #1, #2 and #3) sampled residents. This failed practice had the potential to affect 64 residents/families according to the Roster Matrix provided by the Administrator on 03/15/23 at 4:03 p.m. The findings are: 1. Resident #1 had diagnoses of Dementia, Osteoporosis, and Chronic Kidney Disease. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/22 documented the resident required extensive physical assistance of one staff for bed mobility, transfer, dressing, toilet use, and limited physical assistance for personal hygiene, and was frequently incontinent of bowel and bladder. a. On 02/27/23, the Office of Long Term Care (OLTC) received a complaint regarding concerns related to Resident #1 via email, the email documented, .I emailed [Administrator #2] who had been the Administrator of the [Facility] for several years to address my concerns . as well as some minor issues I had in the month of January . I had not heard back from [Administrator #2] on 2-23-2023 . I emailed another administration employee to inform her of what happened to [Resident #1], and to see if [Administrator #2] was out of the office since I hadn't heard from him I was informed [Administrator #2] no longer worked at the [Facility] and I was provided another contact to forward my concerns to, which I immediately did. As of Monday afternoon I have not heard back from anyone [Director of Nursing (DON)] was who I was told I needed to contact, and [DON] was cc'd [carbon copied] on the response to my email . 2. On 03/15/23 at 1:35 PM, the Surveyor held an Entrance Conference with Administrator #1 and the last three months of grievance logs were requested at this time. 3. Resident #3 had diagnoses of Dementia, Heart Failure, and Parkinson's Disease. The Annual MDS with an ARD of 02/01/23 documented the resident scored 11 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two plus persons for bed mobility, transfer, dressing, toilet use, and personal hygiene, was frequently incontinent of bladder and always incontinent bowel. a. On 03/15/23 at 2:49 PM, Resident #3 was lying in bed with the Power of Attorney (POA) at the bedside. The POA stated there were concerns with Resident #3 that had not been addressed. The Surveyor asked the POA, Is there a process in place for concerns. The POA stated, I have sent emails. I have asked about investigations. I have asked for records, and they won't give it to me. I was told there were no forms to fill out, just put it in writing. I sent emails to [Administrator #2] back in September, and there were no follow ups. b. On 03/16/23 at 8:49 AM, the Surveyor asked Administrator #1, Do you have the grievance logs? Administrator #1 replied, They haven't tracked grievances since November 2022, so I have them tracking all emails and concerns now. The Surveyor requested information when available. c. On 03/16/23 at 11:12 AM, the Surveyor asked Administrator #1 about the grievance logs again. Administrator #1 replied, We have been without a Social Director since last November. I've got the DON working on the emails and putting them on grievance forms and should have it no later than 2:00 PM The Surveyor asked, How long have you worked here? Administrator #1 replied, Maybe two weeks. d. On 03/16/23 at 12:15 PM, the Surveyor asked the DON, Who can file a grievance? The DON replied, Until I got them, no one addressed the concerns, we didn't have a Social Worker no Administrator, and no one checked the [Administrator #2's] email, and [Administrator #1] didn't get here till last week. The Surveyor asked, How are residents and their families concerns resolved? The DON replied, Usually if there's a problem, the Social Worker used to send us stuff. I didn't know the concerns were supposed to be on the forms. The Surveyor asked, Who is responsible for following up with grievances? The DON replied, Usually the Social Worker than the Administrator. The Surveyor asked, When should a grievance be resolved? The DON replied, Hopefully immediately. The Surveyor asked, Who managed [Administrator #2's] emails after [Administrator #2] left? The DON replied, I don't know, I don't think anyone. The Surveyor asked, When did you talk to [Resident #1's] family? The DON replied, [Resident #1's] family sent an email on 02/23/23. I was gone and off on vacation. I came back on 02/28/23. [Resident #1's] family was sending emails to [Administrator #2] and [Administrator #2] had left before [Resident #1's] fall. I came back and contacted [Resident #1's] family because [Administrator #2] was not the Administrator anymore. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The DON replied, They should be following them all the time. e. On 03/16/23 at 12:41 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1, What is a grievance? CNA #1 replied, A complaint or concern. The Surveyor asked, Who can file a grievance? CNA #1 replied, Anyone. The Surveyor asked, How are resident's and resident's families concerns resolved? CNA #1 replied, If it's about a CNA, I bring them in and talk to them, and if it's about a nurse, I take it to the DON. The Surveyor asked, Who is responsible for following up with grievances? CNA #1 replied, I'm not sure. The Surveyor asked, Do you have grievance forms out on the floor? CNA #1 replied, I haven't seen them. f. On 03/16/23 at 1:50 PM, the Surveyor asked Administrator #1, Who can file a grievance? Administrator #1 replied, Anyone. The Surveyor asked, Who is responsible for following up with grievances? Administrator #1 replied, The Administrator. The Surveyor asked, When should a grievance be resolved? Administrator #1 replied, As soon as possible. The Surveyor asked, Tell me about [Resident #1's] family and the emails? Administrator #1 stated, We weren't aware of the emails, but as soon as we found out, we called and set up a phone conference. I don't know why [Administrator #2] didn't address [Resident #1's] family concerns. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and the CMS guidelines? Administrator #1 replied, My expectation is that they follow them. 4. The facility policy titled, Residents Rights Summary, provided by the Administrator on 03/15/23 at 4:03 PM documented, .have the right . To an accessible grievance procedure that is easy to use . 5. The facility policy titled, Complaint/Grievance Process, provided by the Administrator on 03/15/23 at 4:03 PM documented, .Allow residents and families to exercise his/her right to complain about services and care provided by [Facility] residents and families should also expect to receive a timely response to such complaint/grievance without fear of reprisal in respect of his/her rights . Procedure: 1. The grievance should be put in writing on a Concern Form located at the nursing stations, social work office or administration offices . A concern given orally to a staff member should be written on a Concern Form by the employee and given to the Social Worker and/or administration . 2. A timely response to the concern (within three work days) should be received from the department supervisor that is responsible for the area of concern. 3. should the concern not be resolved by the department supervisor, the next step is referring it to the administrator . 4. If still not resolved after taking it to the administrator, the next step is to refer it to the Ombudsman .

Based on observation, record review and interviews the facility failed to ensure interventions were developed and implemented to provide adequate supervision after a resident exited the building for 1 (Resident #1) of 3 (Residents #1- #3) who either were at risk of elopement and/or who had exited the facility. This failed practice resulted in immediate jeopardy, which caused or was likely to cause serious injury, serious harm, or death to Resident #1, who was actively mobile and exited the facility through an unsupervised exit door, resulting in injuries after the resident fell . The Administrator was notified of the Immediate Jeopardy on 3/1/22 at 2:20 PM. The findings are: 1. Resident [R] #1 had diagnoses of Cerebral Infarction, Autistic Disorder, [CONDITION(S)], Spinal Stenosis and Traumatic Brain Injury. The Quarterly Minimum Data Set with an Assessment Reference Date of 11/11/21 documented the resident scored 11 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status and had no behaviors of wandering. a. An un-witnessed Incident Report provided by the Interim DON on 3/1/22 at 11:02 AM documented, Date: 2/11/22 00:00 [12:00 midnight] Resident: [Resident #1] Incident Location: Outside . Incident Description: . Resident found lying on ground outside fire stairwell door on first floor by maintenance with bleeding facial injuries on 0000 2/11/22. Resident Description: Resident stated, I stepped in a hole. I was going to see my brother. Immediate Action Taken Description: Nurse and RN met with resident in the maintenance office on first floor . There were no interventions documented on the incident report. b. An Office of Long-Term Care (OLTC) Incident and Accident (I & A) Report form DMS (Division of Medical Service)-7734 documented, . Summary of Incident . [Resident #1] (BIMS 11) had an unwitnessed fall after he exited the 1st floor stairwell and fell right outside the stairwell door. Resident found lying on ground outside fire stairwell door on first floor by maintenance on 0000 2/11/22. Resident stated, I stepped in a hole. I was going to see my brother. Nurse assessed and treated facial wounds and shoulder injury. [Resident #1] denied pain. Upon notification Administrator immediately worked with maintenance to contact door alarm company to disable fire door safety circuit that allows door to open 15 seconds after pressure is applied. Company arrived same day, refused to change door lock due to fire code. Elevating to Fire Marshal and Mayor's Office. Nursing is discussing transfer of [Resident #1] to secure unit . c. On 3/1/22 at 12:10 PM the Administrator was asked, What and how did [R#1] exit the facility on 2/10/22? He stated, [R#1] normally wanders on his floor but has never attempted to exit the building. Was never at risk for elopement before that night. He left his floor (5th) and went down to the first floor and went to the exit door that leads to back alley. That door, you're able to pull door handle to open and after 15 seconds will be able to exit foyer then push back door bar and exit. At that time the Administrator showed surveyor where maintenance found the resident. It was approximately 50 to 60 feet from the back door into a back-alley way. The Administrator then stated, When maintenance found him, he was on the ground. He told maintenance he was going to see his brother and stepped into a hole and fell down. The Administrator was asked, Did anyone not notice he was missing until they found him? He stated, No. The Administrator was asked, How long was it from the time he got out until maintenance found him? He stated, According to our cameras I looked at, he exited the building at 11:00 PM and maintenance didn't find him until midnight. The Administrator was asked, Was he moved to the secured unit? He stated, No, he didn't won't to move. The Administrator was asked, What interventions have been put in place to prevent him from exiting again since he didn't want to move to the secured unit? He stated, You would have to ask nursing that question. d. On 3/1/22 at 10:06 AM, the Interim Director of Nursing (DON) was asked, What can you tell me about [Resident #1] and when he exited the facility on 2/10/22 and what was done to prevent this from occurring again? She stated, We tried to get the Fire Marshal to secure the door but that wasn't allowed because of safety hazards. e. On 3/1/22 at 10:32 AM, the resident was sitting in a wheelchair in his room with his eyes closed. He opened his eyes when surveyor knocked on the door. He was asked, Do you remember leaving the facility approximately 2 weeks ago? He stated, I don't know. f. On 3/1/22 at 10:56 AM, the Administrator was asked, Are you aware of any in-service provided to staff after the incident with [Resident #1]? He stated, The only thing I know is the staff has access to [software program] and in there is a Managing Elopement In-Service. I know it was assigned to some staff but not all of them. g. On 3/1/22 at 11:49 AM, the DON was asked, When you have an incident such as when [Resident #1] exited the facility on 2/10/22 what is your process for in-servicing staff and monitoring to prevent further incidents? She stated, What I would do is assess why he wanted to leave. If behavioral changes or what. From that point assess if he needs to be on more secured unit. From what I understand they addressed this with the family and resident, and they all refused the unit. There is no documentation I can find of that. I was under the impression for the first 48 hours after the incident he was checked every 30 minutes. I don't find the sheet on that either. She was asked, Was any education provided to the staff? She stated, I can't find where any education was provided. I know in [software program] a Managing Elopement Training is available to all staff. There have been 26 enrolled but there is no date and it's showing none have started that training. h. On 3/1/22 at 3:11 PM, Licensed Practical Nurse (LPN) #1 was asked, Are you aware of any monitoring or staff education that was initiated after [Resident #1] exited the facility on 2/10/22? She stated, When that happened, I was off. The story I heard he was found outside, and they treated his eye. I check my patients because that's my job. I was not given any extra monitoring that was to be done on him. I do know I have signed stuff about elopement, but I don't know if it was about him or not. i. On 3/1/22 at 3:17 PM, Registered Nurse (RN #1) was asked, Are you aware of any monitoring or staff education that was initiated after [Resident #1] exited the facility on 2/10/22? She stated, I wasn't here on that shift but came here the next morning. They told me something about it. The nurse that worked that night said maintenance had found him out the door on the first floor. The nurse did not say anything about extra monitoring. I did not receive an Elopement in-service concerning that. j. On 3/2/22 at 10:32 AM, the Maintenance Coordinator was asked, When and where [Resident #1] was found when he exited the facility? He stated, It was not me who found him. It was the [Medical Center] maintenance. I'm not sure who it was or if they saw him out there or if they were making rounds and found him. k. On 3/2/22 at 10:45 AM, Certified Nursing Assistant (CNA #1) was asked, Are you aware of any monitoring or staff education that was initiated after [Resident #1] exited the facility on 2/10/22? She stated, I wasn't here but I remember it happening. The next morning when I came to work, I was told he had gotten outside and had fallen. They said keep a closer eye on him. I was not given any specific monitoring or in-service for him. l. On 3/2/22 at 10:52 AM, CNA #2 was asked, Are you aware of any monitoring or staff education that was initiated after [Resident #1] exited the facility on 2/10/22? She stated, I heard about him leaving the facility, but I wasn't here when it happened. When I came back to work, they told me he went out. Every time something like that happens, they just tell us to be more aware. Like I said I wasn't here when it happened. 2. A Policy and Procedure titled Missing Resident - Code Orange provided by the Administrator on 3/1/22 at 12:30 PM had no documentation regarding the measures to be taken after an elopement had occurred. On 3/2/22 at 2:10 PM, the Administrator was asked, Is there a policy regarding what the facility is to do after a resident does elope? He stated, The only thing we have is the Policy and Procedure for Missing Resident. 3. The immediate jeopardy was removed, and the scope reduced to an D on 3/2/22 at 12:39 PM when the facility implemented the following plan of removal: Step #1 Corrective Action: On March 1, 2022, immediately upon notification of deficient practice, DON initiated q [every] 1 - hour checks for recently eloped resident for four weeks. After four weeks, will reassess and, if needed, will continue. Step #2 Identification of Others with the Potential at Being Affected: On March 1, 2022, DON/designee completed audits of 35 5th Floor resident elopement risk assessments to identify any potential increase in elopement risk. The audit revealed no other residents at increased risk. No further negative findings identified. Step #3 To Ensure Deficient Practice Does Not Recur: On March 1, 2022, DON/designee initiated in-service for all staff, prior to starting next shift, regarding q-1hr [hour] checks for recently eloped resident and procedure related to elopement risk. To be completed by March 18, 2022. Step #4 QA [Quality of Assurance]: DON/Designee to present all findings to the QA committee for further review and recommendations. [Administrator signature] Administrator, Arkansas State Veterans Home at Fayetteville.

Based on observation, record review, and interview the facility failed to ensure a Covid-19 positive resident was separated from a Covid-19 negative resident to decrease the potential spread of Covid-19 for 2 (Residents #1 and #2) of 3 (Residents #1, 2 and 3) sampled residents who were tested for Covid-19. This failed practice resulted in Immediate Jeopardy, which could have caused serious harm or death to Resident #2, who had currently tested negative for Covid-19 and had no associated symptoms. The failed practice had the potential to cause more than minimal harm to 21 residents who had tested negative for Covid-19 and resided on the 5th floor with 15 other Covid-19 positive residents, according to a list provided by the Administrator on 11/17/2020 at 12:39 p.m. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/18/2020 at 4:00 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 10/14/2020 documented the resident was not assessed for a Brief Interview for Mental Status nor was the resident assessed for staff assessment for cognitive status. The resident required one person assist for transfers and toileting needs. The resident was admitted to the facility on [DATE] and was transferred to a room on the 500-hall on 10/29/2020. a. The Facility's 5th Floor Plan dated November 2020 documented, Covid-19 positive residents were in Rooms: 530, 525, 524, 523, 522, 519, 516, 513, 512, 511, 508, 507, and 503. The facility had a total of 15 Covid-19 positive residents and 21 residents who tested negative on the 5th Floor. b. The Facility's COVID-19 Testing During Outbreak in the Facility Policy documented, .Residents will be tested using the Abbott COVID AG ([MEDICATION NAME]) Card rapid test every 3 to 7 days. Any resident showing signs of symptoms of COVID will be placed on transmission-based precautions and a rapid test conducted. If a residents' test confirms positive for COVID, the resident will be placed in isolation for 14 days . c. The Covid-19 Communicable Disease Report documented, .Date of Screening .10/29/2020 . Date Test Completed: 10/29/2020 . Specific Test: BinaxNOW COVID 19 Ag Card . Test Results . Negative . Date of Screening: 11/6/2020 . Has the patient had direct contact with someone who is confirmed to have COVID-19? YES . Date Test Completed: 11/6/2020 . Specific Test: BinaxNOW COVID 19 Ag Card . Test Results . Positive . Date of Screening: 11/13/2020 . Diarrhea . Specific Test: BinaxNOW COVID 19 Ag ([MEDICATION NAME]) Card . Test Results . Positive . d. The Nursing Notes documented, .10/29/2020 10:14 COMMUNICATION - with Family .Note Text: I Just spoke with (Wife) POA (Power of Attorney) about her coming to see him on 10-30-20 at 330pm for a thru the window visit. Res (Resident) informed and is happy. Res is very angry about his room change and wishes to speak with the Admin. (Administrator) informed .11/6/2020 10:39 Health Status Note Text: Res POA notified .of covid positive result, cont (continue) to obs (observe) .11/10/2020 14:24 (2:24 p.m.) Alert Note Text: Resident resting in bed with eyes open. On ac (acute care) for Covid-19 positive. Resident is asymptomatic this shift. No voiced c/o pain. No s/s of acute distress or discomfort. Has had diarrhea this shift. Resp. even and unlabored. Call light and water within reach .11/11/2020 17:09 (5:09 p.m.) Alert Note Note Text: Resident resting in bed with eyes open. On ac for Covid19 positive and on isolation. Resident is asymptomatic this shift .11/12/2020 15:13 (3:13 p.m.) Health Status Note Note Text: CNA (Certified Nursing Assistant) reported resident has diarrhea .11/13/2020 05:00 Health Status Note Note Text: Resident had one bout of diarrhea tonight . Resident is running a fever 99.6 when was taken at 5am. Will continue to observe and keep on Isolation for Covid .11/14/2020 04:36 Health Status Note Note Text: Resident on alert charting r/t (related to) positive covid protocol, resident has had elevated temp this shift of 100.1 oral, he had on gloves, sweats, big sweater and shoes with a blanket on, rechecked @ 0430 and it is 99.3 with no medication . e. On 11/18/2020 at 10:44 a.m., the (Medical Director) was asked, Why wasn't Resident #1 and or Resident #2 moved from (Room #) when Resident #1 tested positive for Covid-19 and Resident #2 tested negative for Covid-19? The Medical Director stated, .Most of the residents are positive and if we move them, they are likely to be positive, anyway. We are increasing the risk of residents getting positive by moving residents. He was asked, How do you decide which resident goes into a private room? He stated, I was going on the advice of (Doctor) and another Doctor from Seattle. We were burning through more PPE (personal protective equipment) when we put residents in private rooms. We could save on PPE if we didn't move the residents and it was likely they would test positive since they were probably already exposed to [MEDICAL CONDITION]. f. On 11/18/2020 at 5:38 p.m., the Administrator was asked, When did you start Outbreak Testing? The Administrator stated, This is our fifth time doing Outbreak Testing. We started on November 2nd, (2020). The Administrator was asked, Is the 5th floor your designated Covid-19 Unit? The Administrator stated, We don't have a Covid Unit. The Administrator was asked, Why didn't you move Resident #1 when he tested positive for Covid-19 on 11/6/2020? The Administrator stated, Because, (Medical Doctor) did not want to move them. He felt it was just as great a risk if we moved either resident. He talked to both resident's family members. We were following his guidance. The Administrator was asked, Did you have any empty rooms on November 6, 2020 on the 5th Floor? The Administrator stated, Yes, we did have some empty rooms at that time. Our census was 69. 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 9/17/2020 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required no assistance with transfers and toileting needs. The resident resided in the B bed of Resident #1's room. a. The Covid-19 Communicable Disease Report documented, .Date of Screening: 11/3/2020 . Date Test Completed: 11/3/2020 . Specific Test: BinaxNOW Covid 19 Ag Card . Test Results . Negative . Date of Screening: 11/09/2020 . Date Test Completed: 11/09/2020 . Specific Test: BinaxNow COVID 19 Ag Card . Test Results . Negative . b. The Nursing Notes documented, .11/7/2020 13:49 (1:49 p.m.) Health Status Note Text: On A/C (acute charting) Related to Res roommate testing Positive for Covid; On Isolation as Per Facility Protocol; Res non complaint with remaining in room; Res will come out of room, yelling for Meds; Res upset and worried about having COVID. Nurse spoke with Res, explain how important it is for him to stay in room to prevent spread; Res expressed understanding, calm at this time. Denies any pain, HA, (headache) Sore Throat, N/V (nausea/vomiting), Cough; SOB (shortness of breath) as Per Res baseline. V/S (vital signs); B/P 132/74, Temp. 98.0, Respirations 20, Heart Rate 84, O2 sat (oxygen saturation) 96% on 2L (liters) via NC (nasal cannula) .11/7/2020 21:18 (9:18 p.m.) Health Status Note Text: Resident on alert charting r/t (related to) being in isolation for covid protocol; Resident remains asymptomatic V/S 98.5, 89, 126/76, 20, 97% via n/c 2 liters, no complaints this shift r/t nausea, vomiting, diarrhea, SOB or anxiety at this time. Resident stated that he had a panic attack earlier in the day r/t nurse reminding him that roommate was positive for covid and that he had forgotten. Stating my memory isn't what it used to be. Call light within reach and resident is able to make needs known, will continue to monitor . c. On 11/17/2020 at 3:10 p.m., Resident #2 was asked how he was doing? Resident #2 stated, I'm doing OK. I had pretty good luck with this room. They just moved my roommate in about a month ago. I hope I don't get it. They told me that my roommate has Covid. When I go to the bathroom, I make sure to wipe down the toilet seat before using it. They have got the Covid pretty bad around here. They do clean my room pretty good. I try to stay safe. I have talked to my son and daughter about what is going on around here. d. On 11/18/2020 at 11:05 a.m., Resident #2 daughter was asked, via phone conversation, Did (Medical Doctor) talk to you about your dad's roommate testing positive for Covid-19? Resident #2 daughter stated, The Doctor told me that they didn't want to move my dad. He told me it was because he had moved a woman who lived there, and she got sick with Covid and ended up dying. He didn't want to move residents, again. He did tell me that his roommate had tested positive and that my dad had tested negative. I did want him moved but our hands are tied, and we have no authority. e. On 11/18/2020 at 6:30 p.m., Certified Nursing Assistant (CNA) #1 was asked, How do you provide direct care for (Residents #1 and #2)? CNA #1 stated, We have our PPE on. We wear those plastic gowns that look like trash bags and are hard to get on. We have our N-95 with a face shield. We put gloves on. We take care of (Resident #2) first then we would take care of (Resident #1). We don't change our gowns until we leave the room. We do change our gloves if we need, too and we make sure to use hand sanitizer or wash our hands before we leave the room. They have red signs on the door, so we know which residents are positive. We can disinfect our face shields. CNA #1 was asked, Does (Resident #1 or Resident #2) have any symptoms? CNA #1 stated, (Resident #1) has had one or two bouts of diarrhea and a low-grade temp. f. On 11/18/2020 at 6:44 p.m., Licensed Practical Nurse (LPN #1) was asked, How do you know which residents are positive and which are negative on the 5th Floor? LPN #1 stated, I take care of the Non-Covid residents first and do the Covid residents last. I have never tested positive for Covid. LPN #1 was asked, Did you know (Resident #1) tested positive for Covid-19 and that (Resident #2) tested negative for Covid-19? LPN #1 stated, I heard both residents tested positive for Covid. g. The CMS (Centers for Medicaid and Medicare Services) Reference: QSO-20-38-NH dated 8/26/2020 documented, .(4) Upon the identification of an individual specified in this paragraph with symptoms consistent with COVID-19, or who tests positive for COVID-19, take actions to prevent the transmission of COVID-19 . h. The Covid-19 Focused Survey for Nursing Homes documented, .Did the facility take actions to prevent the transmission of Covid-19 upon the identification of an individual with symptoms consistent with or who tests positive for Covid-19 .and immediately isolate anyone who is symptomatic .does the facility have a dedicated space in the facility for cohorting and managing care for residents with Covid-19 . plan including appropriate placement for those exposed to Covid-19 . 3. On 11/18/2020 at 5:54 p.m., the Immediate Jeopardy was removed, and the scope and severity reduced to E when the facility implemented the following Plan of Removal: Step #1 Corrective Action: On November 18, 2020, immediately upon notification of deficient practice, ADM initiated transfer of Resident #2 to (Room #) and double checked each room to ensure no other COVID-19 negative residents were in rooms with COVID-19 positive residents. Step #2 Identification of Others with the Potential of Being Affected: Audits of residents positive and negative for COVID-19 revealed no other COVID-19 negative residents were in rooms with COVID-19 positive residents except for a cognitive Husband who insists on staying with COVID-19 positive Wife. No further negative findings identified. Step #3 To Ensure Deficient Practice Does Not Recur: By November 23,2020, all staff in serviced on policy and procedure related to not leaving COVID-19 negative residents in rooms with COVID-19 positive residents. Covid -19 negative residents will be placed on quarantine for 14 days after the move. Step #4 Monitoring: Beginning November 19, 2020, DON/Designee monitor to ensure no COVID-19 negative residents are located in rooms with Covid-19 positive residents, daily for 4 weeks or until compliance is verified by OLTC (Office of Long-Term Care). Any negative findings will be corrected immediately, and Administrator/Designee notified. Step #5 QA (Quality Assurance): DON/Designee to present all findings to the QA committee for further review and recommendations. (Administrator) Administrator, (Facility name) B. The facility also failed to ensure bio-hazard bags were properly removed from resident's rooms and stored properly to prevent the potential spread of bacterial infections for 3 (Residents #1, #2 and #3) of 3 sampled residents whose rooms were observed. This failed practice had the potential to affect all 67 residents, according to the Daily Census dated 11/17/2020. 1. On 11/17/2020 at 3:05 p.m., both Resident #1 and Resident #2 were in bed. Resident #2's bed linens were worn and stained. In the bathroom, there were three red stuffed bio-hazard bags on the floor. A box containing a bio-hazard bag was also in the bathroom. 2. Resident #3 had [DIAGNOSES REDACTED]. The Significant Change in Condition Minimum Data Set with an Assessment Reference Date of 9/16/2020 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required 1 person assist with transfers and toileting needs. The resident had a roommate. a. On 10/17/2020 at 3:25 p.m., in the room in front of Resident #3's bed were 3 full bio-hazard bags stacked on top of a box designated for the bio-hazard bags. A clear, plastic bag full of soiled linens was on the floor. b. On 10/17/2020 at 3:40 p.m., the Assistant Director of Nursing (ADON) was asked, Why are these full, bio-hazard bags stacked in (Resident #1, #2, and #3) rooms? The ADON stated, That is progressively getting worse. (Medical Center) provides the boxes. A guy comes every Thursday to retrieve the biohazards. They are stacked to the ceiling downstairs. We don't have enough boxes to put the bio-hazard bags into. One box will only hold one bio-hazard bag. (Medical Center) owns this building.

