Every finding on record at Concordia Nursing & Rehab, LLC

Number of residents sampled: Number of residents cited: Based on interviews, record review, and facility policy review, it was determined that the facility failed to ensure a Registered Nurse (RN) was available in the building for eight consecutive hours a day for resident needs. Specifically, there was a Registered Nurse (RN) shortage for the eight consecutive hours a day for 21 dates between the months of 04/01/2026 through 08/16/2026. The findings include: A review of the facility policy Facility Assessment revised date October 2024, revealed a facility assessment was conducted annually to determine and update their capacity to meet the needs of and competently care for residents during day-to-day operations. The facility assessment includes a detailed review of the resources available to meet the needs of the residents' population. Each department provides input on current or potential gaps in care or services due to possible misalignment or lack of appropriate resources. The facility assessment is intended to help the facility plan for and respond to changes in the needs of the resident population and helps to determine budget, staffing, training, equipment, and supplies needed. A review of an undated facility document titled Director of Nursing (DON) Job Description revealed that the DON must be able to serve as a charge nurse on the floor as staffing needs may require them to do so. The DON will have a flexible schedule that can accommodate days off during the week/working weekends. The DON schedule is 8-hour shift, Monday to Friday, weekends as needed. A review of a facility document titled RN Time Punches from 04/01/2026 through 08/16/2026, revealed there was no RN coverage for eight consecutive hours on the following dates: 04/17/2026, 04/18/2026, 04/19/2026, 05/05/2026, 05/06/2026, 05/07/2026, 05/08/2026, 05/14/2026, 06/06/2026, 06/07/2026, 06/13/2026, 06/14/2026, 06/20/2026, 06/21/2026, 06/22/2026, 06/26/2026, 06/28/2026, 07/03/2026, 07/13/2026, 07/14/2026, and 07/18/2026. During a concurrent observation and interview on 08/20/2026 at 12:16 PM, with the Business Office Manager (BOM), DON, Administrator, and Minimum Data Set (MDS) Coordinator, the BOM stated she could not pull up some of the time punches due to staff being terminated or no longer employed. The DON stated she had worked some shifts, and the MDS Coordinator had worked some shifts. The Administrator questioned the BOM on the time punches. The Administrator stated there were missing time punch forms that staff had filled out. The BOM stated the MDS Coordinator had time punched some of her hours worked but she did not work the full eight hours. The Administrator turned toward the MDS Coordinator and told her that she had to stay clocked in for the full eight hours. There were time punches for the DON that were not the consecutive eight hours as well. The Administrator voiced loudly that it was required to be consecutive eight hours. The MDS Coordinator stated she worked 20 straight hours. This Surveyor showed the Administrator the date the MDS Coordinator was referencing as working 20 straight hours. This was a shift where she worked six hours consecutively, then went back later that evening for a few more hours but did not work eight hours consecutively. The BOM stated she had given the only missed time punches for the DON and MDS coordinator that they had on file and there were not any other time punches for the dates in question.During an interview on 08/20/2026 at 4:15 PM, the Administrator stated she understood the RNs did not work the required time of eight consecutive hours and understood the deficiency. On 08/21/2026 at 7:36 AM, an email was received from the Administrator with Time Punches for requested dates for the RN consecutive eight-hour daily coverage when the BOM stated the day before that the DON and MDS coordinator had not clocked in other than the dates that were already provided by the facility. During an interview on 08/21/2026 at 4:13 PM, the DON stated for clarification purposes due to being salary, she had not clocked in but a few times since she had started. She stated she was informed she was salary and if she was working extra and wanted overtime, she would need to clock in. The DON stated, I try to remember to clock in on the weekends but if I forget to, I am supposed to fill out a missed time punch form. But I haven't done that too often either. The DON stated, CNA will call in while I am in the building working the Registered Nurse (RN) 8 consecutive hours then I have to work the CNA position to cover the shift. The DON stated, when that happens, I am the RN and work as a CNA at the same time, doing both roles. During an interview on 08/21/2026 at 4:37 PM, the Administrator stated typically the RN that comes in for the 8 consecutive hours walked around, monitoring staff, helped in the dining room, looked at Medication Administration Records (MAR) and supervised the staff. She stated the DON was responsible for scheduling the RNs and LPNs. The Administrator stated she was aware of the RN shortage on some shifts and an RN not working eight consecutive hours. While the surveyors were in the facility from 08/17/2026-8/21/2026, the Administrator informed the surveyors they did not have 'missed time punch forms' for staff on dates requested and that staff failed to fill them out on those dates. An email was received at the State Agency office on 08/24/2026 at 2:44 PM with additional documents included, Missed Punch Forms the facility did not have available to present on 08/21/2026.

Number of residents sampled: Number of residents cited: Based on observations, interviews, and facility document reviews, the facility failed to post completed staffing logs that included the facility name, the current date, resident census, the total number and the actual hours worked by the following categories of Registered Nurses (RN), Licensed Practical Nurse (LPN), and Certified Nurses Assistants (CNA) staff directly responsible for resident care per shift. The findings include: A review of the facility Daily Nursing Assignment Sheets, dated 04/01/2026 through 06/30/2026 and 07/16/2026 through 08/15/2026, the logs were not filled out completely and did not include the facility name, resident census, and the actual hours worked by RNs, LPN, and CNAs. During an interview on 08/18/2026 at 10:00 AM, the Director of Nursing (DON) came into the conference room and asked the surveyor, what was wrong with the daily staffing logs. She also stated, I don't understand why they weren't right. The DON stated that she made the form that she used as her schedule and the Daily Staffing Log. This surveyor notified that DON that she could utilize any form she wanted for the Daily Staffing Log as long as all required information was included on the Daily Staffing Log. The DON stated, I am new to long term care (LTC) and I don't know what is required. The DON asked this surveyor what she needed to do. She was advised to reference the State Operations Manual for guidance and/or ask her administrator. During an interview on 08/18/2026 at 10:24 AM, the Administrator stated that the DON was new and wanted to use her own form as the Daily Staffing Log. She stated, I didn't realize the form didn't have everything on it that was required, and it would be fixed. During an observation on 08/19/2026 at 8:00 AM, the Daily Staffing Logs were hanging on the bulletin board next to the conference room. The form had been revised by adding the name of the facility and the census, but it did not have the actual hours worked per staff on it.

Based on observations, interviews, record review, facility document review, facility policy review, the facility failed to ensure employment of a full-time Director of Nursing to manage the nursing department and provide oversight of care and planning to all residents; and to ensure a registered nurse was available in the building for 8 consecutive hours a day for resident needs. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to State Operation Manual, Appendix PP, 483.35 (Nursing Services) at a scope and severity of L. The IJ began on 02/17/2025 after review of; employee files, timecard reports; Resident #33 TAR; Resident #184's lack of Minimum Data Sheet (MDS) assessments, comprehensive care plan with interventions, and interview; Resident #85's lack of MDS assessment, comprehensive care plan with interventions, and basic care plan; Resident #135's lack of MDS assessment, stage 2 pressure ulcer assessment, EBP implementation for a urinary catheter, and a comprehensive care plan. The Administrator was notified of the IJ on 04/23/2025 at 5:20 PM. A Removal Plan was requested. An IJ removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment or death likely. On 04/25/2025 at 9:51 AM an acceptable Immediate Jeopardy removal plan was accepted in accordance with Appendix Q. The IJ was not removed prior to exit; the survey team was unable to validate the plan of removal. The IJ was cleared on 05/09/2025 at a subsequent survey. Findings include: A review of the facility's undated Facility Assessment with an Addendum attached 08/24/2024 stated, a Director of Nursing (DON) was on staff, but no self-assessed staffing guidelines were identified and no mention of Registered Nurse (RN) coverage. A review of an undated facility document titled, Director of Nursing Job Description, indicated, DON must process the clinical and managerial skills to direct and lead a nursing department. It is vital that the person communicate [communicates] clearly to residents, their families, nurses and all nursing home personnel. The DON must lead the nursing staff in taking positive action to continually upgrade the quality of physical, social, emotional and spiritual care given. Professional requirements included, a willingness to study, learn and implement continuously changing state and federal regulations. Be a role model of professionalism and teamwork. Leadership ability. Responsibilities included, Plan, organize and direct the administration of all nursing units and patient care given based on established goals and objectives, standards, policies and procedures of the company and facility. Put into effect the administrative policies of the company. Maintain records. Review, update and revise policies including OBRA [Omnibus Budget Reconciliation Act] procedures to meet current objectives and state and federal regulations. Regularly inspect the facility, nursing practices and documentation for compliance with federal, state, and local standards and regulations. Insure [Ensure] that all shifts are adequately covered for nursing services following state and federal policies as well as patient needs. Oversee agenda preparation for medical staff and utilization review meetings. Function as the liaison between state and federal agencies in regard to Medicaid, Medicare and any and all other insurances. Complete any required documentation in a timely manner. Meet daily with critical core team members regarding admission, placement, or discharge of patients. In addition, participates in coordination of patient services through departmental staff meetings and assists in the development of patient's care plans. Oversee the complete and timely completion of care plans. Attend department head/administrative meetings. Review all infection control reports, medications incident reports and I&A reports. With appropriate staff, develop [a] corrective action plan. Study all weekly reports such as level of care reports, dietary and pharmacy consultant reports. Meet monthly with staff on each shift. Provide in-services to all shifts as necessary to maintain a quality nursing program. Maintain all required records. Meet monthly with the nursing staff regarding chart audits and physician orders. Perform in-house quality assurance surveys on a quarterly basis and maintain all quality assurance requirements and recommendations. Is on call for all emergencies that other supervisory personnel cannot handle. Stay up to date on state and federal regulations and policies. Plan, organize and direct all patient care. A review of the facility's employee file for the Former DON [Facility Name] New Hire/Stats Change Form, indicated, the Former DON was hired on 07/10/2023 and was terminated 02/16/2025; reason cited was quit without notice. She was an RN and full-time DON/MDS (Minimum Data Sheet) nurse. No acknowledgement of the facility's DON job description was noted signed or otherwise in the employee file. A review of the facility's employee file for the Former DON #8 [Facility Name] New Hire/Stats Change Form, indicated, the Former DON #8 was hired on 03/20/2025 and was terminated on 04/15/2025 reason cited was inability to perform job duties. She was an RN and the full-time DON/MDS nurse. No acknowledgement of the facility's DON job description was noted signed or otherwise in the employee file. During an interview on 04/22/2025 at 4:25 PM, Licensed Practical Nurse (LPN) #7 stated corporate reported Former DON #8 had not done any Minimum Data Sheet (MDS) assessments while employed, this meant no care plans had been developed. A review of the facility's employee file for the RN #4 revealed on a RN license verification for the state of Arkansas and an Arkansas Department of Human Services request for adult maltreatment registry information signed 04/22/2025. Per the Administrator on 04/23/2025 RN #4 was named as an Interim DON, no paperwork in the employee ' s file indicated this. RN #4 worked during the survey a partial 8-hour shift on 4/22/205, then worked 8 hours on 04/23/2025 and 04/24/2025. She was not at the facility again during the survey. The facility had one RN on staff who worked part-time, RN #2 who did not routinely work 8-hour shifts. A review of the Employee Timecard Report 02/16/2025-04/22/2025 and Human Resources identified dates worked by the DON revealed the facility was without 8 consecutive hours of RN coverage on 02/17/2025-02/18/2025, 02/20/2025-03/20/2025, 03/22/2025, 03/23/2025, 03/27/2025, 03/29/2025, 04/01/2025-04/06/2025, 04/09/2025, 04/13/2025-04/22/2025 which was 53 out of 65 days. As a result of no RN coverage or nurse management oversight the following occurred; Resident #25 had two major falls with injury due to lack of care plan re-evaluation and escalation of interventions, Resident #33's Peripherally Inserted Central Catheter (PICC) line was not assessed for 18 days by an RN and intravenous (IV) medications and flushes were administered by a non-IV certified LPN. Resident #85, #135, and #184 received no assessments and had no care plan implemented for care interventions for 26 days, 31 days, and 24 days respectively. A review of the Physician ' s Orders, indicated the facility admitted Resident #25 on 12/18/23 with diagnoses which included dementia, hypertension, insomnia, major depressive disorder with chronic anxiety, atrial fibrillation, dizziness and giddiness. A review of the quarterly MDS, with an Assessment Reference Date (ARD) of 03/16/25 revealed Resident #25's Brief Interview for Mental Status (BIMS) was 00, which indicated severe cognitive impairment. Section GG, functional abilities, revealed Resident # 25 required substantial/maximal assistance for mobility. A review of Resident #25's Care Plan dated 12/17/24, indicated the resident was at a very high risk for falls, lacked safety awareness and was weaker since a hospitalization . Resident #25 did not use call light nor know how. The facility developed interventions which included keeping the bed in the lowest position, attempting to keep gripper socks or shoes on when the resident is up, and to keep the resident room door open so staff could observe them as they walked down the hall. A review of Nursing Fall Risk Evaluation dated 03/24/25, revealed Resident # 25 had 3 or more falls in the last 90 days, no cognitive status changed in last 90 days, eliminated with assistance, was confined to a chair and used bedrails, the resident was not able to balance without physical help, had 3 or more risk factors related to falls on Resident Assessment Instrument (RAI) user's manual, and scored 24 on this. With a score of 10 or higher, the evaluation recommended staff should consider environmental risk factors in the resident's interventions. This form was completed by the Director of Nursing (DON). A review of Nursing Notes for Resident #25 on 03/13/25 at 2140 noted an X-ray of left wrist after an unwitnessed fall. A Radiology Results Report dated on 03/13/25, revealed Resident #25 had an impacted and comminuted distal left radius fracture and probable distal ulnar fracture to the left arm. An ace wrap applied to the left arm/wrist by the nurse. Resident #25 was a direct admitted to hospital for surgery on left arm. Resident #25 was discharged from the hospital on 03/24/25 post surgery with a cast in place to their left arm. The cast was removed by the resident twice. Per a review of Nursing Notes, on 03/26/25 Resident #25 was found on the floor in their room after an unwitnessed fall with complaints of pain to the right arm. An X-ray was performed on 03/28/25 which diagnosed a fracture to the right arm. Neither the Resident's closet care plan nor comprehensive care plan was updated with interventions for the resident's falls. A review of Incident and Accident Report (I&A) dated 03/26/25, indicated Resident #25 was found in the floor by a Certified Nursing Assistant (CNA). The witness statement stated the resident's left cast was off and on the other side of the bed and the resident was on the floor. No interventions were noted on I&A. A review of Radiology Results Report dated on 03/28/25, revealed Resident #25 had an impacted fracture of the right radial head. A review of a Hospital Orthopedic Record dated 03/26/25, revealed Resident #25 was discharged from the hospital with a diagnosis of markedly displaced and comminuted left distal radius and ulna fracture with significant soft tissue swelling status post stabilization with Open Reduction and Internal Fixation (ORIF) and casting by an orthopedic surgeon. During an interview on 04/21/25 at 12:25 PM, Resident #25's family member stated Resident #25 fell about a month ago and had to go to the hospital for surgery on their left wrist. Upon return from the hospital, Resident #25 kept removing their cast and fell ,d+[DATE] days later and sustained a new fracture to the right elbow. Resident #33, who according to the Medication Administration Record (MAR)/Treatment Administration Record (TAR) was admitted on [DATE] with a PICC line in place to receive IV antibiotics and flushed with saline and an anticoagulant twice a day, had no RN assessment or care of the line on 02/18/2025, 02/20/2025-02/23/2025, 02/27/2028-03/02/2025, 03/06/2025-03/09/2025, 03/13/2025-03/17/2025 which was 18 days. 17 doses of IV antibiotics were administered from 02/14/2025-02/28/2025 by the Med Records/LPN Charge Nurse, LPN #7, LPN #11, and LPN #12. During an interview on 04/25/2025 at 10:08 AM LPN #9 stated she was never asked for documentation of her IV certification by the facility, but she was certified as an optional part of her LPN curriculum and the certification shows when her license is verified. She stated prior to using Resident #33 PICC line she would assess for redness or swelling at the site and see if the resident could complete range of motion in the affected arm without pain. During an interview on 04/25/2025 the Administrator stated she did not ask the LPNs if they were IV certified and she did not track it. The Administrator stated there was no IV training in the facility. During an interview on 04/25/2025 at 10:32 AM, the Medical Record LPN stated they would assess the PICC line with every administration by looking for warmth, redness, pain, swelling, and signs and symptoms of infection and touch around the site too. The Medical Record LPN stated the scope of practice for LPNs assessing depended on your home state and she was originally licensed in New Mexico. During an interview on 04/25/2025 at 10:32 AM LPN #9 stated they did admission assessments as an LPN, indicating it was in their scope of practice. A review of a Face Sheet revealed Resident #85 was admitted on [DATE], a review of Resident #85 chart revealed no MDS assessment, a comprehensive care plan, or a basic closet care plan completed as of 04/23/2025. A review of Resident #85's MDS Admission, submitted late, revealed it was signed off by RN #4 on 04/24/2025 and a comprehensive care plan was initiated 04/24/2025. A review of a Face Sheet revealed Resident #135 was admitted on [DATE], a review of Resident #135 chart revealed no MDS assessment, or a comprehensive care plan completed as of 04/23/2025. A review of Resident #135's MDS Admission, submitted late, revealed it was signed off by RN #4 on 04/24/2025 and a comprehensive care plan was initiated 04/24/2025. A review of Resident #184 Face Sheet revealed Resident #184 was admitted [DATE], a review of Resident #184's chart revealed no MDS assessment, or a comprehensive care plan was completed as of 04/23/2025. A review of Resident #184's MDS Admission, submitted late, revealed it was signed off by RN #4 on 04/24/2024 and a comprehensive care plan was initiated 04/25/2025. During an interview on 04/25/2025 at 1:55 PM, the Certified Nursing Assistant (CNA) #1 stated, if a resident had fallen or was declining, she would notify Med Records LPN, and she would assess them if there was no RN available. The Medical Records LPN would tell us to keep an eye on them and update the residents' care plan. If the Medical Records LPN couldn't take care of it, she would notify the DON, if we had one. During an interview on 04/29/2025 at 9:42 AM, the Assistant Director of Nursing (ADON) stated, there is no DON, but as ADON she did not assume the job duties of the DON. She stated she had to work bedside every day and had other work to do. Nobody had assumed those responsibilities, and I was not aware the MDSs, and care plans had not been done. On 04/25/2025 at 9:51 AM an acceptable Immediate Jeopardy removal plan was accepted in accordance with Appendix Q: 1. Interim Registered Nurse/Director of Nursing was hired on 4/22/2025. Registered Nurse to provide weekend coverage and replace Director of Nurses in event of a call in. Schedule will be updated to reflect Registered Nurse Coverage. Registered nurse coverage is considered 8 consecutive hours daily. 2. Administrator was in serviced by Regional Director, on registered nurse and director of nursing coverage and requirement to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week. 3. Resident #33 peripherally inserted central catheter (PICC) Line was removed on 3/20/2025, care plan reviewed and updated as needed a. Bedside LPN in serviced 1: 1 by administrator about scope of practice regarding PICC line and site care on April 24, 2025. b. All LPNs/RN's to be in-serviced by phone or in person by director of nurses on Scope of Practice regarding PICC line and site care on April 25,2025 4. All staff will be in serviced by administrator and/or director of nursing in person or by phone on ESP and infection control by 4/25/25. Onsite Verification: During an interview on 04/25/25 at 11:30 AM the Administrator stated she had not heard from the new RN #4 (new interim DON). Neither she nor the Director of Operations could reach her on the phone. The Administrator stated she was not sure if the facility still had a DON. Onsite verification did not continue at this time. The survey team did not observe a RN in the building on 04/25/2025. Onsite verification was attempted on 05/02/2025 at 1:00 PM and could not be completed due to the Administrator verbalizing a Director of Nursing (DON) position had not been permanently filled and Interim DON verbalized being contracted for Registered Nurse (RN) coverage for 4 days and would be leaving the facility on Sunday 05/04/2025 to return to Oklahoma. Onsite verification was attempted on 05/05/2025 at 4:08 PM and could not be completed due to Interim DON verbalized being in Oklahoma and was not working for the facility. Interim DON verbalized only being contracted for four days as weekend RN coverage, not DON. The IJ was removed on 05/09/2025 at 12.56 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 05/08/2025 at 11:00 AM. Record review included new DON was hired on 05/09/2025 and was present in the facility during the onsite verification. RN coverage was reviewed from 04/22/2025 to 05/09/2025 and verified via interviews. In-services reviewed included requirement of registered nurse and director of nursing coverage and to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week. Resident #33 PICC Line was removed on 3/20/25, the care plan was updated. The Regional Director indicated the facility was no longer admitting residents with a PICC/IV, so there were no IV certifications to review. There were no residents residing in the building that had a PICC/IV. A total of 13 staff interviews were conducted with staff from all shifts to very training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Nurse Consultant, Social Services Director, and Assistant Director of Nursing. The staff interviewed verified they had been trained on the RN/DON requirement, scope of practice for LPNs. A review of in-service sheets provided indicated 16 had been provided training. Those staff who were not physically present to receive the in-services were messaged via telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding.

Based on interview, record review and policy review the administration (governing body) failed to ensure policies were implemented regarding management and operation of the facility to ensure residents were able to attain or maintain the highest practicable physical, mental, and psychosocial well-being. During the survey, the survey team identified no full-time registered nurse (RN) working 8 consecutive hours per day and licensed practical nurses (LPN) were not certified to assess and manage peripherally insert center catheters (PICC). Additionally, the survey team identified bed rails were installed without consent and residents were not assessed for their needs. The survey team identified residents with falls had not received fall assessments and interventions to prevent further falls. Lastly, the survey team identified a newly admitted resident had not been assessed for mobility function, identify interventions, and provide necessary equipment to maintain their most practicable independence. These identified failed practices resulted in Immediate Jeopardy for F727, F726, F700, F689, and F688. These deficient practices have the potential to affect all the residents residing in the facility. It was determined the facility ' s non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to State Operation Manual, Appendix PP, S483.70 Administration at a scope and severity of L . The IJ began on 04/29/2025 after the survey team identified five IJs including F726, F727, F700, F688, F689. The Administrator was notified of the IJ on 04/29/2025 at 12:05 PM. A Removal Plan was requested. An IJ removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment or death likely. On 05/01/2025 at 2:12 PM, an acceptable Immediate Jeopardy removal plan was accepted in accordance with Appendix Q. The findings are: A review of a facility policy titled Administrative Management revised on 10/01/2024, indicated, The facility ' s governing board is the supreme authority and has full legal authority and responsibility for the management and operation of our facility .The governing body is responsible for, but is not limited to: a. Oversight of facility care and services in accordance with professional standards of practice and principles .d. Establishment and ongoing review of all administrative programs governing facility management and operations, including: .(4) Staff orientation, training and development programs. e. Creation of and participation in the annual (pr as needed) facility-wide assessment; f. Establishment and annual review of policies and procedures governing facility operations . During the survey entrance conference on 04/21/2025 at 10:42 AM the Administrator reported there was no Director of Nursing (DON) on staff, the DON would also fill the role of Minimum Data Sheet (MDS) nurse, a corporate LPN was completing MDSs remotely. A review of the facility ' s employee file for the Former DON [Facility Name] New Hire/Stats Change Form, indicated, the Former DON was hired on 07/10/2023 and was terminated 02/16/2025 reason cited was, quit without notice. She was an RN and full-time DON/MDS (Minimum Data Sheet) nurse. No acknowledgement of the facility ' s DON job description was noted signed or otherwise in the employee file. A review of the facility ' s employee file for the Former DON #8 [Facility Name] New Hire/Stats Change Form, indicated, the Former DON #8 was hired on 03/20/2025 and was terminated on 04/15/2025 reason cited was, inability to perform job duties. She was an RN and the full-time DON/MDS nurse. No acknowledgement of the facility ' s DON job description was noted signed or otherwise in the employee file. During an interview on 04/28/2025 at 9:42 AM, the Assistant Director of Nursing (ADON) verbalized working as the Infection Preventionist (IP) and was not able to pick up the DON duties due to working bedside daily and barely having time to complete the IP job duties. During an interview on 04/22/2025 at 12:50 PM, the Med Records Nurse stated it had been a while since they were able to work in medical records due to working on the floor as a bedside nurse for the last six months. During a phone interview on 04/29/2025 at 9:42 AM, the Assistant Director of Nursing (ADON) verbalized the individual serving as the DON completes the care plans, fall assessments, and MDSs. The ADON continued to state no one has assumed the responsibilities since the facility does not have a DON. The ADON continued to verbalize some residents have one care plan in the closet, and it is not comprehensive, it is mainly about transfers, incontinence, or how they eat. A review of a facility policy titled, Central Venous and Midline Catheter Flushing, revised April 2016, indicated, The facility should consult the [state laws and regulations] for RN/LPN scope of practice and function and Insertion site assessment should be done as part of the flushing process to monitor for complications. During an interview on 04/25/2025 the Administrator verbalized, not asking the LPNs who was IV certified and reported they did not track which LPNs were IV certified. The Administrator stated there was no IV training in the facility. During an interview on 04/27/2025 at 01:02 PM, Registered Nurse (RN) #2 revealed there were no bed rail assessments. During an interview on 04/27/2025 at 01:12 PM, Licensed Practical Nurse (LPN) #9 revealed she was unsure of where bed rail assessments or documentation would be in the medical record and the facility usually just asks the residents what their preference was on having bed rails or not. During an interview on 04/27/2025 at 1:31 PM, the Housekeeping/Maintenance (Hskp/Maint) Supervisor verbalized being responsible for putting the bed rails on the beds and taking the bed rails off the beds. The Hskp/Maint Supervisor verbalized most of the beds in the facility have bedrails except for the residents who did not want them on. Hskp/Maint Supervisor revealed there are 3 types of bed rails, but that they (Hskp/Maint Supervisor) does not measure the beds to ensure proper fitment. The Hskp/Maint Supervisor reported being able to look at the bed and know which bedrail goes on the beds. She reported the facility had manufacture guidelines to the bed rails and beds but was unsure where they were at the time of interview, but she would find them. The Hskp/Maint Supervisor stated she had not read the manufacture guidelines. Hskp/Maint Supervisor revealed she checked the high and low beds at least weekly, but some of the beds every couple of days because the bed rails got really loose and must be tightened. When asked how she knew which bed rails to check she replied she just knew. The Hskp/Maint Supervisor revealed there were no forms or logs kept on bed rails. She reported if the bedrails were loose, they were not safe and would not be stable for the residents to use. She revealed the nurses were the ones who determined who got bed rails and who did not, and they would inform her. She revealed they have a standard size mattress in use in the facility. She revealed the facility also had a concave mattress and two types of bariatric size mattresses in use. She revealed it didn 't make a difference on the size of the mattress; it just made the bed rails closer to the mattress, so the mattress didn ' t slide. A review of Falls-Clinical Protocol policy, with a revision date of April 2024, revealed that, based off assessments, staff should identify pertinent interventions to prevent subsequent falls, and to address the risks of clinically significant consequences of falling. Staff will try various relevant interventions until falling reduces or stops or until a reason is identified for its continuation. During an interview on 04/29/2025 at 9:42 AM, the ADON revealed staff look at the time-of-day falls occur. The ADON confirmed fall assessments were completed by the DON and currently the facility does not have a DON. The ADON confirmed that no one has been completing fall assessments and updating care plans when falls occur. The ADON stated the facility utilizes low beds and fall mats for interventions. A facility document review of Facility Assessment Profile, undated, indicated the Director of Nursing pre-screens any new referrals and makes notes based on the information sent and if the facility is able to meet the needs of the resident. The facility provides wheelchairs and has a highlighted list residents regarding mobility. A facility policy review of Resident Assessment Instrument, revision date September 2024, indicated the purpose of the assessment was to describe the resident ' s capability to perform daily life functions and to identify significant impairments in functional capacity. The assessment also derives information from the comprehensive assessment which then helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. A policy for Activities of Daily Living/Mobility was not provided by the Administrator when requested on 04/25/2025. An Admission Nursing Evaluation, dated 03/31/25, Resident #184s evaluation was not an assessment and was completed by Medical Records/Licensed Practical Nurse, revealing one person assist for bed mobility, dressing, toileting, personal/hygiene, and bathing. It documented two persons assist for transfers with wheelchair use. During an interview on 04/29/2025 at 10:14 AM, the Administrator confirmed the role of the Administrator is to complete decision making for the betterment of the facility. During an interview on 04/25/25 at 11:55 AM, the Director of Operations (DOO) verbalized the role of the DOO is to assist the Administrator with policies and procedures, staffing, and budgets. The DOO verbalized the DOO position reports to the manager of the facility. On 05/01/2025 at 2:12 PM, an acceptable Immediate Jeopardy removal plan was accepted in accordance with Appendix Q: 1. In-service/meeting given via phone by regional director to governing body members (Manager, medical director) and in person to administrator. Administrator in-serviced management staff ( DON, COM, SS, HR, MOS) regarding the following: a. Responsibility of the Governing Body (facility oversight, operations and policy/procedure). b. Survey findings and POR to correct: Fall Clinical Protocol, Registered Nurse requirement, Competent staff, Mobility, Bed rail usage and Supervision to prevent accidents. c. Plan moving forward to improve findings Onsite Verification: Onsite verification was attempted on 05/09/2025 at 12:56 PM and could not be completed at that time due to designated staff not fully educated on the plan of removal. The IJ was removed on 05/15/2025 at 8:13 AM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 05/09/2025 after the survey team identified five IJs including F726, F727, F700, F688, F689. Observation of bed rails on beds, care plans for residents in place; in-service provided to Administrator by Regional Director on 04/30/2025; in-service provided to nursing staff regarding policy and procedure of bed rails, assessing, consent to use and physician order required; consent forms for residents with bed rails, bed rail assessments for residents with bed rails. Six (6) residents identified as having bed rails with no assessments / consents. Assessments and consents obtained. Monitoring sheets completed on 05/08/2025 by Administrator and Director of Nursing (DON), 05/12/2025 by Housekeeping Supervisor and 05/13/2025 by Administrator and DON, for bed rail assessment and consents. File containing manufacturer guidelines for bed rails provided. The Housekeeping Supervisor confirmed they were in-serviced by the Administrator regarding bedrails, maintenance, ensuring bedrails are compatible with the bed frame, and has reviewed and will refer to guidelines if needed. Review of the in-service document date 05/02/2025 revealed the regional director in-serviced the governing body by telephone and the Administrator was in-serviced in person regarding responsibility of the governing body, survey findings, plan of removal to correct findings during survey, and plan moving forward to improve findings. A total of 6 staff interviews were conducted with staff from all shifts verifying training had been completed. The staff interviewed included Certified Nursing Assistants, Housekeeping Supervisor. The staff interviewed verified they had been trained on bed rails and enhanced barrier precautions. A review of in-service sheets provided indicated 24 staff were provided with training. Staff who were not physically present to receive the in-services were in-serviced by telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding.

Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 25) of 2 residents reviewed for falls/accidents received proper assessments and interventions to prevent falls. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 04/29/2025 at 8:46 AM after review of Resident 25 incidents/accident reports, care plans and closet care plans. The review revealed three interventions for nine documented falls for Resident 25. The Administrator was notified of the IJ on 04/29/2024 at 8:46 AM. A Removal Plan was requested. An Immediate Jeopardy removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment or death likely. On 05/01/2025 an acceptable IJ removal plan was accepted. The IJ was removed on 05/09/2025. The findings are: 1. A review of Falls-Clinical Protocol policy with a revision date of April 2024 revealed based off assessments staff should identify pertinent interventions to prevent subsequent falls, and to address the risks of clinically significant consequences of falling. Staff will try various relevant interventions until falling reduces or stops or until a reason is identified for its continuation. 2. A review of the Admission Record, indicated the facility admitted Resident # 25 on 12/18/2023. a. A review of the quarterly MDS, with an Assessment Reference Date (ARD) of 03/16/25 revealed Resident #25's Brief Interview for Mental Status (BIMS) was 00, which indicated severe cognitive impairment. Section GG, functional abilities, revealed Resident # 25 required substantial/maximal assistance for mobility. b. A review of Resident #25's care plan dated 12/17/2024, indicated the resident was at a very high risk for falls, lacked safety awareness and was weaker since a hospitalization . Resident #25 did not use call light nor know how. The facility developed interventions which included keeping the bed in the lowest position, attempting to keep gripper socks or shoes on when the resident is up, and keep the resident room door open so staff could observe them as they walked down the hall. c. A review of Nursing Fall Risk Evaluation dated 03/24/2025, revealed Resident # 25 had three or more falls in the last 90 days, no cognitive status changed in last 90 days, eliminated with assistance, was confined to a chair and used bedrails, the resident was not able to balance without physical help, had 3 or more risk factors related to falls on Resident Assessment Instrument (RAI) user's manual, and scored 24 on this. It instructed that when a resident scored 10 or higher staff should consider environmental risk factors in the resident's interventions. This form was completed by the former DON #8. d. A review of nursing notes for Resident #25, dated 03/13/2025 at 9:40 PM, noted an X-ray of left wrist was performed after an unwitnessed fall. A Radiology Results Report dated on 03/13/2025, revealed Resident #25 had an impacted and comminuted distal left radius fracture and probable distal ulnar fracture to the left arm. An ace wrap was applied to the left arm/wrist. Resident #25 was a direct admit to the hospital for surgery on left arm. Resident #25 was discharged from the hospital on 03/24/2025 post surgery with a cast in place to their left arm. The cast was removed by the resident twice after admission to facility. e. A review of Incident and Accident Report (I&A) dated 03/26/2025, indicated Resident #25 was found in the floor by a Certified Nursing Assistant (CNA). The witness statement stated the resident's left cast was off and on the other side of the bed and the resident was on the floor. No new interventions were noted on the I&A. f. A review of nursing notes reveal that on 03/26/2025, Resident #25 was found on the floor in their room after an unwitnessed fall with complaints of pain to the right arm. An X-ray was performed on 03/28/2025 which diagnosed a fracture to the right arm. Neither the resident's closet care plan nor comprehensive care plan was updated with interventions for the resident's falls. A Radiology Results Report dated on 03/28/2025, revealed Resident #25 had an impacted fracture of the right radial head. g. A review of a hospital orthopedic record dated 03/26/2025, revealed Resident #25 was discharged from the hospital with a diagnosis of markedly displaced and comminuted left distal radius and ulna fracture with significant soft tissue swelling status post stabilization with Open Reduction and Internal Fixation (ORIF) and casting by an orthopedic surgeon. h. During an interview on 04/21/2025 at 12:25 PM with Resident #25's family member, they stated Resident #25 fell about a month ago and had to go to the hospital for surgery on their left wrist. Upon return from the hospital, Resident #25 kept removing their cast and fell ,d+[DATE] days later and sustained a new fracture to the right elbow. 3. On 04/27/25 at 11:30 AM during an interview Registered Nurse (RN) #2 explained after a fall the resident is assessed, and an incident and accident (I and A) form is completed. RN #2 revealed the nurses should do immediate interventions and document the interventions on the I and A form, document in the nurses' notes, then the nurses should add it to the closet care plan and update the CNAs. 4. On 04/28/205 at 2:46 PM, during an interview the Former Director of Nurses (DON) stated examples of fall interventions could include fall mats, nonskid strips on the floor, pillows wedges, snacks, the resident participating in an activity, moving the bed, and the position of bed. The Former DON stated the facility should never quit intervening. She revealed most falls had a pattern, such as falls at night where the resident was trying to toilet themselves. She stated a staff intervention could be toileting the person during the night. The Former DON stated not every intervention would work for every resident. 5. On 04/29/2025 at 9:42 AM, during an interview the Assistant Director of Nursing (ADON) revealed that the staff looked at the time-of-day falls occurred. She stated she does not do fall assessments. It was the DON who usually did, the facility did not have a DON so there was no one to complete them and they had not been done. The ADON stated the facility utilizes low beds and fall mats for interventions. She revealed the DON placed the falls on the care plan and without a DON it is not being done. She revealed she worked as a bedside nurse most of the time as does the Medical Records nurse. She revealed she doesn't know what the facility was doing to help fix our systems. On 05/01/2025 an acceptable IJ removal plan was accepted. 1. Fall assessments and interventions reviewed and updated as needed for Residents #15 and #25 by facility nurse. Completed on 4/30/2025. 2. ln-service by administrator, regional director and nurse consultant started 4/29/2025 for Nursing staff ( RN, LPN, CNA) present and via phone for those not in facility regarding the following: a. Assessing, monitoring and intervening in falls to prevent injury and/or reduce falls. b. Proper interventions for falls c. Care plans related to falls d. Notification of PCP,DON, family and administrator 3. DON/Administrator in-serviced by regional director 4/29/2025 in regards to monitoring of incident and accident (I&A), fall records and daily nurse documentation to identify and address any concerns immediately. Onsite Verification: Onsite verification was attempted on 05/02/2025 at 3:51 PM and could not be completed at that time due to R26 had a fall and the facility did not have any documentation regarding the fall or interventions put in place. One LPN and two CNAs had not had training and education on falls, proper interventions, and care plans. Onsite verification was attempted on 05/05/2025 at 3:42 PM and could not be completed at that time due to one LPN verbalizing signing off on in-services but unsure what the in-service was regarding and one CNA verbalizing not receiving any in-services on falls, proper interventions and care plans within the last two weeks. The IJ was removed on 05/09/2025 at 12.56 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 05/08/2025 at 11:00 AM. Record review included fall assessments and interventions were updated for Resident #15 and #25. Inservice included assessing, monitoring, and intervening in falls to prevent injury and/or reduce falls, proper interventions for falls, and care plans related to falls. Falls assessments were completed to identify residents that were a high fall risk. A total of 13 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Nurse Consultant, Social Services Director, and Assistant Director of Nursing. The staff interviewed verified they had been trained on the facility ' s process for falls. A review of in-service sheets provided indicated 18 had been provided training. Those staff who were not physically present to receive the in-services were messaged via telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding. 52347

Based on interviews, record review, and facility document review, the facility failed to ensure bed rail assessments were completed for resident needs and safety, to obtain informed consent prior to installation of bed rails, and to ensure identified bed rails were applied to a compatible bed based on the assessed resident needs. Bed rails found installed on resident beds for 2 residents (Resident #15 and #25) that were reviewed for bed rails. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 04/29/2025 at 8:46 AM after review of Resident 15 and Resident 25's medical chart and found no bed rail assessments, nor informed consents from residents or power of attorneys, notation of establishment of proper bed rails installed and no manufacture guidelines for current bed rails in place on Resident 15 and Resident 25's bed. The Administrator was notified of the IJ on 04/29/2025 at 8:46 AM. A Removal Plan was requested. An Immediate Jeopardy removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment or death likely. On 05/06/2025 an acceptable Immediate Jeopardy removal plan was accepted in accordance with Appendix Q. At time of exit on 05/06/25 at 11:47 AM IJ was not cleared. The findings are: Resident #15 was admitted on [DATE] with diagnoses of falls, dementia, and chronic ischemic heart disease according to Face Sheet and (named hospital) Clinic notes dated 11-15-2024. On 04/23/25 at 2:00 PM, an observation was made of 2 quarter side rails on bed on both sides of mattress in up position on Resident #15 bed. On 04/26/25 at 12:03 PM, an observation was made of 2 quarter side rails on both sides of bed in up position on Resident #15 bed. On 04/27/25 at 9:04 AM, an observation was made of 2 quarter side rails on bed in up position on Resident #15 bed. On 04/26/25 at 1:00 PM, no side rail assessment, bed rail informed consent from power of attorney, or form determining what type of side rail to be used were found in Resident #15 ' s medical record. A review of the Care Plan with initiation date of 11/22/204 did not indicate bed rails where in use for Resident #15. An observation of the Closet Care Plan at 04/27/2025 at 10:26 AM revealed it did not indicate bed rails were to be used. On 04/27/2025 at 10:26 AM Certified Nursing Assistant (CNA) #1 revealed that Resident #15 had bedrails. She revealed that the bedrails are in the up position when in bed but puts them in the down position when Resident #15 is up. On 04/27/2025 at 10:35 AM CNA #3 revealed that Resident #15 has bed rails. She revealed that she is unsure whether they are supposed to be put up or down. CNA #3 observed closet care plan and revealed that bedrails were not on the closet care plan. On 04/27/2025 at 1:01 PM Registered Nurse (RN) #2 revealed that she was unsure if Resident #15 is supposed to have bed rails or not. And she was unsure if they were supposed to be up or down. On 04/29/2025 at 9:42 AM, an interview with the Assistant Director of Nurses (ADON) revealed that the bed rails on the electric beds are pulled up because the bed rails have the bed controls on it. The ADON revealed that bedrails are pulled up for the residents that try to get out of bed. We pull them up to keep them from getting out. She revealed that the facility doesn't have full bed rails on any bed. The ADON revealed that she was told that they only must assess the bedrails if they were full bedrails. The ADON revealed that former Director of Nurses (DON) said they did not have to assess them. The ADON revealed that she does not know who installs the bed rails or does not know anything about the bed rail process. On 04/27/2025 at 1:02 PM, Registered Nurse (RN) #2 revealed that there were no bed rail assessments. RN #2 stated that the MDS did not indicate bed rail use for Resident #15. On 04/27/2025 at 1:12 PM Licensed Practical Nurse (LPN) #9 revealed that she was unsure of where bed rail assessments or documentation would be in the medical record. LPN #9 revealed that the facility usually just asks the residents what their preference was on having bed rails or not. She revealed that they usually keep the bed rail up for mobility and positioning. On 04/27/2025 at 1:31 PM with the Housekeeping/Maintenance Supervisor revealed that she is responsible for putting the bed rails on the beds and taking the bed rails off the beds. She revealed that most of the beds have bedrails on the beds, except for the residents who do not want them on. The Housekeeping/Maintenance Supervisor revealed that there are 3 types of bed rails. She revealed that she does not measure the beds, she is just able to look at the bed and know which bedrail goes on the beds. She reports that she has manufacture guidelines to the bed rails and beds but unsure where they were at the time of interview, but she would find them. She revealed that she has not read the manufacture guidelines. The Housekeeping/Maintenance Supervisor revealed that she has to check the high and low beds at least weekly but some of the beds, every couple of days because the bed rails get really loose. She must tighten the bedrails because they are loose. When asked how she knows whose bed to check she just replied that she knows who to check. The Housekeeping/Maintenance Supervisor revealed there are no forms or logs that she keeps up with. She reported if the bedrails are loose, they are not safe and would not be stable for the residents to use. She revealed that the nurses are the ones who determine who get bed rails and who does not and they just let her know. She revealed that they have a standard size of mattress that they use in the facility. She revealed that they also have a concave mattress and 2 types of bariatric size mattresses. She revealed that it doesn't make a difference on the size of the mattress, it just makes the bed rails closer to the mattress so that the mattress doesn't slide. On 04/28/2025 at 11:51 AM, Certified Nursing Assistant (CNA) #10 assisted the surveyor by flipping mattress and did not observe any mattress size tags on edges or bed itself. Also observed bed frame with no tags for instructions for bed rails or entrapment warnings. Space observed in between concave mattress and bed rail. CNA #10 placed middle 3 fingers in between bed rail and mattress with remaining gap left for more possible fingers to be placed and observed by two surveyors. On 04/29/205 at 8:52 AM, during a phone interview Resident #15's spouse revealed that facility has never spoken to them about the bedrails or received an informed consent. A review of DON job description revealed that they will maintain all required record and regularly inspect all documentation required by federal and state standards and regulations. A review of Side Rail policy revealed that an assessment would be performed to determine a resident's bed mobility, ability to change positions, transfer to and from bed/chair, and to stand and toilet. It also revealed that it would include risk for entrapment for the use of side rails, and the bed's dimensions were appropriate for the resident size and weight. It also revealed that side rails would be addressed in residents' care plans. The policy revealed that an informed consent from the resident or resident power of attorney would be obtained. Resident #25 was admitted on [DATE] at 09:19 AM with diagnoses which included dementia, insomnia, hypertension, anxiety with depression, atrial fibrillation, and gastroesophageal reflux disease per (named hospital) Clinic notes dated 11-15-2024. On 04/24/2025 at 12:33 PM during observation of Resident #25, the bed was in the lowest position, quarter bedrails on both sides of the head of bed were in an up position with resident sitting on side of bed. During observation on 04/27/2025 at 10:02 AM, Resident #25 was lying in bed with eyes closed, the room door was open, the bed with both upper quarter bedrails in an up position. On 04/28/2025 at 8:50 AM during observation, both upper quarter bedrails in an up position. Resident #25 was lying in bed. A review on 04/24/2025 at 12:33 PM of Resident #25's closet care plan indicated two bedrails were used. A review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/2025 indicated no bedrails were in use by Resident #25. A review of a care plan initiation dated 12/17/2024 did not indicate bedrails were in use by Resident #25. On 04/27/2025 at 12:57 PM, an interview with CNA #1 revealed the bedrails were already installed on Resident #25's bed upon admission, the bedrails had been down at times, and housekeepers put the bedrails on the beds. On 04/27/2025 at 1:00 PM, an interview with RN #2 revealed the bedrails had been on Resident #25 bed since admission and housekeeping installed them. On 04/29/2025 at 9:00 AM, an interview with Resident #2 family indicated the facility had not talked to them about bedrails, the possibility of injury, or education of the bedrails. Family knew the bedrails could be raised up or down and the bedrails were installed on the bed before admission. The family denied signing consent for the bedrails. On 05/06/2025 an acceptable Immediate Jeopardy removal plan was accepted in accordance with Appendix Q: 1. ln-service provided to Administrator by Regional Director on 4/30/2025 in regards to bed rails and assessing, getting signed consent and order prior to use. 2. Administrator to provide in-service to nursing staff in person and via phone Regarding policy and procedure of bed rails, assessing, consent to use and physician order requirement completed by 5/1/2025. 3. Review of records to be completed by nurse manager to identify other residents with bed rails. 5/2/2025 4. Identified residents will be assessed by nurse and consent obtained 5/2/2025. 5. Administrator and DON will monitor care areas weekly to ensure bed rails are assessed and consent obtained and in the record. 6. Care plan and MDS will be updated by LPN Nurse consultant 5/2/2025. 7. IDT team will work with environmental services supervisor to ensure bed frame and bed rails are compatible for the provided bed per manufacturers guidelines and recommendations. 8. ln-service provided by administrator to environmental service supervisor regarding bed rails, bed maintenance and ensuring bedrails and bedframe are compatible to prevent entrapment zones. 5/2/2025 Onsite Verification: Onsite verification was attempted on 05/02/2025 at 3:13 PM and could not be completed due to the Administrator verbalizing all items on the Plan of Removal (POR) had not been completed because the process of completing the bed rail assessments were taking a long time. Onsite verification was attempted on 05/05/2025 at 2:03 PM and could not be completed due to the Administrator verbalizing all assessments were not completed and all consents have not been signed. Onsite verification was attempted on 05/09/2025 at 12:56 PM and could not be completed at that time due to staff not using manufacturers guidelines for bed rails and no side rail assessments had been completed. The IJ was removed on 05/15/2025 at 8:35 AM after reviewing all the submitted care plans, consents and bed rail evaluation forms. Onsite verification of the Removal Plan began on 05/09/2025 after reviewing Resident 15 and Resident 25's medical chart and found no bed rail assessments, nor informed consents from residents or power of attorneys, notation of establishment of proper bed rails installed and no manufacture guidelines for current bed rails in place on Resident 15 and Resident 25's bed. Observation of bed rails on beds, care plans for all residents with bed rails including Resident 15 and Resident 25 in place; in-service provided to Administrator by Regional Director on 04/30/2025; in-service provided to nursing staff regarding policy and procedure of bed rails, assessing, consent to use and physician order required; consent forms for residents with bed rails, bed rail assessments for residents with bed rails. Six (6) residents identified as having bed rails with no assessments / consents. Assessments and consents obtained. Monitoring sheets completed on 05/08/2025, 05/12/2025 and 05/13/2025 for bed rail assessment and consents. File containing manufacturer guidelines for bed rails provided. Interview with Housekeeping supervisor confirmed was in-serviced by the Administrator regarding bedrails, maintenance, ensuring bedrails are compatible with the bed frame, and has reviewed and will refer to guidelines if needed. Review of the in-service revealed the regional director in-serviced the governing body by telephone and the Administrator was in-serviced in person regarding responsibility of the governing body, survey findings, plan of removal to correct findings during survey, and plan moving forward to improve findings. A total of 5 staff interviews were conducted with staff from all shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants, Housekeeping Supervisor. The staff interviewed verified they had been trained on bed rails. A review of in-service sheets provided indicated 24 staff had been provided training. Staff who were not physically present to receive the in-services were in-serviced by telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding. An onsite verification was attempted on 5/14/25. The survey staff was unable to validate the POR, resident 15 and Resident 25 did not have a bed rail assessment. The facility was able to provide the documentation on 5/15/25. 52347

Based on interviews, record review, facility document review, facility policy review, the facility failed to ensure a nurse with the training and competencies were on staff to provide the ordered necessary care to the residents. Specifically, the facility did not ensure Licensed Practical Nurses (LPNs) with Intravenous (IV) certification accessed and managed Resident #33's Peripherally Inserted Center Catheter (PICC) line including IV antibiotic administration, IV flushes, and assessment of the line's condition and status. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to State Operation Manual, Appendix PP, 483.35 (Nursing Services) at a scope and severity of K. The IJ began on 02/17/2025 after review of; employee files, timecard reports; Resident #33 TAR; Resident #184's lack of Minimum Data Sheet (MDS) assessments, comprehensive care plan with interventions, and interview; Resident #85's lack of MDS assessment, comprehensive care plan with interventions, and basic care plan; Resident #135's lack of MDS assessment, stage 2 pressure ulcer assessment, EBP implementation for a urinary catheter, and a comprehensive care plan. The Administrator was notified of the IJ on 04/25/2025 at 11:55 AM. A Removal Plan was requested. An IJ removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment or death likely. On 04/26/2025 at 11:55 AM an acceptable Immediate Jeopardy removal plan was accepted in accordance with Appendix Q. At the time of exit on 5/06/2025 the IJ was still ongoing. The findings include: A review of the facility's undated Facility Assessment with an Addendum attached 08/24/2024 indicated, The facility offered 24-hour nursing services which included IV therapy. Our Director of Nurses pre-screens any new referrals and makes notes based on the information sent and if we are able to meet their needs. No self-assessed staffing guidelines were identified and no mention of Registered Nurse (RN) coverage. The 08/24/2024 addendum stated, Direct Care Staff Requirements: The facility will ensure that the composition of direct care staff includes Registered Nurse (RNs), Licensed Practical Nurses/Licensed Vocational Nurses (LPNs/LVNs), and Nursing Assistants (NAs). Unit-Specific Staffing Needs: Each resident unit within the facility will be evaluated to determine specific staffing needs. Adjustments to staffing levels will be made based on changes in the resident population, such as admissions, discharges, and changes in resident care needs, The evaluation will be conducted quarterly or more frequently if significant changes in the resident population occur. Monitoring and Implementation: Any changes in resident population or care requirements will prompt an immediate review and adjustment of staffing levels. A review of a facility policy titled, Central Venous and Midline Catheter Flushing, revised April 2016, indicated, The facility should consult the [state laws and regulations] for RN/LPN scope of practice and function and Insertion site assessment should be done as part of the flushing process to monitor for complications. A review of the facility's LPN/RN Charge Nurse, Job Description indicated the LPN Charge Nurse duties were to Conduct resident rounds as assigned to assess the condition of each resident and report problems to the DON. Assess and report changes in resident's condition take follow-up action as necessary. Assess resident needs and add to resident care plan. The expectation of the Med Records nurse who worked the Foor as an LPN Charge Nurse was to work outside her scope of practice by assessing the residents. A review of the Arkansas Administrative Code, Agency 067-Board of Nursing, Rule and Regulations stated a RN/Professional Nurse was The Practice of Professional Nursing- The performance for compensation of any acts involving the observation, care and counsel of the ill, injured or infirm; the maintenance of health or prevention of illness of others; the supervision and teaching of other personnel as set forth in regulations established by the board; or the administration of medications and treatments as prescribed by an advanced practice nurse holding a certificate of prescriptive authority, a licensed physician, or a licensed dentist, where such acts require substantial specialized judgment and skill based on knowledge and application of the principles of biology, physical and social sciences. A LPN/Practical Nurse The Practice of Practical Nursing- The performance for compensation of acts involving the care of the ill, injured, or infirm or the delegation of certain nursing practices to other personnel as set forth in regulations established by the board; under the direction of a registered professional nurse, an advanced practice nurse, a licensed physician or a licensed dentist, which acts do not require the substantial specialized skill, judgement, and knowledge required in professional nursing. And defined Delegation-Entrusting the performance of a selected nursing task to an individual who is qualified, competent and able to perform such task. The nurse retains the accountability for the total nursing care of the individual. The Arkansas State Borad of Nursing (ASBN) IV Therapy Guidelines stated, IV Therapy Guidelines for Teaching Content Related to IV Therapy for Arkansas Licensed Practical Nurses and Licensed Practical Nursing Students The profession of nursing is a dynamic discipline. Practice potentials change and develop in response to health care needs of society, technical advancements, and the expansion of scientific knowledge. The Arkansas State Board of Nursing developed Position Statement 98-6, Scope of Practice Decision Making Model, to enable nurses to determine if a specific task is within their personal scope of practice. It is recommended that this model continue to be used. The ASBN Position Statement 98-6 Decision Making Model provides an easy-to-follow diagram for nurse to follow when a decision is to be made for appropriate task delegation. The questions is asked, Has the nurse completed special education if needed? and Is there documented evidence of competency and skill? Only LPN #9 provided documented proof of her special training and competency for IV administration, though verification of her practical nursing license an added message indicated she was also IV certified. Resident #33 who according to the Medication Administration Record (MAR)/Treatment Administration Record (TAR) was admitted on [DATE] with a PICC line in place to receive IV antibiotics and flushed with saline and an anticoagulant twice a day had no RN assessment or care of the line on 02/18/2025, 02/20/2025-02/23/2025, 02/27/2028-03/02/2025, 03/06/2025-03/09/2025, 03/13/2025-03/17/2025 which was 18 days. 17 doses of IV antibiotics were administered from 02/14/2025-02/28/2025 by the Med Records/LPN Charge Nurse, LPN #7, LPN #11, and LPN #12. A review of Resident #33's Physician Orders, indicated the facility admitted Resident #33 on 02/10/2025 on a veteran's contract with diagnoses that included heart failure, liver disease, osteomyelitis, anxiety, post-traumatic stress disorder (PTSD), diabetes, hypothyroidism, and neuropathy. The resident had bilateral foot wounds with daily dressing changes, a PICC line was in place and IV antibiotics were ordered twice a day. A review of Resident #33's clinic note dated 02/28/2025, the Medical Director (MD) indicated, the resident was admitted from an acute care hospital for continued IV antibiotic therapy and wound care after a diabetic foot ulcer worsened from close exposure to a heater. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2025, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was Cognitively intact. And incorrectly indicated in Section O the resident did not have any IV access at admission or while a resident. Which was completed by LPN #7 on 03/11/2025. The PICC line was still in place at the time the MDS was completed. During an interview on 04/25/2025 at 1:55 PM, the Certified Nursing Assistant (CNA) #1 stated, if a resident had fallen or was declining, she would notify Med Records LPN, and she would assess them if there was no RN available. Med Records would tell us to keep an eye on them and update the residents' care plan. If Med Records couldn't take care of it, she would notify the DON if we had one. During an interview on 04/25/2025 at 10:08 AM LPN #9 stated she was never asked for documentation of her IV certification by the facility, but she was certified as an optional part of her LPN curriculum and the certification shows when her license is verified. She stated prior to using Resident #33 PICC line she would assess for and redness or swelling at the site and see if the resident could complete range of motion in the affected arm without pain. During an interview on 04/25/2025 at 10:32 AM the Med Record LPN stated they would assess the PICC line with every administration by looking for warmth, redness, pain, swelling, and sign and symptoms of infection and touch around the site too. Med Records LPN stated the scope of practice for LPNs assessing depended on your home state and she was originally licensed in New Mexico. During an interview on 04/25/2025 at 10:32 AM LPN #9 stated they did admission assessments as an LPN indicating it was in their scope of practice. During an interview on 04/25/2025 the Administrator stated she did not ask the LPNs who was IV certified and she did not track it. The Administrator stated there was no IV training in the facility. On 04/26/2025 at 11:55 AM an acceptable Immediate Jeopardy removal plan was accepted in accordance with Appendix Q: 1. Interim Registered Nurse/Director of Nursing was hired on 4/22/2025. Registered Nurse to provide weekend coverage and replace Director of Nurses in event of a call in. Schedule will be updated to reflect Registered Nurse Coverage. Registered nurse coverage is considered 8 consecutive hours daily. 2. Administrator was in serviced by Regional Director, on registered nurse and director of nursing coverage and requirement to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week. 3. Resident #33 peripherally inserted central catheter (PICC) Line was removed on 3/20/2025, care plan reviewed and updated as needed a. Bedside LPN in serviced 1: 1 by administrator about scope of practice regarding PICC line and site care on April 24, 2025. b. All LPNs/RN's to be in-serviced by phone or in person by director of nurses on Scope of Practice regarding PICC line and site care on April 25,2025. 4. In-services to be provided by the Administrator and/or Director of nursing to licensed nursing staff regarding the following items to be completed by 4/24/2025 at 5:00 PM. a. Care plans-Baseline, comprehensive, and closet care plans completed timely b. MDS Timeliness c. RN Assessments and interventions d. Fall Documentation e. Enhanced Barrier Precautions (EBP)/INFECTION CONTROL 5. Regional Director provided in-service via phone to Administrator regarding LPN Administration of IV medication on 4/25/2025 @ 3:30PM. Administrator will in-service DON and Human Resource Coordinator on tracking IV certifications of LPNs in event of another PICC line admission TO be completed 4/26/2025 by 5PM. During an interview on 04/25/25 at 11:30 AM the Administrator stated she had not heard from the new RN #4 (new interim DON). Neither she nor the Director of Operations could reach her on the phone. The Administrator stated she was not sure if the facility still had a DON. Onsite verification did not continue at this time. The survey team did not observe a RN in the building on 04/25/2025. Onsite verification was attempted on 05/02/2025 at 12:56 PM and could not be completed at that time due to staff not fully educated on Enhanced Barrier Precautions (EBP), care plans, and MDS. Onsite verification was attempted on 05/05/2025 at 3:17 PM and could not be completed at that time due to staff not fully educated on Enhanced Barrier Precautions (EBP), care plans, and MDS Onsite verification was attempted on 05/09/2025 at 12:56 PM and could not be completed at that time due to staff not fully educated on Enhanced Barrier Precautions (EBP), care plans, and MDS. The IJ was removed on 05/15/2025 at 8:13 AM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 05/14/2025 at 10:30 AM. Record review included new DON was hired on 05/09/2025 and was present in the facility during the onsite verification. RN coverage was reviewed from 04/22/2025 to 05/14/2025 and verified via interviews. In-services reviewed included requirement of registered nurse and director of nursing coverage and to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week. Resident #33 PICC Line was removed on 3/20/25, the care plan was updated. The Regional Director indicated the facility was no longer admitting residents with a PICC/IV, so there were no IV certifications to review. There were no residents residing in the building that had a PICC/IV. A total of 7 staff interviews were conducted with staff from all shifts to very training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurse, Registered Nurse, and Director of Nursing. The staff interviewed verified they had been trained on care-plans, MDS timeliness, RN Assessments and interventions, fall documentation, and enhanced barrier precautions. A review of in-service sheets provided indicated staff had been provided training and the staff who were not physically present received the in-service were messaged via telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #184) of 1 sampled resident did not have a decline in mobility functions with psychosocial harm after admission. Specifically, the facility failed to assess the resident's mobility function, identify interventions, and provide necessary equipment for Resident #184 to maintain their most practicable independence. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to the resident. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 04/02/25 after Resident #184's admission. Through interviews, observations, and record review it was revealed Resident #184 had become totally dependent upon staff for activities of daily living and mobility with worsening psychosocial health. The administrator was notified of the IJ on 04/25/25 at 03:02 PM. A Removal Plan was requested. On 04/26/25 at 03:25 PM, the facility had submitted an acceptable IJ removal plan in accordance with Appendix Q. The IJ was cleared on 05/09/2025. Findings include: A facility policy review of Facility Assessment, revision date October 2024, indicated the facility assessment included factors that affect the overall acuity of the residents such as need for assistance with Activities of Daily Living and mobility impairments. A facility document review of Facility Assessment Profile, undated, indicated the Director of Nursing pre-screens any new referrals and makes notes based on the information sent and if the facility is able to meet the needs of the resident. The facility provides wheelchairs and has a highlighted list residents regarding mobility. A facility policy review of Resident Assessment Instrument, revision date September 2024, indicated the purpose of the assessment was to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. The assessment also derives information from the comprehensive assessment which then helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. A policy for Activities of Daily Living/Mobility was not provided by the Administrator on 04/25/2025. Review of a Face Sheet revealed Resident #184 was admitted to the facility on [DATE]. Review of the Medical Diagnosis portion of Resident #184 ' s electronic health record revealed diagnoses of respiratory failure, diabetes mellitus, atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and Raynaud's syndrome. Review of an Admission Nursing Evaluation, dated 03/31/25, revealed Resident #184 ' s evaluation was not an assessment and was completed by Medical Records/Licensed Practical Nurse, revealing one person assist for bed mobility, dressing, toileting, personal/hygiene, and bathing. It documented two persons assist for transfers with wheelchair use. Review of Resident #184 ' s health records on 04/22/25 revealed no admission MDS was completed by the deadline of 04/13/15. The facility completed a late admission MDS on Resident # 184 on 04/24/25. The MDS indicated that the resident received maximum assistance with toileting, bathing, putting on/taking off foot ware, personal hygiene, transfers, sit to lying, toileting, rolling left and right, and lying to sitting on side of bed. A wheelchair is used for mobility. The MDS revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of Resident #184 ' s health record on 04/22/25 revealed no comprehensive care plan had been completed. The facility had an undated closet care plan. A comprehensive care plan dated 04/25/25 included interventions of; monitoring for ADL decline, encourage use of prescribed assistive devices, encourage the resident to fully participate, monitor for changes in functional status, encourage to use call light, praise all efforts at self-care, and notify doctor of changes in functional status. An observation on 04/24/25 at 08:43 AM, Resident #184 was sitting in the resident ' s wheelchair at the window while looking outside. The surveyor observed Resident #184 to have multiple fingers amputated on the right hand and multiple fingertips that were blackened on the left hand. The resident reported not being able to maneuver the manual wheelchair without assistance. An observation on 04/24/25 at 01:30 PM, Resident #184 was sitting in the resident ' s wheelchair at the window. Both legs and feet were swollen. CNA #1 and CNA #10 were in the room to transfer the resident to their bed due to swelling. Resident stated they didn't want to get in the bed due to the gospel singing social activity scheduled at 02:00 PM which they desired to attend. CNA #1 stated the resident needed to lay down for a little while to reduce the swelling. The resident was placed in the bed. Resident #184 later stated they did not go to the activity because it was too much trouble to get back up and Resident #184 didn't want to bother the staff. An interview with Resident #184 on 04/22/25 at 01:15 PM revealed they felt like they were in prison and totally dependent. Resident #184 stated, This was supposed to feel like home. If you're not crazy when you get here, you will surely be when you leave. An interview with LPN #7 on 04/22/25 at 04:25 PM, revealed that with no Director of Nursing (DON) employed at this time, no care plans are being generated. LPN # 7 stated they may have a closet care plan which is filled out with admission evaluations, but Resident #184 did not have a comprehensive individualized care plan. On 04/23/2025 at 2:50 PM an interview with the Activities Director/Social Worker revealed she was just implementing social activities since her hire date eight days ago. Due to staff shortage, she transported dependent residents to activities. She revealed Resident #184 was upset because staff did not transport them to the activities, and that Resident #184 was dependent on assistance with the wheelchair. An interview with Resident #184 on 04/24/25 at 08:43 AM, Resident #184 revealed no staff member had intervened to help Resident #184 feel more independent. Resident #184 revealed if they wanted to go outside, the resident had to ask to be let out. Once outside there is not a way to call staff when you are ready go back inside except to holler until someone hears you. Resident #184 revealed the wheelchair they had now is low and they (Resident #184) cannot get up out of it without staff assistance. On 04/26/25 at 11:00 AM, was reportedly Resident #184 ' s first activity participation with other residents since admission. Resident #184 played checkers with another resident. An interview with Resident #184 on 04/26/25 at 01:10 PM revealed the currently utilized mobility aids were brought from home, and were not facility provided, nor had the staff attempted to intervene with anything to promote the resident's independence. On 04/25/25 at 03:25 PM, the Administrator and Activities Director reported Resident #184 had not voiced any need for devices to the Activities Director for bed transfers. The Activities Director stated, I have not ever personally asked the resident any questions regarding how (pronoun) transferred at home, but (pronoun) could have told me if (pronoun) wanted to. An interview with Resident #184 on 04/29/25 at 08:30 AM, reported following their interaction with the survey team, the Administrator spoke to the resident and said, Don't tell me you want your electric wheelchair but what other things are used at home to help do things yourself. Resident #184 reported to the Administrator that the resident used a trapeze bar above the bed, a foot stool, and a transfer belt/strap. Resident #184 revealed they had reported to staff how unhappy they were and missed their independence. Resident #184 stated I'm sitting here waiting to die but I really am not ready. This is no way to live. An interview with Resident #184 representative on 04/29/25 at 09:10 AM, revealed the facility had not inquired about tools available to make the resident's stay better or interventions that could help them. Resident #184's representative revealed the resident had told them how unhappy they were in the facility because all they do is sit at the window and could tell how unhappy the resident was. Resident #184 had reported to their representative coming to the facility was their greatest down fall and had reported to staff multiple times their [NAME] over the loss of independence. The resident representative reported it was only a couple of days ago when the facility reached out inquiring about ways to help with mobility. Resident #184's representative stated someone from the facility called and asked if the trapeze bar on the bed at home could be transferred to the bed at the facility, and the belt/strap they used at home could be brought to the facility for Resident #184. An interview with Assistant Director of Nursing (ADON) on 04/29/25 at 09:42 AM, revealed the care plans are done by the Director of Nursing (DON) and she was not aware the care plan hadn't been done. ADON stated she had not assumed the DON responsibilities, and since there was not a DON nobody had assumed those responsibilities. They (the residents) have one care plan in the closet, but it was not a comprehensive complete individualized care plan just mainly about transfers, how they eat, or if they are incontinent. On 04/26/25 at 03:25 PM, the facility had submitted an acceptable IJ removal plan in accordance with Appendix Q: 1. ln-service provided to Administrator by Nurse Consultant in regards preventing decline in residents level of activities of daily living (ADL) functions. Including providing necessary equipment appropriate for resident and facility. 4/25/25 at 4:00 PM 2. Administrator to provide in-service to DON regarding preventing decline in resident AOL functions, including providing necessary equipment and assessing for appropriate interventions to prevent declines. Completed via Phone: 4/26/2025 3. Administrator and Nurse Consultant began in-service of nursing staff to identify and respond appropriately to a residents decline in AOL functions, including assessing, monitoring and providing interventions. Nurses will be responsible for assessing and providing appropriate interventions. TO BE COMPLETED BY 4/26/2025 at 8pm. 4. Resident #184 family contacted by administrator 4/25/2025 to bring specialized equipment (special belt for foot movement and trapeze bar) from home that is being requested by resident to facility so it can be used to assist with his independent transfer and repositioning. 5. Administrator and DON will monitor care areas routinely to ensure equipment is in place. 6. Primary Care Physician of Resident #184 will be notified of mental health concerns and further direction/orders requested. Family contacted to bring personal items from home, Physician notified for any new orders and pharmacy contacted for medication consult: 4/26/2025 by 5:00 PM 7. Care plan and MOS for Resident #184 completed on: 4/25/2025 Onsite Verification: On 04/29/2025 at 8:30 AM the survey team interviewed Resident #184 but was unable to remove the IJ. The resident had not received new interventions to promote more independent transfers and mobility. Onsite verification was attempted on 05/02/2025 at 1:00 PM and could not be completed due to the Administrator verbalizing a Director of Nursing (DON) position had not been permanently filled and Interim DON verbalized being contracted for Registered Nurse (RN) coverage for 4 days and would be leaving the facility on Sunday 05/04/2025 to return to Oklahoma. Onsite verification was attempted on 05/05/2025 at 4:08 PM and could not be completed due to Interim DON verbalized being in Oklahoma and was not working for the facility. Interim DON verbalized only being contracted for four days as weekend RN coverage, not DON. The IJ was removed on 05/09/2025 at 12.56 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 05/08/2025 at 11:00 AM. In-services reviewed included preventing decline in residents' level of activities of daily living (ADL) functions, providing necessary equipment appropriate for resident and facility, and for nursing staff to identify and respond appropriately to a residents decline in ADL functions, including assessing, monitoring, and providing appropriate interventions. Nurses will be responsible for assessing and providing appropriate interventions. Resident #184 ' s family was contacted by Administrator 4/25/25 to bring specialized equipment (special belt for foot movement and trapeze bar) from home that is being requested by resident to facility so it can be used to assist with independent transfer and repositioning. Primary Care Physician of Resident #184 was notified. Resident #184 ' s care plan and MDS was updated. A total of 13 staff interviews were conducted with staff from all shifts to very training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Nurse Consultant, Social Services Director, and Assistant Director of Nursing. The staff interviewed verified they had been trained on ADLs, equipment, and monitoring/reporting for a decline in a resident ' s functioning. A review of in-service sheets provided indicated 17 had been provided training. Those staff who were not physically present to receive the in-services were messaged via telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding.

Based on observations, interviews, and facility document reviews, it was determined that the facility failed to post the last survey results in an accessible location for the residents' review. The findings include: During an interview on 04/24/25 01:49 PM, with four resident council members and the president of the resident council, it was stated they met monthly. All residents, including Residents # 7, #12, #29, #23, stated they did not know there were survey results posted for them to view. During observation, two surveyors were unable to locate the survey results and requested assistance from staff. The survey results binder was located in a metal and wicker rack on the floor to the right side of a table off the entrance. The last survey results posted were dated 10/03/2023. The facility ' s most recent recertification survey was completed 02/01/2024. During an interview on 04/24/25 at 2:24 PM with the Administrator, she stated, The binder is over here down in this magazine rack. Let's see if it's even been updated. No, it hasn't, I forgot all about it. It probably has dust all over it.

