Every finding on record at Cave City Nursing Home Inc

Based on record review, interview, and facility policy review, the facility failed to ensure medications were administered according to physician's orders for one (Resident #40) of five residents reviewed. The findings include: A review of Resident #40’s quarterly Minimum Data Set with an Assessment Reference Date of 06/26/2025, indicated the resident had a Brief Interview for Mental Status score of 14, which indicated Resident #40 was cognitively intact. A review of Resident #40's active Physician's Orders, as of 07/01/2025, revealed the resident had diagnoses which included post-traumatic stress disorder, osteoarthritis, and generalized anxiety disorder. The resident’s Physician’s Orders also revealed the resident had medication orders, with an order date of 04/23/2025, for one benzodiazepine tablet for generalized anxiety disorder, to be given at bedtime, and one compound opioid pain medication tablet for pain, to be given every eight hours as needed. Resident #40’s Physician’s Orders also revealed not to administer either medication within two hours of each other. A review of Resident #40’s Administration History Report, from 06/06/2025 through 06/21/2025, revealed a compound opioid pain medication was administered four times, within the restricted period, with a benzodiazepine. Below are the findings: On 06/06/2025, one benzodiazepine tablet was documented as administered by Licensed Practical Nurses (LPN) #2 at 8:00 PM, and one compound opioid pain medication tablet was documented as administered at 8:01 PM. On 06/12/2025, one benzodiazepine tablet and one compound opioid pain medication tablet were documented as administered by LPN #4 at 8:05 PM. On 06/15/2025, one benzodiazepine tablet was documented as administered at 8:13 PM, and one compound opioid pain medication tablet was documented as administered by LPN #3 at 8:14 PM. On 06/21/2025, one benzodiazepine tablet and one compound opioid pain medication tablet were documented as administered by LPN #4 at 7:19 PM. A review of Resident #40’s Psychiatric Clinic Progress Note, dated 04/23/2025, revealed for Medication safety: Instruct nursing home staff to separate administration of pain medication and [benzodiazepine] by a minimum of two hours for patient safety. A review of a Psychiatric Clinic Visit Sheet for Resident #40, dated 04/23/2025, and signed by the provider, read in part, be sure there is a two-hour window between opioid pain pill, and benzodiazepine. During a phone interview on 07/01/2025 at 9:34 AM, with LPN #1 at Resident #40's psychiatric clinic, LPN #1 confirmed the prescriber would routinely write the order as indicated with benzodiazepines and opioids. The medications were not to be administered together, which was why the prescriber ordered not to administer the medications within two hours of each other. During a phone interview on 07/02/25 at 10:02 AM, LPN #2 confirmed her initials were on Resident #40’s electronic medical record for administration of the compound opioid pain medication on 06/06/2025 at 8:00 PM. LPN #2 indicated Resident #40 often voiced complaints of pain, usually in the evening. LPN #2 confirmed the resident would receive pain medication with anxiety medication, and they were usually given at the same time, at the resident’s request. She then confirmed the facility’s expectation of the staff was to administer medications according to the physician's order and to comply with the medication administration policy. LPN #2 was asked to confirm the meaning of an order that specifically stated not to administer a medication within two hours of another medication. LPN #2 confirmed that a physician's order with those parameters would not be administered within the time period specified. She then reported that the purpose of not combining the two medications would be for complications such as oversedation, overdose, and kidney problems. LPN #2 confirmed when administering medications, she compared the medication with the physician's order to ensure the correct rights were observed. LPN #2 confirmed that if Resident #40 had an order not to administer a benzodiazepine and a compound opioid pain medication together, then they should not be administered together. During an interview on 07/02/2025 at 10:15 AM, the Medical Director confirmed he was familiar with Resident #40’s specific medication order not to administer their benzodiazepine and compound opioid pain medication at the same time, and to wait at least two hours between the administrations. The Medical Director indicated he expected staff to administer medications as written by the prescriber, and he had not been notified of a medication error with Resident #40. During an interview on 07/02/2025 at 10:20 AM, the Assistant Director of Nursing (ADON) confirmed Resident #40 often voiced complaints of pain and was medicated with as needed pain medications. The ADON confirmed the expectation of staff was to follow the Physician's Orders as written, and if the order was written as do not administer medications within two hours of each other, then they should not be administered. The ADON confirmed that the order for Resident #40, written by the practitioner, was not to administer the benzodiazepine and compound opioid pain medication within two hours of each other. She then stated the purpose of waiting between benzodiazepines and opioids was the possibility of respiratory depression. The ADON confirmed the facility’s expectation of staff was to follow the facility’s medication administration policy. During an interview on 07/02/2025 at 10:28 AM, the Director of Nursing (DON) confirmed Resident #40 occasionally had complaints of pain and was medicated with as needed medications. The DON confirmed Resident #40 had routine orders for an antianxiety medication, a benzodiazepine, and a compound opioid for pain. He then confirmed the benzodiazepine was given at 8:00 PM. The DON reported the expectation of the facility, was for staff to follow facility policies, and to administer medications as written by the provider. If orders were written not to administer two medications within two hours of each other, then they should not be administered within the restricted time. The DON reported that benzodiazepines and opioids were not given together to avoid respiratory depression. During a phone interview on 07/02/2025 at 5:04 PM, LPN #3 confirmed familiarity with Resident #40. LPN #3 had provided care and administered medications to the resident. LPN #3 confirmed Resident #40 often voiced complaints of pain and was medicated, if it was within the parameters of the physician's order. LPN #3 confirmed the pain medication that Resident #40 often received was an opioid. LPN #3 confirmed Resident #40 had physician's orders for a benzodiazepine antianxiety medication. LPN #3 confirmed the physician's orders should be administered, as written. LPN #3 stated if the order specifically was written not to give medications together, then they should not be given together. LPN #3 confirmed knowledge of the medication administration policy, and to administer medications as written. LPN #3 denied knowledge of the two-hour restriction between Resident #40’s benzodiazepine and compound opioid pain medication. A review of a facility policy, Medication Administration, with a review date of 12/02/2024, revealed medications were to be administered as ordered by the physician. Policy Explanation and Compliance Guidelines ensure that the six rights of medication administration are followed: Right Time, Compare medication with medication administration record to verify the correct time. Administer within one hour before or after the scheduled time unless otherwise ordered by the physician. Administer medication as ordered in accordance with manufacture specification. A review of the National Institute on Drug Abuse, with a review date of 11/07/2022, indicated taking opioids in combination with other central nervous system depressants like benzodiazepines increased the risk of life-threatening overdose.

Based on record review and interview, the facility failed to provide Provider Enhanced Reporting Payroll Based Journal (PBJ) mandatory staffing data to the Center for Medicare and Medicaid Services (CMS) for the 2nd Quarter of 2025. The findings include: Upon review of the PBJ Monthly Data Report provided by the facility, PBJ data was submitted for January 2025, February 2025, and March 2025 to the state, but not to CMS. During an interview on 06/30/2025 at 2:30 PM, the Administrator confirmed being responsible for completing the staffing reports and sending the PBJ data to the state and to CMS. When asked about the process for submitting the PBJ report, the Administrator stated, I was submitting the information in the QuickBase program monthly. I was unaware the data wasn't going to CMS due to not being trained properly and not being notified by CMS that they were not receiving the data. I didn't know until you notified me that they did not have the data. We called them after notification to see if they would take it, and they said they would not at this point. It's now fixed and will be submitted correctly for this next quarter. This surveyor requested a policy or procedure on reporting PBJ data, and the Administrator stated, “We do not have a policy or procedure regarding PBJ data and reporting.”

Based on observation, interview and record review, the facility failed to ensure resident fingernails were kept clean for 3 (Residents #8, #53, and #66) of 3 sampled residents, oral hygiene was being completed for 1 (Resident #66) of 1 sampled resident, and male residents were shaved to promote good personal hygiene for 2 (Resident #53, and #66) of 2 sampled residents. The findings are: A facility policy titled, 'Activities of Daily Living (ADLs)' dated 10/04/2022 documented, .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . 1. Resident #8's Care Plan dated 03/15/2019 revealed, .CNA'S [Certified Nursing Assistants] assist to keep nails clean and observe for jagged edges report prn [as needed] Nurse provide trimming due to DM [Diabetes Mellitus] . a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/2023 documented Resident #8 scored 2 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS). Section GG0130. Self- Care revealed in section I. Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face, and hands (excludes baths, showers, and oral hygiene). 05. Setup or clean-up assistance. b. On 04/01/2024 at 11:38 AM, Resident #8's fingernails were long and chipped. When asked, Do staff trim your nails or do you like them long? Resident #8 stated, I wish someone would cut them. c. On 04/02/2024 at 10:47 AM, the Surveyor interviewed CNA #5 at the Resident #8's bedside and asked, Can you describe what is under the resident's fingernails? CNA #05 stated, Looks like food under the nails. When asked, Can you describe what the resident's fingernails look like? She stated, They need to be filed and the nurse will trim them because [Resident #08] is diabetic. When asked, How often should the residents nails be cleaned, filed and trimmed? She stated, When showering and when you have extra time. The nurse trims because we can't, [Resident #8] is diabetic. d. On 04/02/2024 at10:50 AM, the Surveyor asked Registered Nurse (RN) #2, Can you describe what is under the resident's fingernails? She stated, [Resident #8] has a broken nail too, but food. When asked, Can you describe what the resident's fingernails look like? She stated, Some of them are jagged and they shouldn't be. When asked, How often should the residents nails be cleaned, filed and trimmed? She stated, A nurse has to trim the nails, CNA's clean and file them. e. On 04/04/2024 at 09:06 AM, the Surveyor asked the Director of Nursing (DON), Should [Resident #8's] fingernails be kept clean and trimmed? The DON stated, Yes. When asked, Why? She stated, To reduce the risk of infection and injury. 2. During an observation on 04/01/2024 at 10:59 AM, Resident #53 had facial hair 0.5 inches long on the face and neck, and the fingernails were 0.5 to 0.75 inches long with jagged edges and a brown substance under the nails and around the cuticle areas of both hands. a. During a concurrent observation and interview on 04/01/2024 at 03:27 PM, Resident #53 had facial hair 0.5 inches long on the face and neck, and the fingernails were 0.5 to 0.75 inches long with jagged edges and a brown substance under the nails and around the cuticle areas of both hands. b. During a third observation on 04/02/2024 at 08:28 AM, Resident #53 had facial hair 0.5 inches long on the face and neck, and the fingernails were 0.5 to 0.75 inches long with jagged edges and a brown substance under the nails and around the cuticle areas of both hands. During an interview on 04/03/2024 at 03:13 PM, CNA #1 was asked who was responsible for making sure nails were trimmed and cleaned. CNA #1 said the CNAs are, unless they are diabetic then the nurses trim them, but the CNAs still clean them. The Surveyor asked when does a resident get their nails trimmed and cleaned? CNA #1 said daily or as needed. The Surveyor asked should a resident have 0.5 inch jagged nails with a brown substance under the nails and around the cuticle area? CNA #1 replied absolutely not. CNA #1 was asked what negative outcome could occur from long jagged dirty fingernails? CNA #1 said they could scratch themselves and cause a skin tear or get an infection. The Surveyor asked when does a resident get shaved? CNA #1 said on shower days. The Surveyor asked who was responsible for making sure a resident gets shaved? CNA #1 said the CNAs are. The Surveyor asked if a resident has 0.5 inch whiskers on the face and neck and the resident doesn't want them, is this acceptable? CNA #1 said absolutely not. During an interview on 04/03/2024 at 03:18 PM, the DON was asked, who was responsible for making sure residents nails are trimmed and cleaned? The DON said, the CNAs are, unless they are diabetic then the nurses do them, but the nursing staff can clean the nails. The DON was asked, when do the residents get their nails trimmed and cleaned? The DON said they should be cleaned daily and trimmed as needed. The DON asked if a resident should have 0.5 to 0.75 inch jagged nails with brown substance under nails and around the cuticles on both hands? The DON said, absolutely not. The DON was asked what negative outcome can occur from nails being left long and jagged with a brown substance under them? The DON said they can get an infection. 3. Resident #66's Care Plan dated 10/06/2022 revealed Resident #66 had an Activity of Daily Living (ADL) self-care performance deficit related to Disease Process . Review of the Admit Diagnoses revealed . impaired balance, weakness, muscle wasting Limited x one assist . bathing/ showering: Provide assist 2 x weekly and prn give choice of AM or PM provide privacy and maintain dignity, assist with nail care keeping clean and trimmed prn - Report Resident #66 request only one shower per week Saturday - staff continue to offer x 2 week respect wishes/[Resident #66] has requested to have only one bath per week and on Saturday. a. The Quarterly MDS with an ARD of 12/28/2023 revealed, Section GG0130. Self-Care . I. Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face, and hands (excludes baths, showers, and oral hygiene) .3. Partial/ moderate assistance . b. On 04/01/2024 at 02:56 PM, Resident #66 was lying in bed unshaven. Resident #66 stated, They won't shave it. Resident #66's fingernails had a brown/black substance underneath them. Resident #66 stated, I only get one bath every week. Resident #66 stated staff do not help the resident clean the resident's mouth. Resident #66 had a thick yellow build up in the mouth. c. On 04/02/2024 at 10:36 AM, the Surveyor interviewed CNA #4 and asked, Can you describe how the resident ' s nails appear to you? She stated, Dirty. When asked, How often should his fingernails be cleaned? She stated, At least when [he/she] gets a shower. When asked, Does the resident appear to have been recently shaved? She stated, No, it looks long, like it's been a while. When asked, Can you describe how the inside of the residents mouth looks? She stated, [Resident #66] needs oral care definitely. [The resident] has thick stuff in there. d. On 04/02/2024 at 10:42 AM, the Surveyor interviewed RN #1 and asked, Can you describe how the resident's nails appear to you? She stated, They are dirty, and need cleaned. When asked, How often should the residents nails be cleaned? She stated, Every time they are dirty and at every shower. When asked, Does the resident appear to have been recently shaved? She stated, No, [the resident] needs one. When asked, Can you describe how the inside of the residents mouth looks? She stated, [The resident] should be cleaned up, that mouth isn't clean. e. On 04/04/2024 at 09:06 AM, the Surveyor asked the DON, Should [Resident #66] fingernails be kept clean, face shaved, and oral care provided? She stated, Yes. When asked, Why? She stated, To reduce risk of infection, and should be shaved because it's [Resident #66's] choice. 49071

