Every finding on record at Cavalier Healthcare of England

Based on observations, interviews, and facility policy review, it was determined that the dietary staff failed to ensure hand hygiene was completed for one of one meal service observed. The findings include: During an observation on 07/01/2025 at 11:20 AM, this surveyor observed Dietary [NAME] (DC) #4 open a box of rolls, without gloves on. DC #4 then reached into the box with their bare hands and took out a hand full of rolls to prepare, without washing their hands in between touching the outside of the box and the food. During an interview on 07/01/2025 at 11:42 AM, DC #4 stated, I touched the box and didn't wash my hands. I should have washed my hands after opening the box before touching the rolls because it is cross contamination. During an observation on 07/01/2025 at 12:33 PM, DC #4 opened the lid to the hot metal plate warmer container, retrieved a metal plate, and closed the lid with his bare hands. DC #4 then placed the metal plate on the base of the heat keeper combination. Then DC #4 opened the ceramic hot plate container with his bare hands, retrieved a ceramic plate, and placed the ceramic plate on top of the metal hot plate, and proceeded to the tray line to serve. No hand hygiene was performed by DC #4 between touching the top of the hot plate warmer container and returning to the tray line. During an interview on 07/01/2025 at 3:06 PM, the Administrator stated, The staff should not have to open and close anything to get the plates out, because it was spring loaded and all they had to do was take the round tops off and use the suction cup to pick up plates and put them on the base. An unidentified Dietary Aide present during the interview indicated, We don't have one for those. We had them when they were on the tray line table. The Administrator agreed the staff could not touch the top of the plate warmers, wash their hands, and then return to the tray line. The Administrator stated, The top of the plate warmer was considered dirty, so every time staff touched the top to open it, staff hands were considered dirty when returning to the tray line. A review of a facility policy titled, Hand Washing, dated 2013, indicated, Clean hands and exposed portions of arms (or surrogate prosthetic devices) immediately before engaging in food preparation including working with exposed food. After handling soiled equipment or utensils. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.

Based on record review and interview, the facility failed to ensure the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment or change in condition for four (Resident #10, #47, #35, and #43) of five sampled residents. The findings include: Resident #10 A review of Resident #10’s Medical Diagnosis record revealed diagnoses which included muscle wasting and atrophy, dementia with behavioral disturbance, anxiety disorder, cognitive communication deficit, schizophrenia, dementia with agitation, and schizoaffective disorder. A review of Resident #10’s annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. A review of Resident #10’s Care Plan, revised on 09/02/2024, the Care Plan identified the resident to be at high risk for falls, with the resident’s last fall documented on 03/11/2024. A review of Resident #10’s Progress Notes revealed the following documented fall: On 05/19/2025 at 11:30 AM, a Certified Nursing Assistant reported Resident #10 was on the floor, the nurse observed the resident’s upper body lying on the fall mat with their head resting on a pillow and their legs on the bed. The nurse noted she was unable to complete a head-to-toe assessment because the resident was uncooperative. She noted no visible injuries and Resident #10 was positioned back in bed. During a concurrent observation and interview on 06/30/2025 at 11:59 AM, this surveyor observed Resident #10 lying half off the side of the resident’s mattress. The resident was positioned with their elbows on the floor and was attempting to crawl off the bed. The Director of Nursing (DON) went to the resident’s room and confirmed Resident #10’s extra mattress on the floor. The DON stated it was because the resident kept sliding off the bed onto the fall mat and the mattress provided more padding. The resident kept trying to get onto the floor. Resident #47 A review of Resident #47 admission Record revealed the resident was admitted to the facility on [DATE], with diagnoses which included end stage renal disease, high blood pressure, compression of vein, and chronic pain syndrome. A review of Resident #47’s Medical Record on 07/02/2025 at 10:00 AM, revealed the facility had not developed a comprehensive Care Plan, following Resident #47’s admission date of 06/10/2025. During an interview on 07/02/2025 at 10:30 AM, the MDS Coordinator stated the Care Plan should have been reviewed and updated upon admission, at least quarterly, and with each new MDS. She verified the MDS should have been updated with any change of condition or with any new findings. The MDS Coordinator stated the Resident Assessment Instrument (RAI) requirements were to complete the MDS and Care Plan upon admission, and depending on payor source, maybe quarterly. She said the Care Plan team, which included all departments, developed the Care Plan. She said the development of the baseline Care Plan was developed by all departments, because it was a collaboration to ensure the resident was getting what they needed. The MDS Coordinator was asked to review Resident #47's MDS and Care Plan. She stated Resident #47 did not have a comprehensive Care Plan. She stated the baseline Care Plan was due within 24 hours of admission, and that the next review was due on 06/23/2025, but it had not been done. She stated it was important for the Care Plan to be done timely, so staff had it available as a reference tool when providing care to the residents. The MDS Coordinator was then asked to review Resident #10’s MDS and Care Plan. She stated Resident #10’s last review was on 10/13/2024. She also stated that Resident #10’s Care Plan should have been updated in January, but there was not a record review completed. She stated Resident #10's annual was done on 12/30/2024, and the review should have been completed with that annual. The MDS Coordinator revealed Resident #10 had a quarterly MDS on 03/28/2025 and stated there should have been a Care Plan review at that time. She then said, Resident #10 has had several trips out to the hospital, but I do not have a review recorded for those hospitalizations. Resident #35 A review of Resident #35’s admission Record indicated the resident was admitted on [DATE], with diagnoses which included Parkinson's Disease, abnormalities of gait and mobility, muscle wasting, and unsteadiness on feet. A review of Resident #35’s Order Summary revealed the resident had an order to Evaluate and treat for hospice services, with a start date of 04/25/2025. A review of a telephone order for Resident #35, from the hospice company on 04/25/2025 at 12:47 PM, indicated to Evaluate and treat for hospice services, signed by the physician. A review of Resident #35's Care Plan Report, revised on 04/01/2024, did not indicate the resident was on hospice services. Resident #43 A review of Resident #43’s Progress Notes indicated the resident had falls on the following dates: An unwitnessed fall on 04/07/2025, with no interventions noted. On 05/13/2025, indicated the resident reported falling earlier in the week (no date documented), with no interventions noted. An unwitnessed fall on 05/28/2025, with an intervention for Certified Nursing Assistants (CNAs) to offer the resident help with toileting and to remind the resident to use the call light for assistance. A witnessed fall in the dining room on 06/30/2025, with no interventions noted. An unwitnessed fall on 06/30/2025, with an intervention of resident was reminded to use call light to ask for assistance. A review of Resident #43’s Care Plan Report indicated the resident was at a high risk for falls related to confusion, gait/balance problems, incontinence, psychoactive drug use with interventions that included directed staff to ensure the resident’s call light was in reach, to encourage the resident to use the call light for assistance, and to ensure the resident was wearing appropriate footwear when ambulating. The Care Plan report did not indicate the resident had falls dated 04/07/2025, 05/13/2025, 05/28/2025, 06/19/2025, or 06/30/2025. During an interview on 07/03/2025 at 8:29 AM, the MDS Coordinator revealed, A Significant Change Minimum Data Sheet should be completed with 14 days of the [significant] change. The MDS Coordinator reviewed Resident #43’s MDS history. The MDS Coordinator indicated, There is a Significant Change MDS with a start date of 04/28/2025 that is not complete. It should have been completed 14 days from 04/28/2025 which would have been around 05/09/2025. When this is completed, it should update the care plan. A review of the Comprehensive Plan of Care policy indicated, Upon completion of the comprehensive assessment the interdisciplinary team will develop the plan of care for the resident. All Care Assessment Areas (C.A.A.) triggered by the Minimum Data Set (M.D.S.3.0) will be considered in developing the plan of care. Any other factors identified by the interdisciplinary team will also be considered. The facility’s rationale for deciding whether to proceed with care planning will be evidenced in the clinical. The Comprehensive M.D.S. 3.0 Resident Assessment Instrument (R.A.I.) will be completed within 14 days of admission; quarterly, annually, and with a significant change of status. The comprehensive plan of care will be completed within 7 days of the completed admission R.A.I., annually, and with a significant change of status assessments. The plan of care will be reviewed and revised quarterly, annually, with a significant change of status and as needed to enhance the residents ability to meet his/her objectives.

Based on record review and interview, the facility failed to ensure a resident’s family member serving as Power of Attorney was invited to participate in a care plan meeting for one (Resident #13) of three residents reviewed for care plans. The findings include: A review of Resident #13’s admission Record indicated the facility admitted the resident on 10/20/2023, with diagnoses which included Alzheimer’s and dementia. The admission Record indicated the resident had a designated Power of Attorney (POA) when admitted . A review of Resident #13’s quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/28/2025 revealed the resident had a Brief Interview for Mental Status score of 04, which indicated severe cognitive impairment. A review of Resident #13's Care Plan, initiated on 11/27/2023, revealed the resident had impaired cognitive function, dementia or impaired thought processes. The Care Plan also revealed Resident #13 had impaired nutrition, with an intervention to include family in their nutritional evaluation. During an interview on 07/02/2025 at 3:23 PM, Resident #13's POA stated they had not heard of, or been invited to participate in, a Care Plan meeting since the resident was admitted (10/20/2023). During an interview on 07/02/2025 at 3:26 PM, the Nurse Manager indicated there was no one to conduct Care Plan meetings, and the facility was currently hiring. During an interview on 07/02/2025 at 3:33 PM, the MDS Coordinator indicated Care Plan meetings were scheduled quarterly. She stated the POA, or whoever the resident wanted to be involved in their Care Plan meeting, was contacted. During an interview on 07/03/2025 at 8:29 AM, the MDS Coordinator revealed Resident #13 had not had a Care Plan meeting since being admitted . During an interview on 07/03/2025 at 10:04 AM, the Administrator stated the Care Plan meetings were conducted quarterly, upon admission, and with a change of condition. He verified Resident #13 had not had a Care Plan meeting because two of the resident’s family members worked at the facility. The Administrator stated he was not sure if Resident #13’s POA had been contacted for a Care Plan meeting. During an interview on 07/03/2025 at 10:23 AM, the DON indicated Care Plan meetings were supposed to be conducted quarterly. She stated she did not know why Resident #13 had not had a Care Plan meeting, since being admitted .

Based on record review, interview, and observation, the facility failed to ensure one (Resident #15) of one resident reviewed had formulated an advanced directive that provided a clear understanding of the resident's wishes. Specifically, documentation regarding Resident #15’s code status containing conflicting information regarding life-sustaining treatments. The findings include: A review of Resident #15’s Code Status, on 06/30/2025 at 8:14 PM, revealed a signed Acknowledgement of Receipt of Advance Directive was signed by their family member on 08/08/2023. A second acknowledgment of Receipt of Advanced Directives/Medical Treatment Decisions was signed on 08/09/2023 and read, “I have chosen to formulate and issue the following Advance Directives,” with the Do Not Resuscitate box checked and an enacted date of 08/08/2023. Another checked box stated, I do not choose to formulate or issue any Advance Directives at this time. I want efforts made to prolong my life and I want life-sustaining treatment to be provided. The family member who signed these documents were not documented as being Resident #15’s Power of Attorney (POA). A review of Resident #15’s admission Record revealed an admission date of 08/09/2023. A review of Resident #15’s Medical Diagnosis report revealed the resident was admitted with diagnoses which included dementia, attention and concentration deficit, cognitive communication deficit, and stage three chronic kidney disease. A review of Resident #15’s quarterly Minimum Data Set with an Assessment Reference Date of 04/04/2025, revealed the resident had a Brief Interview for Mental Status score of 03, which indicated severe cognitive impairment. During an interview on 07/01/2025 at 1:00 PM, this surveyor asked the Administrator for Resident #15’s Healthcare POA. The Administrator stated, We do not have a Healthcare POA on file for Resident #15.” During a concurrent record review and interview on 07/01/2025 at 1:00 PM, the Administrator reviewed the Acknowledgement of Receipt of Advance Directive signed by Resident #15’s family member on 08/08/2023. The Administrator also reviewed Resident #15’s second Acknowledgment of Receipt of Advance Directives/Medical Treatment Decisions, signed on 08/09/2023 with the, “I have chosen to formulate and issue the following Advance Directives” box checked. The document revealed there were two different documented decisions regarding Resident #15’s Advance Directive. The Administrator then called Resident #15’s family member and asked if they had the healthcare POA for Resident #15. The resident’s family member stated they did not, because Resident #15 was not competent to appoint them as the healthcare POA. The Administrator then told Resident #15's family member that a new form would need to be completed due to the conflicting information checked on the current form concerning whether to resuscitate Resident #15 or not. A review of the facility Policy “Advance Directives and Life-Sustaining Measures revealed: The decision of the resident or legal surrogate to forgo life-sustaining treatment will be honored, pursuant to advance directives completed prior to the resident being diagnosed as incompetent to make these decisions. Advance directives honored by this institution are a complete, signed, legal Durable Power of Attorney for Healthcare. A statement written in the resident’s own handwriting, dated and signed by the resident outlining their wishes for life-sustaining treatment. A verbal statement made by the resident and or surrogate informing Advanced Healthcare Management facility staff or medical staff of wishes.

Based on record review and interview, it was determined the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days after the facility determined there had been a significant change in a resident’s physical or mental condition for one (Resident #35) of one resident. The findings include: A review of Resident #35’s “admission Record indicated the facility initially admitted the resident on 01/06/2021, with diagnoses which included abnormal finding of blood chemistry and pneumonia. A review of Resident #35’s “Arkansas Department of Health and Human Services Evaluation of Medical Need Criteria” form indicated the resident was re-admitted from the hospital, on hospice services on 04/25/2025, with a diagnosis of acute kidney injury. The form indicated Resident #35 had multiple hospitalizations within the last month and had decided to transition to hospice care. A review of Resident #35’s Minimum Data Set (MDS) dashboard on the resident's electronic health record revealed the resident’s Significant Change MDS was started on 04/28/2025. A review of Resident #35’s MDS dashboard within the electronic health record on 07/03/2025, revealed the Significant Change MDS status was pending completion from the MDS Coordinator. A review of Resident #35’s Hospice admission Order indicated the resident was admitted to hospice services on 04/25/2025. A review of Resident #35's Care Plan Report, last revised on 04/01/2024, did not indicate the resident was admitted to hospice services. A review of Resident #35’s Order Summary revealed the resident had an order for Evaluate and Treat for Hospice Services, with a start date of 04/25/2025. A review of a telephone order for Resident #35, from the hospice company on 04/25/2025 at 12:47 PM, indicated Evaluate and treat for hospice services, and was signed by the physician. During an interview on 07/03/2025 at 8:29 AM, the MDS Coordinator revealed, A Significant Change Minimum Data Set should be completed within 14 days of the change. The MDS Coordinator reviewed Resident #35’s MDS dashboard and confirmed, There is a Significant Change MDS, with a start date of 04/28/2025, that is not complete. It should have been completed 14 days from 04/28/2025, which would have been around 05/09/2025. When the MDS is completed, it should update the Care Plan. I don’t know why it did not show up on my dashboard. A review of Required Assessment Summary Ombudsman Budget Reconciliation Act(cont.) indicated that a significant correction to prior comprehensive Minimum Data Sheet must be complete within 14 calendar days after determination that significant error in prior comprehensive assessment occurred.

Based on record review and interview, it was determined that the facility failed to ensure an entry Minimum Data Set (MDS) comprehensive assessment was encoded and transmitted in the allotted timeframe for one (Resident #35) of one resident reviewed for MDS requirements. The findings include: A review of Resident #35's admission Record indicated the facility initially admitted the resident on 01/06/2021, with diagnoses which included chronic obstructive pulmonary disease and pneumonia. A review on 07/03/2025 of Residents #35's electronic health record revealed a discharge MDS with an assessment review date (ARD) of 04/23/2025. Also present was an entry MDS, ARD date of 04/25/2025, with n export ready status, a significant change MDS with an ARD of 04/28/2025, with an in-progress status, and a quarterly MDS with an ARD of 06/20/2025, with an in-progress status. A review of Resident #35's Care Plan Report, last revised on 04/01/2024, did not reflect any of the resident's changes in care, such as the resident being admitted to hospice services. During an interview on 07/03/2025 at 8:39 AM, the MDS Coordinator stated the facility did not have a policy for Minimum Data Set timing, but that they followed the Required Assessment Summary Ombudsman Budget Reconciliation Act (RAI OBRA) for MDS timing. The RAI manual indicated a significant change MDS should be completed within 14 calendar days of the significant change. A quarterly MDS should be completed within 92 calendar days from the previous MDS. The MDS Coordinator reviewed Resident #35's MDS dashboard and confirmed, There is a significant change MDS with a start date of 04/28/2025, that is not complete. It should have been completed 14 days from 04/28/2025, which would have been around 05/09/2025. There is also a quarterly and a discharge [MDS] that are in progress and should have been completed.

Based on record review, observation, interviews, facility document review, and facility policy review, the facility failed to ensure a resident was checked and changed every two hours for perineal care and repositioned to prevent the risk of infection and skin breakdown for one (Resident #39) of one resident reviewed. The findings include: During an observation on 07/01/2025 at 3:00 PM, this surveyor observed Certified Nursing Assistant (CNA) #1 and CNA #2 transfer Resident #39 from a wheelchair to their bed, using a gait belt. When the resident was assisted in placing their legs on the bed, this surveyor observed a large, dark wet spot on the back of both legs going from the groin to just above the knees, and a dark wet spot streaking across the front of Resident #39's jeans. CNA #1 described the resident's jeans as soaked and dirty. The resident's demeaner indicated embarrassment. This surveyor was granted permission to observe care by the resident nodding their head. During an observation on 07/01/2025 at 3:10 PM, this surveyor observed Resident #39 during perineal care and noted a full, wet saturated brief containing stool. CNA #1 stated, [Resident 39] was last changed early this morning and CNA #2 agreed with this and revealed it could have been “around 8:00 [AM],” but CNA #2 was not sure. CNA #1 said they had been asked to help with other residents and that [Resident #39] had been overlooked. CNA #2 revealed staff were trained to bring residents to the room and check to see if they were wet or dirty every two hours to ensure their skin was clean and dry. A review of Resident #39’s Medical Diagnosis report revealed the resident had diagnoses which included stroke, dementia, and depression. A review of Resident #39’s quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/04/2025, revealed the resident had a Brief Interview for Mental Status score of 02, which indicated severe cognitive impairment. The MDS also revealed Resident #39 was dependent on staff for toileting, bathing, dressing, and personal care, and that the resident was always incontinent of bladder and frequently incontinent of bowel. A review of Resident #39’s Care Plan, dated 02/02/2024, revealed the resident had mixed incontinence related to cognitive impairment and impaired mobility. The resident’s Care Plan included interventions that directed staff to check Resident #39 as required for incontinence, change clothing as needed, and to monitor for signs and symptoms of urinary tract infection. Resident #39’s Care Plan also revealed the resident had an activities of daily living self-care deficit related to stroke, revised 11/27/2023, and the resident required maximum assistance of one staff for toileting. The resident's Care Plan indicated Resident #39 had an actual fall related to poor communication comprehension, with an included intervention that directed certified nursing assistance (CNA)s and nursing staff to monitor the resident with frequent rounds every hour, while Resident #39 was sitting up in a wheelchair. During an interview on 07/03/2025 at 8:19 AM, Registered Nurse (RN) #6 said, CNAs are responsible for peri-care. RN #6 stated they were not sure what the process was for checking residents sitting in wheelchairs. Nursing rounds on the hour, but I'm not sure about the CNAs. During an interview on 07/03/2025 at 8:21 AM, the Treatment Nurse revealed she worked the floor and nursing staff oversaw the CNAs, but everyone is responsible for checking residents, and heavy wetters should be checked on every two hours or as needed because we do not want skin breakdown or infection, so it is important to make sure residents are clean and dry. During an interview on 07/03/2025 at 8:25 AM, the Director of Nursing (DON) revealed CNAs, and ultimately the nurses should check residents every two hours and keep the residents clean, dry, and turned. The DON stated the nursing staff was expected to supervise to make sure rounding and changing residents is being done. The DON revealed residents in wheelchairs should be checked every two hours the CNAs should take residents to the room and check to see if the residents need to be changed. During an interview on 07/03/2025 at 9:30 AM, the Administrator revealed staff were expected to check perineal care and positioning of residents in wheelchairs every two hours. Some residents could tell you when they were wet, and staff could feel to see if residents were wet to ensure their skin was clean and dry. If CNAs refused to help other aids or yelled at residents for soiling themselves, they would not work here. A review of a policy titled Prevention of Pressure Ulcers, dated January 2014, revealed pressure ulcers occur when residents remain in the same position for an extended time, with a combination of pressure, which could result in decreased circulation and moisture irritants including urine and feces. Residents should be repositioned and on a change program, at least every two hours. A review of a policy titled Bowel and Bladder Habits, Urinary incontinence, Catheter Care, revised 09/15/2022, revealed residents that were incontinent of urine should receive appropriate care to prevent urinary tract infections. The attached in-service revealed CNA #1 and CNA #2 were both educated on perineal care. A review of an untitled in-service from 02/26/2024, revealed residents were to be checked for turning, repositioning, hydration, and episodes of incontinence every two hours, and that a charge nurse was to be notified if a resident refused care. The sign-in sheet for this in-service revealed CNA #1 and CNA #2 both were educated on this matter. A review of the Facility Assessment, dated 01/03/2025, revealed responding to bathroom and toileting assistance promptly were addressed in order to maintain continence and integrity.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure meals were served in a method that conserved the nutritive value and maintained the appearance of cold and hot products and serving of food items at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The findings are: 1. The Grievance complaint form initiated 1/6/2025 provided by the Assistant Director of Nursing (ADON) on 3/10/2025, indicated meals on the evening shift were cold when served down the halls. 2. On 3/10/2025 at 12:20 pm, during an interview, Resident #14 stated to this surveyor that the food was sometimes cold when it was served. When asked if the food was cold in the dining room or bedroom, Resident #14 stated, both. 3. On 3/10/2025 at 12:39 PM, Dietary Aide (DA) #1 left the door to an unheated food cart open while loading the lunch meal trays inside the cart. After loading 9 lunch trays into the cart DA #1 closed the door at 12:48 PM and pushed the food cart outside the kitchen door. Certified Nursing Assistant (CNA) #1 then pushed the food cart to the A Hall and the food cart remained open while the meal trays were being served to the residents. At 1:08 PM, immediately after the last resident was served in their room on the A Hall, the temperature of the food items on the tray used as test tray was taken and read by the Dietary Manger with the following results. a. Cream corn - 100 degrees Fahrenheit. b. Chili - 125 degrees Fahrenheit. 4. On 3/10/2025 at 12:55 PM, DA #1 left the door to an unheated food cart open while loading lunch meal trays to be delivered to the C Hall. At 1:05 PM, after loading 13 meal trays inside the cart, DA #1 closed the door and pushed the food cart outside the kitchen. CNA #3 delivered the food cart to the C Hall for passing. The door was left open while CNA #2 passed the meal trays to the residents. At 1:16 PM, immediately after the last resident was served in their room on the C Hall, the temperature of the food items on the tray used as a test tray were taken and read by the Dietary Manger with the following results. a. Milk - 50 degrees Fahrenheit. b. Hamburger patty - 102 degrees Fahrenheit. c. Cream corn - 103 degrees Fahrenheit. d. Hamburger patty - 100 degrees Fahrenheit. The Dietary Manager was interviewed and was asked what temperature cold foods and hot foods should be served to the residents. He stated cold foods are supposed to be 40 degrees Fahrenheit and below, and hot food foods 150 degrees Fahrenheit and above. 5. On 3/10/2025 at 1:21 PM, CNA #3 was interviewed and was asked what temperature cold foods and hot foods should be before being served to the residents. She stated cold foods are supposed to be at least 40 degrees Fahrenheit and below, for milk 50 degrees Fahrenheit is hot, and hot foods should be 150 degrees Fahrenheit and above. CNA #3 was asked if any residents had complained about the food being cold. CNA #3 stated Resident #13 always complained about receiving cold meat. When asked why the door was left open on the food cart, CNA #3 stated it was faster but would cause the temperature to drop. 6. On 3/10/2025 at 1:21 PM, CNA #4 was interviewed and was asked what temperature cold foods and hot foods should be before being served to the residents. She stated cold foods are supposed to be 30 degrees Fahrenheit and hot foods 150 degrees Fahrenheit and above. The milk was hot, and the hamburger patty was not hot. When asked why the door was left open on the food cart, CNA #4 stated it was faster but would cause the temperature to drop. 7. During an interview on 3/10/2025 at 1:26 PM, Resident #13 was asked how the food was. Resident #13 stated the hamburger patty was always cold by the time it got to [pronoun]. 8. On 3/10/2025 at 5:02 PM, the temperatures of the food items when checked and read on the steam table by Dietary [NAME] (DC) #2 were: a. Salisbury steak - 120 degrees Fahrenheit. b. Pureed baked potatoes - 125 degrees Fahrenheit. c. Pureed Salisbury steak - 120 degrees Fahrenheit. d. Pureed broccoli - 115 degrees Fahrenheit. 9. On 3/10/2025 at 5:49 PM, Dietary Aide (DA) #8 left the door to an unheated food cart open while loading the supper meal trays to be delivered to the A Hall. After loading 16 meal trays inside the food cart, DA #8 closed the door at 5:56 PM and pushed the food cart outside the kitchen. CNA #6 delivered the food cart to the A Hall for passing. At 6:13 PM, immediately after the last resident was served in their room on the A Hall, the temperature of the food items on the tray used as test tray was taken and read by CNA #9 with the following results: a. Pureed Salisbury steak - 100 degrees Fahrenheit. b. Pureed baked potatoes - 110 degrees Fahrenheit. c. Pureed broccoli - 108 degrees Fahrenheit. d. Ground Salisbury steak - 105 degrees Fahrenheit. e. Salisbury steak with gravy -100 degrees Fahrenheit. When asked why the door was left open on the food cart, CNA #6 stated it was faster but will cause the temperature to drop down. 10. On 3/10/25 at 6:05 PM, DA #8 left the door to an unheated food cart open while loading the supper meal trays to be delivered to the C Hall. After loading 13 supper meal trays inside the food cart, DA #8 closed the door at 6:22 PM, and pushed the food cart outside the kitchen. CNA #9 delivered the cart to the C Hall for passing. The door was left open while CNA #9 was passing the supper meal trays to the residents. At 6:30 PM, immediately after the last resident was served in their room on the C Hall, the temperature of the food items on the tray used as test tray was taken and read by CNA #8 - with the following results: a. Milk - 45 degrees Fahrenheit. b. Sailsbury steak with gravy - 100 degrees Fahrenheit. c. Broccoli - 111 degrees Fahrenheit. d. Baked Potato - 112 degrees Fahrenheit. When asked why the door was left open on the food cart, CNA #9 stated it was quicker but will cause the food temperature to drop. 11. On 3/10/2025 at 6:40 PM, DA #8 was interviewed and was asked the reason it took so long to load food trays into the food cart. DA #8 stated she could not see the tray cards on the food trays at the back to see what each resident liked to drink. DA #8 was asked the reason the food cart was left open while she was loading food trays inside the cart. She stated keeping the door open made it quicker, but it would make the temperature of the food drop down. 12. On 3/10/2025 at 6:44 PM, DC #5 was asked what the holding temperature on the steam table should be. He stated 150 degrees Fahrenheit. When asked if all food temperatures were hot before serving it to the residents, DC #5 stated most of them were very low. DC #5 then was asked what he should have done when the food items were not hot enough to serve. DC #5 stated he should have reheated them. DC #5 was asked why there was no water in the pan where most food pans were setting on the steam table, awaiting service. DC # 5 stated, the water must have evaporated. 13. On 3/11/2025 at 9:20 AM, DA #1 was interviewed and was asked the reason the food cart was left open while she was loading food trays inside the cart. DA #1 stated keeping the door open made it faster to load but would cause food to lose temperature. 14. On 3/11/25 at 1:11 PM, the Administrator was interviewed and was asked if any residents had complained to him about receiving cold foods. He stated he had received some from the resident council meetings regarding food begin cold and that the facility was addressing the issue to resolve it. The facility changed the card order and implemented the changes on 3/4/2025. Additionally, he contacted the facility representative to order new food carts. As of now, the facility had two food carts that were being used in the kitchen, each holding sixteen meal trays. He further stated that the facility representative was at the facility today and provided him with a quote for the food carts. However, he had not yet received a quote from the direct supplier. His plan was to send two food carts to each hall. 15. On 3/11/24 at 1:52 PM, the Assistant Director of Nursing (ADON) was interviewed and was asked if any residents had complained to her about receiving cold foods. She stated the residents had not complained to her. She received a report from Medical Records staff, who also assisted with resident council meetings, that revealed the residents had complained about receiving cold food by the time it gets to their room. The ADON stated the kitchen had some good food carts which they have begun using as frequently as possible to speed up the process of passing meal trays. Additionally, she provided in-service training on teamwork to ensure food items were delivered as quickly as possible, preventing the food from getting cold. When the ADON was asked if there was additional help available to distribute meal trays to the residents in their rooms, she stated two CNAs assigned to the A Hall had already been on the hall before she arrived to assist with meal distribution. 16. On 3/11/2024 at 1:43 PM, the Dietary Manager was interviewed and was asked if any residents had complained to him about receiving cold foods. He stated when the kitchen had problems with the steam table, about a month or two months ago, the steam table turn switch had to be fixed, and the facility brought a portable one to use until the other steamtable was fixed in the middle of February, but we still have problems with the steam table and the food carts are not heated. 17. On 3/11/2025 at 3:11 PM, the Medical Records employee was interviewed and was asked if any residents had complained to her about receiving cold food. She stated during the resident council meeting on 11/15/2024 the residents complained about receiving colds foods when they received their meal trays in their rooms. The Medical Records employee stated she documented it on grievance, and the facility did an in service and began monitoring how quickly the food carts could be delivered to each hall to prevent the food from getting cold. 18. The Grievance complaint form initiated 11/6/2024 provided by Medical Records on 3/11/2024 indicated resident complaints about meals been cold when transported from the kitchen to the halls. 19. A review of the facility titled, In-service, initiated on 11/15/2024 provided by the Medical Record #1 ion 3/11/2025 indicated Residents have voiced another complaint in regards of meals arriving to them cool or cold on halls, and staff need to work together regardless of hall assignment. As meal trays come out and staff that are not working in the dining room should work together in each hall to pass the trays out quickly and to utilize the use of green plastic carts and keep the door closed between passes to aid in keeping the food warmer. 20. The review of facility policy titled, In-Service Ensuring Proper Temperature of Meal Trays, initiated on 10/4/2024, indicated food trays should remain warm when delivering to the residents to maintain satisfaction and food quality. Residents are receiving cold food which could affect resident satisfaction and health. Delays in passing trays contribute to food cooling down further and CNAs assigned to halls should start passing trays as soon the cart arrives to aid in eliminating the time food spent in the cart before being served to residents, and to keep the cart closed between tray passes and to maintain warmth inside. 21. A review of facility policy titled, Food Temperatures, initiated 3/2024, provided by the Dietary Manager on 3/11/2025, indicated all cold food items should be maintained and served at 41 degrees Fahrenheit and hot food temperatures should be maintained and served at 135 degrees Fahrenheit or above and food delivered the units should be transported and maintained at the temperatures of 41 degrees Fahrenheit or below for cold foods and at above 135 degrees Fahrenheit for hot foods.