Complaint # (AR 024) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure the resident environment was as free of accident hazards as possible, as evidenced by failure to ensure an identified fall hazard (raised threshold or metal bar embedded in floor) on the 5th floor was promptly removed, repaired or replaced, which caused a resident on anticoagulant therapy to fall and sustain a head injury for 1 (Resident #1) of 4 (Residents #1, 2, 4 and 5) case mix residents who required a wheelchair for mobility. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, whose wheelchair stopped abruptly when it hit the metal bar, causing the resident to fall face-first onto the floor, and had the potential to cause more than minimal harm to 20 residents who resided on the 5th floor and used a wheelchair for mobility and 19 other residents who resided on the 5th floor and were ambulatory as identified by a list provided by the Administrator on 2/28/18. The facility was notified of the Immediate Jeopardy condition on 2/13/18 at 3:23 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 12/11/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status, required extensive assistance of 2-plus people with transfers and locomotion and used a wheelchair for mobility. a. An Incident and Accident Report dated 1/6/18 at 12:00 p.m. documented, .(Resident #1) . Nursing Description: Res. (resident) was being brought from 5A hallway to TV (television) room / dining room via wheelchair by daughter, (daughter's name), when, as he was leaning forward in wheelchair, they simultaneously hit the front wheels of the wheelchair on a metal bar embedded in the floor between the two areas, which stopped the wheelchair suddenly and caused res. (resident) to tumble forward out of the wheelchair. 'I fell out of the chair after we hit that bump' . Intervention: the metal bar in the floor needs to be removed and the floor fixed so it is flat . Injury Type . Abrasion . Right scapula . Discoloration . Left elbow . Hematoma . Top of Scalp . Other Info (information): Where res. tumbled out of w/c (wheelchair), there is a metal bar embedded in the floor between the two areas, which stopped the wheelchair suddenly and caused res. to tumble forward out of the wheelchair. It extends approx. (approximately) 5-7 mm (millimeters) above the floor . b. Nurses' Notes dated 1/6/18 at 12:00 p.m. documented, .Res. was being brought from 5A hallway to TV room / dining room via wheelchair by daughter .simultaneously hit the front wheels of the wheelchair on a metal bar embedded in the floor between the two areas, which stopped the wheelchair suddenly and caused res. to tumble forward out of the wheelchair. The bar extends approx 7 mm above the floor. He landed on his forehead and the right side of his body. Caused a very large goose egg on his right forehead, along with an abrasion on the right side of his back. Res. did c/o (complain of) minor right shoulder and forehead pain. After full inspection, also found a silver-dollar-sized round red-purple bruise on his left lateral distal upper arm. Using a gait belt, two persons got him to his feet as a wheelchair was placed behind him. Cleaned the abrasion with wound cleanser and patted dry. No change in movement of extremities. VS (vital signs) along with neurochecks (neurological checks) done per protocol. Ice pack to forehead. He ate in dining room without problems afterward. Neurochecks as documented - no neuro status changes. Daughter already aware. Tried paging Dr. (Doctor but hasn't called back yet. Intervention: the metal bar in the floor needs to be removed and the floor fixed so it's flat . 1/6/2018 16:30 (4:30 p.m.) . (Physician's Name) called back at this time and I informed her of all the above. No new orders at this time. I informed her we will continue monitoring & (and) neurochecks . 1/6/2018 17:13 (5:13 p.m.) . Resident awake, alert times 3 has a swelling over the right side of his face causing his right eye to be almost swelled shut. Resident's family is here. Wants resident sent to hospital for CT (computed tomography) scan, so called physician. (Physician) ordered CT scan transfer to (Hospital) ER (emergency room ). Resident is on [MEDICATION NAME] for heart issues. Called report to ER (emergency room ) and ambulance here to pick up. Family are very angry that this had not already been done hours ago. Resident assisted on stretcher and left facility. Resident was awake, alert, oriented on transfer. Family went with resident . 1/6/2018 22:07 (10:07 p.m.) Resident returned from (hospital) without further orders. Right side of face remains discolored with eye swollen shut. Resident appears sleepy at this time. Res. returned via ambulance with daughter at his side. Meds (medications) as ordered. [MEDICATION NAME] held per orders. B/P (blood pressure) 146/60 P (pulse) 62 R (respirations) 22 T (temperature) 98.4 O2 (oxygen saturation) 94 % (percent) . c. The Hospital Radiology Record dated 1/6/18 at 6:23 p.m. documented, .Reason for Exam CT Head or Brain w/o (without) contrast. Head Injury . Impression: 1. No Acute Intracranial Process . Right Frontal Scalp Hematoma . 1.) On 2/13/18 at 3:20 p.m., Licensed Practical Nurse (LPN) #1 was asked about Resident's #1 fall on 1/6/18 and stated, I saw the whole thing. I was back and to the left from the room to the lunch room. Him (resident), her (resident's daughter), and three dogs. All the dogs were on leashes and one was trying to jump on his lap. She basically dumps him out of the wheelchair pushing him one handed. The Nurse Manager does the assessments .I was looking at his head . He hit his face pretty hard. He didn't have much reflex to catch himself. I yelled for help and the Nurse Manager came. We didn't send him out, because he was fine. He did have some bruising, did not break the skin. If we sent out everybody that had a fall, we would have an emergency vehicle downstairs all the time. No one has fallen other than (Resident #1). He normally doesn't take that way to go to the lunch room. She normally doesn't bring all three dogs, and she wasn't going at a high rate of speed . He didn't have any open wounds, no bump on his head. 2.) On 2/14/18 at 9:59 a.m., Registered Nurse (RN) #1 was asked about Resident #1's fall on 1/6/18 and stated, I will have to go back and look at my notes. I was working the 5 Hall pushing the cart and supervising. I was taking care of another fall at the time. I paged the doctor; I did it (called physician regarding both falls) at the same time. People wouldn't have got (sic) their insulin, if I would have kept trying to page the doctor. Neuro checks were completed more often than needed to be done. I tend to watch my patients like a hawk. The one daughter eventually left. A different daughter started yelling at the nurses' station about getting their Dad sent out. I was going to be asking questions every 15 minutes. If he had any changes with his neuro status I would've called 911. I would be watching for any changes in his pupils, in his orientation, speech. I watch people; I have saved a lot of peoples' life . It was the weekend . The second lady visiting insisted that the threshold be removed, for that metal piece to be removed. I felt that it needed to be fixed right away. I have seen people trip on that thing. I did not like that thing being there. I did tell the old administration. I put it in the maintenance book . 3.) On 2/14/18 at 10:30 a.m., RN #2 was asked about metal bar embedded in the floor and the reason for waiting for it to be repaired or replaced and stated, We discussed in morning meetings. We went over it when talking about past falls. I don't know if the (Maintenance Manager) was there at the first meeting. It would have been (previous Administrator). We brought it up in another meeting, because of (Resident #4) making comments about it being a fall hazard. I think (Maintenance Manager) was here that day. He didn't have anything available to fix it and was going to get bids to have it replaced. He decided to fix it the way they did on the (hospital) side . 4.) On 2/14/18 at 10:50 a.m., RN #3 was asked about the raised metal bar / threshold and whether it was a fall hazard. The RN stated, I have never seen anybody fall related to that, but I have seen residents bump up against it with their walkers and wheelchairs. When a walker gets to that ridge, it's going to bump it. It could've caused someone to fall . 5.) On 2/14/18 at 11:55 a.m., Resident #1 was asked about his fall on 1/6/18 and stated, It beats me why they took so long to take me to the hospital . I hit that bump and out I went. I finally went to the hospital; I wasn't thrilled about it. My daughter wanted me to go . They did a CT of my head, that was it . d. A Hospital Discharge Instruction sheet dated 1/6/18 at 7:59 p.m. documented, .Other Medications .[MEDICATION NAME] (3 mg (milligram)) 1 tablet oral q (every) (Monday, Wednesday, Friday, Saturday) [MEDICATION NAME] (6 mg) 1 tablet oral 3 days /week; q (Sunday, Tuesday, Thursday) blood thinner ., A Physicians Note dated 1/6/18 documented, [MEDICATION NAME] Sodium Tablet 5 mg give 5 mg by mouth at bedtime for blood clots . A Clinical Physicians Orders dated 1/8/18 at 8:00 p.m. documented, Comadin Tablet 5 mg on hold. e. The Resident Council Minutes dated 1/15/18 documented, .Maintenance: A.D. (Administration Department) told the council a different threshold plate between the Activity area and the hallway on 5th floor is being considered. The council unanimously expressed a need for something different there . f. The Resident Council Minutes dated 2/12/18 documented, .Maintenance: (Non-case mix resident) and (Resident #2) commented on the raised threshold plate, that it has not been changed out yet . g. As of 2/13/17 at 10:50 a.m., a period of 38 days after Resident #1's fall with head injury, the raised metal bar / threshold remained on the 5th floor and had not yet been removed, repaired or replaced. The 'threshold' was approximately 5 to 6 feet in length and was a metal bar that was screwed into the floor to cover a gap in the floor's surface. The area where the threshold was located provided access to the hallway going from the day area to residents' rooms on the 5th floor. The height of the metal bar was measured by the Maintenance Manager at this time. The object protruded greater than 1/4 of 1 inch above the level of the floor. h. On 2/13/18 at 2:39 p.m., the Maintenance Manager was asked about the threshold on the 5th floor and stated, .I think a buffer took a piece or chunk out of the floor. The seam was coming up and the floor was chipping . I'm contracted over here from (hospital) I am waiting on some bids to come in. I got some insight from another person and I replaced the metal bar with a non-skid strip, today . The Maintenance Manager was asked if he was aware of Resident #1's fall in January and stated, .I did hear about the fall; what I heard she was pushing (Resident #1) in a wheelchair and pulling three dogs at the same time. I heard from the nurses that the daughter has had multiple complaints . i. On 2/14/18 at 11:03 a.m., Resident #4, whose MDS with an ARD of 12/11/17 documented he was cognitively intact, was asked about the raised metal area on the 5th floor and stated, I seen a guy that flew out of his wheelchair. (Resident #1) got hurt on it. I told (Maintenance Manager) about it . I know they had a meeting, decided you had to get 3 bids on it . I would fill it (gap in floor surface) with plastic cement, something that would give. I would put that on there. Mainly, because it was rough crossing it . It was an inch or two inches wide before the earthquake tremors opened it up . We are right on top of a fault. (Maintenance Manager) never listened to me. j. On 2/14/18 at 11:39 a.m., Resident #5, whose MDS with an ARD of 1/8/18 documented the resident was cognitively intact, was asked about the raised metal area between the day area and the 500 hall on the 5th floor and stated, .Before they fixed it, it was hard to get over. They tried to fix it a long time ago; decided to put a bump on it . k. The immediate jeopardy was removed and the scope / severity reduced to E on 2/13/17, when the facility implemented the following plan of removal: 1.) The facility immediately (2/13/18) corrected leveling repair to threshold on Hall 5 between front lounge and entrance to first hallway. (On 2/13/17 at 2:30 p.m., the metal plate had been replaced with a non-skid strip that was level to the floor). 2.) On 2/13/18 Maintenance Supervisor is assessing all thresholds on Hall 5 and Hall 6 that may need leveling repair. Upon completion of threshold assessments, Maintenance Supervisor will correct all thresholds found to be in need of leveling repair that could have a potential of a resident from falling. 3.) All thresholds will be monitored weekly by Maintenance Supervisor for any concerns. All threshold concerns will be brought to the Quality Assurance committee for review

Based on observation, record review and interview, the facility failed to ensure thorough investigation of a fracture that occurred during a lab draw and to ensure that staff did not attempt to restrain and continue to provide care for a resident who became agitated and combative to reduce the potential for injury for 1 (Resident #1) of 1case mix residents who had a history of [REDACTED].#1 who sustained a wrist/hand fracture and had the potential to cause more than minimal harm to 9 residents who had a history of [REDACTED]. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an Assessment Reference Date (ARD) of 1/22/13 documented the resident scored 6 (0 - 7 indicates severely impaired) on the Brief Interview for Mental Status, had inattention and disorganized thinking that comes and goes and changes in severity; exhibited no physical Behavioral Symptoms directed toward other during the last seven days of the ARD; required extensive assistance of one staff member with bed mobility, transfer, locomotion on and off the unit and with dressing and was totally dependent on one staff member for toilet use and personal care/bathing; and had no falls with major injuries since prior assessment. a. A Nurses Notes dated 12/9/12 at 4:55 p.m. and signed by Licensed Practical Nurse (LPN) #1 documented, "...Lab tech here to draw blood. Resident took to room. When lab tech begin needle withdrawal, resident became combative and begin hitting and kicking lab tech. A CNA passing room went in and tried to assist lab tech with a pressure dressing on (left) arm. Two more CNAs walked in to assist. Resident continued to kick and hit and threw her arms up and everyone in room stated they heard what sounded like a knuckle pop loudly. Instantly a discolored area on (right) forearm appeared. A CNA informed me of the situation immediately. Ask resident if arm hurt. Stated, 'a little.' Could move fingers but could not move her hand laterally... At 1715 (5:15 p.m.) Tylenol 325 mg (milligrams) (two) given. Still refused to allow a pressure (dressing) on hematoma. X-ray ordered for (right) forearm, wrist and hand... At 1755 (5:55 p.m.) x-ray tech here. Resident allowed x-rays to be done (without) incident. Swelling around discolored area... At 1905 (7:05 p.m.) Order from (Physician #1) to transport resident to (Hospital) ER for a fracture of distal ulna... At 1915 (7:15 p.m.) Ambulance here for transport to (Hospital ER)... Late Entry: At 2030 (8:30 p.m.), "...Called (Acting Administrator) and I was advised how to handle situation..." b. An Incident/Accident (I&A) Reporting Form documented, "...Resident: (Resident #1)...Date: 12/9/12...Time: 1655 (4:55 p.m.) (1) Where did incident/accident occur? Rsd (Resident's) Room (checked)... (2) What happened? Became combative during blood draw and began hitting and kicking lab tech. At one point while throwing arms around all four witnesses heard a loud pop. (Right) forearm began swelling immediately... (4) What did the resident or witness say about the incident? "That hurts some." according to witnesses in room...Name(s) of any witness(es): (Certified Nurse Assistant (CNA)) #1, (CNA #2), (CNA #3)... (5) Were there any injuries? Yes (checked)... (6) Did incident require any type of treatment? (checked yes) and documented "x-ray showed fractured (right) ulna. Sent to (Hospital)emergency room ) per (Physician #1)... " (9) Notifications: Time Physician Notified: 1900 (7:00 p.m.)...Unable to reach family per numbers on face sheet...Time Administrator Notified: 2030 (8:30 p.m.)...Time (facility name) Police called: (not called)...Nurse Completing the I & A : (Licensed Practical Nurse (LPN) #1)...DON/ADON: (Director of Nurses/Assistant Director of Nursing)...Administrator: (Administrator) 12/10/12..." c. The DMS (Division of Medical Services)-7734 OLTC (Office of Long Term Care) Incident and Accident Report (I&A) (completed by the Acting Administrator) page 2 documented, "...This I and A dated 12/9/12 at 2040 was first reviewed by Resident Safe Handling Committee on 12/10/12 which meets Mon - Fri (Monday thru Friday) revealed a report of a resident with a fractured right ulna. Resident became combative during a routine lab draw resulting in a fracture of the right arm. Phlebotomist and CNAs (2) were in the room at the time of the incident. Incident became known to the Acting Administrator at 2045 hours on 12/9/12. Reporting process begun..." d. The DMS-762 Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long-Term Care Facilities (page 2) dated 12/9/12 at 2040 (8:40 p.m.) documented, "...Facility Staff Member Completing DMS-762: (Acting DON)...Type of Incident: Physical Abuse (checked)...Name of Involved Resident: (Resident #1)...Date and Time of Incident (if known): 12/9/12 at 2040 PM...Date and Time of Discovery: 12/9/12 at 2040 PM...Date Incident Reported to OLTC: 12/10/12 1555 (3:55 p.m.)...Ambulatory? No (checked)...Oriented: Person (checked)...Physical Functional Level/Impairment: Propels self in wheelchair, Requires assist with all ADL's (Activities of Daily Living's) and transfers...Mental Functional Level: Alert to person only requires frequent reorientation to place and time...Primary Diagnosis: [REDACTED]. Page 3 documented, "...During a routine lab draw resident became combative with lab staff and facility staff. She was swinging her arms and hitting and kicking the staff when they heard a popping noise. An x-ray was obtained which identified a fracture of the ulna. Resident was sent to the ER for evaluation and treatment. All notifications were made and report was filed. Resident is wheelchair bound and requires assist with ADL's and transfers..." Page 4 documented, "...Witness statements were obtained and interviews conducted. After reviewing all findings and consulting with the physician it is believed that no abuse occurred and the fracture happened while the resident was being combative with staff (signed by the Acting DON and dated 12/17/12)..." e. The Witness Statements: 1) The Witness Statement completed by Lab Tech #1 documented, "...Pt: (Resident #1)...Date: 12/6/12... Time: around 1700 (5:00 p.m.)...Started to draw blood of pt. (patient) when pt. became very abusive both physical and talkative. Pt. pulled needle out of her (left) arm. I tried to get her to let me tape her up but Pt. again started hitting me. Went to find a nurse or CNA. Got help from CNAs. Pt. still fighting and kicking us. All I was trying to do was get her arm cleaned up and bandage put on. As she was fighting us something made a popping sound...." 2) The Witness Statement completed by CNA #2 documented, "...As me and (CNA #3) were walking by to get the resident up for supper. The Phlebotomist ask if we can help. So me and (CNA #3) walked into the room. At that time (CNA #1) was already in the room. (Resident #1) were too. So, I was standing by 'A' bed. So (CNA #3) and (CNA #1) was verbally telling her (Resident #1) that it would be okay for the Phlebotomist to put a Band-Aid on her arm so she agreed and was calm. But, when the Phlebotomist put pressure to the hematoma, she started hitting and kicking at the Phlebotomist as (CNA #1) was bending over and she hit her on the shoulder. But, as she (resident) was bringing her (right) arm up that's when I heard a loud pop sound..." 3) The Witness Statement completed by (CNA #1) documented, "...When I was walking down the hall, I was called over by (Lab Tech #1) for assistance with (Resident #1). (Lab Tech #1) told me she was very combative hitting and kicking her while she was drawing her blood and the resident had pulled out the needle from her left arm where she has drawn one tube of blood...(Resident #1) was in her wheelchair and I asked to see her arm. She complied. I then asked if we could go to her room so we could put a bandage on her she started that was fine. I wheeled her into the room and she became upset once again and that is when (CNA #3 and #2) walked by and (Lab Tech #1) asked if they could assist with talking with her about her bandage. While (CNA #3) was caressing her left arm and I was on her right side and was caressing her arm and shoulder trying to assure her it was going to be ok when (Lab Tech #1) put pressure with the cotton ball on her left arm, she became upset and started kicking the Lab Tech; at this time I bent over to get in the path of her kicking she had hit me and raised up her right arm and we all heard the pop and we went to find the charge nurse to report..." 4) The Witness Statement completed by (CNA #3) documented, "...(CNA #2) and I were walking by (Resident #1) room when the Phlebotomist yelled out at us to come help her with (Resident #1) The Phlebotomist said she was trying to put a dressing on her arm because she had a hematoma and (Resident #1) was not letting her do it. (CNA #2) and I went into the room. That is when I noticed that (CNA #1) was standing on the right side of (Resident #1) wheelchair. She said that her hematoma was really bad. As I got closer to (Resident #1), she smiled at me and said that she was glad I came. I then squatted down by her left side and started to explain to her that we are here to help and pointed out the hematoma to her and she agreed that we could put a dressing on it. The Phlebotomist began to apply pressure to the hematoma on her left arm when (Resident #1) began hitting at (CNA #1) when I heard the 'pop'. I am not sure if it was on the up swing or down swing. I was looking at the Phlebotomist because she was about to kick her in the head. (CNA #1) reacted a lot quicker to shield the Phlebotomist, but got hit in the process. Once we/I heard the popping noise I left the room immediately to go get (LPN #1), the LPN in charge. (CNA #1and #2) and the Phlebotomist stayed in the room with (Resident #1) while I left to go get (LPN #1), but I could not find her so I got the PRN (As Needed) LPN (LPN #2)..." 