Based on interview and record review, the facility failed to ensure written information regarding the right to formulate an advanced directive was provided to the residents or their responsible parties, to enable them to make informed decisions regarding which measures would be provided or withheld at the end of life for 2 (Residents #8 and #45) of 3 residents reviewed for Advance Directive. The findings include: 1. Resident #45 was admitted on [DATE] with a diagnosis of Dementia. a. On 04/01/2024 at 02:31 PM, during a review of Resident #45's chart, no advance directive was located. b. On 04/02/2024 at 12:04 PM, the Facility provided a Do Not Resuscitate (DNR) order, and an order appointing guardian of the person and estate and an order for disbursement of funds. c. On 04/04/2024 at 09:01 AM, the Director of Nursing (DON) was asked, Should [Resident #45] have an advance directive located in the resident's medical chart? She stated, Yep. When asked, Why? She stated, So we know what [Resident #45's] wishes are. 2. Resident #8 was admitted on [DATE] with a diagnosis of Dementia. a. On 04/01/2024 at 02:19 PM, during a review of Resident #8's chart, an advance directive was not found. b. On 04/02/2024 at 12:08 PM, the Facility provided a DNR order and a durable Power Of Attorney (POA), but no advance directive for Resident #8. c. On 04/04/2024 at 09:01 AM, the Director of Nursing was asked, Should [Resident #8] have an advance directive located in the residents medical chart? She stated, Ya, should have it on [Resident #8's] chart. When asked, Why? She stated, So we know what [Resident #8's] wishes are. 49071

Based on observation, interview and record review, the facility failed to ensure the clothes dryers remained free of lint build-up to decrease the potential for fire and loss of laundry services in 1 of 1 laundry room. This failed practice had the potential to affect all 78 residents due to the potential for the interruption of laundry services and due to the proximity of the laundry room. The findings are: On 04/03/2024 at 11:03 AM, the Surveyor observed all 3 dryers in the laundry room had a 0.5 inch lint buildup on their lint screens. On 04/03/2024 at 11:12 AM, Laundry Worker #1 was asked, how often do you remove the lint from the dryers? Laundry Worker #1 said, every two hours. The Surveyor asked, can you explain why the dryer lint removal log was not signed off on 04/02/2024 for the evening shift? Laundry Worker #1 said, I guess she forgot to sign it. The Surveyor asked, why is the log not signed for this morning (04/03/24)? Laundry Worker #1 said, I was going to sign them off, but I was going to lunch first. The Surveyor asked, what can happen if lint isn't removed every two hours? Laundry Worker #1 said, chance it could catch on fire. On 04/04/2024 at 8:37 AM, the Administrator was asked, how often should lint be removed from the dryers? The Administrator said, every two hours. The Surveyor asked, how is this documented to prove the lint had been removed? The Administrator said, on the log sheet. The Surveyor asked, why is it important to assure the lint is removed from dryers every two hours? The Administrator said it was to prevent a fire. A facility policy titled, Laundry and Linen Services, documented, .job description for Day Laundry . Clean lint filters on dryers every 2 hours. Document on dryer log . The Dryer Log indicates that on 04/02/2024 from 06:00 PM through midnight that all three dryers had not had lint removal checked off. On 04/03/2024 the lint removal log had not been signed off at 08:00 AM or 10:00 AM.

Based on observation, interview and record review, the facility failed to ensure proper handwashing/hand sanitizing was completed during dining observation. The findings are: On 04/01/2024 at 12:06 PM, the Surveyor observed Certified Nursing Assistant (CNA) #2 take a tray from a meal cart and set it up for a resident, then CNA #2 removed another tray from the cart and set it up for another resident. The CNA did not perform hand sanitation before providing either tray. During a concurrent observation on 04/01/2024 at 12:06 PM, the Surveyor observed CNA #3 removing a tray from a meal cart and setting it up for a resident. The CNA then repeated the process without performing hand sanitation for two other residents. CNA #3 then went and picked up a chair and placed it in between 2 residents and began feeding both residents without performing hand sanitization before beginning, or between feeding each resident. During an interview on 04/01/2024 at 12:52 PM, CNA #3 was asked, what should be done before serving a tray to a resident? CNA #3 said, sanitize my hands. During an interview on 04/12/2024 at 12:55 PM, CNA #4 was asked, what should be done before serving a tray to a resident? CNA #4 said, sanitize my hands. CNA #4 was asked, what should be done between passing out trays? CNA #4 said, sanitize my hands. CNA #4 was asked, what should be done after picking up a chair and setting down to start feeding a resident? CNA #4 said, sanitize my hands. CNA #4 was asked, what should be done in between feeding 2 different residents? CNA #4 said, sanitize my hands. During an interview on 04/03/2024 at 03:13 PM, the Director of Nursing (DON) was asked what should be done before and between passing trays. The DON stated, Sanitize hands. The DON was asked when feeding 2 residents what should be done in between feeding each of them? The DON said, sanitize hands. The DON was asked, why should staff sanitize their hands during meal service? The DON said, to prevent spreading germs. A facility policy titled, Hand Hygiene, dated 10/04/2022, indicated, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .

Based on observation, interview and record review, the facility failed to ensure thickened liquids kept in a cooler remained on ice/with ice packs for 1 (Resident #14) of 1 sampled resident who required thickened liquids. The findings are: The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/08/2024 documented Resident #14 scored 7 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS). The Physician orders dated 04/01/2024 documented, Regular diet, Mechanical Soft texture, Nectar consistency add yogurt, applesauce and nectar thick liquids to each meal for choking. On 04/01/2024 at 10:29 AM, Resident #14 had a red and white cooler at the bedside. Thickened water was found in the cooler sitting in water/melted ice. On 04/02/2024 at 10:38 AM, the Surveyor interviewed Certified Nursing Assistant (CNA) #4 at Resident #14's bedside and asked, Should the residents thicken liquids in the cooler be kept on ice? CNA #4 stated, Yes, it should've been passed with ice water because [Resident #14] is nectar thick. On 04/02/2024 at 10:39 AM, the Surveyor interviewed Registered Nurse (RN) #1 at Resident #14's bedside and asked, Should the residents thicken liquids in the cooler be kept on ice? She stated, Yes. When asked, Why should it be kept on ice? She stated, I guess because [Resident #14] likes it cold. On 04/02/2024 at 09:06 AM, the Director of Nursing (DON) was asked, Should [Resident #14's] thickened liquids at the bedside be kept cold with ice or ice packs? She stated, Yes. When asked, Why should thickened liquids be kept cold? She stated, It helps to have them at bedside. A facility policy titled, Thickened Liquids, dated 10/04/20/2022 revealed, .Policy Explanation and Compliance Guidelines: Personal coolers and ice packs will be provided at the resident's bedside to keep thickened liquids within easy reach of the resident .

Based on observation, record review, and interview the facility failed ensure humidified oxygen was administered at the physician prescribed rate for 1 (Resident #58) of 6 (R #4, R #17, R #24, R #58, R #69, R #233) sampled residents who received oxygen according to a list provided by the Director of Nursing (DON) on 2/3/23. The findings are: 1.Resident #58 had diagnoses of Chronic Obstructive Pulmonary Disease and Asthma. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/23 documented the resident scored 3 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); oxygen used in the past 14 days while a resident. a. Physician Orders dated 4/8/21 documented, .02 [oxygen] at 2L[liters] via NC [nasal canula] PRN [as needed] for SOB [shortness of breath] 02 [oxygen] >90% [percent] .change 02 tubing q [every]72 hours and PRN every 72 hours .Change water on concentrator weekly on Fridays and PRN one time a day every Fri . b. Resident #58's Comprehensive Plan of Care documented, [R #58] .COPD .Revision on: 07/29/2021 .OXYGEN provide 2 lpm via NC as ordered prn .change all tubing and humidifier bottle as directed .Revision on: 10/18/2022 . c. On 01/30/23 at 11:09 AM, Resident #58 sat in a wheelchair in her room. An oxygen concentrator was, set to infuse at a rate between the 3 1/2 [half] and 4 liters per minute (lpm). An empty humidifier bottle was attached by tubing to a nasal canula. The empty humidifier bottle was dated 1/6/23. The nasal canula was placed in a plastic bag and attached to the concentrator. The resident was not receiving the oxygen treatment at the time of the observation. d. On 01/30/23 at 02:55 PM, Resident #58 was lying in bed the nasal canula administered oxygen in the nose. The oxygen concentrator administered oxygen at a rate between 3 1/2 to 4 lpm. The nasal canula was attached to an empty humidifier bottle dated 1/6/23. e. On 02/02/23 at 2:31 PM, the Surveyor entered Resident #58 room with Licensed Practical Nurse (LPN) #2. The resident was lying in bed. Oxygen concentrator was not on at that time. The surveyor asked LPN #2 if Resident #58 used oxygen. She stated, yes, prn [as needed]. The Surveyor asked, what is the rate [of administration] ordered? She stated, 2 [liters per minute] (lpm) The Surveyor asked, when is the humidifier filled; should it be administered empty? She stated, it should be done weekly, they change the tubing every 3 days. No. The Surveyor asked, should it be administered between 3 1/2 and 4 lpm? She stated, no. It should be on 2. LPN #2 stated, let me check. She turned on the oxygen concentrator. The concentrator was set to administer between 3 1/2 and 4 lpm. She turned the administration rate to 2 lpm. f. On 02/03/23 at 4:02 PM, the Surveyor asked the DON, if a resident's oxygen is ordered to be administered at 2 lpm, should it be administered at 3 1/2 to 4 lpm? She stated, no. The Surveyor asked, when are the humidifiers filled? She stated, the humidifier is every 72 hours and as needed. The Surveyor asked, should it [the oxygen] be administered when the humidifier is empty? She stated, no. g. A Policy provided by the DON on 2/2/23 titled, Oxygen Administration, documented, .Oxygen is administered under orders of a physician .Change humidifier bottle when empty, every 72 hours .

Based on observation and interview the facility failed to ensure that dishes and utensils were stored properly, food was covered, and hands were washed between clean and dirty tasks to minimize the risk of cross contamination. The failed practice had the potential to affect 82 residents who received their meals from 1 of 1 kitchen according to a list provided by the administrator on 2/3/23 at 8:28 AM. a. On 1/30/23 at 11:20 AM, three nested mixing bowls were stored right side up. There were two large metal pans that were right side up under the steam table. b. On 1/30/23 at 12:05 PM, the tray line was serving lunch, the insulated base and dome plate covers were stored with the inside exposed to air and contaminants. c. On 2/2/23 at 10:42 AM, there were two trays of rolls sitting on the shelf above the range. The rolls were uncovered and open to contaminants. Four full size steam table pans of strawberry cake were cooling on the worktable located toward the back of the kitchen. The cakes were uncovered and open to air and contaminates. d. On 2/2/23 at 10:45 AM, Dietary Employee (DE) #1 used a hot pad and obtained a stainless-steel bowl from the oven. DE #1 placed 10 servings of green beans in the bowl for the residents who required a pureed diet. Dietary Employee #1 used the hot pad and poured the green beans into the bowl of the [named blender]. With contaminated hands, DE #1 obtained a 1/4 steam table pan, a can of nonstick cooking spray, and applied the spray to the pan. As the green beans were blended DE #1 used the scraper in the top of the [named blender] lid and scraped the side of the bowl during processing. DE #1 placed her hand inside her pocket and obtained a marker. She wrote the date and food name on a piece of aluminum foil and then placed the foil on top of the 1/4 steam table pan to cover it. DE #1 opened the oven and placed the green beans in the oven. DE #1 took the bowl, lid, and blade of the [named blender] to the dish room. At no time during this process did DE # wash her hands. e. On 2/2/23 at 10:55 AM, DE #1 approached the oven, used her hand to open the oven door, utilized a hot pad, and removed a bowl of breaded chicken patties. The bowl of chicken patties was placed on the worktable by the base of the [named blender]. DE #1 used tongs and placed the chicken patties into the bowl. DE #1 completed this process 3 times and also completed the mechanical soft diets. When she completed the chopping process DE #1 obtained a marker and wrote the date and food name on top of a piece of aluminum foil which was used to cover the chicken. DE #1 returned the steam table pan to the oven. f. On 2/2/23 at 11:10 AM, DE #1 used a hot pad and retrieved a bowl of chicken patties from the oven to process for 10 residents who received a pureed diet. DE #1 retrieved a Styro-foam cup, opened the reach-in refrigerator and obtained a container of chicken broth base. After she added a spoon full of the base to the cup, she took the cup to the coffee maker/dispenser and added hot water. DE #1 returned to the workstation. DE #1 repeated the process of making chicken broth 3 times. When DE #1 completed the puree of the chicken, DE #1 retrieved her marker from her pocket. She wrote the date and food name on top of foil and placed it on top of the steam table pan and folded the foil around the edges. g. On 2/2/23 at 11:20 AM, Dietary Employee #1 opened the door to the walk-in refrigerator and retrieved a carton of milk. She opened the carton and poured the milk into a measuring cup. She took the cup to the microwave, opened the door, and placed the cup inside for warming. The warm milk was brought back to the workstation and was added to hot rolls which had been placed in the bowl of the [named blender]. DE #1 returned to the walk-in refrigerator for a second carton of milk. She warmed the milk a second time. She did not wash her hands prior to the return to the workstation. When puree process was completed, DE#1 retrieved her marker and wrote the date and food name on the aluminum foil which was then placed on top of the container. The Steam table pan was then returned to the oven. h. On 2/2/23 at 11:51 AM, DE #2 removed the lids of the steam table pans which contained the lunch meal. Without washing her hands, Dietary Employee #2 continued to take the temperatures of the food and served the lunch meal. i. On 2/3/23 at 8:28 AM, a policy entitled, Handwashing Guideline for Dietary Employees states: 6. Frequency of Handwashing a. After hands have touched anything unsanitary i.e. [that is] garbage, soiled utensils/equipment, dirty dishes, etc. f. While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. j. After engaging in any activity that may contaminate the hands. j. On 2/3/23 at 8:40 AM, the Surveyor asked the Dietary Manager, how should dishes and pans be stored? She stated, upside down. The Surveyor then asked, when should hands be washed? Dietary Manager stated, after any task.