Based on facility document review, and facility policy review, it was determined that the facility failed to conduct a thorough self-assessment for facility staffing available, the competencies and training of the staff, conduct community-based risk analysis identifying the potential natural disasters, and formulate a plan for staff recruitment to meet the needs of the residents when the facility assessment was received. The findings include: 1. A review of a facility policy titled, Facility Assessment, revised October 2024, indicated: a. A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in the assessment. The team responsible for conducting, reviewing, and updating the facility assessment includes the Administrator, a representative of the governing body, Medical Director, Director of Nursing, Infection preventionist and a director/designee from the following departments: environmental services, physical operations, dietary services, social services, activities services, and rehabilitation services. The facility assessment includes a detailed review of the resident population. This part of the assessment includes: Resident census data from the last 12 months, resident capacity and the occupancy rate for the late 12 months, factors that affect the overall acuity of the residents such as assistance with ADLs (Activities of Daily Living), mobility impairments, incontinence of bowel and bladder, cognitive or behavioral impairments, and conditions or diseases that require specialized care (dialysis, ventilators, wound care). A breakdown of the training, licensure, education, skill level, and measures of competency for all personnel. The current status of health information technology includes electronic health records, electronic exchange of information with organizations, and personnel access to devices, equipment, and internet. b. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment, and supplies needed. It is separate from the Quality Assurance and Performance Improvement evaluation. c. Our facility's ability to meet the requirements of our residents during emergency situations is a component of the facility assessment. This assessment is based on the information acquired during the assessment of operations under normal conditions, and the facility's Hazards Vulnerability Assessment conducted as part of our emergency preparedness plan. d. Our facility's ability to address the needs of residents during emergencies of infectious disease events or outbreaks is a component of the facility assessment. This assessment is based on information acquired during a facility-based infection control risk assessment, as well as a community-based risk assessment. e. The facility assessment is reviewed and updated annually, and as needed. Facility or resident changes or modifications that may prompt a reassessment sooner include; A decision to provide specialized care or services that had not been previously available to residents; A change in the physical, environment that would affect the care and services provided to our residents; A significant change in the resident census and/or overall acuity of our residents; or A change in cultural, ethnic, or religious factors that may affect the provision of care or services. 2. A review of the undated Facility Assessment Profile, revealed: a. A nursing service provided was Intravenous (IV) therapy. The Director of Nurses (DON) reviews the history and physical of all new referrals along with their medication list to identify equipment needed. No plan for education or training was provided to the Licensed Practical Nurses (LPN) nor outside certification tracked for IV medication administration or care of a Peripherally Inserted Center Catheter (PICC) or other IV access. The facility failed to assess/reassess their nurse's qualifications to meet their identified nursing services. These services were ordered for Resident #33 from 02/10/2025-03/20/2025. b. No self-assessment was conducted by the facility to identify the potential for natural disasters, analysis of the impact on the residents including staff availability, basic utilities, and goods, nor a plan for continued care. Referral was made to a separate binder labeled Emergency Preparedness Plan. This information compiled for Life Safety Code (LSC) regulations was not incorporated into the planning or development of their facility assessment. c. No plan was outlined to identify openings or additional needs for bedside staff, ancillary staff, or department head needs. There is no recruitment plan to fill those needs and no retention for maintaining current employees. During the survey entrance conference on 04/21/2025 at 10:42 AM the Administrator reported there was no DON on staff, who was also the Minimum Data Sheet (MDS) nurse, a cooperate LPN was completing MDSs remotely. It was revealed during an Interview on 04/28/2025 at 9:42 AM the ADON stated she was also the Infection Preventionist (IP) on staff and was not able to pick up the DON duties because she was working bedside every day and barely had time to complete her own work. During an interview on 04/22/2025 at 12:50 PM the Med Records Nurse stated it had been a while since she was able to work in medical records because she had worked the floor for six months. d. Staffing needs by shift were outdated on the facility assessments, reflecting staffing ratios which were revoked during the 93rd General Assembly, Regular Session in 2021 and approved on 04/14/2021. The facility added an addendum to their facility assessment addressing the staffing requirements and adjustments on 08/01/2024. The addendum indicated the facility would ensure; the composition of direct care staff would include Registered Nurses (RNs), LPN,/LVNs, and Nursing Aides (NAs); each unit would be evaluated to determine specific staffing needs; adjustments to staffing would be made based on changes in resident population, such as admissions, discharges, and changes on resident needs; and the evaluation will be conducted quarterly or more frequently if significant changes in the resident population occur. There were to be shift specific staffing adjustments identified (Day, Evening, and Night Shifts) and continuous monitoring of staffing and resident care needs to ensure compliance with the new regulations. The addendum stated this would be documented and to include the rationale for adjustments. The committee never outlined what the staffing needs were for the facility.

Based on interviews, record review, and facility document review, it was determined that the facility failed to have an organized record management system, accurately documented and readily available to staff, nor completed medical records of the residents to ensure proper treatment, continuity of care and clarity for the facility's staff to safely care for the residents. Specifically, physician orders, comprehensive care plans, Minimum Data Sets (MDS), Medication Administration Record (MAR), and Treatment Administration Record (TAR). The findings include: During an interview on 04/22/2025 at 12:50 PM with Medical Record/Licensed Practical Nurse (LPN), she stated, I am medical records and have been working the floor for about 6 months and haven't been able to do medical records, but I do it whenever I can. It has been a while since I've been able to do medical records, but resident care comes first, and paperwork comes second. On 04/22/2025 at 4:25 PM during an interview LPN #7 stated no care plans had been generated since they didn't have a Director of Nursing (DON). The residents had a closet care plan which was filled out with their admission evaluations at the time of admission. These were filled out usually by Medical Records, who was also the charge nurse. During an interview on 04/27/2025 9:18 AM with Registered Nurse (RN) #2, she stated We had a DON here for 2 weeks. That's why we have a written MAR. Resident #184s oxygen orders were not on the chart. The written orders are no longer on the paper chart and nurses don't know where they are or where to find them. During a medical record review on 04/23/205 at 12:45 PM, Resident #85's medical record (admitted [DATE]) did not include a MDS which showed how the resident was assessed, a baseline care plan which directs and informs bedside staff of how to initially take care of resident until comprehensive care plan is developed, comprehensive care plan which directs and informs bedside staff how to care for the resident and what to monitor, physician progress notes which had to be emailed from the Medical Director's (MD) office, or activity notes that indicated activity participation or the offering of activities to the resident. During a record review on 04/22/2025 at 2:00 PM, Resident #184's medical record (admitted [DATE]) did not include a comprehensive care plan, MDS, Preadmission Screening and Resident Review (PASARR) I, provider notes, or provider orders for oxygen or continuous positive airway pressure (CPAP). No diagnoses were not found in the paper chart. During an interview with the MD on 04/27/2025 at 11:18 AM, he stated when a resident is admitted from the hospital he gets a call. The nurses will ignore what the order was before the resident returned from the hospital. The order will be in the communication binder at the nurses' station, and I sign them off from the binder. While discussing Resident #184 oxygen status and looking at the paper chart, the MD got up and left the room two times to go look for the orders in medical records. The MD came back and stated, There is a delay of trying to get caught up and it is my fault why notes are not in the chart. The order sheet was not in the chart, and I could not find it. He did find one piece of paper in medical records that he stated, was in a pile. He responded, I don't know how nurses check orders or where nurses' get the orders and information from to provide care to the residents and I don't know where my order for (Resident #184s) Oxygen and CPAP is. The MD stated there was a system failure. I don't know how staff take care of residents if it's not in the paper chart. The MD stated, I don't have anything to do with resident care plans and I don't look at them. A lot of them come out of a book. They just do it to say they do it. He stated, I would rather have a good floor nurse than a DON. The DON does Administrator stuff, and I haven't been totally impressed by the DONs in the past. They come in, care for the patients, and don't know them. If they just come in for a short time, their primary concern is not the patient. It's more paperwork and stuff like that and there is a lack of paperwork. The MD didn't know if there is a Registered Nurse (RN) in the building and stated, it doesn't affect him. He was informed an RN had to be the one to do resident assessments and nine (9) assessments had not been done as required, he stated I don't know. He stated, He understands the importance of having RNs due to assessments and orders but I don't have anything to do with it. On 04/26/25 at 1:39 PM, the Surveyor received an email from the Administrator providing some after visit summaries, history and physicals, and doctor notes and visits from the medical director for requested residents. Orders are on paper and appear to be signed as he comes in for telephone orders. During a phone interview on 04/29/2025 at 9:42 AM the Assistant Director of Nursing (ADON), stated the DON was responsible for doing the care plans, fall assessments, and MDSs. Since there is not currently a DON, nobody had assumed those responsibilities. Some residents have one care plan in the closet, and it is not comprehensive, it is mainly about transfers, incontinence, or how they eat. She stated, I have all I can do with working the floor and keeping up with infection control. A review of policy Resident Assessment Instrument, revision dated September 2024, indicated a comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. The Assessment Coordinator was responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviewed according to the following schedule: Within fourteen (14) days of the resident's admission to the facility; when there had been a significant change in the resident's condition; at least quarterly; and once every twelve (12) months. It revealed the comprehensive assessment helped the staff to plan care that allowed the residents to reach their highest practicable level of functioning and within seven (7) days of completion of the residents' assessment, a comprehensive care plan would be developed. All staff that completed any portion of the MDS Resident Assessment Form must sign the assessment document attesting to the accuracy of such information. A review of a facility policy, Care Plans, Comprehensive Person-Centered, revision dated July 2024, revealed a comprehensive, person-centered care plan which included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). The Interdisciplinary Team must review and update the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. A review of a facility document, Director of Nursing Facility Job Posting, dated 04/23/2025, indicated the DONs responsibilities were not limited to maintaining and monitoring procedures for administration and control of medication and policies for the care, use and stocking of all nursing supplies and equipment; meet daily with critical core team members regarding admission, placement or discharge of patients, in addition, participates in coordination of patient services through departmental staff meetings and assists in the development of patient's care plans. Oversee the complete and timely completion of care plans; review all infection control reports, and pharmacy consultant reports; maintain all required records and meet monthly with the nursing staff regarding chart audits and physician orders. A review of a facility document, Director of Nursing Job Description, undated, indicated the same information as the job posting but included plan, direct, and organize patient care, recommend the number of nursing personnel to be employed within sound fiscal guidelines and quality patient care, and meet with staff on each shift monthly providing in-services as necessary to maintain a quality nursing program. A facility document review, Medical Director Retainer Agreement, dated January 2, 2014, indicated the MD would assume the administrative authority, responsibility, and accountability of implementing the facility's medical services, policies, and procedures; the MD would implement methods to keep the quality of care under constant surveillance; participating in the development of a system providing a medical care plan for each resident which covers medications, nursing care and other services as appropriate; and being knowledgeable concerning policies and programs of public health agencies which may affect resident care programs of the facility. During an interview on 05/05/2025 at 11:56 AM, the Human Resources Director (HR), now former HR director, stated, I have a hard moral line, and I could not stay there anymore. She stated after the surveyors ' arrival and when items were requested, I have witnessed the Administrator [NAME] signatures on assessments for registered nurses, signing staff names to in-services, wanted me to change time punches to show an RN was in the building for eight (8) hours. Referring to a TAR for Resident #33 the HR Director stated, I knew you would know it was fake since it took so long to get it. The interim DON said there was all kinds of problems and didn't think some of the diagnoses on the MDs were right. The Interim DON left on Sunday 05/04/2025.

Based on interviews, the facility failed to provide disclosure of ownership paperwork upon request. On 04/26/2025 at 10:44 AM, a request was made to the Administrator for disclosure of ownership paperwork. On 04/28/2025 at 12:46 PM, a request was made to the Administrator for disclosure of ownership paperwork. On 04/29/2025 at 8:40 AM, a request was made to the Administrator for disclosure of ownership paperwork. On 04/29/2025 at 8:40 AM, the Administrator reported that the Director of Operations was coming that day and information would be provided as requested. On 05/06/2025 at 11:47 AM, at time of survey exit, disclosure of ownership was never provided as requested.

Based on interviews and facility document reviews, it was determined that the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training for all staff members in the facility upon hire, and provide in-services to direct staff when reviewed for required QAPI training. The findings include: On 04/24/2025 at 9:17 AM, a record review of the QAPI Binder, revision date of April 2023, reviewed signatures of committee dated 04/09/2025, indicated, staff are trained in QAPI systems and culture as well as QAPIs underlying principles, including the concept that systems of care and business practices must support quality care or be changed; gathering and using QAPI data in an organized and meaningful way, such as monitor and evaluate Minimum Data Set (MDS) assessment data and care plans. No trainings were located in the QAPI binder. On 04/26/2025 at 2:18 PM, a record review of the Facility Assessment, unknown date, indicated, in-services are held monthly for the entire staff, they include: disaster drills, abuse/neglect, staff burnout, resident rights, oral hygiene, lock out tag out, elopement, dementia training/difficult residents and corona virus. No QAPI in-services listed. On 04/26/2025 at 3:30 PM, a record review of Employee File for Certified Nurse Assistant (CNA) #1 revealed no QAPI training upon hire. Signed hiring acknowledgement training was found including abuse, neglect, misappropriation of property, and burnout. On 04/26/2025 at 3:30 PM, a record review of Employee File for Licensed Practical Nurse (LPN) #13, revealed no QAPI training upon hire, signed hiring acknowledgement training was found including abuse, neglect, misappropriation of property, burnout, enteral feeding, tracheostomy care and suctioning. During an interview on 04/24/2025 at 9:17 AM, the Administrator stated when she provided the book that this was all the in-services they did at the facility, and if it was not in there, they did not cover it. She stated, QAPI in-services were in the QAPI book. During an interview on 04/28/2025 at 11:55 AM, with the Director of Operations, she stated they had QAPI meetings quarterly, the Medical Director (MD) assisted with how to fix things, put together orders, and any input needed from the Medical Director. There was not an executive team over QAPI, it did include the Administrator, Medical Director, Director of Nursing, Minimum Data Set Nurse, Business Office Manager, and herself. The Administrator ensured QAPI was implemented and monitored to ensure the plan was completed. 52347

Based on interviews and facility document reviews, it was determined that the facility failed to provide Compliance and Ethics training for all staff members in the facility upon hire, and provide in-services to direct staff, when reviewed for required compliance and ethics training. The findings include: On 04/24/2025 at 9:17 AM, a record review of Required In-Service Book, indicated in-services provided to staff included the following: dementia/behavioral training, resident rights, infection control, emergency response, abuse and neglect and misappropriation of property. These in-services were all checked off by Certified Nurse Assistant (CNA), Licensed Practical Nurse (LPN), and Registered Nurse (RN) staff. On 04/26/2025 at 2:18 PM, a record review of the Facility Assessment, unknown date, indicated in-services are held monthly for the entire staff which included: disaster drills, abuse/neglect, staff burnout, resident rights, oral hygiene, lock out tag out, elopement, dementia training/difficult residents and corona virus . No compliance and ethics in-services were listed. During an interview on 04/24/2025 at 9:17 AM, the Administrator stated when she provided the book that this was all the in-services they did at the facility, and if it was not in there, they did not cover it. When asked specifically about ethics training, she did not respond. During an interview on 04/25/2025 at 1:55 PM, Certified Nursing Assistant (CNA) #1, stated all in-services that were provided were done by the Administrator. The in-services that were done included: abuse, fire, evacuation, gait and transfer, infection control, falls and that was all. CNA #1 said, we had enhanced barrier precautions today, but no training on this before, we did not even know what it was. On 04/26/2025 at 3:30 PM, a record review of Employee File for Certified Nurse Assistant (CNA) #1, revealed no Compliance and Ethics training upon hire. A signed hiring acknowledgement training was found including: abuse, neglect, misappropriation of property and burnout. On 04/26/2025 at 3:30 PM, a record review of Employee File for Licensed Practical Nurse (LPN) #13 revealed no Compliance and Ethics training upon hire. A signed hiring acknowledgement training was found including: abuse, neglect, misappropriation of property, burnout, enteral feeding, tracheostomy care and suctioning. 52347

Based on observations, interviews, record review, facility document review and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment was completed in the required timeframe of 14 days for 4 (Resident #26, #85, #135, #184) of 4 residents reviewed for MDS assessment and timing. The findings include: 1. A review of a facility policy, Resident Assessment Instrument, revision dated September 2024, indicated a comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. The Assessment Coordinator was responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviewed according to the following schedule: Within fourteen (14) days of the resident's admission to the facility; when there had been a significant change in the resident's condition; at least quarterly; and once every twelve (12) months. It revealed the comprehensive assessment helped the staff to plan care that allowed the residents to reach their highest practicable level of functioning and within seven (7) days of completion of the residents' assessment, a comprehensive care plan would be developed. All staff that completed any portion of the MDS Resident Assessment Form must sign the assessment document attesting to the accuracy of such information. 2. A facility document review, Director of Nursing Job Description, undated, indicated they must maintain regular attendance and meet daily with critical core team members regarding admission, placement, and discharge of patients. 3. A review of an Admission Record indicated Resident #26 was admitted on [DATE] with medical diagnoses of congestive heart failure, dementia, and type 2 diabetes mellitus. a. A review of Resident #26's current MDS on 04/23/2025 revealed the assessment had not been completed. b. A second review of Resident #26 ' s MDS on 04/23/2025 revealed the MDS was in progress in the resident ' s electronic health record (EHR). The Assessment Reference Date (ARD) for the quarterly MDS was 04/06/2025 and was not identified to be complete on 05/05/2025 per Resident #26 ' s electronic health record. 4. A review of a Face Sheet revealed Resident #85 was admitted on [DATE]. a. A review Resident #85 ' s MDS on 04/23/2025 revealed it had not been completed. b. A second review on 04/29/2025 of the EHR for Resident #85 revealed two MDSs indicated in progress ARD for the entry MDS of 03/28/2025 indicated to be 18 days overdue. The ARD for the admission MDS was 04/10/2025 and indicated 12 days overdue. 5. Review of a Face Sheet revealed Resident #135 was admitted on [DATE]. a. Review of Resident #135 ' s EHR revealed the current MDS had not been completed on 04/23/2025. b. A review of the completed MDS for Resident #135 was electronically signed as completed by Registered Nurse (RN) #4 on 04/24/2025. 6. Review of a facility document, Notice of Admission, indicated Resident #184 was admitted on [DATE] with diagnoses that included respiratory failure, diabetes mellitus, atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease and Raynaud's syndrome. a. A record review of Resident #184 ' s EHR on 04/22/2025 at 10:12 AM, revealed no admission MDS was completed by the deadline of 04/13/2025. The facility completed the admission MDS for Resident #184 on 04/24/2025. 7. During an interview on 04/22/2025 at 2:01 PM, Licensed Practical Nurse (LPN) #7 stated she had just started in the MDS position and was told (some) residents didn't have one [MDS] done. 8. During an interview on 04/22/25 at 4:25 PM, LPN #7 stated the former Director of Nursing (DON), who started 03/20/2025, was fired on 4/14/2025, had not done any MDSs while employed. LPN #7 reported Residents #85 nor #184 had a 5-day entry or admission MDS completed. 9. On 04/28/2025 at 2:46 PM during an interview the Former DON stated as DON she was responsible for the completion of resident MDSs. She revealed they were due every 3 months, but she liked to do them a little early, so she did not wait to the last minute to get them done. She revealed she would take the assessment to all departments and get their information. She would then print the MDS and put them in the charts. 10. During an interview on 04/29/25 at 9:42 AM, the Assistant Director of Nursing (ADON) stated she did not know anything about the MDSs, and that the last DON did this. I have not assumed the DON responsibilities and since there is no DON, nobody has assumed those responsibilities. I was not aware the MDSs, and care plans were not done. 11. During an interview on 04/27/25 at 11:18 AM, the Medical Director was told there were nine MDS assessments not completed on time in this facility while a DON was not there, and stated I understand the importance of it, but I don't have anything to do with it. 52347

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for 2 (Residents #25, #184) of 3 residents reviewed for MDS accuracy. Specifically, the facility failed to identify and ensure information regarding bedrails was accurately assessed and completed on the MDS for Resident #25; and to identify and ensure the Oxygen Nasal Cannula (NC) and Continuous Positive Airway Pressure (CPAP) were accurately assessed and completed on the MDS for Resident #184. The findings include: 1. A review of facility policy, Resident Assessment Instrument, revised September 2024, indicated the purpose of the assessment was to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity and information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach their highest practicable level of functioning. 2. A review of the document titled, CMS's [Centers for Medicare & Medicaid Services] RAI [Resident Assessment Instrument] Version 3.0 Manual, Page P-2 stated code 0-not used, 1-used less than daily, 2-used daily for bed rails used in bed. The facility should have placed a 2. P0100 On P-2 stated, Physical restraints are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Page P-5 and Page P-6 stated, the use of bedrails even if they improve the resident's bed mobility must be coded by the facility as a restraint, specifically at P0100A. Page J-34 Question J1800 asked Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent. The facility should have checked 1- Yes. If checked yes, continue to J1900. Page J-36 Question J1900 states, Number of falls since admission/entry or reentry or prior assessment (OBRA or scheduled PPS), whichever is more recent. Coding 0- None, 1- One, 2- Two or more. The code should have been placed to either A-No injury, B-Injury (except major), C- Major injury. Page O-1, Question O0110 stated performs while a resident of this facility and within the last 14 days the facility should have checked C1 Oxygen therapy, C2 Continuous therapy, G1 Non-Invasive Mechanical Ventilator, and G3 CPAP. 3. A review of facility policy, Falls, Clinical Protocol, revised April 2024, indicated based on the assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Staff will try various relevant interventions, based on assessment of nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. 4. A review of facility policy, Proper Use of Side Rails, dated December 2024, indicated an assessment will include a review of the resident's bed mobility, ability to change positions, transfer to and from bed or chair, and to stand and toilet, risk of entrapment from the use of side rails; and that the bed's dimensions are appropriate for the resident's size and weight. 5. Review of a Face Sheet on 04/23/2025 at 1:30 PM, revealed Resident #25 was admitted on [DATE]. a. Review of Resident #25 ' s quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/2025 indicated it was completed and e-signed on 03/17/2025 by Licensed Practical Nurse (LPN) #7 and e-signed on 03/26/2025 by Former Director of Nursing (DON) #8. No bedrails were indicated to be in use on the MDS. b. Review of Unusual Occurrence Report, dated 03/10/2025, revealed, Resident #25 had fallen. Interventions documented were increased frequency of checks after 05:00 pm, provide education related to safe transfers without bearing all of body weight on wrists. The resident fractured left arm with this fall. c. Review of Unusual Occurrence Report on 04/23/2025 at 1:30 PM, revealed Resident #25 was admitted to the hospital on 03/17/2025 for surgery to left arm and returned to the facility on [DATE] with a hard cast to left arm. d. Review of Unusual Occurrence Report, dated 03/26/2025, revealed, Resident #25 was found on the floor by an aide with the left arm cast removed. No interventions documented. The resident fractured their right arm during this fall. e. An interview with Resident #25 ' s family on 04/29/2025 at 9:00 AM revealed the family had never been educated about bedrails. No education was provided related to possible injury or the reason for use of them, and a consent was not signed for the bedrails. 6. Review of a Face Sheet on 04/22/2025 at 10:12 AM, revealed Resident #184 was admitted on [DATE]. a. Review of the admission MDS with an ARD of 04/07/2025 was completed and e-signed on 04/24/2025 by LPN #7 and e-signed by RN #4 on 04/24/2025. No special treatments were identified on the admission MDS for continuous oxygen NC or CPAP use on Resident #184. b. During an interview on 04/22/2025 at 4:25 PM, Licensed Practical Nurse (LPN) #7 stated the Director of Nursing (DON) who started 03/20/2025 and was fired on 4/15/2025 had not done any MDSs while employed. c. During an interview on 04/27/2025 at 9:18 AM, RN #2 stated she doesn't know where to find anything on oxygen for Resident #184. The DON didn't enter stuff for those two weeks working here. The nurse changes the humidified water bottle on the concentrator every Monday evening. The residents' oxygen orders are not on the chart, I don't know where they are and that is why (Resident #184) has a written Medication Administration Record (MAR). The written orders are no longer on the paper chart or I don ' t know where to find them. d. During an interview on 04/25/2025 at 1:55 PM, Certified Nursing Assistant (CNA) #1 stated the Medical Records/Licensed Practical Nurse assessed the residents when there was not a registered nurse in the building. e. During an interview on 04/27/2025 at 11:18 AM, the Medical Director (MD) stated I would rather have a strong floor nurse than a DON. I don't know if the facility has an RN. After being told there were nine assessments that had not been done in this facility while a DON was not there, the MD stated, I understand the importance of it, but I don't have anything to do with it. f. During an interview on 04/28/2025 at 2:46 PM, the Former DON stated she did not do bed rail assessments but did assume they should have been assessed for safety. The Former DON stated she was not aware of what the current regulations were. No bed rail manuals were available to use. If someone needed a bed rail, it was taken off a bed or out of storage and put on. No consents were obtained. g. During an interview on 04/29/2025 at 9:42 AM, the Assistant Director of Nursing (ADON) stated, I know nothing about MDSs, the DON does those. I don't know when they are due, and don't have access to the computer system. I have not assumed the DON responsibilities, since there is no DON, nobody has assumed those responsibilities. I was not aware the MDSs were not done. She stated the DON does fall assessments but there is not anyone doing those now and we haven't been doing them. The ADON stated regarding bedrails, And it depended if residents were trying to get out of the bed, we put bedrails in place to keep them from getting out. 52347

Based on observations, interviews, record review, and facility document review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for 4 (Residents #26, # 85, #135, and #184) of 4 residents reviewed for comprehensive care planning. The findings include: 1. A review of a facility policy Care Plans, Comprehensive Person-Centered, revision dated July 2024, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The implementation of the policy stated, the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 2. A review of the MD notes on residents, electronically signed on 04/26/2025, revealed Resident #184 was admitted on [DATE]. a. During a record review for Resident #184, this surveyor noted there was not a Minimum Data Set (MDS) completed for Resident #184, so no care plan could be developed, with interventions to guide resident care. b. A review of Resident #184's Closet Care Plan on 04/22/2025 revealed the resident required assistance of two (2) staff members and used a wheelchair. c. A review of Resident #184 Minimum Data Set (MDS) progress page in the Electronic Health Record (EHR) on 04/22/2025, revealed no comprehensive Care Plan was started for Resident #184 at admission, and passed the deadline of 04/13/2025. After facility staff were interviewed on 04/22/2025, a comprehensive Care Plan was completed for Resident #184 on 04/25/2025. d. For twenty-six (26) days after admission, the EHR revealed Resident #184 was not assessed, and no care plan was developed for staff utilization of resident care and interventions. 2. A review of MDS with an ARD of 04/04/2025 for Resident #85, indicated the resident was admitted on [DATE]. a. A review of Hospice Paperwork for Resident #85 revealed the resident was receiving hospice services. b. An attempt to review the MDS for Resident #85 revealed an MDS had not been completed. A second attempt to review the MDS revealed that two MDSs were set in progress mode in the electronic medical record system. The ARD for the entry MDS was 03/28/2025 and was 18 days overdue. The ARD for the admission MDS was 04/10/2025 and was 12 days overdue. c. An attempt to review the baseline Care Plan revealed no baseline Care Plan for Resident #85 was completed. 3. A review of Resident #26 ' s MDS with an ARD of 01/06/2025, indicated the resident was admitted on [DATE]. a. An attempt to review Resident #26 ' s current MDS revealed the MDS was not completed on 04/23/2025. A second attempt to review the MDS was attempted on 04/23/2025 and revealed the MDS was in progress in the EHR. The ARD for the quarterly MDS was 04/06/2025 and was not completed on 05/05/2025, per the EHR. b. A review of Resident #26 ' s Care Plan, initiated on 04/27/2025, revealed the resident was at risk for skin breakdowns. Interventions included pillows used for positioning, providing nutritional support, and encouraging good nutritional intake. The Care Plan also revealed the resident was at risk for falls. Interventions included Resident #26 used a wheelchair for long mobility, keep call light in reach, and staff to keep frequently used items in reach. Resident #26 had a history of chronic pain and was at risk for breakthrough pain. Resident #26 received pain medication as ordered and was monitored for pain worsening. 4. A review of MDS with an ARD of 03/31/2025, revealed Resident #135 was admitted on [DATE], with medical diagnoses which included generalized anxiety and pain. a. A review of Physicians Orders, for Resident #135 revealed the resident also had a diagnosis of malignant neoplasm of the scalp and neck. b. A review of Resident #135 ' s EHR revealed the current MDS had not been completed on 04/23/2025. c. A review of the completed MDS for Resident #135 was electronically signed as completed by Registered Nurse (RN) #4 on 04/24/2025. d. On 04/23/2025, an attempt was made to review a comprehensive Care Plan for Resident #135. No comprehensive Care Plan was completed at that time. 5. During a phone interview on 04/29/2025 at 9:42 AM the Assistant Director of Nursing (ADON) stated the Director of Nursing (DON) was responsible for doing the care plans, fall assessments, and MDSs. Since there was not currently a DON, nobody had assumed those responsibilities. Some residents had one care plan in the closet, and it was not comprehensive, it was mainly about transfers, incontinence, or how they ate. 52347

Based on observations, interviews, record review, and facility document review, the facility failed to review and revise the comprehensive person-centered care plan in the required timeframe for two (Residents #15, #25) of two sampled residents reviewed for comprehensive care plan completion. Specifically, Resident #15 did not have revisions and escalated interventions for repeated falls; Resident #25 did not have revisions and interventions after a fall with major injury. The findings include: A review of a facility policy Care Plans, Comprehensive Person-Centered, revision dated July 2024, revealed a comprehensive, person-centered care plan which included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). The Interdisciplinary Team must review and update the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. A review of a facility policy Falls-Clinical Protocol, revision dated April 2024, revealed the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Staff will try various relevant interventions, based on assessment of nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. A review of Resident #15 ' s quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/21/25, indicated that R #15 had not had any falls since the previous assessment dated [DATE] and had received routine and PRN (as needed) pain medication. A Brief Interview for Mental Status (BIMS) score of 6 revealed severe cognitive impairment. Resident #15 required supervision or touching assistance with ambulation, set up or clean up assistance with toileting, bathing, dressing, and personnel hygiene. Resident #15 was independent with ambulating, sitting up from chair required supervision/touch assistance, chair to chair transfer and toilet transfer required supervision/touch assistance. A review of Resident #15 ' s comprehensive care plan dated 11/22/24 revealed the comprehensive care plan had not been updated with each fall or interventions. No documentation of problem onset for risk for falls or falls that had occurred. On 04/26/25 at 12:30 PM, a record review of the revised comprehensive care plan for Resident #15 that listed falls included the following dates:11/24/24, 12/06/24, 12/09/24, 01/24/25, 02/04/25, 02/07/25. On 04/26/25 at 12:30 PM, a record review of the list of falls for Resident #15 that were not included in the revised comprehensive care plan included dates:12/10/24, 12/11/24, 12/27/24, 12/30/24, 01/06/25, 01/10/25, 01/15/25, 01/17/25, 01/20/25, 02/05/25, 02/06/25, 02/11/25, 02/13/25, 03/2/25, 03/11/25, 03/12/25, 03/28/25, 04/1/25, 04/24/25. On 04/26/25 at 11:15 AM, a record review of Unusual Occurrence Report forms indicated Resident #15 had a total of 22 falls since 11/15/24. Out of 22 falls, four (4) falls had documented interventions indicated the use of nonslip socks, concave bed, walker replaced, encouraged to use call light, staff to check room and staff to make sure clothes are in the closet. 18 of the 22 falls did not have interventions or escalation of interventions documented. During an interview on 04/27/25 at 10:26 AM, Certified Nursing Assistant (CNA) #1 stated they had worked there almost two years ago and taken care of Resident #15 since (pronoun) been here. The closet care plan or report tells us how to take care of the resident. There are not any fall interventions on the closet care plan. Fifteen-minute checks are done on Resident #15. If (pronoun) keeps getting up, we push a wheelchair with the resident to the nurses' station to monitor (pronoun). Resident #15 doesn't remember for very long but knows who the staff are. Reminders to use the call light are given to Resident #15. Most of the falls have been while getting out of bed. Stand by one assist for transfers and the CNA usually holds the residents' hand with transfers for the resident to feel safe. CNA #1 reported that the side rails are in the up position when in bed but puts them in the down position when the resident up. During an interview on 04/27/25 at 10:35 AM, CNA #3 stated the closet care plan tells how to take care of the residents. The closet care plan or report will state the fall interventions. Resident #15 is checked every two hours and has a history of falls. There aren't any current fall interventions for Resident #15. During an interview on 04/27/25 01:02 PM, Registered Nurse (RN) #2 stated a floor mat had been used as an intervention, the closet care plan had not been updated. RN #2 went to get a floor mat for Resident #15, but the administrator informed them to remove it. Review of Resident #25 ' s entry MDS indicated it was completed on 03/24/25. A review of Resident #25 ' s comprehensive care plan dated 12/17/24 revealed no revision was done to the care plan after the resident's Entry MDS from an unwitnessed fall with major injury on 03/26/25. A record review of Resident #25 ' s Unusual Occurrence Reports indicated Resident #25 had a total of two falls post facility readmitted [DATE]. Resident #25 fell on [DATE] with interventions on form to check resident more frequently; fall dated 04/16/25 no interventions on form. On 04/23/25 at 1:30 PM, a record review for Resident #25 ' s list of falls not included on the revised comprehensive care plan included dates: 01/02/25, 01/06/25, 02/03/25, 03/10/25, 03/26/25, 04/14/25, 04/16/25. During an interview on 04/22/25 at 4:25 pm, Licensed Practical Nurse (LPN) #7 stated no care plans had been generated since they didn't have a Director of Nursing (DON). The residents have a closet care plan which is filled out with their admission evaluations at the time of admission. These are filled out usually by Medical Records who is the charge nurse. During a phone interview on 04/29/25 at 9:42 AM, the Assistant Director of Nursing (ADON) stated, I have not assumed the DON responsibilities since there is no Director of Nursing (DON). With working the floor, there is no time to do that and keep up with infection control. Nobody has assumed the DON responsibilities. The ADON was not aware the MDSs, and care plans were not completed. They have one care plan in the closet, it is not a comprehensive complete individual care plan, it is mainly about transfers or how they eat or if they are incontinent. During an interview on 04/27/25 at 11:30 AM, RN #2 stated if a witnessed fall for Resident #15 occurs, staff will come get the nurse, the resident is assessed, and they are gotten up. The doctor is notified as well as family and hospice. An Incident & Accident form (I & A) is filled out, including two witnesses, and a neuro check is done if needed. Immediate intervention should be done and written on the I & A and in the nurses' notes. Staff should probably add it to the closet care plan. 52347

Based on observations, interviews, and record review, it was determined that the facility failed to ensure Certified Nursing Assistants (CNAs) were certified as CNAs in the State of Arkansas, and failed to ensure background checks were completed for 2 Nurse Aides reviewed for qualified staffing. The findings include: A review of a facility job description titled, Certified Nursing Assistant , undated, indicated qualifications included, Must be a Certified Nursing Assistant and in good standing and currently licensed by the state. A review of a facility policy titled, Nurse Aide Qualifications and Training Requirements, revised on October 2024, indicated, Nurse aides must undergo a state-approved training program. Policy interpretation and implementation indicated, 4. Our facility will not employ any individual . unless: . b. That individual has completed a training program an competency evaluation program, or a competency evaluation program approved by the state; or c. That individual has been deemed competent as provided in S483.150 (a) and (b) of the Requirements of Participation. During an interview on 05/14/2025 at 1:09 PM, Certified Nursing Assistant (CNA) #18 stated they work for the corporate [Director of Operations] and had been working in this facility for one month. CNA #18 stated they have been certified as a CNA since 2014, and were unsure what state the certification was in. CNA stated, Mother helped me with the website so I'm not sure. CNA #18 was not aware of what Enhanced Barrier Precautions or EBP were. CNA #18 stated the bin outside of resident rooms meant to put on gown and gloves before entering the room. We use that to gear up, if someone has sores. A review of CNA #18 ' s Employee File, received by email from the Administrator on 05/14/2025 at 11:40 AM, revealed a Uniform Employment Application for Nurse Aide Staff with an effective date of 11/01/2012, that indicated the application was required by the Oklahoma (OK) State Board of Health Rules. The application revealed CNA #18 was certified in Long Term Care (LTC). A review of an Oklahoma State Department of Health letter dated 10/05/2021, Determination #340135, indicated there were no disqualifying convictions reported by FBI and OK State Bureau of Investigation. You must validate employment annually in OK-SCREEN to maintain a monitored criminal history. No annual employment screening was documented. A review of Oklahoma State Department of Health - Nurse Aide Search Results documented active certification Record ID 202840, Certification Number 37V121796012 with an expiration date of 01/31/2026. A review of the Final Registry Results Form, indicated the Office of Inspector General (OIG) research completed 11/16/2023; National Sex Offender Public Website research completed 11/16/2023; OK Nurse Aide & Non-Technical Service Worker Abuse Registry research completed on 11/16/2023; OK Sex Offender Registry research completed on 11/16/2023; Ok Violent Offender Registry research completed on 11/16/2023; OK on Demand Court Records, Research Results: Registry Not Checked; OK State Court Network, Research Results: Registry Not Checked; OK State Department of Health - Nurse Aide Search Results, Record ID 202840 Certification Type: Long Term Care Aide; Issue Date 01/06/2022, Expiration date 01/31/2026 Orientation Dated 12/03/2023 Skills 12/02/2023 and 12/03/2023. No other documentation was contained in CNA #18 employee file indicating CNA #18 was certified, had a current Abuse Registry or other background check in the State of Arkansas. The skills check-off was dated 12/02/2023. During an interview on 05/14/2025 at 2:12 PM, CNA #17 stated they worked for the main facility in [city name], OK as a CNA for four years. CNA #17 stated they were a regular employee, working for the corporate office and traveled between the Tulsa, [NAME], and [NAME] facilities. CNA # 17 indicated they were certified as a CNA in Oklahoma. There is a process in place through the facility, [Administrator] and [Director of Operations] are working it out, I don't remember what it is called, I can work at [NAME] with Oklahoma license. A review of CNA #17 ' s Employee File, received by email from Administrator on 05/14/2025 at11:39 AM, included an application dated 12/06/2021. A review of an Oklahoma State Department of Health letter dated 12/06/2021, titled Final Registry Results Form indicated license or certification information not entered for this applicant. OIG List of Excluded Individuals/Entities, Research Completed 12/06/2021; National Sex Offender Public Website Research Completed 12/06/2021; OK Nurse Aide & Non-Technical Service Worker Abuse Registry Research Completed on 12/06/2021; OK Sex Offender Registry, Research Completed on 12/06/2021; OK Violent Offender Registry, Research Completed 12/06/2021; OK on Demand Court Records, Research Results: Registry Not Checked; OK State Court Network, Research Results, Registry Not Checked; OIG Search Results dated 12/06/2021, No results found. A review of an Oklahoma State Department of Health letter dated 12/06/2021 Determination #282132, indicated there were no disqualifying convictions reported by FBI and OK State Bureau of Investigation. You must validate employment annually in OK-SCREEN to maintain a monitored criminal history. No annual employment screening was documented. No other documentation was contained in CNA #17 employee file indicating CNA #17 was certified, had a current Abuse Registry or other background check in the State of Arkansas. There were no skills check-off documents in the file.