5) The Witness Statement completed by LPN (Licensed Practical Nurse) #2 documented, "...At approximately 1650 (4:50 p.m.) (CNA #3) reported that (Resident #1) (right) arm had made a large popping sound. I asked, did she hit it on anything. 'No' stated (CNA #3); we were holding her right arm down when I heard a loud pop." Other nurse; (LPN #1) came down hall and I reported to her. Assessed Resident. Upon assessment (right) (forearm) swollen and purple (right) 2nd digit curved in. (Resident #1) c/o (complained of) pain. Other nurse medicated. I notified (Physician #1); received x-ray order...Notified (Registered Nurse (RN) #1)..." 6) The Witness Statement completed by (LPN #1) documented, "...At approx (approximately) 1655 (4:55 p.m.) I was notified by (left blank) that (Resident #1) became very combative while lab tech was doing a blood draw. While resident was throwing arms around everyone in room heard a loud pop. I entered room and an area on (right) forearm was turning blue and resident could not move her hand laterally. Swelling began. At 1715 (5:17 p.m.) given Tylenol because resident stated it 'hurt a little'. Ordered Xray for right forearm, wrist and hand. Results being a fractured right ulna. At 1915 transferred to (Hospital) ER per ambulance." f. The Orthopedic Report dated 12/13/12 documented, "(Resident #1) is a 90 - year old nursing home patient who injured her right arm 12/9/12. Someone came in to draw her blood early in the morning and she did not want them to. She fought them and they restrained her physically to try and get that blood drawn and somehow she ended up with an ulnar shaft fracture. She splintered. She is reasonably comfortable. She certainly seems pleasantly confused today. Physical Examination: She is in a short arm splint. She has normal range of motion of her fingers. Sensory exam is not terrible easy to get cooperation with. X-Rays: AP(anterioposterial) and lateral x-rays of the right forearm from the emergency room reveal a minimally displaced fracture of the distal ulnar shaft. There is some mild angulation and about 50% translation ... Assessment: Minimally displaced right ulnar shaft night stick fracture. Plan: We switched her over to a short arm cast. We will keep her in that cast for 5 more weeks. I will see her back in the office 5 weeks from now with AP and lateral x-rays of her right forearm out of plaster ...." g. The Plan of Care dated 1/22/13 thru 4/22/13 documented, "...Problem: Behavior...Problem Date: 2/18/13 Physically Abusive - slapping, hitting, and kicking staff and other residents..." Approaches: Always have two Health Care Workers when providing personal care...Explain purpose of care or medication before giving...Intervene as needed to protect the rights & safety of others...Reapproach resident later, when she becomes agitated...If resident refuses care, provide time & space so that she does not escalate in her behavior. Re-approach using calm tone, alternate staff member. If resident becomes combative during lab draw, do not attempt to draw lab... Problem: Osteoporosis...Problem Date: 3/23/10 Resident is at risk for Fracture R/T (related to) dx: osteoporosis... Approaches: 12/10/12 Notify physician of any increase in combativeness because of increased potential for injury/fractures of her bones...Do not attempt to provide care when resident behaviors starts to escalate..." h. Staff who were in the resident's room at the time of the injury were interviewed: 1) On 3/25/13 at 4:40 p.m., CNA #1 stated she had been working the 3 - 11 shift on the 6th floor since August 2012. She stated that she had been taught (at time of Orientation but not since) that if a resident becomes too combative during care they are to leave alone and come back; but sometimes I'll try talking to them first to attempt to calm them down before I leave them alone. When asked if she remembered the incident with (Resident #1) back in December 2012. She stated, "Yes, (Resident #1) wasn't being cooperative with the lab draw - kicking Phlebotomist. I was the first CNA to assist before (CNA #2 and #3) came in to help as well. I had already attempted to calm her down unsuccessfully before the other two CNAs were asked to come help by the Phlebotomist. (CNA #3) got her to agree to let Phlebotomist draw blood but when she knelt down and began trying to draw blood she started kicking at Phlebotomist and I knelt down trying to block the kicks and she hit me two times once on my left shoulder and once on the back of my head ... is when we heard snap then (Resident #1) looking up at (CNA #3) stated, 'Look what you did, you broke my arm,' then (CNA #3) told us, 'All I was doing was holding her shoulders trying to talk to her'." On 3/26/13 at 4:23 p.m., CNA #1 was asked to verify the interview notes above (3/25/13 at 4:40 p.m.). She stated, "If Resident #1 is upset she will hit and kick. I'm not aware of any prior fractures due to her hitting and kicking at people/objects. The interview was stopped and the CNA left and returned at 5.50 p.m., she returned and stated, "I wrote my witness statement after the phlebotomist had told what had happened when she became combative. I'm not sure if (CNA #2 and #3) came in after Phlebotomist asked them to or not. I am not sure who was holding her down, I think it was (CNA #3). I was on left side putting my back in front of Phlebotomist because Resident #1 was kicking at her. I didn't see how she was being held. I knew there would be a State Investigation. I did hear (CNA #3) say, "I'm holding as tight as I can." I could not see where she was held from the position I was in. (LPN #1) told us what had to be said in the Witness Statements in a room her, me, (CNA #2 and #3). I told (LPN #1) what I just told you about what I saw and heard. At first (CNA #3) told (LPN #1) she was holding her arm down then she changed her story to she was holding her shoulders. I told (CNA #3), I thought she said that she was holding her arm down and she said, "No, you must have misunderstood me." After this meeting,( LPN #1) took (CNA #3) into the room by themselves for about 30 minutes, then (LPN #1) called us all back into a room, gave us all a blank Witness Statement and told us to fill out the statements and do not put down that she was being restrained. This is when (CNA #3) said I wasn't restraining her, I was holding her. I did not tell the Administrator or DON about what actually happened because after (LPN #1) talked to us, I was afraid for my job. I just didn't know what to do. I'm just proud this is out in the open now, it has been eating at me ever since." 2) On 3/26/13 at 3:20 p.m., CNA #2 was asked if she remembered the incident with Resident #1 back in December 2012. She stated, "Yes, Me, (CNA #1and CNA #3) and the Phlebotomist were in her room when her arm was fractured. We went into her room due to the Lab needed to put band aid over hematoma, I call it a big bubble, on her left arm. Me and (CNA #3) was together, (CNA #1) was already in there. I stood by the door because there were already two CNAs and the Phlebotomist in there. (CNA #1), was standing in front of left leg and (CNA #3), was standing in front of her right leg, tried to calm her down by talking to her. Initially it worked, but when lab started putting on the band aid both of the CNAs squatted down in same location and she (resident) starting kicking and screaming. They all were in front of resident so I was unable to see what was going on but I did hear a very loud pop even from where I was standing because it was so loud." When asked what she had been instructed to do when a resident becomes combative during care, she stated, "You are suppose to leave room immediately and wait for them to calm down and let nurse know. She was probably already upset before me and (CNA #3) came in there. Should not have had that many people try to get her to do something when she was so agitated. Should have stepped back and see if she calmed down. I feel like it was abuse because she got hurt and from what I said from the beginning when she started swinging we maybe should have left the room. I know it wasn't done on purpose. I do think this could have been handled differently but it just happened so fast. After reading interview notes back to CNA #2 she said, "I don't agree with what I said about abuse, I believe it was an accident." She agreed to the above statement after making the last adjustment in the statement and she signed and dated the statement 3/26/13. 3) On 3/27/13 at 10:57 a.m., CNA #3 was asked if she remembered Resident #1 and the incident with her back in December 2012 when her arm was fractured during a blood draw? She stated, "Yes, I was present during that incident. From my memory the Phlebotomist; I don't remember her name asked (CNA #2) and I as we were walking by (Resident #1) room if we could come help. I said, ok. We go into the room and (CNA #1) was already in there. (Resident #1) was sitting in her wheel chair at the bottom of her bed (B - bed) facing the door and (CNA #1) was on her right side. She stayed on the right side; none of us switched around. (CNA #1) was on (Resident #1) right side. (CNA #2), I'm not sure she didn't come all the way in there. She stayed closer to the bottom of the A - bed. (CNA #1) still on right side and Phlebotomist was kneeled down on her left side. I'm right here, (CNA #3) demonstrated as standing to the left back side of the wheel chair. I take care of her all the time, I know how to handle her. She was upset with the Phlebotomist and started to kick at her. She was holding her left arm and pressed the band aid on it and (Resident #1) verbally said,' It hurts.' She goes to kick her again and I want to say at least 2 or 3 times in that hot second. Then (CNA #1), her reaction was a lot quicker than mine and she went down to block the hit and pushed the Phlebotomist out of the way. That's when (Resident #1) reached down and hit (CNA #1) with her right arm. Then we heard a pop; I'm going to say I heard a pop because I know what I heard and it was a loud pop. I don't know if it was the up swing or the down swing when she hit (CNA #1) that I heard the pop. I think it was when she went down and hit (CNA #1) and then swung arm up and that's when I heard the pop. This is the critical point, I don't really know it just happened so fast. We heard the pop and that's when (CNA #2) said, did you all hear that and we said, yeah we heard that...Like it was loud enough for (CNA #2) to hear it and she was still there at the bottom of A - bed. It was loud enough for her to say what was that. After hearing the pop, I left the room to get the nurse. I had trouble finding her initially. She wasn't on the floor. I don't remember who I told. I know I came back with a nurse. I want to say it was (LPN #1) that I brought back to the room. Did I bring (LPN #2), I don't know. Trying to think who it was. (LPN #1) wrote the report. It might have been (LPN #2), then (LPN #1) came later." She was then asked what she told the nurse? She stated, "This is what I don't remember in detail because whatever I told them it had to be what I heard. Sounded like she broke her arm. Before doing our Witness Statements, we were called into a room with( LPN #1). It was (CNA #2, CNA #1, LPN #1) and myself. I don't remember if (LPN #2) was in there. (LPN #1) didn't say much; said we could get into trouble and it would be reported to the State. She didn't say why we would be in trouble. I think we all understood why. If the xray had come back with her wrist then said arm fractured, we would be in bad trouble. That meant to me a mark on our license. The meeting in the room was to warn us how serious the situation was. I think we explained what happened before we went into the room; it might have been in the room, we weren't in there long. I want to say we did." She was then asked if anyone told them what to write or not write on their Witness Statements. She said, "No, (LPN #1) basically said be careful what you say because this will be reported and the State will review it. That's basically what she said. I have never been through anything like this before. I have completed Witness Statements before but not anything like this. I was expecting to hear from State. I did not talk to the Administrator or DON. They didn't talk to me; they may have talked to (LPN #1, CNA #1 and CNA #2). It's been awhile ago and I don't remember talking to them. We were all really scared. LPN #1 scared us but I haven't heard anything since the incident." She was then asked to read her Witness Statement and after reading it she was asked if what was in her Witness Statement was an accurate account of the incident. After a long pause, she stated, "To say, I don't remember in particular her right arm held when after she swung to hit (CNA #1). To say someone held her arm, that's not how I remember the incident. I don't remember. I'm trying to be as honest as I can. The Phlebotomist is knelt down to put the dressing on her left arm. She swings down and hits (CNA #1). As far as (CNA #1) maybe grabbing her right arm then, I don't remember. I don't remember her continuing hitting after hearing the pop. From my memory, it's not like it happened yesterday. Knowing (Resident #1), she gets combative real quick. I can't know if (CNA #1) was holding her arm after she swung. I don't know if (CNA #2) held her arm after she swung. (CNA #2) could have been there, her and (CNA #1) were both there. (CNA #2) was on (Resident #1) right side with (CNA #1). (CNA #2) could have come up before the pop, I don't remember." She was asked if there was anything she would change about her Witness Statement? She stated, "I can add to my statement, ( LPN #1) did take us in a room. She did tell us not to say anything in the Witness Statements that could be viewed as Abuse" She was then asked if she held Resident #1 arm down? After a very long pause she stated, "I want to say No, then I want to say Yes...I did not break her arm...she had already hit (CNA #1) and that's when we heard the pop when her arm was up in the air and she was coming down to hit (CNA #1) again and that's when I grabbed her arm. When we heard the pop, I think (Resident #1) was still focused on the Phlebotomist because she is still kicking at her and (CNA #1) knelt down trying to shield the Phlebotomist. (CNA #1) was looking down. When (Resident #1) was going down to hit her again is when I reached over her. I don't think I grabbed her. I think I just pushed her arm back up and (CNA #1) is on her right side now. (Resident #1) is trying to hit again and I'm trying to calm her down. I'm saying we were holding her arm down on the arm of the wheel chair. I was holding her arm and trying to get her to calm down. She did try to move her arm while I was holding it and she was mad at the Phlebotomist. This is what I reported to (LPN #1) and then she told us that we couldn't write that she was held down because that is Abuse and the State is going to be reviewing this and we could lose our license." After another pause she said, "So when (LPN #1) told us this, what I should have done is reported that immediately to the Administrator and DON." 4) On 3/26/13 at 4:35 p.m., Lab Tech #1 (Phlebotomist) was asked if she remembered the incident with Resident #1 in December 2012. She stated, "Yes, but I don't remember if she was in the hallway or in her room when she let me stick her after I had explained to her what I was going to do. I stuck her (in the arm opposite from the one that was broken) and she did ok for about a second after I stuck her. After that she bent her arm up and took the tourniquet off and became a little combative, ie: she was fighting me to stop, she was trying to push me away. I was just concerned about getting cotton ball on her arm because she was bleeding everywhere. There was no pressure applied and she had the hematoma but I can't remember the size of the hematoma. It is not common practice to have people help with combative residents until it gets done. I don't remember if I got band aid on or not. I did not hear a popping sound. At this time she was shown her Witness Statement and after reading it, she stated, "Hmmm, I don't have very good memory." She was then asked if this is really what happened as documented in her Witness Statement? At this time she began crying and stated, "I'm so proud this is over, I couldn't even sleep that night. (CNA #3) was holding her right arm down while I was cleaning the blood off of left arm where I had drawn the blood. She was holding her right arm down during this time. I don't remember who told me but I was told not to put (CNA #3's) name in there that she was holding her down. It could have been (CNA #3) that told me this but I honestly don't remember who told me that. I was told the next day by (CNA #3) that they were all pulled into a room and got their butt chewed out. I do not know who did this." She was then asked if prior to her and the CNAs filling out their Witness Statements if anybody said, this is what we have to say? She stated, "The CNAs were at the medication cart discussing what had to be said on the Witness Statements. (CNA #3) told everyone that they should say they were just helping and she was flailing her arms around when they heard the pop." She was asked after that night, did anyone from the facility ever question you about this incident? She stated, "No, I filled out the Witness Statement before I left that night." She was then asked to demonstrate how (Resident #1) was held down. She stated, "(CNA #3) was standing at the resident's right side of her wheel chair where her arm was lying on the right arm rest of the wheel chair. She held with one hand at her elbow and the other hand across her wrist/hand. She said, "I'm holding her as tight as I can. At that time (Resident #1) tried to raise her right hand/arm when (CNA #3) beared down hard smashing her right hand/wrist down on top of the wheel chair's right arm rest. She did not flail her arm around when this happened. Immediately after she pushed her arm back down she stated, 'Oh ----, I think I broke her arm' !" i. The nurses who received report of the resident injury were interviewed: 1) On 3/26/13 at 2:27 p.m. via phone, LPN #2 was asked if she remembered the incident with Resident #1 back in December 2012. She stated, "Yes, I was passing meds on "B" hall when I had a CNA come up and asked for (LPN #1) because she couldn't find her. This was my 1st night on the floor. After seeing her (CNA #3) the 3rd time still looking for (LPN #1) and appearing very panicky, I asked her if there was anything I could help with. She told me the lab was in the room and they were holding her (Resident #1) arm and they heard a snap. I then said, wait a minute, you heard a snap and asked her if she was sure she didn't hit her arm on something. She said no, she didn't hit her arm on anything. After assessing her, I determined at that point it was probably broken and I called the Doctor and he ordered an Xray. I pulled (LPN #1) to the side and told her the story they (CNAs) told me and this is a reportable; you can't hold people down...it's abuse. Before I got Xray results and before I got to tell (LPN #1) what I had been told; their stories had changed. I didn't know what to do since the stories had changed from it broke when they were holding her down to she hit it on wheel chair then to she did it when she was flailing her arms around. (LPN #1) then pulled all of the CNAs and myself into the office together and said, 'Get your stories straight; what happened?' No one at that point admitted to holding her arm down. I asked (CNA #3) why she told me that they were holding her down when her arm snapped. She told me that I must have misunderstood her because that's not what she told me. I do know the lab lady was talked to because she told me the next day, 'I don't want to get anybody in trouble but, I'm not going to hold anybody down anymore.' I talked to the Administrator the next morning and told her what they had originally told me what happened but now their stories had changed. I do not know how she could have fractured it like that just by flailing her arms around." 2) On 3/27/13 at 9:54 a.m., LPN #1 was interviewed via telephone and asked if she remembered the incident with (Resident #1) in December 2012 when her arm was fractured during a blood draw. The LPN stated, "Yes, I knew (Resident #1). She was a resident on my hall. I was the nurse. I did not witness it but they came to get me when the resident became combative. I don't remember who came to get me... I remember (LPN #2) being there because she told me she had gotten another story from one of the CNAs, (#2 or #3). She told me this after I shipped (Resident #1)... She told me (Resident #1) got combative when they were drawing blood. ... She thought they held her arm too hard when (Resident #1) became combative. I don't know if an aide told her this or what. I took (CNA #3) in the office to ask her what happened. It might have been after (Resident #1) was shipped out that I talked to her... I told her (CNA #3), that (LPN #2) had told me they were holding her down. (CNA #3) said 'no'. The Lab Tech told me the same thing. I didn't know at the time I was talking to the lab tech, there were conflicting statements... (LPN #2) was the only one that told me her arm broke because staff was holding down her arm... This is when I asked (CNA #3) what happened and she denied (LPN #2's) statement... I usually get all witnesses to come to nurses station to fill out witness statements. I don't remember what I did that night. I only talked to (CNA #3) in a room. I d