Based on observation, record review, and interview, the facility failed to ensure palm grips was consistently utilized to prevent further decline in range of motion for 1 (Residents #45) of 5 (Resident #19, R #45, R #32, R #33 and R #23) sample mix residents who had contractures. The findings are: 1.Resident #45 had diagnoses of Alzheimer's and Contractures. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/22 documented the resident was severely impaired in cognitive skills for daily decision, required total assistance of two person assist for bathing, and extensive assistance of two-person assist for bed mobility, transfer, dressing, toilet use, and personal hygiene; had impairment to the upper extremity on one side. a. The Physician Order dated 3/8/22 documented, Ensure bilateral palm grips are in place every morning and at bedtime for contractures . b. The revised Care Plan documented, [Resident's Name] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] . Alzheimer's . Limited Mobility, . CONTRACTURES: . Review Order Ensure Bilateral Palm Grips are in place q [every] morning and at bedtime r/t contractors report s/s [signs/symptoms] of worsening PRN [as needed] . c. On 1/30/23 at 11:48 AM and on 2/2/23 at 10:33 AM, Resident #45 sat in a [named] chair, her right hand was in fist position with no positioning device in place. d. On 2/02/23 at 10:45 AM, LPN [Licensed Practical Nurse] #1 accompanied the Surveyor to Resident #45's room. The Surveyor asked LPN #1, , does Resident #45 have any contractures? LPN #1 stated, I do not think so. The Surveyor asked, is Resident #45 able to open her right hand? LPN #1 attempted to open Resident #45's right hand and stated, no. The Surveyor asked, should Resident #45 have a positioning device in place? LPN #1 stated, I will have to look in her orders and Care Plan. LPN #1 proceeded to search into the resident's Electronic Health Record and stated, according to the Physicians Orders, yes, she should have a device in place. The Surveyor asked, who is responsible to ensure the positioning device is in place? LPN #1the Restorative Assistant. e. On 2/02/23 at 4:24 PM, the Policy on Restorative Nursing Programs was provided by the DON documented, it is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Nursing personnel are trained on basic, or maintenance nursing care . This training may include, but not limited to: . Assisting residents in adjustment to their disabilities and use of any assistive devices . Residents . will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include: . Splint or brace assistance.

Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) was completed accurately, related to functional status for 1 (Resident #33) of 4 (Resident #32, R #23, R #33, and R #45) sampled residents who required extensive assistance with eating. The findings are: 1.Resident #33 had a diagnosis of Moderate Protein-Calorie Malnutrition. The Annual Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 11/27/22 documented the resident scored 3 (0 - 7 Indicates Severely Impaired) on a Brief Interview for Mental Status (BIMS); required limited assistance with one person assist for eating; had a feeding tube and was on a mechanical altered diet. a. The Physician Order dated 1/12/21 documented, Regular diet Mechanical Soft texture, Nectar consistency . b. The revised Care Plan dated 5/21/21 documented, [Resident's Name] has an ADL [Activities of Daily Living] self-care performance deficit . EATING: feeding tube and oral diet as directed . current order for regular w. Mech [mechanical] soft and Nectar liquids If resi. [resident] eats more than 50% [percent] of breakfast or lunch hold bolus feeding . c. The Physician Order dated 10/26/22 documented, Enteral Feed Order two times a day give 1 can bolus (named fortified nurtrition) 1.5, May substitute [named protein supplement] 1.5 . Enteral Feed Order in the evening Run [named fortified nutrition] 1.5 Cal [calories] at 60mL/hr [milliliter/hour] for 14 hours 4pm-6am May sub with [named protein supplement] 1.5 . d. The MDS section G0110 Functional Status (H) documented, . Eating - Self- Performing (2) limited assistance; Support (2) One-person physical assist[assistance] . e. On 1/30/23 at 12:40 PM, the resident was in the dining room for meal service. A staff member was sitting beside her, spoon feeding her a regular mechanical diet for lunch. f. On 2/02/23 at 2:55 PM, the Surveyor asked the MDS Coordinator, who completes section G of the MDS? The MDS Coordinator stated, I do. The Surveyor asked, what level of assistance does Resident #33 require for eating? The MDS Coordinator stated, extensive. The Surveyor asked, the annual MDS for Resident #33, under functional status for eating, is it coded correctly? She replied, no, I will do a modification.

Based on observation, record review, and interview, the facility failed to ensure food items were dated when received and when opened; the ice machine was maintained in clean condition; dented cans were removed from stock; dietary staff washed their hands between dirty and clean tasks; hot foods were maintained at or above a temperature of 135 degrees Fahrenheit (F.) while awaiting service; and kitchen appliances were maintained in sanitary condition to decrease the potential for food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 65 residents who received meals from the kitchen, as documented on a list provided by the Assistant Director of Nursing on 10/08/21. The findings are: 1. On 10/04/21 at 10:24 A.M., the following opened food items were stored in Refrigerator #1 in the kitchen with no opened date documented on the products: a. One carton of Med Pass. b. One carton of tomato juice. c. One bottle of lemon juice. d. Two containers of apple juice. e. Two containers of grape juice. f. One gallon of barbecue Sauce. g. One gallon of pickles. 2. On 10/04/21 at 10:29 A.M., there was a sack lunch stored in Refrigerator #1 in the kitchen. The Dietary Manager (DM) was asked what was in the bag. She replied, That's an employee's lunch. 3. On 10/04/21 at 10:30 A.M., the following food items were stored in Refrigerator #1 in the kitchen without a shelf date (received date): a. Three containers of grape juice. b. Two tubs of potato salad. 4. On 10/04/21 at 10:35 A.M., the following food items were stored in the walk-in cooler in the kitchen without a shelf date: a. One package of shredded lettuce. b. Eighteen containers of juice of the juice dispenser. 5. On 10/04/21 at 10:39 A.M., the following food items were stored on the bread rack with no shelf date: a. One package of hamburger buns b. Two packages of hot dog buns c. Four loaves of wheat bread d. Six loaves of white bread 6. On 10/04/21 at 10:42 A.M., there was one opened loaf of white bread on the same bread rack with no shelf date and no opened date. 7. On 10/04/21 at 10:45 A.M., the following items were stored in the dry goods area with no shelf date: a. One large box of glazed pies b. Seven boxes of peanut butter crackers 8. On 10/04/21 at 10:47 A.M., there was dented can of Great Northern Beans and a dented can of Fruit Cocktail on the shelf in the dry goods area. 9. On 10/04/21 at 10:54 A.M., the Dietary Manager (DM) opened the front of the deep fryer. There was a thick, light-brown substance all over the inside of the door and under the deep fryer area. The DM was asked to describe what she saw. She replied, A lot of grease build-up. She was asked how often the deep fryer was cleaned. She replied, They are supposed to clean it after each use. 10. On 10/04/21 at 10:56 A.M., there was an open can of non-stick cooking spray sitting on top of the microwave in the kitchen area with no shelf date on it. 11. On 10/04/21 at 10:58 A.M., Dietary Employee #1 opened the left oven door. There was a thick black substance covering the bottom of the oven. She was asked to describe what she saw. She replied, Looks like spillage. She was asked how often the ovens were cleaned. She replied, I don't know; I only work Saturday, Sunday, and Monday. The DM was asked how often the ovens were cleaned. She replied, They are supposed to be cleaned after each use. 12. On 10/04/21 at 10:58 A.M., the DM opened the ice machine on the Blue Hall. There was a watery, brown substance on the white plastic that holds the ice inside the front of the machine. The DM was asked to describe what she saw. She replied, It looks like brown slime. When the substance was wiped with a white paper towel, a brown residue transferred onto the paper towel. The DM was asked how often the ice machine was cleaned. She replied, I don't know; Housekeeping is supposed to clean it. 13. On 10/05/21 at 09:10 A.M., the hot water sanitization dishwasher temperatures were: Wash temperature 150 degrees Fahrenheit (F), Rinse tank temperature 150 degrees F, and Final rinse temperature 190 degrees F. The manufacturer's label on the front of the dishwasher documented, .Rinse tank minimum temperature 160 degrees Fahrenheit . 14. On 10/05/21 at 11:02 A.M., DE #2 touched her shirt pocket with her bare hand. Without washing her hands, she poured broth into the blender, then measured five #8 scoops of meatloaf into the blender to puree for residents for lunch. 15. On 10/05/21 at 11:04 A.M., DE #2 touched a food cart that was holding dirty dishes with her bare hands. She then picked up a can of non-stick spray and then opened a drawer and removed a utensil. Without washing her hands, she then picked up a pan, to put the pureed meat into, touching the inside of the pan with her thumb. She then scooped the pureed meat into the pan to be served to the residents. 16. On 10/05/21 at 11:08 A.M., DE #2 touched the menu on the wall, then she opened a drawer and removed a scoop. She then used a #8 scoop and placed 5 scoops of mixed vegetables into a bowl. She then picked up a can of non-stick spray and sprayed the inside of a pan. She turned a page in the recipe book. She picked up a container of beef base and placed it inside the refrigerator. She then went into the walk-in cooler and got a carton of milk. Without washing her hands, she opened the blender and scooped the mixed vegetables into the blender to puree for residents for lunch. 17. On 10/05/21 at 11:20 A.M., DE #2 picked up a carton of milk and a measuring cup. She then touched the pocket on her shirt. Without washing her hands, she picked up a bowl containing 5 rolls, touching the inside surface of the bowl with her thumb. She then placed the 5 rolls into the blender to puree for residents for lunch. 18. On 10/05/21 at 11:50 the food temperatures on the steam table were: a. Puree rolls 120 degrees F b. Mashed potatoes 130 degrees F 19. On 10/07/21 at 1:39 P.M., DE #2 was asked what she should do between dirty and clean tasks. She replied, Wash your hands, constantly. She was asked what could happen if you don't wash your hands. She replied, Spread germs and bacteria. 20. On 10/07/21 at 1:50 P.M., the DM was asked what staff should do between dirty and clean tasks. She replied, Wash their hands. She was asked what could happen if they don't wash their hands. She replied, Cross-contamination. She was asked if all foods should be labeled when they are stored in the kitchen. She replied, Yes. She was asked if all food should be dated when they are opened. She replied, Yes. She was asked why. She replied, Because if you don't put an open date on it, somebody could get some spoiled food because you don't know how long it's been there. She was asked if employees should store their lunch in the refrigerators in the kitchen. She replied, I thought if they were labeled and dated it could go on the bottom shelf. The DM was asked what the rinse tank temperature should be on the dishwasher, according to the manufacturer's instructions on the machine. She replied, 160. She was asked why this was important. She replied, I don't want anybody to get dirty dishes and potentially get a food borne illness. She was asked if all appliances in the kitchen should be kept clean and sanitary. She replied, Yes, I got onto them about that. She was asked what could happen if the appliances are not kept clean. She replied, Grease fire would be my first thought. The DM was asked if the ice machine should be kept clean. She replied, Yes. She was asked what could happen if it was not kept clean. She replied, You can get mold spores in the ice chips. She was asked what the food temperature should be for hot food on the steam table. She replied, Hot foods should be 140 degrees I think. She was asked why this is important. She replied, That is one thing that will cause a food-borne illness if it's not properly temped and everything. She was asked if dented cans should be stored for use in the dry goods area. She replied, No. She was asked why. She replied, Food-borne pathogens. 21. The facility's Policy and Procedure Manual, Food Storage, provided by the DM on 10/07/21 at 2:36 P.M. documented, .b. Food should be dated as it is placed on the shelves if it is required by state regulation . 11. Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated .Hand Washing . 1. When to wash hands . f. After handling soiled equipment or utensils. g. During food preparation, as often as necessary to remove soil or contamination when changing tasks . j. After engaging in other activities contaminate the hands . Food Temperatures . 1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F . b. Hot food times may not fall below 135 degrees F after cooking . prior to servicing .