Based on observation and interview, the facility (1) failed to ensure food items stored in the refrigerator were covered and dated, (2) failed to ensure that the kitchen vents were cleaned to provide a sanitary environment for food preparation, (3) failed to ensure floors, dish washer the door frames, baseboard and ceiling tiles were free of chipped, holes, paint peeling, rust, stains, (4) failed to ensure dietary staff washed their hands when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen, dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, and (5) failed to ensure hot food item was maintained at 135 degrees Fahrenheit or above on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; The failed practices had the potential to affect 57 residents who received meals from the kitchen (total census: 57). The findings are: 1. On 04/03/2024 at 07:41 AM, the following observations were made in the 6-doors refrigerator: a. There was an open gallon of enchilada sauce on a shelf in the refrigerator with no open on it. b. An opened box of bacon on a shelf. The box was not covered or sealed. 2. On 04/03/2024 at 07:45 AM, the ceiling tile above the 6 doors refrigerator had paint peeling, exposing the wood. 3. On 04/03/2024 at 07:53 AM, the following observations were made in the meat and vegetable freezer. a. An opened zip lock bag that contained onion rings was on a shelf in the freezer. The bag was not covered or sealed. b. An opened zip lock bag that chicken fried steak was on a shelf in the freezer. The bag was not sealed. 4. On 04/03/2024 at 10:03 AM, Dietary Employee (DE) #3 turned on the hand washing sink faucet and washed his hands. After washing his hands, he turned off the faucet with his hands, contaminating them. He then removed gloves from the glove box and placed them on his hands, contaminating the gloves in the process. Without washing gloves and washing his hands, he removed shredded cheese from the original bag to be used in preparing lasagna to be served to the residents for lunch. The surveyor immediately asked DE #3, What should you have done after touching dirty objects and before handling clean equipment? DE #3 stated, I should have washed my hands. 5. On 04/03/2024 at 10:06 AM, the following observations were made in the dish washing room: a. The ceiling tile by the vent hood in the dirty dish washing machine had paint peeling, exposing the cement. b. The right side of the ceiling tile had paint peeling, exposing the cement. The area had water damage, sage color, and a hole in it. c. The floor of the dirty dish machine had black/brown stains on it. d. The left side of the door frame leading to the dirty dish washing machine room was missing, exposing the metal. e. The baseboard on the right side of the door leading to the dirty dish washing machine was chipped. The area that was chipped had rust stain on it. f. 8 of 8 dish racks in the dirty dish machine room had accumulations of white sediments on them. 6. On 04/03/2024 at 10:15 AM, DE #2 was wearing gloves on his hands when he picked up a pitcher of water from the sink and emptied it into the pans on the steam table. Without changing the gloves and washing his hands, he picked up utensils by the area that went into the mouth and placed them in an individual napkin wrapped for the residents to use when eating their lunch meal. The Surveyor asked DE #2, What should you have done after touching dirty objects and before handling clean equipment? DE #2 stated, I should have washed my hands. 7. On 04/03/2024 at 10:28 AM, the following observations were made in the kitchen. a. The kitchen floor around the 3-compartment sink, 2- compartment sink had light green stains on it. b. The floor by the deep fryer and the oven had grease stains on it. c. The floor throughout the kitchen had stains on it. The metal cover on the wall by the oven had dried grease stain on it. The wall by the oven had brown stain on it. 8. On 04/03/2024 at 10:48 AM, DE #3 removed a container of slices of tomatoes from the refrigerator and placed it on the counter. He removed gloves from the glove box and placed them on his hand contaminating the gloves. He then used the same gloved hand to remove a slice of tomato from the container and placed it on top of shredded lettuce inside a bowl to be served to the resident who requested it. The Surveyor asked DE #3, What should you have done after touching dirty objects and before handling clean equipment? DE #3 stated, I should have washed my hands. 9. On 04/03/2024 at 10:56 AM, the baseboard in the janitor's closet was loose from the wall. The floor had gray stains on it. 10. The temperature of the regular vegetable on the steam table when checked and read by DE #3 was 120 degrees Fahrenheit. The above vegetable was not reheated before being served to the residents. 11. On 04/03/2024 at 12:43 PM, DE #4 removed 2 bags of bread from the bread rack and placed them on the counter. He placed gloves on his hands, contaminating the gloves. Without washing his hands, DE # 4 removed slices of bread from the bread bag and placed them on a pan liner on the counter, then slices of cheese were placed on top of a slice of bread and placed another slice of bread on top to prepare grilled chesses sandwich to be served to the resident who asked for it. The Surveyor asked DE #4, What should you have done after touching dirty objects and before handling clean equipment? DE #3 stated, I should have washed my hands. 12. A facility policy titled, Hand Hygiene technique when using soap and water documented, Wet hands with water. Avoid using hot water to prevent drying of skin. Apply to hands the amount of soap recommended by the manufacturer. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Rinse hands with water. Dry thoroughly with a single-use towel. Use clean towel to turn off the faucet.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets. The findings are: 1. On 04/03/2024 at 11:14 AM, Dietary Employee (DE) #3 used a #6 scoop to place 8 servings of lasagna into a blender, added tomato sauce and pureed. At 11:19 AM, DE # 3 poured the pureed lasagna into a pan and placed it in a pan of hot water on the stove. The consistency of the pureed lasagna was gritty and not smooth. 2. On 04/03/2024 at 11:21 AM, DE #3 placed 8 servings of garlic bread into a blender, added 3 cartons of 2% milk and pureed. At 11:22 AM, DE #3 poured the pureed garlic bread into a pan. The consistency was thick, lumpy, and not smooth. There were pieces of bread left in the mixture. 3. On 04/03/2024 at 11:44 AM, DE #3 used a #8 scoop to place 8 servings of vegetable blend into a blender and pureed. At 11:46 AM, DE #3 poured the pureed vegetables into a pan. The consistency of the pureed vegetable blend was runny. DE #3 placed a pan that contained pureed vegetable blend in a pan of hot water on the steam. At 11:50 AM, DE #3 added thickener to the pureed vegetables and used a spoon to stir it. The consistency of the pureed vegetable was lumpy and not smooth. The thickener was not completely dissolved into the mixture. 4. On 04/04/2024 at 07:40 AM, the following observations were made on the steamtable. a. A pan of pureed bread to be served to the residents on pureed diets. The consistency of pureed bread was thick. b. A pan of pureed sausage to be served to the resident who required pureed diets. The consistency of pureed sausage was gritty and not smooth. 5. On 04/04/2024 at 07:42 AM, the Surveyor asked DE #1 to describe the consistency of the pureed food items. DE #1 stated, Pureed bread was thick and pureed sausage was gritty it needed to be smooth.

Based on observation, interview, and policy review, the facility failed to ensure the biohazard and oxygen rooms remained locked at all times. This failed practice had the potential to affect all 57 residents. The findings are: On 04/02/2024 at 03:09 PM, the Surveyor observed an unattended set of keys in the doorknob to the Biohazard Room on 300 Hall. The Surveyor knocked on the door with no answer. On 04/02/2024 at 03:19 PM, the Surveyor observed Maintenance walk up to the Biohazard room door and remove the keys. The Surveyor asked Maintenance to open the door and observed oxygen cylinders and biohazard boxes with full containers of syringes and needles inside. The Surveyor asked, Should the keys be left in the door? Maintenance stated, No, but I was only gone for a couple of minutes. The Surveyor asked, What time is it? Maintenance stated, It's 3:19. On 04/02/2024 at 03:33 PM, the Administrator confirmed the keys were left in the door unattended. On 04/03/2024 at 10:11 AM, the Surveyor observed a door on Hall 3 with a sign showing, .keep closed at all times . with a built-in combination lock. The door was unlocked and opened with no combination. The Surveyor observed 2 full containers with used syringes and needles, 7 oxygen cylinders, disinfecting wipes, a small refrigerator, and multiple Personal Protective Equipment (PPE) items. On 04/03/2024 at 10:15 AM, the Director of Nursing (DON) confirmed the room contained 7 oxygen cylinders, lab equipment, a biohazard refrigerator (empty), supplies of masks, disinfecting wipes, and 2 full containers holding used syringes and needles, and that the door was unlocked. On 04/03/2024 at 10:26 AM, the Administrator confirmed the door was unlocked. A document provided by the Administrator on 04/04/2024 at 09:22 a.m. titled, Incident and Accident Reporting effective 05/15/2024 with a revised date of 08/22/2017 showed, .everything possible should be done to avoid accidents or incidents involving patients .

Based on observation and interview, the facility failed to ensure the refrigerated narcotic medications in 1 of 1 medication storage room were stored in a permanently affixed compartment to prevent the potential misappropriation of resident property. The findings are: On 04/03/2024 at 11:47 AM, Licensed Practical Nurse (LPN) #1 pulled the medication narcotic box out of the refrigerator and placed it on the counter. The narcotic box was not affixed to the refrigerator. On 04/03/2024 at 11:48 AM, LPN #1 confirmed that the narcotic box hadn't been affixed to the refrigerator. On 04/03/2024 at 01:12 PM, the Director of Nurses (DON) was asked, Can you tell me why the narcotic box is not permanently affixed to the refrigerator? She stated, I'm not sure, but it should be. On 04/04/2024 at 09:22 AM, the Administrator provided a policy titled, Drug Acquisition, Storage and Inspection. It documented, .Medications shall be stored in a secure manner .

Based on observations, interviews, record review, and policy review, the facility failed to ensure a safe and hazard-free environment for 2 (Resident #43 and #50) sample mixed residents. The findings are: 1. Resident # 50 had diagnoses of Dementia without behavioral disturbance, Psychotic disturbance, Mood disturbance, and Anxiety. 1 a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/2024 showed a Brief Interview for Mental Status (BIMS) of 4 (a score of 0-7 suggests severe cognitive impairment.) The Resident required supervision or touch assistance with personal hygiene. 1 b. The care plan showed Resident #50 has a communication problem related to dementia. Staff are to ensure/provide a safe environment. 1 c. On 04/01/2024 at 10:54 AM, the Surveyor observed aftershave, shaving gel, shave cream, and body lotion sitting on the dresser by the door. 1 d. On 04/01/2024 at 12:34 PM, the Surveyor observed aftershave, shaving gel, shave cream, and body lotion sitting on the dresser by the door. 1 e. On 04/02/2024 at 09:23 AM, the Surveyor observed aftershave, shaving gel, shave cream, and body lotion sitting on the dresser by the door. 1 f. On 04/03/2024 at 02:00 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1, Can you tell me what is on Resident # 50 dresser, and if should it be there? CNA #1 stated there were things on the dresser that are not supposed to be there, body wash, lotion, and aftershave. The Surveyor asked, Who is responsible for putting the items away? CNA #1 stated, The aides are. 1 g. On 04/03/2024 at 02:05 PM, the Director of Nursing (DON) confirmed the items on the dresser and should not be there with demented and confused Residents. 1 h. A document provided by the Administrator on 04/04/2024 at 09:22 a.m. titled, Incident and Accident Reporting effective 05/15/2015 with a revised date of 08/22/2017 showed, .everything possible should be done to avoid accidents or incidents involving patients . 1 i. A document provided by the Administrator on 04/04/2024 at 11:06 a.m. titled, Job Description: Certified Nursing Assistant Effective 01/16/2015 and Revised 11/28/2017 showed, .duties and responsibilities .promote a safe .environment in which the residents may live . Resident #43 had diagnoses that included Chronic obstructive pulmonary disease with (acute) exacerbation, Pain, unspecified, Gastro-esophageal reflux disease without esophagitis, Hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side. The Quarterly MDS, with an ARD of 12/21/2023, revealed Resident #43 had a BIMS score of 12 (7-12 indicates moderate cognitive impairment). A review of Resident #43's Care Plan revealed the resident had impaired physical mobility related to CVA (cerebral vascular accident, commonly referred to as a stroke) with left hemiplegia. Interventions included: Assist Resident in performing movements/tasks and educate Resident/Representative on safety precautions. During an observation on 04/01/2024 at 12:27 PM, Resident #43 was observed vaping in his/her room. A review of Resident #43 ' s Progress Note, dated 04/01/2024 at 4:05 PM, documented, Copy of smoking policy explained and given to resident for the use of electronic cigarette. Resident acknowledged and signed policy. Resident gave electronic cigarettes to this nurse. Electronic cigarettes placed inside nursing cart. During observation and interview on 04/03/2024 at 09:56 AM, Resident #43 indicated staff came around and took the vape, and will not allow Resident #43 to vape in the Resident's room. Resident #43 was given a new policy on vaping that showed to only vape outside. Resident #43 stated prior to 04/01/2024 vaping was only allowed in Resdnet's room. On 04/04/2024 at 04:04 PM, the Administrator was asked when the facility became a vape-free facility, because the admission packet indicated they are a smoke-free facility. The Administrator stated, I have no answer, when I came here, they were vaping. A review of facility updated policy titled, Smoking Policy, dated 04/02/2024, indicated, Smoking will only be allowed in designated (outdoor) area(s) in the facility that are not near flammable substances or where oxygen is in use.

Based on observation, interview, and record review, the facility failed to ensure nails were clean and trimmed for 1 (Resident #2) of 1 sampled resident. The findings are: Resident #1 had a diagnosis of Type 2 Diabetes mellitus. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/09/2024 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). A care plan for Resident #2 documented, .Check nail length and trim and clean on bath day and as necessary. Report changes to the nurse . On 04/01/2024 at 10:41 AM, Resident #2 ' s fingernails were long with a black substance underneath. She stated, They clean them whenever they have enough help. On 04/01/2024 at 01:04 PM, Resident #2 ' s fingernails were long with a black substance underneath. On 04/04/2024 at 09:19 AM, Certified Nurse Aide (CNA) #3 was asked, Who's responsible for cutting and cleaning Resident #2 nails? She stated, The nurses, because the [Resident] is a diabetic. On 04/04/2024 at 09:22 AM, Licensed Practical Nurse (LPN) # 2 was asked, Who's responsible for cutting and cleaning Resident #2 nails? She stated, The nurses. She was asked, Can you tell me why Resident #2 nails were long and had a black substance underneath them when we entered on Monday? She stated, I don't know. Sometimes the [Resident] doesn't want them cut, but that's not an excuse for them being dirty. On 04/04/2024 at 09:22 AM, the Administrator provided a form titled, Activities of Daily Living. It documented, .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain .grooming .

Based on observation and interview, the facility failed to ensure that the residents had knowledge of the State Inspection Book, and it was made accessible to them if they chose to read it. The findings are: On 04/02/2023 at 09:30 AM, the Resident Council meeting was conducted. The Surveyor asked the Residents if they were familiar with the State Inspections Book and where it was located in the facility if they chose to read it. All 4 (Resident #1, #3, #26, and #34) residents stated that they were not aware of the State Inspections Book, or where it was located. On 04/02/2023 at 10:15 AM, this Surveyor looked around the facility for the survey results binder. The survey results binder was not located. On 04/02/2024 at 10:22 AM, the Activity Director was asked where the results of the state inspections were located. The state inspection results were located behind the nurse's station, in a location inaccessible to Residents and their Representatives. On 04/02/2024 at 10:24 AM, the Administrator stated, They didn't put the state inspection book back on the wall after they painted.

Based on observation, interview and record review, the facility failed to ensure meals were served in a method that maintained the appearance of cold product and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. This failed practice had the potential to affect 16 residents who receive meal trays in their rooms on the A Hall, 15 residents who receive meal trays on the B hall, 24 residents who receive meal trays in their room on the C hall. The findings are: 1. Resident #41 had diagnoses of Vitamin deficiency, Mood (affective disorder, Hypo-osmolality, and Hyponatremia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/05/2024 showed a Brief Interview for Mental Status (BIM) of 15 (13-15 indicates cognitively intact). Resident was independent for eating. a. A Physician's Order Summary for April 2024 documented, Regular diet Regular texture, Regular/Thin consistency. b. The care plan showed Resident #41 was able to feed themselves after the tray was set up. c. On 04/03/2024 at 10:26 AM, the Surveyor asked, How is the temperature of the food? Resident #41 stated, The hot stuff is usually cold, and the cold stuff is usually warm. 2. Resident #30 had diagnoses of Type 2 diabetes mellitus, Irritable bowel syndrome, Vitamin deficiency, and Nausea. The Quarterly MDS with an ARD of 01/04/2024 documented a BIMS of 15. The Resident was independent for eating. a. A Physician's Order Summary for April 2024 documented a Regular diet, Regular texture, Regular/Thin consistency. b. The care plan for Resident #30 documented, provide meal support per resident's need. c. On 04/03/2024 at 10:29 AM, the Surveyor asked, Is the food ever cold or the milk ever warm? Resident #30 stated, It happens a lot. They stock the cart and leave it out until they are ready to deliver it. We are at the end of the hall, so our food is not as hot as it should be, and our cold stuff is usually warm. 3. On 04/03/2024 at 07:20 AM, an unheated food cart that contained 15 trays for breakfast was delivered to the B hall by the Certified Nursing Assistant (CNA) #2. Immediately after the last resident was served in their room on front hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary Employee (DE) #1 with following results. a. Milk 50 degrees Fahrenheit. b. Biscuit with gravy 102.7 degrees Fahrenheit. c. Sausage 103 .6 degrees Fahrenheit. d. Pureed sausage 110 degrees Fahrenheit. e. Pureed biscuit with gravy 105.6 degrees Fahrenheit. f. Pureed eggs 105 degrees Fahrenheit. g. Scrambled eggs 110 degrees Fahrenheit. 4. On 04/03/2024 at 07:25 AM, an unheated food cart that contained 24 trays for breakfast was delivered to the C hall by the CNA #3. At 07:36 AM, immediately after the last resident was served in their room on the C hall, temperature of the food items on the tray used as test trays were taken and read by the Dietary Supervisor with following results. a. Milk 45 degrees Fahrenheit. b. Pureed eggs 110 degrees Fahrenheit. c. Pureed biscuit with gravy 115 degrees Fahrenheit. d. pureed sausage with gravy 110 degrees Fahrenheit. e. Ground sausage with gravy 112 degrees Fahrenheit. f. Biscuit with gravy 105 degrees Fahrenheit. g. Scrambled eggs 111 degrees Fahrenheit 4. On 04/04/2024 at 07:45 AM, an unheated food cart that contained 16 trays for breakfast trays was delivered to the A hall by the CNA #3. Immediately after the last resident was served in their room on front hall, temperature of the food items on the tray used as test trays were taken and read by the DE #1 with following results. a. Milk 53 degrees Fahrenheit. b. Biscuit with gravy 106 degrees Fahrenheit. c. Sausage 108 .6 degrees Fahrenheit.

Based on observation, staff interviews, record review and review of manufacturer's instructions, the facility failed to properly secure the seat belt for 1 Resident #1 of 2 (Resident #1, and #2) case mix residents who were transported in the facility's transport van. This failed practice resulted in a past immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1. These findings were determined to be a past Immediate Jeopardy. The Administrator was notified of the findings of Immediate Jeopardy on 01/31/2024 at 11:35 AM. The findings included: 1. During record review on 1/30/24 at 9:20 AM Resident #1 was admitted on [DATE] with a diagnosis of Orthopedic aftercare following and amputation and Dementia. Resident ' s Minimum Data Set, dated dated dated [DATE] assessed the resident cognitive ability as being severely impaired with a Brief Interview for mental Status (BIMS) score of 3. Resident #1 ' s Care Plan dated 10/07/23 Focus: I am at moderate risk for falls related to gait/balance problems right below knee amputation. Focus: I have an activity of daily living self-care performance deficit related to Dementia, Impaired balance, Limited mobility, Musculoskeletal impairment. 2. On 1/31/24 during record review the Office of Long-Term Care (OLTC) incident and accident report (762) was reviewed. Date of Incident 12/13/23. Time of I&A reported 1:30 PM. Type of incident transportation. Description of Incident: Resident #1 was transported back to facility via van from appointment, driver had to stop abruptly due to traffic stopping and Resident #1 fell from wheelchair along with staff member making attempts to secure Resident #1. Resident had been pulling several times to remove seat belt from herself. Staff remarked she had to resecure Resident #1 several times. Upon return to the facility, the Registered Nurse (RN) assessed and sent the Resident out to hospital for evaluation. 3. Finding and actions taken: Statements were obtained from staff and resident present. In service on proper seat belt placement and securement. A professional van securement officer will be contacted to provide updated securement training for drivers and supervisor transportation. Wheelchair to be purchased for van only. Care plan revised. 4. On 1/30/24 at 3:00 PM during Review of the manufacturer ' s instructions for the wheels chair securement company ' s User Instructions. Section B. Secure passenger. Attach lap belts- Use integrated stiffeners to feed belts through opening between seat backs and bottoms, and/ or arm rest to ensure proper belt fit around occupant. 5. On 1/30/24 at 1:30 PM, Certified Nursing Assistant (CNA) #1, CNA #2 and CNA #3 reenacted applying the seat belt on a wheelchair as it had been applied on 12/13/23. CNA #1 said she was the one to place the seat beat on Resident #1. She stated as she applied the seat belt on the volunteer for reenactment in the wheelchair (w/c) that she did not know the arm rest on this w/c could be raised up so the seat belt to be applied across the hips of the resident. She said this type of w/c does not have a split between the seat and the back, so I thought I had to put it over the arm rest. When I did that the seat belt was under her breast and not across her pelvic area. We did not realize that it was not tight enough. Resident #1 could put her arms under it, and then she slipped it over her head. I didn't realize it was not on her correctly. It should have been across her hips. 6. CNA #2 said the Resident #1 had removed the seat belt during transport back from her appointment and slid down in her w/c. Her and CNA #1 pulled her back up in the w/c and refastened the seat belt again which was reapplied across the top of the stomach and was under her breast. We stood by her trying to keep her from removing it, but it was too dangerous for us to continue standing with the van moving and we were in a construction area. Then in about 15 minutes she removed the seat belt again by putting her arms under it and lifting it. I was trying to reach her, but CNA #3 hit the brakes and Resident #1 fell out of the w/c. 7. On 1/30/24 at 2:57 PM, CNA #2 said Resident #1 was on the floor for approximately 5 minutes while I assessed her to make sure she was ok. I asked her and she said she was. There were no skin tears or bleeding. I checked her legs and arms. Me and CNA #1 picked her up and placed her back in the w/c and reapplied the seat belt and headed back to the facility. I called the Director of Nursing that worked at the facility at that time to tell her what had happened, and we were heading back. She never told me to call 911 or wait for a nurse to come. We should have paid attention when she removed it the first time without unclicking it. I should have known it was not right when she was able to remove it. 8. On 1/30/24 at 11:18 during an interview with the Director of Nursing, she said the CNA ' s was not able to assess the Resident and should have called facility or 911 before moving her. When Resident #1 returned. 9. On 1/30/24 at 2:00 during record review of the nurses notes of the incident documented on 12/13/23 at 14:10 (2:10 PM) the Resident was sent out of the facility by ambulance to the ER (emergency room ) . Resident slid out of wheelchair unto floor; possibly hitting head on floor. Resident being transported via ambulance to (Named Facility) 12/15/23 10:48 Note Text: Resident had Left knee X-ray performed 12/14/23. Results: Left mildly displaced Patella FX (fracture). MD (Medical Doctor) notified. new order: Transfer to (Named Facility) emergency room department for evaluations and orthopedic consult. Transported via ambulance on stretcher. Resident exited the building at 1040. Family at bedside. 12/15/23 at 16:04 Note Text: Patient returned from ER via ambulance. Patient entered facility on stretcher. Knee immobilizer place to lower left extremity. 10. On 1/30/24 at 1:45 PM, CNA #1, CNA #2 and CNA #3 stated said they had been trained about a year ago by someone on using the lift and securing the residents and chair in the van. They had not been trained since that time. They were asked about the in service that they had signed on 12/13/23 at 2:30 PM documenting wheelchair securement training. They all said they signed it but there was no training. The Maintenance Director has said to sign it and the next day he will go over it with them. He had other stuff to do at that time. They were in the facility when they discussed this. CNA #2 and CNA #1 said they did not do return demonstration for the Maintenance Director nor discuss the correct way to apply seat belts for this w/c. They said there was no training completed the next day. 11. On 1/30/24 at 12:25 PM, the Maintenance Director said that he did not have a skill check list to use when he trains the staff. He in- serviced the three van CNA's on 12/13/23 after the incident. He said he talked to them and showed them how to make sure the straps were applied correctly. He stated said they had a man come from (Named Company) about a year ago to train them on the lifts and securing the resident and chairs in the transport van. He said he had not completed spot checked or trained on seat belt application that he mostly does the spot checks for tires and maintenance of the vehicle. 12. On 1/31/24 at 10:08 AM, the Administrator provided an invoice from (Named Company) dated 5/10/23. The charge was for securement training. 13. On 1/31/24 at 8:47 AM, the Administrator provided the facility's Transportation Program- Best Practices Recommendations for Van Safety. Transport staff responsibilities Form- number 3. The resident in a wheelchair will have a properly adjusted and fastened seatbelt on at all times when vehicle is moving. Transport staff education: Inform staff, if resident is injured in the van while traveling, a timeline of events and how they were handled will be needed in their statement, such as, how the resident was injured; type of injury; when was the facility called and who they spoke to; what instruction was given, when/how was resident taken to hospital. 14. The Immediate Jeopardy was removed and the scope / severity was reduced to D on 12/13/23, as evidenced by the following: On 1/31/24 during record review the OLTC incident and accident report (762) was reviewed. Finding and actions taken: In service on proper seat belt placement and securement on 12/13/23. A professional van securement officer was contacted and scheduled to come and train facility. The facility identified wheelchair for van only. That has the back open and is a transport van chair.

Based on observation, record review, and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment; the freezer temperature was maintained at 0 degrees Fahrenheit to prevent growth of bacteria; food in the refrigerator was covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; and leftover food items were used properly to maintain food quality for residents who received meal trays from 1 of 1 kitchen. The failed practices had the potential to affect 59 residents who received meals from the kitchen (total census:59 ), as documented on a list provided by Dietary Supervisor on 01/19/2023. The findings are: 1. On 01/18/23 at 7:27 AM Dietary Employee (DE) #1 turned on the hand washing sink and washed her hands, she removed tissue paper from the dispenser and used it to wipe her face, contaminating the tissue papers. She used the tissue paper to dry her hands. Without washing her hands, she removed clean plates from the plate warmer with her fingers touching the interior surfaces of the plates She placed the plates on the counter by the steam table and used them to serve the resident's breakfast. The Surveyor immediately asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. DE #1 removed the plates and used clean plates. 2. On 01/18/23 at 7:46 AM, the following were in the three door refrigerator: a. A ziplock bag of leftover bacon and sausage patties was on a shelf. The Surveyor asked the Dietary Supervisor, What do you do with leftover food items from breakfast? He stated, We use them for pureed and mechanical soft diets the next day. b. One opened box of sausage was on a shelf. The box was not covered or sealed.