Based on observation, facility policy review, and interviews, the facility failed to ensure that the kitchen's fryer was clean and free from food particles; food had not been kept past the expiration and storage date; food was labeled and dated; to separate resident's food from employee's food in unit refrigerator; and food was covered for one of one kitchen reviewed for food storage, preparation, and sanitation practices. The findings include: 1. On [DATE] at 10:47 AM, during the initial tour of the kitchen with the Certified Dietary Manager (CDM), the following were observed stored in the dry pantry, walk-in refrigerator, walk-in freezer, and spice storage area: a. Three (3) 1-gallon zipper storage bags of lettuce, with a date of [DATE], stored in the walk-in refrigerator. b. One (1) large container of crackers, with a received date of [DATE], stored in the dry pantry. c. Four (4) 5-pound bags of buttermilk biscuit mix, with an expiration date of [DATE], stored in the dry pantry. d. Four (4) 20-ounce loaves of Texas toast, with no expiration dates. With a received on date of [DATE], stored in the dry pantry. e. Four (4) 5-pound bags of buttermilk biscuit mix, with an expiration date of [DATE], stored in the dry pantry. f. Two (2) packets of unopened sloppy joe mix, and one (1) opened and half used, with an expiration date of [DATE], stored in the dry pantry. g. 19 cups of ice cream, in serving bowls, in the walk-in freezer, not labeled or dated. h. 12-count hamburger buns, with a received on date of [DATE], with no expiration date, stored in the dry pantry. i. One (1) container of leftover peas and carrots, dated [DATE], stored in the walk-in refrigerator. j. Five (5) serving containers of cherry delight, in the walk-in refrigerator, with no label or date stored. h. Three (3) small saucers with pieces of apple pie, with no label or dates, stored in the walk-in refrigerator. 2. On [DATE] at 11:20 AM, accompanied by Dietary Staff #14, this surveyor observed the grill and fryer, next to each other. The fryer had dried oil/grease and thick brown dried on particles, surrounding the edges of the fryer. The oil in fryer was dark brown and unable to see through to the bottom and had noticeable particles in it. 3. On [DATE] at 11:20 AM, Dietary Staff #14 reported the fryer was used the day before yesterday [[DATE]] and it was dirty and needed to be cleaned. She reported the fryer and grill, which did not get used and was covered in aluminum foil, was cleaned every three (3) days and had not been cleaned since use. 4. On [DATE] at 11:00 AM, the CDM discarded multiple spices due to being expired. No spices were observed to be beyond the expiration date. The CDM reported they were only good for three (3) months. The CDM also revealed leftovers were good for 72 hours, then should be discarded. He also reported all food should be labeled, covered and dated. 5. On [DATE] at 10:50 AM, this surveyor observed 17 containers of cherry cheesecake uncovered and not dated in the walk-in refrigerator. The CDM revealed the cheesecake should have been covered and dated. The top row was covered and dated, but not the bottom row. The dietary staff was doing it but must have stopped. The CDM revealed all foods should be covered and dated. 6. On [DATE] at 10:07 AM, the East Unit refrigerator was observed by this surveyor, along with Certified Nursing Assistant (CNA) #3. This surveyor and CNA #3 observed both employee and resident foods stored in the refrigerator and freezer, with the following findings: a. One (1) lunch bag with nuts, grapes, and yogurt with a [DATE] date, but not labeled with a name, in the refrigerator. b. One (1) can of [name brand] soda, with no name or date, in the refrigerator. c. One (1) bottle of [Name Brand Meal Replacement Shake], without a date or name, with an expiration date of ,d+[DATE], in the refrigerator. d. One (1) 16 ounce bottle of tea, with a nurse ' s name and date on it, in the refrigerator. e. One (1) bottle of energy drink, with no name, but current date on it, in the refrigerator. f. One (1) box of ice cream, with no date or room number labeled on it, in the freezer. g. One (1) peanut butter and jelly (PB&J) sandwich, with a date of [DATE], in the freezer. h. One (1) PB&J, with no date, in the freezer. 7. On [DATE] at 10:28 AM, this surveyor observed the ice machine in front of the kitchen dish room. This surveyor observed the ice machine flap, that stops the ice from building up. The DM, after wiping the front and back of flap with a paper towel, reported he observed small black specks on paper towel. He stated he would get it cleaned. 8. On [DATE] at 1:25 PM, this surveyor observed the [NAME] Unit resident/employee refrigerator, with the Administrator. Below were the findings: a. One (1) resident's box of bagel bites, no date per the Administrator. b. Three (3) frozen dinners, that belonged to a resident, per the Administrator. c. Seven (7) bottles of [Name Brand Meal Replacement Shake]. d. Three (3) 20 oz Cokes, that belonged to a resident, per the Administrator. e. One (1) ham/turkey party tray dated with no name, belonged to an employee, per the Administrator. f. Grapes and cheese dated with no name, which belonged to an employee, per the Administrator. g. One (1) energy drink, with a date, belonged to an employee, per the Administrator. h. Four (4) bottles of Pepsi, no date or name. i. One (1) [Name Brand Meal Replacement Shake] drink, and two (2) cream sodas, that belonged to a resident, per the Administrator. 9. On [DATE] at 11:00 AM, the Registered Dietician (RD) reported all food stored in the refrigerator should be covered and dated. She revealed leftover foods were only good for 72 hours and then should be discarded. 10. On [DATE] at 10:07 AM, CNA #3 revealed the refrigerator had employee and residents' food stored in it. She revealed the ice cream, meal replacement shake, and PB&J sandwiches belonged to the residents. 11. On [DATE] at 10:30 AM, the CDM revealed the ice machine was cleaned weekly, mostly by him, but sometimes other dietary staff. There was an ice machine log that he kept each week. After reviewing the ice machine log, it showed the ice machine had not been cleaned since [DATE]. The cleaning log revealed the ice machine was not cleaned last week. 12. On [DATE] at 1:25 PM, the Administrator reported she had always had the employee and residents' food and drinks in the same refrigerator together, and was told it was fine by other state surveyors, if it was dated. 13. A review of facility policy Food Receiving and Storage, with a revision date of [DATE], revealed no staff food or items would be stored in residents' refrigerators. It also revealed all food stored in refrigerator will be labeled, covered, and dated. Policy revealed all foods belonging to residents will be labeled with name, item, and use by date. 14. A review of an in-service, dated [DATE], revealed all foods need to be labeled, dated, and tightly covered.

Based on observation, interview, and record review the facility failed to promptly notify the Medical Director and the Registered Dietitian of progressive weight loss in order to minimize further weight loss and to maintain nutritional status to the extent possible for 1 (Resident #21) of 3 sampled residents (Residents #9, #21, and #26) who had experienced weight loss. The failed practice resulted in a pattern of actual harm for Resident #21 who experienced a severe unplanned 24lb (24.8%) weight loss in 6 months and had the potential of cause more than minimal harm for 3 residents who had experienced weight loss in the past 6 months, according to list provided by the Director of Nursing on 1/31/24 at approximately 11:50 AM. The findings are: Resident #21 had a diagnosis of cerebral vascular accident (CVA), anemia, gastroesophageal reflux disease (GERD), urinary tract infection (UTI), malnutrition, failure to thrive, and chronic obstructive pulmonary disease (COPD). The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/23 documented the resident received a score of 11 (8-12 indicates moderately cognitively impaired) on the Brief Interview for Mental Status (BIMS) did not have a swallowing disorder, weighed 115 pounds. A Physicians Order dated 12/10/23 documented, Regular diet with regular fluids. The Vital Signs and Weight Record located in Resident #21's record documented, .7/12/23 Wt. [Weight] (lbs) [pounds] 140.8 .8/1/23 Wt. (lbs) 137.8 .9/1/23 Wt (lbs) 134.2 .10/2/23 Wt (lbs) 126.4 .11/2/23 Wt (lbs) 116.6 .12/4/23 Wt (lbs) 115 .1/2/24 Wt (lbs) 111.2 .1/17/24 Wt (lbs) 106.6 . This record shows that that Resident #21 had weight loss of: a. 24 pounds in 6 months (24.28% indicates severe weight loss) weight 140.8 lbs on 7/1/23 - weight 106.6 lbs on 1/17/23. b. 19.8 pounds in 90 days (15.81% indicates severe weight loss) weight 126.4 lbs on 10/2/26 - weight 106.6 lbs on 1/17/23. c. 8.4 pounds (7.3%) in the past 30 days. Weight 115 lbs on 12/4/23 - weight 106.6 lbs on 01/017/24. d. On 10/2/23, a weight loss of 7.8 lbs in 30 days (5.5% indicates significant weight loss) - No interventions, no doctors progress notes, no note by the Dietary Manager, and no note by the DON addressing Resident #21's weight loss was found in the resident's record. e. On 11/2/23, a weight loss of 9.8 lbs in 30 days (7.75% indicates significant weight loss) - No interventions, no doctors progress notes, no note by the Dietary Manager, and no note by the DON addressing Resident #21's weight loss was found in the resident's record. The Nutritional Progress Note (quarterly) documented, .Date Q [Quarter] 2 6/13/23 .Current weight: Wt 140.4 Date 6/8 Significant weight change at 1 mo [month] 3 mo 6 mo [no weight loss indicated] Current diet fluids: Diet: Reg [Regular] Fluids: Reg, Usual % [Percent] food intake 25-50% Snack supplement .Ice cream . The form then documented Date: Q3 1/13/24 Current weight: Wt 111.2 date 1/8/24 Significant weight change at 1mo 3mo 6mo [check mark written on form next to 6 months] Current diet fluids: Diet: Reg Fluids: Reg. Usual % food intake 25-50% Snack Supplement .Ice cream . There was no documentation in the progress note that the Registered Dietitian had been notified of any changes in the residents' weights. The Emergency Transfers from Facility dated 12/7/23 in the medical record documented, .Location of Transfer: hospital .Reason for Transfer: heavy chest, severe weakness, pneumonia, not eating/drinking . A Physician History and Physical from (Hospital) dated 12/7/23 documented, .presented for evaluation of weakness .he did not eat or drink yesterday .He was actively taking Doxycycline for pneumonia. He started on 12/4. He had an appointment today and had concern for aspiration during transport .he has been diagnosed with pneumonia 3 times .Assessment: 1. Pneumonia due to infectious organism 2. Acute Respiratory failure with hypoxia 3. Hyponatremia .Plan: 1. Admit .4. SLP (Speech Language Pathologist) .11. Diet: NPO (Nothing by mouth) with ice chips . A Physicians Progress Note dated 12/30/23 documented, Subjective: He was sent to the emergency room with breathing difficulties a week or so ago, returned. He is diagnosed as having influenza and had staph [Staphylococcus] in his sputum. He was treated with Omnicef [antibiotic]; is off and now appears to be doing fairly well. He is not near as active as previously. Not motoring around on his wheelchair as previously, but he denies any specific complaints . The note does not address the residents progressive weight loss. A Physician's Progress Note dated 1/13/24 did not address the residents weight loss. A Physician's Order dated 1/18/24 at 1:30 PM documented (Named Hospice Agency) to evaluate hospice services . A Physician's Progress Note dated 01/21/24 documented, .Subjective: .He was evaluated by Hospice, will be going on Hospice on Monday. Assessment and Plan: He has lost a significant amount of weight just is not eating, not drinking much. He continues to decline again and will be on hospice later this next week .He has lost 10 pounds in the past 2 months, has lost 28 pounds in the past year. He is just not eating or drinking anything. Does not want a feeding tube. He does not want resuscitation, signed DNA (Do Not Resuscitate) paperwork . A Physician's Progress Note dated 1/23/24 documented, The patient continues to decline. He is not eating, not drinking much. He refuses to do so. He is refusing a feeding tube. He does not want resuscitative efforts. Continues to be significantly weaker. He has had a significant amount of weight loss due to his not eating .He has been placed on comfort care here .He is end stage COPD [Chronic Obstructive Pulmonary Disease] .Anticipate he will be succumbing to his illness sometime in the next couple of weeks . A Physicians Order dated 1/23/24 at 11:30 AM documented, v/o (verbal order) for comfort care . A Physicians Order dated 1/30/24 at 22:35 documented, . Release body to [Named] funeral home . On 1/30/24 at 12:20 PM, Resident #21's medical record did not show any notes from the Registered Dietitian. On 1/30/24 at 12:50 PM, the Registered Dietician (RD) was asked if she was aware of Resident #21 and his current weight loss. The RD stated, His name isn't ringing a bell. There are so many, I would have to check my records. She was asked how she completes her assessments. The RD described completing her assessments based on the weights and assessment forms that she receives from the facility each month. The RD stated, I can only go on what they send me. The RD was asked if the facility held weekly weight meetings. She stated, I think. I know that they were the last time I was there. On 1/30/23 at 1:30 PM, the Surveyor interviewed the Administrator who reported that she has spoken to the Dietitian concerning the lack of notes/assessments. The Dietitian reported that she completed an initial assessment at admission and has not seen the resident since. The Dietitian does not come to the facility monthly, attempting to come to the facility on a quarterly basis, however during the last year it has been closer to every 6 months. The Administrator also denied having weekly weight or skin meetings. She stated, These issues are talked about in stand up. On 1/31/24 at 11:30 AM, review of Resident #21's Physicians Orders in the medical record from September 2023 to present did not show any orders for nutritional interventions or supplements. On 1/31/24 at 11:40 AM, review of Resident #21's Nursing Progress notes from 8/1/23 to present did not show any documentation that the Physician had been notified of the resident's weight loss. On 1/31/24 at 11:40 AM, the Director of Nursing (DON) was asked what the facilities process was for monitoring the weights of the residents. The DON described how she and a Certified Nursing Assistant (CNA) collected the weights at the first of the month. If the resident experiences a significant weight loss, then they are placed on weekly weights. When asked to identify what she considered significant, the DON stated, Three to five pounds or five percent, but then it really depends on the person. If a resident who is receiving Hospice services loses a significant amount they remain on monthly weights. For clarification the Surveyor asked if she calculated the weight loss percentages. The DON reported that she doesn't calculate the percentage unless she is completing an MDS. At this time the DON retrieved a spread sheet which recorded the weights of the residents beginning in January 2023. The DON described that when she became the DON she went back to April, collected the information, and recorded it on the spread sheet. The DON was asked if she contacted the physician concerning Resident #21's weight loss. She stated, I feel like I did, but I know I didn't write it down. When asked if the facility conducts weekly weight meetings, the DON reported that since July 2023 she is not aware of a sit down weight meeting unless the previous DON had one. The DON stated, I have been in this position for the past 3 months and before that I was doing MDS and medical records. Now I am the DON and do the MDS. The DON was asked when she contacted the doctor concerning a weight loss. The DON reported, I talked to [Physician's name] last week when he [Resident #21] was 109 [pounds]. I told him that he was uncomfortable and couldn't rest so he gave him a fentanyl patch. The patch was used because the resident was refusing PO [oral] medication. [Physician's name] talked about how the resident had lost 40 pounds and even said that the resident was going to die. The DON continued to outline how she had probably not contacted the doctor in September, October, or November. The DON said she did not remember sending him a note. When asked to clarify if a note was an actual handwritten or electronic communication the DON reported that there is a communication book at each nurse's station and that she also contacts the doctor through telephone calls and texts. The DON was asked if she could provide copies of the communication to the doctor from the notebooks at the nurse's station. The DON replied that the physician tears out the pages and discards them once he has addressed the issue so they would not be available. The DON was asked what interventions were put in place. The DON reported that the resident was admitted in November 2022 and that problems were evident from the start with the resident refusing to eat. He was a sick man with his bipolar. He had had bypass surgery; he didn't have family and he was very unhappy. Alternatives were offered by the Dietary Department. Different staff members brought in all kinds of food to try to get him to eat. The resident would even order food to be delivered and after it got here, he wouldn't eat it and then he would get mad if we finally had to throw it away. When asked about the possibility of providing supplements. The DON reported that the facility only provides [Protein Shake] and has one resident that has protein powder added to her eggs. All other supplements, if prescribed, must be provided by the family. We only have one doctor but if he was to order something else, we would call him and tell him what we have so he could order something else. The DON was asked if the families were informed of this policy prior to admission and she stated, No, before we actually write an order for a supplement, we offer it for three days. The DON expressed the feeling as if the resident had given up. The resident was last physically able to go to the casino in November which was his favorite activity. The DON was asked how the Registered Dietitian (RD) is involved in the care of the residents. She stated, I haven't seen her since I came back in July. When asked if she had called the RD to discuss the resident's weight loss the DON stated, I didn't call her, that's the Dietary Managers job. When asked how the Dietary Manager is made aware of a weight loss, the DON reported that the information is shared in the morning stand up and that the Dietary Manager is there most of the time. The DON stated, I feel like I have failed this resident by not contacting the doctor. The DON was asked if the QA (Quality Assurance) committee had addressed the problems with weights and she denied being aware of any QA or Quality Assurance and Performance Improvement (QAPI) plan. On 2/1/24 at 10:10 AM, the Surveyor spoke with the Medical Director by telephone. The Medical Director was asked if he was aware that Resident #21 had experienced weight loss. The Medical Director replied, Yes, he refuses to eat. I talked to him about it this month and I believe last month. He would tell me that he was going to start eating and then he never would. The Medical Director was asked how long he had been aware that the resident was having a weight loss. The Medical Director stated, Oh, for a month or two, yeah about two months, no longer than that, I'm sure. When asked how he is made aware of weight loss the Medical Director described a book that is located at each nurse's station where the staff will leave him notes of concern, including weight. He described how they will typically leave a series of weights and possibly the interventions that have been tried. He also has received calls with concerns as well. The Medical Director was asked if he was aware of the interventions that had been tried with Resident #21. The Medical Director replied, I don't really recall anything specific. I mean you try to do what you can. He refused most stuff. I feel like he was like most of them when they are toward the end of their illness. They just aren't interested. On 2/2/24 at approximately 3:00 PM, the Administrator was asked for a policy concerning the management of weight loss or weight loss. The Administrator denied being aware of a policy but agreed to look. No policy was provided.

Complaint # (AR 462) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure all allegations of abuse were immediately reported to the Administrator, immediately and thoroughly investigated and measures were taken to protect residents from further potential abuse for 2 (Residents #4 and #6); and failed to ensure investigations of abuse allegations included witness statements from residents who received care from the alleged perpetrator and staff who worked with the alleged perpetrator in an effort to determine if actual abuse occurred and to determine if other residents may have been affected for 3 (Residents #1, 2 and 3) of 6 (Residents #1, 2, 3, 4, 5 and 6 ) case mix residents who had allegations of abuse. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Residents #4 and #6, who alleged staff-to-resident verbal and physical abuse and Residents #1, 2 and 3 who were alleged victims of staff-to-resident abuse. The failed practices also had the potential to cause more than minimal harm to 12 residents who resided in the facility and had allegation of abuse within the last 5 months, as documented on a list provided by the Acting Administrator on 9/27/16. The facility was notified of the Immediate Jeopardy condition on 9/13/16 at 12:40 p.m. The findings are: 1. Resident #6 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 9/1/16 documented the resident scored 11 (8 - 12 indicates moderately) on the brief interview for mental status (BIMS), required extensive assistance of two plus persons for bed mobility, one person for personal hygiene, total assistance of two plus persons for transfers and toilet use and toilet use and was incontinent of bowel and bladder. a. On 9/13/16 at 3:18 p.m., during an interview for the Task 5-G Abuse Protocol, Certified Nurse Assistant (CNA) #2 was asked if she had ever witnessed abuse of residents and stated, One of the residents I worked with Friday (9/9/16), the resident looked like she was going to cry. She said she had trouble with (CNA #1). She said (CNA #1) had treated her really roughly, and she hit her head on the wall. The resident was on the west hall, (Resident #6). I told her she needed to tell someone if someone hurts her. The way I feel, I asked the other girls if they had seen anything. I didn't report this to a supervisor. (CNA #1) kept coming to me and asking what the resident had said, and (CNA #1) had told me the resident makes things up and she's not right. I don't work with her a lot. (CNA #1) told a nurse that the resident makes things up, and the nurse said they were going to look into it and see what's going on. I don't work with the resident a lot; she seems nice. I didn't report it, because I didn't see any marks and didn't see it happen. CNA #2 was asked how she had been trained on abuse and she stated she had been trained to report any abuse immediately. 1.) On 9/13/16 at 3:45 p.m., Licensed Practical Nurse (LPN) #3 was asked about the allegation made by CNA #2 during the above interview and stated, The resident told me she (CNA #1) used a mean tone of voice with her. She didn't tell me (CNA #1) had handled her roughly. I did not report it, because that's how (CNA #1) is, and the resident is weepy a lot. I feel like, if I think they have been abused emotionally or physically, then I would report it. I saw the resident, and she was trying to tell me she was upset. Knowing what the resident is like and what and how (CNA #1) is, I didn't report it. I guess I should have reported it. You have to take anything a resident says seriously, and I should have reported it. 2.) As of 9/13/16 at 3:45 p.m., no interview could be conducted with CNA #1 who was named in this incident. According to the Consultant, the CNA was not working due to a different allegation and had been suspended. 3.) On 9/14/16 at 8:34 a.m., Resident #6 was lying in bed and was asked how long she had lived here and stated, I think it has been a year (actual date of admission was approximately 5 months prior to this interview). The first 2 weeks I was here, I was raped. I told the lady in charge. They did not come and talk to me, and I have not been to the hospital. I was in a different room . I was held down by 3 girls while my pubic hair was shaved. The resident was asked if this was what she was referring to when she said she had been raped and she stated Yes. The resident also stated, Last Friday (9/9/16), (CNA #1) was in here, and I can't turn myself. I wasn't turning fast enough, and she shoved me hard 2 times, she shoved my head and knee into the wall. I told the nurse . b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and (&) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762, dated 4/2/16 (date of discovery) documented, Section II - Complete Description of Incident . On 4/2/16 resident (Resident #3) stated to Charge Nurse (name) that she 'was in jail being charged with a crime and was being held against her will and that she had been raped multiple times on the night of 4/1/16'. An investigation was initiated immediately . Section III - Findings and Actions Taken: .An investigation was initiated immediately on 4/2/16 by notifying the Administrator, (Name) Police Department, family and physician . (Resident #6) description was that of a man in a police uniform with short grey hair. She could not give any other info and no staff matched this description, therefore no one was suspended pending the investigation. She also reported to the Police Officer that it occurred 2-3 nights ago, away from the facility at an address she didn ' t know. This indicates her story is changing and is confused regarding the incident . Upon notification of the family, the POA (Power of Attorney) stated that they were with her earlier in the day on 4/2/16 and she never reported anything to them about rape, just stated she wanted to leave and go home. They also stated that they know that she didn ' t get raped, but was happy the facility was taking it serious and conduction an investigation . The nurse immediately conducted a body audit of (Resident #6) on 4/2/16 and there were no signs of marks or bruising to the peri area or anything that would indicate sexual abuse . The investigation continued by interviewing other female residents regarding the incident and asked them if they have ever been sexually abused and they all stated, 'No.' .Staff interviews were also conducted, but no pertinent information was found to the investigation . A urine analysis was then obtained for (Resident #6) and it indicated that she currently has a UTI (urinary tract infection) and will be started on an antibiotic. This explains why she has been more confused and disoriented . The Administrator also interviewed (Resident #6) on 4/4/16 and asked her about the incident and she did not remember saying that on 4/2/16 . Due to the fact that the body audit revealed no indication of sexual abuse, the resident and staff interviews had no negative findings, (Resident #6) didn't remember the allegation on 4/4/16, and she didn't report anything to her family on the same day, the facility strongly believes that sexual abuse did not occur, but will continue to treat (Resident #6) for her UTI to resolve her cognition concerns . The investigation was signed by the Administrator and dated 4/7/16. c. On 9/14/16 at 9:45 a.m., CNA #2 was asked regarding any abuse to (Resident #6) and stated, (Resident #6) told me that that girl raped me and I said what do you mean. She said she secured me without asking me and without permission. I talked to the other CNA's and they told me they were told by the nurse to go shave her because she had thick long pubic hair and they were having difficulty cleaning her. The resident felt like this was rape. d. On 9/14/16 at 11:47 a.m., CNA #5 was asked regarding any abuse to (Resident #6) and stated she had taken care (Resident #6) and was involved with shaving of the resident's pubic hair. The CNA stated, I couldn't remember who the CNA's were. (We) started with 3 CNA's. Think one was from 1st (day) shift and she left and doesn ' t work her anymore. It was a shift change. I think it was (CNA #5) .It was a prn (work days as needed) nurse who told us to secure her. (Resident #6) had been here maybe a week. She was so combative and aggressive and every time we went to give her care she was very physical and hits and scratches us. Her pubic hair was thick and when she had bowel movements it was very gritty and very hard to clean her properly .I told her what I was doing. Did not accuse us of raping her but when I came to work the next night they told me she had said someone raped her. She accused. They then called the police to do an investigation and the policeman I was told she accused the policeman of raping her . 2. Resident #4 was admitted on [DATE], had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/16 documented the resident scored 12 (8 - 12 indicates moderately impaired) on the brief interview for mental status (BIMS). a. On 9/13/16 at 8:45 a.m., Nurses Notes dated April 2013 were reviewed with Licensed Practical Nurse (LPN) #1, who stated the year was documented incorrectly and that the notes should be dated 2016: 1.) A Nurses Note dated 4/12/13 at 8:00 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, .Resident noted with several c/o (complaints) this am (morning) . Resident then began to voice several complaints that 'the Mexican girl . crawled in bed with me and pulled my arms.' Resident unable to remember staff's name . 2.) A Nurses Note dated 4/12/13 at 9:00 a.m. and signed by LPN #1 documented, .Resident requested bed pan, this nurse enter room, resident states 'I know you think I'm ignorant', resident explains that staff treats her this way . Resident assured no one believes she's ignorant . 3.) A Nurses Note dated 4/12/13 at 11:30 a.m. and signed by LPN #1 documented, .Resident noted receiving a permanent in the beauty shop - Resident voices that 'when the new girl and that man put her in the shower chair that morning they flung me around almost causing me to be paralyzed.' Resident then began to speak of staff that is 'ill-mannered'. Resident noted to continue to complain the previous issue of her arms being pulled, but this version was a different person and a different body part . 4.) A Nurses Note dated 4/13/16, not timed, and signed by LPN #1 documented, .Resident noted to complain staff is inattentive. Noted with several request of staff. When staff attempts to assist resident she complain 'rude people, no one helps me'. 5.) A Nurses Note dated 8/12/16 on the 7:00 a.m. to 3:00 p.m. (7-3) shift and signed by LPN #2 documented, Stating to CNAs (Certified Nursing Assistants) that someone is stealing expensive things out of her room and that she had boxes that were delivered to her and someone stole them. On 24-hour report . b. The 24-Hour Nursing Report dated 8/12/16 and signed by LPN #2 documented, .Hall: East (and) Central . Date 8/12/16 . Patient's Full Name: (Resident #4) - people stealing things from her. c. On 9/13/16 at 8:30 a.m., the Assistant Director of Nurses (ADON) was asked if a reportable (report to the Office of Long Term Care (OLTC)) was initiated on the above two allegations of abuse and stated, No, I do not believe they were. The ADON was asked if the allegations should have been reported and stated, Yes, the person taking the complaint should report to their Supervisor and then they should report it to Administration right away. d. On 9/13/16 at 8:45 a.m., LPN #1 was asked if she was aware of the allegations of verbal and physical abuse alleged by Resident #4 and stated, Yes, I was the one she reported them to . I immediately reported to the (former) Administrator, and he told me to just document it on the Nurses Notes and that's what I did. I do remember checking her body, but I did not document anything, but I should have. I did not check any other residents. I did not get witness statements from this resident or any other resident. I did ask staff that gave her direct care. All they had used was a draw sheet on her. I did not get witness statements from them, but I should have. e. On 9/13/16 at 9:00 a.m., the Regional Director was asked if a reportable had ever been initiated for the allegations of abuse documented in the Nurses Notes for April and August 2016 and stated, No, the one on 4/14/16 was not part of the one on 4/12/16. The one on 4/12/16 should have also been a reportable and investigated. I've talked with (LPN #1), and she told me that she did report it to the Administrator at that time, whom is no longer here. I don't know why he dropped the ball. A reportable should have been done on that one . I've also talked to (LPN #2) that received the allegation of misappropriation of property on 8/12/16, and she told me she just documented it on the Nurses Notes and 24-hour Report and said no one told her to do that. She was trained to report all allegations of abuse to her Supervisor, and then they should report to Administration. At that time, the DON (Director of Nursing) had just quit, the ADON (Assistant Director of Nurses) was on vacation and the Administrator at that time no longer works here either. The 24-hour Report should have gone to him, but I don't know why he didn't initiate a reportable on this one either. He should have. f. On 9/13/16 at 11:33 a.m., LPN #2 was asked if she was aware of the allegation of misappropriation of property alleged by Resident #4 and stated, Yes, the aides told me about the missing items. I acknowledged what they told me, and I then documented it on the Nurses Notes and 24-hour Report that goes to Management. I should have reported it right away to my Supervisor, but I didn't. g. As of 9/13/16 at 9:00 a.m., no investigation had been completed regarding the resident's allegations on 4/12/16 and 8/12/16, and no protective measures were implemented to prevent further potential abuse or misappropriation. 3. Resident #1 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/2/16 documented the resident scored 6 (0-7 indicates severely impaired) on the BIMS. a. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long Term Care Facilities (DMS form 762) documented a discovery date and time as 8/25/16 at 3:15 p.m., with the following information: 1.) Section II - Complete Description of Incident . On 8/25/16 at approximately 3:15 p.m., the facility received a telephone call from (name) OLTC (Office of Long Term Care) informing the facility she received an anonymous telephone call alleging resident abuse from former employee, (CNA #4). The caller stated the alleged abuse happened between May-July. (Name) stated the anonymous caller said the former employee talked down to resident, jerked resident, hit resident, and threatened to throw the resident out the window. 2.) Section III - Findings and Actions Taken: Conclusion: The facility has unsubstantiated the allegation of verbal, physical and emotional/mental Abuse . Investigation and Action Taken: .The Regional Manager immediately initiated an investigation and notifying the Administrator, (City) Police Department, family, and physician . The involved party is no longer employed as of 7/17/2016 and was attempted to be notified but last known phone number was no answer . (Resident #1) discharged from the facility on 6/17/2016 . Per family (Resident #1) passed away on 8/20/2016 . Other residents were then interviewed and asked if they had ever been verbal, physicial, or emotional/ment abused by any employee at (facility) and they all stated 'No.' .The investigation continued by interviewing staff that had worked with (CNA #4) in the past and asked if they had ever withnessed any form of abuse from her towards any residents and all said 'No.' .Due to the fact that the all residents interviewed and employees interviewed at (facility) clam to have not witnessed any abuse allegation regarding (CNA #4) I cannot validate the accusation of abuse were ever done therefore find them to be unfounded. The form was singed by the Regional Manager and dated 8/31/16. 3.) Section IV- Accused Party Information . Name of accused party: (CNA #4). 4.) The Witness Statements included in the facility's investigation consisted of interviews with 3 residents, 2 CNAs and 1 LPN. b. On 9/12/16 at 1:30 p.m., CNA #3, a former employee of the facility, was asked during a telephone interview what he had witnessed with regard to the allegation of abuse for Resident #1. He stated, I witnessed her hitting (Resident #1) and threatening to throw her out the window . The CNA was asked why this was not reported to the facility immediately and stated, I did not report this because I was afraid of what she (CNA #4) would do to me. The CNA was asked when he was supposed to report abuse and stated, Immediately. CNA #3 then stated, I was the only one that witnessed this behavior with (CNA #4) when she was there. There was no indication that CNA #3 took any measures to protect or intervene on the resident's behalf at the time the alleged incidents occurred. CNA #3 stated, I told (CNA #4) I was going to report her if she didn't stop, and she said she was just playing, but the look on their (residents') faces told otherwise. They didn't know if she was playing or not. 4. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/25/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS. a. The Office of Long Term Care (OLTC) Incident & Accident Next Day Reporting Form (DMS form 7734) documented a date / time of discovery of 8/25/16 at 3:15 p.m. regarding the following allegation: 1.) The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long Term Care Facilities (DMS form 762) documented, .Summary of Incident . On 8/25/16 at approximately 3:15 p.m., the facility received a telephone call from (name) OLTC, stating she had received an anonymous telephone call alleging resident physical, emotional / mental, and verbal abuse from a former employee (CNA #4) . The Regional Manager immediately initiated an investigation and notifying the administrator, (City) Police Department, family, and physician . The involved party is no longer employed as of 7/17/2016 and was attempted to be notified by last known phone number was no answer . (Resident #2) was then interviewed and stated that none of the nursing staff or any staff member at (facility) had ever been verbal, physical, or emotional/mental abusive toward her . Other residents were then interviewed and asked if they had ever been verbal, physical, or emotional/mental abused by any employee at (facility) and they all stated 'No' . The investigation continued by interviewing staff that had worked with (CNA #4) in the past and asked if they had ever witnessed any form of abuse from her towards any residents and all said 'No' . Due to the fact that (Resident #2) has denied any type of abuse from any employee at (facility) I cannot validate the accusations of abuse made against (CNA #4) and find them to be unfounded . 2.) Section IV - Name of accused party: '(CNA #4). The form was signed by the Regional Manager and dated 8/31/16. 3.) The Witness Statements included in the facility's investigation consisted of interviews with 2 staff members (1 LPN and 1 CNA) and two residents. b. On 9/12/16 at 1:30 p.m., CNA #3, a former employee of the facility, was asked during a telephone interview about the allegations involving Resident #2 and stated, It's not that she ever hit (Resident #2). I never witnessed her hitting or talking badly to (Resident #2). I just gave her name because she knows everything going on there . 5. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD date of 7/19/16 documented the resident scored 6 (0-7 indicates severely impaired) on the BIMS. a. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long Term Care Facilities (DMS form 762) documented a discovery date / time as 8/25/16 at 3:15 p.m. and: 1.) .Summary of Incident . On 8/25/16 at approximately 3:15 p.m., the facility received a telephone call from (name) OLTC stating she had received an anonymous telephone call alleging resident physical, emotional/mental, and verbal abuse from a former employee (CNA #4) . The Regional Manager immediately initiated an investigation and notifying the administrator, (City) Police Department, family, and physician . The involved party is no longer employed as of 7/17/2016 and was attempted to be notified by last known phone number was no answer . (Resident #3) is unable to be interviewed due to her mental functional level being orientated to person only . Other residents were then interviewed and asked if they had ever been verbal, physical, or emotional/mental abused by any employee at (facility) and they all stated 'No' . The investigation continued by interviewing staff that had worked with (CNA #4) in the past and asked if they had ever witnessed any form of abuse from her towards any residents and all said 'No' . Due to the fact that all residents interviewed and employees interviewed at (facility) claim to have not witnessed any abuse allegation regarding (CNA #4), I cannot validate the accusations of abuse were every done therefore find them to be unfounded . The form was signed by the Regional Manager and dated 8/31/16. 2.) The Witness Statements included in the facility's investigation consisted of interviews with 3 staff members (1 LPN and 2 CNAs) and two residents. b. On 9/12/16 at 1:30 p.m., CNA #3 was asked, during a telephone interview about the allegations involving Resident #3 and stated, She (CNA #4) would smack the resident, (Resident #3) and threaten to throw her out the window. She would smack her on the rear or on her arm or any place that was open skin. I never seen a mark left on the resident. I told her she shouldn't be talking like that . There was no indication that CNA #3 took any measures to protect or intervene on the resident's behalf at the time the alleged incidents occurred. CNA #3 stated, I told (CNA #4) I was going to report her if she didn't stop, and she said she was just playing, but the look on their (residents') faces told otherwise. They didn't know if she was playing or not. CNA #3 was asked if any of the residents ever cried after being hit by CNA #4. He stated, No. The CNA was asked if he had ever reported the alleged incidents to the facility and stated, I did not report this, because I was afraid of what she (CNA #4) would do to me. The CNA was asked when was he was supposed to report abuse and he stated, Immediately. CNA #3 then stated, I was the only one that witnessed this behavior with (CNA #4's) when she was there. 6. On 9/12/16 at 2:52 p.m., the Regional Director (RD) was asked why the investigations for the allegations involving Residents #1, #2 and #3 only consisted of interviews with 3 residents and 3 staff members. The RD stated, We were trying to find staff that had actually worked with her (CNA # 4); she was hired in April. The Social Worker went through and did interviews with the residents, and I don't know why she just chose 3. We did not do body audits, because this was called to us on 8/25/16, and the dates given were May - July 2016, but no specific time, shifts or dates were given. The Regional Director then obtained the staffing assignments for CNA #4 from April 2016 through July 2016. The Regional Director reviewed the assignment forms and stated, She worked all over the facility, so there should have been more than 3 resident interviews done. 7. The Immediate Jeopardy was removed and the scope and severity decreased to E on 9/13/16 at 5:08 p.m., when the facility implemented the following plan of removal: 1.) HR (Human Resources) began new in-services on Immediate Reporting of Abuse, Neglect and protection of residents who alleged abuse and to all other residents, Theft of property, and the failure to report starting at 1:45 p.m. on 9/13/2016 to all staff present and will in-service all shifts prior to start of shifts until all employees have been in-serviced. Any employee who is out will not return to work until in-serviced. 2.) Body audits started at 1:30 p.m. on 9/13/2016 by DON, ADON, additional RNs (Registered Nurses) on all non-verbal residents. All body audits will be completed by end of day on 9/13/2016. Any negative findings will be addressed immediately. 3.) Body audit for all non-verbal residents will be done by DON/designee 3 x (times) per week for 2 weeks. Then 2 x per week until substantial compliance is achieved. Any negative findings will be addressed immediately. 4.) Body audit done on resident with allegation on 9/12/2016 completed by DON with no negative findings. 5.) Body audit done on resident with allegation on 9/09/2016 completed by RN with no negative findings. 6.) Interviews with all cognitive residents was initiated on 9/13/2016 at 6:30 a.m. by Regional Manager and to be completed by Departmental Managers by 7:00 p.m. on 9/13/2016. All negative findings will be addressed immediately. 7.) CNA with allegation against her on 4/12/2016 was suspended on 9/13/16 by Regional Manager pending a thorough investigation. The other CNA with allegation against her on 4/12/2016 is no longer employed at the facility. 8.) CNA with allegation against her on 9/9/16 was suspended on 9/13/16 due to a previous allegation by Regional Manager pending a thorough investigation. Also the LPN and another CNA the resident reported allegation to on 9/9/16 were also suspended on 9/13/2016 pending a thorough investigation. 9.) DON / designee to perform random interviews of staff and residents daily for 2 weeks starting on 9/13/2016. Then DON / designee to perform random interviews of staff and residents 3 x a week until substantial compliance is achieved. All interviews will be logged. Any negative findings will be addressed immediately. 10.) DON/designee to review nursing notes and 24-hour Report on daily basis for 2 weeks starting on 9/13/2016. Then DON/designee to review nursing notes and 24-hour Report 3 x a week until substantial compliance is achieved. All review of nursing notes will be logged. Any negative findings will be addressed immediately.