Based on observation and interview, the facility failed to ensure trash was properly contained within 1 of 3 dumpsters and failed to ensure the lids were closed on 3 of 3 dumpsters to minimize the presence of foul odors and decrease the potential for pest infestation. This failed practice had the potential to affect all 66 residents who resided in the facility, as documented on the Daily Census provided by the Administrator on 10/04/21. The findings are: 1. On 10/04/21 at 10:49 A.M., the lids were open on 3 of 3 dumpsters. There was a blue cloth hanging over the front of dumpster #2. There were liquids, paper, and plastic gloves on the ground in front of the dumpsters. The Dietary Manager (DM) was asked to describe what she saw. She replied, All the lids are open, trash hanging out, and there is trash and liquid on the ground. She was asked if the lids should be open. She replied, No. She was asked if there should be trash hanging out of the dumpsters. She replied, No. She was asked if there should be trash and liquids on the ground around the dumpsters. She replied, No. 2. On 10/07/21 at 2:36 P.M., the DM provided a policy that documented, Waste Disposal, Policy: Garbage will be disposed of as needed throughout the day . 2. Containers will be emptied as often as necessary throughout the day . Trash bags shall be sealed prior to removing them from the facility. Trash will be deposited into a sealed container outside the premises .

Based on observation and interview, the facility failed to ensure staff sat at residents' eye level to assist them with their meal to promote dignity for 3 (Residents #12, #32 and #55) of 7 (Residents #4, #12, #18, #32, #43, #55 and #64) sampled residents who required assistance with meals. The findings are: 1. Resident #12 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Care Plan dated as revised 4/27/21 documented, [Resident #12] has an ADL [activities of daily living] self-care performance deficit r/t [related to] Alzheimer's . EATING: . cut meat into small bites . assist with tray set up . b. On 10/04/21 at 12:28 P.M., Resident #12 was sitting in his wheelchair in his room. Certified Nursing Assistant (CNA) #3 was standing in front of the resident feeding him lunch. She was asked if she should be standing to assist the resident with his meal. She replied, No. c. On 10/07/21 at 1:22 P.M., the Director of Nursing (DON) was asked if staff should stand over residents while they assist them with meals. She replied, No. She was asked why. She replied, It's a dignity issue of standing over someone. 2. Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 09/14/21 documented the resident was severely impaired in cognitive skills for daily decision-making per a SAMS and required supervision with eating. a. The Care Plan dated as revised 6/16/21 documented, [Resident #32] has an ADL self-care performance deficit r/t aggressive behavior, Alzheimer's . EATING: .often chooses to feed self and at times does get food on clothing, assist with meals as she will allow . finger foods at times will just hold in hand or crumble up. re-direct offer new and assistance . b. On 10/04/21 at 12:20 P.M., Resident #32 was in her room eating lunch. CNA #4 was standing over Resident #32 while feeding her. CNA #4 was asked, What is the proper way to feed a resident? CNA #4 stated, Sit in a chair at eye level with the resident. We don't have any chairs to sit in. 3. Resident #55 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 09/14/21 documented the resident was moderately impaired in cognitive skills for daily decision-making per a SAMS and required limited assistance of one person with eating. a. The Care Plan dated as revised 9/21/21 documented, [Resident #55] has an ADL self-care performance deficit r/t Alzheimer's . EATING: .provide tray set up observe and assist prn [as needed] . b. On 10/04/21 at 12:20 P.M., Resident #55 was in her room eating lunch. Registered Nurse (RN) #1 was standing over Resident #55 while feeding her. RN #1 was asked, What is the proper way to feed a resident? RN #1 stated, At eye level with the resident. RN #1 was asked, Why? RN #1 stated, Because I'm hovering over her. 4. The facility's policy and procedure titled, The Dining Experience, provided by the Assistant Director of Nursing on 10/07/21 at 12:42 P.M., documented, .Staff will sit next to a person when assisting them with eating (rather than standing over them) .

Based on record review and interview, the facility failed to ensure Advanced Directives were readily available for review in the clinical record for residents who had formulated Advanced Directives, to protect resident rights for 3 (Residents #4, #6 and #13) of 37 (Residents #39, #55, #54, #15, #29, #44, #63, #25, #32, #18, #36, #64, #50, #13, #38, #17, #57, #40, #42, #46, #12, #5, #1, #34, #62, #4, #117, #65, #116, #61, #27, #43, #165, #6, #47, #118 and #2) sampled residents whose clinical records were reviewed for advanced directive information. The findings are: 1. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 10/07/21 documented the resident scored 7 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS). On 10/04/21 at 8:24 P.M., Resident #6's electronic medical record documented on the Advanced Directive selection information that the resident did have an advanced directive; however, there was no copy of the advanced directive available for review in the medical record. The Admissions Director was asked if the resident had a Power of Attorney. She replied, Yes. She was asked if the facility had a copy. She replied. There is not a copy in her file. 2. Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 07/15/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS. On 10/05/21 at 4:40 P.M., Resident #13's electronic medical record indicated on the Advance Directive selection that the resident had an advance directive; however, there was no copy available for review in the medical record. The Admissions Director was asked if the resident had a Power of Attorney. She replied, Yes. She was asked if the facility had a copy. She replied. She has a POA, her daughter, but it's not in here. We don't have hers. 3. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/30/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS. On 10/04/21 at 8:18 P.M., Resident #4's electronic medical record indicated on the Advance Directive selection that the resident had an advance directive; however, there was no copy available for review in the medical record. The Admissions Director was asked if the resident had a Power of Attorney. She replied, Yes. She was asked if the facility had a copy. She replied, They must not have brought it. We don't have a copy of it either. 4. On 10/06/21 at 3:00 P.M., the Billing Administrator was asked to provide Residents #4, #6 and #13's Advanced Directives. She stated, It's not in here. We don't have theirs. She was asked, Should the residents' Advanced Directive be completed and in the residents' record? She stated, Yes.

Based on record review and interview, the facility failed to ensure the facility's Abuse and Neglect policies and procedures were implemented, as evidenced by failure to thoroughly investigate an allegation of physical abuse for 1 (Resident #12); and failure to report allegations of abuse to the state agency and other officials in accordance with state law for 1 (Residents #12) of 2 (Residents #12 and #118) sampled residents who were the alleged victims of abuse or neglect. These failed practices had the potential to affect all 66 residents, according to the Resident Census and Conditions of Residents form dated 10/04/21. The findings are: 1. Resident #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/14/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and required extensive assistance with bed mobility, transfers, personal hygiene, and bathing. Resident #4, the roommate of Resident#12, had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual MDS with an ARD of 09/30/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. An Incident and Accident Report dated 08/23/21 documented, .Date and Time Submitted (if known): 08/24/21 11:00 AM, Date and Time of Discovery: 08/23/21 at 1:30 PM . Resident [#4] alleges that CNA [Certified Nursing Assistant] was being rough with his roommate [Resident #12] . Investigation protocols initiated. Alleged perpetrator suspended pending investigation. Abuse in-service started for all staff . Based on the date / time of discovery, the allegation should have been reported to the Office of Long Term Care (OLTC) no later than 8/23/21 at 3:30 PM. b. Resident #4's Witness Statement dated 08/23/21 at 2:25 P.M. documented, .Aide was getting rough & [and] holding resident's arms down. Resident slapped aide & I heard Aide slap or spank resident & yelling 'Stop hitting.' I did not have my glasses on, but it's not the first time she has been rough with him . c. CNA #7's Witness Statement dated 08/23/21 at 2:28 P.M. documented, .While I was assisting resident [Resident #12] . he was being a little rude. His roommate said he was probably still worked up because it looked like the night aide [Name] had either hit his back or his butt the last time she was assisting him . d. CNA #8's Witness Statement dated 08/23/21 at 2:29 P.M. documented, .While me and my partner was working on getting a resident up for breakfast he was very worked up. His roommate had stated that the night shift aide [Name] that night was hitting him, and that was probably why he was worked up. He also stated that the privacy curtain was left open and that he wasn't sure if she was slapping his back or spanking him . e. The Body Audit dated 08/23/21 at 2:46 P.M. for Resident #12 documented, .No new skin issues . f. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and Exploitation of Residents in Long-Term Care Facilities (Division of Medical Services form 762) dated 8/23/21 documented, .Findings and Actions Taken . Physical abuse unsubstantiated as: 1. No evidence of marks, bruises, abrasions, etc. [et cetera] per body audit conducted at 14:16 [2:16 P.M.]. 2. Resident has a BIMS score of 0 and is unable to answer questions. 3. Witness states he did not have his glasses on. 4. Alleged perpetrator denies hitting resident or holding his arms down . Action Taken: Employment of alleged perpetrator terminated as of 08/31/2021 . g. On 10/07/21 at 9:49 A.M., Resident #4 was asked what happened the night that he reported the allegation of abuse for Resident #12. He stated, I could tell she hit him, but I didn't have my glasses on so I couldn't see exactly where, but the slapping was obvious. h. On 10/07/21 at 3:30 P.M., the Administrator was asked what steps were taken when he was notified of the allegation of abuse on Resident #12. He stated, We began the abuse investigation protocol, which includes in-service for staff, suspend alleged perpetrator, and began doing interviews. He was asked if he had a policy that documented the investigation protocol. He reported, That's part of our abuse policy. He was asked if the facility did body audits on other residents that were not cognitively intact. He replied, There wasn't any that revealed anything that instigated anything that would have initiated another report. We don't put anything in the reportable that pertains to another resident. He was asked for copies of all body audits completed for this investigation. Resident #12's body audit was the only one provided. He was asked if the facility interviewed other residents that were cognitively intact. He replied, I don't have anything in this file. Again, if anything came of an interview, we would have done another reportable. He was asked, You don't have any evidence that you did those interviews? He replied, No. He was asked if the facility interviewed all staff members about knowledge of abuse. He replied, No. He was asked how he determined the allegation of physical abuse was unfounded. He replied, By his body audit, but I did substantiate two things. He was asked, How long do you have to report allegations of abuse to the state agency? He replied, Two hours. 2. Resident #118 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. An Incident and Accident Report dated 5/12/21 documented, Date and Time Submitted (if known): 05/13/21, Date and Time of Discovery: 05/12/21 at 16:30 [4:30 PM] . Abuse: Verbal . Resident states a lady from the kitchen came to her to bring her syrup, woman bent down to her and said 'You hateful, you are hateful and this is why no one likes you' then threw syrup cup on the table . Based on the date / time of discovery, the allegation should have been reported to OLTC no later than 5/12/21 at 6:30 PM. b. On 10/05/21 at 8:40 A.M., the Assistant Administrator was asked why the allegations of abuse on Resident #12 and Resident #118 were not reported to the state agency within 2 hours. She replied, I thought you had until 11:00 AM the next business day. c. On 10/07/21 at 3:30 P.M., the Administrator was asked, How long do you have to report allegations of abuse to the state agency? He replied, Two hours. 3. A facility Abuse, Neglect, and Exploitation policy provided by the Assistant Administrator on 10/04/21 at 2:30 P.M. documented, . 3. Verbal Abuse means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability Investigation of Alleged Abuse . Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: .Interview the involved resident, if possible and document all responses . Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. Obtain witness statements, according to appropriate policies . Contact the State Agency to report the alleged abuse.

Based on record review and interview, the facility failed to ensure allegations of abuse were immediately reported to the state agency and other officials in accordance with state law to enable those agencies / officials to provide oversight of the facility's investigative and protective measures for 2 of 2 (Residents #12 and #118) sampled residents who were the alleged victims of abuse or neglect. The failed practice had the potential to affect all 66 residents, according to the Resident Census and Conditions of Residents form dated 10/04/21. The findings are: 1. Resident #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/14/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and required extensive assistance with bed mobility, transfers, personal hygiene, and bathing. Resident #4, the roommate of Resident#12, had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual MDS with an ARD of 09/30/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. An Incident and Accident Report dated 08/23/21 documented, .Date and Time Submitted (if known): 08/24/21 11:00 AM, Date and Time of Discovery: 08/23/21 at 1:30 PM . Resident [#4] alleges that CNA [Certified Nursing Assistant] was being rough with his roommate [Resident #12] . Investigation protocols initiated. Alleged perpetrator suspended pending investigation. Abuse in-service started for all staff . Based on the date / time of discovery, the allegation should have been reported to the Office of Long Term Care (OLTC) no later than 8/23/21 at 3:30 PM. b. Resident #4's Witness Statement dated 08/23/21 at 2:25 P.M. documented, .Aide was getting rough & [and] holding resident's arms down. Resident slapped aide & I heard Aide slap or spank resident & yelling 'Stop hitting.' I did not have my glasses on, but it's not the first time she has been rough with him . c. On 10/07/21 at 3:30 P.M., the Administrator was asked, How long do you have to report allegations of abuse to the state agency? He replied, Two hours. 2. Resident #118 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. An Incident and Accident Report dated 5/12/21 documented, Date and Time Submitted (if known): 05/13/21, Date and Time of Discovery: 05/12/21 at 16:30 [4:30 PM] . Abuse: Verbal . Resident states a lady from the kitchen came to her to bring her syrup, woman bent down to her and said 'You hateful, you are hateful and this is why no one likes you' then threw syrup cup on the table . Based on the date / time of discovery, the allegation should have been reported to OLTC no later than 5/12/21 at 6:30 PM. b. On 10/05/21 at 8:40 A.M., the Assistant Administrator was asked why the allegations of abuse on Residents #12 and #118 were not reported to the state agency within 2 hours. She replied, I thought you had until 11:00 AM the next business day. c. On 10/07/21 at 3:30 P.M., the Administrator was asked, How long do you have to report allegations of abuse to the state agency? He replied, Two hours.