Based on observation, interview, and record review the facility failed to review and revise the care plan to include that a resident had a wound on the right hip to ensure appropriate coordination of care for 1 (Resident #35) of 3 (Residents #35, #58 and #62) sampled residents who had wounds, and failed to ensure the care plan documented the correct code status for 1 (Resident #29) of 2 (Residents #29 and #56) sampled residents who had a change in code status in the past 120 days. These failed practices had the potential to affect 7 residents who had wounds according to a list provided by the Administrator on [DATE] at 3:25 PM, and 5 residents who had changed their code status in the past 120 days according to a list provided by the Administrator on [DATE] at 1:45 PM. The findings are: 1. Resident #35 had a diagnosis of Metabolic Encephalopathy, Seizure Disorder and End Stage Renal Disease. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 14 (,d+[DATE] indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and did not have pressure ulcers, other ulcers wounds and/or skin problems. a. The Care Plan with an initiated date of [DATE] documented, .Focus: The resident has potential impairment to skin r/t [related to] obesity . Goal: The resident will maintain or maintain clean or intact skin . The Care Plan did not address the resident had a wound on her right hip. b. The Physicians Order dated [DATE] documented, .Dakins (,d+[DATE] strength) Solution (Sodium Hypochlorite) Apply to right hip topically one time a day for wound Cleans wound with dakins solution, pack wound and apply wet to dry dressing using dakins solution and 2x2 gauze and cover with dry dressing . c. On [DATE] at 11:07 AM, Resident #35 was lying in bed. There was a dressing on her right hip. The dressing was clean, dry, and intact and was dated [DATE]. Resident #35 stated, I broke my hip a while back and the wound got infected. d. On [DATE] at 3:05 PM, the Surveyor asked the Director of Nursing (DON), When did [Resident #35] have the original surgery on her hip? The DON stated, It was about 3 years ago I believe. She had swelling on the incision, and we sent her to the wound clinic. They opened the wound up and gave the orders for the Dakins, and to pack the wound. She is currently taking antibiotics for the infection. Resident #35 stated, I think this is my second set of antibiotics for it. I am glad it is getting better. e. On [DATE] at 1:45 PM, the Surveyor asked the MDS Coordinator, Does [Resident #35] have wounds? The MDS Coordinator stated, Yes, she does. The Surveyor asked, Does [Resident #35's] care plan address that she has wounds? The MDS Coordinator looked at the resident's electronic record and stated, I do not see her wounds on her care plan. The Surveyor asked, Should [Resident 35's] wounds be addressed on her care plan? The MDS Coordinator stated, Yes. The Surveyor asked, Why is it important that the care plan address that the resident has wounds? The MDS Coordinator stated, To let the nurses know the interventions and so they know to monitor for things such as signs of infection. f. On [DATE] at 1:50 PM, the Surveyor asked the DON, Should the fact a resident has a wound be addressed on the resident's care plan? The DON stated, Yes. The Surveyor asked, Why is it important that the resident's care plan address the fact the resident has wounds? The DON stated, It is important so that staff know the plan of action to get the wound healed and resolve it. 45065 2. Resident #29 had diagnoses of Vitamin B12 Deficiency Anemias, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Cerebral Infarction, Edema, Hypertension and Depressive Disorders. The Significant Change MDS with an ARD of [DATE] documented the resident scored 14 (,d+[DATE] indicates cognitively intact) on a BIMS and required extensive physical assistance of two plus persons for bed mobility, extensive physical assistance of one person with toilet use and limited physical assistance of one person with transfer. a. The Care Plan with an Initiated Date of [DATE] documented, .Advanced Directives I Am a Full Code - I Wish to Have CPR Performed . b. The NO CPR (Cardiopulmonary Resuscitation) Do Not Resuscitate DNR .Emergency Medical Services Do Not Resuscitate Order dated [DATE] was signed by a family member on [DATE]. c. The Physician Orders dated [DATE] documented, .DNR (Do Not Resuscitate) . d. On [DATE] at 10:45 am, the Surveyor requested the MDS Nurse to pull up Resident #29's Electronic Health Record (EHR) and look at the Physician Orders, Advance Directive document and the Care Plan. The Surveyor asked, Who is responsible for care plan revisions? She stated, Me and the other nurses. The Surveyor asked, Should the care plan match the residents DNR document and the physician's order? She stated, Yes. The Surveyor asked, What could the care plan not being revised and updated with correct code status cause for the resident? She stated, Could cause us to do something against her wishes. e. On [DATE] at 2:00 pm, the Surveyor asked the Administrator, Who is responsible for care plan revisions with a residents change in advance directive, code status? She stated, I would think it would be the MDS nurse, or one of the other nurses that uploaded the document or got the Physicians Order. The Surveyor asked, What could the care plan not being updated with the resident's code status change, cause? She stated, The staff will not have the correct information on the care plan. 3. The facility policy titled, Comprehensive Plan of Care, provided by the Administrator on [DATE] at 2:10 PM documented, .Policy: Plans of Care are developed by the interdisciplinary team to coordinate and communicate care approaches and goals for the resident related to clinical diagnosis and identified concerns . Policy Explanation and Compliance Guidelines: .The care plan will be reviewed and revised . as needed to enhance the resident's ability to meet his/her objectives .

A. Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accident hazards by allowing residents to have over the counter medications in their room and not locked up for 1 (Resident #58) of 8 (Residents #7, #19, #29, #50, #56, #57, #58 and #59) sampled residents who resided on the 200 Hall. The failed practice had the potential to affect 21 residents with cognitive impairments and ambulated by any means and had access to the medications according to a list provided by the Administrator on 01/18/23. The findings are: 1. Resident #58 had diagnoses of Hypertension, Obstructive Sleep Apnea, and Pain in Left Leg. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two people with bed mobility, transfer, and toilet use. a. On 01/16/23 at 10:50 am, the Surveyor observed 1 tube of Hydrocortisone ointment, and 1 tube of Triple Antibiotic Ointment on Resident #58's over bed table. Resident #58 was not in his room. b. On 01/17/23 at 2:00 pm, Resident #58 was in his room, the Surveyor asked, Are these medication's lying here on the table? He replied, Yes, I just have them there so I can use them when I need to. c. On 01/18/23 at 9:00 am, the Surveyor asked Licensed Practical Nurse (LPN) #2, Do you have anyone in the facility that is able to keep medication in their rooms? She stated, No. The Surveyor asked, Are there any residents that have had a medication self-administration assessment that you are aware of? Stated, No, not that I know of. The Surveyor asked, Are residents allowed to keep over the counter ointments in their room to use when they need to? Stated, No, I don't think they can. d. On 01/18/23 at 10:30 am, the Surveyor went into Resident #58's room, Resident #58 was out in the common area. The 2 tubes of over-the-counter medications remained on the over bed table. e. On 01/18/23 at 10:55 am, the Surveyor asked the Director of Nursing (DON), Are residents allowed to have over the counter medication ointments in their rooms? She stated, No, we don't have anyone that can do that. The Surveyor asked, Do you have anyone that has a medication self-administration assessment? She stated, No, we don't. The Surveyor asked, What could happen with these two medication ointments being out within reach of anyone that goes into residents' room? She stated, They could eat it or put it in their eye or anything. f. On 01/18/23 at 11:15 am, the Surveyor asked the Administrator, Are residents allowed to keep over the counter medication ointments in their room to use? Stated, No, not unless they have been assessed to do so and it is on the care plan for them to do so. The Surveyor asked, Do you have anyone in the facility that has a self-assessment completed and has it on the care plan? Stated, No, we don't have anyone at this time. The Surveyor asked, What could happen by allowing those medications out and in the resident's room for anyone to have access to? She stated, If the resident is confused, they could ingest them or harm themselves with them. g. The facility policy titled, Self-Administration of Medication and Bedside Medications + [plus] Assessment, provided by the Director on 01/18/23 at 2:11 pm stated, .The manner of storage should prevent access by other residents. Lockable drawers or cabinets may be required if unlocked storage is ineffective . 46319 B. Based on observation, interview, and record review, the facility failed to ensure the hot water was maintained at a safe temperature to the resident rooms on the 200 Hall, 300 Hall, and the public restrooms located on the 200 Hall, that are not locked, giving anyone access. The findings are: 1. On 01/18/23 at 11:05 am, the door to the public bathroom opened on the 200 Hall by the Nurses Station. The Surveyor washed his hands in the bathroom, and noted the water was extremely hot. The Surveyor placed his right wrist under the water and the wrist turned red within 3 seconds after being under the water. The Surveyor asked the Maintenance Director to check the water temperature with his thermometer. The temperature displayed was 126.9 degrees. The Surveyor asked him to place his hands under the water. He did and withdrew his hand. He said, Oh [expletive]. The Surveyor asked, What could happen if a resident placed their hand under that water? He said, They would get burned. 2. On 01/18/23 at 11:10 am, the Surveyor went into Resident #53's room to check the hot water in the restroom. Resident #53 stated, Don't let it burn you, it gets really hot. 3. On 01/18/23 at 11:12 am, the Surveyor went into Resident #57's room to check the hot water in his restroom. Resident #57 stated, It gets hot, but that is why we have cold water to mix with it, so it is not too hot. It needs to get hot doesn't it. 4. On 01/18/23 at 11:15 am, Maintenance Director and the Surveyor checked the temperature of the hot water on each hall. The temperatures were as follows: a) On the 100 Hall in room [ROOM NUMBER], the hot water temperature was 106 degrees. b) On the 200 Hall in room [ROOM NUMBER], the hot water temperature was 122.1 degrees. c) On the 300 Hall in room [ROOM NUMBER], the hot water temperature was 123 degrees. d) On the 300 Hall in room [ROOM NUMBER], the hot water temperature was 122.3 degrees. 5. Maintenance Director said they have had someone come out and work on the water pump since the pipes busted on December the 26th at 6:00 pm. He stated, We have been having issues with the water ever since. 6. On 01/18/23 at 11:30 am, the Maintenance Director showed the Surveyors the pipes and regulator that were replaced when the pipes burst during below freezing weather. There was a traditional water heater that supplied the kitchen and two on demand water heaters per the Maintenance Director, he stated that the temperature for the traditional water heater that supplied the kitchen was 134 degrees and the two on demand water heater that supplied the rest of the facility was set at 140 degrees. He stated that because of the location of the water heaters that it was recommended to set temperatures at that. 7. On 01/18/23 at 12:10 pm, the Surveyor asked the Maintenance Director, How often are you monitoring the water temperatures? He stated, Weekly. 8. On 01/18/23 at 12:15 pm, the Administrator stated that due to the city watermain bursting, the entire city has had water issues. The plumbing service has been to the facility on multiple occasions after 12/24/22, related to water issues. 9. On 01/18/23 at 12:20 pm, the Surveyor asked the Administrator, Are you doing any monitoring for the hot water in the residents' rooms? She said, No, I didn't even think about that.

Complaint # (AR 052) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure the call light system was in proper working order to assure residents could call for assistance when needed for 3 of 3 (Residents (R) #1, #2 and #3) case mix residents who were capable of using a call light. This failed practice resulted in Immediate Jeopardy and had the potential to cause more than minimal harm to all 42 residents in the facility, according to the Roster Matrix provided by the Administrator on 01/20/21 at 10:32 am. The Administrator was informed of the Immediate Jeopardy situation on 01/20/21 at 09:45 pm. The findings are: 1. On 01/20/21 at 09:15 am, Maintenance #1 was painting walls of the common area. He stated, We have been remodeling the facility the last couple of months. He was asked, Is the call lights working? He stated, Not at this time. The call system went out and someone came to fix it, but they fried the system and we haven't been able to find parts to replace it. So we are getting a whole new system. There's a company coming from (another state) and they were supposed to be here January 18 (2021). 2. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/08/20 documented the resident scored 11 (8-12 indicates moderate impairment) on a Brief Interview for Mental Status (BIMS); required physical help with 1 person assist for bathing, supervision with set up for toilet use and personal hygiene; needed set up for dressing; was independent for bed mobility, transfer and eating; and always continent of bowel and bladder. a. The Care Plan dated 12/11/20 documented, I have the potential for Falls r/t (related to): Unsteady Gait, Goal: Any falls will be kept to a minimum over the next Quarter (QTR), Intervention: Keep my call light in reach and encourage usage. b. On 01/20/21 at 09:45 am, Resident #1 and Resident #2 (roommates) were asked, When you push your call light, does the staff answer in a timely manner? R #1 stated, Well, the call lights ain't working right now. Resident #1 was asked, How long have they not worked? R #1 stated, I really don't know for sure, but would estimate 2 or 3 months. Resident #1 was asked, How do you get help when you need it if you don't have a call light? R #1 stated, Well by the grace of God, I can walk and do for myself, but my roommate is in a wheelchair and she has trouble getting around. I try to help her when she needs it, but I can't always do what needs to be done to help her. I'll go out in the hall and get someone to help. I've stood out in the hall before and waited for someone to walk by to get help for my roommate. c. On 01/20/21 at 09:51 am, R #1 was asked, Have you asked or been told why the call lights aren't working? R #1 stated, Yes. They told us that they had someone trying to fix it, but it was so old that the whole thing was gonna have to be replaced. 3. Resident #2 [DIAGNOSES REDACTED]. The MDS with an ARD of 11/13/20 documented the resident scored 05 (0-7 indicates severe cognitive impairment) on a BIMS; required limited assistance with one person assist for bed mobility, transfer, dressing, toilet use and personal hygiene; needed physical help with one for bathing; was independent without set up for eating, always incontinent with bladder and occasionally incontinent of bowel. a. The Care Plan dated 12/19/19 documented, I have the potential for Falls r/t: Impaired Balance due to [MEDICAL CONDITION], Goal: My Falls will be kept to a minimum over the next QTR, Intervention: Keep my Call light within reach, encourage use and wait for assistance. b. On 01/20/21 at 09:50 am, Resident #2 was asked, Does the staff do regular rounding where they come check to see if you need anything? She stated, Yes. They are really good to come every 2 hours, but sometimes they are needed before they get around to helping us. It's worse on days because they are busy on other halls and they can't always come fast enough to help us, or we can't find anyone to help us. c. On 01/20/21 at 10:00 am, Certified Nursing Assistant (CNA) #1 was asked, How often do you check on the residents? She stated, Every 2 hours or as needed. CNA #1 was asked, Well how do you know when it's needed, when the call lights don't work? She stated, Some of the residents will come out into the hall and tell us or when we walk by their rooms, we will stop in and ask them if they need anything. CNA #1 was asked, How long have the call lights not worked? She stated, They went out about 2 months ago, I think. I've heard people talking about it and they said it's going to be fixed, but I don't know for sure when. 4. Resident #3 had [DIAGNOSES REDACTED]. The MDS with an ARD of 12/29/2020 documented the resident scored 15 (13-15 indicates intact cognitive responses) on a BIMS; required total dependence with 2 person assist for transfer and toilet use; extensive assistance with 2 for bed mobility and dressing, bathing; limited assistance with 1 for personal hygiene; was independent without set up for eating; and always incontinent for bowel and bladder. a. The Care Plan dated 11/21/19 documented, I have the potential for Falls r/t: The Need for Staff to Provide Assistance with Transfers, Goal: My Falls will be kept to a Minimum over the next QTR, Intervention: Keep my call light within reach. b. On 01/20/21 at 10:15 am, Resident #3 was asked, Does the staff check on you often? She stated, Yes. They are really good about checking on me every 1 ½ - 2 hours during the day but I don't usually need them during the night, so I don't know if they check on me then or not. Resident #3 was asked, So, I've heard that the call lights aren't working. Do you know how long the facility has been without call lights? R#3 stated, I think around 2 months or so. It doesn't really affect me because I have a cellphone that if I need assistance, I will call the desk and ask for it. It usually takes about 10 minutes at the most for me to get help after I call. Resident #3 was asked, So you are happy with the care that you receive here? She stated, Oh, yes. I'm happy. They have some great staff who really care here, and I don't have any complaints about my care. The DON (Director of Nurses) is wonderful, but I'm so sad because he is leaving to go work somewhere else. He really cares about us. 5. On 01/20/21 at 11:30 am, the Administrator was asked, So, the call lights aren't working? He stated, The call lights quit working around mid-November (2020), and I called and had someone come to fix them. They sent 2 techs out and while attempting to fix them, they fried the motherboard and the system went completely down. There was an attempt to find parts to replace the motherboard, but because of the system's age, the parts are obsolete and can't be found. I contacted and received quotes from 3 different vendors, then placed an order for [REDACTED]. 6. On 01/20 21 at 01:51 pm, the Administrator gave a copy of an email that was sent on 01/03/21 from the owner of a company in another state stating projection of call light installation. 7. On 01/20/21 at 08:10 pm Licenses Practical Nurse (LPN) #1 was asked, So there are no working call lights in the facility, is that correct? She stated, That is correct. She was asked, What is the plan to check on the residents then if they don't have any way to call for help? LPN #1 stated, I have my CNAs check on the residents more frequently than the required every two hours. There is always 1 person on the main hall, and they check on non-mobile residents every 15-20 minutes. On Hall C, those residents are more mobile, and they come out into the hall or yell at us when they need help. The Administrator was asked, Has the facility had an in-service related to Not having working call lights in place? She stated, No. a. On 01/20/21 at 08:16 pm, CNA #2 was asked, How often are you monitoring the residents since the call lights aren't working? She stated, Every 30 minutes if not more, depending on which hall I'm working. CNA #2 was asked, How many staff work on night shift? She stated, We have 2 nurses and 3 CNAs working 3-11 shift. CNA #2 was asked, Has the facility done an in-service on monitoring residents without working call lights? She stated, Not that I'm aware of. b. On 01/20/21 at 8:17 PM, CNA #3 was asked, Does the facility have a call light system in use? She stated, No. We don't. CNA #3 was asked, How do you make sure the resident needs are being met? She stated, We check on them every 10-15 minutes. CNA #3 was asked, Is there a way for the residents to request assistance? She stated, Some of the residents have cell phones and they will call the front desk if they need help. CNA #3 was asked, Were you told the call lights weren't working? CNA #3 stated, Yes. CNA #3 was asked, When were you told the call lights weren't working? She stated, They were working on September (2020). I came back to work in January (2020), and they told me they weren't working then. CNA #3 was asked, Have you had any in-services on making rounds in the facility? CNA #3 stated, No. We haven't. c. On 01/20/21 at 9:07 PM, The Director of Nurses (DON) was asked, Is there a plan in place to assist the residents since the call lights aren't working? He stated, We've upped staffing per State Minimum to help make extra rounds on residents. The DON was asked, Has there been an in-service provided on Call lights not working/monitoring residents? He stated, No. Not official in-service, it's been all verbal. The DON was asked, Have you thought about using bells or something, so the residents can notify staff if they need help? He stated, It was brought up, but nothing is in place. 8. On 01/20/21 at 09:45 pm, Immediate Jeopardy was called and an extended survey was conducted. a. The facility's Plan of Removal written by the Administrator dated 01/20/21 was accepted at 10:30 pm. - All residents assessed by DON/Designee immediately. No negative findings. - All residents will be placed on 15-minute rounds and this will be documented. - All residents will be provided a bell to utilize until call light system is installed. - Any resident unable to utilize bells will have a 15-minute rounds until new call light system is installed. DON/Designee will determine which residents this applies to and in-service staff on those residents. - DON/Designee began in-servicing all current staff and will continue providing in-service training until 100% compliance. - New Nurse Call System installation is scheduled to begin at 0700am on 01/25/2021. 9. On 01/21/21 at 12:30 pm Observation of residents using bells to summon assistance. The bells will be used by residents until the call light system is installed. 10. A in-service dated 01/20 & (and)01/21 documenting the staff had been instructed on monitoring residents every 15 minutes and documentation of said monitoring. 11. On 01/21/21 at 01:30 pm, The Administrator was asked for a Call Light Policy/Procedure and was unavailable to provide it.