Complaint # was substantiated (all or in part) in these findings. Based on record review, and interview, Administration and Nursing Administration failed to ensure Resident #5 received the necessary care and services to maintain the highest practicable physical well-being as evidenced by the facility failure to ensure assessment was immediately provided for a reported change in the mental and physical status of a resident for 1 of 1 (Residents # 5) case mix residents with a reported change of condition. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident # 5 who had a change of condition that was reported to the charge nurse who failed to immediately assess the resident and had the potential to affect 50 residents who had a change in condition since [DATE] according to the listing received from the Administrator on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE] at 2:30 p.m. The findings are: 1. The job description titled "Nursing Home Administrator" documented "... Typical Functions: Plans, implements, directs, and monitors programs and services provided for nursing home residents by developing internal policies and procedures to ensure compliance with regulations. ... Investigate and resolves complaints regarding staff, residents, and programs. Develops and revises disciplinary rules and standards operating procedure for the facility. ...". 2. The job description titled "Job Duties and Responsibilities - Director of Nursing" documented "Summary of Duties: The Director of Nursing is a registered nurse ... and has, in writing, administrative authority, responsibility, and accountability for the functions, activities, and training of nursing services staff, and is responsible for nursing services twenty-four hours a day, seven days a week. Specific duties and responsibilities include, but are not limited to: 1. Nursing administration - Provides guidance and direction to the nursing staff to ensure health needs of the veterans are met. Develops, implements, and evaluates departmental policies and procedures that are in accordance with accepted standards of care ... Conducts interviews and makes recommendations for hiring, and disciplining nursing personnel; ... 2. Regulatory compliance - Utilizes current knowledge of (Veteran Affairs), state and federal regulations in the long-term care setting and ensures the nursing department remains in compliance with the rules and regulations that govern the provision of care. ...". 3. The facility's policy titled "Condition Change, of the Resident (Observing, Recording and Reporting)" documented "Basic Responsibility: Licensed Nurse. Purpose: To observe, record and report any condition change to the attending physician so proper treatment will be implemented. ... Procedure: After all resident falls, injuries or changes in physical or mental function, monitor the following: 1. ... f. Observe for alterations in consciousness. ... n. Take vital signs and include temperature. ... r. Observe for dyspnea or variations in respirations (irregular). ... 2. Have someone stay with the resident while the nurse is calling the attending physician ... 6. Notify DON or Supervisor of any falls, injuries, or changes in mental or physical condition. ...". 4. Resident # 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 9 (8 - 12 indicates moderately impaired) on the Brief Interview for Mental Status and required supervision with ambulation and locomotion. a. A facility form titled "Concern" documented, "Date of Concern: [DATE]. Name of Person Voicing Concerns: (OT (Occupational Therapist) # 1). Title: OT. Nature of Concern (Be Specific): OT entered room at (approximately) 11:30 a.m. (Patient) was only able to respond to verbal stimuli by opening eyes. No verbal response or other movement. It was noted that (patient) had severe rattling (with) breathing. OT went straight to Nurse (LPN (Licensed Practical Nurse) # 1) (and) asked how (patient) was doing this a.m. She stated that he was doing OK (and) had been up for breakfast earlier. I (OT)explained to her that (Resident # 5) was not responding to me like he normally does, that he sounds very congested (and) something is wrong. Nurse did not go check on (Resident # 5) at this time. I then found a CNA (Certified Nursing Assistant) and requested that she check his vitals. She did so right away. CNA stated, 'They are really low' upon leaving (patient) room. I asked what it was, she stated ,[DATE], as she proceeded to nurse office to tell nurse. There was still no response from nurse so I asked CNA to check (oxygen) level, which she did right away. As she came out of room she stated 'It's 90'. I then went back into room at (approximately) 11:45 a.m. to check on (patient). I immediately noticed very shallow breathing (with) (patient) and congested sounds. I attempted to wake (patient) by shaking him on (right) shoulder (without) any response ... It appeared that (patient) was in trouble, so I ran to hallway. (LPN # 1) was at the nurses station (and) I stated, '(LPN # 1), he is in big trouble, you need to come now'. She did follow me this time into (patient) room. I then attempted to arouse (patient) by saying '(name, name, name)' and shaking his (right) shoulder. I noted 1 breath taken by (patient) (and) then (no) chest movement as (patient) stopped breathing. (LPN # 1) was also saying '(name, name)'. I then asked (LPN # 1) what I could do to help. She said (I) need (RN (Registered Nurse) Supervisor # 1). I immediately left room and found (RN Supervisor # 1) on opposite hall (and) told him that (LPN # 1) needed his help. He went straight to (Resident # 5's) room. As he entered room and saw (Resident # 5) he stated '(It) appears that (Resident # 5) is gone'. I then left room and went to 5th floor to begin writing statement of events that had happened. (OT Supervisor # 1) happened to walk by so I asked her to sit down (and) explained to her what happened. We then decided at that time to meet (with) Administrator to explain what had happened. Administrator did meet (with) (OT Supervisor # 1) (and) I, (and) I was able to explain exactly what had happened." b. The Nurse's Notes dated [DATE] at 11:50 a.m., signed by Registered Nurse (RN) Supervisor # 1, documented, "(Resident) event (respiratory/[MEDICAL CONDITION]) pupils fixed, (non responsive), (no) (breath sounds), (no) pulse ... (resident) (expired) at 11:50 a.m." On [DATE] at 2:40 p.m., RN Supervisor # 1 was asked if he remembered (Resident # 5). RN Supervisor # 1 stated "Yes." RN Supervisor # 1 was asked, "Can you tell me how you got involved with him on the day he died ?" RN Supervisor # 1 stated, "(LPN # 1) came and got me when I was in the hallway on the 6th floor. She said she felt like the resident's vital signs were low and level of consciousness was decreased. She said (OT # 1) had come and reported a condition change and I needed to check him. As I walked in (Resident # 5) stopped breathing." c. On [DATE] at 8:16 a.m., OT # 1 was asked, "What happened on [DATE] with (Resident # 5)?" OT # 1 stated, "I went into see (Resident # 5), tried to around him by calling his name and he didn't respond. He usually woke right up, so I left the room and went to the office on the 6th floor by the nursing station. I told (LPN # 1), she was just outside the office. I asked her how (Resident # 5) was doing and she said he was fine he'd been to breakfast and I said OK and told her he didn't look right and was not responding and his breathing was not right. She didn't do anything. I grabbed a CNA and asked them to do vital signs." OT # 1 was asked "Do you recall who the CNA was?" OT # 1 stated, "No. The CNA got stuff and went to (Resident # 5's) room and got vital signs. I sat down at the nursing station with another resident as the CNA went into the room. She came back out and said they were really low and I said what were they. She told me and they are in my written statement. She took the vital signs to (LPN # 1) in the office by the nursing station. The CNA came out and (LPN # 1) was still sitting there and I asked her (CNA) to check O2 (oxygen) level and she did. She said they were 90. At that point I stood up and went into (Resident # 5's) room. (LPN # 1) was still in the office eating lunch. I went back to (Resident # 5's) room and he was breathing really shallow and there was no response and he was in trouble. I went back to (LPN # 1) who was at a med cart and told her she had to get in there because he was in trouble. We went in and (Resident # 5) was gasping and she sent me for (RN Supervisor # 1) the RN and (RN Supervisor # 1) came right away and the resident had passed. I was really upset with this. I went down to 5th floor and grabbed a sheet of paper and started writing. My boss came by and I told her what happened and she said lets talk with (Administrator). We went down and talked with (Administrator) within 15 minutes of this." d. A sheet of paper dated [DATE], signed by CNA # 1, documented, "On [DATE], I was asked (to) get (Resident # 5's) vitals by the therapist. I got them and his blood pressure was very low so I told the nurse, (LPN # 1). She was in the nurses office eating. She said his vitals were low that morning during breakfast about 2 hours before (Resident # 5's) passing. She also told me not (to) worry about doing the vitals and that she would do them as well. This was before breakfast." On [DATE] at 2:30 p.m., CNA # 1 was asked, "What happened on the day (Resident # 5) died ?" CNA # 1 stated, "(LPN # 1) told me she was going to get vital signs that day and not to worry about it. I walked the resident from the dining room to his room and he had to stop and sit down. He said he felt weak. He sat down for a little then I walked him on to bed. After that PT (Physical Therapy) or OT came to me and asked me to get (Resident # 5's) vital signs. I did and they were really low." CNA # 1 was asked, "Did you also get a pulse and respiration?" CNA # 1 stated,, "Yes and they were low too." CNA # 1 was asked, "How was the resident breathing when you did the vital signs?" CNA # 1 stated, "Heavy, like he was short of breath and he wouldn't wake up like he normally did." CNA # 1 was asked, "After you took the vital signs, did you tell (LPN # 1) and tell her what the resident was like?" CNA # 1 stated, "Yes, she said his blood pressure was low. I told her he wasn't breathing right or acting right." CNA # 1 was asked, "What did she say when you told her about the resident not breathing right or acting right?" CNA #1 stated, "She said, 'OK," that his vital signs were low that a.m. She wasn't concerned. She didn't come check him like I thought she should have." CNA #1 was asked, "Did you tell anyone else about the resident's problems?" CNA #1 stated, "I didn't see anyone else to tell." CNA #1 was asked, "With (LPN #1), had you ever had this concern before with her not responding to your concerns about the residents?" CNA #1 stated, "Yes, she usually say 'Whenever I get a second I'll come.' She was never very attentive." CNA #1 was asked, "Did you tell anyone about your concerns with (LPN # 1)? CNA #1 stated, "Not (RN Supervisor # 1) or (Director of Nursing (DON)) but I did talk with the other aides." CNA # 1 was asked, "Did you tell any of the other LPNs about your concerns with (LPN # 1)?" CNA #1 stated, "No." CNA #1 was asked, "What does the '4' mean on the schedule by your name for today?" CNA # 1 stated, "That's section 4, rooms (number) to (number). I'm working that section today and that is where I always work." CNA #1 was asked, "Did anyone talk with you before today about letting someone else know when a nurse does not respond to you about a resident's condition change?" CNA # 1 stated, "No." e. A lined sheet of paper dated [DATE], signed by LPN # 1, documented, "I had personally taken (Resident # 5's) (blood pressure) after counting narcotics with the 11:00 p.m. to 7:00 a.m. shift at 7:00 a.m. He was alert and getting ready to go to the dining room for breakfast. I administered his 8:00 a.m. medication in the dining room (and) he denied pain/discomfort. He was taken back to his room (at) approximately 8:30 a.m. Some time after the OT stated (Resident # 5) did not seem as alert, no urgency in his speech. I had a CNA check his (blood pressure) (and) SpO2 (pulse oximetry) - which were within normal limits for him. He was in bed (and) appeared to be sleeping when I entered the room to give his room a 10:00 a.m. medication. I had asked the RN Supervisor to examine him and he replied he would after accessing (assessing) the new admission. Around 10:45 a.m. the OT call out from (Resident # 5's) room (and) I entered to find him expired." On [DATE] at 2:40 p.m., RN Supervisor #1 was asked, "Are you sure it was (LPN # 1) who came to get you and not OT?" RN Supervisor #1 stated, "No, It was (LPN # 1), I never saw that (OT #1) guy." RN Supervisor #1 was asked, "Had any of the staff reported concerns with (LPN #1) not responding to their concerns about residents?" RN Supervisor # 1 stated, "Seems to me a CNA did come to talk with me about a resident's dressing being off after his shower and that it had been some time since the shower and it still wasn't on. When I went to check the dressing, it was on and the aide didn't know (LPN #1) been in. I had one LPN tell me that (LPN # 1) was slow to respond." RN Supervisor #1 was asked, "Who was the nurse?" RN Supervisor # 1 stated, "(LPN # 2.)." RN Supervisor #1 was asked, "What did you do?" RN Supervisor #1 stated, "I talked with (LPN # 1) and she said she was busy with meds." RN Supervisor #1 was asked, "Did you tell (DON) or (Administrator) about the concerns regarding (LPN #1)?" RN Supervisor #1 stated, "No, once I had words with (LPN # 1) I thought that would be the end of it. I never heard anything else so I thought it was fixed." RN Supervisor #1 was asked, "Were you asked to monitor (LPN # 1's) residents for unnoticed/unreported condition changes after [DATE]?" RN Supervisor # 1 stated, "No, I'd check residents when she asked me to." f. There were no documented statements from other staff regarding LPN # 1's response to reported resident condition changes provided by the Administrator with the DMS 7734 OLTC (Office of Long Term Care) Incident and Accident Report (I & A) as of [DATE]. There was no assessment of other residents on [DATE] for possible unreported/unrecognized condition changes provided by the Administrator with the DMS 7734 as of [DATE]. There were no documented interviews with residents regarding response to condition changes provided by the Administrator with the DMS 7734 as of [DATE]. g. On [DATE] at 9:00 a.m., LPN # 2 stated she had worked on the 6th floor for 1 ,[DATE] years with last year being on the 7:00 a.m. to 3:00 p.m. shift. LPN # 2 was asked, "Do you work with (LPN # 1) much?" LPN # 2 stated, "Two of the four days I work every week, I worked with her. She relieved for me and the other LPN." LPN # 2 was asked, "Any concerns with (LPN # 1) not responding to resident condition changes?" LPN # 2 stated, "No. I did have CNAs come to me with concerns that she did not respond to them. I passed those on to (RN Supervisor # 1). What I saw was a communication barrier. A CNA would tell her something and she'd say OK, then would go take care of it but never got back to the CNA who had the concern to let them know and she didn't go right away." h. On [DATE] at 9:18 a.m., CNA #2 was asked, "Ever work with (LPN # 1)?" CNA # 2 stated, "Yes." CNA #2 was asked, "Did you ever tell (LPN # 1) that a resident had a condition change and have concerns that she didn't do anything?" CNA #2 stated, "Yes, about one month ago ... I told her and I didn't think she listened to me. I told (RN Supervisor # 1) about my concerns." i. On [DATE] at 10:05 a.m., the DON was asked, "Has any staff member reported a concern with a resident's condition change not being responded to?" The DON stated, "Yes, a therapist." The DON was asked, "When was this?" The DON stated, "[DATE]." The DON was asked, "Who was the resident?" The DON stated, "(Resident # 5)." The DON was asked, "What was the therapist concern?" The DON stated, "The concern went from the OT to the Administrator, who told me of the OT's concern." The DON was asked, "What was the concern?" The DON stated, "That he'd gone into (Resident # 5's) room for therapy and the resident did not arouse and he went to the charge nurse who was in the nursing office eating lunch and she did not get up to assess (Resident # 5). Then he saw a CNA and asked the CNA to get vital signs on (Resident # 5). The CNA got the blood pressure and told OT what it was. The OT asked the CNA to let the nurse know and then he asked if she had gotten a pulse ox and she said no. So he asked her to go back and get a pulse ox." The DON was asked, "Who was the CNA?" The DON stated, "(CNA # 1). She got a pulse ox and was 90%. She told him and she told the nurse. His concern was the nurse still did not respond to (Resident # 5's) needs. He was there so he went back to the room and now (Resident # 5) had labored breathing and that point (LPN # 1) was in the hall and he told (LPN # 1) 'You need to come now' and then (LPN # 1) went into the room. (OT # 1) asked 'What can I do to help' and she said 'Go get (RN Supervisor # 1). When (RN Supervisor # 1) got there, the resident had expired." The DON was asked, "This was the story/allegation as you knew it on [DATE]?" The DON was asked, "How were you monitoring (LPN # 1)?" The DON stated, "The RN Supervisor was doing rounds and watching. (RN Supervisor # 1) and myself were doing that?" The DON was asked, "How often, any set times?" The DON stated, "No, I try to go out every 2 hours and (RN Supervisor # 1) is on 5 and 6 all the time, back and forth." The DON was asked, "Besides being on 6th and watching, did you do anything else?" The DON stated, "Not specifically, no." The DON was asked, "Did you go in and assess (LPN # 1's) assigned residents?" The DON stated, "No, I did not." The DON was asked, "How would you know that (LPN # 1) wasn't responding to a resident's condition change if you didn't go in and check the residents of hers?" The DON stated, "We wouldn't. I check the 24 hours report when I come in and when I go home. The DON was asked, "Any reports prior to this from staff that (LPN # 1) was not responding to their reports of resident condition changes?" The DON stated, "None brought to my attention." The DON was asked, "Did (RN Supervisor #1) ever share concerns that staff was telling him that (LPN # 1) was not responding to staff concerns?" The DON stated, "No, I never heard any complaints on that about (LPN # 1)." The DON was asked, "Was (LPN # 1) terminated due to the outcome of the investigation?" The DON stated, "No, it was her 3rd disciplinary action. It's an automatic termination no matter the outcome." The DON was asked, "What was it (disciplinary action) for?" The DON stated, "She didn't document on the resident." j. On [DATE] at 10:55 a.m., the Administrator was asked, "When did (OT # 1) report his concerns to you regarding (Resident # 5 )?" The Administrator stated, "Initially on [DATE]." The Administrator was asked, "What did you think his concern was?" The Administrator stated, "A lack of response on the part of the LPN." The Administrator was asked, "Did you go assess or have others assess (LPN # 1's) other residents on [DATE]?" The Administrator stated, "No." The Administrator was asked, "Did you get any staff statements from the other staff regarding concerns with reported condition changes not being responded to?" The Administrator stated, "No." The Administrator was asked, "Did you question residents if they had concerns with condition changes not being identified or treated?" The Administrator stated, "No." The Administrator was asked, "Any in-services with staff on reporting condition changes since [DATE]?" The Administrator stated, "No." The Administrator was asked, "What has happened with (LPN # 1)?" The Administrator stated, "She worked until [DATE]. She was terminated." 1) The Weekly Time Sheets from [DATE] through February 4, 2013 receved from the Director of Nursing on [DATE] at 4:06 p.m. documented LPN # 1 worked from 6:30 a.m. until 3:30 p.m. on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 2) The letter from the State of Arkansas Department of Veterans Affairs to (LPN # 1) dated [DATE] documented, "... Subject: Disciplinary Action, Administrative Leave Without Pay. You are being place on Administrative Leave Without Pay, effective immediately, pending the results of an investigation of the Office of Long Term Care (OLTC) regarding possible resident abuse or neglect on [DATE]. Regardless of the outcome of the investigation, your performance in the subject incident was substandard, and because you have been the subject of progressive disciplinary actions, will lead to your termination. ..." k. On [DATE] at 6:30 p.m., the Quality Assurance Nurse, the DON, and the Administrator were asked, "Any in-services with staff regarding reporting change of condition since [DATE]?" The Quality Assurance Nurse, the DON, and the Administrator all stated, "No." The Quality Assurance Nurse, the DON, and the Administrator were asked, "Did you talk with (LPN # 1) about reporting/responding to reports of a residents change of condition?" The DON stated, "No, only about not documenting." l. The Immediate Jeopardy was removed and the scope/severity reduced to "H" on [DATE] at 4:20 p.m. when the facility implemented the following Plan of Removal: 1) Identification: There are no current residents in the facility with an unstable medical condition. There are sixteen residents (16) residing on 6th floor Avenue that are at risk for the same failed practice of failure to assess following a reported change of condition and implement interventions. 2) Assessments: An assessment of all residents in the facility, including observing for respiratory distress, level of consciousness, and current complaints will be conducted by DON/RN Supervisors on [DATE], beginning at 3:00 p.m. and completed by 5:00 p.m. to ensure no resident has an unidentified condition change. 3)Training: Beginning on [DATE] at 3:30 p.m., all nursing staff will be in-serviced at the beginning of each shift, and will be ongoing to include new hires and staff returning from leave. The in-servicing will done by the NHA (Nursing Home Administrator)/DON/RN Supervisor, and in-service sign-in sheets used. Training will take place before staff work on the floor. The in-service will include who to report a change of condition to and what to do if the Charge Nurse/RN Supervisor do not respond to the report. The in-service will include the policy on change of condition, with a signed acknowledgement of receipt. 4) Monitoring: The 24-Hour Shift Reports will be monitored by the shift RN for condition changes. The RN will make resident rounds on each resident once a shift to monitor resident condition and observe for changes in condition. Any negative findings or unreported change of condition will be addressed by the shift RN and reported to the DON for retraining of staff.