Based on observation, record review and interview, the facility failed to ensure fingernails were cleaned regularly to maintain good personal hygiene for 1 (Resident #44) of 14 (Residents #4, #6, #12, #13, #18, #27, #29, #32, #39, #43, #44, #55, #157, and #165) sampled residents who required assistance with personal hygiene; and failed to ensure bathing services were regularly provided and a resident was assisted to change clothing regularly to maintain good hygiene for 1 (Resident #15) of 15 (Residents #4, #6, #12, #13, #15, #18, #27, #29, #32, #39, #43, #44, #55, #157, and #165) sampled residents who required the assistance of staff for bathing. These failed practices had the potential to affect all 66 residents, according to a list provided by the Director of Nursing (DON) on 10/08/21. The findings are: 1. Resident #15 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/20/21 documented the resident scored 12 (8-12 indicates moderate impairment) on a Brief Interview for Mental Status (BIMS), required limited assistance of 1 person for dressing, and required one person physical assistance for bathing. a. The Care Plan dated as initiated 07/16/21 documented, .has an ADL [activities of daily living] self-care performance deficit r/t [related to] Disease . BATHING / SHOWERING: Provide 2 x [times] weekly and prn [as needed] offer am [morning] or pm [evening] bathing, place all items in reach . b. As of 10/7/21, the Bathing Task documentation for September and October 2021 documented the resident received a shower on 9/10/21, 9/17/21, 9/21/21, 9/24/21, and 10/1/21. No other bathing was documented for the resident during this timeframe. c. On 10/04/21 at 11:41 A.M., the resident was sitting in the day room area wearing a green shirt that had spots of a white, crusty substance and gray sweatpants that had the white, crusty substance and brown stains. d. On 10/05/21 at 10:35 A.M., the resident was ambulating on the Blue Hall. He continued to wear the green shirt and gray sweatpants. e. On 10/06/21 at 10:25 A.M., the resident was sitting in the day room area. He continued to wear the green shirt and gray sweatpants. f. On 10/07/21 at 11:35 A.M., during the resident council meeting, Resident #15 stated, I haven't had a shower since last Friday [10/1/21]. He continued to wear the green shirt and gray sweatpants. At 11:37 A.M., during this resident council meeting, 5 residents reported they were not getting showers twice weekly as scheduled. g. On 10/07/21 at 2:48 P.M., Certified Nursing Assistant #8 was asked which days Resident #15 was scheduled to receive showers. She replied, Tuesdays and Fridays. She was asked if he was getting his showers as scheduled. She replied, Yes, he should be. She was asked if Resident #15 refused showers. She replied, No. h. On 10/07/21 at 2:59 P.M., Licensed Practical Nurse #10 was asked how often residents were scheduled to get a shower or bath. She replied, As far as I know, it's twice a week. She was asked if residents were getting their showers as scheduled. She replied, As far as I know, unless they refuse. i. On 10/07/21 at 1:06 P.M., the Director of Nursing (DON) was asked how often residents should get a shower or bath. She replied, They have a twice a week bath schedule. She was asked if the residents were getting their baths as scheduled. She replied, We attempt to bathe everyone twice a week. 2. Resident #44 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required one-person physical assistance for personal hygiene. a. The Care Plan dated as reviewed 09/04/21 documented, . [Resident #44] has limited physical mobility requires ADL and Transfer assist daily - r/t [related to] s/p [status post [MEDICAL RECORD OR PHYSICIAN ORDER] . observe and assist prn [as needed] .nurses to provide nail care keeping clean, trimmed . b. On 10/04/21 at 11:17 A.M., the resident was resting in bed. The fingernails on his right hand and had a brown substance under them. c. On 10/05/21 at 10:23 A.M., the resident was resting in bed. His fingernails had a brown substance under them. He stated, I'm okay with the length, but I'd like them to be clean, but I try not to overrun the staff. d. On 10/06/21 at 2:45 P.M., the resident was resting in bed. His fingernails had a brown substance under them. e. On 10/07/21 at 3:00 P.M., Licensed Practical Nurse (LPN) #9 was asked how often nail care was performed for diabetic residents. She replied, As far as the schedule, I'm not sure, but it's supposed to be done on shower days. Also, if the nurses notice it, we will do it too. Nail care is part of their shower. She was asked why it was important to provide nail care. She replied, It's important because it can lead to infection if the nails are not clean. Also, you feel cleaner if the nails are clean and trimmed nice and neat. I know I don't like my nails like that. f. On 10/07/21 at 1:10 P.M., the DON was asked how often nail care should be provided for diabetic residents. She replied, With their showers, so twice a week, and as needed. She was asked if the care was being given. She replied, I would say we are attempting to provide the care. She was asked why it was important to provide diabetic nailcare. She replied, Diabetics have [CONDITION(S)], they don't have good feeling, so it's important for us to do the nailcare so we can examine the skin. g. The facility's policy and procedure titled, Providing Nail Care, provided by the DON on 10/7/21 at 3:19 P.M. documented, .3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 [3:00 PM to 11:00 PM shift). Nail care will be provided between scheduled occasions as the need arises .

Based on observation, record review, and interview, the facility failed to ensure restorative nursing services were provided per the Plan of Care and / or Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #44, #57 and #64) sampled residents who had contractures and / or physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Resident #18 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/21 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, required extensive assistance of 2-plus persons for bed mobility, transfer, and dressing, required extensive assistance of 1 person for eating, and had functional limitation in range of motion to the upper and lower extremities on both sides. a. The Advanced Practice Nurse (APN) Progress Notes dated 7/15/21 documented, Musculoskeletal: Motor strength and tone: abnormal and hypertonic joints, bones, and muscles: limited ROM, secondary to hypertonicity and spasm . b. The Care Plan dated 7/30/21 documented, . has an ADL [activities of daily living] self-care performance deficit . r/t [related to] Disease Process .Limited ROM [range of Motion, contractures . Interventions: Contractures: [Resident #18] has contractures .with risk of further decline . RNA [Restorative Nurse Aide] program offered and encouraged 3 to 5 x [times] per week, hand rolls daily report if c/o [complains of] discomfort or refuses hand rolls . c. On 10/04/21 at 11:57 A.M., the resident was sitting in a geri-chair. He was asked if he was receiving any kind of physical therapy and stated, I've had a little therapy . a while back. d. On 10/4/21 at 12:38 P.M., the resident was in his room sitting in a geri-chair with staff feeding him bites of his lunch. The resident was not assisting to feed himself. e. As of 10/7/21, there was no documentation in the resident's medical record of any restorative services currently being provided. f. On 10/7/21 at 2:38 P.M., Resident #18 was lying on a shower gurney with a towel covering his body. Certified Nursing Assistant (CNA) #5 stated, I don't think he can sit in a shower chair for his shower, because he is contracted . The resident stated, I can't close my hands . The resident's upper and lower extremities were rigid. g. On 10/8/21 at 10:15 A.M., Registered Nurse (RN) #2 was asked, Is [Resident #18] receiving Restorative Therapy? She stated, No, he is not on my list . She began to review Resident #18's electronic record and stated, I don't see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked, When was that added to his Care Plan? She stated, It has April 16, 2020 .I started in January 2021, and I haven't gotten anything on him .I'm going back to December of 2020 and I'm not seeing any restorative on him . She was asked if she had ever assessed him for the need for Restorative therapy. She stated, No, I have not. h. On 10/8/21 at 10:59 A.M., CNA #7 was asked, What shift do you work? She stated, I work 6 AM to 6 PM. When asked if she provided care for Resident #18, she confirmed that she did. She was asked, Do you provide range of motion to [Resident #18]? She stated, Yes, when we go in there to turn him every two hours, we will work with his arms; his legs are really stiff though, but we try. The CNA was asked to show the surveyor where she had been documenting [Resident #18's] Restorative therapy, and she began to click on the kiosk on the wall to access the resident's record. She stated, It is usually here so we can put it in here . We are supposed to do range of motion on him since there is no RNA [Restorative Nursing Assistant] . She was unable to show the surveyor any documentation of Restorative services for Resident #18. She was asked, How long have you been doing range of motion on [Resident #18]? She stated, They told us to do range of motion a couple of days ago. She was asked, When did you start doing range of motion on [Resident #18]? She stated, It just started today. i. On 10/8/21 at 10:39 A.M., the Director of Nursing (DON) was asked, What is [Resident #18's] mobility status? She stated, He is wheelchair-bound, non-ambulatory. She was asked, Can he feed himself? She stated, No, staff assist him. She was asked, Why do staff have to feed him? She stated, He has hand contractures . he can't stand or walk due to his neck injury . She was asked, What type of therapy has he received since he was admitted here? She turned to her computer and stated, PT [Physical Therapy] was ordered October 17th, 2020. I don't see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] j. On 10/08/21 at 12:58 P.M., the Assistant DON (ADON) stated, We missed getting the hand roll and the Restorative transferred to his [Resident #18's] tasks . 2. Resident #44 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and had functional limitation in range of motion to the upper and lower extremity on one side. a. The Care Plan dated as reviewed 09/04/21 documented, .RNA [Restorative Nursing Assistant] Program . Maintain tissue extensibility of LUE [left upper extremity] / LLE [left lower extremity] to decrease contractures maintain and increase walking ability with hemi walker, stretching exercises LUE and LLE 3 x [times] week report if refuses and continue to offer and encourage report c/o discomfort or pain to charge nurse continue hand roll and tx [treatment] as directed (hx. [history] of removing hand roll per self) . b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Maintain and increase walking ability with use of hemi-walker/gait belt. Treatment: Can alternate stretching all joints of LUE, stretching / elevations of LLE, and ambulation 3 x's [times] week ongoing. This was documented as an active order in the resident's medical record as of 10/4/21. c. The Restorative Nurse Aide (RNA) Task documentation indicated, Not Applicable on June 7th, 10th, 17th, and 21st; July 5th, 8th, 15th, 19th, 22nd, 26th, and 29th; August 2nd, 5th, 9th, 12th, 16th, 23rd, 26th, and 30th; September 2nd, 6th, 9th, 13th, and 16th; and October 4th and 7th. The section designated for documentation of the number of minutes provided documented 15 minutes provided on 6/14/21, 6/24/21, 6/28/21, 7/1/21, 7/12/21, 9/20/21; and 10 minutes provided on 9/23/21 and 9/27/21. d. On 10/04/21 at 11:17 A.M., the resident was resting in bed. He had a contracture to his left hand. He did not have a hand roll or splint in place. e. On 10/05/21 at 10:23 A.M., the resident was resting in bed. He did not have a hand roll or splint in place to the left hand. He was asked if the staff ever put a hand roll in his left hand. He replied, No, sometimes I'll put a washcloth in there, but I don't always. He was asked if a staff member had come in to provide range of motion (ROM) on his hand. He replied, No. f. On 10/06/21 at 2:45 P.M., the resident was resting in bed. There was no hand roll or splint to the left hand. He was asked if a staff member had come in to stretch his left hand or put anything in his hand. He replied, No. g. On 10/08/21 at 2:53 P.M., the Restorative Nurse was asked how often Resident #44 received restorative nursing. She replied, He should be getting it 3 times a week. She was asked if Resident #44 had been getting the restorative services as ordered. She replied, The CNA [Certified Nursing Assistant] on the hall should be giving the restorative therapy. She was asked why it was important for the resident to receive the ordered restorative services. She replied, To keep from increased contractures and prevent injury to the palm of his hands with his nails causing pressure. She was asked if the resident should have a hand roll in place. She replied, Yes. 3. Resident #57 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/16/21 documented the resident scored 3 (0-7 severe impairment) on a Brief Interview for Mental Status (BIMS); was independent in bed mobility, transfers, walking, and locomotion; required limited assistance with dressing, toileting, and personal hygiene; required supervision with eating; and had no functional limitation in range of motion. a. A Progress Note dated 9/23/21 at 5:33 P.M. documented, .Received x-ray results . resident has displaced fracture of the distal radius . APRN [Advanced Practice Registered Nurse] notified, order to obtain ortho [orthopedic] appt [appointment] for resident. Resident has ortho appt 930 am 9/24. b. A Clinic Visit Sheet dated 09/24/21 documented, .Findings: Right Distal Radius Fracture with cast placed today .Finger ROM and fingers daily . c. As of 10/7/21, there was no documentation in the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . d. On 10/07/21 at 10:47 A.M., LPN #2 was asked, Who is responsible for identifying residents who have a decline in ROM or other identified need for restorative therapy? LPN #2 stated, All nursing staff. The LPN was asked when and to whom these changes were to be reported. LPN #2 stated, In our charting. The LPN was asked, Where is this documented when a report is initiated? LPN #2 did not respond. The LPN was asked, When a physician or consulting physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? LPN #2 stated, After we obtain the order, if PT [Physical Therapy], they usually write out exercise that they want residents to receive, and we put it in the computer on task for the restorative or the CNA to know what to do. The LPN was asked, How are you documenting participation? LPN #2, stated, The restorative aide has a paper that they sign when they go in and do the exercise, et cetera, if they refuse or not. The LPN was asked, Do you have a policy for contracture prevention? LPN #2 stated, We do have resource books and we will talk to the PT to give us ideas. The LPN was asked, Is [R #57] getting any restorative therapy? LPN #2 stated, I just checked her care plans, and she does not. The LPN was asked, Who would be responsible for notifying you if a doctor ordered restorative therapy? The LPN stated, I would get the order. The LPN was asked, On my record review, I found an Orthopedic Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #57] to have daily ROM of the fingers and elbow; where is that order and who is performing this? RN #2 stated, That happened while I was gone, so it just didn't happen. e. On 10/07/2021 at 3:30 P.M., the DON was asked, When you receive orders from outside physicians or consults, how do you handle those? The DON stated, When I receive orders, we process those orders. The DON was asked, Who is responsible for processing? The DON stated, The nurse caring for the patient at that time. The DON was asked, Do you have any sort of protocol or policy for verifying orders? DON stated, .I don't have a policy on that. What I have is my Medical Records Nurse, and she checks orders each morning to ensure they are in the system correctly. The DON was asked, Who is responsible for reviewing the consultation or Progress Notes from outside physicians? The DON stated, The nurse that's on [duty] when the resident returns. The DON was asked, If you had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? The DON stated, I mean, if it was during the Restorative Nurse's hours, the nurse would page them. Otherwise, if they have already gone home for the day then they will leave a note for the Restorative at her desk or they would notify [CNA #4] or myself. The DON was asked, Were you aware that [Resident #57] had orders for daily ROM of the fingers and elbow? The DON stated, No. The DON was asked, Who would have or should have been aware of the order? The DON stated, The nurse that received the orders, the Restorative Aide [CNA #4]. f. On 10/07/21 at 11:20 A.M., RN #1 provided a document titled Restorative/Nursing Care Program from the Restorative book that documented the last contracture management provided to Resident #57 occurred on 06/11/21. 4. On 10/08/21 at 1:10 P.M., the DON was asked, If a resident has orders for restorative, should those services be provided as ordered? She replied, Yes. She was asked why and stated, To maintain their functional abilities. 5. The facility's policy and procedure titled, Restorative Nursing, provided by the DON on 10/7/21 at 3:19 P.M., documented, Restorative nursing program . refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning . The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision-making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment, goals, and preferences .e. Assisting residents in adjustment to their disabilities and use of any assistive devices . Assisting residents with range of motion exercises, performing passive range of motion for residents who lack active range of motion ability . all residents will receive maintenance nursing services as described above . These services may include passive or active range of motion, splint or brace assistance .