Complaint # (AR 953) was substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure that before a secure unit was initiated, the following measures were completed, to avoid the use of involuntary seclusion and / or unnecessary restriction of residents' freedom of movement and disruption of their routines and activities for 5 (Residents #1, #2, #3, #4 and #5) of 5 case mix residents who resided on the B Hall: Failure to develop a plan, with participation of the facility's Medical Director and interdisciplinary team (IDT), on how best to implement a secure unit and on the criteria that would be used to determine which residents exhibited the clinical indicators and / or behavioral symptoms that would necessitate admission to a secure unit; Failure to ensure all residents on the unit were assessed to determine if a secure unit was a necessary and appropriate intervention; Failure to ensure residents on the unit were allowed to participate in activities that were meaningful to them (such as church services) to prevent potential psychosocial harm, boredom, agitation and / or exacerbation of behaviors; Failure to ensure less restrictive measures were attempted for each resident prior to placing them on the secure unit; Failure to ensure staff who worked on the unit were trained on the appropriate interventions to address how to implement securing the unit, on the necessary monitoring of each resident's response, and on how to address behavioral symptoms exhibited by residents with dementia; and, Failure to ensure all residents and their responsible parties were notified in advance of the plan to convert the hall into a secure unit and that informed consent was obtained for each resident affected. The failed practices resulted in immediate jeopardy, which caused or could have caused serious psychological harm to Resident #1, who resided on the B Hall and was involuntarily secluded and restricted from moving freely about the facility, and had the potential to cause more than minimal harm to all 15 residents who resided on the B Hall, as documented on a list provided by the Administrator on 8/24/18. The facility removed the immediate jeopardy on 8/20/18, prior to the survey entrance date; however, the underlying failed practices remained uncorrected at the time of the survey. The Administrator was notified of the removed immediate jeopardy condition on 8/22/18 at 6:50 p.m. The findings are: 1. The facility's Abuse and Neglect Policy and Procedures, provided by the Administrator on 8/27/18, documented, .Healthcare Management shall protect residents from real or perceived abuse, negligence or exploitation from anyone . This policy did not address involuntary seclusion. 2. The Resident Rights Policy and Procedure, provided by the Administrator on 8/27/18, documented, Residents of Rehabilitation and Long Term Care Facilities have the rights that are guaranteed by the Federal Nursing Home Reform Law. The Law requires that we 'promote and protect the rights of each resident' and stresses individual dignity and self-determination. Freedom from abuse, neglect, exploitation and misappropriation of property . Ability of life is maintained or improved . Right to self-Determination, Choice of activities, schedules . Participate in developing and implementing a person-centered plan of care that incorporates personal and cultural preferences . Right to be fully informed . the type of care to be provided and risks and benefits of proposed treatments, changes to the plan of care or in medical or health status . 3. Resident #1 was admitted to the facility on [DATE], resided on the B Hall, and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/8/18 documented the resident scored 5 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS), was independent with bed mobility, transfers and ambulation, exhibited verbal behaviors directed towards others and rejection of care that occurred over 1 to 3 days and wandering that occurred daily, and had no functional limitation in range of motion. a. The Initial Activities Evaluation dated for 1/11/18 documented, Cognitive Short term memory seems or appears to recall after 5 minutes. Long Term memory, seems or appears to recall long past. Faith is important aspect of daily living. Socialization, Moderately social b. The Comprehensive Care Plan, not dated, documented, Problem Onset: 2/15/18 I am at risk for elopement . wear a Wanderguard. Goal & Target Plan, I will have no critical elopement over the next qrt (quarter) . Approaches . Monitor me for location frequently. Staff will be alert for alarm sounding and respond appropriately, provide activities of interest to keep me busy and involved, maintaining a calm, safe environment to help me feel secure . monitor placement of my Wanderguard. c. The Elopement assessment dated [DATE] documented the resident's elopement risk score was 40, with a score of 20-45 indicating a risk for elopement. A handwritten notation at the bottom of the page documented, .Order for Wanderguard in place. d. The Departmental Notes dated 8/15/18 through 8/19/18 documented the following: 8/15/18 at 11:15 a.m. - Resident resting on her bed / no signs symptoms of pain or discomfort. Resident alert to name only. Has not been up roaming this morning . 8/19/18 at 2:05 p.m. - Resident continues to attempt to go through closed doors. In and out of other residents' rooms on hall. Not easily redirected. e. Nurses Notes dated 8/19/18 and signed by Licensed Practical Nurse (LPN) #1 documented, At approximately 1420 (2:20 p.m.), this resident's daughter called the facility stating her father, which visited earlier this day, informed her there were 4 people physically restraining (Resident #1), keeping her from exiting the hall. The daughter then called back at approximately 1445 (2:45 p.m.) saying her father is now saying there were 2 people holding resident back, 2 more people were on the other side of the doors holding them as well. Daughter asked if a specific CNA (Certified Nursing Assistant) was on the hall at this time then responded her Mother 'don't get along'. She then stated, 'You can't tell my Mother what to do that is not going to work. That makes her agitated'. I informed the daughter I would speak with the CNAs @ (at) this time. There was no documentation to indicate LPN #1 reported this incident to administration or to the physician / Medical Director. f. A Resident Incident Report dated 8/19/18 at 4:00 p.m. documented, Daughter brought resident to Nurses Station concerned about areas on resident's left and right arm. Small purple discolored area to the right, lower forearm and a small purple discoloration to mid, left forearm found upon assessment. There was no reference to the aforementioned incident on this report, nor was there any documentation as to efforts to determine the cause of the bruising. g. The Office of Long Term Care (OLTC) Incident and Accident Report (I&A) dated 8/19/18 documented, .Date of Incident 8/19/18 a 1:33 p.m. Type of incident: Physical . The staff holding the door as the resident trying to leave area . Steps taken to prevent continued abuse or neglect during the investigation . Allow resident to leave area with supervision by staff . The facility is still in the process of the investigation . 1.) A Witness Statement dated 8/19/18 from CNA #1 documented, (Resident #1) was trying to get out of the door behind her husband. His statement to her was 'get your damn ass back' and raised his hand over the head and (Resident #1) stated to him 'don't hit me' and backup. I was hung between the two doors with both arms up, and the other CNA had to get her (resident) back. 2.) A Witness Statement dated 8/19/18 from CNA #2 documented, On 8/19/18 (Resident #1) was trying to get out the door behind her husband, his statement to her was 'get you damn ass back' and raised his hand over (CNA #1's) head with his fist balled up. (CNA #1) was hollering of (sic) help because (Resident #1) was trying to get past her (through the double doors on the B Hall) and had a hold of (CNA #1's) arm. When her husband raised his fist, (Resident #1) stated (to husband) 'Don't you hit me'. (Housekeeper #1) and me redirected (Resident #1) back away from the door so (CNA #1) could get back in . 3.) A Witness Statement dated 8/21/18 from Licensed Practical Nurse (LPN) #1 documented, I was sitting at the Nurses Station when I heard a voice crying 'Help' coming from B Hall. When I got to the hall, (Resident #1's husband) was walking towards the front. (CNA #1) was standing on B Hall as well. I walked (Resident #1's husband) to the front door. He stated he won't be coming back on a Sunday, then he exited the building. I returned to B Hall. (CNA #1) told me she was saying help because she was hung between the doors and (Resident #1) was trying to get out. At his time, (Resident #1) was in her room. CNA #1 told me that (Resident #1's husband) raised his hand at her. (Resident #1) stated 'Don't hit me'. 4.) The facility's written investigation did not include witness statements from Housekeeper #1, the Weekend Supervisor or any residents; however, the investigation was still in progress at the time of the survey. h. On 8/22/18 at 5:45 p.m., the facility's surveillance footage was viewed by the surveyor. The camera angle showed the outside of the double doors leading to the B Hall. The footage for 8/19/18 at approximately 4:00 p.m. showed Resident #1's husband leaving the B Hall through the double doors, which were closed. CNA #1 walked quickly to the door, stepped between Resident #1 and her husband, and faced the resident, blocking her from walking through the door with her husband. Resident #1's arm came over CNA #1's left shoulder as she attempted to get to her husband. CNA #1 blocked Resident #1 from exiting the B Hall. On 8/22/18 at 6:15 p.m., the Director of Nursing (DON) was asked, in reviewing the video, was (CNA #1) blocking (Resident #1) from exiting the double doors? The DON stated, Yes. The DON was asked if there was a reason CNA #1 was blocking the resident from leaving the B Hall and stated, No. The DON was asked, Did this increase the resident's anxiety? The DON stated, Yes. The DON was asked what instructions had been provided to staff on the B Hall and stated, The doors were supposed to be closed to see how the residents reacted to the doors being closed, and if the residents wanted to leave, they would be allowed to leave the hall. 4. Resident #2 was admitted to the facility on [DATE], resided on the B Hall, and had [DIAGNOSES REDACTED]. The Admission (MDS) with an ARD of 8/13/18 documented the resident scored 2 (0-7 indicates severe impairment) on a was independent with ambulation with supervision, and exhibited verbal behaviors directed towards others and wandering that occurred daily, and rejection of care that occurred every 1 to 3 days. a. Departmental Notes dated 8/11/18 documented, R (Resident) has Wanderguard in place ambulatory throughout the facility. Unable to be redirected, randomly using inappropriate language . Exit seeking at this time . b. The Comprehensive Care Plan, not dated, did not address the Wanderguard, but documented, Problem . I have inappropriate behaviors noted e.g. (for example) verbal aggression (curses) toward staff. Refuses care at times, wanders about the facility and will use the bathroom in inappropriate places. Delusional at times . Goal - I will not exhibit more than 3 episodes of inappropriate behaviors over the next QTR (quarter). Approaches . Gently redirect me to other activity. Be patient and take time to work with me. Provide a calm environment . 5. Resident #3 was admitted to the facility on [DATE], resided on the B Hall, and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/6/18 documented the resident scored 12 (8-12 indicates moderate impairment) on a BIMS; had no behavioral symptoms; and was independent with bed mobility, transfers, ambulation, and locomotion on and off the unit. The Departmental Notes dated 8/23/18 at 3:01 p.m. by the Social Service Director (SSD) documented, .the resident ambulates ad lib (as desired) but has a very unsteady gait . Resident is alert and oriented x (times) 3 most of the time, gets confused often, she has delusions at times . She is very paranoid at times . Resident is easily agitated. Likes to stay in room a lot in bed, but likes to sit in hall and Sun Room . 6. Resident #4 was admitted to the facility on [DATE], resided on the B Hall, and had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 8/6/18 documented the resident scored 2 (of 0-7 indicates severe impairment) on a BIMS, had no behavioral symptoms, and was independent with supervision for transfer and walking in room and corridor. Departmental Notes dated 8/23/18 documented the resident ambulates with assistance, and without assistance at times and, .in wheelchair, someone pushes her, she can propel self at times. She enjoys sitting in Sun Room . 7. Resident #5 was admitted to the facility on [DATE], resided on B Hall, and had [DIAGNOSES REDACTED]. The Admission Medicare 5-Day MDS with an ARD of 8/13/18 documented the resident scored 9 (8-12 indicates moderate impairment) on a BIMS, had no behavioral symptoms, and was independent with transfers ambulating in room, and required supervision of 1 person for ambulating in corridor. a. Departmental Note dated 8/8/18 documented, Wanderguard Bracelet placed to right ankle . b. The Comprehensive Care Plan, not dated, documented, Problem . I am at risk for elopement . I wear Wanderguard. Goal - I will have no critical elopement over the next QTR . Approaches . Monitor me for my location frequently, Provide activities of interest to keep me busy and involved, Maintain a calm safe environment to help me feel secure . Monitor placement of my Wanderguard. c. The Departmental Notes dated 8/23/18 documented, Resident ambulates freely with cane. 8. On 8/24/18 at 9:54 p.m., CNA #3 stated she had been employed with the facility for approximately 2 years and, I work on the B Hall; I do the showers now, for about 1 month. The CNA was asked, Have you had any Dementia training? The CNA stated, No. The CNA was asked, Did you work when the B Hall doors were closed? The CNA stated, Yes. The CNA was asked, What were you told when the doors were closed? The CNA stated, If the residents tried to get out, we were to detour them. The CNA was asked if a list of residents was provided to staff to inform them of which residents were to be prevented from leaving the 200 Hall or of residents who were allowed to leave the hall. The CNA stated, No. The CNA was asked, If a resident tried to get off the hall, what did you do? The CNA stated, We stood in front of the door and didn't allow them to leave. The CNA was asked, Were there any residents who tried to get off of the hall and that were not allowed to do so? The CNA stated, Yes, (Resident #1). The CNA was asked who stopped the resident and stated, Me and (CNA #4) stood in front of the door. (Resident #1) got agitated and hit (CNA #4) in the head with her cane. The CNA was asked, Who wanders on the B Hall? The CNA stated the names of Residents #1 and #2 and a non-case mix resident. The CNA was asked, Who gave you the instructions not to allow the residents to leave the B Hall? The CNA stated, The DON. 9. On 8/23/18 at 1:34 p.m., Licensed Practical Nurse (LPN) #2 stated she was assigned to half of the B Hall on Friday (8/17/18). The LPN was asked, What were you told about the doors being closed on the B Hall? She stated, I was told by the DON it was going to be a locked-down unit for the residents on the hall for their safety. The residents were to stay on the hall. The LPN was asked, You were told that the residents were stay on the hall? The LPN stated, Yes, they were not supposed to come off the hall. They were to stay on the hall, and if they tried to leave, they were to be redirected. The LPN was asked, if the residents on the B Hall tried to leave, were they prevented from doing so? The LPN stated, Yes. The LPN was asked if specific residents tried to leave the hall during that period and stated, Yes, (Resident #1). 10. On 8/24/18 at 10:18 a.m., the Administrator was asked, When were the doors on the B Hall actually closed? The Administrator stated, Wednesday afternoon (8/15/18). The Administrator was asked, Were you aware staff blocked the doors and prevented residents from leaving the hall at the direction of the DON? The Administrator stated, No, I wasn't aware . I was not aware of any instructions that the residents were not to leave the hall. I was not aware. 11. On 8/23/18 at 9:55 a.m., CNA #1 was interviewed via telephone. The CNA stated she had been employed with the facility for approximately [AGE] years and that she primarily worked on A Hall and B Hall. The CNA was asked if she could explain the events that took place with the double doors on the B Hall. The CNA stated, The morning was good, routine, go in after breakfast and opened the closet to get her (Resident #1's) fresh clothes. She had a bruise on her arm. I got her clothes and went down A Hall and reported a bruise to her Nurse. We were told there were only 6 residents that could leave the hall. The CNA was asked, Why were there were only certain residents who could leave the hall? The CNA stated, I don't know; that's what I was told when I came in to work on Saturday (8/18/18 - three days after the doors were initially closed). (Resident #1) was trying to get off the hall. At this time, I told her she was worrying and was trying to get out the back door. Another CNA came back with (Resident #1's) husband and went in the resident's room. I encountered that she was at the door (double doors on the B Hall). I ran down there, and the R was trying to get out. I got between them (husband and Resident #1). The husband was on the outside of the door. The husband reached over my head, 'don't bring your damn ass out of there'. That's when I hollered for help. That's when CNA #2 came out. The resident said, 'You better not hit me'. (Housekeeper #1) was standing inside the hall by the left door. The CNA was asked, Who was the resident talking to when she said, 'Don't hit me'? The CNA stated, The husband; she was looking up at her husband when she made that statement. The CNA was asked, Why were you not letting (Resident #1) off the hall? The CNA stated, I was told to redirect her back and not let her out of the doors. The CNA was asked, Did you touch the resident? The CNA stated, No, my arms were down, and her arms were extending out. My left arm was against the door that was closed, and the other arm was pushed up against the right side of the door that was open. I did not touch or grab the resident. The CNA was asked whose decision it was to close the doors on the B Hall and stated, I don't know who the decision was about the doors. When I got to work on Saturday (8/18/18), the doors were closed, and I was told by the 11-7 (11:00 p.m. to 7:00 a.m.) CNA that there was (sic) only 6 residents that could come off the halls. (Resident #1) was one that couldn't come off the hall. (Resident #1) made several attempts to go out the doors. The CNA was asked if she had any dementia training. The CNA stated, Just the in-services that we have had. The CNA was asked if there was any in-service that addressed how to deal with behaviors of residents with Dementia. The CNA stated, No. The CNA was asked, When you re-directed the residents, how was this done? The CNA stated, When we redirected the residents, 'let's sit down, let's go get a drink. The CNA was asked, Were there any activities planned for the residents? The CNA stated, No, they were not allowed to go out to the activities. The CNA was asked, There were no activities for the residents on the B Hall for the weekend? The CNA stated, No. 12. On 8/22/18 at 10:13 a.m., CNA #2 was interviewed via telephone. The CNA stated she had been employed with the facility for approximately 1 year and that she rotated halls. The CNA was asked if she worked on the B Hall on Saturday 8/18/18 and Sunday 8/19/18. The CNA stated Yes. The CNA was asked if she could explain what occurred that weekend and stated, The doors were closed and there were particular residents that were allowed out. (Resident #1) wasn't allowed to leave. I don't know why she wasn't able to leave. That's what we were told. (Resident's #1) husband was leaving, and she wanted to go with him. Since we were told we couldn't let her leave the hall, (CNA #1) was blocking the door and trying to redirect her . the resident got agitated and grabbed (CNA #1). Then me and (Housekeeper #1) tried to redirect her, and she wanted to go with her husband. The CNA was asked, Did any staff member grab the resident? The CNA stated, No, the husband screamed at her and cursed at her, 'Get your GD ass back in there' and the resident said, 'Don't hit me'. The CNA was asked who the resident was talking to and stated, I think the husband. The CNA was asked if she had received any Dementia training and stated, No actual training. The CNA was asked who gave staff the instructions that residents were not to leave the B hall. The CNA stated, The DON. 13. On 8/22/18 at 10:44 a.m., Registered Nurse (RN) #1 was interviewed via telephone. The RN stated she worked Friday through Sunday, 8/17/18 through 8/19/18. The RN was asked, Can you explain why the (B Hall) doors were closed? The RN stated, This was a Dementia Hall, and there are a few back there that come out. The RN was asked which residents were allowed to leave the hall and was able to verbalize the names of 5 non-case-mix residents. The RN was asked, Who gave you these instructions? The RN stated, The DON. The RN was asked, The DON gave you a list? The RN stated, Yes. The RN was asked, Was the B Hall a secure unit? The RN stated, It's a Dementia Hall. The RN was asked why some residents were not allowed to leave the hall and stated, They live on that hall, and they are used to that hall, and they were to stay on the hall. The RN was asked why Resident #1 was not allowed to go to church services and stated, They didn't tell me anything about that. The RN was asked, Have you had dementia training? The RN stated, I've been a nurse a long time in Long Term Care. I guess I would have to say 'No', since I don't know what you are talking about. The RN was asked about the incident involving Resident #1 and her husband on 8/19/18, but stated she did not witness the incident, nor was the incident reported to her. 14. On 8/23/18 at 1:10 p.m., RN #1 was again interviewed via telephone and was asked if she was provided with any documentation with regard to the B Hall. The RN stated, The DON told me a list of residents who could leave the hall. I wrote it on a scrap piece of paper, and I don't remember if I left it in the DON's office or at the Nurses Station. I worked Friday, Saturday and Sunday, and the doors were closed, not locked, but the residents were not supposed to leave the hall, except for the 6 residents that I was told by the DON (the RN was able to recall the 5 non-case mix residents whose names she provided to the surveyor in the previous interview). The RN also stated, There was a CNA that was sitting at the door in a chair and table, to keep the residents from exiting the hall. The RN was asked who told the CNA to sit at the door. The RN stated, She took it upon herself; I didn't tell her to sit there. I don't recall her name, but she had long pony tail. 15. On 8/23/18 at 3:05 p.m., Housekeeper #1 stated she had been employed with the facility for approximately 11 months. The Housekeeper was asked to explain the incident on the B hall that occurred on 8/19/18. The Housekeeper stated, (Resident #1) was trying to get off the hall, and the door was closed. (CNA #1) was trying to stop the resident from leaving the hall. 16. On 8/23/18 at 1:45 p.m., Resident #1's daughter (Daughter #1) stated the Administrator had spoken to her about the B Hall becoming a secured unit for residents with Dementia and wandering behaviors and, They did tell me that they were going to close the doors to see how the residents responded. I told them that was fine, but if my Mother wanted to leave the hall, she would be allowed, because she was used to walking freely around the facility. Then the incident happened with my Father. He drove from the facility directly to my house. He was very upset over the incident that had happened. When he was leaving and they stopped Mom from leaving the hall, they were holding her. There were 2 on one side of the door and 2 on the other side. It was horrible. He was very upset. I called my sister (Daughter #2), and she said she was in the parking lot and went in. She called me and told me that Mom had a bruise on her left arm and it looked like a handprint . 17. On 8/23/18 at 10:38 a.m., the Administrator was asked if the facility had provided dementia training for dealing with resident behaviors prior to converting the B Hall to a secure hall. The Administrator stated, We are working on training; they were just in the process of the B Hall becoming a secure unit, and they closed the door to see how the residents would respond to a closed door. The Administrator was again asked if there was any training for the staff on dealing with Dementia-related behaviors. The Administrator stated, We are just in the planning stages, but no, we had not done the training before the doors were closed. The doors were just supposed to have been closed to see how the residents reacted to the doors being closed; if they wanted to leave the hall, they were supposed to be allowed to leave the B Hall. The Administrator was asked, Whose decision was it to prevent residents from exiting the B Hall when the doors were closed? The Administrator stated, I was not aware the residents were not allowed to leave the hall until I arrived at the facility on Monday morning (8/20/18), and we opened the doors immediately. 18. On 8/23/18 at 2:45 p.m., the Medical Director was asked about the incident with Resident #1 that occurred on 8/19/18. The Medical Director stated he was called regarding the area on (Resident #1's) arms and, .it appeared to be an area that the elderly residents get, Senile Purpura, just a purple area. The Medical Director was asked about implementation of the B Hall as a secure unit and stated he had been informed that, .they were thinking about making the B Hall a secured unit, but I was not aware of the plans to close the doors (on 8/15/18). The MD was asked if he was involved any of the planning to make the B Hall a secure unit and stated, No. 19. On 8/23/18 at 5:10 p.m., the Administrator was asked if the facility had any documentation regarding any plans they had developed to make the B Hall a secured unit, prior to the doors being closed on the B Hall. The Administrator stated, No. The Administrator was asked, Did the facility develop any policies and procedures prior to the B Hall doors being closed? The Administrator stated No. The Administrator was asked, Did the facility do any training with the staff prior to the B Hall doors being closed? The Administrator stated. No. The Administrator was asked if the families on the B Hall were notified that the doors were being closed and of the plans to convert the B Hall into a secure unit. The Administrator stated, Only (Resident #1) and (one non-case mix resident). (Resident #1's) family stated it was okay as long as if (Resident #1) wanted to leave, she would be allowed to leave. The Administrator was asked if there were any instructions given to the staff on how the closure of the B Hall doors should be implemented and stated, No. The Administrator was asked if any plans for activities were made for the residents on B Hall for the dates (8/15/18 through 8/20/18) that the B Hall was used as a secure unit. The Administrator stated, No. The Administrator was again asked about the list of 6 residents who were allowed to leave the hall and stated, I was not aware of anyone being told that there were only 6 residents who were allowed to leave the hall. The Administrator was informed of the multiple staff interviews that indicated staff were instructed by the DON on which residents were allowed to leave the hall and that the other 9 residents on the hall were not allowed to leave the hall. The Administrator stated, I was not aware. The Administrator was asked about Resident #1 missing church services on Sunday because there was no staff available to accompany her. The Administrator stated, I was not aware. 20. On 8/23/18 at 10:24 a.m., the DON was asked who made the decision for the B Hall doors to be closed last week. The DON stated, The Administrator, but the residents were to be free to leave the hall. The DON was asked who determined that there were only 6 residents who could leave the hall. The DON stated. I don't know; the doors were closed, but the residents could freely leave. I don't know who the 6 residents were who could leave the hall. I was not aware that there were only 6 residents who they said could leave the hall. The DON was asked if she had given any instructions to staff that residents were not allowed to leave the hall. The DON stated, No, I did not; I told them that the doors were just supposed to be closed, and the residents were supposed to leave the hall, just to be closed to see how the residents responded to the closed doors. The Administrator told them the same thing. The DON was asked why Resident #1 was not allowed to leave the hall and attend church services and stated, I was not aware of that. 21. The facility removed the immediate jeopardy on 8/20/18 and reduced the scope/severity to H when the doors to B Hall were opened and residents were again allowed to move freely about the facility, and an investigation was initiated. The facility remained in the 5-day regulatory investigative window at the time of the survey. A statement from the facility titled, Investigation Report Detail, received on 8/26/18 at 4:20 p.m., documented, .Plan: On Monday, (MONTH) 20, (YEAR) the doors to the B-hall were opened as they were before Wednesday, (MONTH) 15, (YEAR) . Plans for a 'special care' unit were dismissed, and the doors to B-hall have remained open . There are no plans for a 'special care' unit or 'lock down' unit to be created. Other means will used to provide person-centered care and one-on-one time with residents with Alzheimer's/Dementia and other cognitive impairments. Staff will be educated on dementia management and abuse preventing . After facility investigation of incident on Sunday, (MONTH) 19, (YEAR) regarding a certified nursing assistant allegedly 'physically restraining' a resident, it has been determined that both certified nursing assistants associated with incident have suspended. In-services began on Monday, (MONTH) 20, (YEAR) on abuse and neglect and resident rights and will continue until 100% compliance is achieved . As well as in-service the staff that the doors to all halls are to remain open .