Complaint # was substantiated (all or in part) in these findings. Based on record review, and interview the facility failed to ensure necessary care and services were provided to attain or maintain the highest practicable physical well-being for Resident #5. The facility failed to ensure to immediately assess a resident's condition for a reported change in mental and physical status for 1 of 1 (Resident # 5) case mix resident who had a change in condition. The failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident # 5 who had a change of condition that was reported to the charge nurse who failed to immediately assess the resident condition and had the potential to affect 50 residents who had a change of condition since [DATE] according to a list received from the Administrator on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE] at 2:30 p.m. The findings are: 1. The facility's policy titled "Condition Change, of the Resident (Observing, Recording and Reporting)" documented "Basic Responsibility: Licensed Nurse. Purpose: To observe, record and report any condition change to the attending physician so proper treatment will be implemented. ... Procedure: After all resident falls, injuries or changes in physical or mental function, monitor the following: 1. ... f. Observe for alterations in consciousness. ... n. Take vital signs and include temperature. ... r. Observe for dyspnea or variations in respirations (irregular). ... 2. Have someone stay with the resident while the nurse is calling the attending physician ... 6. Notify DON (Director of Nursing) or Supervisor of any falls, injuries, or changes in mental or physical condition. ..." 2. Resident # 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 9 (8 - 12 indicates moderately impaired) on the Brief Interview for Mental Status and required supervision with ambulation and locomotion. a. A facility form titled "Concern" documented, "Date of Concern: [DATE]. Name of Person Voicing Concerns: (OT (Occupational Therapist) # 1). Title: OT. Nature of Concern (Be Specific): OT entered room at (approximately) 11:30 a.m. (Patient) was only able to respond to verbal stimuli by opening eyes. No verbal response or other movement. It was noted that (patient) had severe rattling (with) breathing. OT went straight to Nurse (LPN (Licensed Practical Nurse) # 1) (and) asked how (patient) was doing this a.m. She stated that he was doing OK (and) had been up for breakfast earlier. I (OT)explained to her that (Resident # 5) was not responding to me like he normally does, that he sounds very congested (and) something is wrong. Nurse did not go check on (Resident # 5) at this time. I then found a CNA (Certified Nursing Assistant) and requested that she check his vitals. She did so right away. CNA stated, 'They are really low' upon leaving (patient) room. I asked what it was, she stated ,[DATE], as she proceeded to nurse office to tell nurse. There was still no response from nurse so I asked CNA to check (oxygen) level, which she did right away. As she came out of room she stated 'It's 90'. I then went back into room at (approximately) 11:45 a.m. to check on (patient). I immediately noticed very shallow breathing (with) (patient) and congested sounds. I attempted to wake (patient) by shaking him on (right) shoulder (without) any response ... It appeared that (patient) was in trouble, so I ran to hallway. (LPN # 1) was at the nurses station (and) I stated, '(LPN # 1), he is in big trouble, you need to come now'. She did follow me this time into (patient) room. I then attempted to arouse (patient) by saying '(name, name, name)' and shaking his (right) shoulder. I noted 1 breath taken by (patient) (and) then (no) chest movement as (patient) stopped breathing. (LPN # 1) was also saying '(name, name)'. I then asked (LPN # 1) what I could do to help. She said (I) need (RN (Registered Nurse) Supervisor # 1). I immediately left room and found (RN Supervisor # 1) on opposite hall (and) told him that (LPN # 1) needed his help. He went straight to (Resident # 5's) room. As he entered room and saw (Resident # 5) he stated '(It) appears that (Resident # 5) is gone'. I then left room and went to 5th floor to begin writing statement of events that had happened. (OT Supervisor # 1) happened to walk by so I asked her to sit down (and) explained to her what happened. We then decided at that time to meet (with) Administrator to explain what had happened. Administrator did meet (with) (OT Supervisor # 1) (and) I, (and) I was able to explain exactly what had happened." b. The Nurse's Notes dated [DATE] at 11:50 a.m., signed by Registered Nurse (RN) Supervisor # 1, documented, "(Resident) event (respiratory/[MEDICAL CONDITION]) pupils fixed, (non responsive), (no) (breath sounds), (no) pulse ... (resident) (expired) at 11:50 a.m." On [DATE] at 2:40 p.m., RN Supervisor # 1 was asked if he remembered (Resident # 5). RN Supervisor # 1 stated "Yes." RN Supervisor # 1 was asked, "Can you tell me how you got involved with him on the day he died ?" RN Supervisor # 1 stated, "(LPN # 1) came and got me when I was in the hallway on the 6th floor. She said she felt like the resident's vital signs were low and level of consciousness was decreased. She said (OT # 1) had come and reported a condition change and I needed to check him. As I walked in (Resident # 5) stopped breathing." c. On [DATE] at 8:16 a.m., OT # 1 was asked, "What happened on [DATE] with (Resident # 5)?" OT # 1 stated, "I went into see (Resident # 5), tried to around him by calling his name and he didn't respond. He usually woke right up, so I left the room and went to the office on the 6th floor by the nursing station. I told (LPN # 1), she was just outside the office. I asked her how (Resident # 5) was doing and she said he was fine he'd been to breakfast and I said OK and told her he didn't look right and was not responding and his breathing was not right. She didn't do anything. I grabbed a CNA and asked them to do vital signs." OT # 1 was asked "Do you recall who the CNA was?" OT # 1 stated, "No. The CNA got stuff and went to (Resident # 5's) room and got vital signs. I sat down at the nursing station with another resident as the CNA went into the room. She came back out and said they were really low and I said what were they. She told me and they are in my written statement. She took the vital signs to (LPN # 1) in the office by the nursing station. The CNA came out and (LPN # 1) was still sitting there and I asked her (CNA) to check O2 (oxygen) level and she did. She said they were 90. At that point I stood up and went into (Resident # 5's) room. (LPN # 1) was still in the office eating lunch. I went back to (Resident # 5's) room and he was breathing really shallow and there was no response and he was in trouble. I went back to (LPN # 1) who was at a med cart and told her she had to get in there because he was in trouble. We went in and (Resident # 5) was gasping and she sent me for (RN Supervisor # 1) the RN and (RN Supervisor # 1) came right away and the resident had passed. I was really upset with this. I went down to 5th floor and grabbed a sheet of paper and started writing. My boss came by and I told her what happened and she said lets talk with (Administrator). We went down and talked with (Administrator) within 15 minutes of this." d. A sheet of paper dated [DATE], signed by CNA # 1, documented, "On [DATE], I was asked (to) get (Resident # 5's) vitals by the therapist. I got them and his blood pressure was very low so I told the nurse, (LPN # 1). She was in the nurses office eating. She said his vitals were low that morning during breakfast about 2 hours before (Resident # 5's) passing. She also told me not (to) worry about doing the vitals and that she would do them as well. This was before breakfast." On [DATE] at 2:30 p.m., CNA # 1 was asked, "What happened on the day (Resident # 5) died ?" CNA # 1 stated, "(LPN # 1) told me she was going to get vital signs that day and not to worry about it. I walked the resident from the dining room to his room and he had to stop and sit down. He said he felt weak. He sat down for a little then I walked him on to bed. After that PT (Physical Therapy) or OT came to me and asked me to get (Resident # 5's) vital signs. I did and they were really low." CNA # 1 was asked, "Did you also get a pulse and respiration?" CNA # 1 stated,, "Yes and they were low too." CNA # 1 was asked, "How was the resident breathing when you did the vital signs?" CNA # 1 stated, "Heavy, like he was short of breath and he wouldn't wake up like he normally did." CNA # 1 was asked, "After you took the vital signs, did you tell (LPN # 1) and tell her what the resident was like?" CNA # 1 stated, "Yes, she said his blood pressure was low. I told her he wasn't breathing right or acting right." CNA # 1 was asked, "What did she say when you told her about the resident not breathing right or acting right?" CNA #1 stated, "She said, 'OK," that his vital signs were low that a.m. She wasn't concerned. She didn't come check him like I thought she should have." CNA #1 was asked, "Did you tell anyone else about the resident's problems?" CNA #1 stated, "I didn't see anyone else to tell." CNA #1 was asked, "With (LPN #1), had you ever had this concern before with her not responding to your concerns about the residents?" CNA #1 stated, "Yes, she usually say 'Whenever I get a second I'll come.' She was never very attentive." CNA #1 was asked, "Did you tell anyone about your concerns with (LPN # 1)? CNA #1 stated, "Not (RN Supervisor # 1) or (Director of Nursing (DON)) but I did talk with the other aides." CNA # 1 was asked, "Did you tell any of the other LPNs about your concerns with (LPN # 1)?" CNA #1 stated, "No." CNA #1 was asked, "What does the '4' mean on the schedule by your name for today?" CNA # 1 stated, "That's section 4, rooms (number) to (number). I'm working that section today and that is where I always work." CNA #1 was asked, "Did anyone talk with you before today about letting someone else know when a nurse does not respond to you about a resident's condition change?" CNA # 1 stated, "No." e. A lined sheet of paper dated [DATE], signed by LPN # 1, documented, "I had personally taken (Resident # 5's) (blood pressure) after counting narcotics with the 11:00 p.m. to 7:00 a.m. shift at 7:00 a.m. He was alert and getting ready to go to the dining room for breakfast. I administered his 8:00 a.m. medication in the dining room (and) he denied pain/discomfort. He was taken back to his room (at) approximately 8:30 a.m. Some time after the OT stated (Resident # 5) did not seem as alert, no urgency in his speech. I had a CNA check his (blood pressure) (and) SpO2 (pulse oximetry) - which were within normal limits for him. He was in bed (and) appeared to be sleeping when I entered the room to give his room a 10:00 a.m. medication. I had asked the RN Supervisor to examine him and he replied he would after accessing (assessing) the new admission. Around 10:45 a.m. the OT call out from (Resident # 5's) room (and) I entered to find him expired." On [DATE] at 2:40 p.m., RN Supervisor #1 was asked, "Are you sure it was (LPN # 1) who came to get you and not OT?" RN Supervisor #1 stated, "No, It was (LPN # 1), I never saw that (OT #1) guy." RN Supervisor #1 was asked, "Had any of the staff reported concerns with (LPN #1) not responding to their concerns about residents?" RN Supervisor # 1 stated, "Seems to me a CNA did come to talk with me about a resident's dressing being off after his shower and that it had been some time since the shower and it still wasn't on. When I went to check the dressing, it was on and the aide didn't know (LPN #1) been in. I had one LPN tell me that (LPN # 1) was slow to respond." RN Supervisor #1 was asked, "Who was the nurse?" RN Supervisor # 1 stated, "(LPN # 2.)." RN Supervisor #1 was asked, "What did you do?" RN Supervisor #1 stated, "I talked with (LPN # 1) and she said she was busy with meds." RN Supervisor #1 was asked, "Did you tell (DON) or (Administrator) about the concerns regarding (LPN #1)?" RN Supervisor #1 stated, "No, once I had words with (LPN # 1) I thought that would be the end of it. I never heard anything else so I thought it was fixed." RN Supervisor #1 was asked, "Were you asked to monitor (LPN # 1's) residents for unnoticed/unreported condition changes after [DATE]?" RN Supervisor # 1 stated, "No, I'd check residents when she asked me to." f. There were no documented statements from other staff regarding LPN # 1's response to reported resident condition changes provided by the Administrator with the DMS 7734 OLTC (Office of Long Term Care) Incident and Accident Report (I & A) as of [DATE]. There was no assessment of other residents on [DATE] for possible unreported/unrecognized condition changes provided by the Administrator with the DMS 7734 as of [DATE]. There were no documented interviews with residents regarding response to condition changes provided by the Administrator with the DMS 7734 as of [DATE]. g. On [DATE] at 9:00 a.m., LPN # 2 stated she had worked on the 6th floor for 1 ,[DATE] years with last year being on the 7:00 a.m. to 3:00 p.m. shift. LPN # 2 was asked, "Do you work with (LPN # 1) much?" LPN # 2 stated, "Two of the four days I work every week, I worked with her. She relieved for me and the other LPN." LPN # 2 was asked, "Any concerns with (LPN # 1) not responding to resident condition changes?" LPN # 2 stated, "No. I did have CNAs come to me with concerns that she did not respond to them. I passed those on to (RN Supervisor # 1). What I saw was a communication barrier. A CNA would tell her something and she'd say OK, then would go take care of it but never got back to the CNA who had the concern to let them know and she didn't go right away." h. On [DATE] at 9:18 a.m., CNA #2 was asked, "Ever work with (LPN # 1)?" CNA # 2 stated, "Yes." CNA #2 was asked, "Did you ever tell (LPN # 1) that a resident had a condition change and have concerns that she didn't do anything?" CNA #2 stated, "Yes, about one month ago ... I told her and I didn't think she listened to me. I told (RN Supervisor # 1) about my concerns." i. On [DATE] at 10:05 a.m., the DON was asked, "Has any staff member reported a concern with a resident's condition change not being responded to?" The DON stated, "Yes, a therapist." The DON was asked, "When was this?" The DON stated, "[DATE]." The DON was asked, "Who was the resident?" The DON stated, "(Resident # 5)." The DON was asked, "What was the therapist concern?" The DON stated, "The concern went from the OT to the Administrator, who told me of the OT's concern." The DON was asked, "What was the concern?" The DON stated, "That he'd gone into (Resident # 5's) room for therapy and the resident did not arouse and he went to the charge nurse who was in the nursing office eating lunch and she did not get up to assess (Resident # 5). Then he saw a CNA and asked the CNA to get vital signs on (Resident # 5). The CNA got the blood pressure and told OT what it was. The OT asked the CNA to let the nurse know and then he asked if she had gotten a pulse ox and she said no. So he asked her to go back and get a pulse ox." The DON was asked, "Who was the CNA?" The DON stated, "(CNA # 1). She got a pulse ox and was 90%. She told him and she told the nurse. His concern was the nurse still did not respond to (Resident # 5's) needs. He was there so he went back to the room and now (Resident # 5) had labored breathing and that point (LPN # 1) was in the hall and he told (LPN # 1) 'You need to come now' and then (LPN # 1) went into the room. (OT # 1) asked 'What can I do to help' and she said 'Go get (RN Supervisor # 1). When (RN Supervisor # 1) got there, the resident had expired." The DON was asked, "This was the story/allegation as you knew it on [DATE]?" The DON was asked, "How were you monitoring (LPN # 1)?" The DON stated, "The RN Supervisor was doing rounds and watching. (RN Supervisor # 1) and myself were doing that?" The DON was asked, "How often, any set times?" The DON stated, "No, I try to go out every 2 hours and (RN Supervisor # 1) is on 5 and 6 all the time, back and forth." The DON was asked, "Besides being on 6th and watching, did you do anything else?" The DON stated, "Not specifically, no." The DON was asked, "Did you go in and assess (LPN # 1's) assigned residents?" The DON stated, "No, I did not." The DON was asked, "How would you know that (LPN # 1) wasn't responding to a resident's condition change if you didn't go in and check the residents of hers?" The DON stated, "We wouldn't. I check the 24 hours report when I come in and when I go home. ..." The DON was asked, "Any reports prior to this from staff that (LPN # 1) was not responding to their reports of resident condition changes?" The DON stated, "None brought to my attention." The DON was asked, "Did (RN Supervisor #1) ever share concerns that staff was telling him that (LPN # 1) was not responding to staff concerns?" The DON stated, "No, I never heard any complaints on that about (LPN # 1)." The DON was asked, "Was (LPN # 1) terminated due to the outcome of the investigation?" The DON stated, "No, it was her 3rd disciplinary action. It's an automatic termination no matter the outcome." The DON was asked, "What was it (disciplinary action) for?" The DON stated, "She didn't document on the resident." j. On [DATE] at 10:55 a.m., the Administrator was asked, "When did (OT # 1) report his concerns to you regarding (Resident # 5 )?" The Administrator stated, "Initially on [DATE]." The Administrator was asked, "What did you think his concern was?" The Administrator stated, "A lack of response on the part of the LPN." The Administrator was asked, "Did you go assess or have others assess (LPN # 1's) other residents on [DATE]?" The Administrator stated, "No." The Administrator was asked, "Did you get any staff statements from the other staff regarding concerns with reported condition changes not being responded to?" The Administrator stated, "No." The Administrator was asked, "Did you question residents if they had concerns with condition changes not being identified or treated?" The Administrator stated, "No." The Administrator was asked, "Any in-services with staff on reporting condition changes since [DATE]?" The Administrator stated, "No." The Administrator was asked, "What has happened with (LPN # 1)?" The Administrator stated, "She worked until [DATE]. She was terminated." 1) The Weekly Time Sheets from [DATE] through February 4, 2013 receved from the Director of Nursing on [DATE] at 4:06 p.m. documented LPN # 1 worked from 6:30 a.m. until 3:30 p.m. on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 2) The letter from the State of Arkansas Department of Veterans Affairs to (LPN # 1) dated [DATE] documented, "... Subject: Disciplinary Action, Administrative Leave Without Pay. You are being place on Administrative Leave Without Pay, effective immediately, pending the results of an investigation of the Office of Long Term Care (OLTC) regarding possible resident abuse or neglect on [DATE]. Regardless of the outcome of the investigation, your performance in the subject incident was substandard, and because you have been the subject of progressive disciplinary actions, will lead to your termination. ..." k. On [DATE] at 6:30 p.m., the Quality Assurance Nurse, the DON, and the Administrator were asked, "Any in-services with staff regarding reporting change of condition since [DATE]?" The Quality Assurance Nurse, the DON, and the Administrator all stated, "No." The Quality Assurance Nurse, the DON, and the Administrator were asked, "Did you talk with (LPN # 1) about reporting/responding to reports of a residents change of condition?" The DON stated, "No, only about not documenting." l. The Immediate Jeopardy was removed and the scope/severity reduced to "H" on [DATE] at 4:20 p.m. when the facility implemented the following Plan of Removal: 1) Identification: There are no current residents in the facility with an unstable medical condition. There are sixteen residents (16) residing on 6th floor Avenue that are at risk for the same failed practice of failure to assess following a reported change of condition and implement interventions. 2) Assessments: An assessment of all residents in the facility, including observing for respiratory distress, level of consciousness, and current complaints will be conducted by DON/RN Supervisors on [DATE], beginning at 3:00 p.m. and completed by 5:00 p.m. to ensure no resident has an unidentified condition change. 3)Training: Beginning on [DATE] at 3:30 p.m., all nursing staff will be in-serviced at the beginning of each shift, and will be ongoing to include new hires and staff returning from leave. The in-servicing will done by the NHA (Nursing Home Administrator)/DON/RN Supervisor, and in-service sign-in sheets used. Training will take place before staff work on the floor. The in-service will include who to report a change of condition to and what to do if the Charge Nurse/RN Supervisor do not respond to the report. The in-service will include the policy on change of condition, with a signed acknowledgement of receipt. 4) Monitoring: The 24-Hour Shift Reports will be monitored by the shift RN for condition changes. The RN will make resident rounds on each resident once a shift to monitor resident condition and observe for changes in condition. Any negative findings or unreported change of condition will be addressed by the shift RN and reported to the DON for retraining of staff.

Based on observation, record review and interview, the Nursing Administration failed to ensure effective infection control procedures were put in place to prevent the recurrence of [MEDICAL CONDITIONS] for 1 of 1 (Resident #3) case mix resident who had recurring episodes of [MEDICAL CONDITION]. Nursing Administration failed to have an infection control program for monitoring recurring infections to assist with development and implementation of care to prevent further infections. Nursing Administration failed to ensure staff were trained in contact isolation procedures for personal protection and disposal of soiled items; for cleaning, sanitizing and disinfecting floors, shower stalls, shower chairs, sinks, and personal care items; and for washing hands and changing gloves after contamination and before continuing personal care. Nursing Administration failed to develop and implement laundry procedures that were effective in destroying the [MEDICAL CONDITION] spores. These failed practices caused a pattern of actual harm to Resident #3 who had recurring episodes of [MEDICAL CONDITION] and only had the potential to affect this 1 resident according to a list of residents who presently had [MEDICAL CONDITION] according to a list received from the Administrator on 4/20/12. The findings are: 1. The Facility Job Duties and Responsibility - Director of Nursing documented, "Summary of Duties: The Director of Nursing is a Registered Nurse who is currently licensed by the state, and has, in writing, administrative authority, responsibility, and accountability for the function, activities, and training of the nursing services staff and is responsible for nursing services twenty-four hours a day, seven days a week. " 1. Nursing Administration-Provides guidance and direction to the nursing staff to ensure the health needs of the veterans are met. Develops, implements and evaluates departmental policies and procedures that are in accordance with accepted standards of care and that are evidenced-based. Conducts interviews and makes recommendations for hiring, and disciplining nursing personnel, conducts and guides performance appraisals. Supervises the ordering and distribution of supplies and equipment, initiates purchase order requisitions to ensure adequate inventory levels, and demonstrates fiscal responsibility. Uses interpersonal skills to delegate effectively and follows up with results and feedback leadership. Leadership skills to delegate effectively and follows up with results and feedback... ..3. Staff development-Develops and coordinates annual in-service calendar for employees and provides adequate training opportunity to staff to comply with continuing education requirements. Develop and coordinates the orientation program for nursing personnel and provides adequate training to assist new employees to become familiar with departmental policies and procedures and work assignments. Actively participates in staff retention activities and focuses on minimizing turnover and creating a safe and supportive work place. 2. The Facility Job Description for the Registered Nurse Coordinator received form the Director of Nursing/Acting Administrates on 4/20/12 documented, "...Monitors evaluates and revises the program or delivery of the program as needed. Provides administrative and clinical assistance for program and coordinates the provision of program services with other health care disciplines. Coordinates nursing services by monitoring and evaluating nursing and patient care, activities, staff levels, reports, case histories and quality control activities. Determines work priorities and assigns personal ...Determines and monitors nursing contracts. Identifies in-services training needs, locates training resources and monitors training budget. " 3. The CDC (Centers for Disease and Control and Prevention) documented, that the "[MEDICAL CONDITION] is an anaerobic, gram-positive bacterium. Normally fastidious in its vegetative state, it is capable of sporulation when environmental conditions no longer support its continued growth. The capacity to form spores enables the organism to persist in the environment (e.g., in soil and on dry surfaces) for extended periods of time. Environmental contamination by this microorganism is well known, especially in places where fecal contamination may occur. The environment (especially housekeeping surfaces) rarely serves as a direct source of infection for patients. However, direct exposure to contaminated patient-care items (e.g., rectal thermometers) and high-touch surfaces in patients 'bathrooms (e.g., light switches)' have been implicated as sources of infection. [DIAGNOSES REDACTED]icile spores can survive in the environment, on floors, bed rails or around toilet seats in its spore form for up to six months. Transfer of the pathogen to the patient via the hands of health-care workers is thought to be the most likely mechanism of exposure. Standard isolation techniques intended to minimize [MEDICATION NAME] contamination of patients, health-care-workers, hands, patient-care items, and environmental surfaces have been published. Hand washing remains the most effective means of reducing hand contamination. Proper use of gloves is an ancillary measure that helps to further minimize transfer of these pathogens from one surface to another. The degree to which the environment becomes contaminated with [DIAGNOSES REDACTED]icile spores is proportional to the number of patients with [DIAGNOSES REDACTED]icile -associated diarrhea, although asymptomatic, colonized patients may also serve as a source of contamination... The recommended approach to environmental infection control with respect to the [DIAGNOSES REDACTED]icile is meticulous cleaning followed by disinfection using hypochlorite-based germicides as appropriate. However, because no EPA-registered surface disinfectants with label claims for inactivation of the [DIAGNOSES REDACTED]icile spores are available, the recommendation is based on the best available evidence from the scientific literature. The Detergent and water physically remove many microorganisms from the linen through dilution during the wash cycle. An effective way to destroy microorganisms in laundry items is through hot water washing at temperatures above 160?F (Fahrenheit) (71?C) for 25 minutes. Alternatively, low temperature washing at 71 to 77 degrees F (22-25 degrees C (centigrade) plus a 125-ppp (parts per million) chlorine bleach rinse has been found to be effective and comparable to high temperature wash cycles. The linen is sent off to a professional laundry, the facility should obtain an initial agreement between the laundry service and facility that stipulates the laundry will be hygienically clean and handled to prevent recontamination from dust and dirt during loading and transport." 