Based on record review and interview, the facility failed to ensure a Surety Bond was purchased in an amount that would cover the balance in the resident trust funds managed by the facility, to prevent potential financial loss for 5 (Residents #44, #32, #13, #157, and #4) of 24 residents whose funds were managed by the facility. This failed practice had the potential to affect 24 residents who had individual Trust Fund Accounts managed by the facility, as documented on a list provided by the Administrator on 10/11/21. The findings are: 1. A Bank Activity Report dated for the period of 09/01/21 to 09/30/21 and provided by the Administrator on 10/06/21 at 2:24 P.M. documented, .Ending Balance $29,465.00. 2. A surety Billing Notice dated as effective 10/01/2021 and provided by the Assistant Administrator on 10/06/21 at 2:20 P.M. It documented, .Bond Desc [Description]: Patient Trust Fund, Bond Amount $15,000 . 3. On 10/07/21 at 1:34 P.M., the Assistant Administrator was asked if the Surety Bond amount should be greater than or equal to the current Trust Fund account balance. She replied, Well, we are currently working on getting it corrected. She was asked if she was aware that the Surety Bond was currently not enough to cover the Trust Fund Balance. She replied, The only thing I'm going to say is we are currently working on getting it corrected.

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure the physician was immediately consulted regarding continued low blood sugars prior to administering diabetic medications for 1 (Resident #1) of 3 (Resident #s 1, 6 and 7) case mix residents who were taking oral diabetic medications and received accuchecks. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1, who had low blood sugars and the staff continued to administer oral diabetic medications resulting in hospitalization of the resident, and had the potential to affect 3 residents who received oral diabetic medication and accuchecks. The facility was notified of the Immediate Jeopardy on 9/26/13 at 1:50 p.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 9/6/13 documented the resident was cognitively impaired per staff assessment of mental status; the required limited staff assist with bed mobility, transfers, and to walk in room; and required set up help only for eating. a. Physician orders [REDACTED]. b. The Nursing Drug Handbook 2013 page 661 documented the onset of [MEDICATION NAME] was 1 hour, the peak was at 2-3 hours and the duration was greater than 24 hours. The book also documented that [MEDICATION NAME] was used to lower the glucose level in patients with Type II Diabetes. The Nursing Drug Handbook 2013 page 880 documented the onset for the [MEDICATION NAME] was unknown, the peak was 2-4 hours, and the duration was unknown. The book also documented that [MEDICATION NAME] was used to lower the glucose level in patients with Type II Diabetes. c. The September 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. d. On 9/5/13 at 5:00 a.m., the MAR indicated [REDACTED]. The MAR indicated [REDACTED] On 9/26/13 at 11:17 a.m., LPN #1 stated that on 9/5/13 at 5:00 a.m., when the blood sugar was 67, she was not told about it in report. She was asked, "Did you notify the physician of the low blood sugar prior to administering his medications at 8:00 a.m.?" She replied, "No, I didn't." e. Licensed Practical Nurse (LPN) #1 initialed the completion of an accucheck for 9/5/13 at 5:00 p.m. and documented the reading was 42 on the MAR. There was no documentation in the nurses notes or the 24 hours report that the physician was consulted. The MAR indicated [REDACTED]. On 9/26/13 at 11:17 a.m., LPN #1 was asked, "What did you do on 9/5/13 when his blood sugar was 42?" She stated, "I got his meal tray and gave him two packages of sugar in his juice." She was asked, "Did you re-check is blood sugar?" She stated, "I don't remember if I did or not." She was also asked, "Did you call the physician about the lower blood sugar prior to giving him his [MEDICATION NAME] at 5:00 p.m..?" She replied, "No, I didn't." f. The September 2013 MAR indicated [REDACTED] Nurses notes dated 9/5/13 at 8:00 p.m. and signed by LPN #3 documented, "(Resident) ACK (accucheck) 34. Orange juice and sugar given. At 20:15 (8:15 p.m.) ack 140. Resident was sweating and shaking at first ack. Resident feeling better now." Nurses notes dated 9/5/13 at 10:30 p.m. documented, "Resident ack 29. juice, milk sugar and food administered. At 10:45 p.m., ack 98." There was no documentation in the Nurses Notes that the physician was consulted regarding the hypoglycemic incidents. g. Nurses notes dated 9/6/13 at 1:00 a.m. and signed by LPN #3 documented, "ack 58. Milk, sugar and food given. 1:15 a.m., ack 88." Nurses notes dated 9/6/13 at 2:00 a.m. and signed by LPN #3 documented, "ack 48. juice & sugar given. at 2:20 a.m., ack 88." Nurses notes dated 9/6/13 at 4:00 a.m. and signed by LPN #3 documented, "ack 75." Nurses notes dated 9/6/13 at 5:45 a.m. and signed by LPN #3 documented, "ack 44. Milk and sugar given. 6:15 a.m., ack 85." h. On 9/26/13 at 1:00 p.m., LPN #3 was asked about his documentation 9/5/13 and 9/6/13 of the low blood sugars. He was asked, "Why didn't you call the physician?" He replied, "Because it would come up with food. He had no signs or symptoms of [DIAGNOSES REDACTED]" He further stated that he looked up the [MEDICATION NAME] in the drug book and the half life was 4-6 hours, so he thought if he could get him through this time it would be ok. He was asked, "What did you tell the on-coming nurse?" He replied, "I told her about it and that it needed to be watched real close. In hindsight I should have called the MD (medical doctor) and sent him to the hospital." i. The September 2013 MAR indicated [REDACTED]. On 9/26/13 at 11:17 a.m., LPN #1 was asked "What were you told in report on 9/6/13 related to the resident's blood sugar?" She stated she was told that his blood sugar kept dropping throughout the night but was stable at this point." She was asked, "Did you notify the physician of the lower blood sugars prior to administering his [MEDICATION NAME] and [MEDICATION NAME] at 8:00 a.m.?" She replied, "No, I didn't." j. Nurses notes dated 9/6/13 at 12:40 p.m., documented, "This nurse came into building at 12:00 p.m., after lunch break, CNA ((Certified Nursing Assistant) #1) stopped me in the hall and stated 'something isn't right with (Resident #1). This nurse went to resident room, (LPN #4) LPN and CNA (CNA #2) was in room. CNA (CNA #2) was getting vitals and LPN (LPN #4) was assessing resident, this nurse went to med (medication) room to get glucose meter, returned to resident room and resident glucose was 87 @ (at) 12:03 p.m. Resident was non-responsive, sweaty, cold, clammy, family member (name) at bedside. This nurse called ambulance @ 12:10 p.m., LPN (LPN #4) stayed with resident while this nurse filled out transport papers. EMT (Emergency Medical Technician) X 2 arrived at 12:25 p.m., to transport resident to local hospital. Report called to ER (emergency room ). CNA (CNA #1) stated, 'I was in the room at 11:25 (a.m.), (and) R (resident) was talking to me (and) acted fine." The Hospital Emergency Report dated 9/6/13 documented, "Patient presents from (Name) Nursing Home. Patient found to be unresponsive while at the facility. Blood sugar was found to be 27. EMD (Emergency Medical Department) administered amp ([MEDICATION NAME]) of D ([MEDICATION NAME]) 50. Upon arrival to emergency department patient was responsive but sluggish. Repeat glucose found to have BFS (blood finger stick) in low 30's. Blood sugar found to be consistently low, Patient given 2 D50 amps while here in ED (emergency department). Will start patient on D5NS ([MEDICATION NAME] 5 Normal Saline) at 125ml (milliliters)/hr (hour). Will hold Diabetic Medications." 2. On 9/26/13 at 3:15 p.m., the Immediate Jeopardy was removed and the scope and severity lowered to an "H" when the facility implemented the following plan of removal. a. On 9/26/13, a list of diabetic residents was identified and each resident was assessed for signs and symptoms of [DIAGNOSES REDACTED]. There were no residents identified to be symptomatic. b. On 9/26/13, in-service training for licensed nursing personnel was initiated at 3:15 p.m., and will continue until all licensed nursing employees are in-serviced on facility policies regarding blood sugar monitoring, guidelines for nursing care for residents with Diabetes Mellitus, Diabetic Testing, Notification of responsible party/physician, general guidelines for documentation guidelines for treating [DIAGNOSES REDACTED], Standard Plan of Care for Diabetes Management, if fasting blood sugar is 60 or below, give 4 oz (ounces) of orange juice with 2 teaspoons of sugar and recheck blood sugar in 30 minutes and then if still below 60, contact MD, give 4 oz of Milk, 2 crackers and recheck in another 30 minutes; if blood sugar is low prior to administration of diabetic medication, contact MD prior for treatment orders; the importance of the information gained from accu-check, the importance of administering as ordered and documenting sliding scale insulin, and to notify the doctor if accu-check is not within acceptable range as ordered by the physician and documentation of this. c. Director of Nursing or designee will monitor accu-checks four times per week for four weeks, then two times per week for 2 weeks, them monthly for 2 months to ensure that all accu-checks are completed and documented as ordered by the attending physician, that low blood sugar reading result in appropriate steps, up to and including physician notification. Negative findings will result in immediate corrective action.