Complaint # (AR 462) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure its abuse prohibition policies and procedures were implemented, as evidenced by failure to ensure all allegations of abuse were immediately reported to the Administrator, immediately and thoroughly investigated and measures were taken to protect residents from further potential abuse for 2 (Residents #4 and #6); and failure to ensure investigations of abuse allegations included witness statements from residents who received care from the alleged perpetrator and staff who worked with the alleged perpetrator in an effort to determine if actual abuse occurred and to determine if other residents may have been affected for 3 (Residents #1, 2 and 3) of 6 (Residents #1, 2, 3, 4, 5 and 6) case mix residents who resided in the facility. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Residents #4 and #6, who alleged staff-to-resident verbal and physical abuse and Residents #1, 2 and 3 who were alleged victims of staff-to-resident abuse. The failed practices also had the potential to cause more than minimal harm to 12 residents who resided in the facility and had allegation of abuse within the last 5 months, as documented on a list provided by the Acting Administrator on 9/27/16. The facility was notified of the Immediate Jeopardy condition on 9/13/16 at 12:40 p.m. The findings are: 1. The facility's policy titled Abuse Investigations provided by the Nurse Consultant on 9/12/15 documented: Policy Statement: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Policy Interpretation and Implementation: 1.) Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 3.) The individual conducting the investigation will, as a minimum g.) Interview staff member (on all shifts) who have had contact with the resident during the period of the alleged incident: h.) Interview the resident's roommate, family members, and visitors. i.) Interview other residents to whom the accused employee provides care or services, and 8.) Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. 2. Resident #6 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 9/1/16 documented the resident scored 11 (8 - 12 indicates moderately) on the brief interview for mental status (BIMS), required extensive assistance of two plus persons for bed mobility, one person for personal hygiene, total assistance of two plus persons for transfers and toilet use and toilet use and was incontinent of bowel and bladder. a. On 9/13/16 at 3:18 p.m., during an interview for the Task 5-G Abuse Protocol, Certified Nurse Assistant (CNA) #2 was asked if she had ever witnessed abuse of residents and stated, One of the residents I worked with Friday (9/9/16), the resident looked like she was going to cry. She said she had trouble with (CNA #1). She said (CNA #1) had treated her really roughly, and she hit her head on the wall. The resident was on the west hall, (Resident #6). I told her she needed to tell someone if someone hurts her. The way I feel, I asked the other girls if they had seen anything. I didn't report this to a supervisor. (CNA #1) kept coming to me and asking what the resident had said, and (CNA #1) had told me the resident makes things up and she's not right. I don't work with her a lot. (CNA #1) told a nurse that the resident makes things up, and the nurse said they were going to look into it and see what's going on. I don't work with the resident a lot; she seems nice. I didn't report it, because I didn't see any marks and didn't see it happen. CNA #2 was asked how she had been trained on abuse and she stated she had been trained to report any abuse immediately. 1.) On 9/13/16 at 3:45 p.m., Licensed Practical Nurse (LPN) #3 was asked about the allegation made by CNA #2 during the above interview and stated, The resident told me she (CNA #1) used a mean tone of voice with her. She didn't tell me (CNA #1) had handled her roughly. I did not report it, because that's how (CNA #1) is, and the resident is weepy a lot. I feel like, if I think they have been abused emotionally or physically, then I would report it. I saw the resident, and she was trying to tell me she was upset. Knowing what the resident is like and what and how (CNA #1) is, I didn't report it. I guess I should have reported it. You have to take anything a resident says seriously, and I should have reported it. 2.) As of 9/13/16 at 3:45 p.m., no interview could be conducted with CNA #1 who was named in this incident. According to the Consultant, the CNA was not working due to a different allegation and had been suspended. 3.) On 9/14/16 at 8:34 a.m., Resident #6 was lying in bed and was asked how long she had lived here and stated, I think it has been a year (actual date of admission was approximately 5 months prior to this interview). The first 2 weeks I was here, I was raped. I told the lady in charge. They did not come and talk to me, and I have not been to the hospital. I was in a different room . I was held down by 3 girls while my pubic hair was shaved. The resident was asked if this was what she was referring to when she said she had been raped and she stated Yes. The resident also stated, Last Friday (9/9/16), (CNA #1) was in here, and I can't turn myself. I wasn't turning fast enough, and she shoved me hard 2 times, she shoved my head and knee into the wall. I told the nurse . b. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and (&) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762, dated 4/2/16 (date of discovery) documented, Section II - Complete Description of Incident . On 4/2/16 resident (Resident #3) stated to Charge Nurse (name) that she 'was in jail being charged with a crime and was being held against her will and that she had been raped multiple times on the night of 4/1/16'. An investigation was initiated immediately . Section III - Findings and Actions Taken: .An investigation was initiated immediately on 4/2/16 by notifying the Administrator, (Name) Police Department, family and physician . (Resident #6) description was that of a man in a police uniform with short grey hair. She could not give any other info and no staff matched this description, therefore no one was suspended pending the investigation. She also reported to the Police Officer that it occurred 2-3 nights ago, away from the facility at an address she didn ' t know. This indicates her story is changing and is confused regarding the incident . Upon notification of the family, the POA (Power of Attorney) stated that they were with her earlier in the day on 4/2/16 and she never reported anything to them about rape, just stated she wanted to leave and go home. They also stated that they know that she didn ' t get raped, but was happy the facility was taking it serious and conduction an investigation . The nurse immediately conducted a body audit of (Resident #6) on 4/2/16 and there were no signs of marks or bruising to the peri area or anything that would indicate sexual abuse . The investigation continued by interviewing other female residents regarding the incident and asked them if they have ever been sexually abused and they all stated, 'No.' .Staff interviews were also conducted, but no pertinent information was found to the investigation . A urine analysis was then obtained for (Resident #6) and it indicated that she currently has a UTI (urinary tract infection) and will be started on an antibiotic. This explains why she has been more confused and disoriented . The Administrator also interviewed (Resident #6) on 4/4/16 and asked her about the incident and she did not remember saying that on 4/2/16 . Due to the fact that the body audit revealed no indication of sexual abuse, the resident and staff interviews had no negative findings, (Resident #6) didn't remember the allegation on 4/4/16, and she didn't report anything to her family on the same day, the facility strongly believes that sexual abuse did not occur, but will continue to treat (Resident #6) for her UTI to resolve her cognition concerns . The investigation was signed by the Administrator and dated 4/7/16. c. On 9/14/16 at 9:45 a.m., CNA #2 was asked regarding any abuse to (Resident #6) and stated, (Resident #6) told me that that girl raped me and I said what do you mean. She said she secured me without asking me and without permission. I talked to the other CNA's and they told me they were told by the nurse to go shave her because she had thick long pubic hair and they were having difficulty cleaning her. The resident felt like this was rape. d. On 9/14/16 at 11:47 a.m., CNA #5 was asked regarding any abuse to (Resident #6) and stated she had taken care (Resident #6) and was involved with shaving of the resident's pubic hair. The CNA stated, I couldn't remember who the CNA's were. (We) started with 3 CNA's. Think one was from 1st (day) shift and she left and doesn ' t work her anymore. It was a shift change. I think it was (CNA #5) .It was a prn (work days as needed) nurse who told us to secure her. (Resident #6) had been here maybe a week. She was so combative and aggressive and every time we went to give her care she was very physical and hits and scratches us. Her pubic hair was thick and when she had bowel movements it was very gritty and very hard to clean her properly .I told her what I was doing. Did not accuse us of raping her but when I came to work the next night they told me she had said someone raped her. She accused. They then called the police to do an investigation and the policeman I was told she accused the policeman of raping her . 3. Resident #4 was admitted on [DATE], had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/16 documented the resident scored 12 (8 - 12 indicates moderately impaired) on the brief interview for mental status (BIMS). a. On 9/13/16 at 8:45 a.m., Nurses Notes dated April 2013 were reviewed with Licensed Practical Nurse (LPN) #1, who stated the year was documented incorrectly and that the notes should be dated 2016: 1.) A Nurses Note dated 4/12/13 at 8:00 a.m. and signed by Licensed Practical Nurse (LPN) #1 documented, .Resident noted with several c/o (complaints) this am (morning) . Resident then began to voice several complaints that 'the Mexican girl . crawled in bed with me and pulled my arms.' Resident unable to remember staff's name . 2.) A Nurses Note dated 4/12/13 at 9:00 a.m. and signed by LPN #1 documented, .Resident requested bed pan, this nurse enter room, resident states 'I know you think I'm ignorant', resident explains that staff treats her this way . Resident assured no one believes she's ignorant . 3.) A Nurses Note dated 4/12/13 at 11:30 a.m. and signed by LPN #1 documented, .Resident noted receiving a permanent in the beauty shop - Resident voices that 'when the new girl and that man put her in the shower chair that morning they flung me around almost causing me to be paralyzed.' Resident then began to speak of staff that is 'ill-mannered'. Resident noted to continue to complain the previous issue of her arms being pulled, but this version was a different person and a different body part . 4.) A Nurses Note dated 4/13/16, not timed, and signed by LPN #1 documented, .Resident noted to complain staff is inattentive. Noted with several request of staff. When staff attempts to assist resident she complain 'rude people, no one helps me'. 5.) A Nurses Note dated 8/12/16 on the 7:00 a.m. to 3:00 p.m. (7-3) shift and signed by LPN #2 documented, Stating to CNAs (Certified Nursing Assistants) that someone is stealing expensive things out of her room and that she had boxes that were delivered to her and someone stole them. On 24-hour report . b. The 24-Hour Nursing Report dated 8/12/16 and signed by LPN #2 documented, .Hall: East (and) Central . Date 8/12/16 . Patient's Full Name: (Resident #4) - people stealing things from her. c. On 9/13/16 at 8:30 a.m., the Assistant Director of Nurses (ADON) was asked if a reportable (report to the Office of Long Term Care (OLTC)) was initiated on the above two allegations of abuse and stated, No, I do not believe they were. The ADON was asked if the allegations should have been reported and stated, Yes, the person taking the complaint should report to their Supervisor and then they should report it to Administration right away. d. On 9/13/16 at 8:45 a.m., LPN #1 was asked if she was aware of the allegations of verbal and physical abuse alleged by Resident #4 and stated, Yes, I was the one she reported them to . I immediately reported to the (former) Administrator, and he told me to just document it on the Nurses Notes and that's what I did. I do remember checking her body, but I did not document anything, but I should have. I did not check any other residents. I did not get witness statements from this resident or any other resident. I did ask staff that gave her direct care. All they had used was a draw sheet on her. I did not get witness statements from them, but I should have. e. On 9/13/16 at 9:00 a.m., the Regional Director was asked if a reportable had ever been initiated for the allegations of abuse documented in the Nurses Notes for April and August 2016 and stated, No, the one on 4/14/16 was not part of the one on 4/12/16. The one on 4/12/16 should have also been a reportable and investigated. I've talked with (LPN #1), and she told me that she did report it to the Administrator at that time, whom is no longer here. I don't know why he dropped the ball. A reportable should have been done on that one . I've also talked to (LPN #2) that received the allegation of misappropriation of property on 8/12/16, and she told me she just documented it on the Nurses Notes and 24-hour Report and said no one told her to do that. She was trained to report all allegations of abuse to her Supervisor, and then they should report to Administration. At that time, the DON (Director of Nursing) had just quit, the ADON (Assistant Director of Nurses) was on vacation and the Administrator at that time no longer works here either. The 24-hour Report should have gone to him, but I don't know why he didn't initiate a reportable on this one either. He should have. f. On 9/13/16 at 11:33 a.m., LPN #2 was asked if she was aware of the allegation of misappropriation of property alleged by Resident #4 and stated, Yes, the aides told me about the missing items. I acknowledged what they told me, and I then documented it on the Nurses Notes and 24-hour Report that goes to Management. I should have reported it right away to my Supervisor, but I didn't. g. As of 9/13/16 at 9:00 a.m., no investigation had been completed regarding the resident's allegations on 4/12/16 and 8/12/16, and no protective measures were implemented to prevent further potential abuse or misappropriation. 4. Resident #1 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 5/2/16 documented the resident scored 6 (0-7 indicates severely impaired) on the BIMS. a. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long Term Care Facilities (DMS form 762) documented a discovery date and time as 8/25/16 at 3:15 p.m., with the following information: 1.) Section II - Complete Description of Incident . On 8/25/16 at approximately 3:15 p.m., the facility received a telephone call from (name) OLTC (Office of Long Term Care) informing the facility she received an anonymous telephone call alleging resident abuse from former employee, (CNA #4). The caller stated the alleged abuse happened between May-July. (Name) stated the anonymous caller said the former employee talked down to resident, jerked resident, hit resident, and threatened to throw the resident out the window. 2.) Section III - Findings and Actions Taken: Conclusion: The facility has unsubstantiated the allegation of verbal, physical and emotional/mental Abuse . Investigation and Action Taken: .The Regional Manager immediately initiated an investigation and notifying the Administrator, (City) Police Department, family, and physician . The involved party is no longer employed as of 7/17/2016 and was attempted to be notified but last known phone number was no answer . (Resident #1) discharged from the facility on 6/17/2016 . Per family (Resident #1) passed away on 8/20/2016 . Other residents were then interviewed and asked if they had ever been verbal, physicial, or emotional/ment abused by any employee at (facility) and they all stated 'No.' .The investigation continued by interviewing staff that had worked with (CNA #4) in the past and asked if they had ever withnessed any form of abuse from her towards any residents and all said 'No.' .Due to the fact that the all residents interviewed and employees interviewed at (facility) clam to have not witnessed any abuse allegation regarding (CNA #4) I cannot validate the accusation of abuse were ever done therefore find them to be unfounded. The form was singed by the Regional Manager and dated 8/31/16. 3.) Section IV- Accused Party Information . Name of accused party: (CNA #4). 4.) The Witness Statements included in the facility's investigation consisted of interviews with 3 residents, 2 CNAs and 1 LPN. b. On 9/12/16 at 1:30 p.m., CNA #3, a former employee of the facility, was asked during a telephone interview what he had witnessed with regard to the allegation of abuse for Resident #1. He stated, I witnessed her hitting (Resident #1) and threatening to throw her out the window . The CNA was asked why this was not reported to the facility immediately and stated, I did not report this because I was afraid of what she (CNA #4) would do to me. The CNA was asked when he was supposed to report abuse and stated, Immediately. CNA #3 then stated, I was the only one that witnessed this behavior with (CNA #4) when she was there. There was no indication that CNA #3 took any measures to protect or intervene on the resident's behalf at the time the alleged incidents occurred. CNA #3 stated, I told (CNA #4) I was going to report her if she didn't stop, and she said she was just playing, but the look on their (residents') faces told otherwise. They didn't know if she was playing or not. 5. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 8/25/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS. a. The Office of Long Term Care (OLTC) Incident & Accident Next Day Reporting Form (DMS form 7734) documented a date / time of discovery of 8/25/16 at 3:15 p.m. regarding the following allegation: 1.) The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long Term Care Facilities (DMS form 762) documented, .Summary of Incident . On 8/25/16 at approximately 3:15 p.m., the facility received a telephone call from (name) OLTC, stating she had received an anonymous telephone call alleging resident physical, emotional / mental, and verbal abuse from a former employee (CNA #4) . The Regional Manager immediately initiated an investigation and notifying the administrator, (City) Police Department, family, and physician . The involved party is no longer employed as of 7/17/2016 and was attempted to be notified by last known phone number was no answer . (Resident #2) was then interviewed and stated that none of the nursing staff or any staff member at (facility) had ever been verbal, physical, or emotional/mental abusive toward her . Other residents were then interviewed and asked if they had ever been verbal, physical, or emotional/mental abused by any employee at (facility) and they all stated 'No' . The investigation continued by interviewing staff that had worked with (CNA #4) in the past and asked if they had ever witnessed any form of abuse from her towards any residents and all said 'No' . Due to the fact that (Resident #2) has denied any type of abuse from any employee at (facility) I cannot validate the accusations of abuse made against (CNA #4) and find them to be unfounded . 2.) Section IV - Name of accused party: '(CNA #4). The form was signed by the Regional Manager and dated 8/31/16. 3.) The Witness Statements included in the facility's investigation consisted of interviews with 2 staff members (1 LPN and 1 CNA) and two residents. b. On 9/12/16 at 1:30 p.m., CNA #3, a former employee of the facility, was asked during a telephone interview about the allegations involving Resident #2 and stated, It's not that she ever hit (Resident #2). I never witnessed her hitting or talking badly to (Resident #2). I just gave her name because she knows everything going on there . 6. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD date of 7/19/16 documented the resident scored 6 (0-7 indicates severely impaired) on the BIMS. a. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Residents in Long Term Care Facilities (DMS form 762) documented a discovery date / time as 8/25/16 at 3:15 p.m. and: 1.) .Summary of Incident . On 8/25/16 at approximately 3:15 p.m., the facility received a telephone call from (name) OLTC stating she had received an anonymous telephone call alleging resident physical, emotional/mental, and verbal abuse from a former employee (CNA #4) . The Regional Manager immediately initiated an investigation and notifying the administrator, (City) Police Department, family, and physician . The involved party is no longer employed as of 7/17/2016 and was attempted to be notified by last known phone number was no answer . (Resident #3) is unable to be interviewed due to her mental functional level being orientated to person only . Other residents were then interviewed and asked if they had ever been verbal, physical, or emotional/mental abused by any employee at (facility) and they all stated 'No' . The investigation continued by interviewing staff that had worked with (CNA #4) in the past and asked if they had ever witnessed any form of abuse from her towards any residents and all said 'No' . Due to the fact that all residents interviewed and employees interviewed at (facility) claim to have not witnessed any abuse allegation regarding (CNA #4), I cannot validate the accusations of abuse were every done therefore find them to be unfounded . The form was signed by the Regional Manager and dated 8/31/16. 2.) The Witness Statements included in the facility's investigation consisted of interviews with 3 staff members (1 LPN and 2 CNAs) and two residents. b. On 9/12/16 at 1:30 p.m., CNA #3 was asked, during a telephone interview about the allegations involving Resident #3 and stated, She (CNA #4) would smack the resident, (Resident #3) and threaten to throw her out the window. She would smack her on the rear or on her arm or any place that was open skin. I never seen a mark left on the resident. I told her she shouldn't be talking like that . There was no indication that CNA #3 took any measures to protect or intervene on the resident's behalf at the time the alleged incidents occurred. CNA #3 stated, I told (CNA #4) I was going to report her if she didn't stop, and she said she was just playing, but the look on their (residents') faces told otherwise. They didn't know if she was playing or not. CNA #3 was asked if any of the residents ever cried after being hit by CNA #4. He stated, No. The CNA was asked if he had ever reported the alleged incidents to the facility and stated, I did not report this, because I was afraid of what she (CNA #4) would do to me. The CNA was asked when was he was supposed to report abuse and he stated, Immediately. CNA #3 then stated, I was the only one that witnessed this behavior with (CNA #4's) when she was there. 7. On 9/12/16 at 2:52 p.m., the Regional Director (RD) was asked why the investigations for the allegations involving Residents #1, #2 and #3 only consisted of interviews with 3 residents and 3 staff members. The RD stated, We were trying to find staff that had actually worked with her (CNA # 4); she was hired in April. The Social Worker went through and did interviews with the residents, and I don't know why she just chose 3. We did not do body audits, because this was called to us on 8/25/16, and the dates given were May - July 2016, but no specific time, shifts or dates were given. The Regional Director then obtained the staffing assignments for CNA #4 from April 2016 through July 2016. The Regional Director reviewed the assignment forms and stated, She worked all over the facility, so there should have been more than 3 resident interviews done. 8. The Immediate Jeopardy was removed and the scope and severity decreased to E on 9/13/16 at 5:08 p.m., when the facility implemented the following plan of removal: 1.) HR (Human Resources) began new in-services on Immediate Reporting of Abuse, Neglect and protection of residents who alleged abuse and to all other residents, Theft of property, and the failure to report starting at 1:45 p.m. on 9/13/2016 to all staff present and will in-service all shifts prior to start of shifts until all employees have been in-serviced. Any employee who is out will not return to work until in-serviced. 2.) Body audits started at 1:30 p.m. on 9/13/2016 by DON, ADON, additional RNs (Registered Nurses) on all non-verbal residents. All body audits will be completed by end of day on 9/13/2016. Any negative findings will be addressed immediately. 3.) Body audit for all non-verbal residents will be done by DON/designee 3 x (times) per week for 2 weeks. Then 2 x per week until substantial compliance is achieved. Any negative findings will be addressed immediately. 4.) Body audit done on resident with allegation on 9/12/2016 completed by DON with no negative findings. 5.) Body audit done on resident with allegation on 9/09/2016 completed by RN with no negative findings. 6.) Interviews with all cognitive residents was initiated on 9/13/2016 at 6:30 a.m. by Regional Manager and to be completed by Departmental Managers by 7:00 p.m. on 9/13/2016. All negative findings will be addressed immediately. 7.) CNA with allegation against her on 4/12/2016 was suspended on 9/13/16 by Regional Manager pending a thorough investigation. The other CNA with allegation against her on 4/12/2016 is no longer employed at the facility. 8.) CNA with allegation against her on 9/9/16 was suspended on 9/13/16 due to a previous allegation by Regional Manager pending a thorough investigation. Also the LPN and another CNA the resident reported allegation to on 9/9/16 were also suspended on 9/13/2016 pending a thorough investigation. 9.) DON / designee to perform random interviews of staff and residents daily for 2 weeks starting on 9/13/2016. Then DON / designee to perform random interviews of staff and residents 3 x a week until substantial compliance is achieved. All interviews will be logged. Any negative findings will be addressed immediately. 10.) DON/designee to review nursing notes and 24-hour Report on daily basis for 2 weeks starting on 9/13/2016. Then DON/designee to review nursing notes and 24-hour Report 3 x a week until substantial compliance is achieved. All review of nursing notes will be logged. Any negative findings will be addressed immediately.