4. The facility Policy and Procedure received from the Director of Nurses (DON)/Acting Administrator on 4/20/12 were as follows. a. The Policy and Procedure for [MEDICAL CONDITION] documented, 1) "Purpose, The purpose of this procedure is to provide guidelines of the care of person with diarrhea associated with [MEDICAL CONDITIONS] (Verified by culture or by evidence of positive cytotoxin assay) and to prevent transmission of [MEDICAL CONDITION] to others. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies needed..." 2) "General Guidelines: 1. The facility adopted Standard Precautions and all residents' blood, body fluids, excretions and secretions are considered potentially infectious. Resident with diarrhea associated with [MEDICAL CONDITION] (e.g. residents who are colonized and symptomatic) will be placed on Contact Precautions. Residents who are colonized with [MEDICAL CONDITION] but are asymptomatic do not require Contact Precautions... 6. Steps toward prevention and early intervention include. a. Increasing awareness of risk factors for residents. b. Considering [MEDICAL CONDITION] in differential diagnosis, especially in residents with high risk factors. c. Hand washing of staff and residents. d. Wearing gloves when handling feces or locally-contaminated articles. e. Increased attention and education regarding infection control techniques when providing tube feedings and: f. Disinfection of items with fecal soiling (e.g. bedpans, commode chairs, bedrails, etc.) 7. Appropriate surveillance information must be entered on [MEDICAL CONDITION]. Line Listing Report. The following equipment and supplies will be necessary when preforming this procedure. 1. Disinfectant. 2. Personal protective. as equipment (e.g. gowns, gloves, mask, etc. as needed). b. The Policy and Procedure for Isolation for Communicable Diseases Standard/Universal Precautions Transmission Based Precautions documented, 1) "Purpose, to ensure appropriate use of barriers by all employees. The first level of precautions (Standard/Universal) applies to all residents because signs and symptoms of infection are not always obvious and therefore may unknowingly pose a risk for susceptible person. The second level (Transmission Based) is intended for individuals who have a known or suspected infection with certain organisms." 2) Policy Transmission Based Precautions Isolation. A. Isolation refers to the precautions that are taken in the facility to prevent the spread of an infectious agent from an infected or colonized resident to susceptible persons. B. Additional precautions will be used with Standard/Universal Precautions when required to reduce the risk of transmission of infectious agents. The precautions are divided into three categories that reflect the differences in the way infections are transmitted. Some disease may require more than one isolation category.... 3. Contact Precautions prevent the spread of organisms from and infected resident through direct or indirect contact. Some examples are antibiotic resistant bacteria, [MEDICAL CONDITION], scabies, impetigo and lice. A private room may be needed in special circumstances, e.g. copious drainage not contained by a dressing or respiratory infection caused [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus). Healthcare workers should wear gloves when entering the room and change gloves if they have touched the infected material. Prior to leaving the room, workers should remove their gloves and wash their hands. In addition workers may need to wear protective gowns if contact with the infected material is likely (diarrhea, wound drainage, etc.). Care items such as stethoscope should not be shared with other residents until properly cleaned and disinfected." c. The Policy and Procedure for Categories of Isolation Precautions documented: 1) "Purpose: To prevent transmission of infections or colonized microorganisms." 2) "Policy: Transmission based isolation precautions have been established in order to ensure that appropriate isolation techniques are implemented in this facility when necessary. Our facility currently uses the three types of transmission based isolation precautions (airborne, contact and droplet) recommended by CDC... Contact Precautions; will be implemented for resident known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident environment. Examples of infections requiring Contact Precautions include, but are not limited to: a... 2. [MEDICAL CONDITIONS]... b. Room Arrangements. A private room may be needed in special circumstances, ie copious drainage not contained completely by a dressing. Confinement to the room will depend on the resident condition, personals hygiene and ability to comply with instructions. c. Gowns 1. Gowns are to be worn upon entering resident room. 2. Remove gown before leaving the room and dispose in the isolation container. d. Gloves and hand washing 1. Gloves are to be worn upon entering resident room [ROOM NUMBER]. Remove gloves before leaving the room and wash hands immediately with antimicrobial agent or waterless antiseptic agent. (Note; only soap, water and friction are to be used with [MEDICAL CONDITIONS]. e. Trash and Linen Trash and linen will be placed in red bags and disposed of or dealt with per Bio-Hazardous waste standards. ...g. Resident Care Equipment: 1. When possible, use disposable care equipment. If not feasible, disinfect with approved cleaner after isolation is discontinued." d. The Policy and Procedure for Cleaning the Occupied Isolation Room documented, "The Facility will provide a sanitary, safe and comfortable environment in which residents reside to help prevent the development of disease and infection. Isolation rooms will be cleaned daily, and or as needed, to help prevent the spread of disease or infection. In the event a resident is isolated due to contagious or infectious organisms, the isolation room will be cleaned last and the following precautions will be followed for cleaning the occupied room. 1. The Housekeepers will put on clean, non-sterile gloves and any other protective equipment required for the type of isolation before entering the room. 2. Do not sweep or use a dust/dry mop. Use of broom or dust/dry mop may push organisms into the air. Clean sinks, countertops, overbid tables, bedside table tops, and equipment within the room with a hospital-grade disinfectant. 4. The mop bucket will be placed in the door way of the room. USING A hospital-grade disinfectant wet mop the floor of the isolation room. The mop head used in the isolation room will be removed from the mop handle, double bagged and taken directly to the laundry (or the area where contaminated linen is stored) and laundered with other housekeeping supplies. No special laundry procedure is required for laundering mop handles used in cleaning isolation rooms. 5. All trash will be placed in the red bag lined step-on trash can in the isolation room and bag tie. Another person will stand outside the room with an open bag and the person inside the room will drop the tied trash bag into the open without contaminating the outside of the bag. The open bag will be tied and taken directly to the area designated for contaminated trash located in the dirty utility room. The person inside the isolation room will place a clean, red bag into the step-on trash can in the room. ...7. Contaminated gloves must be discarded in the trash can in the room and hands washed per facility policy. Mop bucket, mop handle and any other equipment used in cleaning the isolation room must be taken to a designated area, cleaned and disinfected immediately." 5. The facility policy titled "Dressing Change Technique" documented, "Aseptic technique will be observed for all dressing changes to minimize the spread of microorganisms. ... Preparation: 1. Clean a work site in the resident's room (such as an over bed table or bedside table top). ... 2. Assemble all equipment on the work surface. Take only the supplies that you need into the resident's room. Unused supplies cannot be returned to the cart or storage area. ... Remove the Old Dressing: ... 3. Wash hands ... put on clean gloves. 4. Loosen the soiled dressing ... 5. Slowly remove the soiled dressing ... 6. Discard the dressing and the gloves ... Care for the Wound: 1. Wash your hands or use a waterless antiseptic agent. ... 3. Put on clean gloves ..." 6. Resident #3 had [DIAGNOSES REDACTED].), Diarrhea, Urinary Tract Infection, [MEDICAL CONDITION], Retention of Urine. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 3/20/12 documented the resident scored a 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required limited assistance with bed mobility, transfers, dressing, bathing and personal hygiene, had an indwelling catheter, was incontinent of bowel, and had a weight loss in the past 3 - 6 months. a. Laboratory Reports documented the following: 1) "Collected 10/18/11 Reported 10/19/11 Stool type-Semi-solid [MEDICAL CONDITION] by Lamp- Positive. Positive- Sample contains toxigenic[DIAGNOSES REDACTED]icile strain with the pathogen. Treatment, [MEDICATION NAME] 250 mg (milligrams) PO (by mouth). TID (three times daily) x 14 days." 2) Collected 11/6/11 Reported 11/8/11 Stool type formed. C- Difficile by lamp Positive A." 3) Collected 11/22/11 Reported 11/25/11 Stool type semi-solid [MEDICAL CONDITION] by lamp Positive." Documented on the laboratory slip was "[MEDICATION NAME] 250 mg TID x (times) 14 day Vanc ([MEDICATION NAME]) 250 g po QID (four times daily) x 14 days." 4) "Collected 12/19/11 Reported 12/21/11 Stool Type- Semi-solid [MEDICAL CONDITION] by lamp Positive" 5) "Collected 12/21/11 Reported 12/22/11 Stool type Liquid [MEDICAL CONDITION] by Lamp Positive Out of Reference range." Documented on the laboratory slip was "[MEDICATION NAME] 250 mg 1 po qid x 14 days." 6) "Collected 2/9/12 Reported 2/10/12 Stool type -Liquid [MEDICAL CONDITION] Positive Out of Reference Range." Documented on the Laboratory slip was "2/10/12 [MEDICATION NAME] 500 mg 1 po TID (three times daily) x 2 weeks." 7) Collected 2/26/12 Reported 2/26/12 Stool type Semi-solid [MEDICAL CONDITION] Positive Out of Reference Range." Documented on the laboratory slip and signed by the Advanced Practice Nurse (APN) was, "Wait until Thur (Thursday) 3/1. Report to (Physician) if symptomatic or not (no) action @ (at) this time." b. The Physician order [REDACTED]. Then send stool for [MEDICAL CONDITION]. Continue isolation precautions. Start Florester when it arrives at facility." c. The Resident Plan of Care updated on 3/15/12 did not document any isolation precautions. d. The facility weights for the past 7 months were reviewed by the survey team. The weights from the Monthly Weight record were as follows: October 2011 - 136.5 pounds November 2011 - 136 pounds December 2011 - 127.8 pounds January 2012 - 128 pounds February 2012 - 132.8 pounds March 2012 - 130.5 pounds April 2012 -124.5 pounds The resident had a 6 pound weight loss in one month, which resulted in a 4.5% weight loss and an 8.3 pound weight loss in 2 months resulting in a 6.25% weight loss. e. On 4/16/12 at 2:35 p.m., Licensed Practical Nurse (LPN) #6 stated during initials that there resident was on isolation due to C -Diff. f. On 4/17/12 at 11:44 a.m., Housekeeper #1 entered Resident #3's room that was on contact isolation. The Housekeeper entered the resident's room wearing a mask and gloves. The Housekeeper removed a bottle of Clean Power Blue Glass and Surface Cleaner. The Housekeeper sprayed the sink and wiped it off with paper towels. Then the Housekeeper replaced the Clean Power Blue Glass and Surface Cleaner back on the housekeeping cart. At 11:45 a.m., Licensed Practical Nurse (LPN) #6 came by the room and told the Housekeeper she needed to wear a gown. The Housekeeper stated, "Oh you have to wear a gown." The Housekeeper then put on the blue isolation gown. The Housekeeper removed the broom and dust pan and entered the resident's room. The Housekeeper swept the resident's floor and emptied the dust pan in the housekeeping cart and replaced the broom and dustpan on the housekeeping cart. The Housekeeper then removed the mop from the mop bucket and mopped the resident's room. The Housekeeper then replaced the mop in the mop bucket. The Housekeeper then left the resident's room. The Housekeeper did not clean any other surfaces in the resident's room. The Housekeeper then took the housekeeping cart to the utility room removed the mop head and placed in a plastic bag and emptied the mop bucket of the water. Then the housekeeper rinsed the mop bucket. The Housekeeper was asked what type of cleaner was used to mop the isolation room. The Housekeeper stated Neutral Floor Cleanser. The Housekeeper was asked what she used to clean out the mop bucket. The Housekeeper stated, Neutral Floor Cleanser. The Housekeeper was asked what she used to clean the sink. The Housekeeper pointed to a bottle on the shelf of Clean Power Blue Glass and Surface Cleaner. The Housekeeper was asked what she cleaned in the resident's room. The Housekeeper stated, "I just cleaned the sink, sweep and mopped the floor." g. On 4/17/12 at 12:08 p.m. Certified Nursing Assistant (CNA) #2 entered the room do perform incontinent care. The CNA washed her hands put the paper towel in the trash can with a foot pedal, then touched the top of the white trash can with her bare hand and proceeded to apply gloves and an isolation gown. At 12:11 p.m., CNA #9 and #10 were performing incontinent care. The resident was incontinent of bowel. CNA #9 got stool on the right glove while providing incontinent care. The CNA wiped off the stool with a peri-wipe and proceeded with the incontinent care with the contaminated glove. The CNA picked up the peri-wipe bottle with his contaminated gloves and sprayed the peri-wash on the wipes and provided incontinent care. The CNA picked up the container of wipes with the lid off; sit the box of peri-wipes and the peri-wash on top of the floor mat with the lid sitting top up on the floor mat. The CNA #9 picked up the clean incontinent brief and placed the clean incontinent brief on the resident. CNA #9 picked up the box of peri-wipes and peri-wash off the floor and placed them in the resident's bedside table, then touched the Foley catheter bag, bed covers, the resident's pant, the resident's hat by the bill, the gait belt and the resident's jacket. At 12:21 p.m., CNA #2 assisted with incontinent care, then washed her hands placed the paper towels in the white trash can with a foot pedal. Touched the top of the trash can and did not rewash her hands and left the resident's room. The resident was then taken to the dining room for lunch. h. On 4/17/12 at 6:14 p.m., the resident was taken to the shower room on the 5th floor by CNA #11. The resident was incontinent of semi-formed stool on 2 areas of the shower floor. The CNA cleaned the rectal area, did not change gloves then proceeded with the shower. The CNA touched the cabinet, removed a can of shaving cream and applied the shaving cream to the resident's face with the contaminated gloves. The CNA touched the cabinet again getting a razor out of the cabinet. The CNA proceeded to shave the resident with the contaminated gloves. Then the CNA picked up the clean towels with the contaminated gloves and dried the resident's body including the face. The CNA picked up the bath blanket and placed the blanket around the resident and a towel around the resident head. The CNA sat the resident's feet on the contaminated floor of the shower. The CNA replaced the shaving cream in the cabinet with the contaminated gloves. The CNA picked up the bottle of cleanser that was sitting on top of the cabinet and sprayed the shower with Heavy Duty Oxygen Enhanced Cleaner, then rinsed off the cleanser. The resident was taken to his room in the shower chair. The resident was incontinent of semi-loose stool in 2 areas of his room. One by the doorway and one by the resident's bed. The CNA changed his gown, gloves and washed hands before entering the resident's room. After the resident was dressed and put in the bed. The dressing on the resident's coccyx was loose. The CNA removed the dressing and placed the dressing in the trash can. The CNA did not change gloves and proceeded with incontinent care. The CNA then cleaned the stool off the floor with peri-wipes and placed them in the trash can. With the same contaminated gloves, the CNA picked up the container of peri-wipes and the peri-wash and placed them in the bedside table. With the contaminated gloves, the CNA touched the bed control, the call light when the CNA placed the call light on the resident's bed. The CNA picked up the gait belt and placed the gait belt on the window sill. The CNA picked up the bedside mat and placed the bedside mat on the contaminated floor. The CNA then returned to the shower room. The CNA picked up the soiled linens. Wearing the same gloves, the CNA picked up the Heavy Duty Oxygen Enhanced Cleaner and sprayed the shower floor, then immediately rinsed the shower floor. The CNA got a wash cloth out of the cabinet and wiped the shower floor spraying the floor with the Heavy Duty Enhanced Cleanser and rinsed the shower floor. The CNA, with the same gloves on, reached into the cabinet, got a washcloth out of the cabinet, sprayed the Heavy Duty Enhanced Cleanser, wiped the shower chair and then rinsed the shower chair. The CNA sprayed the shower stall and chair and left the cleaner on the shower and shower chair. The CNA removed the isolation gown and gloves. The CNA went to the resident's room with a red bag of soiled linens and 1 red bag with trash and sat the bags on the floor. The CNA washed his hands and applied an isolation gown and gloves and took the 2 plastic red bags in the containers in the resident's bathroom. The CNA did not change gloves before he picked up the Foley catheter leg strap and placed it in the resident's drawer. i. On 4/17/12 at 7:22 p.m., LPN #3 set up the supplies on the care then removed the dressing off the treatment cart. The LPN placed the wound cleanser bottle under the left arm. and carried loose unsterile 4 x 4 gauze; loose 2 x 2 gauze, 2 packages of Q-Tips, one Island dressing and a tube of Santyl. The LPN sat the dressing supplies on the isolation cart sitting outside the resident's room that contained the isolation supplies. The LPN entered the room, washed her hands, and applied the gown and gloves. The LPN picked up the dressing supplies and placed then directly on top of the bedside table with the loose 4 x 4 dressing touching the top of the bedside table. The LPN loosened the resident's incontinent brief and stated, "I will have to get the CNA to clean him up before I can do the dressing." The LPN left the dressing supplies uncovered on the bedside table. At 7:30 p.m., CNA #10 performed incontinent care. The resident was incontinent of stool. The resident had semi-formed stool. The CNA removed the soiled incontinent brief and placed the incontinent brief on top of the white trash can that was by the resident's bedside table. The CNA performed incontinent with the same contaminated gloves and applied the clean incontinent brief with the contaminated gloves. At 7:35 p.m., LPN #3 changed the dressing to the pressure ulcer on the coccyx area. The dressing supplies had remained on the bedside table during the incontinent care. The LPN picked up the loose 2 x 2s and sprayed them with the wound cleanser bottle that she had placed under her left arm. With the same gloves, the LPN then picked up the 4 x 4 gauze that was touching the bedside table and dried the pressure ulcer. The LPN with the same gloves opened the Q-tips and placed Santyl on the end of the Q-tips and applied the Santyl on the bed of the pressure ulcer. The LPN reached her left hand under the isolation gown reaching into her pocket and removing a pen and wrote the date on back of the island dressing with the same contaminated gloves used to apply the dressing to the pressure ulcer on the resident's coccyx area. j. On 4/19/12 at 8:15 a.m., Laundry Personnel #1 was asked who was responsible for doing the resident's laundry. The Laundry Personnel stated, "The 5th and 6th floor had 1 washer and 1 dryer. We only wash the personal clothing. The bed linens, towels, washcloths were sent to the VA (Veteran's Administration hospital) Laundry to be cleaned. The Isolation Linen was sent in the red bags to indicate that it was isolation laundry. The resident isolation clothing is washed separately. They wash it on sanitation cycle in the washing machine, which is a 2 ? hour cycle. The Laundry Personnel was asked how hot the water was for the sanitation cycle. The Laundry Personal stated, "I'm not for sure." The Laundry Personal was asked if they used bleach. The Laundry Personal stated, "Yes only on whites." 1) On 4/20/12 at 11:30 p.m., the Literature for Using the Controls on the washing machine was received from the Maintenance Man/Housekeeping Supervisor documented, "Sanitary (select models)-for heavily soiled, colorfast garments. This cycle heats the water to a 150 degree F to eliminate bacteria. " 2) On 4/20/12 at 1:30 p.m., the Maintenance Man/Housekeeping Supervisor stated, The Clear Power Blue Glass and Surface Cleaner and the Heavy Duty Oxygen Enhanced Cleaner is not a disinfectant. This cleaner is not effective for cleaning isolation rooms or shower rooms for [MEDICAL CONDITION]. I don't know why that cleaner was in the 5th floor shower room. I can't say why the housekeeper used the glass cleanser to clean the sink." The Maintenance Man/Housekeeping Supervisor was asked what surfaces should be cleansed in an isolation room during general cleaning and he stated, "They should clean all non-porous surfaces, the bedside table, side rails, window sills, over bed tables, and of course the bathroom. The Neutral Floor Cleaner contains Altima 128." The Maintenance Man/Housekeeper Supervisor was asked if the Altima 128 was effective against [MEDICAL CONDITION]. The Maintenance Man/Housekeeping Supervisor stated it was not listed as an effective agent. The Maintenance Man/Housekeeping Supervisor was asked the procedure for mopping an isolation room. The Maintenance Man/Housekeeping Supervisor stated they can mop the room and place the mop head in a plastic bag or replace the mop in the mop bucket, empty the water and then clean the mop bucket. They are using a Neutral Floor cleaner that contains Altima 128. The Maintenance Man/Housekeeping Supervisor was asked if the Altima 128 was effective against [MEDICAL CONDITION]. The Maintenance Man/Housekeeping Supervisor stated, "It's not listed as an effective agent." The Maintenance Man/Housekeeping Supervisor stated that the housekeepers use Steriphene II, brand Disinfectant Deodorant. "It is used to clean the hand rails and door knobs at night. It was in a spray can." The product information sheet documented, "Steriphene II Brand Disinfectant Deodorant is a versatile, ready to use aerosol disinfectant deodorant. It is ideal for convenient disinfection after spot clean up. The special instruction for cleaning and decontamination against HBV and HIV-1 on surfaces or objects soiled with blood and body fluids. The Contact time, Leave surfaces wet for 10 minutes. " 3) The Altima 128 Disinfectant manufacturer's instructions documented, "Altima 128 Disinfectant. One-Step Disinfectant, Germicidal. Detergent, and Deodorant ... Directions for Use: ... Disinfection/Cleaning/Deodorizing Directions: Remove heavy solid deposits from surface, then thoroughly wet surface with a use-solution of 1 (ounce) of the concentrate per gallon of water. The use-solution can be applied with a cloth, mop, sponge, or coarse spray, or by soaking. Let solution remain on surface for a minimum of 10 minutes. Rinse or allow to air dry ... Effective against the following organisms: ..." [MEDICAL CONDITION] was not listed. k. On 4/19/12 at 2:40 p.m., CNA #9 was asked about the incontinent care that was provided for Resident #3 that was on isolation. The CNA was asked if he knew what the resident was on isolation for. The CNA stated, "Yes, [MEDICAL CONDITION]." The CNA was asked if he recalled performing incontinent care on 4/17/12. The CNA stated, "Yes, I do, I kind of messed up. I knew not to sit the wipes in the floor. I was nervous and I couldn't sit them on the bed side table by his water. So I just set them on the floor." The CNA was asked if he recalled getting stool on his glove. The CNA stated, "Yes, I should have changed my gloves." The CNA was asked the direction he should wipe during incontinent care. The CNA stated, "Front to back, I know I wiped one area several times to get it clean and you don't wipe but once and change surface of the wipe or change the wipe." The CNA was asked how did he know if a resident was on isolation and why the resident was on isolation. The CNA stated, "The Charge Nurse will tell you or the previous shift during report." The CNA was asked what he should do when entering an isolation room. The CNA stated, "You always wash your hands, apply gown and gloves. You change your gloves as