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure that Resident #1 received the necessary care and services to attain or maintain the highest practicable physical well-being. The facility failed to ensure that nursing staff promptly responded to continuing episodes of low blood sugar readings as evidenced by the staffs failures to immediately consult the physician regarding continued low blood sugar readings, to hold diabetic medications when blood sugar readings were low; and to ensure that the accuchecks were completed and documented consistently for 1 (Resident #1) of 3 (Resident #s 1, 6 and 7) case mix residents who were taking oral diabetic medications and received accuchecks. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1, who had low blood sugars and the staff continued to administer oral diabetic medications resulting in hospitalization of the resident, and had the potential to affect 3 residents who received oral diabetic medication and accuchecks. The facility was notified of the Immediate Jeopardy on 9/26/13 at 1:50 p.m. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 9/6/13 documented the resident was cognitively impaired per staff assessment of mental status; the required limited staff assist with bed mobility, transfers, and to walk in room; and required set up help only for eating. a. Physician orders [REDACTED]. b. The Nursing Drug Handbook 2013 page 661 documented the onset of [MEDICATION NAME] was 1 hour, the peak was at 2-3 hours and the duration was greater than 24 hours. The book also documented that [MEDICATION NAME] was used to lower the glucose level in patients with Type II Diabetes. The Nursing Drug Handbook 2013 page 880 documented the onset for the [MEDICATION NAME] was unknown, the peak was 2-4 hours, and the duration was unknown. The book also documented that [MEDICATION NAME] was used to lower the glucose level in patients with Type II Diabetes. c. The September 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The space provided for the 8:00 p.m., accucheck on 9/4/13 was also left blank. The MAR indicated [REDACTED]. d. On 9/5/13 at 5:00 a.m., the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 9/26/13 at 11:17 a.m., LPN #1 stated that on 9/5/13 at 5:00 a.m., when the blood sugar was 67, she was not told about it in report. She was asked, "Did you notify the physician of the low blood sugar prior to administering his medications at 8:00 a.m.?" She replied, "No, I didn't." e. Licensed Practical Nurse (LPN) #1 initialed the completion of an accucheck for 9/5/13 at 5:00 p.m. and documented the reading was 42 on the MAR. There was no documentation in the nurses notes or the 24 hours report that the physician was consulted. The MAR indicated [REDACTED]. On 9/26/13 at 11:17 a.m., LPN #1 was asked, "What did you do on 9/5/13 when his blood sugar was 42?" She stated, "I got his meal tray and gave him two packages of sugar in his juice." She was asked, "Did you re-check is blood sugar?" She stated, "I don't remember if I did or not." She was also asked, "Did you call the physician about the lower blood sugar prior to giving him his [MEDICATION NAME] at 5:00 p.m..?" She replied, "No, I didn't." f. The September 2013 MAR indicated [REDACTED] Nurses notes dated 9/5/13 at 8:00 p.m. and signed by LPN #3 documented, "(Resident) ACK (accucheck) 34. Orange juice and sugar given. At 20:15 (8:15 p.m.) ack 140. Resident was sweating and shaking at first ack. Resident feeling better now." Nurses notes dated 9/5/13 at 10:30 p.m. documented, "Resident ack 29. juice, milk sugar and food administered. At 10:45 p.m., ack 98." There was no documentation in the Nurses Notes that the physician was consulted regarding the hypoglycemic incidents. g. Nurses notes dated 9/6/13 at 1:00 a.m. and signed by LPN #3 documented, "ack 58. Milk, sugar and food given. 1:15 a.m., ack 88." Nurses notes dated 9/6/13 at 2:00 a.m. and signed by LPN #3 documented, "ack 48. juice & sugar given. at 2:20 a.m., ack 88." Nurses notes dated 9/6/13 at 4:00 a.m. and signed by LPN #3 documented, "ack 75." Nurses notes dated 9/6/13 at 5:45 a.m. and signed by LPN #3 documented, "ack 44. Milk and sugar given. 6:15 a.m., ack 85." h. On 9/26/13 at 1:00 p.m., LPN #3 was asked about his documentation 9/5/13 and 9/6/13 of the low blood sugars. He was asked, "Why didn't you call the physician?" He replied, "Because it would come up with food. He had no signs or symptoms of [DIAGNOSES REDACTED]" He further stated that he looked up the [MEDICATION NAME] in the drug book and the half life was 4-6 hours, so he thought if he could get him through this time it would be ok. He was asked, "What did you tell the on-coming nurse?" He replied, "I told her about it and that it needed to be watched real close. In hindsight I should have called the MD (medical doctor) and sent him to the hospital." i. The September 2013 MAR indicated [REDACTED]. On 9/26/13 at 11:17 a.m., LPN #1 was asked "What were you told in report on 9/6/13 related to the resident's blood sugar?" She stated she was told that his blood sugar kept dropping throughout the night but was stable at this point." She was asked, "Did you notify the physician of the lower blood sugars prior to administering his [MEDICATION NAME] and [MEDICATION NAME] at 8:00 a.m.?" She replied, "No, I didn't." j. Nurses notes dated 9/6/13 at 12:40 p.m., documented, "This nurse came into building at 12:00 p.m., after lunch break, CNA ((Certified Nursing Assistant) #1) stopped me in the hall and stated 'something isn't right with (Resident #1). This nurse went to resident room, (LPN #4) LPN and CNA (CNA #2) was in room. CNA (CNA #2) was getting vitals and LPN (LPN #4) was assessing resident, this nurse went to med (medication) room to get glucose meter, returned to resident room and resident glucose was 87 @ (at) 12:03 p.m. Resident was non-responsive, sweaty, cold, clammy, family member (name) at bedside. This nurse called ambulance @ 12:10 p.m., LPN (LPN #4) stayed with resident while this nurse filled out transport papers. EMT (Emergency Medical Technician) X 2 arrived at 12:25 p.m., to transport resident to local hospital. Report called to ER (emergency room ). CNA (CNA #1) stated, 'I was in the room at 11:25 (a.m.), (and) R (resident) was talking to me (and) acted fine." The Hospital Emergency Report dated 9/6/13 documented, "Patient presents from (Name) Nursing Home. Patient found to be unresponsive while at the facility. Blood sugar was found to be 27. EMD (Emergency Medical Department) administered amp ([MEDICATION NAME]) of D ([MEDICATION NAME]) 50. Upon arrival to emergency department patient was responsive but sluggish. Repeat glucose found to have BFS (blood finger stick) in low 30's. Blood sugar found to be consistently low, Patient given 2 D50 amps while here in ED (emergency department). Will start patient on D5NS ([MEDICATION NAME] 5 Normal Saline) at 125ml (milliliters)/hr (hour). Will hold Diabetic Medications." 2. On 9/26/13 at 3:15 p.m., the Immediate Jeopardy was removed and the scope and severity lowered to an "H" when the facility implemented the following plan of removal. a. On 9/26/13, a list of diabetic residents was identified and each resident was assessed for signs and symptoms of [DIAGNOSES REDACTED]. There were no residents identified to be symptomatic. b. On 9/26/13, in-service training for licensed nursing personnel was initiated at 3:15 p.m., and will continue until all licensed nursing employees are in-serviced on facility policies regarding blood sugar monitoring, guidelines for nursing care for residents with Diabetes Mellitus, Diabetic Testing, Notification of responsible party/physician, general guidelines for documentation guidelines for treating [DIAGNOSES REDACTED], Standard Plan of Care for Diabetes Management, if fasting blood sugar is 60 or below, give 4 oz (ounces) of orange juice with 2 teaspoons of sugar and recheck blood sugar in 30 minutes and then if still below 60, contact MD, give 4 oz of Milk, 2 crackers and recheck in another 30 minutes; if blood sugar is low prior to administration of diabetic medication, contact MD prior for treatment orders; the importance of the information gained from accu-check, the importance of administering as ordered and documenting sliding scale insulin, and to notify the doctor if accu-check is not within acceptable range as ordered by the physician and documentation of this. c. Director of Nursing or designee will monitor accu-checks four times per week for four weeks, then two times per week for 2 weeks, them monthly for 2 months to ensure that all accu-checks are completed and documented as ordered by the attending physician, that low blood sugar reading result in appropriate steps, up to and including physician notification. Negative findings will result in immediate corrective action.

Complaint # was substantiated, all or in part, with these findings. Based on interview and record review, the facility failed to ensure the Abuse Prohibition policy and procedures regarding neglect were implemented. Facility staff failed to follow written protocols that identified the reporting mechanism to be utilized when neglect was suspected and procedures to be followed for change in condition that would have ensured that neglect did not occur for 1 (Resident #2) of 1 case mix residents who had [MEDICAL CONDITION]. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious injury, harm, impairment or death for Resident #2 and had the potential to cause serious injury, harm, impairment or death for 17 residents who had [MEDICAL CONDITION], as documented on a list provided by the Director of Nursing on 7/18/11 at 3:10 p.m. The Administrator was notified of the Immediate Jeopardy on 8/18/11 at 1:55 p.m. The findings are: 1. The facility's policy and procedure, provided by the Administrator on 8/18/11 at 2:42p.m. and titled "Abuse Prohibition " , documented, " ...The requirement that facility personnel, including but not limited to, licensed nurses, nursing assistants, physicians, social workers, mental health professionals and other employees in the facility who have reasonable cause to suspect that a resident has been subjected to conditions or circumstances which have or could have resulted in abuse or neglect are required to immediately notify the facility administrator or his or her designated agent ..." 2. The facility's policy and procedure, provided by the Administrator on 8/17/11 at 1:00 p.m. and titled "Condition Change of the Resident " , documented, "Purpose To observe, record and report any condition change to the attending physician so proper treatment will be implemented ... Procedure 1. After all resident falls, injuries or changes in physical or mental function, monitor the following:.....f. Observe for alterations in consciousness....i. Observe for generalized weakness....n. Take vital signs and include temperature....r. Observe for dyspnea or variations in respirations (irregular)....2. Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director....4. Notify resident's responsible party. 5. Monitor resident's condition frequently until stable ... general documentation guidelines 1. Date, time condition change was identified. 2. Observation of the resident's findings. 3. Emergency care provided. 4. Notification of a physician. 5. Notification of the resident's responsible party. 6. Signature and title." 3. Resident #2 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident scored 9 on the Brief Interview for Mental Status (8 - 12 indicates moderate impairment), had no shortness of breath and required no oxygen therapy. a. The Plan of Care dated 5/28/11 documented a problem of "potential for difficulty breathing related to chronic condition" with interventions to "Observe for changes in/development of signs and symptoms of breathing difficulty and report to nurse. If noted: SOB (shortness of breath), cough (productive or nonproductive), fever, difficulty speaking, changes in cognition, report to charge nurse and MD (Medical Doctor) promptly. Report changes in respiratory status to physician." b. The physician orders [REDACTED]. Call MD (medical doctor) if needs above 6 liters per n/c and monitor Sp02 until above 90%". c. There were no entries in the Nurses Notes dated 7/29/11 until 7:15 p.m. when orders were received to send the resident to the emergency room . Staff and Resident interviews were conducted regarding the events that led up to the resident ' s transfer to the emergency room : 1) On 8/18/11 at 8:45 a.m., Certified Nursing Assistant (CNA) #1 stated, "On 7/29/11 I worked 2:00 p.m. till 10:00 p.m. (CNA #2) and I were working the Blue Hall (Halls 200, 300 and 400). At the first of the shift, (CNA #2) had answered (Resident #2's) call light 3 or 4 times between 6:15 p.m. and 6:45 p.m. I answered the call light 3 times. Each time (Resident #2) said she was having a hard time breathing. (Resident #2) said she wanted to go to the ER (emergency room ). Each time I reported her concerns to (LPN #1). Each time (LPN #1) said, "OK. I know about the problem" and she said she had already checked on (Resident #2). The last time, the oncoming LPN (LPN #3) was there. (LPN #1) said going to the hospital was not going to happen now. (LPN #3) told us to get vital signs. I really never thought of contacting the other LPN or any other professional." 2) On 8/18/11 at 9:10 a.m., CNA #2 was interviewed and stated, "On 7/29/11, I worked from 5:45 a.m. until 10:15 p.m. The first time (Resident #2) complained that she could not breathe was around 5:30 p.m. I told (LPN #1). She said, 'Is her O2 on?' I said 'yes' and she said, 'is it in her nose?' I said 'yes'. (Resident #2) put her call light on 3 or 4 times with the same complaint and with me telling the nurse before the nurse went to see her. I was not in the room. After that (Resident #2) turned her call light on again and said that she could not breathe and wanted to go to the doctor. I told (LPN #1) and she said, 'that's not going to happen'. (Resident #2) turned her call light on again with the complaint and wished to go see a doctor. I told (LPN #1). (LPN #1) did not respond. (CNA #1) answered her light several times and she had the same complaint. I don't know what (LPN #1) and (CNA #1) said." The surveyor asked CNA #2, "Why did you not contact the other LPN in the building or call the Director of Nursing? Did you believe (Resident #2) was in distress?" CNA #2 stated, "Yes, (Resident #2) was pale and having trouble breathing, gasping and begging for a doctor." 3) On 8/18/11 at 10:30 a.m., Resident #2 stated, "That night (7/29/11) they put the oxygen on me and I was still short of breath. I told them 5 or 6 times that I needed help. I got worse and worse. I couldn't hardly talk to tell them I couldn't breathe. I did not see (LPN #1) that night. I saw another nurse right before I left. It was (LPN #3)." 4) On 8/18/11 at 1:50 p.m., LPN #1 stated over the telephone, "I assessed her (Resident #2) on 7/29/11. I did not document my assessment. (Resident #2) had no signs or symptoms of respiratory distress. Her lungs were clear. I did not check her vital signs. I went to a resident that had fallen. I was busy. I did not have time." 5) On 8/17/11 at 1:43 p.m., LPN #2 stated, "On 7/29/11 I worked from approximately 6:45 a.m. until 7:30 p.m. I was not made aware of any problems related to (Resident #2)." 6) On 8/18/11 at 9:37 a.m., LPN #3 stated, "On 7/29/11 I worked 7 p.m. until 7 a.m. on 7/30/11. When I came on duty one of the aides said that (Resident #2) was still complaining of not being able to breathe. I asked (LPN #1) if vital signs had been taken. She said not lately. I told the CNAs to get them now. I went to (Resident #2's) room. She had oxygen at 2 liters per minute via nasal cannula. She said she had been having trouble for a couple of hours and needed to see a doctor. I said OK. I got orders to transfer her to the ER." d. The Nurse's Notes dated 7/29/11 at 7:15 p.m., written and signed by LPN #3 documented, "Resident c/o (complained of) SOB. O2 (oxygen) at 2 L/M (liters per minute) via N/C. Stated 'I can't breathe. I've been like this for a couple of hours. I want to see a doctor. ' V/S (vital signs)T (temperature) 97.6, P (pulse)71, R (respirations) 24, B/P (blood pressure) 220/100, Oxygen Saturation of 96%. Denies pain at this time." The Nurse 's Notes documented that LPN #3 contacted the physician and received an order to transfer Resident #2 to the emergency room for evaluation and treatment. The Nurse's Notes dated 7/29/11 at 7:35 p.m., documented the resident was transported to the hospital via ambulance. e. The Radiology Report dated 7/29/11 at 9:15 p.m. documented, "Cardiomegaly with mild [MEDICAL CONDITION] changes." f. The emergency room Physician notes dated 7/29/11 documented, "Chief Complaint Describes episode of sudden onset of shortness of breath with wheezing. Oxygen does not relieve shortness of breath. Episodes last to up to several hours. Episodes occur at both night and day. Denies any chest pain. ... Assessment: [MEDICAL CONDITION]." g. The Office of Long Term Care (OLTC) Incident and Accident Report (I&A) Form Division of Medical Services (DMS) -7734, documented a date and time of submission of 8/2/11 at 11:00 a.m., a date and time of discovery of 08/01/2011 of 11:30 a.m., the name of the resident as (Resident #2) and the type of incident as "Neglect". The Summary of Incident documented, "On 07/29/2011 during evening shift, resident complained of not being able to breath and requested to see a doctor, resident oxygen was on at 2 Liters while LPN attended to other concerns." The Steps Taken To Prevent Continued Abuse or Neglect During the Investigation documented, "LPN suspended this date pending investigation of possible neglect related to proper assessment of resident condition." h. The DMS-762 documented in the Findings and Actions Taken section, "Based on record review and interview, (LPN #1) failed to properly assess resident following a change in resident condition. Contacted (LPN #1) at approximately 1:25 p.m. on 08/04/2011, requested she come to facility so we could discuss. (LPN #1) stated she did not want to drive thirty minutes to discuss what we could discuss over the phone. This Administrator informed (LPN #1) the investigation concluded there was neglect on her part in failing to properly assess a change in condition of the resident and subsequently (LPN #1) is no longer an employee of this facility. (LPN #1) went on for several minutes about other things that occupied her time during the time period from 5:55 p.m. until the night nurse shipped (Resident #2) to the hospital." i. On 8/18/11 at 9:10 a.m., Certified Nursing Assistant (CNA) #2 was asked if she had attended any in-services since this issue. CNA #2 stated, "No". j. On 8/18/11 at 9:37 a.m., LPN #3 stated, "I have not been in an in-service since that date." k. On 8/18/11 at 10:35 a.m., the Administrator stated, "Since (Resident #2) 's incident, I have not counseled the CNAs regarding notification of the other LPN in the building or the Director of Nursing if the resident had a change of condition. Before the complaint survey started, we had not in-serviced or counseled any employee except (LPN #1) who was terminated. We had scheduled an in-service for 8/25/11 at 2:00 p.m. to discuss Resident Rights, Abuse and Neglect and Change In Resident Condition. As of today (8/18/11) we have started one-on-one in-services with all nursing employees on Resident Rights, Abuse and Neglect and Change In Resident Condition." l. The Immediate Jeopardy was removed and the scope/severity reduced to "G" on 8/18/11 at 4:52 p.m., when the facility implemented the following Plan of Removal: 1) Resident #2 was assessed by Licensed Nurse on 08/18/11 at 2:45 p.m. Resident #2 complained of burning during urination this morning. Physician notified, UA (urinalysis) ordered, and family notified. No complaint of shortness of breath at this time and no other change of condition. She denies any neglect has happened to her while at the Cave City Nursing Home. 2) All residents will be assessed by Licensed Nurses on 08/18/11 to identify any changes in resident's condition. Residents will also be asked if they have been neglected. Any new change(s) of condition will be addressed as needed for each individual resident. Any allegation(s) of neglect will be investigated and reported as per facility policy and regulation. Assessment of residents in the facility will be completed by 8:00 p.m. on 08/18/11. 3) All nursing staff on duty on 08/18/11 will be in-serviced on Change of Condition and Abuse/Neglect. Oncoming nursing staff will be in-serviced prior to beginning of their shift for the next 3 shifts. All other nursing staff will be in-serviced prior to beginning of their next scheduled shift. All other staff on duty 08/18/11 will be in-serviced on Abuse/Neglect. 4) The Director of Nursing/designee will review report sheets daily for seven days beginning on 08/19/11 at 8:00 a.m. to assure the resident with a change in condition has been appropriately addressed, weekly for one month or until compliance achieved. Any negative findings regarding change in condition will be immediately corrected with proper notification to the physician, resident and responsible party. The Quality Assurance Nurse/designee will randomly interview three residents on each unit regarding neglect daily for seven days and then weekly for one month beginning 08/19/11 at 8:00 a.m. or until compliance is achieved. Any allegation(s) of neglect will be immediately reported to the Administrator for investigation and reporting as per facility policy and regulation. 5)The Director of Nursing/designee and the Quality Assurance Nurse/designee will report findings to the Quality Assurance Committee on a weekly basis for one month or until compliance achieved beginning 08/24/11. Negative findings will be addressed by the Quality Assurance Committee to determine if alternate interventions are more appropriate. "