Complaint # (AR 953) was substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility's administration and nursing administration failed to identify the potential risks and necessary staff training and resident care involved in implementation of a secure unit and failed to ensure that before a secure unit was implemented, the following measures were completed, to avoid the use of involuntary seclusion and / or unnecessary restriction of residents' freedom of movement and disruption of their routines and activities for 5 (Residents #1, #2, #3, #4 and #5) of 5 case mix residents who resided on the B Hall: Failure to develop a plan, with participation of the facility's Medical Director and interdisciplinary team (IDT), on how best to implement a secure unit and on the criteria that would be used to determine which residents exhibited the clinical indicators and / or behavioral symptoms that would necessitate admission to a secure unit; Failure to ensure all residents on the unit were assessed to determine if a secure unit was a necessary and appropriate intervention; Failure to ensure all residents on the unit were allowed to participate in activities (such as church services) to prevent potential psychosocial harm and minimize boredom, agitation and exacerbation of behaviors; Failure to ensure less restrictive measures were attempted for each resident on the unit prior to placing them on the secure unit; Failure to ensure staff who worked on the unit were trained on the appropriate interventions to address how to implement securing the unit, on the necessary monitoring of each resident's response, and on how to address behavioral symptoms exhibited by residents with dementia; and, Failure to ensure all residents and their responsible parties were notified in advance of the plan to convert the hall into a secure unit and that informed consent was obtained for each resident affected. The failed practices resulted in immediate jeopardy, which caused or could have caused serious psychological harm to Residents #1 through #5, who resided on the B Hall and were involuntarily secluded and restricted from moving freely about the facility, and had the potential to cause more than minimal harm to all 15 residents who resided on the B Hall, as documented on a list provided by the Administrator on 8/24/18. The facility removed the immediate jeopardy on 8/20/18, prior to the survey entrance date; however, the underlying failed practices remained uncorrected at the time of the survey. The Administrator was notified of the removed immediate jeopardy condition on 8/22/18 at 6:50 p.m. The findings are: 1. The facility's Abuse and Neglect Policy and Procedures, provided by the Administrator on 8/27/18, documented, .Healthcare Management shall protect residents from real or perceived abuse, negligence or exploitation from anyone . This policy did not address involuntary seclusion. 2. The Resident Rights Policy and Procedure, provided by the Administrator on 8/27/18, documented, Residents of Rehabilitation and Long Term Care Facilities have the rights that are guaranteed by the Federal Nursing Home Reform Law. The Law requires that we 'promote and protect the rights of each resident' and stresses individual dignity and self-determination. Freedom from abuse, neglect, exploitation and misappropriation of property . Ability of life is maintained or improved . Right to self-Determination, Choice of activities, schedules . Participate in developing and implementing a person-centered plan of care that incorporates personal and cultural preferences . Right to be fully informed . the type of care to be provided and risks and benefits of proposed treatments, changes to the plan of care or in medical or health status . 3. Resident #1 was admitted to the facility on [DATE], resided on the B Hall, and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/8/18 documented the resident scored 5 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS), was independent with bed mobility, transfers and ambulation, exhibited verbal behaviors directed towards others and rejection of care that occurred over 1 to 3 days and wandering that occurred daily, and had no functional limitation in range of motion. a. The Comprehensive Care Plan, not dated, documented, Problem, I am at risk for elopement . wear a Wanderguard. Goal & Target Plan, I will have no critical elopement over the next qrt (quarter) . Approaches . Monitor me for location frequently. Staff will be alert for alarm sounding and respond appropriately, provide activities of interest to keep me busy and involved, maintaining a calm, safe environment to help me feel secure . monitor placement of my Wanderguard. b. The Elopement assessment dated [DATE] documented the resident's elopement risk score was 40, with a score of 20-45 indicating a risk for elopement. A handwritten notation at the bottom of the page documented, .Order for Wanderguard in place. c. The Departmental Notes dated 8/15/18 through 8/19/18 documented the following: 8/15/18 at 11:15 a.m. - Resident resting on her bed / no signs symptoms of pain or discomfort. Resident alert to name only. Has not been up roaming this morning . 8/19/18 at 2:05 p.m. - Resident continues to attempt to go through closed doors. In and out of other residents' rooms on hall. Not easily redirected. d. Nurses Notes dated 8/19/18 and signed by Licensed Practical Nurse (LPN) #1 documented, At approximately 1420 (2:20 p.m.), this resident's daughter called the facility stating her father, which visited earlier this day, informed her there were 4 people physically restraining (Resident #1), keeping her from exiting the hall. The daughter then called back at approximately 1445 (2:45 p.m.) saying her father is now saying there were 2 people holding resident back, 2 more people were on the other side of the doors holding them as well. Daughter asked if a specific CNA (Certified Nursing Assistant) was on the hall at this time then responded her Mother 'don't get along'. She then stated, 'You can't tell my Mother what to do that is not going to work. That makes her agitated'. I informed the daughter I would speak with the CNAs @ (at) this time. There was no documentation to indicate LPN #1 reported this incident to administration or to the physician / Medical Director. e. A Resident Incident Report dated 8/19/18 at 4:00 p.m. documented, Daughter brought resident to Nurses Station concerned about areas on resident's left and right arm. Small purple discolored area to the right, lower forearm and a small purple discoloration to mid, left forearm found upon assessment. There was no reference to the aforementioned incident on this report, nor was there any documentation as to efforts to determine the cause of the bruising. f. The Office of Long Term Care (OLTC) Incident and Accident Report (I&A) dated 8/19/18 documented, .Date of Incident 8/19/18 a 1:33 p.m. Type of incident: Physical . The staff holding the door as the resident trying to leave area . Steps taken to prevent continued abuse or neglect during the investigation . Allow resident to leave area with supervision by staff . The facility is still in the process of the investigation . 1.) A Witness Statement dated 8/19/18 from CNA #1 documented, (Resident #1) was trying to get out of the door behind her husband. His statement to her was 'get your damn ass back' and raised his hand over the head and (Resident #1) stated to him 'don't hit me' and backup. I was hung between the two doors with both arms up, and the other CNA had to get her (resident) back. 2.) A Witness Statement dated 8/19/18 from CNA #2 documented, (Resident #1) was trying to get out the door behind her husband, his statement to her was 'get you damn ass back' and raised his hand over (CNA #1's) head with his fist balled up. (CNA #1) was hollering of (sic) help because (Resident #1) was trying to get past her (through the double doors on the B Hall) and had a hold of (CNA #1's) arm. When her husband raised his fist, (Resident #1) stated (to husband) 'Don't you hit me'. (Housekeeper #1) and me redirected (Resident #1) back away from the door so (CNA #1) could get back in . 3.) A Witness Statement dated 8/21/18 from Licensed Practical Nurse (LPN) #1 documented, I was sitting at the Nurses Station when I heard a voice crying 'Help' coming from B Hall. When I got to the hall, (Resident #1's husband) was walking towards the front. (CNA #1) was standing on B Hall as well. I walked (Resident #1's husband) to the front door. He stated he won't be coming back on a Sunday, then he exited the building. I returned to B Hall. (CNA #1) told me she was saying help because she was hung between the doors and (Resident #1) was trying to get out. At his time, (Resident #1) was in her room. CNA #1 told me that (Resident #1's husband) raised his hand at her. (Resident #1) stated 'Don't hit me'. 4.) The facility's written investigation did not include witness statements from Housekeeper #1, the Weekend Supervisor or any residents; however, the investigation was still in progress at the time of the survey. g. On 8/22/18 at 5:45 p.m., the facility's surveillance footage was viewed by the surveyor. The camera angle showed the outside of the double doors leading to the B Hall. The footage for 8/19/18 at approximately 4:00 p.m. Resident #1's husband leaving the B Hall through the double doors, which were closed. CNA #1 walked quickly to the door, stepped between Resident #1 and her husband, and faced the resident, blocking her from walking through the door with her husband. Resident #1's arm came over CNA #1's left shoulder as she attempted to get to her husband. CNA #1 blocked Resident #1 from exiting the B Hall. On 8/22/18 at 6:15 p.m., the Director of Nursing (DON) was asked, in reviewing the video, was (CNA #1) blocking (Resident #1) from exiting the double doors? The DON stated, Yes. The DON was asked if there was a reason CNA #1 was blocking the resident from leaving the B Hall and stated, No. The DON was asked, Did this increase the resident's anxiety? The DON stated, Yes. The DON was asked what instructions had been provided to staff on the B Hall and stated, The doors were supposed to be closed to see how the residents reacted to the doors being closed, and if the residents wanted to leave, they would be allowed to leave the hall. 4. Resident #2 was admitted to the facility on [DATE], resided on the B Hall, and had [DIAGNOSES REDACTED]. The Admission (MDS) with an ARD of 8/13/18 documented the resident scored 2 (0-7 indicates severe impairment) on the BIMS, was independent with ambulation with supervision, and exhibited verbal behaviors directed towards others, rejection of care and exhibited verbal behaviors directed towards others and wandering that occurred daily, and rejection of care that occurred every 1 to 3 days. a. Departmental Notes dated 8/11/18 documented, R (Resident) has Wanderguard in place ambulatory throughout the facility. Unable to be redirected, randomly using inappropriate language . Exit seeking at this time . b. The Comprehensive Care Plan, not dated, did not address the Wanderguard, but documented, Problem . I have inappropriate behaviors noted e.g. (for example) verbal aggression (curses) toward staff. Refuses care at times, wanders about the facility and will use the bathroom in inappropriate places. Delusional at times . Goal - I will not exhibit more than 3 episodes of inappropriate behaviors over the next QTR (quarter). Approaches . Gently redirect me to other activity. Be patient and take time to work with me. Provide a calm environment . 5. Resident #3 was admitted to the facility on [DATE], resided on the B Hall, and had [DIAGNOSES REDACTED]. The Quarterly MDS with an (ARD of 8/6/18 documented the resident scored 12 (8-12 indicates moderate impairment) on a BIMS, had no behavioral symptoms, and was independent with bed mobility transfers, ambulation, and locomotion on and off the unit. The Departmental Notes dated 8/23/18 at 3:01 p.m. by the Social Service Director (SSD) documented, .the resident ambulates ad lib (as desired) but has a very unsteady gait . Resident is alert and oriented x (times) 3 most of the time, gets confused often, she has delusions at times . She is very paranoid at times . Resident is easily agitated. Likes to stay in room a lot in bed, but likes to sit in hall and Sun Room . 6. Resident #4 was admitted to the facility on [DATE], resided on the B Hall, and had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 8/6/18 documented the resident scored 2 (of 0-7 indicates severe impairment) on a BIMS, had no behavioral symptoms, and was independent with supervision for transfer and walking in room and corridor. Departmental Notes dated 8/23/18 documented the resident ambulates with assistance, and without assistance at times and, .in wheelchair, someone pushes her, she can propel self at times. She enjoys sitting in Sun Room . 7. Resident #5 was admitted to the facility on [DATE], resided on B Hall, and had [DIAGNOSES REDACTED]. The Admission Medicare 5-Day MDS with an ARD of 8/13/18 documented the resident scored 9 (8-12 indicates moderate impairment) on a BIMS, had no behavioral symptoms, and was independent with transfers ambulating in room, and required supervision of 1 person for ambulating in corridor. a. Departmental Note dated 8/8/18 documented, Wanderguard Bracelet placed to right ankle . b. The Comprehensive Care Plan, not dated, documented, Problem . I am at risk for elopement . I wear Wanderguard. Goal - I will have no critical elopement over the next QTR . Approaches . Monitor me for my location frequently, Provide activities of interest to keep me busy and involved, Maintain a calm safe environment to help me feel secure . Monitor placement of my Wanderguard. c. The Departmental Notes dated 8/23/18 documented, Resident ambulates freely with cane. 8. On 8/24/18 at 9:54 p.m., CNA #3 stated she had been employed with the facility for approximately 2 years and, I work on the B Hall; I do the showers now, for about 1 month. The CNA was asked, Have you had any Dementia training? The CNA stated, No. The CNA was asked, Did you work when the B Hall doors were closed? The CNA stated, Yes. The CNA was asked, What were you told when the doors were closed? The CNA stated, If the residents tried to get out, we were to detour them. The CNA was asked if a list of residents was provided to staff to inform them of which residents were to be prevented from leaving the 200 Hall or of residents who were allowed to leave the hall. The CNA stated, No. The CNA was asked, If a resident tried to get off the hall, what did you do? The CNA stated, We stood in front of the door and didn't allow them to leave. The CNA was asked, Were there any residents who tried to get off of the hall and that were not allowed to do so? The CNA stated, Yes, (Resident #1). The CNA was asked who stopped the resident and stated, Me and (CNA #4) stood in front of the door. (Resident #1) got agitated and hit (CNA #4) in the head with her cane. The CNA was asked, Who wanders on the B Hall? The CNA stated the names of Residents #1 and #2 and a non-case mix resident. The CNA was asked, Who gave you the instructions not to allow the residents to leave the B Hall? The CNA stated. The DON. 9. On 8/23/18 at 1:34 p.m., Licensed Practical Nurse (LPN) #2 stated she was assigned to half of the B Hall on Friday (8/17/18). The LPN was asked, What were you told about the doors being closed on the B Hall? She stated, I was told by the DON it was going to be a locked-down unit for the residents on the hall for their safety. The residents were to stay on the hall. The LPN was asked, You were told that the residents were stay on the hall? The LPN stated, Yes, they were not supposed to come off the hall. They were to stay on the hall, and if they tried to leave, they were to be redirected. The LPN was asked, if the residents on the B Hall tried to leave, were they prevented from doing so? The LPN stated, Yes. The LPN was asked if specific residents tried to leave the hall during that period and stated, Yes, (Resident #1). 10. On 8/24/18 at 10:18 a.m., the Administrator was asked, When were the doors on the B Hall actually closed? The Administrator stated, Wednesday afternoon (8/15/18). The Administrator was asked, Were you aware staff blocked the doors and prevented residents from leaving the hall at the direction of the DON? The Administrator stated No, I wasn't aware . I was not aware of any instructions that the residents were not to leave the hall. I was not aware. 11. On 8/23/18 at 9:55 a.m., CNA #1 was interviewed via telephone. The CNA stated she had been employed with the facility for approximately [AGE] years and that she primarily worked on A Hall and B Hall. The CNA was asked if she could explain the events that took place with the double doors on the B Hall. The CNA stated, The morning was good, routine, go in after breakfast and opened the closet to get her (Resident #1's) fresh clothes. She had a bruise on her arm. I got her clothes and went down A Hall and reported a bruise to her Nurse. We were told there were only 6 residents that could leave the hall. The CNA was asked, Why were there were only certain residents who could leave the hall? The CNA stated, I don't know; that's what I was told when I came in to work on Saturday (8/18/18 - three days after the doors were initially closed). (Resident #1) was trying to get off the hall. At this time, I told her she was worrying and was trying to get out the back door. Another CNA came back with (Resident #1's) husband and went in the resident's room. I encountered that she was at the door (double doors on the B Hall). I ran down there, and the R was trying to get out. I got between them (husband and Resident #1). The husband was on the outside of the door. The husband reached over my head, 'don't bring your damn ass out of there'. That's when I hollered for help. That's when CNA #2 came out. The resident said, 'You better not hit me'. (Housekeeper #1) was standing inside the hall by the left door. The CNA was asked, Who was the resident talking to when she said, 'Don't hit me'? The CNA stated, The husband; she was looking up at her husband when she made that statement. The CNA was asked, Why were you not letting (Resident #1) off the hall? The CNA stated, I was told to redirect her back and not let her out of the doors. The CNA was asked, Did you touch the resident? The CNA stated, No, my arms were down, and her arms were extending out. My left arm was against the door that was closed, and the other arm was pushed up against the right side of the door that was open. I did not touch or grab the resident. The CNA was asked whose decision it was to close the doors on the B Hall and stated, I don't know who the decision was about the doors. When I got to work on Saturday (8/18/18), the doors were closed, and I was told by the 11-7 (11:00 p.m. to 7:00 a.m.) CNA that there was (sic) only 6 residents that could come off the halls. (Resident #1) was one that couldn't come off the hall. (Resident #1) made several attempts to go out the doors. The CNA was asked if she had any dementia training. The CNA stated, Just the in-services that we have had. The CNA was asked if there was any in-service that addressed how to deal with behaviors of residents with Dementia. The CNA stated, No. The CNA was asked, When you re-directed the residents, how was this done? The CNA stated, When we redirected the residents, 'let's sit down, let's go get a drink. The CNA was asked, Were there any activities planned for the residents? The CNA stated, No, they were not? allowed to go out to the activities. The CNA was asked, There were no activities for the residents on the B Hall for the weekend? The CNA stated, No. 12. On 8/22/18 at 10:13 a.m., CNA #2 was interviewed via telephone. The CNA stated she had been employed with the facility for approximately 1 year and that she rotated halls. The CNA was asked if she worked on the B Hall on Saturday 8/18/18 and Sunday 8/19/18. The CNA stated Yes. The CNA was asked if she could explain what occurred that weekend and stated, The doors were closed and there were particular residents that were allowed out. (Resident #1) wasn't allowed to leave. I don't know why she wasn't able to leave. That's what we were told. (Resident's #1) husband was leaving, and she wanted to go with him. Since we were told we couldn't let her leave the hall, (CNA #1) was blocking the door and trying to redirect her . the resident got agitated and grabbed (CNA #1). Then me and (Housekeeper #1) tried to redirect her, and she wanted to go with her husband. The CNA was asked, Did any staff member grab the resident? The CNA stated, No, the husband screamed at her and cursed at her, 'Get your GD ass back in there' and the resident said, 'Don't hit me'. The CNA was asked who the resident was talking to and stated, I think the husband. The CNA was asked if she had received any Dementia training and stated, No actual training. The CNA was asked who gave staff the instructions that residents were not to leave the B hall. The CNA stated, The DON. 13. On 8/22/18 at 10:44 a.m., Registered Nurse (RN) #1 was interviewed via telephone. The RN stated she worked Friday through Sunday, 8/17/18 through 8/19/18. The RN was asked, Can you explain why the (B Hall) doors were closed? The RN stated, This was a Dementia Hall, and there are a few back there that come out. The RN was asked which residents were allowed to leave the hall and was able to verbalize the names of 5 non-case-mix residents. The RN was asked, Who gave you these instructions? The RN stated, The DON. The RN was asked, The DON gave you a list? The RN stated, Yes. The RN was asked, Was the B Hall a secure unit? The RN stated, It's a Dementia Hall. The RN was asked why some residents were not allowed to leave the hall and stated, They live on that hall, and they are used to that hall, and they were to stay on the hall. The RN was asked why Resident #1 was not allowed to go to church services and stated, They didn't tell me anything about that. The RN was asked, Have you had dementia training? The RN stated, I've been a nurse a long time in Long Term Care. I guess I would have to say 'No', since I don't know what you are talking about. The RN was asked about the incident involving Resident #1 and her husband on 8/19/18, but stated she did not witness the incident, nor was the incident reported to her. 14. On 8/23/18 at 1:10 p.m., RN #1 was again interviewed via telephone and was asked if she was provided with any documentation with regard to the B Hall. The RN stated, The DON told me a list of residents who could leave the hall. I wrote it on a scrap piece of paper, and I don't remember if I left it in the DON's office or at the Nurses Station. I worked Friday, Saturday and Sunday, and the doors were closed, not locked, but the residents were not supposed to leave the hall, except for the 6 residents that I was told by the DON (the RN was able to recall the 5 non-case mix residents whose names she provided to the surveyor in the previous interview). The RN also stated, There was a CNA that was sitting at the door in a chair and table, to keep the residents from exiting the hall. The RN was asked who told the CNA to sit at the door. The RN stated, She took it upon herself; I didn't tell her to sit there. I don't recall her name, but she had long pony tail. 15. On 8/23/18 at 3:05 p.m., Housekeeper #1 stated she had been employed with the facility for approximately 11 months. The Housekeeper was asked to explain the incident on the B hall that occurred on 8/19/18. The Housekeeper stated, (Resident #1) was trying to get off the hall, and the door was closed. (CNA #1) was trying to stop the resident from leaving the hall. 16. On 8/23/18 at 1:45 p.m., Resident #1's daughter (Daughter #1) stated the Administrator had spoken to her about the B Hall becoming a secured unit for residents with Dementia and wandering behaviors and, They did tell me that they were going to close the doors to see how the residents responded. I told them that was fine, but if my Mother wanted to leave the hall, she would be allowed, because she was used to walking freely around the facility. Then the incident happened with my Father. He drove from the facility directly to my house. He was very upset over the incident that had happened. When he was leaving and they stopped Mom from leaving the hall, they were holding her. There were 2 on one side of the door and 2 on the other side. It was horrible. He was very upset. I called my sister (Daughter #2), and she said she was in the parking lot and went in. She called me and told me that Mom had a bruise on her left arm and it looked like a handprint . 17. On 8/23/18 at 10:38 a.m., the Administrator was asked if the facility had provided dementia training for dealing with resident behaviors prior to converting the B Hall to a secure hall. The Administrator stated, We are working on training; they were just in the process of the B Hall becoming a secure unit, and they closed the door to see how the residents would respond to a closed door. The Administrator was again asked if there was any training for the staff on dealing with Dementia-related behaviors. The Administrator stated, We are just in the planning stages, but no, we had not done the training before the doors were closed. The doors were just supposed to have been closed to see how the residents reacted to the doors being closed; if they wanted to leave the hall, they were supposed to be allowed to leave the B Hall. The Administrator was asked, Whose decision was it to prevent residents from exiting the B Hall when the doors were closed? The Administrator stated, I was not aware the residents were not allowed to leave the hall until I arrived at the facility on Monday morning (8/20/18), and we opened the doors immediately. 18. On 8/23/18 at 2:45 p.m., the Medical Director was asked about the incident with Resident #1 that occurred on 8/19/18. The Medical Director stated he was called regarding the area on (Resident #1's) arms and, .it appeared to be an area that the elderly residents get, Senile Purpura, just a purple area. The Medical Director was asked about implementation of the B Hall as a secure unit and stated he had been informed that, .they were thinking about making the B Hall a secured unit, but I was not aware of the plans to close the doors (on 8/15/18). The MD was asked if he was involved any of the planning to make the B Hall a secure unit and stated, No. 19. On 8/23/18 at 5:10 p.m., the Administrator was asked if the facility had any documentation regarding any plans they had developed to make the B Hall a secured unit, prior to the doors being closed on the B Hall. The Administrator stated, No. The Administrator was asked, Did the facility develop any policies and procedures prior to the B Hall doors being closed? The Administrator stated No. The Administrator was asked, Did the facility do any training with the staff prior to the B Hall doors being closed? The Administrator stated. No. The Administrator was asked if the families on the B Hall were notified that the doors were being closed and of the plans to convert the B Hall into a secure unit. The Administrator stated, Only (Resident #1) and (one non-case mix resident). (Resident #1's) family stated it was okay as long as if (Resident #1) wanted to leave, she would be allowed to leave. The Administrator was asked if there were any instructions given to the staff on how the closure of the B Hall doors should be implemented and stated, No. The Administrator was asked if any plans for activities were made for the residents on B Hall for the dates (8/15/18 through 8/20/18) that the B Hall was used as a secure unit. The Administrator stated, No. The Administrator was again asked about the list of 6 residents who were allowed to leave the hall and stated, I was not aware of anyone being told that there were only 6 residents who were allowed to leave the hall. The Administrator was informed of the multiple staff interviews that indicated staff were instructed by the DON on which residents were allowed to leave the hall and that the other 9 residents on the hall were not allowed to leave the hall. The Administrator stated, I was not aware. The Administrator was asked about Resident #1 missing church services on Sunday because there was no staff available to accompany her. The Administrator stated, I was not aware. 20. On 8/23/18 at 10:24 a.m., the DON was asked who made the decision for the B Hall doors to be closed last week. The DON stated, The Administrator, but the residents were to be free to leave the hall. The DON was asked who determined that there were only 6 residents who could leave the hall. The DON stated. I don't know; the doors were closed, but the residents could freely leave. I don't know who the 6 residents were who could leave the hall. I was not aware that there were only 6 residents who they said could leave the hall. The DON was asked if she had given any instructions to staff that residents were not allowed to leave the hall. The DON stated, No, I did not; I told them that the doors were just supposed to be closed, and the residents were supposed to leave the hall, just to be closed to see how the residents responded to the closed doors. The Administrator told them the same thing. The DON was asked why Resident #1 was not allowed to leave the hall and attend church services and stated, I was not aware of that. 21. The facility removed the immediate jeopardy on 8/20/18 and reduced the scope/severity to H when the doors to B Hall were opened and residents were again allowed to move freely about the facility, and an investigation was initiated. The facility remained in the 5-day regulatory investigative window at the time of the survey. A statement from the facility titled, Investigation Report Detail, received on 8/26/18 at 4:20 p.m., documented, .Plan: On Monday, (MONTH) 20, (YEAR) the doors to the B-hall were opened as they were before Wednesday, (MONTH) 15, (YEAR) . Plans for a 'special care' unit were dismissed, and the doors to B-hall have remained open . There are no plans for a 'special care' unit or 'lock down' unit to be created. Other means will used to provide person-centered care and one-on-one time with residents with Alzheimer's/Dementia and other cognitive impairments. Staff will be educated on dementia management and abuse preventing . After facility investigation of incident on Sunday, (MONTH) 19, (YEAR) regarding a certified nursing assistant allegedly 'physically restraining' a resident, it has been determined that both certified nursing assistants associated with incident have suspended. In-services began on Monday, (MONTH) 20, (YEAR) on abuse and neglect and resident rights and will continue until 100% compliance is achieved . As well as in-service the staff that the doors to all halls are to remain open .

Complaint # (AR 637) was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure Administration and Nursing had a system in place to ensure there was a thorough investigation of an incident of alcohol poisoning for 1 (Resident #6) of (Residents #1, #6 through #15) case mix residents who consumed alcohol, alcoholic beverages were not permitted without a physician conducting a review of resident's conditions/medications for contraindications regarding alcohol consumption, physician orders [REDACTED].#1, #6 through #15) case mix residents who were provided alcoholic beverages by staff, failed to monitor resident possession/usage of alcohol in resident rooms, and failed to investigate and intervene when staff reported suspicions of alcohol use in resident rooms. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #6 who was hospitalized for [REDACTED].#1 and 7-15 who currently consumed alcohol in the facility according to a list provided by the Administrator on 11/19/14 at 4:31 p.m. The Administrator was informed of the Immediate Jeopardy 11/20/14 at 12:50 p.m. The findings are: 1. The Job Description of the Administrator received from the Administrator 11/21/14 at 12:05 p.m. documented, "The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long term care facilities to assure that the highest degree of quality care can be provided to our patients at all times...Administrative functions: Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities. Maintain written policies and procedures that govern the operation of the facility... Miscellaneous Functions: Ensure that all patients receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other patients." 2. The Job Description of the Director of Nursing Services received from the Administrator on 11/21/14 at 12:05 p.m. documented, "The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility...Administrative Functions: Plan, develop, organize, implement, evaluate, and direct the nursing services department as well as its programs and activities. Maintain written policies and procedures that govern the day to day functions of the nursing service department and ensure that personnel comply with such policies and procedures." 3. Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/7/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and was independent in all activities of daily living with set up help and supervision for eating and bathing. a. A form provided by the Administrator on 11/18/14 at 3:00 p.m. documented, "7/30/14 - Dear family members, (Facility) would like to start having Happy hour for our Residents weekly. By signing below you are in agreement with Happy Hour for your family member." This form was signed by the resident, who is her own responsible party. b. A Nurse's Note dated 10/8/14 at 4:30 p.m. and signed by Licensed Practical Nurse (LPN) #2 documented, "Upon entering resident's room, resident was unresponsive to attempts to wake her. Fingerstick blood sugar 311. No response to fingerstick. DON (Director Nursing) notified of condition. (Physician) notified. Order received to send to ER (emergency room )... At 2 PM (earlier)resident was alert, awake, drank a coke float, talked to staff member." c. A Hospital Patient Care Timeline dated 10/8/14 documented, "[MEDICATION NAME] Resulted: 0.194 (0.151 to 0.200 g/dl - Moderate to severe poisoning...)..." A Hospital Emergency Department Note dated 10/8/14 documented, "Since altered mental status was thought to be due to her alcohol intake, we monitored her in the ER and her vital signs remained stable so I think she can sleep off her bender at the nursing home." d. A Nurse's Note dated 10/9/14 at 4:42 p.m. documented, "Spoke with resident's mother related alcoholic intake. Mother reported this resident will drink until she blacks out... Repeatedly request for alcoholic beverage..." e. A Physician order [REDACTED]. f. On 11/19/14 at 3:00 p.m., Resident #6 was asked about the incident that occurred on 10/8/14 when she was sent to the hospital. She stated, "Yes I remember it. It was the wine. That box. I didn't drink all of it, but I guess I just didn't realize how much I did drink." She was asked how she got the wine. She stated, "I brought it in with me, but I have learned my lesson. I won't do it again." She was asked if she participated in Happy Hour. She stated, "Not any more. I used to." On 11/20/14 at 4:15 p.m., Resident #6 entered the room and asked to talk to the surveyors. She made reference to the conversation the surveyor had with her yesterday (11/19/14) and apologized for not being truthful. She stated she lied about where the alcohol came from and that a staff person did get it for her, but that it wasn't the employee's fault because the employee didn't know she had a drinking problem. She stated she spoke with her Mom last night on the phone and her Mom told her she couldn't lie to State. She stated her Mom explained to her that the employee who bought the liquor for her should have checked her chart and then she would have known she had a drinking problem. She stated her Mom explained to her that alcohol doesn't mix with some of her medications and that the employee shouldn't have done that. She confirmed that CNA #3 was the person who bought the wine for her. She stated, "She took my card and got it for me." Resident #6 then went on to explain that the reason she wasn't truthful about where the alcohol came from was because another employee had asked her to lie about it to protect CNA #3. She stated (Employee #6) came to her and told her CNA #3 had small children and it's Christmas time and it wouldn't be good if she lost her job. The resident stated she felt "bullied" because she was told to lie. She stated she didn't want to get CNA #3 in trouble and that Employee #6 didn't threaten her and was very nice about asking her to lie. g. The following interviews were conducted: On 11/18/14 at 3:06 p.m., Certified Nursing Assistant (CNA) #1 was asked if she knew anything about the 10/8/14 incident involving the resident being sent to the hospital due to drinking. She stated, "(Resident #6) was sent to the hospital due to drinking too much wine." She was asked how she got the wine. She stated, "They purchase it for Happy Hour and I heard they got extra for (Resident #6), a box of wine, and (Resident #8), a 12 pack." On 11/18/14 at 4:49 p.m., CNA #2 was asked if she knew anything about the 10/8/14 incident involving Resident #6 being sent to the hospital due to drinking. She stated, "I heard she got a lot of alcohol one night from (CNA #3). I heard (CNA #3) got it for her and that she got sick and went to the ER because of the alcohol." On 11/18/14 at 5:04 p.m., CNA #3 was asked if she was in charge of Happy Hour. She stated, "Yes. The most they get is 2 cups, like those cups the nurses use to give water during med pass. No whiskey or vodka. And that's once a month. Not everyone gets alcohol. We have consent forms for those who get it. I think during wine and cheese, it's just wine. During Happy Hour, we have a margarita, a wine cooler, or beer. We also have non-alcoholic beverages." She was asked if she was aware of the incident involving Resident #6 on 10/8/14 when she was sent to the hospital. She stated, "All I know is they thought something was wrong with her. She was sent out and she was drunk." She was asked if she got the alcohol for the resident. She stated, "I didn't get her any. I don't do that." She was told that a 5 liter box of wine was found in her room after the incident. She stated, "I don't know anything about that. All I get is what we have during Happy Hour." On 11/19/14 at 8:40 a.m., LPN #1 was asked if she was aware of the incident involving Resident #6 on 10/8/14 when she was sent out to the hospital. She stated, "I wasn't there that day, but I heard about it. I heard that she poured whiskey down her G tube." She was asked where she would have gotten whiskey. She stated, "Maybe from (Resident #7). She likes (Resident #8), and I have seen a can of beer by his bed. (Physician) was very upset. There are people taking medications that don't mix with alcohol. (Resident #11) is another one. I'm not sure where (Resident #8) gets his, but he gives (Resident #11) and (Resident #6) alcohol. One day last week, (Resident #11) wasn't able to stand and get in his room because he had too much to drink." She was asked how she knew this. She stated, "I could smell it. It smelled like whiskey." She was asked if this was reported to anyone. She stated, "We always tell (DON). She calls every night." She was asked if CNA #3 had purchased the alcohol that made Resident #6 so sick. She stated, "Somebody told me she took (Resident #6) credit card to the liquor store and got what she wanted." On 11/19/14 at 10:26 a.m., the DON was asked if staff had reported to her residents were getting too much alcohol to drink. She stated, "There has never been a time that I haven't addressed something that's been reported to me. I call out here every day. They've not told me this stuff." The DON was asked if the incident involving Resident #6 on 10/8/14 when she was sent to the hospital had been investigated. She stated she talked to employees to try and find out where the alcohol came from, but didn't get answers. She stated there were no witness statements and the investigation had not been documented or reported. On 11/19/14 at 1:36 p.m., CNA #4 was asked if she was aware of the incident on 10/8/14 involving Resident #6 when she was sent to the hospital. She stated, "I know that night when I came in, the nurse told me she had to send her out because she was lethargic. I was there when she came back and the report said it was intoxication." She was asked if it was known that the resident had a drinking problem prior to this incident. She stated, "I know when she first came here, I found 3 or 4 empty beer bottles by her bed. I reported this to the nurse. She seemed fine when she got back from the hospital. I helped her lay down. I asked her how she got all that alcohol. She said they got her credit card and went and bought it. She wouldn't say who. A day or so before that, I was there on 2-10 (2:00 p.m. - 10:00 p.m. shift) when (CNA #3) came back with the stuff for Happy Hour and I was told that's when she got it." She was asked if any other residents drank alcohol in the facility. She stated, "(Resident #7) keeps alcohol in his room. (Resident #8) - they usually keep a beer for him in the fridge. Those two share alcohol. I think the family brings it in for those guys." She was asked if this had been reported to anyone. She stated, "Everybody is aware of that. They just don't say anything. I have come in at night and they will be dog drunk, loud and rowdy. On 11/19/14 at 2:57 p.m., CNA #5 was asked if she was aware of the incident on 10/8/14 involving Resident #6 when she was sent to the hospital. She stated, "I know when we came in, they said she had went to the hospital and had been drinking some alcohol." She was asked where the resident got the alcohol. She stated, "I'm not sure. (Resident #8)... he drinks. He has had some Bud Light. I've seen 3 or 4 bottles. He's supposed to have like one a day and he keeps them..." She was asked if he keeps whiskey. She stated, "No. That's (Resident #7). He keeps a bottle of whiskey in his room. He shares it with (Resident #8) and (Resident #11)." She was asked if the residents on the hall drink too much at times. She stated, "Oh yes ma'am. One night (Resident #11) peed all over himself and threw up." She was asked if that was normal for him. She stated, "No. And (Resident #8 and #11) were getting loud and angry one night and they both had a beer in their hand then." She was asked what the nurse did about that. She stated, "Nothing." On 11/19/14 at 3:55 p.m., LPN #2 was asked if she was aware of the incident on 10/8/14 involving Resident #6 when she was sent to the hospital. She stated, "I was called down the hall to check on her. She was unresponsive to verbal stimuli. I got the glucometer. I remember her blood sugar being up so that wasn't the problem. I get (DON) and ask her to come look at her. She looks at her and we decide to send her to the ER. When the results came back, I was thoroughly disgusted. We did a sweep of the room and found opened empty bottles of beer - Bud Light, a full 6 pack of wine coolers, there was a wine bottle that was empty. One of the empty beer bottles was in her bed." She was asked where the alcohol came from. She stated, "I personally do not know. It would be my guess she got the beer from (Resident #8)." On 11/20/14 at 9:03 a.m., the facility Social Services director, who is Resident #7's niece and Power of Attorney, was asked if Resident #7 drank alcohol. She stated, "Yes. I bring him half a pint every other weekend." She was asked what she would bring him. She stated, "Early Times whiskey, or Evan Williams. He drinks during ball games." She was asked if he shared with other residents. She stated, "Knowing my uncle, no he doesn't. I've never seen him share with anybody." She was asked where he kept the whiskey. She stated, "He keeps it under his pillow or in his pocket." She was asked if the resident participated in Happy Hour at the facility. She stated, "Yes. He gets one beer. And that's two times a month." She was asked what she knew about the incident involving Resident #6 being sent to the hospital on [DATE]. She stated, "After the hospital called report, we went and checked her room and found a box of wine and 6 pack of beer." She was asked how she got the alcohol. She stated, "I don't know." She was asked if the facility had a policy for alcohol consumption. She stated, "Not that I'm aware of." On 11/20/14 at 9:26 a.m., LPN #3 was asked if she was aware of the incident involving Resident #6 when she was sent to the hospital on [DATE]. She stated, "I came in that night. (DON) asked me to check her out. I couldn't get any response from the resident. Then when she came back they said she had been drinking." She was asked if she knew the resident had a history of [REDACTED]. I have read her chart more than once. I had never seen any in her room, but during her room search they found stuff." She was asked how the resident got the alcohol. She stated, "I don't know..." h. On 11/19/14 at 10:55 a.m., the Administrator brought the box of wine that was found in Resident #6's room. The remaining wine was emptied into a graduated container. There was 1.8 liters left in the 5 liter box of wine, indicating the resident had drank 3.2 liters. 4. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/23/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS; was totally dependent for bed mobility, transfers and toilet use; required extensive assistance with dressing and bathing; had range of motion limitations on both lower extremities and used a wheelchair for mobility. a. On 11/19/14 at 9:00 a.m., LPN #4 was asked if she was aware of Resident #1 having a male visitor that stayed overnight. She stated, "I worked that night the guy came in. She wasn't my resident that night, but I had (LPN #1) call (DON) and they said she had a right to have company. He stayed in her room most of the time except to go out and smoke. When I got off work that next morning I stayed to talk to (DON) and expressed my concerns to her about it being so late at night and we didn't know him from Adam. He said some really inappropriate stuff to me and to a CNA. He didn't go in anybody else's room." She was asked if the visitor had been drinking. She stated, "Me and (LPN #1) told (DON) he smelled like alcohol. Even at 6:00 a.m. the next morning he still smelled like it." b. On 11/19/14 at 4:00 p.m., Resident #1 was asked about her overnight visitor. She stated she had known him for about [AGE] years and that he was from Little Rock. She stated she does drink during Happy Hour and had asked her friend to bring her some Apple Rita. She stated she didn't like it so she didn't drink it. She stated he wasn't mean to her and didn't hurt her but that he had been drinking. c. On 11/19/14 at 8:40 a.m., LPN #1 was asked if she was aware of the male visitor that stayed overnight with Resident #1. She stated, "Yes. She apparently called and set up a meeting with this guy. When he came in I called (DON) and asked if it was OK. (DON) said it was OK for him to stay. He came out of the room several times saying curse words, not at other people." She was asked if he brought anything with him. She stated, "He had a bag. I don't know what was in it." She was asked if he went into any other resident's rooms. She stated, "I don't think so. But (DON) said yeah we know about it. Just put a gerichair in there for him to sleep in." On 11/19/14 at 1:36 p.m., CNA #4 was asked if she was aware of the overnight male visitor who came to see Resident #1. She stated, "I was there the night he came in. He was drunk..." She was asked if the visitor brought any alcohol. She stated, "He had a plastic bag. I don't know what was in it but another girl said it looked like whiskey." 5. Resident #7 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 10/11/14 documented the resident scored 12 (8-12 indicates moderately impaired) on the BIMS and had verbal behavioral symptoms directed towards others. A Physician order [REDACTED]." 6. Resident #8 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/19/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS. The November 2014 Physician order [REDACTED]. 7. Resident #9 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/2/14 documented the resident scored 8 (8-12 indicates moderately impaired) on the BIMS. The November 2014 Physician order [REDACTED]. 8. Resident #10 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The November 2014 Physician order [REDACTED]. 9. Resident #11 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/16/14 documented the resident scored 6 (0-7 indicates severe impairment) on the BIMS. The November 2014 Physician order [REDACTED]. On 11/18/14 at 3:06 p.m., CNA #1 was asked if any of the other residents drank alcohol at any time other than Happy Hour. She stated, "(Resident #11)... I don't know how he gets his alcohol. According to one of the nurses, he was so drunk he was puking on the floor." 10. Resident #12 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/5/14 documented the resident scored 7 (0-7 indicates severe impairment) on the BIMS and required extensive to total assist from staff for activities of daily living. The November 2014 Physician order [REDACTED]. 11. Resident #13 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/12/14 documented the resident scored 10 (8-12 indicates moderately impaired) on the BIMS and required extensive to total assist from staff for activities of daily living. The November 2014 Physician order [REDACTED]. 12. Resident #14 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/22/14 documented the resident scored 14 (13-15 indicates cognitively intact) on the BIMS. The November 2014 Physician order [REDACTED]. 13. Resident #15 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/1/14 documented the resident scored 5 (0-7 indicates severe impairment) on the BIMS. The November 2014 Physician order [REDACTED]. 14. On 11/19/14 at 12:46 p.m., the Medical Director was asked about the incident involving Resident #6 on 10/8/14. He stated, "She is very interesting. She impresses me with her knowledge and can make you believe all is legit. The nursing home was unaware she was drunk and they sent her out. That was her diagnosis. I don't know if she drank it or put it in her G tube. The story was she got some wine brought in to her." He was asked about Happy Hour. He stated, "I came in and the DON and ADON were in a tiz because Happy Hour had been started. I believe the Administrator started it. I don't know what was served... they don't have to take it." He was asked if he had talked with facility administration concerning alcohol being served in the facility and had he reviewed the resident's medications and conditions to ensure there were no contraindications with the alcohol. He stated, "We had a sit down about it. I told them there's no way we can have demented patients with their medications without the family being aware and that good sense is being used. I didn't have an in depth conversation with the Administrator about this. (DON) assured me that the residents who are on drugs aren't drinking, but as far as reviewing all of the records, I haven't done that." He was asked if he was aware of a facility policy about consuming alcohol. He stated, "If you're asking if I have participated in a written policy for this, the answer is no. I do remember a consultant telling me something like... There's going to be some changes here, to make it like they're living at home... I said this is a dry county and this could be an issue." He was asked if there were physician orders [REDACTED]. He stated, "Written orders... I can tell you that hasn't happened, but the alcohol program has been discussed extensively with the nurses. I have let it be known that demented residents who are on prescription drugs should not be drinking unless I approve it and the family signs off on it." He was asked if Resident #7 drank. He stated, "I do know he drinks a beer occasionally, other than Happy Hour, but it wasn't abused." 15. On 11/19/14 at 3:17 p.m., the Administrator was asked if any of the residents in the facility who participated in Happy Hour had a Physician order [REDACTED].#7) has an order. I don't know of anybody else off the top of my head." She was asked if the facility could provide documentation to show the physician reviewed the conditions and medications of the residents who consumed alcohol to ensure there were no contraindications. She stated, "The only thing (physician) said was to get consents from the families. I did what my Medical Director said to do." She was asked who mixed the drinks for Happy Hour. She stated, "They are frozen pre-mixed drinks. You just pour it into a cup and it's ready to drink. We get the Strawberry Margarita or Strawberry Daiquiri. And we have beer. Bud Light." She was asked about Resident #7 having whiskey. She stated, "I think his niece gets it for him. I don't know if he keeps it in his room." She was asked about Resident #8. She stated, "He did at one time. He had a few beers in his room. We told him he couldn't keep them in there. That's been about a month ago." She was asked if the facility had a policy and procedure on alcohol consumption. She stated, "No." 16. The Immediate Jeopardy was removed on 11/20/14 at 2:15 p.m. and the scope and severity lowered to an "E" when the facility implemented the following plan of removal: a. 11/20/14 at 1:14 p.m. - DON/Designee will make a sweep of the facility to ensure that there are no alcoholic beverages in the facility. Complete by 11/20/14 by 3:00 p.m. b. 11/20/14 at 2:45 p.m. - DON/Designee will inservice staff and residents that we will no longer have happy hour. Any employee on vacation or unable to attend inservice on 11/21/14 will be inserviced before allowed to perform resident care. Complete 11/21/14 by 11:00 a.m. c. 11/20/14 at 3:00 p.m. - Administrator/Designee will send out letters to the families that we will no longer have happy hour and no alcoholic beverages will be allowed into the facility. Complete 11/20/14 by 5:00 p.m. d. 11/24/14 - DON/Designee will perform random room sweeps 3 times (x) per week for 3 weeks with one of the checks occurring on the weekend, then 2 x per month for 4 months to ensure that there are no alcoholic beverages in the facility.