Complaint # (AR 022) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure necessary treatment and services were provided to promote healing and prevent potential infection of existing pressure ulcers and to prevent the development of new pressure ulcers, as evidenced by: failure to ensure licensed nursing staff followed clean technique and nursing standards of practice during the provision of pressure ulcer treatments to promote healing and prevent potential infection for 1 (Resident # 3) of 4 (Residents #1, #2 #3 and #5) case mix residents who had pressure ulcers; Failure to ensure loose or missing wound dressings were replaced immediately to prevent potential infection for 1 (Resident #3) of 4 (Residents #1, #2, #3 and #5) case mix residents who had pressure ulcers; Failure to ensure pressure ulcer wound care was provided at the frequency ordered by the physician and that the physician was promptly notified of the need for any changes in the treatment regimen to promote healing of pressure ulcers for 3 (Residents #2, #3 and #5) of 4 (Residents #1, #2, #3 and #5) case mix residents with pressure ulcers; Failure to ensure a pressure relieving device was present in a resident's wheelchair as per the plan of care to prevent further skin breakdown for 1 (Resident #3) of 4 (Residents #1, #2, #3 and #5) case mix residents who were care planned for pressure relieving devices in wheelchairs; and, Failure to ensure wounds were assessed and measured weekly with the results documented, to include the type / stage of the wound, measurements, condition of the surrounding tissue and the presence or absence of drainage / odor to enable accurate tracking of healing progress or prompt identification of deterioration for 4 (Residents #1, #2, #3 and #5) of 4 case mix residents who had pressure ulcers. The failed practices resulted in a pattern of actual harm to Resident #5, who experienced deterioration and / or delayed healing of existing pressure ulcers, and had the potential to affect 4 residents who had pressure ulcers and 35 residents who were care planned for pressure relieving devices in wheelchairs, according to lists received from the Administrator on 3/10/16. The findings are: 1. The facility's policy titled, Dressings, Dry/Clean, provided by Administrator on 3/10/16, documented, .Preparation: 1. Verify that there is a physician's order for this procedure . 3. Check the treatment record . Steps in the procedure: 1. Clean bed side stand. Establish a clean field. 2. Place the clean equipment on the clean field . 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressing(s) . 11. Used clean technique, open other products . 12. Wash and dry your hands thoroughly. 13. Put on clean gloves . 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area, (usually from the center outward). 16. Use dry gauze to pat the wound dry. 17. Apply the ordered dressing and secure . 2. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/23/16 documented the resident scored 1 (0 - 7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), required extensive assistance with bed mobility, was totally dependent for toilet use, had an indwelling catheter, was always incontinent of bowel, was at risk of developing pressure ulcers and had one Stage 4 pressure ulcer that was present on admit/reentry. a. The Resident Plan of Care dated 10/23/14 and reviewed /revised 3/8/16 documented, .Pressure Ulcers. Problem Date: 10/23/14. Resident has pressure ulcer Stage IV to coccyx upon admission to facility . Approaches: . Monitor effectiveness of/response to treatment . Risk for Pressure Ulcers. Problem Date: 10/23/14. Resident is at risk for developing a pressure ulcer related to immobility . b. The Weekly/Monthly Wound Log dated 10/23/14 documented, .Wound Type: (Pressure) . Location: Center buttocks . Stage IV . Size: 4.0 x (by) 1.5 cm (centimeter), 1.2 depth . c. The Weekly/Monthly Wound Logs documented: .12/4/15 . Location: Coccyx . Stage IV . Size: 1.7 x 1.8 x 2.6 (centimeter) . (Continues) wound clinic 2 (times) weekly. Dr. (Doctor) at wound clinic talking with wife about getting [MEDICAL CONDITION]. . 12/11/15 . Location: Coccyx . Stage IV . Size: 1.8 x 2.0 x 2.4 (centimeter) . He is going to wound clinic only one a week now. .12/16/15 . Location: Coccyx . Stage IV . Size: 2.0 x 2.0 x 2.4 (centimeter) . .12/28/15 . Location: Coccyx . Stage IV . Size: 1.8 x 1.9 x 2.0 (centimeter) . .1/8/16 . Location: Coccyx . Stage IV . Size: 2.4 x 2.6 x 2.8 (centimeter). Wound has regressed some . Moderate amount of drainage . .1/13/16 . Location: Coccyx . Stage IV . Size: 2.4 x 2.8 x 2.6 (centimeter) . Moderate amount of drainage . .1/22/16 . Location: Coccyx . Stage IV . Size: 2.8 x 2.8 x 3.5 (centimeter) . (Continues) wound clinic . No progress at this time. .2/3/16 . Location: Coccyx . Stage IV . Size: 3.0 x 3.0 x 4.5 (centimeter). Wound has gotten worse. (Treatment) changed . visits to wound clinic (discontinued). Moderate amount of drainage. Skin around wound starting to get some breakdown . .2/9/16 . Location: Coccyx . Stage IV . Size: 3.1 x 3.0 x 4.1 (centimeter). Wound to coccyx showing some progress . Butt cheeks have some redness, was open but closed at this time. Duoderm applied prior to dressing for protection. The next documented weekly measurements found in the clinical record were dated 3/2/16. (See below) d. The facility's laboratory report with a collection date of 2/12/16 documented . Reported 2/16/16 . Culture, Wound . Moderate growth: Proteus Mirabilis . Moderate growth: ESBL (Extended Spectrum Beta-Lactamases) producing Escherichia coli . e. The Nurse's Notes dated 2/12/16 at 1:00 p.m. documented, Resident has declined mentally and (new order) for wound culture to coccyx wound . f. The Nurse's Notes dated 2/14/16 at 8:15 a.m. documented, Resident (at) dining room, noted eating paper napkin . (oxygen saturation) was 86% with oxygen (at) 3 (liters) via (nasal cannula) . received order to transfer to ER (emergency room ) . g. The hospital record documented wound measurements dated 2/15/16 at 6:01 p.m. as, .Location: Sacral . 4.7 x 3.0 x 3.8 (centimeters). h. A hospital laboratory report dated 2/19/16 documented, .Specimen source: Coccyx . Results: Heavy growth of Escherichia coli (ESBL), Light growth of Staphylococcus (staph) aureus . i. The Admission/Re-admission Skin Audit dated 2/19/16 documented, .Stage IV on coccyx, has staph infection . There was no documentation of measurements of the coccyx wound upon readmission to the facility. j. Physician's orders dated 2/19/16 documented, Cleanse . wound to coccyx with (wound cleanser). Pack wound with [MEDICATION NAME] AG (silver). Cover with foam dressing every day and as needed. Cleanse . wounds to right butt cheek and lower left buttock with (wound cleanser). Pat dry. Apply Duoderm every 3 days prior to dressing change and as needed. k. The Weekly/Monthly Wound Log dated 3/2/16 documented, .Wound Type: (Pressure) . Location: Coccyx . Stage IV . Size: 4.0 x 3.8 x 3.6 (centimeter) . Wound Type: (Pressure) . Location: (Left) butt cheek . Stage II . Size: 1.3 x 1.2 (no depth measured or estimated per documentation) . Wound Type: (Pressure) . Location: (Right) upper thigh . Stage II . Size: 1.5 x 1.2 (no depth measured or estimated per documentation) . Wound Type: (Pressure) . Location: (Left) upper thigh . Stage II . Size: 1.2 x 2.5 (no depth measured or estimated per documentation) . l. On 3/6/16 at 2:45 p.m., the March 2016 TAR documented, Cleanse . wound to coccyx with (wound cleanser). Pack with [MEDICATION NAME] AG. Cover with foam dressing every day and as needed. The TAR documented this treatment was done on 3/1/16, 3/2/16, 3/3/16, and 3/4/16. The treatments due on 3/5/16 and 3/6/16 were not initialed as completed. Cleanse . wound to right butt cheek and lower left buttock with (wound cleanser). Pat dry. Apply Duoderm every 3 days prior to dressing change and as needed. The TAR documented this treatment was done on 3/1/16, 3/2/16, 3/3/16, and 3/4/16. m. On 3/8/16 at 10:10 a.m., the Treatment Nurse provided wound care and measured the wounds at this surveyor's request. On completion of the wound care, the Treatment Nurse was asked, Where do you chart wound measurements? The Treatment Nurse stated, On the weekly/monthly wound log and I copy them and give them to the DON (Director of Nursing). The Treatment Nurse was asked, Are they in the chart (clinical record) or with the TAR? The Treatment Nurse stated, No, I don't know what the DON does with them. The measurement were as follows: Coccyx /Stage IV: 4.5 centimeter (cm) by (x) 3.7 cm x 3.5 cm Right Buttock Stage I: 2.2 (not open) Left Buttock Stage II: 1 cm x 1 cm Left upper thigh/ posterior lower buttock Stage II: 1 cm x 2.6 cm Right upper/inner posterior buttock Stage II: 1.2 cm x .2 cm n. On 3/8/16 at 4:05 p.m., the Director of Nursing (DON) was asked, I've looked at the TARs and in the resident's chart - where are the weekly wound measurements kept? The DON stated, I have a copy in my office. Aren't they in the chart? This surveyor requested wound measurements for this resident and all case mix residents. o. The Weekly/Monthly Wound Log dated 3/8/16 documented, .Wound Type: (Pressure) . Location: Coccyx . Stage IV . Size: 4.5 x 3.7 x 3.5 (centimeter) . Wound Type: (Pressure) . Location: (Left) butt cheek . Stage II . Size: 1.0 x 1.0 (no depth measured or estimated per documentation) . Wound Type: (Pressure) . Location: (Left) upper thigh . Stage II . Size: 1.0 x 2.6 (no depth measured or estimated per documentation) . Wound Type: (Pressure) . Location: (right) upper thigh . Stage II . Size: 1.2 x 1.2 (no depth measured or estimated per documentation) . p. On 3/10/16 at 11:00 a.m., the Treatment Nurse was asked, Were any measurements done on 2/19/16 on return to the facility? The Treatment Nurse stated, No. The Treatment Nurse was asked, Any measurements done from 2/19/16 until 3/2/16? The Treatment Nurse stated, No. The Treatment Nurse was asked, Any change in treatment, since the coccyx wound is not improving? The Treatment Nurse stated, No, I hate to change it. q. On 3/10/16 at 2:15 p.m., Registered Nurse (RN) #1 was asked, Do you do treatments on weekends? RN #1 stated, Yes. RN #1 was asked, Did you do (Resident #5's) treatment to his coccyx this past weekend, 3/5/16 and 3/6/16? RN #1 stated, No, and I'll tell you why I didn't. Feces gets under the dressing and you have to change it. I didn't want to put a dressing on it and it just get dirty and the dressing hold it in. I told the CNAs (Certified Nursing Assistants) to let me know if he went for 2 hours without a BM (bowel movement) so I could put a dressing on. The aides told me after every bowel movement, and I cleaned it, but I didn't put a dressing on. r. On 3/10/16 at 2:40 p.m., the DON and ADON were asked to review the wound measurements. The DON and ADON were asked, Were the pressure ulcer wounds measured weekly for 2/19/16 through 3/2/16? The DON stated No. The DON and ADON were asked, Have you asked (RN #1) if he did the weekend treatments on 3/5/16 and 3/6/16? The ADON stated, I did, and he said, 'I signed out every treatment I did'. The DON and ADON were asked, Should a nurse be leaving the resident's coccyx wound uncovered, with his Stage IV pressure ulcer and chronic diarrhea? The DON and ADON stated, No. 3. Resident #3 had a [DIAGNOSES REDACTED]. was 2/16/16. a. The Admission/Re-admission Skin Audit dated 2/16/16 and signed by the Treatment Nurse documented, .3 Stage II pressure ulcers (drawn on the anatomical diagram on the form, with 1 to the left buttock and 2 to the right buttock) . Notes: . 1 Stage II on (left) butt cheek, 1 Stage II and smaller Stage II on (right) butt cheek . There was no measurements were documented on the audit form. b. A physician order dated 2/16/16 documented, Cleanse .wounds to right butt cheek with (wound cleanser). Pat dry. Apply Duoderm every 3 days and as needed. Cleanse . wound to left butt cheek with (wound cleanser). Pat dry. Apply Duoderm every 3 days and as needed. c. A physician order dated 2/18/16 documented, Soft cushion to wheelchair for protection (every shift). d. The Weekly/Monthly Wound Log dated 2/19/16 documented, .Wound Type: (Pressure) . Location: (Right) butt cheek . Stage II . Size: 1.0 x (by) 2.5 . Location: (Left) butt cheek . Stage II . Size: 2.6 x 1.0 . No depth was documented. e. The Plan of Care dated as reviewed on 3/1/16 documented, Pressure Ulcer. Problem Date: 3/1/16. Resident has pressure ulcer(s). Location: Right buttocks Stage II, Left buttocks Stage II .Approaches: . Monitor effectiveness of/response to treatment(s) . Provide pressure relieving or reduction device . Chair cushion . f. The Closet Care Plan, with no date, documented, .Skin: .Monitor skin during bath and ADL (activities of Daily Living) care. Pressure relief cushion in wheelchair . Currently has wound located: coccyx . g. The March 2016 TAR documented, Cleanse . wound to left butt cheek with (wound cleanser). Apply Duoderm every 3 days and as needed. As of 3/6/16 at 2:35 p.m., the TAR documented this treatment was done on 3/1/16 only. Cleanse . wound to right butt cheek with (wound cleanser). Apply Duoderm every 3 days and as needed. As of 3/6/16 at 2:35 p.m., the TAR documented this treatment was done on 3/1/16 only. h. The Weekly/Monthly Wound Log dated 3/6/16 documented, .Wound Type: (Pressure) . Location: (Right) butt cheek . Stage II . Size: 1.0 x (by) 1.6 . Location: (Left) butt cheek . Stage II . Size: 2.2 x 1.0 . No depth was documented. i. On 3/8/16 at 11:50 a.m., Certified Nurse Assistant #1 and 2 provided incontinent care and catheter care to the resident. There was one Duoderm dressing present on the resident's left buttock and no dressing in place to the right buttock. The dressing on the left buttock was not dated and there was an open wound with no dressing on the right lower buttock area. On 3/9/16 at 9:15 a.m., the treatment Nurse was asked if the CNA informed him the dressing was off yesterday and stated, No. j. On 3/8/16 at 1:22 p.m., CNAs #1 and 2 transferred the resident from a wheelchair into bed. The wheelchair seat had a white pillow case covering an object in the seat of the wheelchair. CNA # 2 was asked, What's inside the pillow case in the wheelchair seat? CNA #2 pulled back the pillow case. A blue bed/head pillow was inside the pillow case. There was no pressure relieving device in the seat of the wheelchair. k. On 3/9/16 at 8:50 a.m., the Director of Nursing (DON) provided a copy of the March 2016 TARs. The TARs documented: Cleanse . wound to left butt cheek with (wound cleanser). Apply Duoderm every 3 days and as needed. This treatment, which as of 3/6/16 at 2:35 p.m. had documented nurses' initials only on 3/1/16, now documented additional initials on 3/4/16 and 3/7/16. Cleanse . wound to right butt cheek with (wound cleanser). Apply Duoderm every 3 days and as needed. This treatment, which as of 3/6/16 at 2:35 p.m. had documented nurses' initials only on 3/1/16, now documented additional initials on 3/4/16 and 3/7/16. l. On 3/9/16 at 9:15 a.m., the Treatment Nurse provided wound care. The Treatment Nurse set up wound care supplies, placing one 4 by 4 into a med cup and sprayed the 4 by 4 with wound cleanser. The Treatment Nurse entered the resident's room with wound care supplies on a clean field and the set up was placed on the over bed table. The resident was in bed. The resident's wheelchair was in the room and the Treatment Nurse was asked to look at the seat of the resident's wheelchair, which only had a pressure pad alarm strip in the seat. The Treatment Nurse was asked, Does (Resident #3's) chair have a pressure relieving device? The Treatment Nurse stated, No, and she's supposed to. The Treatment Nurse turned the resident to the left side. There was no dressing on the open wound on the lower right buttock. The Treatment Nurse removed the Duoderm from the left buttock. There was no open wound present. The Treatment Nurse cleaned the open wound on the right lower buttock with multiple wipes across the wound, using the same area of the 4 by 4. m. On 3/9/16 at 1:30 p.m., the Treatment Nurse was asked, Did (Resident #3) have a pressure relieving device in her wheelchair? The Treatment Nurse stated She did have on Monday (3/7/16); it was black, and I don't know what happened to it. The Treatment Nurse was asked Did you do any measurements between 2/16/16 and 3/6/16? The Treatment Nurse stated, No, I didn't. n. On 3/10/16 at 2:40 p.m., the DON and ADON were asked, Is a bed/head pillow a pressure relieving device? The DON and ADON stated, No. The DON and ADON were asked to review the Admission/Readmission Skin Audit dated 2/16/16, then were asked, How many pressure ulcers are documented? The DON stated, Stage II times 3 on the buttocks. The DON was asked, Were any of them measured on re-admit? The DON stated, No. The DON and ADON were asked, Have measurements been done weekly? The DON stated, No. 4. Resident #2 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 3/2/16 documented the resident scored 14 (13 - 15 indicates cognitively intact) on the BIMS, required supervision for bed mobility, was at risk of developing pressure ulcers, and had one unstageable deep tissue injury that was present at admission. a. The Admission/Re-admission Skin Audit form dated 2/24/16 documented, .0.2 x (by) 0.2 (centimeter) unstageable . This was handwritten next to a circled area on the lateral aspect of the resident's left heel on the anatomical diagram on the form. As of 3/9/16 at 12:10 p.m., there were no further wound measurements documented in the Nurses Notes. b. A physician order dated 2/24/16 documented, Cleanse wound on (left) great toe and on side of left of heel on (left) foot (with) wound cleanser, apply [MEDICATION NAME], cover (with) gauze and wrap (with) Kerlix (every day) and (as needed). c. The March 2016 TAR documented, Cleanse . Wounds on left great toe and wound on side of left heel with (wound cleanser. Apply [MEDICATION NAME] and cover with gauze wrap with kerlix every day and as needed. A handwritten entry following this order documented, QOD (every other day) and prn (as needed). The TAR documented nurses' initials to indicate this treatment was done on 3/1/16 and 3/6/16 only. d. The Care Area Assessment (CAA) dated 3/2/16 documented, .Pressure Ulcers. Triggered: Yes. Date: 3/3/16. Location of Information: Wound Nurse Report, Nursing Skin Assessment. Resident has pressure area to left heel . Will continue to plan of care . e. The Resident Plan of Care dated as reviewed on 3/8/16 documented, Risk for Pressure (Ulcers). Problem Date: 3/2/16. Resident is at risk for developing a pressure ulcer . Approaches: Complete Weekly Skin Assessment . The Plan of Care did not address the presence of, and care required for, any existing pressure ulcers. f. On 3/8/16 at 8:35 a.m., the Treatment Nurse gathered and set up wound care supplies from the treatment cart to provide wound care for the resident. The Treatment Nurse removed an opened, undated package of [MEDICATION NAME] from the treatment cart and placed it on the overbed table used to establish a clean field. The Treatment Nurse placed a bottle of plain packing strips on the clean field. The Treatment Nurse was asked, What's in the bottle? The Treatment Nurse stated Xeroform, then read the label on the bottle at the surveyor's request. The Treatment Nurse stated, Plain packing strips. After setting up the clean field with the supplies, the Treatment Nurse entered the room wearing a gown and gloves and asked the resident to remove his shirt. The Treatment Nurse removed a dressing dated 3/6/16 from the left scapula and pulled the packing from the wound. After changing gloves, the Treatment Nurse cleaned the wound using a 4 by 4 wet with wound cleanser and wiping back and forth across the wound bed three times. The Treatment Nurse cleaned a pair of scissors using an alcohol pad, then used the scissors to cut a strip of [MEDICATION NAME] from the opened and previously cut [MEDICATION NAME] pad. The Treatment Nurse used the wooden end of Q-tip to pack the strip of [MEDICATION NAME] into the wound. After cleaning the scissors with another alcohol pad, the Treatment Nurse cut a piece of plain packing strip from the bottle and placed it on top of the [MEDICATION NAME], then covered the wound with a bordered dressing. The Treatment Nurse washed his hands and put on clean gloves. Using a 4 by 4 wet with wound cleanser to clean the index and ring finger knuckles on the resident's left hand, the Treatment Nurse patted both wounds multiple times and moved back and forth from one knuckle to the other using the same area of the 4 by 4 for both knuckles. The Treatment Nurse then used his scissors to cut a strip of [MEDICATION NAME], then covered the wounds with a bordered dressing. After washing his hands and putting on new gloves, the Treatment Nurse removed a dressing dated 3/6/16 from the resident's left shin, then without changing gloves, cleansed the wound using a 4 by 4 wet with wound cleanser, dried the shin with a dry 4 by 4, cut a strip of [MEDICATION NAME], placed it on the wound bed and covered the wound with a bordered foam dressing. The Treatment Nurse continued wearing the same gloves and used his scissors to cut the dressing from the resident's left foot. The Treatment Nurse placed the scissors on the over bed table and not on the clean field. The Treatment Nurse removed the dressing from the resident's left foot which included a [MEDICATION NAME] pad from the left great toe area that was not ordered by the physician. The Treatment Nurse washed his hands and changed his gloves. The Treatment Nurse picked up the scissors from the over bed table and started cleaning the scissors and then dropped them on the floor. The Treatment Nurse picked the scissors up from the floor and cleaned them off using an alcohol pad. The Treatment Nurse washed his hands and changed gloves. The Treatment Nurse used a 4 by 4 wet with wound cleanser to clean the left great toe, dried the wound, and used the scissors he had cleaned with alcohol after dropping them on the floor of the isolation room to cut a strip of [MEDICATION NAME] from the [MEDICATION NAME] pad. The Treatment Nurse then placed the strip of [MEDICATION NAME] into the wound bed of the left great toe, covered the wound with a folded 4 by 4 and applied a bordered dressing. After exiting the room the Treatment Nurse was asked Did I see you remove a [MEDICATION NAME] pad from the left great toe? The Treatment Nurse stated, Yes. The Treatment Nurse was asked, Is there an order for [REDACTED]. g. On 3/9/16 at 1:30 p.m., the Treatment Nurse was asked, Did the resident have a pressure ulcer? The Treatment Nurse stated, Not from what he told me on his toe. (Resident # 2) said it started off as a pimple and it turned black. He didn't say much about the heel. It was a small black area, and I assumed it was pressure. The Treatment Nurse was asked, He came in on 2/24/16? The Treatment Nurse stated, Yes. The Treatment Nurse was asked, How often do you measure pressure ulcers? The Treatment Nurse stated, Every week. The Treatment Nurse was asked, Do you have any measurements since 2/24/16? The Treatment Nurse stated, No. The Treatment Nurse was asked, What does the order for the heel and great toe say as far as frequency? The Treatment Nurse stated, Every day. I thought I changed the order to every other day. The Treatment Nurse was asked for a copy of a physician order to change the treatment to every other day. (As of exit on 3/10/16, the requested information had not been provided). The Treatment Nurse was asked, On 3/6/16, I copied the March TAR. Did you do the resident's treatments on 3/3/16 and 3/4/16? The Treatment Nurse stated, I figured you had already copied these. Yes, I did, but I forgot to initial it, so I went back yesterday and did it. On 3/9/16 at 1:30 p.m., the Treatment Nurse was asked, Do alcohol pads kill germs and bacteria? The Treatment Nurse stated, Some, but not all. The Treatment Nurse was asked, What is (Resident #2) in isolation for? The Treatment Nurse stated, MRSA in wounds. The Treatment Nurse was asked, Are alcohol pads effective [MEDICAL CONDITION]? The Treatment Nurse stated, No. The Treatment Nurse was asked, Was the [MEDICATION NAME] that was used for wound care in an unopened packet on 3/8/16? The Treatment Nurse stated, No, and I thought about it last night. I should not have used it. I should have got a new packet. The Treatment Nurse was asked, Should you have changed gloves between the dressing on his shin and his foot? The Treatment Nurse stated, Yes. The Treatment Nurse was asked, What did you use to clean the scissors with after they were on the floor? The Treatment Nurse stated, Alcohol pad and you're going to tell me I needed to clean them with something other than alcohol. The Treatment Nurse was asked, Did you clean the resident's scapula and do a treatment every other day? The Treatment Nurse stated, Yes, the scapula and left great toe, and left heel every other day. The Treatment Nurse was asked, What does the order for the heel and great toe say as far as frequency? The Treatment Nurse stated Every day. I thought I changed the order to every other day. The Treatment Nurse was asked to bring the order for every other day treatment to this surveyor. The Treatment Nurse was asked On 3/6/16, I copied the March (2016) TAR. Did you do the resident's treatments on 3/3/16 and 3/4/16? The Treatment Nurse stated I figured you had already copied these. Yes, I did, but I forgot to initial it, so I went back yesterday and did it. h. On 3/10/16 at 2:15 p.m., Registered Nurse (RN) #1 was asked, Do you do treatments on weekends? RN #1 stated, Yes. RN # 1 was asked, Did you do (Resident #2's) treatments this past weekend? RN # 1 reviewed the March 2016 TAR then stated, Yes, to his foot and toes on Sunday 3/6/16. He asked me not to do his treatments on Saturday, and his bandages were intact and not draining. i. On 3/10/16 at 2:40 p.m., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were asked to review the March 2016 TARs copied by this surveyor on 3/6/16 and the one presented by the DON on 3/9/16. The DON and ADON were asked, Who's monitoring TARs to ensure treatments are done? The DON stated, It wasn't being done. I've not been looking at them. We did an audit on Monday (3/7/16), and I saw omissions on 3/5/16 and 3/6/16 on the weekend. The DON and ADON were asked, Who was supposed to do treatments on the weekend? The DON and ADON stated, (RN # 1). The DON and ADON were asked to review the physician orders versus the TAR. The DON and ADON were asked, What was the frequency to change the dressing on the left great toe and heel per the doctor's order? The DON and ADON stated, Every day. The DON and ADON were asked, What's the frequency on the March TAR? The DON and ADON stated Every other day. The DON and ADON were asked, When was it done? The DON and ADON stated, 3/1/16 and 3/6/16. The DON and ADON were asked, Was it done daily as per the doctor's orders? The DON and ADON stated, No. The DON and ADON were asked, Did you talk to the nurse who was supposed to do the treatments on the weekends? The DON stated, (ADON) did on Monday (3/7/16). The ADON was asked, What did he say about the treatments? The ADON stated, He said he initialed every one he did and did not have time for the others. The DON and ADON were asked to review the wound measurements presented for Resident # 2. The DON and ADON were asked, Were the weekly measurements of the pressure ulcer of the left heel done for (Resident # 2)? The DON stated, No. The DON was asked, What is your process to ensure weekly wound measurements are done? The DON stated, We do a weekly skin meeting. The DON was asked, What do you look at? The DON stated, His (Treatment Nurse) weekly reports. The DON was asked, Did you identify that the pressure ulcer measurements were not done? The DON stated, No. The DON was asked, So what reports are you reviewing weekly? The DON stated, I must have missed one. 5. Resident #1 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 1/15/16 documented the resident scored 15 (13 - 15 indicates cognitively intact) on a BIMS, , was at risk of developing pressure ulcers, had one Stage 2 pressure ulcer that was present on admission, required extensive assistance for bed mobility, limited assistance for transfer and toilet use, was incontinent of bowel and bladder. a. A physician order dated 1/8/16 documented, Cleanse wound to (left) heel (with) wound cleanser apply dermagram and cover (with) dressing every other day and (as needed). b. The Admission/Re-admission Skin Audit dated 1/8/16 at 2:10 p.m. documented, . Stage II pressure ulcer (left) heel 3.0 x (by) 2.6 x 0.1 (centimeters). c. The Weekly/Monthly Wound Log dated 1/22/16 documented, .Wound type: (Pressure) . Location: (Left) heel. Stage II . Size: 2.7 x 2.6 x 0.1 . Slow progress at this time. Small amount of drainage . d. A physician order dated 1/27/16 documented, .(discontinue) (treatment) to (left) heel. e. On 3/9/16 at 1:30 p.m., the Treatment Nurse was asked, Does (Resident # 1) have a pressure ulcer? The Treatment Nurse stated, He had one that was open when he came in and now it's calloused over and closed. The Treatment Nurse was asked, Any measurements other than 1/8/16 and 1/22/16? The Treatment Nurse stated, No, when I'm a floor nurse I don't get them measured, but I'm also bad about not asking someone else to measure for me. f. On 3/10/16 at 2:40 p.m., the DON and ADON were asked to review the pressure ulcer wound measurements for the resident. The DON and ADON were asked, Was his (Resident #1) pressure ulcer wound measured weekly? The DON stated, No. 6. On 3/9/16 at 1:30 p.m., the Treatment Nurse was asked, How long have you worked as the Treatment Nurse? The Treatment Nurse stated, 6 months. The Treatment Nurse was asked, Did you get any training? The Treatment Nurse stated, 2 days from the previous Treatment Nurse. The Treatment Nurse was asked, If you see treatments that are not initialed as done on the TARs on weekends or other shifts what have you done? The Treatment Nurse stated, I've told (DON) and (Assistant Director of Nursing (ADON)). 7. On 3/10/16 at 11:37 a.m., the Treatment Nurse was as