Based on observation, record review and interview, the facility failed to ensure infection control procedures were put in place to prevent the recurrence of Clostridium Difficile (C-Diff) for 1 of 1 (Resident #3) case mix resident who had recurring episodes of[DIAGNOSES REDACTED]. The facility failed to have an infection control program for monitoring recurring infections to assist with development and implementation of care to prevent further infections. The facility failed to ensure staff were trained in contact isolation procedures for personal protection and disposal of soiled items; for cleaning, sanitizing and disinfecting floors, shower stalls, shower chairs, sinks, and personal care items; and for washing hands and changing gloves after contamination and before continuing personal care. The facility failed to develop and implement laundry procedures that were effective in destroying the[DIAGNOSES REDACTED] spores. These failed practices caused a pattern of actual harm to Resident #3 who had recurring episodes of[DIAGNOSES REDACTED] and only had the potential to affect this 1 resident according to a list of residents who presently had[DIAGNOSES REDACTED] according to a list received from the Administrator on 4/20/12. The facility failed to ensure staff changed their gloves when soiled to prevent cross contamination during incontinent care for 5 (Resident #1, #2, #3, #4 and #5), handled incontinent care supplies in a manner to prevent cross contamination for 4 (Resident #1, #3 #4, #5) and handled soiled linens in a manner to prevent cross contamination for 2 (Resident #5 and #6) of 8 (Residents #1, 2, 3, 5, 6, 7, 8, and 10) case mix residents who were incontinent of bowel or bladder. These failed practice had the potential to affect 50 residents who were incontinent of urine and/or bowel according to the listing received from the Director of Nurses on 4/20/12. The facility failed to ensure resident handwashing after toileting for 2 (Resident #6 and 7) of 4 (Residents #3, 6, 7, and 8) case mix residents who required assistance with toileting and fed themselves. This failed practice had the potential to affect 26 residents who required assistance with toileting and fed themselves according to . The facility failed to ensure the floor was cleaned and disinfected after stool was on the resident room floor for 2 (Resident #3 and #) of (Resident #1, 2, 3, 7, 8, 10, 11, 12, 13, 14 and 18) case mix residents who were incontinent of bowel. This failed practice had the potential to affect 50 residents according to a list provided by the Director of Nursing on 4/20/12. The facility failed to ensure Altima 128 Disinfectant Cleaner was used in accordance with the manufacturer's instructions to prevent possible cross contamination from shower chairs/benches for 1 (Resident # 6) of 2 (Residents # 5, and 7) case mix residents who received showers on a shower chair or bench. These failed practices had the potential to affect 72 residents who used shower chairs/benches according to the listing provided by the Administrator on 4/20/12; The facility failed to ensure wound care supplies were maintained in a manner to prevent possible contamination for 2 (Resident #3 and 4) of 3 (Residents #2, 3, and 4) case mix residents who received wound care. This failed practice had the potential to affect 19 residents who received wound care treatments according to the listing received from the Assistant Director of Nurses on 4/20/12. The facility failed to ensure [DIAGNOSES REDACTED] (TB) skin test or Purified Protein Derivative (PPD), were administered to 1 (Resident #7) of 2 (Residents #5 and 7) case mix residents admitted since 3/1/12. This failed practice had the potential to affect 10 residents who had been admitted since 3/1/12 according to the listing received from the Administrator on 4/20/12. The facility failed to ensure bathing water, washcloths, and towels were not cross contaminated by not changing gloves after picking up fall mats off the floor for 1 (Resident # 4) of 2 (Residents #4 and 5) case mix residents who had fall mats on the floors and received bed baths. This failed practice had the potential to affect 2 residents who had fall mats and received bed baths according to the listing received from the Director of Nurses on 4/20/12. The facility failed to ensure soiled linens and soiled peri wipes were not placed on the floor during incontinent care for 1 (Residents #5) of 7 (Residents #1, 2, 3, 5, 7, 8, and 10) case mix residents who were incontinent of urine and/or bowel and required assistance with toilet use. This failed practice had the potential to affect 50 residents who were incontinent of urine and/or bowel and required assistance with toilet use according to the listing received from the Director of Nurses on 4/20/12. The findings are: 1. The CDC (Centers for Disease and Control and Prevention) documented, that the "C-Difficile is an anaerobic, gram-positive bacterium. Normally fastidious in its vegetative state, it is capable of sporulation when environmental conditions no longer support its continued growth. The capacity to form spores enables the organism to persist in the environment (e.g., in soil and on dry surfaces) for extended periods of time. Environmental contamination by this microorganism is well known, especially in places where fecal contamination may occur. The environment (especially housekeeping surfaces) rarely serves as a direct source of infection for patients. However, direct exposure to contaminated patient-care items (e.g., rectal thermometers) and high-touch surfaces in patients 'bathrooms (e.g., light switches)' have been implicated as sources of infection. [DIAGNOSES REDACTED]icile spores can survive in the environment, on floors, bed rails or around toilet seats in its spore form for up to six months. Transfer of the pathogen to the patient via the hands of health-care workers is thought to be the most likely mechanism of exposure. Standard isolation techniques intended to minimize [MEDICATION NAME] contamination of patients, health-care-workers, hands, patient-care items, and environmental surfaces have been published. Hand washing remains the most effective means of reducing hand contamination. Proper use of gloves is an ancillary measure that helps to further minimize transfer of these pathogens from one surface to another. The degree to which the environment becomes contaminated with [DIAGNOSES REDACTED]icile spores is proportional to the number of patients with [DIAGNOSES REDACTED]icile -associated diarrhea, although asymptomatic, colonized patients may also serve as a source of contamination... The recommended approach to environmental infection control with respect to the [DIAGNOSES REDACTED]icile is meticulous cleaning followed by disinfection using hypochlorite-based germicides as appropriate. However, because no EPA-registered surface disinfectants with label claims for inactivation of the [DIAGNOSES REDACTED]icile spores are available, the recommendation is based on the best available evidence from the scientific literature. The Detergent and water physically remove many microorganisms from the linen through dilution during the wash cycle. An effective way to destroy microorganisms in laundry items is through hot water washing at temperatures above 160?F (Fahrenheit) (71?C) for 25 minutes. Alternatively, low temperature washing at 71 to 77 degrees F (22-25 degrees C (centigrade) plus a 125-ppp (parts per million) chlorine bleach rinse has been found to be effective and comparable to high temperature wash cycles. The linen is sent off to a professional laundry, the facility should obtain an initial agreement between the laundry service and facility that stipulates the laundry will be hygienically clean and handled to prevent recontamination from dust and dirt during loading and transport." 2. The facility Policy and Procedure received from the Director of Nurses (DON)/Acting Administrator on 4/20/12 were as follows. a. The Policy and Procedure for Clostridium Difficile documented, 1) "Purpose, The purpose of this procedure is to provide guidelines of the care of person with diarrhea associated with Clostridium Difficile (C-Diff) (Verified by culture or by evidence of positive cytotoxin assay) and to prevent transmission of Clostridium Difficile to others. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies needed..." 2) "General Guidelines: 1. The facility adopted Standard Precautions and all residents' blood, body fluids, excretions and secretions are considered potentially infectious. Resident with diarrhea associated with Clostridium Difficile (e.g. residents who are colonized and symptomatic) will be placed on Contact Precautions. Residents who are colonized with Clostridium Difficile but are asymptomatic do not require Contact Precautions... 6. Steps toward prevention and early intervention include. a. Increasing awareness of risk factors for residents. b. Considering Clostridium Difficile in differential diagnosis, especially in residents with high risk factors. c. Hand washing of staff and residents. d. Wearing gloves when handling feces or locally-contaminated articles. e. Increased attention and education regarding infection control techniques when providing tube feedings and: f. Disinfection of items with fecal soiling (e.g. bedpans, commode chairs, bedrails, etc.) 7. Appropriate surveillance information must be entered on Clostridium Difficile. Line Listing Report. The following equipment and supplies will be necessary when preforming this procedure. 1. Disinfectant. 2. Personal protective. as equipment (e.g. gowns, gloves, mask, etc. as needed). b. The Policy and Procedure for Isolation for Communicable Diseases Standard/Universal Precautions Transmission Based Precautions documented, 1) "Purpose, to ensure appropriate use of barriers by all employees. The first level of precautions (Standard/Universal) applies to all residents because signs and symptoms of infection are not always obvious and therefore may unknowingly pose a risk for susceptible person. The second level (Transmission Based) is intended for individuals who have a known or suspected infection with certain organisms." 2) Policy Transmission Based Precautions Isolation. A. Isolation refers to the precautions that are taken in the facility to prevent the spread of an infectious agent from an infected or colonized resident to susceptible persons. B. Additional precautions will be used with Standard/Universal Precautions when required to reduce the risk of transmission of infectious agents. The precautions are divided into three categories that reflect the differences in the way infections are transmitted. Some disease may require more than one isolation category.... 3. Contact Precautions prevent the spread of organisms from and infected resident through direct or indirect contact. Some examples are antibiotic resistant bacteria, hepatitis A, scabies, impetigo and lice. A private room may be needed in special circumstances, e.g. copious drainage not contained by a dressing or respiratory infection caused by MRSA (Methicillin-resistant Staphylococcus aureus). Healthcare workers should wear gloves when entering the room and change gloves if they have touched the infected material. Prior to leaving the room, workers should remove their gloves and wash their hands. In addition workers may need to wear protective gowns if contact with the infected material is likely (diarrhea, wound drainage, etc.). Care items such as stethoscope should not be shared with other residents until properly cleaned and disinfected." c. The Policy and Procedure for Categories of Isolation Precautions documented: 1) "Purpose: To prevent transmission of infections or colonized microorganisms." 2) "Policy: Transmission based isolation precautions have been established in order to ensure that appropriate isolation techniques are implemented in this facility when necessary. Our facility currently uses the three types of transmission based isolation precautions (airborne, contact and droplet) recommended by CDC... Contact Precautions; will be implemented for resident known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident environment. Examples of infections requiring Contact Precautions include, but are not limited to: a... 2. Clostridium Difficile (C-Difficile)... b. Room Arrangements. A private room may be needed in special circumstances, i.e. copious drainage not contained completely by a dressing. Confinement to the room will depend on the resident condition, personals hygiene and ability to comply with instructions. c. Gowns 1. Gowns are to be worn upon entering resident room. 2. Remove gown before leaving the room and dispose in the isolation container. d. Gloves and hand washing 1. Gloves are to be worn upon entering resident room [ROOM NUMBER]. Remove gloves before leaving the room and wash hands immediately with antimicrobial agent or waterless antiseptic agent. (Note; only soap, water and friction are to be used with[DIAGNOSES REDACTED] (Clostridium Difficile). e. Trash and Linen Trash and linen will be placed in red bags and disposed of or dealt with per Bio-Hazardous waste standards. ...g. Resident Care Equipment: 1. When possible, use disposable care equipment. If not feasible, disinfect with approved cleaner after isolation is discontinued." d. The Policy and Procedure for Cleaning the Occupied Isolation Room documented, "The Facility will provide a sanitary, safe and comfortable environment in which residents reside to help prevent the development of disease and infection. Isolation rooms will be cleaned daily, and or as needed, to help prevent the spread of disease or infection. In the event a resident is isolated due to contagious or infectious organisms, the isolation room will be cleaned last and the following precautions will be followed for cleaning the occupied room. 1. The Housekeepers will put on clean, non-sterile gloves and any other protective equipment required for the type of isolation before entering the room. 2. Do not sweep or use a dust/dry mop. Use of broom or dust/dry mop may push organisms into the air. Clean sinks, countertops, overbid tables, bedside table tops, and equipment within the room with a hospital-grade disinfectant. 4. The mop bucket will be placed in the door way of the room. USING A hospital-grade disinfectant wet mop the floor of the isolation room. The mop head used in the isolation room will be removed from the mop handle, double bagged and taken directly to the laundry (or the area where contaminated linen is stored) and laundered with other housekeeping supplies. No special laundry procedure is required for laundering mop handles used in cleaning isolation rooms. 5. All trash will be placed in the red bag lined step-on trash can in the isolation room and bag tie. Another person will stand outside the room with an open bag and the person inside the room will drop the tied trash bag into the open without contaminating the outside of the bag. The open bag will be tied and taken directly to the area designated for contaminated trash located in the dirty utility room. The person inside the isolation room will place a clean, red bag into the step-on trash can in the room. ...7. Contaminated gloves must be discarded in the trash can in the room and hands washed per facility policy. Mop bucket, mop handle and any other equipment used in cleaning the isolation room must be taken to a designated area, cleaned and disinfected immediately." 3. The facility policy titled "Dressing Change Technique" documented, "Aseptic technique will be observed for all dressing changes to minimize the spread of microorganisms. ... Preparation: 1. Clean a work site in the resident's room (such as an over bed table or bedside table top). ... 2. Assemble all equipment on the work surface. Take only the supplies that you need into the resident's room. Unused supplies cannot be returned to the cart or storage area. ... Remove the Old Dressing: ... 3. Wash hands ... put on clean gloves. 4. Loosen the soiled dressing ... 5. Slowly remove the soiled dressing ... 6. Discard the dressing and the gloves ... Care for the Wound: 1. Wash your hands or use a waterless antiseptic agent. ... 3. Put on clean gloves ..." 4. Resident #3 had [DIAGNOSES REDACTED].), Diarrhea, Urinary Tract Infection, Renal Failure, Retention of Urine. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 3/20/12 documented the resident scored a 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS), required limited assistance with bed mobility, transfers, dressing, bathing and personal hygiene, had an indwelling catheter, was incontinent of bowel, and had a weight loss in the past 3 - 6 months. a. Laboratory Reports documented the following: 1) "Collected 10/18/11 Reported 10/19/11 Stool type-Semi-solid[DIAGNOSES REDACTED]icile by Lamp- Positive. Positive- Sample contains toxigenic[DIAGNOSES REDACTED]icile strain with the pathogen. Treatment, [MEDICATION NAME] 250 mg (milligrams) PO (by mouth). TID (three times daily) x 14 days." 2) Collected 11/6/11 Reported 11/8/11 Stool type formed. C- Difficile by lamp Positive A." 3) Collected 11/22/11 Reported 11/25/11 Stool type semi-solid[DIAGNOSES REDACTED]icile by lamp Positive." Documented on the laboratory slip was "[MEDICATION NAME] 250 mg TID x (times) 14 day Vanc ([MEDICATION NAME]) 250 g po QID (four times daily) x 14 days." 4) "Collected 12/19/11 Reported 12/21/11 Stool Type- Semi-solid[DIAGNOSES REDACTED]icile by lamp Positive" 5) "Collected 12/21/11 Reported 12/22/11 Stool type Liquid[DIAGNOSES REDACTED]icile by Lamp Positive Out of Reference range." Documented on the laboratory slip was "[MEDICATION NAME] 250 mg 1 po qid x 14 days." 6) "Collected 2/9/12 Reported 2/10/12 Stool type -Liquid[DIAGNOSES REDACTED]icile Positive Out of Reference Range." Documented on the Laboratory slip was "2/10/12 [MEDICATION NAME] 500 mg 1 po TID (three times daily) x 2 weeks." 7) Collected 2/26/12 Reported 2/26/12 Stool type Semi-solid[DIAGNOSES REDACTED]icile Positive Out of Reference Range." Documented on the laboratory slip and signed by the Advanced Practice Nurse (APN) was, "Wait until Thur (Thursday) 3/1. Report to (Physician) if symptomatic or not (no) action @ (at) this time." b. The Physician order [REDACTED]. Then send stool for[DIAGNOSES REDACTED]. Continue isolation precautions. Start Florester when it arrives at facility." c. The Resident Plan of Care updated on 3/15/12 did not document any isolation precautions. d. The facility weights for the past 7 months were reviewed by the survey team. The weights from the Monthly Weight record were as follows: October 2011 - 136.5 pounds November 2011 - 136 pounds December 2011 - 127.8 pounds January 2012 - 128 pounds February 2012 - 132.8 pounds March 2012 - 130.5 pounds April 2012 -124.5 pounds The resident had a 6 pound weight loss in one month, which resulted in a 4.5% weight loss and an 8.3 pound weight loss in 2 months resulting in a 6.25% weight loss. e. On 4/16/12 at 2:35 p.m., Licensed Practical Nurse (LPN) #6 stated during initials that there resident was on isolation due to C -Diff. f. On 4/17/12 at 11:44 a.m., Housekeeper #1 entered Resident #3's room that was on contact isolation. The Housekeeper entered the resident's room wearing a mask and gloves. The Housekeeper removed a bottle of Clean Power Blue Glass and Surface Cleaner. The Housekeeper sprayed the sink and wiped it off with paper towels. Then the Housekeeper replaced the Clean Power Blue Glass and Surface Cleaner back on the housekeeping cart. At 11:45 a.m., Licensed Practical Nurse (LPN) #6 came by the room and told the Housekeeper she needed to wear a gown. The Housekeeper stated, "Oh you have to wear a gown." The Housekeeper then put on the blue isolation gown. The Housekeeper removed the broom and dust pan and entered the resident's room. The Housekeeper swept the resident's floor and emptied the dust pan in the housekeeping cart and replaced the broom and dustpan on the housekeeping cart. The Housekeeper then removed the mop from the mop bucket and mopped the resident's room. The Housekeeper then replaced the mop in the mop bucket. The Housekeeper then left the resident's room. The Housekeeper did not clean any other surfaces in the resident's room. The Housekeeper then took the housekeeping cart to the utility room removed the mop head and placed in a plastic bag and emptied the mop bucket of the water. Then the housekeeper rinsed the mop bucket. The Housekeeper was asked what type of cleaner was used to mop the isolation room. The Housekeeper stated Neutral Floor Cleanser. The Housekeeper was asked what she used to clean out the mop bucket. The Housekeeper stated, Neutral Floor Cleanser. The Housekeeper was asked what she used to clean the sink. The Housekeeper pointed to a bottle on the shelf of Clean Power Blue Glass and Surface Cleaner. The Housekeeper was asked what she cleaned in the resident's room. The Housekeeper stated, "I just cleaned the sink, sweep and mopped the floor." g. On 4/17/12 at 12:08 p.m. Certified Nursing Assistant (CNA) #2 entered the room do perform incontinent care. The CNA washed her hands put the paper towel in the trash can with a foot pedal, then touched the top of the white trash can with her bare hand and proceeded to apply gloves and an isolation gown. At 12:11 p.m., CNA #9 and #10 were performing incontinent care. The resident was incontinent of bowel. CNA #9 got stool on the right glove while providing incontinent care. The CNA wiped off the stool with a peri-wipe and proceeded with the incontinent care with the contaminated glove. The CNA picked up the peri-wipe bottle with his contaminated gloves and sprayed the peri-wash on the wipes and provided incontinent care. The CNA picked up the container of wipes with the lid off; sit the box of peri-wipes and the peri-wash on top of the floor mat with the lid sitting top up on the floor mat. The CNA #9 picked up the clean incontinent brief and placed the clean incontinent brief on the resident. CNA #9 picked up the box of peri-wipes and peri-wash off the floor and placed them in the resident's bedside table, then touched the Foley catheter bag, bed covers, the resident's pant, the resident's hat by the bill, the gait belt and the resident's jacket. At 12:21 p.m., CNA #2 assisted with incontinent care, then washed her hands placed the paper towels in the white trash can with a foot pedal. Touched the top of the trash can and did not rewash her hands and left the resident's room. The resident was then taken to the dining room for lunch. h. On 4/17/12 at 6:14 p.m., the resident was taken to the shower room on the 5th floor by CNA #11. The resident was incontinent of semi-formed stool on 2 areas of the shower floor. The CNA cleaned the rectal area, did not change gloves then proceeded with the shower. The CNA touched the cabinet, removed a can of shaving cream and applied the shaving cream to the resident's face with the contaminated gloves. The CNA touched the cabinet again getting a razor out of the cabinet. The CNA proceeded to shave the resident with the contaminated gloves. Then the CNA picked up the clean towels with the contaminated gloves and dried the resident's body including the face. The CNA picked up the bath blanket and placed the blanket around the resident and a towel around the resident head. The CNA sat the resident's feet on the contaminated floor of the shower. The CNA replaced the shaving cream in the cabinet with the contaminated gloves. The CNA picked up the bottle of cleanser that was sitting on top of the cabinet and sprayed the shower with Heavy Duty Oxygen Enhanced Cleaner, then rinsed off the cleanser. The resident was taken to his room in the shower chair. The resident was incontinent of semi-loose stool in 2 areas of his room. One by the doorway and one by the resident's bed. The CNA changed his gown, gloves and washed hands before entering the resident's room. After the resident was dressed and put in the bed. The dressing on the resident's coccyx was loose. The CNA removed the dressing and placed the dressing in the trash can. The CNA did not change gloves and proceeded with incontinent care. The CNA then cleaned the stool off the floor with peri-wipes and placed them in the trash can. With the same contaminated gloves, the CNA picked up the container of peri-wipes and the peri-wash and placed them in the bedside table. With the contaminated gloves, the CNA touched the bed control, the call light when the CNA placed the call light on the resident's bed. The CNA picked up the gait belt and placed the gait belt on the window sill. The CNA picked up the bedside mat and placed the bedside mat on the contaminated floor. The CNA then returned to the shower room. The CNA picked up the soiled linens. Wearing the same gloves, the CNA picked up the Heavy Duty Oxygen Enhanced Cleaner and sprayed the shower floor, then immediately rinsed the shower floor. The CNA got a wash cloth out of the cabinet and wiped the shower floor spraying the floor with the Heavy Duty Enhanced Cleanser and rinsed the shower floor. The CNA, with the same gloves on, reached into the cabinet, got a washcloth out of the cabinet, sprayed the Heavy Duty Enhanced Cleanser, wiped the shower chair and then rinsed the shower chair. The CNA sprayed the shower stall and chair and left the cleaner on the shower and shower chair. The CNA removed the isolation gown and gloves. The CNA went to the resident's room with a red bag of soiled linens and 1 red bag with trash and sat the bags on the floor. The CNA washed his hands and applied an isolation gown and gloves and took the 2 plastic red bags in the containers in the resident's bathroom. The CNA did not change gloves before he picked up the Foley catheter leg strap and placed it in the resident's drawer. i. On 4/17/12 at 7:22 p.m., LPN #3 set up the supplies on the care then removed the dressing off the treatment cart. The LPN placed the wound cleanser bottle under the left arm. and carried loose unsterile 4 x 4 gauze; loose 2 x 2 gauze, 2 packages of Q-Tips, one Island dressing and a tube of Santyl. The LPN sat the dressing supplies on the isolation cart sitting outside the resident's room that contained the isolation supplies. The LPN entered the room, washed her hands, and applied the gown and gloves. The LPN picked up the dressing supplies and placed then directly on top of the bedside table with the loose 4 x 4 dressing touching the top of the bedside table. The LPN loosened the resident's incontinent brief and stated, "I will have to get the CNA to clean him up before I can do the dressing." The LPN left the dressing supplies uncovered on the bedside table. At 7:30 p.m., CNA #10 performed incontinent care. The resident was incontinent of stool. The resident had semi-formed stool. The CNA removed the soiled incontinent brief and placed the incontinent brief on top of the white trash can that was by the resident's bedside table. The CNA performed incontinent with the same contaminated gloves and applied the clean incontinent brief with the contaminated gloves. At 7:35 p.m., LPN #3 changed the dressing to the pressure ulcer on the coccyx area. The dressing supplies had remained on the bedside table during the incontinent care. The LPN picked up the loose 2 x 2s and sprayed them with the wound cleanser bottle that she had placed under her left arm. With the same gloves, the LPN then picked up the 4 x 4 gauze that was touching the bedside table and dried the pressure ulcer. The LPN with the same gloves opened the Q-tips and placed Santyl on the end of the Q-tips and applied the Santyl on the bed of the pressure ulcer. The LPN reached her left hand under the isolation gown reaching into her pocket and removing a pen and wrote the date on back of the island dressing with the same contaminated gloves used to apply the dressing to the pressure ulcer on the resident's coccyx area. j. On 4/19/12 at 8:15 a.m., Laundry Personnel #1 was asked who was responsible for doing the resident's laundry. The Laundry Personnel stated, "The 5th and 6th floor had 1 washer and 1 dryer. We only wash the personal clothing. The bed linens, towels, washcloths were sent to the VA (Veteran's Administration hospital) Laundry to be cleaned. The Isolation Linen was sent in the red bags to indicate that it was isolation laundry. The resident isolation clothing is washed separately. They wash it on sanitation cycle in the washing machine, which is a 2 ? hour cycle. The Laundry Personnel was asked how hot the water was for the sanitation cycle. The Laundry Personal stated, "I'm not for sure." The Laundry Personal was asked if they used bleach. The Laundry Personal stated, "Yes only on whites." 