Complaint # (AR 637) was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to have a written policy and procedure to provide guidance to staff and visitors regarding resident alcohol consumption in order to prevent complications from drug/alcohol combination or previous history of [MEDICAL CONDITION]. The facility failed to have a physician review the residents' diagnoses/medications for contraindications regarding alcohol consumption prior to offering alcoholic beverages during "Happy Hour" for 11 of 11 (Residents #1, #6, and 8 through #15) case mix residents who were provided alcoholic beverages. The facility failed to monitor resident possession/usage of alcohol in resident rooms and failed to promptly investigate and intervene when staff reported suspicions of alcohol use in resident rooms for 1 of 1 case mix resident (Resident #6). The facility also failed to thoroughly investigate an incident of alcohol poisoning for 1 (Resident #6) of 11 (Residents #1, #6 through #15) case mix residents who were provided alcoholic beverages by staff or visitors. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #6 who had a [DIAGNOSES REDACTED].#s 1 and 7-15 who currently consumed alcohol in the facility during Happy Hour according to a list provided by the Administrator on 11/19/14 at 4:31 p.m. The Administrator was informed of the Immediate Jeopardy on 11/20/14 at 12:50 p.m. The findings are: 1. On 11/19/14 at 3:17 p.m., the Administrator was asked if any of the residents in the facility who participated in Happy Hour had a Physician order [REDACTED].#7) has an order. I don't know of anybody else off the top of my head." She was asked if the facility could provide documentation to show the physician reviewed the conditions and medications of the residents who consumed alcohol to ensure there were no contraindications. She stated, "The only thing (physician) said was to get consents from the families. I did what my Medical Director said to do." She was asked who mixed the drinks for Happy Hour. She stated, "They are frozen pre-mixed drinks. You just pour it into a cup and it's ready to drink. We get the Strawberry Margarita or Strawberry Daiquiri. And we have beer. Bud Light." She was asked about Resident #7 having whiskey. She stated, "I think his niece gets it for him. I don't know if he keeps it in his room." She was asked about Resident #8. She stated, "He did at one time. He had a few beers in his room. We told him he couldn't keep them in there. That's been about a month ago." She was asked if the facility had a policy and procedure on alcohol consumption. She stated, "No." 2. Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/7/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and was independent in all activities of daily living with set up help and supervision for eating and bathing. a. A form provided by the Administrator on 11/18/14 at 3:00 p.m. documented, "7/30/14 - Dear family members, (Facility) would like to start having Happy hour for our Residents weekly. By signing below you are in agreement with Happy Hour for your family member." This form was signed by the resident, who is her own responsible party. b. A Nurse's Note dated 10/8/14 at 4:30 p.m. and signed by Licensed Practical Nurse (LPN) #2 documented, "Upon entering resident's room, resident was unresponsive to attempts to wake her. Fingerstick blood sugar 311. No response to fingerstick. DON (Director Nursing) notified of condition. (Physician) notified. Order received to send to ER (emergency room )... At 2 PM (earlier)resident was alert, awake, drank a coke float, talked to staff member." c. A Hospital Patient Care Timeline dated 10/8/14 documented, "[MEDICATION NAME] Resulted: 0.194 (0.151 to 0.200 g/dl - Moderate to severe poisoning...)..." A Hospital Emergency Department Note dated 10/8/14 documented, "Since altered mental status was thought to be due to her alcohol intake, we monitored her in the ER and her vital signs remained stable so I think she can sleep off her bender at the nursing home." d. A Nurse's Note dated 10/9/14 at 4:42 p.m. documented, "Spoke with resident's mother related alcoholic intake. Mother reported this resident will drink until she blacks out... Repeatedly request for alcoholic beverage..." e. A Physician order [REDACTED]. f. On 11/19/14 at 3:00 p.m., Resident #6 was asked about the incident that occurred on 10/8/14 when she was sent to the hospital. She stated, "Yes I remember it. It was the wine. That box. I didn't drink all of it, but I guess I just didn't realize how much I did drink." She was asked how she got the wine. She stated, "I brought it in with me, but I have learned my lesson. I won't do it again." She was asked if she participated in Happy Hour. She stated, "Not any more. I used to." On 11/20/14 at 4:15 p.m., Resident #6 entered the room and asked to talk to the surveyors. She made reference to the conversation the surveyor had with her yesterday (11/19/14) and apologized for not being truthful. She stated she lied about where the alcohol came from and that a staff person did get it for her, but that it wasn't the employee's fault because the employee didn't know she had a drinking problem. She stated she spoke with her Mom last night on the phone and her Mom told her she couldn't lie to State. She stated her Mom explained to her that the employee who bought the liquor for her should have checked her chart and then she would have known she had a drinking problem. She stated her Mom explained to her that alcohol doesn't mix with some of her medications and that the employee shouldn't have done that. She confirmed that CNA #3 was the person who bought the wine for her. She stated, "She took my card and got it for me." Resident #6 then went on to explain that the reason she wasn't truthful about where the alcohol came from was because another employee had asked her to lie about it to protect CNA #3. She stated (Employee #6) came to her and told her CNA #3 had small children and it's Christmas time and it wouldn't be good if she lost her job. The resident stated she felt "bullied" because she was told to lie. She stated she didn't want to get CNA #3 in trouble and that Employee #6 didn't threaten her and was very nice about asking her to lie. g. The following interviews were conducted: On 11/18/14 at 3:06 p.m., Certified Nursing Assistant (CNA) #1 was asked if she knew anything about the 10/8/14 incident involving the resident being sent to the hospital due to drinking. She stated, "(Resident #6) was sent to the hospital due to drinking too much wine." She was asked how she got the wine. She stated, "They purchase it for Happy Hour and I heard they got extra for (Resident #6), a box of wine, and (Resident #8), a 12 pack." On 11/18/14 at 4:49 p.m., CNA #2 was asked if she knew anything about the 10/8/14 incident involving Resident #6 being sent to the hospital due to drinking. She stated, "I heard she got a lot of alcohol one night from (CNA #3). I heard (CNA #3) got it for her and that she got sick and went to the ER because of the alcohol." On 11/18/14 at 5:04 p.m., CNA #3 was asked if she was in charge of Happy Hour. She stated, "Yes. The most they get is 2 cups, like those cups the nurses use to give water during med pass. No whiskey or vodka. And that's once a month. Not everyone gets alcohol. We have consent forms for those who get it. I think during wine and cheese, it's just wine. During Happy Hour, we have a margarita, a wine cooler, or beer. We also have non-alcoholic beverages." She was asked if she was aware of the incident involving Resident #6 on 10/8/14 when she was sent to the hospital. She stated, "All I know is they thought something was wrong with her. She was sent out and she was drunk." She was asked if she got the alcohol for the resident. She stated, "I didn't get her any. I don't do that." She was told that a 5 liter box of wine was found in her room after the incident. She stated, "I don't know anything about that. All I get is what we have during Happy Hour." On 11/19/14 at 8:40 a.m., LPN #1 was asked if she was aware of the incident involving Resident #6 on 10/8/14 when she was sent out to the hospital. She stated, "I wasn't there that day, but I heard about it. I heard that she poured whiskey down her G tube." She was asked where she would have gotten whiskey. She stated, "Maybe from (Resident #7). She likes (Resident #8), and I have seen a can of beer by his bed. (Physician) was very upset. There are people taking medications that don't mix with alcohol. (Resident #11) is another one. I'm not sure where (Resident #8) gets his, but he gives (Resident #11) and (Resident #6) alcohol. One day last week, (Resident #11) wasn't able to stand and get in his room because he had too much to drink." She was asked how she knew this. She stated, "I could smell it. It smelled like whiskey." She was asked if this was reported to anyone. She stated, "We always tell (DON). She calls every night." She was asked if CNA #3 had purchased the alcohol that made Resident #6 so sick. She stated, "Somebody told me she took (Resident #6) credit card to the liquor store and got what she wanted." On 11/19/14 at 10:26 a.m., the DON was asked if staff had reported to her residents were getting too much alcohol to drink. She stated, "There has never been a time that I haven't addressed something that's been reported to me. I call out here every day. They've not told me this stuff." The DON was asked if the incident involving Resident #6 on 10/8/14 when she was sent to the hospital had been investigated. She stated she talked to employees to try and find out where the alcohol came from, but didn't get answers. She stated there were no witness statements and the investigation had not been documented or reported. On 11/19/14 at 1:36 p.m., CNA #4 was asked if she was aware of the incident on 10/8/14 involving Resident #6 when she was sent to the hospital. She stated, "I know that night when I came in, the nurse told me she had to send her out because she was lethargic. I was there when she came back and the report said it was intoxication." She was asked if it was known that the resident had a drinking problem prior to this incident. She stated, "I know when she first came here, I found 3 or 4 empty beer bottles by her bed. I reported this to the nurse. She seemed fine when she got back from the hospital. I helped her lay down. I asked her how she got all that alcohol. She said they got her credit card and went and bought it. She wouldn't say who. A day or so before that, I was there on 2-10 (2:00 p.m. - 10:00 p.m. shift) when (CNA #3) came back with the stuff for Happy Hour and I was told that's when she got it." She was asked if any other residents drank alcohol in the facility. She stated, "(Resident #7) keeps alcohol in his room. (Resident #8) - they usually keep a beer for him in the fridge. Those two share alcohol. I think the family brings it in for those guys." She was asked if this had been reported to anyone. She stated, "Everybody is aware of that. They just don't say anything. I have come in at night and they will be dog drunk, loud and rowdy. On 11/19/14 at 2:57 p.m., CNA #5 was asked if she was aware of the incident on 10/8/14 involving Resident #6 when she was sent to the hospital. She stated, "I know when we came in, they said she had went to the hospital and had been drinking some alcohol." She was asked where the resident got the alcohol. She stated, "I'm not sure. (Resident #8)... he drinks. He has had some Bud Light. I've seen 3 or 4 bottles. He's supposed to have like one a day and he keeps them..." She was asked if he keeps whiskey. She stated, "No. That's (Resident #7). He keeps a bottle of whiskey in his room. He shares it with (Resident #8) and (Resident #11)." She was asked if the residents on the hall drink too much at times. She stated, "Oh yes ma'am. One night (Resident #11) peed all over himself and threw up." She was asked if that was normal for him. She stated, "No. And (Resident #8 and #11) were getting loud and angry one night and they both had a beer in their hand then." She was asked what the nurse did about that. She stated, "Nothing." On 11/19/14 at 3:55 p.m., LPN #2 was asked if she was aware of the incident on 10/8/14 involving Resident #6 when she was sent to the hospital. She stated, "I was called down the hall to check on her. She was unresponsive to verbal stimuli. I got the glucometer. I remember her blood sugar being up so that wasn't the problem. I get (DON) and ask her to come look at her. She looks at her and we decide to send her to the ER. When the results came back, I was thoroughly disgusted. We did a sweep of the room and found opened empty bottles of beer - Bud Light, a full 6 pack of wine coolers, there was a wine bottle that was empty. One of the empty beer bottles was in her bed." She was asked where the alcohol came from. She stated, "I personally do not know. It would be my guess she got the beer from (Resident #8)." On 11/20/14 at 9:03 a.m., the facility Social Services director, who is Resident #7's niece and Power of Attorney, was asked if Resident #7 drank alcohol. She stated, "Yes. I bring him half a pint every other weekend." She was asked what she would bring him. She stated, "Early Times whiskey, or Evan Williams. He drinks during ball games." She was asked if he shared with other residents. She stated, "Knowing my uncle, no he doesn't. I've never seen him share with anybody." She was asked where he kept the whiskey. She stated, "He keeps it under his pillow or in his pocket." She was asked if the resident participated in Happy Hour at the facility. She stated, "Yes. He gets one beer. And that's two times a month." She was asked what she knew about the incident involving Resident #6 being sent to the hospital on [DATE]. She stated, "After the hospital called report, we went and checked her room and found a box of wine and 6 pack of beer." She was asked how she got the alcohol. She stated, "I don't know." She was asked if the facility had a policy for alcohol consumption. She stated, "Not that I'm aware of." On 11/20/14 at 9:26 a.m., LPN #3 was asked if she was aware of the incident involving Resident #6 when she was sent to the hospital on [DATE]. She stated, "I came in that night. (DON) asked me to check her out. I couldn't get any response from the resident. Then when she came back they said she had been drinking." She was asked if she knew the resident had a history of [REDACTED]. I have read her chart more than once. I had never seen any in her room, but during her room search they found stuff." She was asked how the resident got the alcohol. She stated, "I don't know..." h. On 11/19/14 at 10:55 a.m., the Administrator brought the box of wine that was found in Resident #6's room. The remaining wine was emptied into a graduated container. There was 1.8 liters left in the 5 liter box of wine, indicating the resident had drank 3.2 liters. 3. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/23/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS; was totally dependent for bed mobility, transfers and toilet use; required extensive assistance with dressing and bathing; had range of motion limitations on both lower extremities and used a wheelchair for mobility. a. On 11/19/14 at 9:00 a.m., LPN #4 was asked if she was aware of Resident #1 having a male visitor that stayed overnight. She stated, "I worked that night the guy came in. She wasn't my resident that night, but I had (LPN #1) call (DON) and they said she had a right to have company. He stayed in her room most of the time except to go out and smoke. When I got off work that next morning I stayed to talk to (DON) and expressed my concerns to her about it being so late at night and we didn't know him from Adam. He said some really inappropriate stuff to me and to a CNA. He didn't go in anybody else's room." She was asked if the visitor had been drinking. She stated, "Me and (LPN #1) told (DON) he smelled like alcohol. Even at 6:00 a.m. the next morning he still smelled like it." b. On 11/19/14 at 4:00 p.m., Resident #1 was asked about her overnight visitor. She stated she had known him for about [AGE] years and that he was from Little Rock. She stated she does drink during Happy Hour and had asked her friend to bring her some Apple Rita. She stated she didn't like it so she didn't drink it. She stated he wasn't mean to her and didn't hurt her but that he had been drinking. c. On 11/19/14 at 8:40 a.m., LPN #1 was asked if she was aware of the male visitor that stayed overnight with Resident #1. She stated, "Yes. She apparently called and set up a meeting with this guy. When he came in I called (DON) and asked if it was OK. (DON) said it was OK for him to stay. He came out of the room several times saying curse words, not at other people." She was asked if he brought anything with him. She stated, "He had a bag. I don't know what was in it." She was asked if he went into any other resident's rooms. She stated, "I don't think so. But (DON) said yeah we know about it. Just put a gerichair in there for him to sleep in." On 11/19/14 at 1:36 p.m., CNA #4 was asked if she was aware of the overnight male visitor who came to see Resident #1. She stated, "I was there the night he came in. He was drunk..." She was asked if the visitor brought any alcohol. She stated, "He had a plastic bag. I don't know what was in it but another girl said it looked like whiskey." 4. Resident #7 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 10/11/14 documented the resident scored 12 (8-12 indicates moderately impaired) on the BIMS and had verbal behavioral symptoms directed towards others. A Physician order [REDACTED]." 5. Resident #8 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/19/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS. The November 2014 Physician order [REDACTED]. 6. Resident #9 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/2/14 documented the resident scored 8 (8-12 indicates moderately impaired) on the BIMS. The November 2014 Physician order [REDACTED]. 7. Resident #10 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The November 2014 Physician order [REDACTED]. 8. Resident #11 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/16/14 documented the resident scored 6 (0-7 indicates severe impairment) on the BIMS. The November 2014 Physician order [REDACTED]. On 11/18/14 at 3:06 p.m., CNA #1 was asked if any of the other residents drank alcohol at any time other than Happy Hour. She stated, "(Resident #11)... I don't know how he gets his alcohol. According to one of the nurses, he was so drunk he was puking on the floor." 9. Resident #12 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/5/14 documented the resident scored 7 (0-7 indicates severe impairment) on the BIMS and required extensive to total assist from staff for activities of daily living. The November 2014 Physician order [REDACTED]. 10. Resident #13 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/12/14 documented the resident scored 10 (8-12 indicates moderately impaired) on the BIMS and required extensive to total assist from staff for activities of daily living. The November 2014 Physician order [REDACTED]. 11. Resident #14 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/22/14 documented the resident scored 14 (13-15 indicates cognitively intact) on the BIMS. The November 2014 Physician order [REDACTED]. 12. Resident #15 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/1/14 documented the resident scored 5 (0-7 indicates severe impairment) on the BIMS. The November 2014 Physician order [REDACTED]. 13. On 11/19/14 at 12:46 p.m., the Medical Director was asked about the incident involving Resident #6 on 10/8/14. He stated, "She is very interesting. She impresses me with her knowledge and can make you believe all is legit. The nursing home was unaware she was drunk and they sent her out. That was her diagnosis. I don't know if she drank it or put it in her G tube. The story was she got some wine brought in to her." He was asked about Happy Hour. He stated, "I came in and the DON and ADON were in a tiz because Happy Hour had been started. I believe the Administrator started it. I don't know what was served... they don't have to take it." He was asked if he had talked with facility administration concerning alcohol being served in the facility and had he reviewed the resident's medications and conditions to ensure there were no contraindications with the alcohol. He stated, "We had a sit down about it. I told them there's no way we can have demented patients with their medications without the family being aware and that good sense is being used. I didn't have an in depth conversation with the Administrator about this. (DON) assured me that the residents who are on drugs aren't drinking, but as far as reviewing all of the records, I haven't done that." He was asked if he was aware of a facility policy about consuming alcohol. He stated, "If you're asking if I have participated in a written policy for this, the answer is no. I do remember a consultant telling me something like... There's going to be some changes here, to make it like they're living at home... I said this is a dry county and this could be an issue." He was asked if there were physician orders [REDACTED]. He stated, "Written orders... I can tell you that hasn't happened, but the alcohol program has been discussed extensively with the nurses. I have let it be known that demented residents who are on prescription drugs should not be drinking unless I approve it and the family signs off on it." He was asked if Resident #7 drank. He stated, "I do know he drinks a beer occasionally, other than Happy Hour, but it wasn't abused." 14. The Immediate Jeopardy was removed on 11/20/14 at 2:15 p.m. and the scope and severity lowered to an "E" when the facility implemented the following plan of removal: a. 11/20/14 at 1:14 p.m. - DON/Designee will make a sweep of the facility to ensure that there are no alcoholic beverages in the facility. Complete by 11/20/14 by 3:00 p.m. b. 11/20/14 at 2:45 p.m. - DON/Designee will inservice staff and residents that we will no longer have happy hour. Any employee on vacation or unable to attend inservice on 11/21/14 will be inserviced before allowed to perform resident care. Complete 11/21/14 by 11:00 a.m. c. 11/20/14 at 3:00 p.m. - Administrator/Designee will send out letters to the families that we will no longer have happy hour and no alcoholic beverages will be allowed into the facility. Complete 11/20/14 by 5:00 p.m. d. 11/24/14 - DON/Designee will perform random room sweeps 3 times (x) per week for 3 weeks with one of the checks occurring on the weekend, then 2 x per month for 4 months to ensure that there are no alcoholic beverages in the facility.