Complaint # , (AR 022), was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility's Nursing Administration failed to ensure quality deficiencies with regard to the facility's pressure ulcer treatment protocols were promptly identified and addressed, to ensure necessary treatment and services were provided to promote healing and prevent potential infection of existing pressure ulcers and to prevent the development of new pressure ulcers, as evidenced by: Failure to ensure licensed nursing staff followed clean technique and nursing standards of practice during the provision of pressure ulcer treatments to promote healing and prevent potential infection for 1 (Resident # 3) of 4 (Residents #1, #2, #3 and #5) case mix residents who had pressure ulcers; Failure to ensure loose or missing wound dressings were replaced immediately to prevent potential infection for 1 (Resident #3) of 4 (Residents #1, #2 #3 and #5) case mix residents who had pressure ulcers; Failure to ensure pressure ulcer wound care was provided at the frequency ordered by the physician and that the physician was promptly notified of the need for any changes in the treatment regimen to promote healing of pressure ulcers for 3 (Residents #2, #3 and #5) of 4 (Residents #1, #2, #3 and #5) case mix residents with pressure ulcers; Failure to ensure a pressure relieving device was present in a resident's wheelchair as per the plan of care to prevent further skin breakdown for 1 (Resident #3) of 4 (Residents #1, #2, #3 and #5) case mix residents who were care planned for pressure relieving devices in wheelchairs; and, Failure to ensure wounds were assessed and measured weekly with the results documented, to include the type / stage of the wound, measurements, condition of the surrounding tissue and the presence or absence of drainage / odor to enable accurate tracking of healing progress or prompt identification of deterioration for 4 (Residents #1, #2, #3 and #5) of 4 case mix residents who had pressure ulcers. The failed practices resulted in a pattern of actual harm to Resident #5, who experienced deterioration and / or delayed healing of existing pressure ulcers, and had the potential to affect 4 residents in the facility who had pressure ulcers and 35 residents who were care planned for pressure relieving devices in wheelchairs, according to lists received from the Administrator on 3/10/16. The findings are: 1. 1. The Director of Nursing Job Description documented, .Responsibilities: Plan, organize and direct the administration of all nursing units and patient care given bases on established goals and objectives, standards, policies and procedures . Regularly inspect the facility, nursing practices and documentation for compliance with federal, state and any local standards and regulations . 2. The facility's policy titled, Dressings, Dry/Clean, provided by Administrator on 3/10/16, documented .Preparation: 1. Verify that there is a physician's order for this procedure . 3. Check the treatment record . Steps in the procedure: 1. Clean bed side stand. Establish a clean field. 2. Place the clean equipment on the clean field . 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressing(s) . 11. Used clean technique, open other products . 12. Wash and dry your hands thoroughly. 13. Put on clean gloves . 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area, (usually from the center outward). 16. Use dry gauze to pat the wound dry. 17. Apply the ordered dressing and secure . 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/23/16 documented the resident scored 1 (0 - 7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), required extensive assistance with bed mobility, was totally dependent for toilet use, had an indwelling catheter, was always incontinent of bowel, was at risk of developing pressure ulcers and had one Stage 4 pressure ulcer that was present on admit/reentry. a. The Resident Plan of Care dated 10/23/14 and reviewed /revised 3/8/16 documented, .Pressure Ulcers. Problem Date: 10/23/14. Resident has pressure ulcer Stage IV to coccyx upon admission to facility . Approaches: . Monitor effectiveness of/response to treatment . Risk for Pressure Ulcers. Problem Date: 10/23/14. Resident is at risk for developing a pressure ulcer related to immobility . b. The Weekly/Monthly Wound Log dated 10/23/14 documented, .Wound Type: (Pressure) . Location: Center buttocks . Stage IV . Size: 4.0 x (by) 1.5 cm (centimeter), 1.2 depth . c. The Weekly/Monthly Wound Logs documented: .12/4/15 . Location: Coccyx . Stage IV . Size: 1.7 x 1.8 x 2.6 (centimeter) . (Continues) wound clinic 2 (times) weekly. Dr. (Doctor) at wound clinic talking with wife about getting [MEDICAL CONDITION]. . 12/11/15 . Location: Coccyx . Stage IV . Size: 1.8 x 2.0 x 2.4 (centimeter) . He is going to wound clinic only one a week now. .12/16/15 . Location: Coccyx . Stage IV . Size: 2.0 x 2.0 x 2.4 (centimeter) . .12/28/15 . Location: Coccyx . Stage IV . Size: 1.8 x 1.9 x 2.0 (centimeter) . .1/8/16 . Location: Coccyx . Stage IV . Size: 2.4 x 2.6 x 2.8 (centimeter). Wound has regressed some . Moderate amount of drainage . .1/13/16 . Location: Coccyx . Stage IV . Size: 2.4 x 2.8 x 2.6 (centimeter) . Moderate amount of drainage . .1/22/16 . Location: Coccyx . Stage IV . Size: 2.8 x 2.8 x 3.5 (centimeter) . (Continues) wound clinic . No progress at this time. .2/3/16 . Location: Coccyx . Stage IV . Size: 3.0 x 3.0 x 4.5 (centimeter). Wound has gotten worse. (Treatment) changed . visits to wound clinic (discontinued). Moderate amount of drainage. Skin around wound starting to get some breakdown . .2/9/16 . Location: Coccyx . Stage IV . Size: 3.1 x 3.0 x 4.1 (centimeter). Wound to coccyx showing some progress . Butt cheeks have some redness, was open but closed at this time. Duoderm applied prior to dressing for protection. The next documented weekly measurements found in the clinical record were dated 3/2/16. (See below) d. The facility's laboratory report with a collection date of 2/12/16 documented . Reported 2/16/16 . Culture, Wound . Moderate growth: Proteus Mirabilis . Moderate growth: ESBL (Extended Spectrum Beta-Lactamases) producing Escherichia coli . e. The Nurse's Notes dated 2/12/16 at 1:00 p.m. documented, Resident has declined mentally and (new order) for wound culture to coccyx wound . f. The Nurse's Notes dated 2/14/16 at 8:15 a.m. documented, Resident (at) dining room, noted eating paper napkin . (oxygen saturation) was 86% with oxygen (at) 3 (liters) via (nasal cannula) . received order to transfer to ER (emergency room ) . g. The hospital record documented wound measurements dated 2/15/16 at 6:01 p.m. as, .Location: Sacral . 4.7 x 3.0 x 3.8 (centimeters). h. A hospital laboratory report dated 2/19/16 documented, .Specimen source: Coccyx . Results: Heavy growth of Escherichia coli (ESBL), Light growth of Staphylococcus (staph) aureus . i. The Admission/Re-admission Skin Audit dated 2/19/16 documented, .Stage IV on coccyx, has staph infection . There was no documentation of measurements of the coccyx wound upon readmission to the facility. j. Physician's orders dated 2/19/16 documented, Cleanse . wound to coccyx with (wound cleanser). Pack wound with [MEDICATION NAME] AG (silver). Cover with foam dressing every day and as needed. Cleanse . wounds to right butt cheek and lower left buttock with (wound cleanser). Pat dry. Apply Duoderm every 3 days prior to dressing change and as needed. k. The Weekly/Monthly Wound Log dated 3/2/16 documented, .Wound Type: (Pressure) . Location: Coccyx . Stage IV . Size: 4.0 x 3.8 x 3.6 (centimeter) . Wound Type: (Pressure) . Location: (Left) butt cheek . Stage II . Size: 1.3 x 1.2 (no depth measured or estimated per documentation) . Wound Type: (Pressure) . Location: (Right) upper thigh . Stage II . Size: 1.5 x 1.2 (no depth measured or estimated per documentation) . Wound Type: (Pressure) . Location: (Left) upper thigh . Stage II . Size: 1.2 x 2.5 (no depth measured or estimated per documentation) . l. On 3/6/16 at 2:45 p.m., the March 2016 TAR documented, Cleanse . wound to coccyx with (wound cleanser). Pack with [MEDICATION NAME] AG. Cover with foam dressing every day and as needed. The TAR documented this treatment was done on 3/1/16, 3/2/16, 3/3/16, and 3/4/16. The treatments due on 3/5/16 and 3/6/16 were not initialed as completed. Cleanse . wound to right butt cheek and lower left buttock with (wound cleanser). Pat dry. Apply Duoderm every 3 days prior to dressing change and as needed. The TAR documented this treatment was done on 3/1/16, 3/2/16, 3/3/16, and 3/4/16. m. On 3/8/16 at 10:10 a.m., the Treatment Nurse provided wound care and measured the wounds at this surveyor's request. On completion of the wound care, the Treatment Nurse was asked, Where do you chart wound measurements? The Treatment Nurse stated, On the weekly/monthly wound log and I copy them and give them to the DON (Director of Nursing). The Treatment Nurse was asked, Are they in the chart (clinical record) or with the TAR? The Treatment Nurse stated, No, I don't know what the DON does with them. The measurement were as follows: Coccyx /Stage IV: 4.5 centimeter (cm) by (x) 3.7 cm x 3.5 cm Right Buttock Stage I: 2.2 (not open) Left Buttock Stage II: 1 cm x 1 cm Left upper thigh/ posterior lower buttock Stage II: 1 cm x 2.6 cm Right upper/inner posterior buttock Stage II: 1.2 cm x .2 cm n. On 3/8/16 at 4:05 p.m., the Director of Nursing (DON) was asked, I've looked at the TARs and in the resident's chart - where are the weekly wound measurements kept? The DON stated, I have a copy in my office. Aren't they in the chart? This surveyor requested wound measurements for this resident and all case mix residents. o. The Weekly/Monthly Wound Log dated 3/8/16 documented, .Wound Type: (Pressure) . Location: Coccyx . Stage IV . Size: 4.5 x 3.7 x 3.5 (centimeter) . Wound Type: (Pressure) . Location: (Left) butt cheek . Stage II . Size: 1.0 x 1.0 (no depth measured or estimated per documentation) . Wound Type: (Pressure) . Location: (Left) upper thigh . Stage II . Size: 1.0 x 2.6 (no depth measured or estimated per documentation) . Wound Type: (Pressure) . Location: (right) upper thigh . Stage II . Size: 1.2 x 1.2 (no depth measured or estimated per documentation) . p. On 3/10/16 at 11:00 a.m., the Treatment Nurse was asked, Were any measurements done on 2/19/16 on return to the facility? The Treatment Nurse stated, No. The Treatment Nurse was asked, Any measurements done from 2/19/16 until 3/2/16? The Treatment Nurse stated, No. The Treatment Nurse was asked, Any change in treatment, since the coccyx wound is not improving? The Treatment Nurse stated, No, I hate to change it. q. On 3/10/16 at 2:15 p.m., Registered Nurse (RN) #1 was asked, Do you do treatments on weekends? RN #1 stated, Yes. RN #1 was asked, Did you do (Resident #5's) treatment to his coccyx this past weekend, 3/5/16 and 3/6/16? RN #1 stated, No, and I'll tell you why I didn't. Feces gets under the dressing and you have to change it. I didn't want to put a dressing on it and it just get dirty and the dressing hold it in. I told the CNAs (Certified Nursing Assistants) to let me know if he went for 2 hours without a BM (bowel movement) so I could put a dressing on. The aides told me after every bowel movement, and I cleaned it, but I didn't put a dressing on. r. On 3/10/16 at 2:40 p.m., the DON and ADON were asked to review the wound measurements. The DON and ADON were asked, Were the pressure ulcer wounds measured weekly for 2/19/16 through 3/2/16? The DON stated No. The DON and ADON were asked, Have you asked (RN #1) if he did the weekend treatments on 3/5/16 and 3/6/16? The ADON stated, I did, and he said, 'I signed out every treatment I did'. The DON and ADON were asked, Should a nurse be leaving the resident's coccyx wound uncovered, with his Stage IV pressure ulcer and chronic diarrhea? The DON and ADON stated, No. 4. Resident #3 had a [DIAGNOSES REDACTED]. was 2/16/16. a. The Admission/Re-admission Skin Audit dated 2/16/16 and signed by the Treatment Nurse documented, .3 Stage II pressure ulcers (drawn on the anatomical diagram on the form, with 1 to the left buttock and 2 to the right buttock) . Notes: . 1 Stage II on (left) butt cheek, 1 Stage II and smaller Stage II on (right) butt cheek . There was no measurements were documented on the audit form. b. A physician order dated 2/16/16 documented, Cleanse .wounds to right butt cheek with (wound cleanser). Pat dry. Apply Duoderm every 3 days and as needed. Cleanse . wound to left butt cheek with (wound cleanser). Pat dry. Apply Duoderm every 3 days and as needed. c. A physician order dated 2/18/16 documented, Soft cushion to wheelchair for protection (every shift). d. The Weekly/Monthly Wound Log dated 2/19/16 documented, .Wound Type: (Pressure) . Location: (Right) butt cheek . Stage II . Size: 1.0 x (by) 2.5 . Location: (Left) butt cheek . Stage II . Size: 2.6 x 1.0 . No depth was documented. e. The Plan of Care dated as reviewed on 3/1/16 documented, Pressure Ulcer. Problem Date: 3/1/16. Resident has pressure ulcer(s). Location: Right buttocks Stage II, Left buttocks Stage II .Approaches: . Monitor effectiveness of/response to treatment(s) . Provide pressure relieving or reduction device . Chair cushion . f. The Closet Care Plan, with no date, documented, .Skin: .Monitor skin during bath and ADL (activities of Daily Living) care. Pressure relief cushion in wheelchair . Currently has wound located: coccyx . g. The March 2016 TAR documented, Cleanse . wound to left butt cheek with (wound cleanser). Apply Duoderm every 3 days and as needed. As of 3/6/16 at 2:35 p.m., the TAR documented this treatment was done on 3/1/16 only. Cleanse . wound to right butt cheek with (wound cleanser). Apply Duoderm every 3 days and as needed. As of 3/6/16 at 2:35 p.m., the TAR documented this treatment was done on 3/1/16 only. h. The Weekly/Monthly Wound Log dated 3/6/16 documented, .Wound Type: (Pressure) . Location: (Right) butt cheek . Stage II . Size: 1.0 x (by) 1.6 . Location: (Left) butt cheek . Stage II . Size: 2.2 x 1.0 . No depth was documented. i. On 3/8/16 at 11:50 a.m., Certified Nurse Assistant #1 and 2 provided incontinent care and catheter care to the resident. There was one Duoderm dressing present on the resident's left buttock and no dressing in place to the right buttock. The dressing on the left buttock was not dated and there was an open wound with no dressing on the right lower buttock area. On 3/9/16 at 9:15 a.m., the treatment Nurse was asked if the CNA informed him the dressing was off yesterday and stated, No. j. On 3/8/16 at 1:22 p.m., CNAs #1 and 2 transferred the resident from a wheelchair into bed. The wheelchair seat had a white pillow case covering an object in the seat of the wheelchair. CNA # 2 was asked, What's inside the pillow case in the wheelchair seat? CNA #2 pulled back the pillow case. A blue bed/head pillow was inside the pillow case. There was no pressure relieving device in the seat of the wheelchair. k. On 3/9/16 at 8:50 a.m., the Director of Nursing (DON) provided a copy of the March 2016 TARs. The TARs documented: Cleanse . wound to left butt cheek with (wound cleanser). Apply Duoderm every 3 days and as needed. This treatment, which as of 3/6/16 at 2:35 p.m. had documented nurses' initials only on 3/1/16, now documented additional initials on 3/4/16 and 3/7/16. Cleanse . wound to right butt cheek with (wound cleanser). Apply Duoderm every 3 days and as needed. This treatment, which as of 3/6/16 at 2:35 p.m. had documented nurses' initials only on 3/1/16, now documented additional initials on 3/4/16 and 3/7/16. l. On 3/9/16 at 9:15 a.m., the Treatment Nurse provided wound care. The Treatment Nurse set up wound care supplies, placing one 4 by 4 into a med cup and sprayed the 4 by 4 with wound cleanser. The Treatment Nurse was asked, Did the CNAs tell you (Resident # 3) had no dressing on her right buttock yesterday? The Treatment Nurse stated, No. The Treatment Nurse entered the resident's room with wound care supplies on a clean field and the set up was placed on the over bed table. The resident was in bed. The resident's wheelchair was in the room and the Treatment Nurse was asked to look at the seat of the resident's wheelchair, which only had a pressure pad alarm strip in the seat. The Treatment Nurse was asked, Does (Resident #3's) chair have a pressure relieving device? The Treatment Nurse stated, No, and she's supposed to. The Treatment Nurse turned the resident to the left side. There was no dressing on the open wound on the lower right buttock. The Treatment Nurse removed the Duoderm from the left buttock. There was no open wound present. The Treatment Nurse cleaned the open wound on the right lower buttock with multiple wipes across the wound, using the same area of the 4 by 4. m. On 3/9/16 at 1:30 p.m., the Treatment Nurse was asked, Did (Resident #3) have a pressure relieving device in her wheelchair? The Treatment Nurse stated She did have on Monday (3/7/16); it was black, and I don't know what happened to it. The Treatment Nurse was asked Did you do any measurements between 2/16/16 and 3/6/16? The Treatment Nurse stated, No, I didn't. n. On 3/10/16 at 2:40 p.m., the DON and ADON were asked, Is a bed/head pillow a pressure relieving device? The DON and ADON stated, No. The DON and ADON were asked to review the Admission/Readmission Skin Audit dated 2/16/16, then were asked, How many pressure ulcers are documented? The DON stated, Stage II times 3 on the buttocks. The DON was asked, Were any of them measured on re-admit? The DON stated, No. The DON and ADON were asked, Have measurements been done weekly? The DON stated, No. 5. Resident #2 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 3/2/16 documented the resident scored 14 (13 - 15 indicates cognitively intact) on the BIMS, required supervision for bed mobility, was at risk of developing pressure ulcers, and had one unstageable deep tissue injury that was present at admission. a. The Admission/Re-admission Skin Audit form dated 2/24/16 documented, .0.2 x (by) 0.2 (centimeter) unstageable . This was handwritten next to a circled area on the lateral aspect of the resident's left heel on the anatomical diagram on the form. As of 3/9/16 at 12:10 p.m., there were no further wound measurements documented in the Nurses Notes. b. A physician order dated 2/24/16 documented, Cleanse wound on (left) great toe and on side of left of heel on (left) foot (with) wound cleanser, apply [MEDICATION NAME], cover (with) gauze and wrap (with) Kerlix (every day) and (as needed). c. The March 2016 TAR documented, Cleanse . Wounds on left great toe and wound on side of left heel with (wound cleanser. Apply [MEDICATION NAME] and cover with gauze wrap with kerlix every day and as needed. A handwritten entry following this order documented, QOD (every other day) and prn (as needed). The TAR documented nurses' initials to indicate this treatment was done on 3/1/16 and 3/6/16 only. d. The Care Area Assessment (CAA) dated 3/2/16 documented, .Pressure Ulcers. Triggered: Yes. Date: 3/3/16. Location of Information: Wound Nurse Report, Nursing Skin Assessment. Resident has pressure area to left heel . Will continue to plan of care . e. The Resident Plan of Care dated as reviewed on 3/8/16 documented, Risk for Pressure (Ulcers). Problem Date: 3/2/16. Resident is at risk for developing a pressure ulcer . Approaches: Complete Weekly Skin Assessment . The Plan of Care did not address the presence of, and care required for, any existing pressure ulcers. f. On 3/8/16 at 8:35 a.m., the Treatment Nurse gathered and set up wound care supplies from the treatment cart to provide wound care for the resident. The Treatment Nurse removed an opened, undated package of [MEDICATION NAME] from the treatment cart and placed it on the overbed table used to establish a clean field. The Treatment Nurse placed a bottle of plain packing strips on the clean field. The Treatment Nurse was asked, What's in the bottle? The Treatment Nurse stated Xeroform, then read the label on the bottle at the surveyor's request. The Treatment Nurse stated, Plain packing strips. After setting up the clean field with the supplies, the Treatment Nurse entered the room wearing a gown and gloves and asked the resident to remove his shirt. The Treatment Nurse removed a dressing dated 3/6/16 from the left scapula and pulled the packing from the wound. After changing gloves, the Treatment Nurse cleaned the wound using a 4 by 4 wet with wound cleanser and wiping back and forth across the wound bed three times. The Treatment Nurse cleaned a pair of scissors using an alcohol pad, then used the scissors to cut a strip of [MEDICATION NAME] from the opened and previously cut [MEDICATION NAME] pad. The Treatment Nurse used the wooden end of Q-tip to pack the strip of [MEDICATION NAME] into the wound. After cleaning the scissors with another alcohol pad, the Treatment Nurse cut a piece of plain packing strip from the bottle and placed it on top of the [MEDICATION NAME], then covered the wound with a bordered dressing. The Treatment Nurse washed his hands and put on clean gloves. Using a 4 by 4 wet with wound cleanser to clean the index and ring finger knuckles on the resident's left hand, the Treatment Nurse patted both wounds multiple times and moved back and forth from one knuckle to the other using the same area of the 4 by 4 for both knuckles. The Treatment Nurse then used his scissors to cut a strip of [MEDICATION NAME], then covered the wounds with a bordered dressing. After washing his hands and putting on new gloves, the Treatment Nurse removed a dressing dated 3/6/16 from the resident's left shin, then without changing gloves, cleansed the wound using a 4 by 4 wet with wound cleanser, dried the shin with a dry 4 by 4, cut a strip of [MEDICATION NAME], placed it on the wound bed and covered the wound with a bordered foam dressing. The Treatment Nurse continued wearing the same gloves and used his scissors to cut the dressing from the resident's left foot. The Treatment Nurse placed the scissors on the over bed table and not on the clean field. The Treatment Nurse removed the dressing from the resident's left foot which included a [MEDICATION NAME] pad from the left great toe area that was not ordered by the physician. The Treatment Nurse washed his hands and changed his gloves. The Treatment Nurse picked up the scissors from the over bed table and started cleaning the scissors and then dropped them on the floor. The Treatment Nurse picked the scissors up from the floor and cleaned them off using an alcohol pad. The Treatment Nurse washed his hands and changed gloves. The Treatment Nurse used a 4 by 4 wet with wound cleanser to clean the left great toe, dried the wound, and used the scissors he had cleaned with alcohol after dropping them on the floor of the isolation room to cut a strip of [MEDICATION NAME] from the [MEDICATION NAME] pad. The Treatment Nurse then placed the strip of [MEDICATION NAME] into the wound bed of the left great toe, covered the wound with a folded 4 by 4 and applied a bordered dressing. After exiting the room the Treatment Nurse was asked Did I see you remove a [MEDICATION NAME] pad from the left great toe? The Treatment Nurse stated, Yes. The Treatment Nurse was asked, Is there an order for [REDACTED]. g. On 3/9/16 at 1:30 p.m., the Treatment Nurse was asked, Did the resident have a pressure ulcer? The Treatment Nurse stated, Not from what he told me on his toe. (Resident # 2) said it started off as a pimple and it turned black. He didn't say much about the heel. It was a small black area, and I assumed it was pressure. The Treatment Nurse was asked, He came in on 2/24/16? The Treatment Nurse stated, Yes. The Treatment Nurse was asked, How often do you measure pressure ulcers? The Treatment Nurse stated, Every week. The Treatment Nurse was asked, Do you have any measurements since 2/24/16? The Treatment Nurse stated, No. The Treatment Nurse was asked, What does the order for the heel and great toe say as far as frequency? The Treatment Nurse stated, Every day. I thought I changed the order to every other day. The Treatment Nurse was asked for a copy of a physician order to change the treatment to every other day. (As of exit on 3/10/16, the requested information had not been provided). The Treatment Nurse was asked, On 3/6/16, I copied the March TAR. Did you do the resident's treatments on 3/3/16 and 3/4/16? The Treatment Nurse stated, I figured you had already copied these. Yes, I did, but I forgot to initial it, so I went back yesterday and did it. On 3/9/16 at 1:30 p.m., the Treatment Nurse was asked, Do alcohol pads kill germs and bacteria? The Treatment Nurse stated, Some, but not all. The Treatment Nurse was asked, What is (Resident #2) in isolation for? The Treatment Nurse stated, MRSA in wounds. The Treatment Nurse was asked, Are alcohol pads effective [MEDICAL CONDITION]? The Treatment Nurse stated, No. The Treatment Nurse was asked, Was the [MEDICATION NAME] that was used for wound care in an unopened packet on 3/8/16? The Treatment Nurse stated, No, and I thought about it last night. I should not have used it. I should have got a new packet. The Treatment Nurse was asked, Should you have changed gloves between the dressing on his shin and his foot? The Treatment Nurse stated, Yes. The Treatment Nurse was asked, What did you use to clean the scissors with after they were on the floor? The Treatment Nurse stated, Alcohol pad and you're going to tell me I needed to clean them with something other than alcohol. The Treatment Nurse was asked, Did you clean the resident's scapula and do a treatment every other day? The Treatment Nurse stated, Yes, the scapula and left great toe, and left heel every other day. The Treatment Nurse was asked, What does the order for the heel and great toe say as far as frequency? The Treatment Nurse stated Every day. I thought I changed the order to every other day. The Treatment Nurse was asked to bring the order for every other day treatment to this surveyor. The Treatment Nurse was asked On 3/6/16, I copied the March (2016) TAR. Did you do the resident's treatments on 3/3/16 and 3/4/16? The Treatment Nurse stated I figured you had already copied these. Yes, I did, but I forgot to initial it, so I went back yesterday and did it. h. On 3/10/16 at 2:15 p.m., Registered Nurse (RN) #1 was asked, Do you do treatments on weekends? RN #1 stated, Yes. RN # 1 was asked, Did you do (Resident #2's) treatments this past weekend? RN # 1 reviewed the March 2016 TAR then stated, Yes, to his foot and toes on Sunday 3/6/16. He asked me not to do his treatments on Saturday, and his bandages were intact and not draining. i. On 3/10/16 at 2:40 p.m., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were asked to review the March 2016 TARs copied by this surveyor on 3/6/16 and the one presented by the DON on 3/9/16. The DON and ADON were asked, Who's monitoring TARs to ensure treatments are done? The DON stated, It wasn't being done. I've not been looking at them. We did an audit on Monday (3/7/16), and I saw omissions on 3/5/16 and 3/6/16 on the weekend. The DON and ADON were asked, Who was supposed to do treatments on the weekend? The DON and ADON stated, (RN # 1). The DON and ADON were asked to review the physician orders versus the TAR. The DON and ADON were asked, What was the frequency to change the dressing on the left great toe and heel per the doctor's order? The DON and ADON stated, Every day. The DON and ADON were asked, What's the frequency on the March TAR? The DON and ADON stated Every other day. The DON and ADON were asked, When was it done? The DON and ADON stated, 3/1/16 and 3/6/16. The DON and ADON were asked, Was it done daily as per the doctor's orders? The DON and ADON stated, No. The DON and ADON were asked, Did you talk to the nurse who was supposed to do the treatments on the weekends? The DON stated, (ADON) did on Monday (3/7/16). The ADON was asked, What did he say about the treatments? The ADON stated, He said he initialed every one he did and did not have time for the others. The DON and ADON were asked to review the wound measurements presented for Resident # 2. The DON and ADON were asked, Were the weekly measurements of the pressure ulcer of the left heel done for (Resident # 2)? The DON stated, No. The DON was asked, What is your process to ensure weekly wound measurements are done? The DON stated, We do a weekly skin meeting. The DON was asked, What do you look at? The DON stated, His (Treatment Nurse) weekly reports. The DON was asked, Did you identify that the pressure ulcer measurements were not done? The DON stated, No. The DON was asked, So what reports are you reviewing weekly? The DON stated, I must have missed one. 6. Resident #1 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 1/15/16 documented the resident scored 15 (13 - 15 indicates cognitively intact) on a BIMS, , was at risk of developing pressure ulcers, had one Stage 2 pressure ulcer that was present on admission, required extensive assistance for bed mobility, limited assistance for transfer and toilet use, was incontinent of bowel and bladder. a. A physician order dated 1/8/16 documented, Cleanse wound to (left) heel (with) wound cleanser apply dermagram and cover (with) dressing every other day and (as needed). b. The Admission/Re-admission Skin Audit dated 1/8/16 at 2:10 p.m. documented, . Stage II pressure ulcer (left) heel 3.0 x (by) 2.6 x 0.1 (centimeters). c. The Weekly/Monthly Wound Log dated 1/22/16 documented, .Wound type: (Pressure) . Location: (Left) heel. Stage II . Size: 2.7 x 2.6 x 0.1 . Slow progress at this time. Small amount of drainage . d. A physician order dated 1/27/16 documented, .(discontinue) (treatment) to (left) heel. e. On 3/9/16 at 1:30 p.m., the Treatment Nurse was asked, Does (Resident # 1) have a pressure ulcer? The Treatment Nurse stated, He had one that was open when he came in and now it's calloused over and closed. The Treatment Nurse was asked, Any measurements other than 1/8/16 and 1/22/16? The Treatment Nurse stated, No, when I'm a floor nurse I don't get them measured, but I'm also bad about not asking someone else to measure for me. f. On 3/10/16 at 2:40 p.m., the DON and ADON were asked to review the pressure ulcer

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 to prevent delays in treatment regarding a significant change in mental status and vital signs with decreased oral intake and refusal of medications and elevations in stat blood counts and blood chemistry for 1 (Resident #1) of 4 (Resident's #1, #2, #3 and #4) case mix residents who had a significant change in condition. This failed practice resulted in a pattern of actual harm for Resident #1 who was admitted to the hospital with [REDACTED]. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 3/4/13 documented the resident was severely impaired in cognitive skills for daily decision making per a staff assessment; had no physical verbal or other behaviors; was totally dependent for transfer with two person physical assist; was totally dependent on one person physical assist for locomotion on and off the unit; was totally dependent on one person physical assist for dressing, eating, bathing and personal hygiene; was impaired in range of motion of both lower extremities; was incontinent of bowel and bladder; had a swallowing disorder; and received antidepressants 7 days in the past 7 days. a. A physician progress notes [REDACTED].#1) has been complaining of some mouth pain. She does appear to have gingivitis with some swelling of the upper lip. It was a difficult evaluation as she did not open her mouth very far. She has not had any significant decline since stopping her [MEDICATION NAME] and [MEDICATION NAME]. We will go ahead and place her on some [MEDICATION NAME] 500 mg three times daily. Otherwise the rest of her medications are good as is." b. A Nurse's Note dated 4/16/13 for the 11:00 p.m. to 7:00 a.m. shift documented, "(Vital Signs) 97.3, 94, 20, 96% O2 (oxygen) sat (saturation) on rm (room) air. Gums still light red and still sore. Remains on [MEDICATION NAME] for Gingivitis. No swelling noted..." c. A Nurse's Note dated 4/18/13 at 2:00 a.m., documented, "Pt (patient) remains on [MEDICATION NAME] for Gingivitis. No n/v/d (nausea, vomiting, diarrhea) or rash noted. Gums not red but still sore when oral care done. Fluids taken fair with much enc (encouragement)." d. A Nurse's Notes dated 4/29/13 (no time noted) documented, " (T) (Temperature) 99.4, (P) (Pulse) 100, (R) (Respirations) 28, (BP) (Blood pressure) 162/98. R (resident) eating/drinking very little. Refused all po (oral) meds (medications) this shift. Did drink (more or less) 60 cc (cubic centimeter) water when offered 2 times." The April 2013 "CNA / RNA (Certified Nursing Assistant/Restorative Nursing Assistant) Flow Sheet" documented, " ...4/29/13 ... 15% of breakfast consumed, refusal of lunch and 25% of supper consumed ..." On 6/5/13 at 8:40 a.m., Registered Nurse (RN) #1 was asked to describe Resident #1's condition on 4/29/13. RN #1 stated, "She (Resident #1) had eaten very little on 4/29/13 on my shift and she had a low grade temperature. She refused all meds on my shift. Her pulse rate was elevated according to other documentation. It was not unusual for her to eat or drink little. I would think her low grade temperature was because she was eating and drinking little. When the temperature is 100 or greater then we would notify the physician. It was evident and apparent that because she was refusing to eat and drink she would be dehydrated. She was depressed. I did not call the physician or family." e. A Nurse's Notes dated 4/30/13 for the 7:00 a.m. to 3:00 p.m. shift were signed by LPN #1 and documented, "Have attempted to contact (R) (Resident) dtr (daughter)/POA (Power of Attorney) in regard to R decline. Msg (message) left times 3. R has not had meds times 2 days, very little during meals, very lethargic. MD (Medical Doctor) is aware and coming in to assess this p.m. VS (vital signs) (BP) 148/102, (T) 99.4, (P) 128, (R) 19, O2 (oxygen) sat (saturation) 90%. R appears to not be in any pain. Social services and son aware of not able to get a hold of dtr." On 6/4/13 at 2:35 p.m., Licensed Practical Nurse (LPN) #1 was asked to describe (Resident #1's) condition and what actions were taken on the resident's behalf on 4/30/13. LPN #1 stated, "The Physician and family were notified of her condition. I reported her condition to (LPN #2) and that (Physician) would be in on that day." On 6/4/13 at 2:55 p.m., LPN #2 was asked to describe the resident's condition on 4/30/13, the report (if any) she had been provided at the start of her shift and what she had documented (if anything) about the resident that day. LPN #2 stated, "I worked 3:00 p.m.-11:00 p.m. on 4/30/13. (Resident #1) refused all meds on 3-11 and refused supper. (LPN #1) probably gave me report. She normally gives a good report. (Physician) usually makes rounds on Tuesdays. I don't know why I did not document. I did document on the MAR indicated [REDACTED]." The April 2013 "CNA /RNA Flow Sheet" documented, " ...4/30/13 ...15% of breakfast consumed, refused lunch and supper ..." On 6/6/13 at 3:00 p.m., the Director of Nursing (DON) was asked if the resident's Physician had been to the facility and assessed her (Resident #1) on 4/30/13. The DON stated, "(Physician) did not come in on 4/30/13." f. The April 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] " ...4/29/13 (Resident) refused all meds..." " ...4/30/13 (Resident) refused all po meds ..." g. A physician's orders [REDACTED]." A Nurse's Note dated 5/1/13 at 9:30 a.m. and signed by LPN #5 documented, "Temp (temperature) 100.5. R (Resident) not responding to verbal or tactile stimuli. Admin (administered) APAP 325 mg suppository at 9:30 a.m. T.O. (telephone order) (Physician). Son notified." On 6/5/13 at 8:50 a.m., LPN #5 was asked if she had spoken to the resident's physician on 5/1/13. LPN #5 stated "On 5/1/13 I called the doctor because she had a temperature. I did not document whether or not it was effective. I only told the doctor that she had an elevated temp and she was not responding. He only ordered the suppository." h. A Physician order [REDACTED]. Please schedule blood work stat (immediately)." A Nurse's Notes dated 5/1/13 at 11 a.m. documented, "... Lab work was scheduled and drawn earlier today and lab results obtained and abnormal." As of 6/6/13 at 12:50 p.m., there were no Nurses' Notes available for review from 5/1/13 at 11:00 p.m. until 5/2/13 7:00 a.m.-3:00 p.m. according to the Director of Nursing. A Hematology Report dated 5/1/13 at 5:55 p.m. documented, "Routine Blood Counts: ... White Blood Count (WBC) 19.1 K/mcl (kilograms per microliter)-High (H) with a reference range of 4.8-10.8 K/mcl." A Chemistry Report dated 5/1/13 at 5:55 p.m. documented," Routine Chemistry: ...Sodium Level 146 mmol/L (millimole per liter) - H with a reference range of 135-145 mmol/L, BUN (Blood Urea Nitrogen) 52.0 mg/dl (milligram per deciliter) with a reference range of 8-20, BUN/Creat (Blood Urea Nitrogen/Creatnine) Ratio 37- H with a reference range of 7-32 ...." On 6/5/13 at 9:10 a.m., LPN #6 was asked to describe Resident #1's condition on 5/1/13. LPN #1 stated, "I worked 11:00 p.m. to 7:00 a.m. At 11:00 p.m. on 5/1/13 I knew her WBC was 19.1, Sodium 146, BUN 52 and BUN/Creatinine ration 37. I did not call the doctor. I took care of (Resident #1) the rest of the night. She did not drink very well." On 6/5/13 at 9:45 a.m., LPN #6 was asked to describe her interventions regarding the resident's condition on 5/2/13. LPN #6 stated, "I faxed the Routine Blood Count and the Routine Chemistry to (Physician) at his office between 4:00 a.m. and 6:00 a.m. I noticed the WBC was elevated and the BUN/Creat ratio. I faxed them to the doctor's office as I always do so he will have a hard copy. I would imagine I did not call the doctor."

Complaint # was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to provide necessary care and services to ensure that Resident #1 maintained the highest practicable physical well being. The facility failed to ensure that the resident was thoroughly assessed and monitored when a change in mental status and vital signs occurred along with the refusal of medications and oral intake; the facility failed to ensure elevations in stat blood counts and blood chemistry were identified and the physician immediately consulted; and failed to ensure that there were no delays in the initiation of antibiotic intravenous therapy and transporting to emergency room for 1 case mix resident (Resident #1) of 4 case mix residents (Resident's #1, #2, #3 and #4) with a change of condition. This failed practice resulted in a pattern of actual harm for Resident #1 who was admitted to the hospital with [REDACTED]. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 3/4/13 documented the resident was severely impaired in cognitive skills for daily decision making per a staff assessment,; had no physical verbal or other behaviors; was totally dependent for transfer with two person physical assist; was totally dependent on one person physical assist for locomotion on and off the unit; was totally dependent on one person physical assist for dressing, eating, bathing and personal hygiene; was impaired in range of motion of both lower extremities; was incontinent of bowel and bladder; had a swallowing disorder; and received antidepressants 7 days in the past 7 days. a. A physician progress notes [REDACTED].#1) has been complaining of some mouth pain. She does appear to have gingivitis with some swelling of the upper lip. It was a difficult evaluation as she did not open her mouth very far. She has not had any significant decline since stopping her [MEDICATION NAME] and [MEDICATION NAME]. We will go ahead and place her on some [MEDICATION NAME] 500 mg three times daily. Otherwise the rest of her medications are good as is." b. A Nurse's Note dated 4/16/13 for the 11:00 p.m. to 7:00 a.m. shift documented, "(Vital Signs) 97.3, 94, 20, 96% O2 (oxygen) sat (saturation) on rm (room) air. Gums still light red and still sore. Remains on [MEDICATION NAME] for Gingivitis. No swelling noted..." c. A Nurse's Note dated 4/18/13 at 2:00 a.m., documented, "Pt (patient) remains on [MEDICATION NAME] for Gingivitis. No n/v/d (nausea, vomiting, diarrhea) or rash noted. Gums not red but still sore when oral care done. Fluids taken fair with much enc (encouragement)." d. The physician's orders [REDACTED]." A Nurse's Note dated 4/26/13 for the 7:00 a.m. to 3:00 p.m. shift documented, "Diet changed to pureed in cups with milk d/t (due to) resident's preference to drink instead of eat from utensils. Family aware. " As of 6/6/13 at 12:50 p.m., there were no Nurse's Notes available for review from 4/26/13 on the 7:00 a.m. shift unitl 4/29/13 at no time noted according to the Director of Nursing. e. A Nurse's Notes dated 4/29/13 (no time noted) documented, " (T) (Temperature) 99.4, (P) (Pulse) 100, (R) (Respirations) 28, (BP) (Blood pressure) 162/98. R (resident) eating/drinking very little. Refused all po (oral) meds (medications) this shift. Did drink (more or less) 60 cc (cubic centimeter) water when offered 2 times." The April 2013 "CNA / RNA (Certified Nursing Assistant/Restorative Nursing Assistant) Flow Sheet" documented, " ...4/29/13 ... 15% of breakfast consumed, refusal of lunch and 25% of supper consumed ..." On 6/5/13 at 8:40 a.m., Registered Nurse (RN) #1 was asked to describe Resident #1's condition on 4/29/13. RN #1 stated, "She (Resident #1) had eaten very little on 4/29/13 on my shift and she had a low grade temperature. She refused all meds on my shift. Her pulse rate was elevated according to other documentation. It was not unusual for her to eat or drink little. I would think her low grade temperature was because she was eating and drinking little. When the temperature is 100 or greater then we would notify the physician. It was evident and apparent that because she was refusing to eat and drink she would be dehydrated. She was depressed. I did not call the physician or family." f. A Nurse's Notes dated 4/30/13 for the 7:00 a.m. to 3:00 p.m. shift and signed by LPN #1 documented, "Have attempted to contact (R) (Resident) dtr (daughter)/POA (Power of Attorney) in regard to R decline. Msg (message) left times 3. R has not had meds times 2 days, very little during meals, very lethargic. MD (Medical Doctor) is aware and coming in to assess this p.m. VS (vital signs) (BP) 148/102, (T) 99.4, (P) 128, (R) 19, O2 (oxygen) sat (saturation) 90%. R appears to not be in any pain. Social services and son aware of not able to get a hold of dtr." On 6/4/13 at 2:35 p.m., Licensed Practical Nurse (LPN) #1 was asked to describe (Resident #1's) condition and what actions were taken on the resident's behalf on 4/30/13. LPN #1 stated, "The Physician and family were notified of her condition. I reported her condition to (LPN #2) and that (Physician) would be in on that day." A Nurse's Notes dated 4/30/13 for the 7:00 a.m. to 3:00 p.m. shift documented, "Spoke with dtr and wants R to have consult with (Hospice Agency)." As of 12:50 p.m. on 6/6/13, there were no additional Nurses' Notes available for review after the 7:00 a.m. to 3:00 p.m. shift on 4/30/13 until an entry was made at 9:30 a.m. on 5/1/13 according to the Director of Nursing. On 6/4/13 at 2:55 p.m., LPN #2 was asked to describe the resident's condition on 4/30/13, the report (if any) she had been provided at the start of her shift and what she had documented (if anything) about the resident that day. LPN #2 stated, "I worked 3:00 p.m.-11:00 p.m. on 4/30/13. (Resident #1) refused all meds on 3-11 and refused supper. (LPN #1) probably gave me report. She normally gives a good report. (Physician) usually makes rounds on Tuesdays. I don't know why I did not document. I did document on the MAR indicated [REDACTED]." The April 2013 "CNA /RNA Flow Sheet" documented, " ...4/30/13 ...15% of breakfast consumed, refused lunch and supper ..." On 6/6/13 at 3:00 p.m., the Director of Nursing (DON) was asked if the resident's Physician had been to the facility and assessed her (Resident #1) on 4/30/13. The DON stated, "(Physician) did not come in on 4/30/13." g. The April 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] " ...4/29/13 (Resident) refused all meds" " ...4/30/13 (Resident) refused all po meds ..." h. A physician's orders [REDACTED]." A Nurse's Note dated 5/1/13 at 9:30 a.m. and signed by LPN #5 documented, "Temp (temperature) 100.5. R (Resident) not responding to verbal or tactile stimuli. Admin (administered) APAP 325 mg suppository at 9:30 a.m. T.O. (telephone order) (Physician). Son notified." On 6/5/13 at 8:50 a.m., LPN #5 was asked if she had spoken to the resident's physician on 5/1/13. LPN #5 stated "On 5/1/13 I called the doctor because she had a temperature. I did not document whether or not it was effective. I only told the doctor that she had an elevated temp and she was not responding. He only ordered the suppository." i. A physician's orders [REDACTED]." A Nurse's Notes dated 5/1/13 at 10:45 a.m., documented, "Spoke with (Name) at (Hospice Agency) gave R info and faxed demographics." j. A Physician order [REDACTED]. Please schedule blood work stat (immediately)." A Nurse's Notes dated 5/1/13 at 11 a.m. documented, "... Lab work was scheduled and drawn earlier today and lab results obtained and abnormal." As of 6/6/13 at 12:50 p.m., there were no Nurses' Notes available for review from 5/1/13 at 11:00 p.m. until 5/2/13 7:00 a.m.-3:00 p.m. according to the Director of Nursing. A Hematology Report dated 5/1/13 at 5:55 p.m. documented, "Routine Blood Counts: ... White Blood Count (WBC) 19.1 K/mcl (kilograms per microliter)-High (H) with a reference range of 4.8-10.8 K/mcl." A Chemistry Report dated 5/1/13 at 5:55 p.m. documented," Routine Chemistry: ...Sodium Level 146 mmol/L (millimole per liter) - H with a reference range of 135-145 mmol/L, BUN (Blood Urea Nitrogen) 52.0 mg/dl (milligram per deciliter) with a reference range of 8-20, BUN/Creat (Blood Urea Nitrogen/Creatnine) Ratio 37- H with a reference range of 7-32 ...." On 6/5/13 at 9:10 a.m., LPN #6 was asked to describe Resident #1's condition on 5/1/13. LPN #1 stated, "I worked 11:00 p.m. to 7:00 a.m. At 11:00 p.m. on 5/1/13 I knew her WBC was 19.1, Sodium 146, BUN 52 and BUN/Creatinine ration 37. I did not call the doctor. I took care of (Resident #1) the rest of the night. She did not drink very well." On 6/5/13 at 9:45 a.m., LPN #6 was asked to describe her interventions regarding the resident's condition on 5/2/13 LPN #6 stated, "I faxed the Routine Blood Count and the Routine Chemistry to (Physician) at his office between 4:00 a.m. and 6:00 a.m. I noticed the WBC was elevated and the BUN/Creat ratio. I faxed them to the doctor's office as I always do so he will have a hard copy. I would imagine I did not call the doctor." k. The May 2013 MAR indicated [REDACTED] " ...5/1/13 (Resident) refused all meds ..." " ... 5/2/13 (Resident) refused all meds..." l. A Nurse's Notes dated 5/2/13 at 1:45 p.m. and signed by LPN #3 documented, "Dtr called and wanted results from UA. Stated did not have report but went over results of blood work. Dtr wanted fluids intravenous (IV). This nurse asked if Hospice had contacted her. She said no she was supposed to meet them on 5/3/13 but couldn't get off work so it was rescheduled to 5/7/13. This nurse explained to dtr, that if an IV is started and successfully completed that it may be just buying time. R very dehydrated and an IV may not be possible. Called MD. N.O. (new order) received for IV and IV ABT (antibiotic). Ordered pump, tubing and meds stat from (Pharmacy). Called dtr back and left message." A physician's orders [REDACTED]...1.) Run D5NS ([MEDICATION NAME] 5%/Normal Saline) (at)150 ml/ hr (milliters/hour) for 3 L (liters) total 1 time. 2.) [MEDICATION NAME] 1 gm (gram) IV for increased WBC ..." On 6/4/13 at 3:10 p.m., LPN #3 was asked if she had received any orders for Resident #1 on 5/2/13. LPN #3 stated, "On 5/2/13 at 1:45 p.m., I made the entry (Nurse's Note) at approximately 2:15 p.m. I told the daughter about the Routine Blood Count, BUN and Sodium. I also called (Physician). He ordered an IV and antibiotic, [MEDICATION NAME] 1 gram IV. I ordered the med in the IV from the pharmacy STAT. I was not aware that the [MEDICATION NAME] we had here could be given IV. I told (LPN #4) in report about the order." m. A Nurse's Notes dated 5/2/13 at 5:40 p.m. and signed by LPN #4 documented, "VS (vital signs) 97.8, 89, 24, 110/62. Daughter at bedside. Resident in bed not responding to verbal/tactile stimuli. Daughter requested resident to be sent to (Hospital) for eval (evaluation) and tx (treatment). This nurse reminded daughter that we are going to run a bag of [MEDICATION NAME] antibiotics when it arrives from pharmacy. Daughter stated that she still wants her (Resident #1) to go to hospital. Call to (Physician). (Physician) gave order to transfer to hospital for eval and tx." A physician's orders [REDACTED]." On 6/4/13 at 3:40 p.m., LPN #4 was asked if she had been aware of the new orders received for Resident #1 on 5/2/13 for Rochepin IV. LPN #4 stated, "I worked 3:00 p.m. till 11:00 p.m. on 5/1/13 and 5/2/13. (Resident #1) did not take her meds on 5/1/13 or 5/2/13. I did not document on her on 5/1/13. I would have documented if I had called the family or the doctor. I knew that [MEDICATION NAME] was to be given IV. I did not check the ER (Emergency) box for [MEDICATION NAME] because [MEDICATION NAME] was not in the ER Box as to my knowledge. I did not administer the [MEDICATION NAME]. On 5/1/13 I did assess her. I checked her vital signs. I checked her lungs for congestion. I did not check her mouth. On 5/2/13 I took her vital signs. She was unresponsive to verbal and tactile stimuli. I did not document a full assessment. I called (Physician) at the family's request. She left the building at 7:30 p.m. per my documentation." A Nurse's Notes dated 5/2/13 at 6:10 p.m. documented, "(Ambulance Services) called for transport to (Hospital)." A Nurse's Notes dated 5/2/13 at 7:30 p.m., documented, "(Ambulance Services) here. Resident transported to (Hospital)." The emergency room (ER) Physician's Clinical Impression dated 5/2/13 at 11:30 p.m. documented, "...Final Diagnosis: [REDACTED]. n. On 6/4/13 at 1:33 p.m., Registered Nurse Consultant and Assistant Director of Nursing went with surveyor to the ER (emergency) Drug Box on East Station. The contents sheet documented that the ER Drug Box contained [MEDICATION NAME]. The ER Drug Box was opened and [MEDICATION NAME] 1 gram for Intramuscular (IM) or Intravenous (IV) use was available. There were IV solutions available. The Assistant Director of Nursing stated, "The ER Drug Box contents have not been changed." o. On 6/6/13 at 3:00 p.m., the DON was asked if she knew why there was a lack of monitoring for Resident #1's hydration status from 4/29/13 until 5/2/13. The DON stated, "I can't tell you. I told them to ask the daughter what she wanted and if she wanted Hospice." The DON was asked why was there a lack of notification of the physician for her change of condition. The DON stated, "They were supposed to notify the doctor." The DON was asked if she knew why the staff did not have knowledge of [MEDICATION NAME] being available in the ER Box. The DON stated, "There is a list of meds on the ER Box." The DON was asked if she knew why there was a failure to report labs results that were outside of reference range for Resident #1. The DON stated, "They have all been schooled that stat labs are to be called to the physician." The DON was asked if she knew why there was a 2 hour delay to transport the resident to the ER after receipt of the original order. The DON stated, "I don't know."