1) On 4/20/12 at 11:30 p.m., the Literature for Using the Controls on the washing machine was received from the Maintenance Man/Housekeeping Supervisor documented, "Sanitary (select models)-for heavily soiled, colorfast garments. This cycle heats the water to a 150 degree F to eliminate bacteria. " 2) On 4/20/12 at 1:30 p.m., the Maintenance Man/Housekeeping Supervisor stated, The Clear Power Blue Glass and Surface Cleaner and the Heavy Duty Oxygen Enhanced Cleaner is not a disinfectant. This cleaner is not effective for cleaning isolation rooms or shower rooms for[DIAGNOSES REDACTED]icile. I don't know why that cleaner was in the 5th floor shower room. I can't say why the housekeeper used the glass cleanser to clean the sink." The Maintenance Man/Housekeeping Supervisor was asked what surfaces should be cleansed in an isolation room during general cleaning and he stated, "They should clean all non-porous surfaces, the bedside table, side rails, window sills, over bed tables, and of course the bathroom. The Neutral Floor Cleaner contains Altima 128." The Maintenance Man/Housekeeper Supervisor was asked if the Altima 128 was effective against[DIAGNOSES REDACTED]. The Maintenance Man/Housekeeping Supervisor stated it was not listed as an effective agent. The Maintenance Man/Housekeeping Supervisor was asked the procedure for mopping an isolation room. The Maintenance Man/Housekeeping Supervisor stated they can mop the room and place the mop head in a plastic bag or replace the mop in the mop bucket, empty the water and then clean the mop bucket. They are using a Neutral Floor cleaner that contains Altima 128. The Maintenance Man/Housekeeping Supervisor was asked if the Altima 128 was effective against[DIAGNOSES REDACTED]. The Maintenance Man/Housekeeping Supervisor stated, "It's not listed as an effective agent." The Maintenance Man/Housekeeping Supervisor stated that the housekeepers use Steriphene II, brand Disinfectant Deodorant. "It is used to clean the hand rails and door knobs at night. It was in a spray can." The product information sheet documented, "Steriphene II Brand Disinfectant Deodorant is a versatile, ready to use aerosol disinfectant deodorant. It is ideal for convenient disinfection after spot clean up. The special instruction for cleaning and decontamination against HBV and HIV-1 on surfaces or objects soiled with blood and body fluids. The Contact time, Leave surfaces wet for 10 minutes. " 3) The Altima 128 Disinfectant manufacturer's instructions documented, "Altima 128 Disinfectant. One-Step Disinfectant, Germicidal. Detergent, and Deodorant ... Directions for Use: ... Disinfection/Cleaning/Deodorizing Directions: Remove heavy solid deposits from surface, then thoroughly wet surface with a use-solution of 1 (ounce) of the concentrate per gallon of water. The use-solution can be applied with a cloth, mop, sponge, or coarse spray, or by soaking. Let solution remain on surface for a minimum of 10 minutes. Rinse or allow to air dry ... Effective against the following organisms: ..." Clostridium Difficile was not listed. k. On 4/19/12 at 2:40 p.m., CNA #9 was asked about the incontinent care that was provided for Resident #3 that was on isolation. The CNA was asked if he knew wh

Based on observation, record review and interview, the facility failed to ensure Physician orders for wound care treatments were not written by nurses without consulting the Physician to obtain the order for 1 (Resident #1) of 3 (Residents #1, #3 and #20) case mix residents with pressure ulcers. The failed practice resulted in a pattern of harm for Resident #1, whose pressure ulcer deteriorated, and had the potential to cause more than minimal harm for 4 residents with pressure ulcers, as identified on a list provided by the Administrator on 3/19/11. The facility failed to ensure Physician Orders were checked for accuracy and clarified by licensed staff on a monthly basis for 3 (Residents #1, #6 and #7) of 9 (Residents #1 through #9) case mix residents who had physician orders. The failed practices had the potential to cause more than minimal harm for all 72 residents in the facility with Physician orders, according to the Resident Census and Conditions of Residents form dated 3/14/11 The findings are: 1. The Arkansas State Board of Nursing Rules located at http://www.arsbn.arkansas.gov/lawsRules/Pages/rules.aspx documented, "...The Practice of Professional Nursing: The performance for compensation of any acts involving the observation, care, and counsel of the ill, injured, or infirm; the maintenance of health or prevention of illness of others; the supervision and teaching of other personnel; the delegation of certain nursing practices to other personnel as set forth in rules established by the board; or the administration of medications and treatments as prescribed by practitioners authorized to prescribe and treat according to state law where such acts require substantial specialized judgment and skill based on knowledge and application of the principles of biological, physical, and social sciences..." 2. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/18/11 documented the resident was severely impaired in cognitive skills for daily decision making per staff assessment for mental status, was totally dependent on two-plus persons for activities of daily living, was always incontinent of bowel and bladder, received as needed pain medication, was at risk of developing a pressure ulcer and received oxygen therapy. The Plan of Care dated 3/3/11 had no documentation regarding a Foley catheter. a. The facility failed to ensure Physician orders for wound care treatments were not written by nurses without consulting the Physician to obtain the order: 1) A Nurses Note dated 1/10/11 documented, "Open area (times) 2 to coccyx area both approximately 1 cm (centimeter) diameter. Bloody drainage noted. N.O.( new order) for [MEDICATION NAME]." The resident's January 2011 Treatment Administration Record (TAR) documented on 1/10/11, "[MEDICATION NAME] coccyx area Q (every) three days." 2) A Nurses Note dated 1/22/11 documented, "[MEDICATION NAME] to buttock (changed). Area dark pink in color with no open area noted." 3) The resident's February 2011 TAR documented, "Coccyx [MEDICATION NAME] resolved 2/8/11." 4) The March 2011 TAR documented by Nurses' initials that a treatment of [REDACTED]. 5) The Physician order dated 3/8/11 documented, "dc (Discontinue) previous coccyx wound care orders. Clean with WC (wound cleaner) apply [MEDICATION NAME] tid (three times a day) and prn (as needed) until resolved..." The Physicians' orders were signed by the Physician on 3/16/11. The March 2011 TAR documented the treatment was changed on 3/8/11 to clean area on coccyx with wound cleaner. Apply [MEDICATION NAME] three times a day (TID) until resolved; this treatment was done from 3/8/11 through 3/18/11. 6) The Quality Assurance Skin Book provided by Registered Nurse (RN) #5 documented: Date: 2/21/11 area: Coccyx 4 (by) 3 cm Stage I Treatment: [MEDICATION NAME] Date: 2/23/11 area: coccyx 1/4 (by) 1/4 Stage I Treatment: [MEDICATION NAME] Date: 3/2/11 area: coccyx 1.5 (by) 1.5 (by) (less than) 0.1 Stage II Treatment: [MEDICATION NAME] Date: 3/8/11 area: coccyx 2.0 (by) 1.0 (by) 0 Stage II Treatment: [MEDICATION NAME] started Date: 3/16/11 area: coccyx 1.0 (by) 1.0 (by) (less than) 0.1 Stage II Treatment: [MEDICATION NAME] 7) On 3/16/11 at 8:55 a.m., a body audit was performed by Registered Nurse (RN) #3; the resident had three small pinpoint stage II open areas in an approximately 1 cm diameter area on his coccyx. The open areas were pink in color and had no drainage. 8) On 3/17/11 at 2:30 p.m., a wound treatment to the coccyx was observed. RN #3 stated, "Oh, it's much worse today than yesterday." The RN took a plastic measure guide out of her pocket and measured the wound by touching the plastic measure guide to the wound. The area measured 3 cm (by) 1 cm. The stage II area had serous sanguineous drainage. The Quality Assurance Skin Book provided by Registered Nurse (RN) #5 documented, date: 3/17/11 3 cm (by) 1 cm Stage II bloody drainage. 9) On 3/18/11 at 9:05 a.m., RN #3 was asked, "What is your procedure when you identify a wound or when a wound is worsening?" The RN stated, "Our doctor has given us the latitude to write our own orders if the area is not improving we normally change the treatment. We also have a wound consultant that comes once a month." RN #3 was asked, "Did you notify the Physician yesterday of the increase in size of the resident's wound?" She stated, "No, If we were to change the order I would have talked to him, but at this time we are going to continue with the [MEDICATION NAME]. Try to stick with [MEDICATION NAME] couple more days, probably until Monday." 10) On 3/18/11 at 10:15 a.m., in reference to obtaining orders for wound treatments RN #3 stated, "We explained to the doctor and showed him the algorithm for wound treatments that we use and he said that's fine. Also, the wound consultant would make recommendations." 11) On 3/18/11 at 11:10 a.m., RN #3 was asked, "Has the doctor seen the resident's wound?" She stated, "No he has not looked at his bottom." The RN was asked, "Is the Doctor aware that the resident has a wound?" She stated, "Oh yeah." The RN was asked, "Can you show documentation where the Physician is aware of the wound?" She stated, "I don't know that we have any, other than his signature on the order for the treatment. At the most it would be a six day period before they (the doctor or the nurse practitioner) would sign off the order. If anything really serious, he (Physician) would be made aware. A phone call would be documented in the Nurses' notes. In terms of sores that have developed here, I can't think of anything serious enough for immediate notification. We rarely get anything greater than a Stage II." 12) A physician progress notes [REDACTED]. Now has curvilinear ulceration on (right) side ~ (approximately)2 - 3 inches long. Will treat (with) [MEDICATION NAME]" 13) On 3/18/11 at 12:20 p.m., when asked about the resident being treated with [MEDICATION NAME] RN #3 stated, "[MEDICATION NAME] is not on the Algorithm but it's been a long time treatment for [REDACTED]." On 3/19/11 at 10:30 a.m., the Director of Nursing (DON) stated, "The nurses follow the algorithm for wound care approved by the doctor." The surveyor stated, "[MEDICATION NAME] is not on the algorithm." The DON stated, "Yes (correct)." The DON was asked if the nurses could write an order without the Physician's approval. She did not answer the question. She was also questioned if this was part of the Arkansas State Board of Nursing practice; she did not answer the question. b. The facility failed to ensure Physician Orders were checked for accuracy and clarified by licensed staff on a monthly basis: 1) The Admission Physician orders documented the resident was readmitted to the facility on [DATE]. As of 3/19/11 at 11:35 a.m., there was no admission orders [REDACTED]. 2) The resident's March 2011 Physician orders contained no documentation of an order for [REDACTED]. The March 2011 Treatment Administration Record (TAR) documented by Nurses' initials that oxygen was administered to the resident from 3/4/11 through 3/16/11. 3) On 3/14/11 at 3:50 p.m., the resident was receiving oxygen at 2 liters per nasal cannula (2L/NC) and had a Foley catheter with amber urine noted in the drainage bag. On 3/15/11 at 8:40 a.m., 10:29 a.m., 11:50 a.m. and 5:10 p.m., the resident was receiving oxygen at 2 liters per nasal cannula and had a Foley catheter. On 3/16/11 at 8:55 a.m., the resident was in bed receiving oxygen at 2 liters per nasal cannula. The resident's Foley catheter was draining dark amber urine. On 3/17/11 at 8:20 a.m., the resident was in bed receiving oxygen at 2 liters per minute via nasal cannula. The resident had a Foley catheter draining urine to a collection bag. On 3/18/11 at 10:10 a.m., Registered Nurse (RN) #3 stated that the person that worked with the resident's Physician orders had been off on extended leave and orders had been dropped off. 3. Resident #6 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/23/10 documented the resident scored 13 (cognitively intact) per brief interview for mental status (BIMS), required supervision with assistance of one person for activities of daily living and was continent of bowel and bladder. a. A physician order dated 10/1/09 documented the resident was to receive a Saline Updraft, 3 milliliters (ml) via nebulizer over 15 minutes, four times daily (qid) while awake. b. The Assessment for Self - Administration of Medications dated 10/29/09 documented, approval granted to self-administer: yes (checked). At the top of the page (Nebulizer) was handwritten in. c. As of 3/15/11 at 9:42 a.m., the resident's March 2011 Physician's orders contained no documentation of an order for [REDACTED]. d. On 3/14/11 at 3:47 p.m., during the 4:00 p.m. medication pass, Licensed Practical Nurse (LPN) #1 entered the resident's room with the saline for the resident's updraft. The resident stated, "I'll do it before supper." The LPN placed the vial of saline on the table with the updraft machine and left the resident's room. e. As of 3/14/11, there was no current physician order on the March 2011 Physician Orders sheet for the resident to self-administer the updraft treatments f. On 3/18/11 at 10:10 a.m., Registered Nurse (RN) #3 stated that the person that worked with the resident's Physician orders had been off on extended leave and orders had been dropped off. 4. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 2/23/11 documented the resident had a score of 13 (cognitively intact) per BIMS and did not receive oxygen. The Plan of Care dated 2/24/11 contained no documentation of the resident requiring oxygen. a. The resident's March 2011 Physician orders signed by the physician (with no signature date) documented, "Oxygen change O2 (oxygen) tubing weekly on Thurs (Thursday)" on the typed form. The March 2011 Physician's orders did not document an order for [REDACTED]. b. The resident's March 2011 TAR documented, "O2 2 L/Min (liters per minute) via N/C (nasal canula) for O2 sats (saturation) less than 90%. Check 2 sats per shift." Oxygen saturation levels were documented on the TAR on 3/15/11 for the 7:00 a.m. to 3:00 p.m. shift as 96% and on 3/16/11 for the 7:00 a.m. to 3:00 p.m. shift as 94%. c. On 3/14/11 at 4:10 p.m., an oxygen concentrator was in the off position in the resident's room. The tubing was bagged and dated 3/10/11. d. On 3/15/11 at 8:52 a.m. and on 3/16/11 at 8:55 a.m., the resident had oxygen on per nasal cannula at 2 liters per minute. e. On 3/18/11 at 10:10 a.m., RN #3 was questioned about the resident having no current oxygen order. The RN looked at the resident's clinical record and found no order on the March 2011 Physician orders or on the February 2011 Physician orders. An oxygen order was printed on the January 2011 Physician orders. The RN stated, "Our person who does this has been off on extended leave. The orders have gotten dropped off."

Based on observation, record review and interview, the facility failed to ensure the physician was immediately consulted upon deterioration of a recurrent Stage II pressure ulcer resulting in a delay in treatment for 1 (Resident #1) of 3 (Residents #1, #3 and #20) case mix residents with pressure ulcers. The failed resulted in a pattern of harm for Resident #1 whose pressure ulcer deteriorated and had the potential to cause more than minimal harm for 4 residents with pressure ulcers, as identified on a list provided by the Administrator on 3/19/11. The facility further failed to ensure the family was notified of the deterioration of a recurrent Stage II pressure ulcer for 1 (Resident #1) of 3 (Residents #1, #3 and #20) case mix residents with pressure ulcers and failed to ensure the family was notified of a psychological evaluation for 1 of 1 (Resident #17) case mix resident with an order for [REDACTED]. 1. The Policy and Procedure for Pressure Ulcer and Skin Conditions, Care and Prevention of documented, "...Notification of the Physician is required when a new pressure ulcer is identified as well as when treatment is not effective..." 2. The Resident Informational Handbook, part of the admission packet, documented, "...Notice of Rights and Services ...The facility must consult with you and notify your physician and interested family member of any significant change in your condition or treatment..." 3. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/18/11 documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent on two-plus persons for activities of daily living, was of incontinent of bowel and bladder, received as needed pain medication and was at risk of developing a pressure ulcer. a. The resident's March 2011 Physician orders [REDACTED]...3/8/11 D/C (Discontinue) previous coccyx (wound) care orders. Clean (with) wc (wound cleaner). Apply [MEDICATION NAME] TID (three times a day) (and) PRN (as needed) until resolved..." The Physician orders [REDACTED]. b. On 3/16/11:00 at 8:55 a.m., a body audit was performed by Registered Nurse (RN) #3; the resident had 3 small pinpoint stage II open areas all in an approximate 1 centimeter (cm) diameter area on his coccyx. They were pink in color and had no drainage. c. On 3/17/11 at 2:30 p.m., a wound treatment to the resident's coccyx was observed. Registered Nurse (RN) #3 stated, "Oh it's much worse today than yesterday." The RN took a plastic measure guide out of her pocket and measured the wound. The area measured 3 cm by 1 cm. The stage II open wound had serous sanguineous drainage present. d. On 3/18/11 at 9:05 a.m., RN #3 was asked, "Did you notify the physician yesterday of the increase in size of the resident's wound?" She stated, "No. If we were to change the order I would have talked to him, but at this time we are going to continue with the [MEDICATION NAME]. Try to stick with [MEDICATION NAME] couple more days probably until Monday." The RN was asked, "Did you notify his family of the change in the wound?" She stated, "No ma'am, but his son comes everyday. Again, the family would get notified if there was a new treatment order. " e. On 3/18/11 at 11:10 a.m., RN #3 was asked, "Has the doctor seen the resident's wound?" She stated, "No, he has not looked at his (resident's) bottom." The RN was asked, "Is the Doctor aware that the resident has a wound?" She stated, "Oh yeah." The RN was asked, "Can you show documentation where the physician is aware of the wound?" She stated, "I don't know that we have any, other than his signature on the order for the treatment. At the most, it would be a 6 day period before they (the doctor or the nurse practitioner) would sign off the order. If it's anything really serious he would be made aware. A phone call would be documented in the nurses' notes. In terms of sores that have developed here I can't think of anything serious enough for immediate notification. We rarely get anything greater than a Stage II." f. A physician progress notes [REDACTED]. Now has curvilinear ulceration on (right) side ~ (approximately) 2 - 3 inches long. Will treat (with) [MEDICATION NAME]" 4. Resident #17 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 12/28/10 documented the resident was moderately impaired in cognitive skills for daily decision making, had no behaviors and was independent in activities of daily living. a. A Physician order [REDACTED]. Send copy of nurses notes to appt.( appointment)..." b. The plan of care reviewed 12/29/10 documented, "3/16/11 Psyc eval ordered." c. As of 3/18/11 at 5:25 p.m., there was no documentation in the Nurses' Notes or in the Social Service Progress Notes that the resident's family had been notified regarding the order for a psychiatric evaluation.

Based on observation, record review and interview, the facility failed to ensure the physician was promptly consulted upon deterioration of a recurrent Stage II pressure ulcer resulting in a delay in a change of treatment for 1 (Resident #1) of 3 (Residents #1, #3 and #20) case mix residents with pressure ulcers. The failed practice resulted in a pattern of harm for Resident #1, whose pressure ulcer deteriorated, and had the potential to cause more than minimal harm for 4 residents with pressure ulcers, as identified on a list provided by the Administrator on 3/19/11. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an assessment reference date (ARD) of 1/18/11 documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent on two-plus persons for activities of daily living, was incontinent of bowel and bladder, received as needed pain medication and was at risk of developing a pressure ulcer. a. A Nurses Note dated 1/10/11 documented, "Open area (times) 2 to coccyx area both approximately 1 cm (centimeter) diameter. Bloody drainage noted. N.O.( new order) for [MEDICATION NAME]." The resident's January 2011 Treatment Administration Record (TAR) documented on 1/10/11, "[MEDICATION NAME] coccyx area Q (every) three days." b. A Nurses Note dated 1/22/11 documented, "[MEDICATION NAME] to buttock (changed). Area dark pink in color with no open area noted." 1) The resident's February 2011 TAR documented, "Coccyx [MEDICATION NAME] resolved 2/8/11." 2) The March 2011 TAR documented by Nurses' initials that a treatment of [REDACTED]. c. The Physician order [REDACTED]. Clean with WC (wound cleaner) apply [MEDICATION NAME] tid (three times a day) and prn (as needed) until resolved..." The Physicians' orders were signed by the Physician on 3/16/11. The March 2011 TAR documented the treatment was changed on 3/8/11 to clean area on coccyx with wound cleaner. Apply [MEDICATION NAME] three times a day (TID) until resolved; this treatment was done from 3/8/11 through 3/18/11. d. The Quality Assurance Skin Book provided by Registered Nurse (RN) #5 documented, 1) date: 2/21/11 area: Coccyx 4 (by) 3 cm Stage I Treatment: [MEDICATION NAME] 2) date: 2/23/11 area: coccyx 1/4 (by) 1/4 Stage I Treatment: [MEDICATION NAME] 3) date: 3/2/11 area: coccyx 1.5 (by) 1.5 (by) (less than) 0.1 Stage II Treatment: [MEDICATION NAME] 4) date: 3/8/11 area: coccyx 2.0 (by) 1.0 (by) 0 Stage II Treatment: [MEDICATION NAME] started 5) date: 3/16/11 area: coccyx 1.0 (by) 1.0 (by) (less than) 0.1 Stage II Treatment: [MEDICATION NAME] e. On 3/16/11 at 8:55 a.m., a body audit was performed by Registered Nurse (RN) #3; the resident had three small pinpoint stage II open areas in an approximately 1 cm diameter area on his coccyx. The open areas were pink in color and had no drainage. f. On 3/17/11 at 2:30 p.m., a wound treatment to the coccyx was observed. RN #3 stated, "Oh, it's much worse today than yesterday." The RN took a plastic measure guide out of her pocket and measured the wound by touching the plastic measure guide to the wound. The area measured 3 cm (by) 1 cm. The stage II area had serous sanguineous drainage. The Quality Assurance Skin Book provided by Registered Nurse (RN) #5 documented, date: 3/17/11 3 cm (by) 1 cm Stage II bloody drainage. g. On 3/18/11 at 9:05 a.m., RN #3 was asked, "What is your procedure when you identify a wound or when a wound is worsening?" The RN stated, "Our doctor has given us the latitude to write our own orders if the area is not improving we normally change the treatment. We also have a wound consultant that comes once a month." RN #3 was asked, "Did you notify the Physician yesterday of the increase in size of the resident's wound?" She stated, "No, If we were to change the order I would have talked to him, but at this time we are going to continue with the [MEDICATION NAME]. Try to stick with [MEDICATION NAME] couple more days, probably until Monday." h. On 3/18/11 at 10:15 a.m., in reference to obtaining orders for wounds RN #3 stated, "We explained to the doctor and showed him the algorithm for wound treatments that we use and he said that's fine. Also, the wound consultant would make recommendations." i. On 3/18/11 at 11:10 a.m., RN #3 was asked, "Has the doctor seen the resident's wound?" She stated, "No he has not looked at his bottom." The RN was asked, "Is the Doctor aware that the resident has a wound?" She stated, "Oh yeah." The RN was asked, "Can you show documentation where the Physician is aware of the wound?" She stated, "I don't know that we have any, other than his signature on the order for the treatment. At the most it would be a six day period before they (the doctor or the nurse practitioner) would sign off the order. If anything really serious, he (Physician) would be made aware. A phone call would be documented in the Nurses' notes. In terms of sores that have developed here, I can't think of anything serious enough for immediate notification. We rarely get anything greater than a Stage II." j. On 3/18/11 at 12:20 p.m., when asked about the resident being treated with [MEDICATION NAME] RN #3 stated, "[MEDICATION NAME] is not on the Algorithm but it's been a long time treatment for [REDACTED]." On 3/19/11 at 10:30 a.m., the Director of Nursing (DON) stated, "The nurses follow the algorithm for wound care approved by the doctor." The surveyor stated, "[MEDICATION NAME] is not on the algorithm." The DON stated, "Yes (correct)." k. A physician progress notes [REDACTED]. Now has curvilinear ulceration on (right) side ~ (approximately)2 - 3 inches long. Will treat (with) [MEDICATION NAME]"