Complaint # (AR 637) was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure Resident #6 received the necessary care and services to maintain the highest practicable physical and mental well being. The facility failed to have a physician review the residents' diagnoses/medications for contraindications regarding alcohol consumption prior to offering alcoholic beverages during "Happy Hour" for 11 of 11 (Residents #1, #6, and 8 through #15) case mix residents who were provided alcoholic beverages. The facility failed to monitor resident possession/usage of alcohol in resident rooms and failed to promptly investigate and intervene when staff reported suspicions of alcohol use in resident rooms for 1 of 1 case mix resident (Resident #6). The facility also failed to thoroughly investigate an incident of alcohol poisoning for 1 (Resident #6) of 11 (Residents #1, #6 through #15) case mix residents who were provided alcoholic beverages by staff or visitors. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #6 who had a [DIAGNOSES REDACTED].#s 1 and 7-15 who currently consumed alcohol in the facility during Happy Hour according to a list provided by the Administrator on 11/19/14 at 4:31 p.m. The Administrator was informed of the Immediate Jeopardy on 11/20/14 at 12:50 p.m. The findings are: 1. Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/7/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and was independent in all activities of daily living with set up help and supervision for eating and bathing. a. A form provided by the Administrator on 11/18/14 at 3:00 p.m. documented, "7/30/14 - Dear family members, (Facility) would like to start having Happy hour for our Residents weekly. By signing below you are in agreement with Happy Hour for your family member." This form was signed by the resident, who is her own responsible party. b. A Nurse's Note dated 10/8/14 at 4:30 p.m. and signed by Licensed Practical Nurse (LPN) #2 documented, "Upon entering resident's room, resident was unresponsive to attempts to wake her. Fingerstick blood sugar 311. No response to fingerstick. DON (Director Nursing) notified of condition. (Physician) notified. Order received to send to ER (emergency room )... At 2 PM (earlier)resident was alert, awake, drank a coke float, talked to staff member." c. A Hospital Patient Care Timeline dated 10/8/14 documented, "[MEDICATION NAME] Resulted: 0.194 (0.151 to 0.200 g/dl - Moderate to severe poisoning...)..." A Hospital Emergency Department Note dated 10/8/14 documented, "Since altered mental status was thought to be due to her alcohol intake, we monitored her in the ER and her vital signs remained stable so I think she can sleep off her bender at the nursing home." d. A Nurse's Note dated 10/9/14 at 4:42 p.m. documented, "Spoke with resident's mother related alcoholic intake. Mother reported this resident will drink until she blacks out... Repeatedly request for alcoholic beverage..." e. A Physician order [REDACTED]. f. On 11/19/14 at 3:00 p.m., Resident #6 was asked about the incident that occurred on 10/8/14 when she was sent to the hospital. She stated, "Yes I remember it. It was the wine. That box. I didn't drink all of it, but I guess I just didn't realize how much I did drink." She was asked how she got the wine. She stated, "I brought it in with me, but I have learned my lesson. I won't do it again." She was asked if she participated in Happy Hour. She stated, "Not any more. I used to." On 11/20/14 at 4:15 p.m., Resident #6 entered the room and asked to talk to the surveyors. She made reference to the conversation the surveyor had with her yesterday (11/19/14) and apologized for not being truthful. She stated she lied about where the alcohol came from and that a staff person did get it for her, but that it wasn't the employee's fault because the employee didn't know she had a drinking problem. She stated she spoke with her Mom last night on the phone and her Mom told her she couldn't lie to State. She stated her Mom explained to her that the employee who bought the liquor for her should have checked her chart and then she would have known she had a drinking problem. She stated her Mom explained to her that alcohol doesn't mix with some of her medications and that the employee shouldn't have done that. She confirmed that CNA #3 was the person who bought the wine for her. She stated, "She took my card and got it for me." Resident #6 then went on to explain that the reason she wasn't truthful about where the alcohol came from was because another employee had asked her to lie about it to protect CNA #3. She stated (Employee #6) came to her and told her CNA #3 had small children and it's Christmas time and it wouldn't be good if she lost her job. The resident stated she felt "bullied" because she was told to lie. She stated she didn't want to get CNA #3 in trouble and that Employee #6 didn't threaten her and was very nice about asking her to lie. g. The following interviews were conducted: On 11/18/14 at 3:06 p.m., Certified Nursing Assistant (CNA) #1 was asked if she knew anything about the 10/8/14 incident involving the resident being sent to the hospital due to drinking. She stated, "(Resident #6) was sent to the hospital due to drinking too much wine." She was asked how she got the wine. She stated, "They purchase it for Happy Hour and I heard they got extra for (Resident #6), a box of wine, and (Resident #8), a 12 pack." On 11/18/14 at 4:49 p.m., CNA #2 was asked if she knew anything about the 10/8/14 incident involving Resident #6 being sent to the hospital due to drinking. She stated, "I heard she got a lot of alcohol one night from (CNA #3). I heard (CNA #3) got it for her and that she got sick and went to the ER because of the alcohol." On 11/18/14 at 5:04 p.m., CNA #3 was asked if she was in charge of Happy Hour. She stated, "Yes. The most they get is 2 cups, like those cups the nurses use to give water during med pass. No whiskey or vodka. And that's once a month. Not everyone gets alcohol. We have consent forms for those who get it. I think during wine and cheese, it's just wine. During Happy Hour, we have a margarita, a wine cooler, or beer. We also have non-alcoholic beverages." She was asked if she was aware of the incident involving Resident #6 on 10/8/14 when she was sent to the hospital. She stated, "All I know is they thought something was wrong with her. She was sent out and she was drunk." She was asked if she got the alcohol for the resident. She stated, "I didn't get her any. I don't do that." She was told that a 5 liter box of wine was found in her room after the incident. She stated, "I don't know anything about that. All I get is what we have during Happy Hour." On 11/19/14 at 8:40 a.m., LPN #1 was asked if she was aware of the incident involving Resident #6 on 10/8/14 when she was sent out to the hospital. She stated, "I wasn't there that day, but I heard about it. I heard that she poured whiskey down her G tube." She was asked where she would have gotten whiskey. She stated, "Maybe from (Resident #7). She likes (Resident #8), and I have seen a can of beer by his bed. (Physician) was very upset. There are people taking medications that don't mix with alcohol. (Resident #11) is another one. I'm not sure where (Resident #8) gets his, but he gives (Resident #11) and (Resident #6) alcohol. One day last week, (Resident #11) wasn't able to stand and get in his room because he had too much to drink." She was asked how she knew this. She stated, "I could smell it. It smelled like whiskey." She was asked if this was reported to anyone. She stated, "We always tell (DON). She calls every night." She was asked if CNA #3 had purchased the alcohol that made Resident #6 so sick. She stated, "Somebody told me she took (Resident #6) credit card to the liquor store and got what she wanted." On 11/19/14 at 10:26 a.m., the DON was asked if staff had reported to her residents were getting too much alcohol to drink. She stated, "There has never been a time that I haven't addressed something that's been reported to me. I call out here every day. They've not told me this stuff." The DON was asked if the incident involving Resident #6 on 10/8/14 when she was sent to the hospital had been investigated. She stated she talked to employees to try and find out where the alcohol came from, but didn't get answers. She stated there were no witness statements and the investigation had not been documented or reported. On 11/19/14 at 1:36 p.m., CNA #4 was asked if she was aware of the incident on 10/8/14 involving Resident #6 when she was sent to the hospital. She stated, "I know that night when I came in, the nurse told me she had to send her out because she was lethargic. I was there when she came back and the report said it was intoxication." She was asked if it was known that the resident had a drinking problem prior to this incident. She stated, "I know when she first came here, I found 3 or 4 empty beer bottles by her bed. I reported this to the nurse. She seemed fine when she got back from the hospital. I helped her lay down. I asked her how she got all that alcohol. She said they got her credit card and went and bought it. She wouldn't say who. A day or so before that, I was there on 2-10 (2:00 p.m. - 10:00 p.m. shift) when (CNA #3) came back with the stuff for Happy Hour and I was told that's when she got it." She was asked if any other residents drank alcohol in the facility. She stated, "(Resident #7) keeps alcohol in his room. (Resident #8) - they usually keep a beer for him in the fridge. Those two share alcohol. I think the family brings it in for those guys." She was asked if this had been reported to anyone. She stated, "Everybody is aware of that. They just don't say anything. I have come in at night and they will be dog drunk, loud and rowdy. On 11/19/14 at 2:57 p.m., CNA #5 was asked if she was aware of the incident on 10/8/14 involving Resident #6 when she was sent to the hospital. She stated, "I know when we came in, they said she had went to the hospital and had been drinking some alcohol." She was asked where the resident got the alcohol. She stated, "I'm not sure. (Resident #8)... he drinks. He has had some Bud Light. I've seen 3 or 4 bottles. He's supposed to have like one a day and he keeps them..." She was asked if he keeps whiskey. She stated, "No. That's (Resident #7). He keeps a bottle of whiskey in his room. He shares it with (Resident #8) and (Resident #11)." She was asked if the residents on the hall drink too much at times. She stated, "Oh yes ma'am. One night (Resident #11) peed all over himself and threw up." She was asked if that was normal for him. She stated, "No. And (Resident #8 and #11) were getting loud and angry one night and they both had a beer in their hand then." She was asked what the nurse did about that. She stated, "Nothing." On 11/19/14 at 3:55 p.m., LPN #2 was asked if she was aware of the incident on 10/8/14 involving Resident #6 when she was sent to the hospital. She stated, "I was called down the hall to check on her. She was unresponsive to verbal stimuli. I got the glucometer. I remember her blood sugar being up so that wasn't the problem. I get (DON) and ask her to come look at her. She looks at her and we decide to send her to the ER. When the results came back, I was thoroughly disgusted. We did a sweep of the room and found opened empty bottles of beer - Bud Light, a full 6 pack of wine coolers, there was a wine bottle that was empty. One of the empty beer bottles was in her bed." She was asked where the alcohol came from. She stated, "I personally do not know. It would be my guess she got the beer from (Resident #8)." On 11/20/14 at 9:03 a.m., the facility Social Services director, who is Resident #7's niece and Power of Attorney, was asked if Resident #7 drank alcohol. She stated, "Yes. I bring him half a pint every other weekend." She was asked what she would bring him. She stated, "Early Times whiskey, or Evan Williams. He drinks during ball games." She was asked if he shared with other residents. She stated, "Knowing my uncle, no he doesn't. I've never seen him share with anybody." She was asked where he kept the whiskey. She stated, "He keeps it under his pillow or in his pocket." She was asked if the resident participated in Happy Hour at the facility. She stated, "Yes. He gets one beer. And that's two times a month." She was asked what she knew about the incident involving Resident #6 being sent to the hospital on [DATE]. She stated, "After the hospital called report, we went and checked her room and found a box of wine and 6 pack of beer." She was asked how she got the alcohol. She stated, "I don't know." She was asked if the facility had a policy for alcohol consumption. She stated, "Not that I'm aware of." On 11/20/14 at 9:26 a.m., LPN #3 was asked if she was aware of the incident involving Resident #6 when she was sent to the hospital on [DATE]. She stated, "I came in that night. (DON) asked me to check her out. I couldn't get any response from the resident. Then when she came back they said she had been drinking." She was asked if she knew the resident had a history of [REDACTED]. I have read her chart more than once. I had never seen any in her room, but during her room search they found stuff." She was asked how the resident got the alcohol. She stated, "I don't know..." h. On 11/19/14 at 10:55 a.m., the Administrator brought the box of wine that was found in Resident #6's room. The remaining wine was emptied into a graduated container. There was 1.8 liters left in the 5 liter box of wine, indicating the resident had drank 3.2 liters. 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/23/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS; was totally dependent for bed mobility, transfers and toilet use; required extensive assistance with dressing and bathing; had range of motion limitations on both lower extremities and used a wheelchair for mobility. a. On 11/19/14 at 9:00 a.m., LPN #4 was asked if she was aware of Resident #1 having a male visitor that stayed overnight. She stated, "I worked that night the guy came in. She wasn't my resident that night, but I had (LPN #1) call (DON) and they said she had a right to have company. He stayed in her room most of the time except to go out and smoke. When I got off work that next morning I stayed to talk to (DON) and expressed my concerns to her about it being so late at night and we didn't know him from Adam. He said some really inappropriate stuff to me and to a CNA. He didn't go in anybody else's room." She was asked if the visitor had been drinking. She stated, "Me and (LPN #1) told (DON) he smelled like alcohol. Even at 6:00 a.m. the next morning he still smelled like it." b. On 11/19/14 at 4:00 p.m., Resident #1 was asked about her overnight visitor. She stated she had known him for about [AGE] years and that he was from Little Rock. She stated she does drink during Happy Hour and had asked her friend to bring her some Apple Rita. She stated she didn't like it so she didn't drink it. She stated he wasn't mean to her and didn't hurt her but that he had been drinking. c. On 11/19/14 at 8:40 a.m., LPN #1 was asked if she was aware of the male visitor that stayed overnight with Resident #1. She stated, "Yes. She apparently called and set up a meeting with this guy. When he came in I called (DON) and asked if it was OK. (DON) said it was OK for him to stay. He came out of the room several times saying curse words, not at other people." She was asked if he brought anything with him. She stated, "He had a bag. I don't know what was in it." She was asked if he went into any other resident's rooms. She stated, "I don't think so. But (DON) said yeah we know about it. Just put a gerichair in there for him to sleep in." On 11/19/14 at 1:36 p.m., CNA #4 was asked if she was aware of the overnight male visitor who came to see Resident #1. She stated, "I was there the night he came in. He was drunk..." She was asked if the visitor brought any alcohol. She stated, "He had a plastic bag. I don't know what was in it but another girl said it looked like whiskey." 3. Resident #7 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 10/11/14 documented the resident scored 12 (8-12 indicates moderately impaired) on the BIMS and had verbal behavioral symptoms directed towards others. A Physician order [REDACTED]." 4. Resident #8 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/19/14 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS. The November 2014 Physician order [REDACTED]. 5. Resident #9 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/2/14 documented the resident scored 8 (8-12 indicates moderately impaired) on the BIMS. The November 2014 Physician order [REDACTED]. 6. Resident #10 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The November 2014 Physician order [REDACTED]. 7. Resident #11 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/16/14 documented the resident scored 6 (0-7 indicates severe impairment) on the BIMS. The November 2014 Physician order [REDACTED]. On 11/18/14 at 3:06 p.m., CNA #1 was asked if any of the other residents drank alcohol at any time other than Happy Hour. She stated, "(Resident #11)... I don't know how he gets his alcohol. According to one of the nurses, he was so drunk he was puking on the floor." 8. Resident #12 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/5/14 documented the resident scored 7 (0-7 indicates severe impairment) on the BIMS and required extensive to total assist from staff for activities of daily living. The November 2014 Physician order [REDACTED]. 9. Resident #13 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/12/14 documented the resident scored 10 (8-12 indicates moderately impaired) on the BIMS and required extensive to total assist from staff for activities of daily living. The November 2014 Physician order [REDACTED]. 10. Resident #14 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/22/14 documented the resident scored 14 (13-15 indicates cognitively intact) on the BIMS. The November 2014 Physician order [REDACTED]. 11. Resident #15 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/1/14 documented the resident scored 5 (0-7 indicates severe impairment) on the BIMS. The November 2014 Physician order [REDACTED]. 12. On 11/19/14 at 12:46 p.m., the Medical Director was asked about the incident involving Resident #6 on 10/8/14. He stated, "She is very interesting. She impresses me with her knowledge and can make you believe all is legit. The nursing home was unaware she was drunk and they sent her out. That was her diagnosis. I don't know if she drank it or put it in her G tube. The story was she got some wine brought in to her." He was asked about Happy Hour. He stated, "I came in and the DON and ADON were in a tiz because Happy Hour had been started. I believe the Administrator started it. I don't know what was served... they don't have to take it." He was asked if he had talked with facility administration concerning alcohol being served in the facility and had he reviewed the resident's medications and conditions to ensure there were no contraindications with the alcohol. He stated, "We had a sit down about it. I told them there's no way we can have demented patients with their medications without the family being aware and that good sense is being used. I didn't have an in depth conversation with the Administrator about this. (DON) assured me that the residents who are on drugs aren't drinking, but as far as reviewing all of the records, I haven't done that." He was asked if he was aware of a facility policy about consuming alcohol. He stated, "If you're asking if I have participated in a written policy for this, the answer is no. I do remember a consultant telling me something like... There's going to be some changes here, to make it like they're living at home... I said this is a dry county and this could be an issue." He was asked if there were physician orders [REDACTED]. He stated, "Written orders... I can tell you that hasn't happened, but the alcohol program has been discussed extensively with the nurses. I have let it be known that demented residents who are on prescription drugs should not be drinking unless I approve it and the family signs off on it." He was asked if Resident #7 drank. He stated, "I do know he drinks a beer occasionally, other than Happy Hour, but it wasn't abused." 13. On 11/19/14 at 3:17 p.m., the Administrator was asked if any of the residents in the facility who participated in Happy Hour had a Physician order [REDACTED].#7) has an order. I don't know of anybody else off the top of my head." She was asked if the facility could provide documentation to show the physician reviewed the conditions and medications of the residents who consumed alcohol to ensure there were no contraindications. She stated, "The only thing (physician) said was to get consents from the families. I did what my Medical Director said to do." She was asked who mixed the drinks for Happy Hour. She stated, "They are frozen pre-mixed drinks. You just pour it into a cup and it's ready to drink. We get the Strawberry Margarita or Strawberry Daiquiri. And we have beer. Bud Light." She was asked about Resident #7 having whiskey. She stated, "I think his niece gets it for him. I don't know if he keeps it in his room." She was asked about Resident #8. She stated, "He did at one time. He had a few beers in his room. We told him he couldn't keep them in there. That's been about a month ago." She was asked if the facility had a policy and procedure on alcohol consumption. She stated, "No." 14. The Immediate Jeopardy was removed on 11/20/14 at 2:15 p.m. and the scope and severity lowered to an "E" when the facility implemented the following plan of removal: a. 11/20/14 at 1:14 p.m. - DON/Designee will make a sweep of the facility to ensure that there are no alcoholic beverages in the facility. Complete by 11/20/14 by 3:00 p.m. b. 11/20/14 at 2:45 p.m. - DON/Designee will inservice staff and residents that we will no longer have happy hour. Any employee on vacation or unable to attend inservice on 11/21/14 will be inserviced before allowed to perform resident care. Complete 11/21/14 by 11:00 a.m. c. 11/20/14 at 3:00 p.m. - Administrator/Designee will send out letters to the families that we will no longer have happy hour and no alcoholic beverages will be allowed into the facility. Complete 11/20/14 by 5:00 p.m. d. 11/24/14 - DON/Designee will perform random room sweeps 3 times (x) per week for 3 weeks with one of the checks occurring on the weekend, then 2 x per month for 4 months to ensure that there are no alcoholic beverages in the facility.

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure Resident #1, who was cognitively impaired, was free from abuse. The facility failed to ensure an allegedly witnessed incident of staff to resident abuse involving CNA #1 and 1 case mix resident (Resident #1) was immediately reported to ensure residents were protected from the potential of further abuse for 5 (Residents #1 - #5) of 5 case mix residents who were cognitively impaired. CNAs #2 and #3 did not intervene and delayed reporting the incident for approximately 17 hours. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1, who was cognitively impaired and the subject of an allegedly witnessed incident of staff to resident abuse and had the potential to affect 39 residents in the facility who were cognitively impaired as documented on a list provided by the MDS (Minimum Data Set) LPN on 9/25/13 at 3:00 p.m. The facility removed the Immediate Jeopardy prior to the survey entrance date but did not correct the underlying failed practices. On 9/25/13 at 3:15 p.m., the facility was informed of the Immediate Jeopardy removed. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/13 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, required extensive assistance from staff for bed mobility and was totally dependent on staff for transfers. a. The care plan documented, "Problem Onset: 11/4/12 - I display verbally aggressive behavior and sexually inappropriate behavior and verbalization..." b. The Resident Incident Report dated 9/20/13 at 6:00 a.m. documented, "Allegation by (2) CNAs (Certified Nursing Assistants) that another CNA had kick (Resident #1) in the groin and hit him on arm and head when trying to provide am care. Complete body audit done by (Director of Nursing (DON)) no negative findings noted." On 9/20/13 at 1:00 p.m., the urinalysis documented Resident #1 had 1+ blood in his urine. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) -762 form documented, "On 9/20/13, at 6:00 a.m. LPN (Licensed Practical Nurse) #2, on 7PM to 7AM called DON (Director of Nursing) to ask her if she could come on in that a CNA (Certified Nursing Assistant) needed to talk to her. DON arrived at approximately 6:30AM. CNA #2 went to Director of Nursing when she arrived and said she had never seen anything like this before, that while giving care to (Resident #1's) roommate (CNA #1) was standing beside (Resident #1) who is on a low bed due to fall risk and kicked him in the groin area. (Resident #1) said 'You are hurting me.' Then (CNA #1) hit him on the arm per (CNA #2's) statement. (Resident #1) continued to state 'You are hurting me.' (CNA #3) entered (DON's) office and stated she also saw (CNA #1) kick (Resident #1) in the groin. She also stated (Resident #1) said 'You are hurting me.' (CNA #3) also stated (CNA #1) hit (Resident #1) upside the head. All along (Resident #1) is continuing to say 'You are hurting me'." c. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) -762 form documented, "Findings: On 9/20/13, when (CNA #1) came in to be interviewed, I (Administrator) told (CNA #1) an allegation of abuse had been alleged against her and asked if she would have any idea what it was concerning. (CNA #1) stated probably the last night I worked (9/18/13) (reported to work at 11:00 p.m. and ended shift at 7:00 a.m. on 9/19/13) and was changing (Resident #1). I asked her what happed she stated he was resisting care and was kicking and swinging she grabbed his leg to keep him from kicking her. She stated she had no knowledge of why they would lie about the incident. Director of Nursing completed a body audit on (Resident #1). She did not find any trauma, bruising, red areas,or swelling on (Resident #1). Body appeared normal for (Resident #1). On the morning of 9/20/13 he complained of hurting when voiding urine. UA was obtained. It was found he had some blood in urine along with a slight UTI (Urinary tract Infection)..." 1) The DMS-762 witness statement form dated 9/20/13 at 0030 a.m. and signed by LPN #1 documented, "0030 (CNA #2) came to desk and ask me what I considered abuse. I asked her why she was asking me this. She stated she saw a CNA kick a resident. I asked who the CNA was and she told me (CNA #1). I asked her to tell me about what she had seen. She stated her and (CNA #3) were helping Resident A-Bed up and getting him dressed when they saw her (CNA #1) kick (Resident #1). I questioned (CNA #3) and she agreed to what was told to me." 2) The DMS-762 witness statement form dated 9/20/13 at 6:45 a.m. and signed by CNA #2 documented, "I was getting (Resident #1's roommate) ready for morning get up as (CNA #1) and (CNA #3) both CNAs entered the room to assist (Resident #1). (Resident #1) has a low bed due to fall risk, but he was laying in the floor beside the bed on his back. (Resident #1) was kicking at (CNA #1) and she rocked back and forth then jumped back on her left leg then kicked (Resident #1) with her right foot in his genitals. I turned away to continue to help (Resident #2 (Resident #1's roommate)) get his clothes on as (CNA #2) left the room I seen out the corner of my eye (CNA #1) hitting (Resident #1) in the arm. I'm not sure how hard she was hitting him, but he stated multiple times while we were in the room that 'Your hurting me'." On 9/25/13 at 12:47 p.m. CNA #2 stated, "I was in the room already around 5 - 6:30 a.m. last Thursday (9/19/13). (CNA #1) came in and she started getting (Resident #1) up. He peed his bed bad. I actually saw her kick him in the groin. I thought was/is she reallly doing that? Oh my God, I can't believe she did that. I didn't know how hard the kick was. ..I heard him (Resident #1) say, 'Your hurting me, your hurting me.' (CNA #1) kinda went back on her foot and then she hauled off and kicked him. He didn't holler in pain, so that's why I didn't know how hard she kicked him. He was fighting back, trying to kick her too." CNA #2 stated she reported what she saw to the nurses (LPN #1 and LPN #2) Thursday (9/19/13) around 12:00 a.m. (incident happened around 5:00 to 6:30 a.m. CNAs returned for night shift duty that started at 11:00 p.m. on 9/19/13 and was reported on 9/20/13 at 12:00 a.m.) CNA #2 was asked did she go right then and report it? She stated, "No, I didn't." CNA #2 was asked why not? She stated, "I really didn't know if she was for real.. I didn't know if she was serious. I turned around and saw it, he didn't look like he was in distress. I see now that we should've reported it right then. I didn't want to be in confrontation with anyone at work. I'm 23 and she's a lot older than me. I didn't know what she would do to me." 3) The DMS-762 witness statement form dated 9/20/13 (no time given) documented by CNA #3, "I was in Room (Number) picking up dirty linen and I saw (CNA #1) kick (Resident #1) in the growing (groin) area and he stated you are hurting me and then (CNA #1) started slapping him around upside head. (Resident #1) was on a low bed with both legs up. (CNA #1) kick him in the growing area this happen about 6:30 a.m. on 9/19/13 and she was laughing during the time she was hitting him." On 9/25/13 at 10:13 a.m., CNA #3 stated, "We (CNA #2 and CNA #3)entered the room Thursday (9/19/13) morning about 6:30 a.m. (CNA #1) went to (Resident #1), she started hitting on him. He was lying on his back, he had his legs up in the air. She proceeded to kick him in his groin area. He told her 'Stop you SOB, your hurting me.' She just kept on and on. She straddled him, hitting him (open handed) back and forth on the side of his head. She did it about 6 - 7 times. I was in shock. I couldn't believe it cause I'd never seen that before, never seen anyone do a resident that way before. She use to talk about her son fighting on the street, she got that street mentality." CNA #3 was asked did she tell the nurse right then. CNA #3 stated, "No." CNA #3 stated, "It was about 11:00 p.m. the following night (approximately 17 hours later), we told it immediately to (LPN #1), (CNA #2) and I, both told that nurse. It scared us. He just laid there afterwards." CNA #3 was asked if it bothered CNA #1 when they walked in the room? She stated, "Evidently not because she kept on." CNA #3 was asked if she had been inserviced on Abuse and Neglect. CNA #3 stated, "Yes. But the last time, I'm just going to be honest, it's been awhile." CNA #3 was asked if she knew when the nurse reported the allegation to Adminsitration? CNA #3 stated, "Evidently they didn't report it till the next morning (9/20/13)." 4) The DMS-762 witness statement form dated 9/20/13 at 1:53 (p.m.) and signed by CNA #1 documented, "On 18th of Sept around 5:50 a.m. we (CNA #3) were changing (Resident #1's) sheets and drying him. (Resident #1) was kicking and swinging, I then grabbed his leg to keep from kicking me. (Resident #1) is very combative and he don't like to be messed with." 5) The DMS-762 witness statement form dated 9/20/13 at 7:00 a.m. and signed by the DON documented, "At approx. 6AM, LPN #2 called me at home asking if I could come on in that a CNA needed to talk to me. I arrived at the facility by 6:30 a.m. CNA #2 came to me first. CNA #2 stated she had never seen anything like this before, that while she was taking care of (Resident #1's roommate) CNA #1 was standing beside (Resident #1) which was on a low bed (fall risk) and kicked him in the groin area. (Resident #1) became resistant to care and saying over and over 'Your hurting me' then CNA #1 hit him on the arm per CNA #2's statement. During ou (our) discussion of incident CNA #3 another 11/7 CNA came in and stated that she also witnessed CNA #1 kick (Resident #1) in the groin and hit him. She too stated Resident was saying 'stop you are hurting me.' CNA #3 also stated that she heard CNA #1 state she could really hurt him. I asked CNA #2 why she waited to the next morning to report. She stated it really bothered her and she had never seen anything like it before but was not sure what to do. Then she stated she realized she should've done something immediately. CNA #3 stated she did not think CNA #1 could do such a thing but also realized she should have reported immediately. Both CNAs (CNA #2 and #3) were inserviced again on Abuse Protocol immediately. CNA #1 was interviewed and denied allegations. She stated, 'They just lied that's all.' When the Administrator and myself started the interview CNA #1 knew what incident and what resident we were going to talk to her about before we said who it was or when it was. All three CNAs were put on suspension until further notice. I, (DON) performed a complete body audit on (Resident #1) and did not find any bruising or red areas, tip of penis slightly pink. He is incontinent and wears a brief. He did complain of hurting when trying to void." d. On 9/25/13 at 6:40 a.m., a body audit was conducted on Resident #1. The body audit revealed Resident #1 had hemorrhage to the sclera of the left eye. The sclera is dark red blood shot. The Administrator stated Resident #1's son was talking him to see the eye doctor tomorrow 9/26/13. e. Additional interviews were conducted: 1) On 9/25/13 at 6:08 a.m., CNA #4 (employed 3 months on the 11/7 shift) stated, "...I came to work (Wednesday 9/18/13 or Thursday 9/19/13). I was sitting on my hall. The 2 girls (CNA #2 and CNA #3) worked the night before. They came and asked me what they should do about CNA #1. They said they had walked in the room. (Resident #1), he fights and is combative. ...They said she (CNA #1) was in there she had kicked him in his privates, had straddled him and slapped him in the face. He was hollering, 'You SOB, your hurting me.' They said she grabbed him by his leg and jerked him off the bed. I said to them 'You need to go report that.' They said they just reported it to the nurses (LPN #1 and LPN #2), the 11/7 shift LPNs. I really didn't want to believe it but then the next night we went down to change him, he was not acting right. He was totally different. He wasn't moving, saying anything, or combative. I said something to the nurse (LPN #2) about it. She said she would watch him." CNA #4 was asked to clarify when the CNAs reported the allegation. CNA #4 stated the CNAs (CNA #2 and CNA #3) said it happened between 5 and 7:00 a.m. on the 11/7 shift (9/19/13) when CNA #1 was trying to get him (Resident #1) up. CNA #4 stated they (CNA #2 and CNA #3) came in at 11:00 p.m. (9/19/13) and reported the allegation, (approximately 17 hours later). CNA #4 was asked why she thought the CNAs waited to report it? CNA #4 stated they said they were scared. The CNA stated, "LPN #2 asked me why (CNA #1) would do it in front of the CNAs. All I said was (CNA #1) must've felt comfortable with them and thought they wouldn't say anything." CNA #4 stated, "The facility has not asked me about anything, no witness statement, nothing." 2) On 9/25/13 at 7:03 a.m., LPN #3 stated she didn't know anything about the allegation. "...(Resident #1) is hard to handle, he will fight if you try to move him, he will stiffen up when he's combative. I will let him hold my arm while (CNA #1) changes him. That's why he's not hitting her and stuff. ...I don't think they (CNA #2 and CNA #3) would lie about it. They were scared about it and didn't want to get anybody in trouble. But they didn't tell me..." LPN #3 was asked if she had been inserviced since the allegation was reported? LPN #3 stated, "No, I work nights. Sometimes, I don't come to the Inservices." LPN #3 was asked if she had seen any changes in Resident #1 since the incident? LPN #3 stated, "Yes." She was asked, "Do you feel it is a direct result from what happened?" LPN #3 stated, "Yes, he's quiet, not usually like that. He's kinda laying around a lot, but we just did a U/A and started him on an antibiotic. When we change him, he does seem scared, he just lays there. ...but those 2 CNAs wouldn't lie about it." f. On 9/25/13 at 1:45 p.m. the Administrator stated, the DON initiated an inservice regarding reporting abuse and neglect on paper and placed at nurse's station on Friday 9/20/13 for the all nursing staff to read and sign. The Administrator was asked since the inservice was initiated how had the facility monitored the effectiveness of the inservice. She stated, "I'm making rounds and listening as I go up and down the halls. I've not asked staff. But I've scheduled Friday (9/27/13) a (formal) inservice on abuse and neglect." She was informed that of all the CNAs who were working this morning (9/25/13), CNA #5, CNA #6 and LPN #3 had not signed the inservice. 2. The facility removed the Immediate Jeopardy on 9/20/13 prior to the survey entrance date reducing the scope and severity to an E by taking the following actions: a. On 9/20/13 - 6:00 a.m. upon notification of the allegations of abuse the facility suspended CNA #1, #2 and #3. b. On 9/20/13 (no time given), (DON) assessed (Residents #1) for any signs/symptoms of abuse. c. CNA #1 was terminated. According to CNA #1's time card, the last day CNA #1 worked was 9/18/13 from 10:54 p.m. - 6:59 a.m. (9/19/13) and did not return to work. d. According to the DMS-762 dated 9/20/13, "CNA #2 and CNA #3 were also terminated for not stopping the abuse and not reporting immediately and leaving the room with (Resident #1) still in room. Incident occurred on the morning of 9/19/13 when coming on 11/7 shift on (at 11:00 p.m.) 9/19/13. They (CNA #2 and CNA #3) reported sometime during the shift to LPN #1 when they came on 11/7 on 9/19/13. They talked to the Director of Nursing on the early morning of 9/20/13." e. Inservice was initiated on 9/20/13 which documented, "This is a reminder as well as inservice for all employees here at (Nursing Home). We have inserviced and talked about abuse. ...what it is ...how it is ...and what needs to be done to prevent it and what to do if it ocurrs. Attached is our policy which describes what our abuse prevention and investigation protocol is. The first and formost thing is we have to protect and care for our residents. Remember if you see or suspect you MUST report immediately! We will also start drug testing prior to employment and random. This is also a way to determine if someone is appropriate to care for our residents. Everyone is to read and sign this inservice." f. Beginning 9/20/13, the facility initiated interviews with staff and residents to assess staff treatment.