Based on record review and interview, the facility failed to ensure that anticoagulant therapy was not continued when physician order [REDACTED].#12) of 1 case mix resident who received anticoagulant therapy. The failed practice resulted in Immediate Jeopardy which likely caused or could have caused serious injury, harm or death for Resident #12, who had an international normalized ratio (INR) of 2.7 and had the potential to affect 2 residents receiving [MEDICATION NAME] injections as identified by the Nurse Consultant on 12/21/12 at 6:02 p.m. and 5 residents who received [MEDICATION NAME] according to a list provided by the Director of Nursing on 1/9/13. The facility was informed of the Immediate Jeopardy on 12/21/12 at 12:02 p.m. The findings are: 1. Resident #12 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/09/12 documented the resident was admitted to the facility on [DATE] from acute hospital, scored 15 (13-15 indicated cognitively intact) on the Brief Interview for Mental Status, and received an anticoagulant for the last 7 days. a. A Physician order [REDACTED]." A Physician's telephone order dated 12/3/12 documented, " ... PT and INR, Monday-Wednesday- Friday (M-W-F). [MEDICATION NAME] 1 mg/kilogram (kg) subcutaneous (sq) every 12 hours until INR > (greater than) 2. Call (Physician) prior 1st dose." b. A physician's telephone order dated 12/5/12 documented, [MEDICATION NAME] 5 mg 1 po every day and "Clarification: [MEDICATION NAME] sq 80 mg - give 70 mg (0.7 ml) sq every 12 hours until INR > 2." c. The December 2012 Medication Administration Record (MAR) documented, [MEDICATION NAME] 68 mg (0.68 ml) sq q 12 hours was administered at 8:00 p.m. on 12/3/12 and 8:00 a.m. and 8:00 p.m. on 12/4/12; [MEDICATION NAME] 70 mg (0.7 ml) sq q 12 hours was administered 8:00 a.m. and 8:00 p.m. on 12/5/12 thru 12/20/12 (per physician's orders [REDACTED]. [REDACTED]. d. A review of the Lab reports for the INR documented the following: 12/3/12 (Monday) INR 1.53 12/5/12 (Wednesday) INR 1.67 12/7/12 (Friday) INR was 2.14. The lab reports documented the reference range for INR for prevention of embolism as 2.0 - 3.0 e. On 12/21/12 at time 9:17 a.m., Licensed Practical Nurse (LPN) #1 was asked when the last time (Resident #12) had his INR checked. After the LPN looked in the resident's record she stated, "It was on December the 7th. He has orders for Monday, Wednesday and Friday. The LPN then called the Lab and asked when the last time they had drawn an INR on this resident and she was told the last INR was drawn on 12/7/12. At 11:00 a.m., Licensed Practical Nurse (LPN) #1 stated, "I notified the Doctor at 9:20 a.m. of the resident's lab and he ordered to hold this AM dose of [MEDICATION NAME] and obtain a stat PT/INR and phone him with the results." f. On 12/21/12 at 9:28 a.m., the Director of Nursing was asked about the orders for this resident and she stated, " I was not aware the lab had not been drawn as ordered. I'm going to call for a stat lab and call the Doctor. The ADON (Assistant Director of Nursing) is responsible for making sure the labs are drawn as ordered." g. On 12/21/12 at 1:30 p.m., a lab report dated 12/21/12 was provided by the ADON with an INR result of 2.7. A note on the report documented, "MD (Medical Doctor) aware NO (new order) rec'd (received) D/C (discontinue) [MEDICATION NAME]. INR 12/24 and 12/28 1300 (1:00 p.m.)." LPN #1 had initialed this note and dated it 12/21/12. h. Staff interviews regarding the administration of the [MEDICATION NAME] after the INR was greater than 2.0: 1) On 12/21/12 at 12:12 p.m., LPN #6 was interviewed by phone and asked why would you give [MEDICATION NAME] without looking for a PT/INR. The LPN stated, "I can't answer that, I didn't look. I knew he had it, I wrote the order. I did not check for the lab. I don't remember looking at the 12/7 lab. I'm sorry, I just can't answer that." 2) On 12/21/12 at 1:13 p.m., LPN #7 was asked what areas were checked during the 24 hour chart check. She stated, "You go through and make sure the telephone orders are written on the physicians order sheet and make sure whatever the order or medication is, it's written on the MAR and actually ordered if it is a medication. I just check to make sure order is everywhere it is suppose to be. The PT/INR should have been written along with the medication directions. It should have said, Continue to give until INR is greater than 2." 3) On 12/21/12 at 1:23 p.m., LPN #8 was interviewed and she stated, "I was not aware of the order for stopping [MEDICATION NAME] when the INR was greater than 2. I didn't think to go check the chart for the PT/INR results. When someone is on [MEDICATION NAME] we don't give it indefinitely. We should be checking the PT/INR before giving it. I just didn't think to check the chart before I gave it. I work back there about every other weekend." 4) On 12/21/12 at 2:30 p.m., LPN #9 was interviewed and she stated, "I have been giving (Resident #12) [MEDICATION NAME] injections on my shift. I have been giving them to him ever since it was ordered. I have no excuse for why I did not check the record for the INR results. I usually check the PT/INR results. I just didn't check it. I did check for unusual bleeding and bruising and just didn't check the PT/INR." 5) On 12/21/12 at 3:00 p.m., LPN #10 was interviewed and she stated, "I am familiar with (Resident #12) and I have administered his [MEDICATION NAME]. I believe I worked with him on the 10th. I remember when he came in we needed to get his weight so they could readjust his [MEDICATION NAME]. (Doctor) readjusted to 0.7 milliliters. I can remember giving him a couple of doses when I worked. The PT/INR should be checked. I don't remember checking it on him. I didn't check his chart for specific orders. I should have." i. The 2013 Nursing Drug Handbook on page ix documented, "SAFETY ALERT!" Usage or meaning: "Drug that presents a heightened avoidable danger." On page 491 documented: [MEDICATION NAME] Sodium - [MEDICATION NAME] - "SAFETY ALERT" and on page 1407 [MEDICATION NAME] Sodium - [MEDICATION NAME] - "SAFETY ALERT." 2. The Immediate jeopardy was removed on 12/21/12 and the scope and severity was reduced to an "E" when the facility initiated the following plan of removal: a. Beginning immediately 12/21/12 DON/Designee began reviewing all residents charts for PT/INR orders past 30 days. All the orders are being compared to the manifest from Gamma Lab which reflect all labs in their system for accuracy. A newly implemented monitoring sheet was placed on the MAR for all residents on [MEDICATION NAME] or any other anticoagulant medication requiring an INR. This was completed on 12/21/12 by 14:00. This will be done 5x's per week for 1 week, 3x's per week for 2 weeks, then once weekly until substantial compliance is achieved. b. On 12/21/12 at 2:45 p.m., the DON/Designee was designated to check all PT/INR orders daily to ensure they have been entered correctly into the lab book and to be certain the newly implemented monitoring sheet is present on the MAR. At this time the Weekend Supervisor was designated to check for the same thing on the weekends and will do so until substantial compliance has been achieved and will correct any issues identified immediately. c. Beginning 12/21/12 and to continue indefinitely, a copy of all lab orders written in the past 24 hrs and 48 hrs on weekends will be brought by DON/Designee to the every weekday morning QA (Quality Assurance) meeting and compared to Gamma Labs updated weekly manifest for accuracy and any orders for [MEDICATION NAME] or any other medication requiring PT/INR will have a monitoring sheet placed on their MAR with the specific lab order and any parameters listed. This monitoring sheet will continue indefinitely and the actual MAR will be checked 5x a week for one week, 3 times a week for one week then once weekly until compliance is achieved. Any lab orders with specific parameters will be logged during each and every weekday morning QA meeting and followed up daily by DON/Designee until parameters are met and there is proof that the specific order has been carried out. This will continue Q weekday until substantial compliance is achieved. d. On 12/21/12 the DON/Designee began shift to shift inservicing with all nursing staff on duty on correct process of entering lab orders as well as the new system of placing a monitoring sheet on the MAR of each resident on [MEDICATION NAME] or any other medication requiring an INR or that an INR has been ordered on. This inservice will be continued at the beginning of each shift by the DON/Designee until all nursing staff are inserviced by January 3rd, 2012. No nurse will be allowed to work until they have been inserviced. Each new hire (nurse) will be inserviced by the DON/Designee prior to being authorized to work. Any negative findings will be corrected immediately. e. Beginning 12/21/12 DON/Designee will randomly select 2 residents from each hall receiving [MEDICATION NAME] or any other anticouagulant medication requiring a PT/INR and compare their lab orders with the lab requisition as well as the monitoring sheet on the MAR. This will continue until substantial compliance is obtained and any negative findings will be corrected immediately. f. Monitoring will be continued indefinitely through the process of the DON/Designee bringing copies of all lab orders to the Q weekday QA meeting and any orders for [MEDICATION NAME] or any other anticoagulant requiring PT/INR will be doubled checked by DON/Designee. g. All negative findings will be brought to the QAA (Quality Assessment and Assurance) committee meeting monthly by the DON/Designee for review of audit results and to implement any new interventions if needed.

Based on record review and interview, the facility failed to ensure the medication regimen was free of unnecessary medications, as evidenced by the administration of Tylenol at an excessive dose, for an excessive duration and in the absence of adequate monitoring for potential adverse effects and a physician's evaluation and documentation of the potential risks versus benefits of continuing the medication for 1 (Resident #9) of 1 case mix residents with physician orders [REDACTED]. The findings are: Resident #9 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of 12/25/12 documented the resident scored 5 (0-7 indicates severely impaired) on the Brief Interview for Mental Status and received scheduled pain medication and non-medication interventions. a. A physician order [REDACTED]." b. A physician order [REDACTED]." c. The September through December 2012 and January 2013 through February 12, 2013 Medication Administration Records (MAR's) documented the resident received Tylenol 1000 mg 4 times daily, for a total of 4000 mg of Tylenol each day for a period of over 3 months. d. On 2/14/13 at 2:20 p.m., the Nurse Consultant was asked about the Tylenol for the resident and stated, "About the Tylenol. That was a Pharmacy Consultant recommendation. We've talked to the Doctor and got a clarification that she can have the 4 gram a day due to pain and he said she needs it ..." The Nursing Consultant was asked how the facility knew the resident had not suffered harm from the continued large doses of Tylenol and were there any recent Liver Function Studies done and stated, " ...We are going to draw some labs ..." e. A Letter dated 2/14/13 and signed by the Physician documented, "History: Patient is doing fairly well. She is getting a little more confused at times and getting a little bit weaker as well. She is on Tylenol 500 mg (milligrams) two tablets up to 4 times daily for a total of 4 g (grams) daily. It works well for her pain and does not cause any changes in her sensorium. She has been having some increased difficulties and has developed some mild dementia. She also has some significant problems with stability and mobility; she is at risk for frequent falls. Plan: I feel that Tylenol is the least sedating thing that can be given to her and anything stronger than that puts her at greater risk for falls. She has no history of liver problems or liver disease and is not on any other medication that would affect her liver. I believe that at this point in time the best course of action is to continue with Tylenol at the present dose, even though it may involve up to 4 g of Tylenol daily."

Based on record review and interview, the facility failed to ensure Resident #12 and Resident #10 were free from significant medication errors: The facility failed to ensure that medications were discontinued per physicians' orders for 1 (Resident #12) who continued receiving [MEDICATION NAME] (anticoagulant therapy) injections after reaching parameters for discontinuation. The failed practice resulted in Immediate Jeopardy which likely caused or could have caused serious injury, harm or death for Resident #12, who had an international normalized ratio (INR) of 2.7 and had the potential to affect 2 residents receiving [MEDICATION NAME] injections as identified by the Nurse Consultant on 12/21/12 at 6:02 p.m. and 5 residents who received [MEDICATION NAME] according to a list provided by the Director of Nursing on 1/9/13. The facility was informed of the Immediate Jeopardy on 12/21/12 at 12:02 p.m. The facility also failed to ensure medications were administered in the dosage prescribed by the physician for 1 (Resident #10) of 12 residents observed during medication passes on 12/20/12. This failed practice had the potential to affect 1 resident on [MEDICATION NAME] 60 milligram (mg) according to the Director of Nurse (DON) on 12/21/12. The findings are: 1. Resident #12 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/09/12 documented the resident was admitted to the facility on [DATE] from acute hospital, scored 15 (13-15 indicated cognitively intact) on the Brief Interview for Mental Status, and received an anticoagulant for the last 7 days. a. A Physician order [REDACTED]." A Physician's telephone order dated 12/3/12 documented, " ... PT and INR, Monday-Wednesday- Friday (M-W-F). [MEDICATION NAME] 1 mg/kilogram (kg) subcutaneous (sq) every 12 hours until INR > (greater than) 2. Call (Physician) prior 1st dose." b. A physician's telephone order dated 12/5/12 documented, [MEDICATION NAME] 5 mg 1 po every day and "Clarification: [MEDICATION NAME] sq 80 mg - give 70 mg (0.7 ml) sq every 12 hours until INR > 2." c. The December 2012 Medication Administration Record (MAR) documented, [MEDICATION NAME] 68 mg (0.68 ml) sq q 12 hours was administered at 8:00 p.m. on 12/3/12 and 8:00 a.m. and 8:00 p.m. on 12/4/12; [MEDICATION NAME] 70 mg (0.7 ml) sq q 12 hours was administered 8:00 a.m. and 8:00 p.m. on 12/5/12 thru 12/20/12 (per physician's orders [REDACTED]. [REDACTED]. d. A review of the Lab reports for the INR documented the following: 12/3/12 (Monday) INR 1.53 12/5/12 (Wednesday) INR 1.67 12/7/12 (Friday) INR was 2.14. The lab reports documented the reference range for INR for prevention of embolism as 2.0 - 3.0 e. On 12/21/12 at time 9:17 a.m., Licensed Practical Nurse (LPN) #1 was asked when the last time (Resident #12) had his INR checked. After the LPN looked in the resident's record she stated, "It was on December the 7th. He has orders for Monday, Wednesday and Friday. The LPN then called the Lab and asked when the last time they had drawn an INR on this resident and she was told the last INR was drawn on 12/7/12. At 11:00 a.m., Licensed Practical Nurse (LPN) #1 stated, "I notified the Doctor at 9:20 a.m. of the resident's lab and he ordered to hold this AM dose of [MEDICATION NAME] and obtain a stat PT/INR and phone him with the results." f. On 12/21/12 at 9:28 a.m., the Director of Nursing was asked about the orders for this resident and she stated, " I was not aware the lab had not been drawn as ordered. I'm going to call for a stat lab and call the Doctor. The ADON (Assistant Director of Nursing) is responsible for making sure the labs are drawn as ordered." g. On 12/21/12 at 1:30 p.m., a lab report dated 12/21/12 was provided by the ADON with an INR result of 2.7. A note on the report documented, "MD (Medical Doctor) aware NO (new order) rec'd (received) D/C (discontinue) [MEDICATION NAME]. INR 12/24 and 12/28 1300 (1:00 p.m.)." LPN #1 had initialed this note and dated it 12/21/12. h. Staff interviews regarding the administration of the [MEDICATION NAME] after the INR was greater than 2.0: 1) On 12/21/12 at 12:12 p.m., LPN #6 was interviewed by phone and asked why would you give [MEDICATION NAME] without looking for a PT/INR. The LPN stated, "I can't answer that, I didn't look. I knew he had it, I wrote the order. I did not check for the lab. I don't remember looking at the 12/7 lab. I'm sorry, I just can't answer that." 2) On 12/21/12 at 1:13 p.m., LPN #7 was asked what areas were checked during the 24 hour chart check. She stated, "You go through and make sure the telephone orders are written on the physicians order sheet and make sure whatever the order or medication is, it's written on the MAR and actually ordered if it is a medication. I just check to make sure order is everywhere it is suppose to be. The PT/INR should have been written along with the medication directions. It should have said, Continue to give until INR is greater than 2." 3) On 12/21/12 at 1:23 p.m., LPN #8 was interviewed and she stated, "I was not aware of the order for stopping [MEDICATION NAME] when the INR was greater than 2. I didn't think to go check the chart for the PT/INR results. When someone is on [MEDICATION NAME] we don't give it indefinitely. We should be checking the PT/INR before giving it. I just didn't think to check the chart before I gave it. I work back there about every other weekend." 4) On 12/21/12 at 2:30 p.m., LPN #9 was interviewed and she stated, "I have been giving (Resident #12) [MEDICATION NAME] injections on my shift. I have been giving them to him ever since it was ordered. I have no excuse for why I did not check the record for the INR results. I usually check the PT/INR results. I just didn't check it. I did check for unusual bleeding and bruising and just didn't check the PT/INR." 5) On 12/21/12 at 3:00 p.m., LPN #10 was interviewed and she stated, "I am familiar with (Resident #12) and I have administered his [MEDICATION NAME]. I believe I worked with him on the 10th. I remember when he came in we needed to get his weight so they could readjust his [MEDICATION NAME]. (Doctor) readjusted to 0.7 milliliters. I can remember giving him a couple of doses when I worked. The PT/INR should be checked. I don't remember checking it on him. I didn't check his chart for specific orders. I should have." i. The 2013 Nursing Drug Handbook on page ix documented, "SAFETY ALERT!" Usage or meaning: "Drug that presents a heightened avoidable danger." On page 491 documented: [MEDICATION NAME] Sodium - [MEDICATION NAME] - "SAFETY ALERT" and on page 1407 [MEDICATION NAME] Sodium - [MEDICATION NAME] - "SAFETY ALERT." j. The Immediate jeopardy was removed on 12/21/12 and the scope and severity was reduced to an "E" when the facility initiated the following plan of removal: 1) Beginning immediately 12/21/12 DON/Designee began reviewing all residents charts for PT/INR orders past 30 days. All the orders are being compared to the manifest from Gamma Lab which reflect all labs in their system for accuracy. A newly implemented monitoring sheet was placed on the MAR for all residents on [MEDICATION NAME] or any other anticoagulant medication requiring an INR. This was completed on 12/21/12 by 14:00. This will be done 5x's per week for 1 week, 3x's per week for 2 weeks, then once weekly until substantial compliance is achieved. 2) On 12/21/12 at 2:45 p.m., the DON/Designee was designated to check all PT/INR orders daily to ensure they have been entered correctly into the lab book and to be certain the newly implemented monitoring sheet is present on the MAR. At this time the Weekend Supervisor was designated to check for the same thing on the weekends and will do so until substantial compliance has been achieved and will correct any issues identified immediately. 3) Beginning 12/21/12 and to continue indefinitely, a copy of all lab orders written in the past 24 hrs and 48 hrs on weekends will be brought by DON/Designee to the every weekday morning QA (Quality Assurance) meeting and compared to Gamma Labs updated weekly manifest for accuracy and any orders for [MEDICATION NAME] or any other medication requiring PT/INR will have a monitoring sheet placed on their MAR with the specific lab order and any parameters listed. This monitoring sheet will continue indefinitely and the actual MAR will be checked 5x a week for one week, 3 times a week for one week then once weekly until compliance is achieved. Any lab orders with specific parameters will be logged during each and every weekday morning QA meeting and followed up daily by DON/Designee until parameters are met and there is proof that the specific order has been carried out. This will continue Q weekday until substantial compliance is achieved. 4) On 12/21/12 the DON/Designee began shift to shift inservicing with all nursing staff on duty on correct process of entering lab orders as well as the new system of placing a monitoring sheet on the MAR of each resident on [MEDICATION NAME] or any other medication requiring an INR or that an INR has been ordered on. This inservice will be continued at the beginning of each shift by the DON/Designee until all nursing staff are inserviced by January 3rd, 2012. No nurse will be allowed to work until they have been inserviced. Each new hire (nurse) will be inserviced by the DON/Designee prior to being authorized to work. Any negative findings will be corrected immediately. 5) Beginning 12/21/12 DON/Designee will randomly select 2 residents from each hall receiving [MEDICATION NAME] or any other anticouagulant medication requiring a PT/INR and compare their lab orders with the lab requisition as well as the monitoring sheet on the MAR. This will continue until substantial compliance is obtained and any negative findings will be corrected immediately. 6) Monitoring will be continued indefinitely through the process of the DON/Designee bringing copies of all lab orders to the Q weekday QA meeting and any orders for [MEDICATION NAME] or any other anticoagulant requiring PT/INR will be doubled checked by DON/Designee. 7) All negative findings will be brought to the QAA (Quality Assessment and Assurance) committee meeting monthly by the DON/Designee for review of audit results and to implement any new interventions if needed. 2. Resident #10 had a [DIAGNOSES REDACTED]. a. On 12/20/12 at 8:36 a.m., during the 8:00 a.m. medication pass , Licensed Practical Nurse (LPN) #1 set up the medications for the resident. LPN #1 had 180 mg of the Allerga in the medication cup. The resident stated that she was nauseated and did not want to take her medications now. The resident stated she had been too nauseated to eat breakfast. b. On 12/20/12 at 11:15 a.m., the surveyor asked LPN #1 what [MEDICATION NAME] does the resident receive? LPN #1 opened the medication cart and pulled out a bottle of Allerga 180 mg. The surveyor showed LPN #1 the strength on the bottle and LPN #1 stated, "This is all we have." c. On 12/20/12 at 3:30 p.m., the surveyor asked the DON to ask the pharmacy provider of over-the-counter medications if they had sent any [MEDICATION NAME] 60 mg to the facility. On 12/21/12 at 9:15 a.m., the surveyor asked the DON, "Did the pharmacy provider send any [MEDICATION NAME] 60 mg?" The DON stated, "All we had was the [MEDICATION NAME] 180 mg and we have never ordered [MEDICATION NAME] 60 mg." d. The 2013 Nursing Drug Handbook on page 586 documented, "Adverse Reactions: "GI: nausea, dyspepsia, vomiting" and Available Forms: "Tablets 30 mg, 60 mg, 180 mg." e. The December 2012 MAR (Medication Administration Record) documented 38 doses was administered. f. This was a significant medication error due to the frequency of the error and condition of the resident.

Based on record review and interview, the facility failed to ensure Resident #5 received the necessary care and services to attain the highest practicable physical well-being. The facility failed to monitor bowel movements, to ensure the physician's plan of care was implemented, and to reassess effectiveness of interventions for 1 (Resident #5) of 5 (Residents #3, #5, #6, #8 and #9) case mix residents who were at risk for constipation. The failed practice resulted in past non compliance at a pattern of actual harm for Resident #5 who from July thru December 13th 2012 experienced severe constipation requiring digital stimulation and manual removal of bowel movement. The failed practice had the potential to cause more than minimal harm to 43 residents who were at risk for constipation, as documented on a list provided by the Assistant Director of Nursing (ADON) on 12/21/12 at 4:40 p.m. The facility was notified of the past noncompliance on 12/21/12 at 12:15 p.m. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/18/12 documented the resident was severely impaired in cognitive skills for daily decision-making per a staff assessment of mental status, made self understood but rarely or never understood, was totally dependent on the assistance of 2 staff for toilet use, was always incontinent of bladder and bowel and received hospice services for End Stage Dementia since 1/18/12. a. Nurse ' s Note dated 7/11/12 on the 7:00 a.m. - 3:00 p.m. (7-3) shift documented, "...Digital impaction removal of large amount soft stool..." Nurse ' s Note dated 7/16/12 at 1:00 a.m. documented, "...appears in distress (secondary to) constipation; digitally removed impacted stool (with) immediate relief noted..." The Care Plan dated 7/23/12 documented, "...Problem: Constipation (checked) Bowel Incontinence (checked) Fecal Impaction (not checked) ...Related to: Low mobility or Immobility (checked) Lack of Voluntary Sphincter Control (checked) and Inability to perceive bowel cues/dementia (checked) ...Goal: Resident will exhibit improved bowel elimination AEB (as evidenced by) BM (bowel movement) q3d(every 3 days)/no fecal impactions (checked) Resident will exhibit adequate BMs AEB ...q3d, no skin breakdown r/t (related to) bowel incontinence... Interventions: Encourage fluid intake. Honor fluid preferences (checked). Assist resident to sitting position to allow optimum usage of abd (abdominal) muscle and effect of gravity during defecation (checked). Monitor BM charting, if no BM in 3 days, assess for abd distention, bowel sounds, perform rectal check if needed (checked). Provide incontinent/peri-care after each incontinent episode (checked) Wears briefs (checked)." b. The July 2012 Physicians Orders and Telephone Orders were reviewed on 12/18/12. There were no physician orders for digital anal stimulation or manual removal of impactions. The July 2012 Physician Orders did not include routine or as needed (prn) orders for constipation. c. The July through August 2012 bowel movement record on the CNA (Certified Nursing Assistant) - ADL (Activities of Daily Living), Physician Orders, Medication Administration Records (MARs), and Nurses Notes were reviewed with the following findings: 1) 7/27/12 - 8/2/12: No BM for 7 days per the CNA-ADL Tracking Form, no medications were administered for constipation per the MARs and no physician notification per the Nurses Notes. 2) 8/5/12 - 8/7/12: No BM for 3 days per the CNA-ADL Tracking Form, no medications were administered for constipation per the MAR and no physician notification per the Nurses Notes. 3) 8/13/12 - 8/23/12: No BM for 11 days per the CNA-ADL Tracking Form. A Physician Telephone Order dated 8/22/12 documented, "[MEDICATION NAME] suppository every day until BM then every 3 days if no BM ..." The August 2012 MAR documented the order, there were no nurses initials to indicate administration of the [MEDICATION NAME] suppository on 8/22/12. The nurses initials were circled on 8/23/12 with a notation on the back that the [MEDICATION NAME] suppository was not administered due to large bowel movement. There 4) 8/25/12 - 8/31/12: No BM for 7 days per the CNA-ADL Tracking Form, no medications were administered for constipation per the MAR and no physician notification per the Nurses Notes. d. The September through October 2012 bowel movement record on the CNA (Certified Nursing Assistant) - ADL (Activities of Daily Living), Physician Orders, Medication Administration Records (MARs), and Nurses Notes were reviewed with the following findings: 1) 9/3/12 - 9/6/12: No BM for 4 days per the CNA-ADL Tracking Form, no medications were administered for constipation per the MAR and no physician notification per the Nurses Notes. 2) 9/10/12 - 9/15/12: No BM for 6 days per the CNA-ADL Tracking Form, no medications were administered for constipation per the MAR and no physician notification per the Nurses Notes. 3) Nurse ' s Note dated 9/16/12 at 9:00 a.m. documented, "...Checked for impaction and removed a large amount of hard stool from the rectal vault..." 4) A Physician Telephone Order dated 9/21/12 documented, "MOM (Milk of Magnesium) prn for constipation..." 5) 9/25/12 - 9/30/12: No BM for 6 days per the CNA-ADL Tracking Form, no medications were administered for constipation per the MAR and no physician notification per the Nurses Notes. 6) 10/2/12 - 10/6/12: No BM for 5 days per the CNA-ADL Tracking Form, no medications were administered for constipation per the MAR and no physician notification per the Nurses Notes. 7) Nurse ' s Note dated 10/8/12 at 2:00 p.m. documented, "... (Resident) was impacted. Digital stimulation (and) no energy to push, large results. " 8) 10/9/12 - 10/20/12: No BM for 12 days per the CNA-ADL Tracking Form, no medications were administered for constipation per the MAR and no physician notification per the Nurses Notes. 9) 10/24/12 - 10/28/12: No BM for 5 days per the CNA-ADL Tracking Form, no medications were administered for constipation per the MAR and no physician notification per the Nurses Notes. 10) 10/30/12 - 10/31/12: No BM for 2 days per the CNA-ADL Tracking Form, no medications were administered for constipation per the MAR and no physician notification per the Nurses Notes. e. The November 2012 bowel movement record on the CNA (Certified Nursing Assistant) - ADL (Activities of Daily Living), Physician Orders, Medication Administration Records (MARs), and Nurses Notes were reviewed with the following findings: 1) 11/01/12 - 11/03/12: No BM for 3 days per the CNA-ADL Tracking Form (Note: last recorded BM was 10/29/12), no medications were administered for constipation per the MAR and no physician notification per the Nurses Notes. 2) Nurse ' s Note dated 11/4/12 at 11:30 a.m. documented, "... (Resident) c/o (complaint of) painful BM, upon assessment (Resident) was impacted. Digital stimulation successful produced large brn (brown) hard." 3) 11/6/12 - 11/14/12: No BM for 9 days per the CNA-ADL Tracking Form, no medications were administered for constipation per the MAR and no physician notification per the Nurses Notes. 4) 11/16/12 - 11/26/12: No BM for 11 days per the CNA-ADL Tracking Form, MOM 30 cc (cubic centimeters) was administered on 11/19/12 with no results per the MAR, no further medication was administered for constipation per the MAR and no physician notification per the Nurses Notes. 5) 11/28/12 - 11/30/12: No BM for 3 days per the CNA-ADL Tracking Form, MOM 30 cc (cubic centimeters) was administered on 11/19/12 with no results per the MAR, no further medication was administered for constipation per the MAR and no physician notification per the Nurses Notes. . f. The December 2012 bowel movement record on the CNA (Certified Nursing Assistant) - ADL (Activities of Daily Living), Physician Orders, Medication Administration Records (MARs), and Nurses Notes were reviewed with the following findings: 1) A Physician Telephone Order dated 12/2/12 (not timed) documented, "...MOM 30 cc po (by mouth) qod (every other day)..." The December 2012 Medication Administration Record (MAR) documented milk of magnesia (MOM) 30 cc was administered on 12/2/12 and 12/4/12 with no results. There were no further medications administered for constipation as ordered by the physician per the MAR and no physician notification of any results from the MOM until 12/5/12. A telephone order dated 12/5/12 documented, "Senna ii (2) po qd (every day) mixed (with) 15 cc (cubic centimeters) med pass ..." A telephone order dated 12/6/12 documented, "D/C (discontinue MOM ...(change) Senna ...to Senna S ii tabs po BID (twice daily) mix (with) 15 cc med pass or shake ..." 2) 12/3/12 - 12/8/12: No BM for 6 days per the CNA-ADL Tracking Form. 3) Nurse ' s Note dated 12/9/12 at 7:00 p.m. documented, "...Called to room where CNAs (Certified Nurses Assistants) were doing pericare and noted hard stool at anus. Patient unable to get it out. Disimpacted (manual removal of impaction) a large amount of hard stool from rectal vault..." 4) Nurse ' s Note dated 12/13/12 on the 7 - 3 shift documented, "... R (Resident) constipation ...digitally removed large hard BM brown in color..." 5) A telephone order dated 12/17/12 (not timed) documented, "...Prune juice (every) breakfast for constipation..." The December 2012 MAR, copied on 12/18/12 at 4:35 p.m., documented, Senna S ii bid was administered from 12/6/12 to 12/18/12 with the exception of the 12/7/12 at 8:00 a.m. and 12/15/12 the spaces provided for documenting administration for these two dates were blank and not initialed or circled. The December 2012 MAR, copied on 12/18/12 at 4:35 p.m., documented prune juice was given on the 12/17/12 and 12/18/12 as ordered. The resident ' s Breakfast Tray Card dated 12/18/12 documented, "...prune juice 4 oz (ounces)...." 2. On 12/20/12 at 2:17 p.m., the surveyor asked the Director of Nursing (DON) if she was aware of this resident's chronic constipation, the need for digital stimulation, having had impactions manually removed and that prn orders for constipation were not followed. The DON stated, "I knew they were having to make her go. I was not aware they were not using prn orders for constipation. I was aware of the disimpactions. She has been having trouble with her bowels since she has been here. The doctor would expect the prn orders for constipation to be followed. The aides are supposed to tell the nurse after they document BMs on the ADL (activities daily living) Record when the residents are not having BMs. The nurse is supposed to review the BM records every day. I remember they said something about her constantly having trouble with constipation. I have a problem with maybe aides not always charting." The surveyor asked if the aides charted "0" under BM, she thought that was accurate. The DON stated, "Yes. I think if a resident has gone this long without a BM and nothing was done about it, this is a problem. " The surveyor asked who was ultimately responsible for what the staff do or don't do. The DON stated, "I am." The surveyor asked if this problem could cause an increase in behaviors, weight loss, loss of appetite and confusion. The DON stated, "Yes." The surveyor asked if digital stimulation and manual removal of impactions required a physician's order. The DON stated, "Yes." The surveyor asked if she ever reviewed the charting in the resident's chart? The DON stated, "I do periodically review the Nurses ' Notes. I saw documentation in her chart of the disimpactions but did not look to see if they had an order." 3. On 12/20/12 at 4:20 p.m., the surveyor asked Licensed Practical Nurse (LPN) #2, who took care of Resident #5, if she was aware of this resident's chronic problems with constipation, having manual removal of impactions often and not following prn orders for constipation. The LPN stated, "I had discussed her decreased appetite and chronic constipation with the hospice nurse on 12/9/12. She told me they were starting her on Senna due to chronic constipation. I don't know why it took 5 months for her chronic constipation to be addressed. I have never talked to the doctor about this or the DON. I wasn't aware how long she had gone without a BM. The nurse is responsible for monitoring that. It could have been my responsibility to monitor that. I have reviewed residents' BM record but never hers. I don't know why I didn't look at hers. I usually go off of what the aides report." 4. On 12/20/12 at 4:30 p.m., the surveyor asked LPN #3, who took care of Resident #5, if she was aware of this resident's chronic problems with constipation, having manual removal of impactions often and not following prn orders for constipation. The LPN stated, "I was not aware how many days and for how long she has had no BMs. The CNAs are responsible for writing down when the residents have a BM or not. I would say yes, the nurse is responsible to monitor the records. I would say everybody is responsible to monitor this. We all work together. I monitor BM records from time to time. It needs to be monitored more closely. I can't deny that. I would not say in her case, but this type of chronic constipation could cause an increase in behaviors, anxiety and discomfort. It would be nice if nurses had monitored hers. I would say that you would need an order to disimpact or digitally stimulate." 5. The facility ' s protocol titled Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol " , provided by the Administrator on 12/21/12 at 5:30 p.m., documented, "...Assessment and Recognition: 1...the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms: for example, residents with a history...fecal incontinence...pain with defecation...alteration in bowel movements...and those taking medications related to bowel motility. 2. In addition, the nurse shall assess and document/report the following: ...c. Change in mental status or level or consciousness d. Presence of fecal impaction...f. Abdominal assessment g. Digital rectal examination h. Onset, duration, frequency, severity of signs and symptoms i. All current medications j. All active diagnoses..."