Complaint # was substantiated, all or in part, with these findings. Based on record review and interview, the facility failed to ensure the provision of necessary care and services to Resident #2 in order to maintain the resident's highest practicable well-being. The facility failed to ensure a significant change in the resident's condition was immediately and thoroughly assessed and reported to the physician for 1 (Resident #2) of 1 case mix resident who had [MEDICAL CONDITION]. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious injury, harm, impairment or death for Resident #2 and had the potential to cause serious injury, harm, impairment or death for 17 residents who had [MEDICAL CONDITION], as documented on a list provided by the Director of Nursing on 7/18/11 at 3:10 p.m. The Administrator was notified of the Immediate Jeopardy on 8/18/11 at 1:55 p.m. The findings are: 1. The facility's policy and procedure, provided by the Administrator on 8/17/11 at 1:00 p.m. and titled " Condition Change of the Resident " , documented, "Purpose To observe, record and report any condition change to the attending physician so proper treatment will be implemented ... Procedure 1. After all resident falls, injuries or changes in physical or mental function, monitor the following:... f. Observe for alterations in consciousness... i. Observe for generalized weakness... n. Take vital signs and include temperature... r. Observe for dyspnea or variations in respirations (irregular)... 2. Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director... 4. Notify resident's responsible party. 5. Monitor resident's condition frequently until stable ... general documentation guidelines 1. Date, time condition change was identified. 2. Observation of the resident's findings. 3. Emergency care provided. 4. Notification of a physician. 5. Notification of the resident's responsible party. 6. Signature and title." 2. Resident #2 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident scored 9 on the Brief Interview for Mental Status (8 - 12 indicates moderate impairment), had no shortness of breath and required no oxygen therapy. a. The Plan of Care dated 5/28/11 documented a problem of "potential for difficulty breathing related to chronic condition" with interventions to "Observe for changes in/development of signs and symptoms of breathing difficulty and report to nurse. If noted: SOB (shortness of breath), cough (productive or nonproductive), fever, difficulty speaking, changes in cognition, report to charge nurse and MD (Medical Doctor) promptly. Report changes in respiratory status to physician." b. The physician orders [REDACTED]. Call MD (medical doctor) if needs above 6 liters per n/c and monitor Sp02 until above 90%". c. There were no entries in the Nurses Notes dated 7/29/11 until 7:15 p.m. when orders were received to send the resident to the emergency room . Staff and Resident interviews were conducted regarding the events that led up to the resident ' s transfer to the emergency room : 1) On 8/18/11 at 8:45 a.m., Certified Nursing Assistant (CNA) #1 stated, "On 7/29/11 I worked 2:00 p.m. till 10:00 p.m. (CNA #2) and I were working the Blue Hall (Halls 200, 300 and 400). At the first of the shift, (CNA #2) had answered (Resident #2's) call light 3 or 4 times between 6:15 p.m. and 6:45 p.m. I answered the call light 3 times. Each time (Resident #2) said she was having a hard time breathing. (Resident #2) said she wanted to go to the ER (emergency room ). Each time I reported her concerns to (LPN #1). Each time (LPN #1) said, "OK. I know about the problem" and she said she had already checked on (Resident #2). The last time, the oncoming LPN (LPN #3) was there. (LPN #1) said going to the hospital was not going to happen now. (LPN #3) told us to get vital signs. I really never thought of contacting the other LPN or any other professional." 2) On 8/18/11 at 9:10 a.m., CNA #2 was interviewed and stated, "On 7/29/11, I worked from 5:45 a.m. until 10:15 p.m. The first time (Resident #2) complained that she could not breathe was around 5:30 p.m. I told (LPN #1). She said, 'Is her O2 on?' I said 'yes' and she said, 'is it in her nose?' I said 'yes'. (Resident #2) put her call light on 3 or 4 times with the same complaint and with me telling the nurse before the nurse went to see her. I was not in the room. After that (Resident #2) turned her call light on again and said that she could not breathe and wanted to go to the doctor. I told (LPN #1) and she said, 'that's not going to happen'. (Resident #2) turned her call light on again with the complaint and wished to go see a doctor. I told (LPN #1). (LPN #1) did not respond. (CNA #1) answered her light several times and she had the same complaint. I don't know what (LPN #1) and (CNA #1) said." The surveyor asked CNA #2, "Why did you not contact the other LPN in the building or call the Director of Nursing? Did you believe (Resident #2) was in distress?" CNA #2 stated, "Yes, (Resident #2) was pale and having trouble breathing, gasping and begging for a doctor." 3) On 8/18/11 at 10:30 a.m., Resident #2 stated, "That night (7/29/11) they put the oxygen on me and I was still short of breath. I told them 5 or 6 times that I needed help. I got worse and worse. I couldn't hardly talk to tell them I couldn't breathe. I did not see (LPN #1) that night. I saw another nurse right before I left. It was (LPN #3)." 4) On 8/18/11 at 1:50 p.m., LPN #1 stated over the telephone, "I assessed her (Resident #2) on 7/29/11. I did not document my assessment. (Resident #2) had no signs or symptoms of respiratory distress. Her lungs were clear. I did not check her vital signs. I went to a resident that had fallen. I was busy. I did not have time." 5) On 8/18/11 at 9:37 a.m., LPN #3 stated, "On 7/29/11 I worked 7 p.m. until 7 a.m. on 7/30/11. When I came on duty one of the aides said that (Resident #2) was still complaining of not being able to breathe. I asked (LPN #1) if vital signs had been taken. She said not lately. I told the CNAs to get them now. I went to (Resident #2's) room. She had oxygen at 2 liters per minute via nasal cannula. She said she had been having trouble for a couple of hours and needed to see a doctor. I said OK. I got orders to transfer her to the ER." d. The Nurse's Notes dated 7/29/11 at 7:15 p.m., written and signed by LPN #3 documented, "Resident c/o (complained of) SOB. O2 (oxygen) at 2 L/M (liters per minute) via N/C. Stated 'I can't breathe. I've been like this for a couple of hours. I want to see a doctor. ' V/S (vital signs)T (temperature) 97.6, P (pulse)71, R (respirations) 24, B/P (blood pressure) 220/100, Oxygen Saturation of 96%. Denies pain at this time." The Nurse 's Notes documented that LPN #3 contacted the physician and received an order to transfer Resident #2 to the emergency room for evaluation and treatment. The Nurse's Notes dated 7/29/11 at 7:35 p.m., documented the resident was transported to the hospital via ambulance. e. The Radiology Report dated 7/29/11 at 9:15 p.m. documented, "Cardiomegaly with mild [MEDICAL CONDITION] changes." f. The emergency room Physician notes dated 7/29/11 documented, "Chief Complaint Describes episode of sudden onset of shortness of breath with wheezing. Oxygen does not relieve shortness of breath. Episodes last to up to several hours. Episodes occur at both night and day. Denies any chest pain. ... Assessment: [MEDICAL CONDITION]." g. The Office of Long Term Care (OLTC) Incident and Accident Report (I&A) Form Division of Medical Services (DMS) -7734, documented a date and time of submission of 8/2/11 at 11:00 a.m., a date and time of discovery of 08/01/2011 of 11:30 a.m., the name of the resident as (Resident #2) and the type of incident as "Neglect". The Summary of Incident documented, "On 07/29/2011 during evening shift, resident complained of not being able to breath and requested to see a doctor, resident oxygen was on at 2 Liters while LPN attended to other concerns." The Steps Taken To Prevent Continued Abuse or Neglect During the Investigation documented, "LPN suspended this date pending investigation of possible neglect related to proper assessment of resident condition." h. The DMS-762 documented in the Findings and Actions Taken section, "Based on record review and interview, (LPN #1) failed to properly assess resident following a change in resident condition. Contacted (LPN #1) at approximately 1:25 p.m. on 08/04/2011, requested she come to facility so we could discuss. (LPN #1) stated she did not want to drive thirty minutes to discuss what we could discuss over the phone. This Administrator informed (LPN #1) the investigation concluded there was neglect on her part in failing to properly assess a change in condition of the resident and subsequently (LPN #1) is no longer an employee of this facility. (LPN #1) went on for several minutes about other things that occupied her time during the time period from 5:55 p.m. until the night nurse shipped (Resident #2) to the hospital." i. On 8/18/11 at 9:10 a.m., Certified Nursing Assistant (CNA) #2 was asked if she had attended any in-services since this issue. CNA #2 stated, "No". j. On 8/18/11 at 9:37 a.m., LPN #3 stated, "I have not been to an in-service since that date." k. The Immediate Jeopardy was removed and the scope/severity reduced to "G" on 8/18/11 at 4:52 p.m., when the facility implemented the following Plan of Removal: 1) Resident #2 was assessed by Licensed Nurse on 08/18/11 at 2:45 p.m. Resident #2 complained of burning during urination this morning. Physician notified, UA (urinalysis) ordered, and family notified. No complaint of shortness of breath at this time and no other change of condition. She denies any neglect has happened to her while at the Cave City Nursing Home. 2) All residents will be assessed by Licensed Nurses on 08/18/11 to identify any changes in resident's condition. Residents will also be asked if they have been neglected. Any new change(s) of condition will be addressed as needed for each individual resident. Any allegation(s) of neglect will be investigated and reported as per facility policy and regulation. Assessment of residents in the facility will be completed by 8:00 p.m. on 08/18/11. 3) All nursing staff on duty on 08/18/11 will be in-serviced on Change of Condition and Abuse/Neglect. Oncoming nursing staff will be in-serviced prior to beginning of their shift for the next 3 shifts. All other nursing staff will be in-serviced prior to beginning of their next scheduled shift. All other staff on duty 08/18/11 will be in-serviced on Abuse/Neglect. 4) The Director of Nursing/designee will review report sheets daily for seven days beginning on 08/19/11 at 8:00 a.m. to assure the resident with a change in condition has been appropriately addressed, weekly for one month or until compliance achieved. Any negative findings regarding change in condition will be immediately corrected with proper notification to the physician, resident and responsible party. The Quality Assurance Nurse/designee will randomly interview three residents on each unit regarding neglect daily for seven days and then weekly for one month beginning 08/19/11 at 8:00 a.m. or until compliance is achieved. Any allegation(s) of neglect will be immediately reported to the Administrator for investigation and reporting as per facility policy and regulation. 5)The Director of Nursing/designee and the Quality Assurance Nurse/designee will report findings to the Quality Assurance Committee on a weekly basis for one month or until compliance achieved beginning 08/24/11. Negative findings will be addressed by the Quality Assurance Committee to determine if alternate interventions are more appropriate. "