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure the facility's Abuse Policy and Procedures were implemented as evidenced by the facility's failures to ensure Resident #1, who was cognitively impaired, was free from abuse. The facility failed to ensure an allegedly witnessed incident of staff to resident abuse involving CNA #1 and 1 case mix resident (Resident #1) was immediately reported by staff to ensure residents were protected from the potential of further abuse for 5 (Residents #1 - #5) of 5 case mix residents who were cognitively impaired. CNAs #2 and #3 did not intervene and delayed reporting the incident for approximately 17 hours. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1, who was cognitively impaired and the subject of an allegedly witnessed incident of staff to resident abuse and had the potential to affect 39 residents in the facility who were cognitively impaired as documented on a list provided by the MDS (Minimum Data Set) LPN on 9/25/13 at 3:00 p.m. The facility removed the Immediate Jeopardy prior to the survey entrance date but did not correct the underlying failed practices. On 9/25/13 at 3:15 p.m., the facility was informed of the Immediate Jeopardy removed. The findings are: 1. The facility's policy titled "Abuse Prevention and Investigation Protocol", provided by the Administrator on 9/25/13, documented, "Policy: To maintain Abuse Prevention and Investigation Program which includes, but is not limited to Screening, Training, Identification, Investigation, Protection, and Reporting/Response in order to eliminate the likelihood of abuse in the Nursing Home. ...All employees will be instructed ...that ...suspicious signs/symptoms must be reported to the Administrator and DON/Charge Nurse immediately. ...All facility staff will be instructed upon employment and at least yearly of the requirement for investigating alleged abuse or neglect and the intial response of the staff. ...Any facility staff who has reasonable cause to suspect that a resident has been subjected to conditions or circumstances which have or could have resulted in abuse or neglect is required to immediately notify the facility administrator or DON. 2. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/13 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, required extensive assistance from staff for bed mobility and was totally dependent on staff for transfers. a. The care plan documented, "Problem Onset: 11/4/12 - I display verbally aggressive behavior and sexually inappropriate behavior and verbalization..." b. The Resident Incident Report dated 9/20/13 at 6:00 a.m. documented, "Allegation by (2) CNAs (Certified Nursing Assistants) that another CNA had kicked (Resident #1) in the groin and hit him on arm and head when trying to provide am care. Complete body audit done by (Director of Nursing (DON)) no negative findings noted." On 9/20/13 at 1:00 p.m., the urinalysis documented Resident #1 had 1+ blood in his urine. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) -762 form documented, "On 9/20/13, at 6:00 a.m. LPN (Licensed Practical Nurse) #2, on 7PM to 7AM called DON (Director of Nursing) to ask her if she could come on in that a CNA (Certified Nursing Assistant) needed to talk to her. DON arrived at approximately 6:30AM. CNA #2 went to Director of Nursing when she arrived and said she had never seen anything like this before, that while giving care to (Resident #1's) roommate (CNA #1) was standing beside (Resident #1) who is on a low bed due to fall risk and kicked him in the groin area. (Resident #1) said 'You are hurting me.' Then (CNA #1) hit him on the arm per (CNA #2's) statement. (Resident #1) continued to state 'You are hurting me.' (CNA #3) entered (DON's) office and stated she also saw (CNA #1) kick (Resident #1) in the groin. She also stated (Resident #1) said 'You are hurting me.' (CNA #3) also stated (CNA #1) hit (Resident #1) upside the head. All along (Resident #1) is continuing to say 'You are hurting me'." c. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) -762 form documented, "Findings: On 9/20/13, when (CNA #1) came in to be interviewed, I (Administrator) told (CNA #1) an allegation of abuse had been alleged against her and asked if she would have any idea what it was concerning. (CNA #1) stated probably the last night I worked (9/18/13) (reported to work at 11:00 p.m. and ended shift at 7:00 a.m. on 9/19/13) and was changing (Resident #1). I asked her what happed she stated he was resisting care and was kicking and swinging she grabbed his leg to keep him from kicking her. She stated she had no knowledge of why they would lie about the incident. Director of Nursing completed a body audit on (Resident #1). She did not find any trauma, bruising, red areas,or swelling on (Resident #1). Body appeared normal for (Resident #1). On the morning of 9/20/13 he complained of hurting when voiding urine. UA was obtained. It was found he had some blood in urine along with a slight UTI (Urinary tract Infection)..." 1) The DMS-762 witness statement form dated 9/20/13 at 0030 a.m. and signed by LPN #1 documented, "0030 (CNA #2) came to desk and ask me what I considered abuse. I asked her why she was asking me this. She stated she saw a CNA kick a resident. I asked who the CNA was and she told me (CNA #1). I asked her to tell me about what she had seen. She stated her and (CNA #3) were helping Resident A-Bed up and getting him dressed when they saw her (CNA #1) kick (Resident #1). I questioned (CNA #3) and she agreed to what was told to me." 2) The DMS-762 witness statement form dated 9/20/13 at 6:45 a.m. and signed by CNA #2 documented, "I was getting (Resident #1's roommate) ready for morning get up as (CNA #1) and (CNA #3) both CNAs entered the room to assist (Resident #1). (Resident #1) has a low bed due to fall risk, but he was laying in the floor beside the bed on his back. (Resident #1) was kicking at (CNA #1) and she rocked back and forth then jumped back on her left leg then kicked (Resident #1) with her right foot in his genitals. I turned away to continue to help (Resident #2 (Resident #1's roommate)) get his clothes on as (CNA #2) left the room I seen out the corner of my eye (CNA #1) hitting (Resident #1) in the arm. I'm not sure how hard she was hitting him, but he stated multiple times while we were in the room that 'Your hurting me'." On 9/25/13 at 12:47 p.m. CNA #2 stated, "I was in the room already around 5 - 6:30 a.m. last Thursday (9/19/13). (CNA #1) came in and she started getting (Resident #1) up. He peed his bed bad. I actually saw her kick him in the groin. I thought was/is she reallly doing that? Oh my God, I can't believe she did that. I didn't know how hard the kick was. ..I heard him (Resident #1) say, 'Your hurting me, your hurting me.' (CNA #1) kinda went back on her foot and then she hauled off and kicked him. He didn't holler in pain, so that's why I didn't know how hard she kicked him. He was fighting back, trying to kick her too." CNA #2 stated she reported what she saw to the nurses (LPN #1 and LPN #2) Thursday (9/19/13) around 12:00 a.m. (incident happened around 5:00 to 6:30 a.m. CNAs returned for night shift duty that started at 11:00 p.m. on 9/19/13 and was reported on 9/20/13 at 12:00 a.m.) CNA #2 was asked did she go right then and report it? She stated, "No, I didn't." CNA #2 was asked why not? She stated, "I really didn't know if she was for real.. I didn't know if she was serious. I turned around and saw it, he didn't look like he was in distress. I see now that we should've reported it right then. I didn't want to be in confrontation with anyone at work. I'm 23 and she's a lot older than me. I didn't know what she would do to me." 3) The DMS-762 witness statement form dated 9/20/13 (no time given) documented by CNA #3, "I was in Room (Number) picking up dirty linen and I saw (CNA #1) kick (Resident #1) in the growing (groin) area and he stated you are hurting me and then (CNA #1) started slapping him around upside head. (Resident #1) was on a low bed with both legs up. (CNA #1) kick him in the growing area this happen about 6:30 a.m. on 9/19/13 and she was laughing during the time she was hitting him." On 9/25/13 at 10:13 a.m., CNA #3 stated, "We (CNA #2 and CNA #3)entered the room Thursday (9/19/13) morning about 6:30 a.m. (CNA #1) went to (Resident #1), she started hitting on him. He was lying on his back, he had his legs up in the air. She proceeded to kick him in his groin area. He told her 'Stop you SOB, your hurting me.' She just kept on and on. She straddled him, hitting him (open handed) back and forth on the side of his head. She did it about 6 - 7 times. I was in shock. I couldn't believe it cause I'd never seen that before, never seen anyone do a resident that way before. She use to talk about her son fighting on the street, she got that street mentality." CNA #3 was asked did she tell the nurse right then. CNA #3 stated, "No." CNA #3 stated, "It was about 11:00 p.m. the following night (approximately 17 hours later), we told it immediately to (LPN #1), (CNA #2) and I, both told that nurse. It scared us. He just laid there afterwards." CNA #3 was asked if it bothered CNA #1 when they walked in the room? She stated, "Evidently not because she kept on." CNA #3 was asked if she had been inserviced on Abuse and Neglect. CNA #3 stated, "Yes. But the last time, I'm just going to be honest, it's been awhile." CNA #3 was asked if she knew when the nurse reported the allegation to Adminsitration? CNA #3 stated, "Evidently they didn't report it till the next morning (9/20/13)." 4) The DMS-762 witness statement form dated 9/20/13 at 1:53 (p.m.) and signed by CNA #1 documented, "On 18th of Sept around 5:50 a.m. we (CNA #3) were changing (Resident #1's) sheets and drying him. (Resident #1) was kicking and swinging, I then grabbed his leg to keep from kicking me. (Resident #1) is very combative and he don't like to be messed with." 5) The DMS-762 witness statement form dated 9/20/13 at 7:00 a.m. and signed by the DON documented, "At approx. 6AM, LPN #2 called me at home asking if I could come on in that a CNA needed to talk to me. I arrived at the facility by 6:30 a.m. CNA #2 came to me first. CNA #2 stated she had never seen anything like this before, that while she was taking care of (Resident #1's roommate) CNA #1 was standing beside (Resident #1) which was on a low bed (fall risk) and kicked him in the groin area. (Resident #1) became resistant to care and saying over and over 'Your hurting me' then CNA #1 hit him on the arm per CNA #2's statement. During ou (our) discussion of incident CNA #3 another 11/7 CNA came in and stated that she also witnessed CNA #1 kick (Resident #1) in the groin and hit him. She too stated Resident was saying 'stop you are hurting me.' CNA #3 also stated that she heard CNA #1 state she could really hurt him. I asked CNA #2 why she waited to the next morning to report. She stated it really bothered her and she had never seen anything like it before but was not sure what to do. Then she stated she realized she should've done something immediately. CNA #3 stated she did not think CNA #1 could do such a thing but also realized she should have reported immediately. Both CNAs (CNA #2 and #3) were inserviced again on Abuse Protocol immediately. CNA #1 was interviewed and denied allegations. She stated, 'They just lied that's all.' When the Administrator and myself started the interview CNA #1 knew what incident and what resident we were going to talk to her about before we said who it was or when it was. All three CNAs were put on suspension until further notice. I, (DON) performed a complete body audit on (Resident #1) and did not find any bruising or red areas, tip of penis slightly pink. He is incontinent and wears a brief. He did complain of hurting when trying to void." d. On 9/25/13 at 6:40 a.m., a body audit was conducted on Resident #1. The body audit revealed Resident #1 had hemorrhage to the sclera of the left eye. The sclera is dark red blood shot. The Administrator stated Resident #1's son was talking him to see the eye doctor tomorrow 9/26/13. e. Additional interviews were conducted: 1) On 9/25/13 at 6:08 a.m., CNA #4 (employed 3 months on the 11/7 shift) stated, "...I came to work (Wednesday 9/18/13 or Thursday 9/19/13). I was sitting on my hall. The 2 girls (CNA #2 and CNA #3) worked the night before. They came and asked me what they should do about CNA #1. They said they had walked in the room. (Resident #1), he fights and is combative. ...They said she (CNA #1) was in there she had kicked him in his privates, had straddled him and slapped him in the face. He was hollering, 'You SOB, your hurting me.' They said she grabbed him by his leg and jerked him off the bed. I said to them 'You need to go report that.' They said they just reported it to the nurses (LPN #1 and LPN #2), the 11/7 shift LPNs. I really didn't want to believe it but then the next night we went down to change him, he was not acting right. He was totally different. He wasn't moving, saying anything, or combative. I said something to the nurse (LPN #2) about it. She said she would watch him." CNA #4 was asked to clarify when the CNAs reported the allegation. CNA #4 stated the CNAs (CNA #2 and CNA #3) said it happened between 5 and 7:00 a.m. on the 11/7 shift (9/19/13) when CNA #1 was trying to get him (Resident #1) up. CNA #4 stated they (CNA #2 and CNA #3) came in at 11:00 p.m. (9/19/13) and reported the allegation, (approximately 17 hours later). CNA #4 was asked why she thought the CNAs waited to report it? CNA #4 stated they said they were scared. The CNA stated, "LPN #2 asked me why (CNA #1) would do it in front of the CNAs. All I said was (CNA #1) must've felt comfortable with them and thought they wouldn't say anything." CNA #4 stated, "The facility has not asked me about anything, no witness statement, nothing." 2) On 9/25/13 at 7:03 a.m., LPN #3 stated she didn't know anything about the allegation. "...(Resident #1) is hard to handle, he will fight if you try to move him, he will stiffen up when he's combative. I will let him hold my arm while (CNA #1) changes him. That's why he's not hitting her and stuff. ...I don't think they (CNA #2 and CNA #3) would lie about it. They were scared about it and didn't want to get anybody in trouble. But they didn't tell me..." LPN #3 was asked if she had been inserviced since the allegation was reported? LPN #3 stated, "No, I work nights. Sometimes, I don't come to the Inservices." LPN #3 was asked if she had seen any changes in Resident #1 since the incident? LPN #3 stated, "Yes." She was asked, "Do you feel it is a direct result from what happened?" LPN #3 stated, "Yes, he's quiet, not usually like that. He's kinda laying around a lot, but we just did a U/A and started him on an antibiotic. When we change him, he does seem scared, he just lays there. ...but those 2 CNAs wouldn't lie about it." f. On 9/25/13 at 1:45 p.m. the Administrator stated, the DON initiated an inservice regarding reporting abuse and neglect on paper and placed at nurse's station on Friday 9/20/13 for the all nursing staff to read and sign. The Administrator was asked since the inservice was initiated how had the facility monitored the effectiveness of the inservice. She stated, "I'm making rounds and listening as I go up and down the halls. I've not asked staff. But I've scheduled Friday (9/27/13) a (formal) inservice on abuse and neglect." She was informed that of all the CNAs who were working this morning (9/25/13), CNA #5, CNA #6 and LPN #3 had not signed the inservice. 3. The facility removed the Immediate Jeopardy on 9/20/13 prior to the survey entrance date reducing the scope and severity to an E by taking the following actions: a. On 9/20/13 - 6:00 a.m. upon notification of the allegations of abuse the facility suspended CNA #1, #2 and #3. b. On 9/20/13 (no time given), (DON) assessed (Residents #1) for any signs/symptoms of abuse. c. CNA #1 was terminated. According to CNA #1's time card, the last day CNA #1 worked was 9/18/13 from 10:54 p.m. - 6:59 a.m. (9/19/13) and did not return to work. d. According to the DMS-762 dated 9/20/13, "CNA #2 and CNA #3 were also terminated for not stopping the abuse and not reporting immediately and leaving the room with (Resident #1) still in room. Incident occurred on the morning of 9/19/13 when coming on 11/7 shift on (at 11:00 p.m.) 9/19/13. They (CNA #2 and CNA #3) reported sometime during the shift to LPN #1 when they came on 11/7 on 9/19/13. They talked to the Director of Nursing on the early morning of 9/20/13." e. Inservice was initiated on 9/20/13 which documented, "This is a reminder as well as inservice for all employees here at (Nursing Home). We have inserviced and talked about abuse. ...what it is ...how it is ...and what needs to be done to prevent it and what to do if it ocurrs. Attached is our policy which describes what our abuse prevention and investigation protocol is. The first and formost thing is we have to protect and care for our residents. Remember if you see or suspect you MUST report immediately! We will also start drug testing prior to employment and random. This is also a way to determine if someone is appropriate to care for our residents. Everyone is to read and sign this inservice."

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure an allegedly witnessed incident of staff to resident abuse involving CNA #1 and 1 case mix resident (Resident #1) was immediately reported by staff to ensure residents were protected from the potential of further abuse for 5 (Residents #1 - #5) of 5 case mix residents who were cognitively impaired. CNAs #2 and #3 did not intervene and delayed reporting the incident for approximately 17 hours. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1, who was cognitively impaired and the subject of an allegedly witnessed incident of staff to resident abuse and had the potential to affect 39 residents in the facility who were cognitively impaired as documented on a list provided by the MDS (Minimum Data Set) LPN on 9/25/13 at 3:00 p.m. The facility removed the Immediate Jeopardy prior to the survey entrance date but did not correct the underlying failed practices. On 9/25/13 at 3:15 p.m., the facility was informed of the Immediate Jeopardy removed. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/13 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, required extensive assistance from staff for bed mobility and was totally dependent on staff for transfers. a. The care plan documented, "Problem Onset: 11/4/12 - I display verbally aggressive behavior and sexually inappropriate behavior and verbalization..." b. The Resident Incident Report dated 9/20/13 at 6:00 a.m. documented, "Allegation by (2) CNAs (Certified Nursing Assistants) that another CNA had kick (Resident #1) in the groin and hit him on arm and head when trying to provide am care. Complete body audit done by (Director of Nursing (DON)) no negative findings noted." On 9/20/13 at 1:00 p.m., the urinalysis documented Resident #1 had 1+ blood in his urine. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) -762 form documented, "On 9/20/13, at 6:00 a.m. LPN (Licensed Practical Nurse) #2, on 7PM to 7AM called DON (Director of Nursing) to ask her if she could come on in that a CNA (Certified Nursing Assistant) needed to talk to her. DON arrived at approximately 6:30AM. CNA #2 went to Director of Nursing when she arrived and said she had never seen anything like this before, that while giving care to (Resident #1's) roommate (CNA #1) was standing beside (Resident #1) who is on a low bed due to fall risk and kicked him in the groin area. (Resident #1) said 'You are hurting me.' Then (CNA #1) hit him on the arm per (CNA #2's) statement. (Resident #1) continued to state 'You are hurting me.' (CNA #3) entered (DON's) office and stated she also saw (CNA #1) kick (Resident #1) in the groin. She also stated (Resident #1) said 'You are hurting me.' (CNA #3) also stated (CNA #1) hit (Resident #1) upside the head. All along (Resident #1) is continuing to say 'You are hurting me'." c. An Office of Long Term Care (OLTC) Division of Medical Services (DMS) -762 form documented, "Findings: On 9/20/13, when (CNA #1) came in to be interviewed, I (Administrator) told (CNA #1) an allegation of abuse had been alleged against her and asked if she would have any idea what it was concerning. (CNA #1) stated probably the last night I worked (9/18/13) (reported to work at 11:00 p.m. and ended shift at 7:00 a.m. on 9/19/13) and was changing (Resident #1). I asked her what happed she stated he was resisting care and was kicking and swinging she grabbed his leg to keep him from kicking her. She stated she had no knowledge of why they would lie about the incident. Director of Nursing completed a body audit on (Resident #1). She did not find any trauma, bruising, red areas,or swelling on (Resident #1). Body appeared normal for (Resident #1). On the morning of 9/20/13 he complained of hurting when voiding urine. UA was obtained. It was found he had some blood in urine along with a slight UTI (Urinary tract Infection)..." 1) The DMS-762 witness statement form dated 9/20/13 at 0030 a.m. and signed by LPN #1 documented, "0030 (CNA #2) came to desk and ask me what I considered abuse. I asked her why she was asking me this. She stated she saw a CNA kick a resident. I asked who the CNA was and she told me (CNA #1). I asked her to tell me about what she had seen. She stated her and (CNA #3) were helping Resident A-Bed up and getting him dressed when they saw her (CNA #1) kick (Resident #1). I questioned (CNA #3) and she agreed to what was told to me." 2) The DMS-762 witness statement form dated 9/20/13 at 6:45 a.m. and signed by CNA #2 documented, "I was getting (Resident #1's roommate) ready for morning get up as (CNA #1) and (CNA #3) both CNAs entered the room to assist (Resident #1). (Resident #1) has a low bed due to fall risk, but he was laying in the floor beside the bed on his back. (Resident #1) was kicking at (CNA #1) and she rocked back and forth then jumped back on her left leg then kicked (Resident #1) with her right foot in his genitals. I turned away to continue to help (Resident #2 (Resident #1's roommate)) get his clothes on as (CNA #2) left the room I seen out the corner of my eye (CNA #1) hitting (Resident #1) in the arm. I'm not sure how hard she was hitting him, but he stated multiple times while we were in the room that 'Your hurting me'." On 9/25/13 at 12:47 p.m. CNA #2 stated, "I was in the room already around 5 - 6:30 a.m. last Thursday (9/19/13). (CNA #1) came in and she started getting (Resident #1) up. He peed his bed bad. I actually saw her kick him in the groin. I thought was/is she reallly doing that? Oh my God, I can't believe she did that. I didn't know how hard the kick was. ..I heard him (Resident #1) say, 'Your hurting me, your hurting me.' (CNA #1) kinda went back on her foot and then she hauled off and kicked him. He didn't holler in pain, so that's why I didn't know how hard she kicked him. He was fighting back, trying to kick her too." CNA #2 stated she reported what she saw to the nurses (LPN #1 and LPN #2) Thursday (9/19/13) around 12:00 a.m. (incident happened around 5:00 to 6:30 a.m. CNAs returned for night shift duty that started at 11:00 p.m. on 9/19/13 and was reported on 9/20/13 at 12:00 a.m.) CNA #2 was asked did she go right then and report it? She stated, "No, I didn't." CNA #2 was asked why not? She stated, "I really didn't know if she was for real.. I didn't know if she was serious. I turned around and saw it, he didn't look like he was in distress. I see now that we should've reported it right then. I didn't want to be in confrontation with anyone at work. I'm 23 and she's a lot older than me. I didn't know what she would do to me." 3) The DMS-762 witness statement form dated 9/20/13 (no time given) documented by CNA #3, "I was in Room (Number) picking up dirty linen and I saw (CNA #1) kick (Resident #1) in the growing (groin) area and he stated you are hurting me and then (CNA #1) started slapping him around upside head. (Resident #1) was on a low bed with both legs up. (CNA #1) kick him in the growing area this happen about 6:30 a.m. on 9/19/13 and she was laughing during the time she was hitting him." On 9/25/13 at 10:13 a.m., CNA #3 stated, "We (CNA #2 and CNA #3)entered the room Thursday (9/19/13) morning about 6:30 a.m. (CNA #1) went to (Resident #1), she started hitting on him. He was lying on his back, he had his legs up in the air. She proceeded to kick him in his groin area. He told her 'Stop you SOB, your hurting me.' She just kept on and on. She straddled him, hitting him (open handed) back and forth on the side of his head. She did it about 6 - 7 times. I was in shock. I couldn't believe it cause I'd never seen that before, never seen anyone do a resident that way before. She use to talk about her son fighting on the street, she got that street mentality." CNA #3 was asked did she tell the nurse right then. CNA #3 stated, "No." CNA #3 stated, "It was about 11:00 p.m. the following night (approximately 17 hours later), we told it immediately to (LPN #1), (CNA #2) and I, both told that nurse. It scared us. He just laid there afterwards." CNA #3 was asked if it bothered CNA #1 when they walked in the room? She stated, "Evidently not because she kept on." CNA #3 was asked if she had been inserviced on Abuse and Neglect. CNA #3 stated, "Yes. But the last time, I'm just going to be honest, it's been awhile." CNA #3 was asked if she knew when the nurse reported the allegation to Adminsitration? CNA #3 stated, "Evidently they didn't report it till the next morning (9/20/13)." 4) The DMS-762 witness statement form dated 9/20/13 at 1:53 (p.m.) and signed by CNA #1 documented, "On 18th of Sept around 5:50 a.m. we (CNA #3) were changing (Resident #1's) sheets and drying him. (Resident #1) was kicking and swinging, I then grabbed his leg to keep from kicking me. (Resident #1) is very combative and he don't like to be messed with." 5) The DMS-762 witness statement form dated 9/20/13 at 7:00 a.m. and signed by the DON documented, "At approx. 6AM, LPN #2 called me at home asking if I could come on in that a CNA needed to talk to me. I arrived at the facility by 6:30 a.m. CNA #2 came to me first. CNA #2 stated she had never seen anything like this before, that while she was taking care of (Resident #1's roommate) CNA #1 was standing beside (Resident #1) which was on a low bed (fall risk) and kicked him in the groin area. (Resident #1) became resistant to care and saying over and over 'Your hurting me' then CNA #1 hit him on the arm per CNA #2's statement. During ou (our) discussion of incident CNA #3 another 11/7 CNA came in and stated that she also witnessed CNA #1 kick (Resident #1) in the groin and hit him. She too stated Resident was saying 'stop you are hurting me.' CNA #3 also stated that she heard CNA #1 state she could really hurt him. I asked CNA #2 why she waited to the next morning to report. She stated it really bothered her and she had never seen anything like it before but was not sure what to do. Then she stated she realized she should've done something immediately. CNA #3 stated she did not think CNA #1 could do such a thing but also realized she should have reported immediately. Both CNAs (CNA #2 and #3) were inserviced again on Abuse Protocol immediately. CNA #1 was interviewed and denied allegations. She stated, 'They just lied that's all.' When the Administrator and myself started the interview CNA #1 knew what incident and what resident we were going to talk to her about before we said who it was or when it was. All three CNAs were put on suspension until further notice. I, (DON) performed a complete body audit on (Resident #1) and did not find any bruising or red areas, tip of penis slightly pink. He is incontinent and wears a brief. He did complain of hurting when trying to void." d. On 9/25/13 at 6:40 a.m., a body audit was conducted on Resident #1. The body audit revealed Resident #1 had hemorrhage to the sclera of the left eye. The sclera is dark red blood shot. The Administrator stated Resident #1's son was talking him to see the eye doctor tomorrow 9/26/13. e. Additional interviews were conducted: 1) On 9/25/13 at 6:08 a.m., CNA #4 (employed 3 months on the 11/7 shift) stated, "...I came to work (Wednesday 9/18/13 or Thursday 9/19/13). I was sitting on my hall. The 2 girls (CNA #2 and CNA #3) worked the night before. They came and asked me what they should do about CNA #1. They said they had walked in the room. (Resident #1), he fights and is combative. ...They said she (CNA #1) was in there she had kicked him in his privates, had straddled him and slapped him in the face. He was hollering, 'You SOB, your hurting me.' They said she grabbed him by his leg and jerked him off the bed. I said to them 'You need to go report that.' They said they just reported it to the nurses (LPN #1 and LPN #2), the 11/7 shift LPNs. I really didn't want to believe it but then the next night we went down to change him, he was not acting right. He was totally different. He wasn't moving, saying anything, or combative. I said something to the nurse (LPN #2) about it. She said she would watch him." CNA #4 was asked to clarify when the CNAs reported the allegation. CNA #4 stated the CNAs (CNA #2 and CNA #3) said it happened between 5 and 7:00 a.m. on the 11/7 shift (9/19/13) when CNA #1 was trying to get him (Resident #1) up. CNA #4 stated they (CNA #2 and CNA #3) came in at 11:00 p.m. (9/19/13) and reported the allegation, (approximately 17 hours later). CNA #4 was asked why she thought the CNAs waited to report it? CNA #4 stated they said they were scared. The CNA stated, "LPN #2 asked me why (CNA #1) would do it in front of the CNAs. All I said was (CNA #1) must've felt comfortable with them and thought they wouldn't say anything." CNA #4 stated, "The facility has not asked me about anything, no witness statement, nothing." 2) On 9/25/13 at 7:03 a.m., LPN #3 stated she didn't know anything about the allegation. "...(Resident #1) is hard to handle, he will fight if you try to move him, he will stiffen up when he's combative. I will let him hold my arm while (CNA #1) changes him. That's why he's not hitting her and stuff. ...I don't think they (CNA #2 and CNA #3) would lie about it. They were scared about it and didn't want to get anybody in trouble. But they didn't tell me..." LPN #3 was asked if she had been inserviced since the allegation was reported? LPN #3 stated, "No, I work nights. Sometimes, I don't come to the Inservices." LPN #3 was asked if she had seen any changes in Resident #1 since the incident? LPN #3 stated, "Yes." She was asked, "Do you feel it is a direct result from what happened?" LPN #3 stated, "Yes, he's quiet, not usually like that. He's kinda laying around a lot, but we just did a U/A and started him on an antibiotic. When we change him, he does seem scared, he just lays there. ...but those 2 CNAs wouldn't lie about it." f. On 9/25/13 at 1:45 p.m. the Administrator stated, the DON initiated an inservice regarding reporting abuse and neglect on paper and placed at nurse's station on Friday 9/20/13 for the all nursing staff to read and sign. The Administrator was asked since the inservice was initiated how had the facility monitored the effectiveness of the inservice. She stated, "I'm making rounds and listening as I go up and down the halls. I've not asked staff. But I've scheduled Friday (9/27/13) a (formal) inservice on abuse and neglect." She was informed that of all the CNAs who were working this morning (9/25/13), CNA #5, CNA #6 and LPN #3 had not signed the inservice. 2. The facility removed the Immediate Jeopardy on 9/20/13 prior to the survey entrance date reducing the scope and severity to an E by taking the following actions: a. On 9/20/13 - 6:00 a.m. upon notification of the allegations of abuse the facility suspended CNA #1, #2 and #3. b. On 9/20/13 (no time given), (DON) assessed (Residents #1) for any signs/symptoms of abuse. c. CNA #1 was terminated. According to CNA #1's time card, the last day CNA #1 worked was 9/18/13 from 10:54 p.m. - 6:59 a.m. (9/19/13) and did not return to work. d. According to the DMS-762 dated 9/20/13, "CNA #2 and CNA #3 were also terminated for not stopping the abuse and not reporting immediately and leaving the room with (Resident #1) still in room. Incident occurred on the morning of 9/19/13 when coming on 11/7 shift on (at 11:00 p.m.) 9/19/13. They (CNA #2 and CNA #3) reported sometime during the shift to LPN #1 when they came on 11/7 on 9/19/13. They talked to the Director of Nursing on the early morning of 9/20/13." e. Inservice was initiated on 9/20/13 which documented, "This is a reminder as well as inservice for all employees here at (Nursing Home). We have inserviced and talked about abuse. ...what it is ...how it is ...and what needs to be done to prevent it and what to do if it ocurrs. Attached is our policy which describes what our abuse prevention and investigation protocol is. The first and formost thing is we have to protect and care for our residents. Remember if you see or suspect you MUST report immediately! We will also start drug testing prior to employment and random. This is also a way to determine if someone is appropriate to care for our residents. Everyone is to read and sign this inservice." f. Beginning 9/20/13, the facility initiated interviews with staff and residents to assess staff treatment.